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There is a new diagnosis — Avoidant/Restrictive Food Intake Disorder (ARFID). A disorder many parents experience and fear, but should they?

Picky eaters — a serious problem for some

Eating disorders experts weigh in on Avoidant/Restrictive Food Intake Disorder — two years after classification as a mental health condition

Jessie is a five-year-old girl who doesn't like foods with much texture or flavor. She prefers to eat foods that don't require lots of chewing, like soup, pasta, or oatmeal. Jessie has difficulty eating a range of foods and her mother struggles daily with getting her to consume the nutrients she needs to grow and thrive. Jessie is the smallest child in her class and has been severely underweight for two years.

Jason is a 10-year-old boy who was not a picky eater at all, until he nearly choked on a hot dog eight months ago. The hot dog dislodged and he did not require medical attention immediately after the incident. However, since that day Jason has been reluctant to eat out of fear of choking. He refuses most foods most of the time, but occasionally accepts milk, yogurt and soft cheeses. He has not gained weight since the incident, and with puberty looming ahead, his parents are growing more concerned by the day.

For years, doctors did not have the necessary tools to diagnose children like Jessie and Jason. Did they have "traditional" eating disorders like anorexia nervosa? No, because they did not have distorted body image or a desire to lose weight.

In May 2013, a new eating disorder emerged in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) a psychiatric diagnostic tool used across North America. The diagnosis of Avoidant-Restrictive Food Intake Disorder (ARFID).

Now, two years later, a new commentary by experts from The Hospital for Sick Children (SickKids) and the Children's Hospital of Eastern Ontario (CHEO) reflects on the clinical impact of ARFID, and the work that remains in terms of treatments and improved outcomes. The commentary is published in the June 18 online edition of the Journal of Adolescent Health.

The classification of ARFID expanded upon a previous diagnostic category of Feeding Disorder of Infancy or Early Childhood, which was rarely used or studied. ARFID is described as substantial restrictions or challenges with food intake, associated with weight loss or lack of expected weight gain in the context of significant physiological and/or psychosocial distress. Drs. Katzman and Norris have led or participated in a variety of studies on the diagnosis since its introduction and are planning future studies in the area as well.

"ARFID is not just about picky eating - it's a very challenging diagnostic category in the DSM-5. These kids have complexity, and this condition persists for long periods of time and requires treatment to address both the medical and psychosocial aspects of the condition. If left untreated, children and teens may be left with serious, long-term complications."

Dr. Debra Katzman, staff physician in the Eating Disorders program and Senior Associate Scientist at The Hospital for SickKids, and publication coauthor.

In addition to the physiological impairments caused by the disorder, there are serious social implications, especially for teens, whose social interactions are often centred around food. "For those teens who are unable to go out to eat pizza with their friends, the condition can be socially limiting," says Katzman, who is also Professor of Paediatrics at the University of Toronto.

"Parents have a significant role in identifying unhealthy patterns in their child," says coauthor Dr. Mark Norris, Adolescent Health Physician and Associate Professor of Paediatrics within the Department of Pediatrics at CHEO. "Concerned parents should talk to their child's paediatrician or family doctor early on, rather than letting the problem persist for months or even years."

It is also critical, he explains, that clinicians on the front-lines and in eating disorders programs alike become more familiar with the diagnosis, so that the depth and range of eating difficulties among children, teens and adults can be further studied. In tandem, eating disorders specialists are working to assess outcomes and evaluate the effectiveness of different interventions.

Abstract
Purpose
To evaluate the DSM-5 diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) in children and adolescents with poor eating not associated with body image concerns.

Methods
A retrospective case-control study of 8–18-year-olds, using a diagnostic algorithm, compared all cases with ARFID presenting to seven adolescent-medicine eating disorder programs in 2010 to a randomly selected sample with anorexia nervosa (AN) and bulimia nervosa (BN). Demographic and clinical information were recorded.

Results
Of 712 individuals studied, 98 (13.8%) met ARFID criteria. Patients with ARFID were younger than those with AN (n = 98) or BN (n = 66), (12.9 vs. 15.6 vs. 16.5 years), had longer durations of illness (33.3 vs. 14.5 vs. 23.5 months), were more likely to be male (29% vs. 15% vs. 6%), and had a percent median body weight intermediate between those with AN or BN (86.5 vs. 81.0 and 107.5). Patients with ARFID included those with selective (picky) eating since early childhood (28.7%); generalized anxiety (21.4%); gastrointestinal symptoms (19.4%); a history of vomiting/choking (13.2%); and food allergies (4.1%). Patients with ARFID were more likely to have a comorbid medical condition (55% vs. 10% vs. 11%) or anxiety disorder (58% vs. 35% vs. 33%) and were less likely to have a mood disorder (19% vs. 31% vs. 58%).

Conclusions
Patients with ARFID were demographically and clinically distinct from those with AN or BN. They were significantly underweight with a longer duration of illness and had a greater likelihood of comorbid medical and/or psychiatric symptoms.

ARFID is typically associated with other medical and psychiatric conditions, often including gastrointestinal conditions like inflammatory bowel disease, as well as anxiety disorders.
The average time to diagnosis is 33 months.
A higher proportion of diagnoses are made in boys than in anorexia nervosa; however, like most eating disorders, ARFID is more common in girls overall (70 per cent girls vs. 30 per cent boys).

Without treatment, ARFID can cause a wide range of complications, including nutritional problems like iron-deficiency anemia and low bone-mineral density; delayed pubertal development; and problems with overall growth and development.
Treatment protocols are still being developed, but current treatment includes outpatient family counseling, as well as exposure therapy, in which new foods are slowly and carefully introduced to the child, with appropriate supports in place.
About 13 per cent of the patients seen in paediatric tertiary-care centres with eating disorders programs, like SickKids, are now diagnosed with ARFID.
About The Hospital for Sick Children

The Hospital for Sick Children (SickKids) is recognized as one of the world's foremost paediatric health-care institutions and is Canada's leading centre dedicated to advancing children's health through the integration of patient care, research and education. Founded in 1875 and affiliated with the University of Toronto, SickKids is one of Canada's most research-intensive hospitals and has generated discoveries that have helped children globally. Its mission is to provide the best in complex and specialized family-centred care; pioneer scientific and clinical advancements; share expertise; foster an academic environment that nurtures health-care professionals; and champion an accessible, comprehensive and sustainable child health system. SickKids is proud of its vision for Healthier Children. A Better World. For more information, please visit http://www.sickkids.ca.

About the CHEO Research Institute
The CHEO Research Institute coordinates the research activities of the Children's Hospital of Eastern Ontario (CHEO) and is affiliated with the University of Ottawa. Its three programs of research include molecular biomedicine, health information technology, and evidence to practice research. Key themes include cancer, diabetes, obesity, mental health, emergency medicine, musculoskeletal health, electronic health information and privacy, and genetics of rare disease. The CHEO Research Institute makes discoveries today for healthier kids tomorrow. For more information, visit http://www.cheori.org or @CHEOhospital

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