What is the evaluation and management of Avoidant/Restrictive Food Intake Disorder (ARFID)?

From the Guidelines

The evaluation and management of Avoidant/Restrictive Food Intake Disorder (ARFID) requires a multidisciplinary approach, with initial assessment including comprehensive medical, nutritional, and psychological evaluations, as recommended by the American Psychiatric Association 1. The treatment plan should be individualized, incorporating medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team 1. Key components of the treatment plan include:

• Cognitive-behavioral therapy adapted for ARFID (CBT-AR) as the first-line psychological treatment, focusing on gradual exposure to feared foods, cognitive restructuring of food-related anxieties, and development of coping skills.
• Family-based treatment may be beneficial, particularly for younger patients.
• Nutritional rehabilitation to address any deficiencies through supplements if needed, while working toward expanding dietary variety.
• In severe cases with significant weight loss or medical complications, higher levels of care including partial hospitalization or inpatient treatment may be necessary.
• Medications are not FDA-approved specifically for ARFID but may be used to target comorbid conditions; for example, SSRIs like fluoxetine (10-80mg daily) or sertraline (25-200mg daily) may help if anxiety is prominent, while appetite stimulants such as cyproheptadine (2-4mg three times daily) might be considered in select cases. Regular monitoring of weight, nutritional status, and psychological well-being is essential throughout treatment, as emphasized by the American Psychiatric Association guidelines 1. ARFID differs from other eating disorders in that body image concerns are not central to the condition; rather, avoidance stems from sensory sensitivities, fear of aversive consequences, or lack of interest in food. The initial psychiatric evaluation should include weighing the patient, quantifying eating and weight control behaviors, identifying co-occurring health conditions, and a comprehensive review of systems, as recommended by the American Psychiatric Association 1. The laboratory assessment should include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests, and an electrocardiogram should be done in patients with a restrictive eating disorder or severe purging behavior 1. A documented, comprehensive, culturally appropriate, and person-centered treatment plan is essential for patients with ARFID, incorporating medical, psychiatric, psychological, and nutritional expertise 1.

From the Research

Evaluation of Avoidant/Restrictive Food Intake Disorder (ARFID)

The evaluation of ARFID should be comprehensive and tailored to the patient's needs, including screening for commonly co-occurring psychiatric conditions 2. The presentation of ARFID varies depending on severity, variety, and volume of diet.

Management of ARFID

The management of ARFID may include:

• Hospitalization with multispecialty care (pediatrician, nutritionist, psychologist, psychiatrist, neurologist) 3
• Cognitive behavioral therapy and/or family-based therapy, in conjunction with pharmacotherapy and/or hospital refeeding 2
• Nutritional management strategies, such as the use of Food Chaining, and introducing "safe" products in the initial stage of therapy 3
• Monitoring of weight, height, and nutritional status by a dietitian 3
• Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder (CBT-AR), a novel exposure-based treatment suitable for people aged ten and older 4

Treatment Outcomes

Studies have shown that a multidisciplinary, medical, and behavioral treatment model can be effective for a variety of clinical presentations of ARFID, with participants meeting at least 80% of their admission treatment goals and sustaining progress for several months following discharge 5. However, more research is needed to evaluate therapeutic interventions, medical follow-up, and prognosis 2, 6.

Key Considerations

• ARFID can affect people of all ages and may require both medical and psychological management 6
• The neurobiology underlying ARFID is unknown, and novel treatments are currently being tested 6
• Pediatricians should be aware of the diagnostic criteria for ARFID and the possibility that these patients may require medical intervention and referral for psychological treatment 6