Objective: To produce a consensus statement on the psychological treatment of feeding/eating aversions seen in pediatric feeding disorder (PFD) and avoidant/restrictive food intake disorder (ARFID), diagnoses that share common symptoms and psychological mechanisms but have historically been addressed separately in the literature. Method: To help bridge the gaps between ARFID and PFD treatment and research, we convened a group of experts to clarify and describe the psychological interventions for treating learned food avoidance. The current manuscript summarizes the conclusions of the meeting. Result: The primary outcome of the consensus process was a description of a common core approach to psychological intervention across the two fields: Exposure to food and the feeding/eating experience with the goal of increasing the volume and variety of food and fluid consumed. Although our consensus process identified some differences in the mode of delivery and incorporation of specific treatment elements, the consensus panel agreed that these differences are related to three primary factors: the severity of clinical impairment, age and developmental status of the patient, and the specific feeding and eating behaviors targeted, rather than to the ARFID/PFD diagnostic distinction. Discussion: Building on the consensus statement, we discuss other considerations in preparing for and delivering exposure-based treatment, including multidisciplinary assessment, readiness for treatment, and systemic factors that influence access and engagement.

ABSTRACTObjectiveTreatment outcomes research for avoidant/restrictive food intake disorder (ARFID) has been limited to small, mixed‐age feasibility trials in face‐to‐face care settings. This study aims to examine clinical characteristics and treatment outcomes in a large sample of youth and adult patients receiving virtual multidisciplinary team treatment for ARFID.MethodThe sample included N = 783 patients (532 youth and 251 adults) diagnosed with ARFID. Patients received cognitive behavioral therapy for ARFID (CBT‐AR) or family‐based treatment for ARFID (FBT‐ARFID) enhanced by specialized support from a multidisciplinary team. Patients (or caregivers) completed a number of measures assessing ARFID and mood‐related symptoms upon admission and throughout treatment.ResultsYouth patients on weight restoration (56%) started treatment around 85% [84%, 86%] of their target weight, and increased to 94% [93%, 96%] by week 35. Adults on weight restoration (47%) started at 85% [84%, 87%] and reached 92% [90%, 94%]. Scores improved for both groups on all PARDI‐AR‐Q subscales: (sensory sensitivity: b = −0.25 [−0.33, −0.16]; lack of interest: b = −0.08 [−0.16, −0.00]; fear of aversive consequences: b = −0.12 [−0.19, −0.04]). Both youth and adults demonstrated reliable improvements in willingness to try new foods (b = −0.64 [−0.89, −0.37]), anxiety symptoms (b = −0.71 [−0.95, −0.48]), and depression symptoms (b = −0.86 [−1.07, −0.64]).DiscussionYouth and adult patients demonstrated reliable symptom improvements over the course of treatment across all measures, offering preliminary support for the effectiveness of FBT‐ARFID and CBT‐AR delivered virtually by a multidisciplinary care team.

Previously, we evaluated early weight gain as a predictor of weight restoration for patients with anorexia nervosa using receiver operating characteristic (ROC) analysis. Models had low performance, and high rates of misclassification. Regression models including percent target weight at admission in addition to early weight gain performed better. This study evaluated the performance of early weight gain as a predictor of remission for patients with AN. We also explore the limitations of ROC analysis and show that the analogous logistic regression models outperform their ROC counterparts. Participants (N = 233) were patients with AN who received virtual outpatient FBT. ROC analyses used early weight gain to predict remission in week 20. Weight gain at week 8 performed best (AUC = 0.65 [0.58-0.72]). The optimal cutpoint was 8.9 pounds; 36% of the patients were misclassified. A regression model, which included percent target weight at admission in addition to early weight gain as a predictor variable, outperformed the ROC and returned the probability that a patient will remit. These data suggest that using early weight gain alone to set cutpoints misclassifies many patients with AN. Accounting for starting weight at admission improves model predictions.

Transgender and gender-expansive (TGE) individuals suffer from eating disorders (EDs) at disproportionate rates relative to their gender-conforming counterparts. While literature on EDs in TGE populations is growing and evolving, best practice guidelines are scant. A framework for providing gender-affirming care (GAC) in an ED treatment setting was developed by integrating findings from a focused literature review and insights from leading experts. Following synchronous and asynchronous training, the protocol was implemented in a virtual ED treatment setting with a national reach serving patients ages 6-24 years. This paper offers a summary of best practices and approaches for providing GAC in ED treatment settings. The use of GAC practices has the potential to address underlying issues and inequities in treatment delivery and outcomes. We encourage ED treatment providers to consider the adoption/adaptation of GAC best practices to more effectively meet the needs of TGE patients. More research is needed to better understand the influence of individual and collective GAC practices on specific ED treatment outcomes.

Background Previous research has demonstrated that early weight gain in family-based treatment (FBT) is predictive of remission for adolescents with anorexia nervosa (AN). However, no published data has addressed if early weight gain is also predictive of reaching weight restoration (i.e., 95% EBW) in patients with avoidant/restrictive food intake disorder (ARFID). Furthermore, no studies have evaluated the performance of the statistical models used to predict weight restoration at the end of treatment. This study sought to examine whether early weight gain in ARFID is predictive of weight restoration at 20 weeks using ROC analysis. Additionally, this study assessed how accurately the model classified patients and what types of misclassifications occurred. Methods Participants (n = 130, 57.7% cisgender female 70.0% white) received virtual outpatient FBT. Receiver operating characteristics (ROC) were used to predict successful weight restoration at end of treatment, using early weight gain as the predictor. Twenty weeks was considered as the end of treatment, to align with the definition of end of treatment in FBT clinical trials. ROC analyses demonstrated that gaining at least 6.2 pounds by week 5 of treatment was the strongest predictor of achieving 95% EBW at 20 weeks (AUC = 0.72 [0.63, 0.81]). ROC analyses misclassified 35% of patients; the most common misclassification was predicting that a patient would not achieve 95% EBW when they actually did (61.6%). A logistical regression model, which included the patients’ %EBW at admission in addition to early weight gain as a predictor, outperformed the ROC analyses (AUC = 0.90 [0.85, 0.95]) and provided additional context by showing the probability that a patient would succeed. Conclusion Taken together, research demonstrates that early weight gain is a useful predictor of 95% EBW at 20 weeks of treatment for patients with ARFID who require weight restoration. Furthermore, results suggest that statistical models need to take into account additional information, such as %EBW at admission, along with early weight gain in order to more accurately predict which patients will reach weight restoration at week 20.

OBJECTIVE:As diagnoses covering dysfunctional feeding and eating in pediatrics, avoidant/restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD) contain inherent areas of overlap in their diagnostic criteria. Areas of overlap include criteria regarding nutritional consequences associated with feeding/eating dysfunction and shared emphasis on possible psychosocial impairment associated with restricted food intake. Complicating the differential diagnosis process is a lack of guidance regarding when the two conditions occur independently, co-qualify, and/or transition into the other. Feeding Matters' Research Initiatives Task Force planned and hosted a PFD-ARFID consensus meeting, with the aim of reaching a consensus regarding diagnostic clarity on PFD and ARFID. METHOD:Criteria for participation focused on US residents who either: (a) served as an author on the ARFID workgroup or PFD consensus papers, or (b) provided community representation via board or committee roles. The consensus process followed three stages: prework, the meeting, and post-work/writing. Twelve participants were present for the meeting, with 14 involved in pre- and post-work/writing. RESULTS:The final panel included four psychologists representing the ARFID community and seven multidisciplinary members representing PFD's four domains (medical, nutrition, skill, and psychosocial) plus a Zero-to-Three community representative and two representatives from Feeding Matters. Results yielded 10 consensus statements and visuals to support the consensus statements. DISCUSSION:The consensus process and results underscore an ongoing need to improve diagnostic systems and reinforce calls for strengthening healthcare expertise for both PFD and ARFID. Community-based participatory research is recommended to advance both diagnoses and reduce ambiguity in practice settings.

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder recently codified in DSM-5 that affects individuals of all ages. A proliferation of ARFID research has emerged over the years, and this review provides a brief overview of the current understanding of ARFID epidemiology, symptoms, comorbid conditions, assessment, and treatment. The review highlights recent research updates regarding ARFID among adults, putative neurobiological mechanisms underlying ARFID, and new treatment trials. Findings from this review demonstrate that ARFID is as prevalent as other eating disorders, even among adults, and is associated with significant medical and psychiatric comorbid conditions. New, promising treatments for children, adolescents, and adults are in the early stages of development. Several assessments are now available to aid in the screening and diagnosis of ARFID and have demonstrated cross-cultural validity. Areas for future research and clinical guidance, including unresolved questions regarding ARFID categorization and differential diagnosis, are discussed.

Background Appetite suppression and weight loss are established potential side effects of most medications for attention deficit/hyperactivity disorder (ADHD). These side effects may be especially problematic when using stimulants to treat ADHD in the context of a restrictive eating disorder, such as avoidant restrictive food intake disorder (ARFID), although these diagnoses are often comorbid in children. This paper presents a combined approach to treating ADHD comorbid with ARFID using stimulant medication and behavior management within a partial hospitalization program (PHP) and intensive outpatient program (IOP)for eating disorders. The aim of this paper is to determine if the continued or new use of stimulant medication allows for adequate weight restoration by reviewing a series of cases receiving the combined treatment. Case presentations Consecutive patients with a historical or new diagnosis of ADHD when presenting for treatment for ARFID were included in this case series. This series included 10 patients (8 male, 2 female) who received pharmacotherapy using stimulants and behavior management interventions involving structured mealtimes and contingency management. All treatment occurred within the context of a PHP/IOP for childhood eating disorders. All youth were able to effectively continue on stimulant medication, show clinical benefit in core ADHD symptoms, and able to gradually restore weight. In all cases, stimulant medications were not discontinued, but in some cases, doses were optimized (increased or decreased), switched to a different stimulant, or augmented with non-ADHD medication, such as mirtazapine, to support the management of ADHD while concurrently assisting in weight gain as necessary for the treatment of ARFID. Only one patient was newly started on a stimulant medication; as this was near the end of her treatment stay, limited conclusions can be drawn from this case. Conclusions These findings support the use of pharmacotherapy, including continuing stimulant medication, when combined with behavior management strategies as a potentially effective treatment approach for ADHD in youth with ARFID in the PHP/IOP setting. Future studies using more rigorous methodology, longer follow-up times, and within other treatment settings are needed.

While disgust is a clinically and theoretically relevant construct for selective eating, limited research has examined how different aspects of disgust relate to selective eating severity in adults. Thus, the present study sought to 1) compare disgust propensity (how easily people are disgusted) and disgust sensitivity (how unpleasant disgust is) across a spectrum of selective eaters, 2) explore the specificity of the associations between disgust sensitivity/propensity and selective eating across selective eating and related phenotypes, and 3) explore whether the relationship between selective eating and disgust is food-specific. Participants were 554 adults recruited on Amazon's Mechanical Turk who completed cross-sectional surveys on study constructs. The sample was recruited to over-represent individuals with high levels of selective eating. Results support that disgust propensity, but not sensitivity, was elevated in the impaired selective eating group compared to non-impaired selective eaters and non-selective eaters. Only the selective eating phenotype was independently associated with both disgust sensitivity and propensity. Correlation results supported that the associations between selective eating and disgust were specific to the disgust elicited by food (i.e., animal protein, fruits, vegetables). Overall, results support that disgust propensity and disgust sensitivity play a role in selective eating. Results imply that disgust sensitivity associated with selective eating appears limited to the food domain and may be more specific to disgust eliciting food itself, rather than signs of food contamination or spoilage.

Purpose of Review In current review, we evaluate the current literature examining the role of disgust in eating disorders (EDs), and provide a theoretical model designed to inform the study and treatment of disgust-based symptoms in EDs. Recent Findings Findings from this review suggest that aberrant disgust-conditioning processes represent promising but understudied mechanisms that may contribute to the risk and maintenance of core eating disorder (ED) psychopathology. In addition, preliminary evidence supports the use of interventions designed to target aversive disgust cues and disrupt maladaptive disgust-based conditioning that may maintain eating pathology. However, experimental studies designed to elucidate the role of disgust and aversive learning processes remain limited. Summary Disgust is a promising risk and maintenance factor in EDs. Future systematic investigation is needed to examine disgust-based processes at a mechanistic level in order to better understand the links between disgust, avoidance behaviors, and EDs. Further investigation of the mechanistic role of disgust in EDs is warranted.

OBJECTIVE:Literature providing clinical characterizations of avoidant/restrictive food intake disorder (ARFID) has proposed the occurrence of three functions for food refusal: fear of negative consequences, lack of hunger, or sensory sensitivity. Recent studies have suggested that these functions may be used to subtype patients presenting with ARFID; however, other work suggests that these categories are not mutually exclusive and instead represent neurobiological dimensions that can cooccur. The current study explored the potential cooccurrence of behavioural phenotypes in patients with ARFID presenting to a partial hospitalization program.METHOD:Two raters conducted a retrospective chart review of patients with ARFID presenting to treatment from June 2014 to May 2018 (N = 59).RESULTS:Regarding cooccurrence of symptoms consistent with behavioural phenotypes, raters showed excellent agreement, and over 50% of the sample endorsed symptoms consistent with more than one phenotype. The sensory sensitivity phenotype was most common in the sample and frequently cooccurred with both other phenotypes.DISCUSSION:Results suggest that multiple functions for food avoidance may be present within one individual. Future work should aim to further characterize individuals presenting with singular versus multiple phenotype characteristics.

OBJECTIVE Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined. METHOD In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder. RESULTS By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment. CONCLUSIONS This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.

This presentation will describe one academic medical center’s experience with treating avoidant/restrictive food intake disorder (ARFID) in a day treatment (partial hospitalization and intensive outpatient) program for children ages 7–13 years. A discussion of selection of the levels of care, structure, and programming of care at our institution and strategies used with difficult cases will be presented.

Embodiment is defined as a state in which one experiences one's physical body as an essential aspect of one's lived experiences, a potential protective factor against body image and eating disturbance. The Physical Activity Body Experiences Questionnaire (PABEQ) was rationally derived as a measure of embodiment based on focus groups, literature reviews, and expert review. The PABEQ and measures of body image, self-objectification, and disordered eating were administered to two samples randomly selected from a pool of 606 female undergraduate students at least 18 years of age and a third test-retest sample of 58 female undergraduates. Exploratory factor analyses and reliability estimates supported a two-factor scale: Mind-Body Connection and Body Acceptance. Results indicated the utility of the subscales in predicting body awareness, body responsiveness, positive body image, body satisfaction, self-objectification, disordered eating, and positive body image.

Selective eating is a common presenting problem in Avoidant/Restrictive Food Intake Disorder (ARFID). Understanding the etiology of selective eating will lead to the creation of more effective treatments for this problem. Recent reports have linked disgust sensitivity to picky eating, and the field has yet to conceptualize the role that disgust might play in ARFID. Disgust has long been tied to formation of taste aversions and is considered at its core to be a food-related emotion. A brief review of the literature on disgust reveals that disgust has a unique psychophysiological profile compared to other emotions, like anxiety, and that disgust is resistant to extinction procedures. If disgust is implicated in the etiology of selective eating, its presence would have a significant impact on treatment approaches. This article provides an overview of the research on disgust and eating, a clinical example of the treatment challenges that disgust may pose, and an overview of the unique clinical features of disgust as they apply to psychopathology. We pose several research questions related to disgust and selective eating and discuss initial hypotheses for pursing this line of inquiry. Finally, we discuss the possible implications of this line of research for treatment.

Avoidant and restrictive food intake disorder (ARFID) is a newly classified disorder in the DSM-5 that describes a pattern of restrictive eating across the lifespan that results in significant weight loss, nutritional deficiency, dependence on enteral feeding or nutritional supplements, or marked interference in psychosocial functioning.1 Currently, there are no evidence-based treatment approaches or medications for this disorder.2 We have administered a range of psychoactive medications to those with ARFID in our treatment program in an attempt to find an effective medication. One medication of interest has been mirtazapine because it promotes appetite and weight gain, decreases nausea and vomiting, and improves gastric emptying. Although mirtazapine is an off-label approach in a pediatric population and carries a black box warning for an increased risk of suicide, it is an effective treatment for depression and anxiety symptoms in adults and is generally well tolerated.3,4 There are no studies to date reporting on the use of mirtazapine in patients with ARFID.

Objectification theory asserts that self-objectification, which manifests as self-surveillance, leads to increased body shame and subsequent eating pathology. Although evidence supports the core mediational model, the majority of this work utilizes primarily White samples, limiting generalizability to other ethnic groups. The current study examined whether the core tenets of objectification theory generalize to Black and Hispanic women. Participants were 880 college women from the United States (71.7% White, 15.1% Hispanic, 13.2% Black) who completed self-report measures of self-surveillance, body shame, and disordered eating. Multivariate analysis of variance tests indicated lower levels of self-surveillance and disordered eating among Black women. Moreover, body shame mediated the relationship between self-surveillance and disordered eating for White and Hispanic women, but not for Black women. These analyses support growing evidence for the role of body shame as a mediator between body surveillance and eating pathology, but only for women in certain ethnic groups.

Avoidant/restrictive food intake disorder (ARFID) captures a broad range of restrictive eating behaviors and presents challenges to treatment providers due to the lack of treatment guidelines. Individuals diagnosed with ARFID may present with extreme selective or picky eating, food phobias, or generally poor appetite. This chapter describes the prevalence and clinical characteristics of ARFID. It also provides treatment recommendations for ARFID that are drawn from the literature on eating disorders, anxiety disorders, and feeding disorders. Family-based treatment approaches, similar to those used in treating anorexia nervosa, are recommended to target weight restoration and correct disruptive mealtime behaviors. Cognitive–behavioral approaches used in treating other anxiety and mood disorders may be helpful in targeting specific food fears. Other adaptations of treatment are discussed for addressing the presence of extreme selective or picky eating.