Defining Feeding Disorders

A feeding disorder involves a child's or an adult's refusal to eat certain food groups, textures, solids, or liquids for a period of at least one month, which causes them to not gain enough weight or grow naturally. Most often seen in children, feeding disorders resemble failure to thrive, except there is no medical or physiological condition that can explain the very small amount of food the children consume or their lack of growth.

In the 5th edition of the DSM (DSM-5), the diagnosis of feeding disorder of infancy or early childhood was renamed to avoidant/restrictive food intake disorder (ARFID), and the criteria were expanded. ARFID is an eating disorder that prevents the consumption of certain foods, and it is often viewed as a phase of childhood that is generally overcome with age. Some people may not grow out of the disorder, however, and may continue to be afflicted with ARFID throughout their adult lives. Previously defined as a disorder exclusive to children and adolescents, the DSM-5 broadened the disorder to include adults who limit their eating and are affected by related physiological or psychological problems, but who do not fall under the definition of another eating disorder.

Foods that are considered "safe" for people with ARFID may be limited to certain food types and even specific brands. In some cases, afflicted individuals will exclude whole food groups, such as fruits or vegetables; others may avoid specific types of foods, such as sauces. Some may only like foods of a certain color, very hot or very cold foods, very crunchy or hard-to-chew foods, or very soft foods. Sufferers can experience physical gastrointestinal reactions to adverse foods such as retching, vomiting, or gagging. Some studies have identified symptoms of social avoidance due to the person's eating habits. 

Feeding Disorders in Childhood

Children with feeding disorders may refuse to eat certain foods based on color, texture, temperature, or other factors.

DSM-5 Diagnostic Criteria

According to the DSM-5, a diagnosis of ARFID requires a disturbance in eating or feeding as evidenced by substantial weight loss (or, in children, absence of expected weight gain), nutritional deficiency, dependence on a feeding tube or dietary supplements, and/or significant psychosocial interference. This disturbance must not be due to unavailability of food; to observation of cultural norms; to anorexia nervosa, bulimia nervosa, or another eating disorder; to perceived flaws in one's body shape or weight; or to another medical condition or mental disorder. When the disorder occurs concurrently with another medical or mental condition, the disturbance must exceed what is normally caused by that condition.

Etiology

The determination of the cause of ARFID has been difficult due to the lack of diagnostic criteria and concrete definition. However, many have proposed other mental disorders that are comorbid with ARFID—indeed, symptoms of ARFID are usually found with symptoms of other disorders. For example, some form of feeding disorder is found in 80% of children that also have a developmental disability. Children with feeding disorders often exhibit symptoms of obsessive-compulsive disorder (OCD) and/or autism spectrum disorder (ASD). Although many people with ARFID have symptoms of these disorders, they often do not qualify for a full diagnosis. Specific food avoidances could also be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Other forms of eating disorders, such as anorexia nervosa or bulimia nervosa, involve a fear of gaining weight; while those who suffer from ARFID do not have this specific fear, the psychological symptoms and resulting anxiety are similar.

Treatment

With time, the symptoms of ARFID can lessen and can eventually disappear without treatment. However, in some cases treatment will be needed as the symptoms persist into adulthood. The most common type of treatment for adults with ARFID is some form of cognitive-behavioral therapy. Working with a clinician can help to change behaviors more quickly than allowing the symptoms to disappear without treatment. Hypnotherapy can also be used to lessen the anxiety associated with food; in addition, there are support groups for adults with ARFID.

Some children with ARFID benefit from a four stage in-home treatment program based on the principles of systematic desensitization. The four stages of the treatment include record, reward, relax, and review:

• In the record stage, children are encouraged to keep a log of their typical eating behaviors as well as their cognitive feelings, without attempting to change their habits.
• The reward stage involves systematic desensitization. Children create a list of foods that they might like to try eating some day. These foods may not be drastically different from their normal diet, but perhaps a familiar food prepared in a different way. Because the goal is for the children to try new foods, children are rewarded when they sample new foods.
• The relaxation stage is most important for those children that suffer severe anxiety when presented with unfavorable foods. Children learn to relax to reduce the anxiety that they feel. Children work through a list of anxiety-producing stimuli and can create a story line with relaxing imagery and scenarios. Children then listen to this story before eating new foods as a way to imagine themselves participating in an expanded variety of foods while relaxed.
• The final stage, review, is important to keep track of the child's progress. It is important to include both one-on-one sessions with the child as well as with the parent in order to get a clear picture of how the child is progressing and if the relaxation techniques are working.