Further support for diagnostically meaningful ARFID symptom presentations in an adolescent medicine partial hospitalization program

Abstract

Objective To identify potential presentations of avoidant/restrictive food intake disorder (ARFID) in a pediatric eating disorder partial hospitalization program (PHP) based on the nature of the eating restriction leading to core symptoms of ARFID. Method A retrospective chart review of 83 patients ages 8–17 admitted to a PHP and diagnosed with ARFID. Charts were independently reviewed by two coders, with high inter‐rater agreement (κ = 0.77). Distinct categories were identified and groups were compared on demographics, anthropometrics, comorbid psychopathology, and core ARFID symptoms. Results We identified cases characterized by predominantly selective eating based on aversions to the sensory properties of foods, lack of interest in eating/low appetite, and fear of aversive consequences from eating. We also distinguished a subset of patients with eating restrictions consistent with both selectivity and limited interest/appetite. The four primary ARFID presentation groups differed on core ARFID criteria, symptom trajectory and illness duration, mood and medical comorbidities, age, gender, and parent‐reported symptoms of psychopathology. Discussion The present findings suggest that there are diagnostically meaningful ARFID subtypes that can be differentiated based on the nature of their eating restrictions, as well as other demographic, illness history features, and psychiatric comorbidity. As treatments for youth with ARFID are developed and refined, it will be important to take into consideration not only demographic differences, but also the variability in symptoms, as this might require distinct interventions and levels of care. Additionally, differing mechanisms that maintain different types of eating restrictions might necessitate unique psychological and psychiatric interventions.

Prevalence and correlates of psychiatric comorbidities in children and adolescents with full and subthreshold avoidant/restrictive food intake disorder

“…Additionally, greater severity in the sensory sensitivity profile was also uniquely associated with a higher likelihood of comorbid anxiety, obsessive-compulsive, and trauma-related disorders. These findings are consistent with an 80% prevalence of anxiety disorders among those exhibiting the "selective eating" profile in a clinical sample (Zickgraf, Lane-Loney, et al, 2019), as well as results from a study suggesting that anxiety and sensory sensitivity were positively correlated in a nonclinical sample of children (Farrow & Coulthard, 2012 Although lack of interest in food or eating is a commonly endorsed symptom of MDD, our study did not find evidence in support of the hypothesis that individuals exhibiting severity in the lack of interest profile would have a higher likelihood of depressive and bipolar-related disorders. Instead, severity in the sensory sensitivity profile was associated with lifetime comorbid depressive and bipolar-related disorders.…”

“…Much like those with ARFID, individuals with ADHD are often hyper‐sensitive and display exaggerated responses to sensory stimuli (Baranek, David, Poe, Stone, & Watson, ), which may include the taste and texture of food. Indeed, the prevalence of ADHD among individuals presenting with the “selective eating” profile of ARFID ranged from 24% to 25% in one study that utilized two raters (Reilly et al, ), and from 16% (Zickgraf, Lane‐Loney, et al, ) to 20% (Zickgraf, Murray, et al, ) in two studies. Exposure to sensory stimuli that produce an exaggerated response may be a relevant treatment target for those with co‐occurring ARFID and neurodevelopmental disorders.…”

“…to 25% in one study that utilized two raters (Reilly et al, 2019), and from 16% (Zickgraf, Lane-Loney, et al, 2019) to 20% (Zickgraf, Murray, et al, 2019) in two studies. Exposure to sensory stimuli that produce an exaggerated response may be a relevant treatment target for those with co-occurring ARFID and neurodevelopmental disorders.…”

“…Lastly, few studies have reported on whether or how psychiatric comorbidities may differ across the three core ARFID presentations described in DSM‐5 . Those that have (Norris et al, ; Reilly et al, ; Zickgraf, Lane‐Loney, Essayli, & Ornstein, ) have conceptualized the presentations as mutually exclusive categories, despite growing evidence that ARFID profiles may overlap (Bryant‐Waugh et al, ). Conversely, our team recently proposed a conceptual three‐dimensional neurobiological model of ARFID (consistent with the National Institute of Mental Health's Research Domain Criteria [RDoC] approach) wherein the three core presentations (i.e., sensory sensitivity, fear of aversive consequences, and lack of interest) occur along a continuum of severity and are not mutually exclusive (Thomas et al, ).…”

Introduction to a special issue on child and adolescent feeding and eating disorders and avoidant/restrictive food intake disorder

“…They argue that subtyping ARFID—perhaps by age of onset and whether eating difficulties involve volume and/or variety—may help to guide research and intervention going forward. Interestingly, Zickgraf, Lane‐Loney, Essayli, and Ornstein () provide data on potential ARFID subtypes, finding five in their pediatric ARFID sample including selective eating, appetite disturbance, both selective eating and appetite disturbance, fear, and other disordered eating (e.g., features of both ARFID and AN), with differences across groups in terms of age. Empirical studies like this one are critical so that we may identify more homogeneous subgroups with the heterogeneous ARFID diagnosis that may have different underlying neurobiology and require different treatment approaches.…”