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Szalai T. D. Treatment methods of avoidant/restrictive food intake disorder…

Research article
UDK 616.89-008.441.42-085.851
COBISS.SR-ID 265719564

TREATMENT METHODS OF
AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER –
REVIEW WITH THERAPEUTIC IMPLICATIONS

Tamás Dömötör Szalai1, Melinda Cserép2

1
Semmelweis University,
Institute of Behavioural Sciences, Budapest, Hungary
2
Semmelweis University,
Department of Pediatrics No. I, Budapest, Hungary

Abstract: Background: The introduction of Avoidant/Restrictive Food Intake Disorder

(ARFID) have refined childhood and adolescent eating disorders, however it meant a significant
change in the diagnostics. Hardly anything is known about its effective interventions and there is a
lack of specific treatment guidelines. Thus, our aim was to review the risk factors, assessment meth-
ods, and chiefly the treatment methods of ARFID to support its clinical management and psycho-
therapy. Method: The reviewing process was conducted in two steps, with the primary focus on the
literature since the introduction of ARFID using the term of ‘avoidant/restrictive food intake disor-
der’ with dates 2012 -2015. The PRISMA flow algorithm was applied to filter results. Results and
discussion: Assessment methods involve structured DSM-V interview, supplemented with Bryant-
Waugh’s diagnostic guideline, and the Children’s Eating Disorder Examination-Questionnaire, or
the Eating Disturbances in Youth-Questionnaire. The heterogeneous treatment shall fit the patients’
and families individual needs, and the different presentations ARFID (e.g. sensory-based selective
eating, of chocking or vomiting phobia and interactional difficulties). A combination of medical
treatment with the primary focus on the weight recovery, nutritional management, and psychother-
apeutic interventions are suggested; in children parents should be involved. Behavior therapy with
exposure, systematic desensitization, CBT with cognitive restructuring, anxiety management, and
family based interventions seemed to be the most useful psychotherapeutic interventions. Conclu-
sions: Studies should start assessing the effectiveness of different treatment approaches based on
longitudinal researches to describe strict evidence-based guidelines for each presentations of
ARFID.

Key words: avoidant/restrictive food intake disorder, assessment, treatment, review

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Szalai T. D. Treatment methods of avoidant/restrictive food intake disorder…

Introduction
The Diagnostics of Avoidant/Restrictive Food Intake Disorder
Avoidant/Restrictive Food Intake Disorder (ARFID) is a new type of
eating disorder freshly introduced by the DSM-5 [1]. Its diagnosis unites and
extends the former categories of Eating Disorders, Feeding and Eating Disor-
ders of Infancy or Early Childhood and Somatoform Disorders characterized
by phobic food avoidance [2]. The introduction of ARFID specified the for-
merly not otherwise classified eating disorders of young people with medical
and psychological comorbidities [3]. It refines the definition of childhood and
adolescent eating disorders reflecting their clinical expression across the de-
velopmental span [3], and also offers mutually exclusive criteria from other
eating disorders [1]. Thus ARFID mean a substantial improvement in the di-
agnostics, but as it is different in its many features from classical eating disor-
ders, the classification of ARFID opens up several questions with regard to the
proper assessment and treatment. Hay and colleagues [2] underlined the lack
of clinical guidelines in ARFID, therefore urged the development of specific
assessment and therapeutic guidance. The DSM-5 [1,4] criteria of ARFID are
the following:
A. An eating or feeding disturbance (e.g., apparent lack of interest in eat-
ing or food; avoidance based on the sensory characteristics of food;
concern about aversive consequences of eating) as manifested by per-
sistent failure to meet appropriate nutritional and/or energy needs as-
sociated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight
gain or faltering growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by
an associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of
anorexia nervosa or bulimia nervosa, and there is no evidence of a dis-
turbance in the way in which one’s body weight or shape is experi-
enced.
D. The eating disturbance is not attributable to a concurrent medical con-
dition or not better explained by another mental disorder. When the
eating disturbance occurs in the context of another condition or disor-
der, the severity of the eating disturbance exceeds that routinely asso-
ciated with the condition or disorder and warrants additional clinical
attention.
The diagnosis shall specify if the disorder is in remission, when the criteria
are not fulfilled for a sustained period after meeting full criteria of ARFID [1].
The most important exclusion criteria are: the presence of body image disturb-
ance, culturally endorsed traditions, and medical problems or other psychiatric
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disorders in the symptoms’ background [5]. Therefore, ARFID should be dif-

ferentiated from gastrointestinal diseases, food allergies, intolerances, neuro-
logical, structural or congenital disorders, autisms spectrum disorders (ASD),
specific phobias, social anxiety or other anxiety disorders, obsessive-compul-
sive disorder, anorexia nervosa, schizophrenia spectrum disorders, factitious
disorder or its imposed on another type, and from reactive attachment disorder
[1]. Zucker and colleagues [6] suggest refining the diagnosis of ARFID with
the precise definition of its subgroups (e.g., deficits in executive or in oral-
motor functioning). Feeding and eating disorders are often conceptualized ex-
clusively by the child’s disturbance, although child-caregiver interactions have
a strong impact on their development and maintenance [7,8]. As childhood
feeding disorders are often relational disorders, Davis and colleagues [9] sug-
gested applying a multiaxial diagnosis that involves the child, the parent, their
relationship, the nutritional or feeding context, and the disorders’ severity to
enable proper treatment plan in each childhood eating or feeding disorder.

Characteristics of patients with ARFID

As ARFID is basically defined by restriction or avoidance of food re-
sulting to negative nutritional or energy balance and at least one clinically rel-
evant consequence, the simple but well defined diagnostics may be the reason
of its high frequency in children [10]. The disorder mostly begins in infancy
or in childhood around the age of 8-13, with high 3.2% prevalence in this age
group, causing weight loss, growth impairment, difficulties in social life and
school attendance [11]. Associated selective eating pattern may persist to
adulthood [1]. Although epidemiological data are heterogeneous indicating
13-32% prevalence of ARFID in young eating disorder patients [5,11,12], ac-
cording to most studies approximately 14% of all eating disorder patients [3,
10] and 5-14% of child gastroenterology patients with eating disorder symp-
toms can meet the criteria of ARFID [13]. This means that every seventh pa-
tient must face with ARFID; while 63% of children with feeding problems can
meet one or more of its criteria: insufficient growth in 19.7%, dependence on
supplements in 54.5%, nutritional deficiency in 21.5% [12]. Patients present-
ing ARFID symptoms are often considered firstly as medically ill then the fo-
cus switches soon to the mental illness [5].
ARFID poses risk to other eating disorders, most of all anorexia ner-
vosa [14], although it can be distinguished from classical eating disorders by
the lack of body image disorder. In spite of this, 21% of ARFID patients have
preoccupation with somatic concerns, although differently from the general
symptoms of body image disorder [5]. According to Forman and colleagues
[15] ARFID patients are more often males than in anorexia or bulimia (29%
vs. 15% vs. 6%), are usually younger (12.9 vs. 15.6 vs. 16.5 years), and more
characterized by comorbid medical conditions (55% vs. 10% vs. 11%) and
anxiety disorders (58% vs. 35% vs. 33%), but less affected by mood disorders
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(19% vs. 31% vs. 58%). ARFID patients usually seem less severe on admis-
sion with smaller weight loss or bradycardia and fewer eating disorder symp-
toms than anorectic patients, but often have longer hospitalization [16].
ARFID is frequently associated with ASD, especially in ones with strong pref-
erences on the food’s sensory qualities. Other comorbid states include pica,
anxiety disorders, obsessive-compulsive disorder, attention deficit/hyperactiv-
ity, neurodevelopmental and intellectual developmental disorders [1], or gas-
trointestinal problems, history of food related traumas (e.g., vomiting or chok-
ing) and food allergies [15].
In spite of the high prevalence and comorbidiy of ARFID, hardly any-
thing is known about its effective interventions [14,16]. The clinical guideline
of DSM-V feeding and eating disorders [2] emphasized the lack of specific its
treatment recommendations. Eating disorders’ researchers are urged to inves-
tigate its predisposing factors, standardized assessment instruments, and to ev-
idence effective treatment methods to guide clinical practice [2].

Aims
The aim was to review the most important risk factors, assessment
methods, and chiefly to summarize treatment methods of ARFID to provide
guidance in its clinical management and psychotherapy.

Method
The Review process focused on the literature since the introduction of
ARFID. As its term was first mentioned in 2012 [e.g., 17], this systematic re-
view was conducted with dates 2012-2015 to identify and synthesize relevant
studies. The search was carried out with Pub Med and Web of Science data-
bases using the key words of ‘avoidant restrictive food intake disorder’, result-
ing in 36 papers in Pub Med, 28 papers in Web of Science, and 11 relevant
matches in Google Scholar. The PRISMA flow algorithm [18] was applied to
filter the results. Excluding the duplicates and non relevant matches, 29 papers
were found about the exact topic to summarize the risk, assessment and treat-
ment-related findings.

Results and Discussion

Risk factors of ARFID
The background of food avoidance or restricted intake in ARFID is
deeply diverse [14], and on the basis of its underlying traits several risk factors
can be highlighted:
1. The child’s temperament, neurodevelopment or intellectual im-
pairments (e.g., ASD, attention deficits) can reduce the responsive-
ness to eating and feeding [1,21]. However, selective eating can
occur with and without background developmental disabilities
[22].
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2. In children restriction is based on the food’s sensory characteristics

in up to 60.9% of the cases [8,11]; which is mostly associated with
autism spectrum disorders or pica [1].
3. Other psychological or psychiatric disorders can also pose risk for
ARFID [14]. Emotional difficulties, anxiety disorders, depressive
or bipolar symptoms, obsessive-compulsive traits, can trigger food
avoidance or selective eating, especially in older children or ado-
lescents [1,3].
4. Food avoidance is often originated from conditioned negative re-
sponse after aversive experiences like choking or vomiting [14] in
up to 15.2% of the cases [11].
5. In some patients food avoidance or restriction can be maintained
by the lack of interest in eating [11], or with the lack of communi-
cation of hunger [1].
6. Physiological conditions like gastrointestinal problems (e.g., re-
flux) can increase the risk of food avoidance or restriction [14].
Although ARFID should not be exclusively ascribed to a concur-
rent medical condition [12].
7. Familial anxiety, parent-child interactional deficiencies owing to
the parent’s psychopathology (e.g., the mother’s eating disorder)
or misinterpreting the infant’s behavior can also contribute to the
development or maintenance of the disorder [1]. Mothers of chil-
dren with feeding disorders are usually unpredictable, overcontrol-
ling, intrusive, more punishing, angry and hostile, less affectionate,
less flexible or accepting, often force feeding, and have difficulties
in recognizing the child’s emotions [8,23]. Caregivers often had
eating or personality disorders, depression, anxiety, or other men-
tal health problems [8,24]. The risk factors of ARFID and avoidant
/ restrictive eating are shown in Table 1.
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Table 1. Risk factors of ARFID and avoidant or restrictive eating

Risk / background factors Frequency* Reference

Avoidance based on the sensory properties of the 60.9% [1,11,21,22,25]
food (often associated with ASD)
Anxiety disorders (e.g. generalized anxiety or obses- 21.4-58% [1,3,15,21,22]
sive-compulsive traits)
Lack of interest in eating or the lack of communica- 39.1% [1,11]
tion of hunger
Eating problems prior to the first 18 month like se- 28.7% [15,22]
lective eating or feeding since early childhood
Gastrointestinal symptoms (e.g., gastroesophageal 19.4% [1,14,15]
reflux)
Mood disorders (e.g., depressive or bipolar symp- 19% [1,3]
toms)
Negative consequences or posttraumatic stress dis- 13.2-15.2% [1,11,15,25]
order related to eating/feeding or direct history of
choking/vomiting
Food allergies 4.1% [15]
Child’s other psychopathologies (e.g., attention def- no data [1,21,25]
icit, infantile anorexia)
Caregiver’s psychopathology (e.g. eating disorders, no data [1,7,8,24,26]
personality disorder, depression, anxiety)
Interactional problems related to eating, forced feed- no data [1,8,9,23,27]
ing (e.g. unpredictable, overcontrolling, hostile care-
giver, difficulties in recognizing the child’s signals
and satiety)

Note: Percent of patients presenting the symptoms of avoidant/restrictive eating.

Assessment methods of AFRID

There are no standardized and formalized measures to assess the diag-
nostic and exclusion criteria of ARFID [2,5]. However, structured DSM-V di-
agnostic interviews, two questionnaires [28,31] with the most important symp-
toms, and a diagnostic guideline [19] can be found that supports the assessment
of ARFID.
The structured DSM-V interview [1,4] may mean the most important
current assessment method, including the child’s observation and parental an-
amnesis. The measurement of the related nutritional deficiency ‒ the most se-
vere accompanying symptom ‒ can be based on clinical assessment including
the laboratory tests, physical examination (e.g., hypothermia, bradycardia,
anemia) and the assessment of dietary restraint. Bryant-Waugh et al. [8,19]
suggested clinicians applying four dimensions to assess the severity of
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childhood food avoidance/restriction: 1. the nutritional adequacy of the diet. 2.

The impact of the disorder on weight, growth, and physical development. 3.
Influence on social and emotional development. (4) Related disturbances in
caregiver interactions and family function. These require special attention the
interview-based assessment of AFRID.
The Children’s Eating Disorder Examination-Questionnaire (ChEDE-
Q; [28,29] is a self-report measure derived from the Eating Disorder Exami-
nation interview [29], assessing eating-disorder attitudes and behaviors in chil-
dren and adolescents in four subscales: Restrained Eating, Weight Concern,
Shape Concern, and Eating Concern. Higher scores on the scales reflect more
pathological concerns. The ChEDE-Q has good psychometric qualities (.82<
Cronbach’s alpha< .94) [30]. The ChEDE-Q is a useful standardized measure
of ARFID, as it assesses restricted eating pattern and its exclusion criteria [11].
The Eating Disturbances in Youth-Questionnaire (EDY-Q) [31] is a
14 item instrument that perfectly represents the DSM-V diagnostic criteria of
ARFID and other early-onset restrictive eating disorders [11]. Items refer to
emotional and sensory food avoidance, avoidance of new foods, interest in
food, selective eating, dysfunctional dysphagia including fear of chocking or
swallowing, underweight and desire to gain weight. The EDY-Q also contains
the exclusion criteria of weight and shape concerns. Items can be rated on a
Likert-type scale from never (sore = 0) to always (score = 6). In the study of
Kurz and colleagues [11] ARFID was fulfilled when the frequency of each
eating behavior was reported as at least ‘often’ (cut-off ≥ 4). Exclusion criteria
needed to be reported less than “sometimes” (cut-off < 3). EDY-Q had good
validity, but their factors seem to have low internal consistencies (.42≤
Cronbach’s alpha ≤.52) [11,32].
Bryant-Waugh [19] offered a guideline about the specific information
need in course of the diagnostic interviews, and suggested to clarify the fol-
lowing questions:
1. What is the current range and amount of food intake? This can es-
tablish, whether the patient fails the required nutritional and energy
needs.
2. How long has the restriction or avoidance been occurring? This
establishes, whether this is a persistent matter.
3. Has the current weight and height been dropped compared to the
expected centiles? This establishes faltering growth and the failure
to gain as it would be expected for current age.
4. Can we observe any signs of nutritional deficiency or malnutri-
tion? To establish the evidence of clinical nutritional deficiency.
5. Do we need to supplement the child’s intake to ensure its adequate
level? To establish the dependence on nutritional supplements or
tube feeding.
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6. Is this eating pattern associated with distress or interference with

the daily functioning? To establish the eating disturbance’s inter-
ference with the social or emotional functioning.
7. Furher questions should certify the exclusion criteria like the lack
of availability of food, social and cultural practices, or body image
disorder including weight and shape concerns.
Although, no consistent evidences refer to the discrete subtypes of
ARFID and its clinical representations are not always mutually exclusive [1],
Bryant-Waugh [19] suggested three different clusters of patients: a. restriction
related to the lack of interest in food, b. sensory-based avoidance, and c. avoid-
ance based on the threatening consequences of eating. Perhaps these subtypes
shall be differentiated in the diagnostics to optimize treatment choice.

Treatment methods of ARFID

Nutritional management
As underweight, nutritional deficiency and dependence supplements
are determining features of ARFID, medical and nutritional management seem
to be central in its treatment. The primary aim of each ARFID treatment is to
minimize the patient’s physical risk and to normalize their body weight
[15,19]. A thorough examination might determine how far the patients’ mala-
daptive behavior is explained by medical conditions [33]. Several authors [e.g.,
15,34,35] applied nutritional management as a substatnital part of the treat-
ment, including supplements, vitamins, nutri drinks, calcium or probiotics. In
the study of Strandjord and colleagues [16] medical management included di-
etary prescriptions of 1500-2200 calories adjusted to a .2 kg of weight gain per
day, balanced with nutri drinks, if refused via nasogastric tube. Patients needed
to undertake continuous cardiorespiratory monitoring with bed rest, complete
metabolic laboratory panels and received phosphorus supplementation. Nutri-
tional management can be combined with pharmacotherapy and psychothera-
pies [19,36], and may also hold potentials to shape eating behavior. As sensory
properties of the food often trigger the avoidant behavior [11] changing the
food’s sensory properties or the attitude towards them holds therapeutic poten-
tials [14]. The lack of interest in food intake is also an essential factor [11] that
might be modified through the environmental, emotional or motivational as-
pects of the feeding process, suggesting that therapeutic interventions are
strongly related to the simple changes of the nutritional process.

Behavior and cognitive-behavior therapy

As food avoidance is the central trait of ARFID, thus Kenney and
Walsh [14] supposed that behavioral interventions like specified forms of ex-
posure therapy can be effective. Patients can respond well to standard treat-
ments of phobias [34]. Behavior therapy techniques can include systematic
desensitization, gradual exposure to the aversive stimuli, and the management
of the associated anxiety. Introducing new foods with similar sensory qualities
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to the accepted ones was suggested by Bryant-Waugh [8,19]. Broadening the

restricted nutritional range and eating pattern with similar then gradually
changing food seems be central in the treatment of ARFID [14,34]. Changing
the avoidant behavior by the modifying the range of accepted foods, increasing
bite sizes or time of meals [e.g., 20], and other shaping strategies serve as gen-
eral step of specific behavioral interventions. While observing emotions and
interactions related to eating may show useful information to other psycholog-
ical interventions. The only intervention-based, randomized pilot trial about an
intensive, manualized behavioral treatment of ARFID was published by Sharp
and colleagues [20]. This contained 14 treatment meal sessions in five consec-
utive days with twenty 1-6-year-old participants. Children were presented one
out of 8 pureed foods. When the child swallowed the food at stable rates bite
volume was gradually increased. Based on Sharp and colleagues [37] struc-
tured parental trainings were added in meal 12 and 13. By meal 14, parents fed
their children; with the therapist’s feedbacks, if needed. This was supported
with a manual-based behavioral feeding intervention (integrated Eating Aver-
sion Treatment; iEAT) containing: a. data collection about mealtime perfor-
mances (e.g., bite acceptance, crying, disruptions), b. automatic data analysis,
c. behavioral treatment focusing on escape extinction, reinforcement proce-
dures, and formalized meal structure (e.g., scripted instructions, reduced bites,
pureed food texture). Patients showed significant increase in accepted bites
and volume of food with slight increase in BMI-percentiles that was stable in
one month follow-up [20].
When emotional factors like severe anxiety associated with eating
strongly contribute to the maintenance of the disorder [e.g., 3, 15] cognitive
behavior therapy (CBT) can be a useful intervention method [14]. However,
authors of present paper would like to emphasize that the use of cognitive
methods can be highly dependent upon the age and cognitive development of
the patients, suggesting the expedience of CBT in adolescent and adult ARFID
patients. Bryant-Waugh [19] implemented CBT in smaller well-defined tar-
gets, combined with parental involvement. The therapy aimed to increase the
patient’s responsibility for own health through addressing nutritional risk.
Core CBT interventions included: 1. self-monitoring, 2. cognitive restructur-
ing, 3. behavioral experiments, and 4. relaxation methods. Behavioral experi-
ments like the introduction of new foods with similar sensory characteristics
were supported in the CBT by anxiety management skills such as breathing
and progressive muscle relaxation. King, Urbach and Stewart [38] presented a
case of a women suffering from illness anxiety [1] and ARFID with anxiety-
based avoidance. The patient was successfully treated with CBT that involved:
1. psychoeducation about the physical symptoms of anxiety that can be misin-
terpreted as signs of illness or choking causing catasrophization and hypervig-
ilance. Avoidance of eating was interpreted as a maladaptive anxiety reducing
strategy. 2. Cognitive restructuring was used to identify evidences against
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catastrophic beliefs and sensations with the rating of possibility of catastrophic

consequences. 3. Systematic desensitization consisted of in-vivo exposures
during meal times, based on a hierarchy of feared foods from “safe” to “un-
safe”. This aimed to increase the amount, variety and bites of food eaten. Sub-
jective level of anxiety was rated from 1 (none) to 10 (extreme). 4. Relaxation
techniques were also implemented to help cope with anxiety.

Self-regulation and anxiety management techniques

Kreipe and Palomaki [34] presented a case of a 14-year-old male ath-
lete with sensory-based food aversion that generating anxiety. Treatment was
based on guided imagery self-relaxation exercises prior to eating. This ap-
proach was supported with nutritional counseling and Fluoxetine intake. The
patient could increase the variety of foods, gained back normal weight, and felt
mastering the emotional responses, although some residual sensory symptoms
remained. Repeated imagination of the avoided food means internal exposure,
and self-relaxation helps decreasing anxiety, therefore this approach can be
interpreted as a systematic desensitization. In another case of Kreipe and Pal-
omaki [34] a 10-year-old girl had almost choked from food, thus she became
unwilling to try new foods and insisted on having only smooth foods. This
resulted to conditioned involuntary spasm of her esophagus, and she lost
weight as well. Biofeedback was offered her demonstrating that she was able
to gain control over conditioned responses. This encouraged her to increase
self-regulation to master the involuntary muscle responses of her esophagus.
Supportive therapy was applied to ventilate her chocking experience. She ex-
perienced success in swallowing different foods, and gained confidence after
four sessions. Techniques like imagination, relaxation and biofeedback can be
realized in course of the CBT [19,36], and seemed supporting patients to re-
cover their ability of self regulation.

Family therapy and family based treatment (FBT)

According to our own clinical experiences, if any childhood eating dis-
order is present, patients receive greater attention with the emergence of the
sick role, familiar dependence or the pressure of eating also increases. When
the child rejects eating, parents, most often mothers may perceive that their
parental roles are questioned. This can increase parental stress, and influence
patents’ attitude towards eating by indicating anxiety or anger that may start a
negative spiral which can fortify the child’s food refusal. This negative spiral
can be interrupted by involving the parents in the treatment. Thus, parents and
often the broader social environment (e.g., kindergarten, school) should be in-
volved in the treatment of child ARFID patients. Lopes and colleagues [36]
reinforces that parents shall be involved in the treatment plan. Family members
need to have psychoeducation about the illness course and the expected rein-
forcement strategies of the child’s healthy behavior [38]. In other cases, higher
involvement of the families can be suspected; several childhood feeding
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disorders can be defined as relational disorders [9]. More authors [e.g., 8,19]
emphasized the child’s and the caregivers’ characteristics, their relationship’s
deficiencies and the nutritional context can all contribute to the feeding and
eating pathology. The primary international treatment recommendation for
young patients with anorexia nervosa is family therapy [2,39]. Considering
similar characteristics of ARFID and anorectic patients such as weight loss,
restricted eating pattern, avoidance of certain foods, childhood or teenager on-
set, the utility of family-based treatments can be suspected in cases where in-
teractional or parental dysfunctions contribute to the disorder. However,
Thomas and colleagues [40] suggested different approaches in anorectic and
ARFID patients. Forman and colleagues [15] found that family based treat-
ments were used in 38% of the patients with restrictive eating disorders, and
were just as effective in weight restoration as individual or other medical treat-
ment methods. According to Norris and colleagues [35] all ARFID patients
were successfully re-nourished and progressed with a psychological treatment
that focused on anxiety and feeding management in a family-based treatment
model. Lopes and colleagues [36] directly emphasized the involvement of the
family as an essential element of the successful treatment in child and adoles-
cent ARFID patients. When interactions contribute to the disorder, or when
individuation from the family is needed FBT can be indicated alone or com-
bined successfully with the other individual treatment modalities
[15,19,35,41].

Pharmacotherapy
When mood or anxiety disorders contribute to ARFID symptoms the
use of pharmacotherapy can be suspected as a supplementary therapeutic
method. In some case studies medicines used for depression or anxiety disor-
ders like selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines
were used as a part of the complex treatment of ARFID [e.g., 35, 36]. Fluoxe-
tine (SSRI) was used beside the psychotherapy to treat sensory-based food
avoidance with comorbid anxiety [34]. SSRIs were efficiently used in child-
hood chocking phobia [35]. However, evidences for the efficacy of pharma-
cotherapy methods in ARFID are lacking [33], and Norris and colleagues [36]
referred on its lower efficacy. While Lopes and colleagues [37] used it effi-
ciently combined with various methods of CBT. Therefore the combination of
pharmacotherapy with psychotherapy can be rather supported, but specific
medication definitely needs to be tested by further clinical studies.

Combined treatments
Lopes and colleagues [37] presented an adult AFRID patient suffered
from chocking phobia treated with combined treatment included pharma-
cotherapy (SSRIs), nutritional management, psychoeducation about conse-
quences of nutritional deficiency and treatment goals. CBT was also
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implemented with three aims: (1) cognitive restructuring as cognitive distor-

tions lead to generalized avoidance behavior. (2) Anxiety management. (3)
Desensitization with gradual exposure therapy, through small well defined in-
termediate goals of exposing foods such as approaching to the feared food,
gradually increased bite sizes and reduced chewing, accompanied with breath-
ing and relaxation techniques. Bryant-Waugh [19] emphasized that necessity
of treatments that commonly include medical intervention, nutritional man-
agement and psychotherapies. Most case studies generally reflect a CBT ap-
proach with restructuring of the avoidant cognitive distortions, gradual expo-
sure of the feared stimuli, changing eating patterns and introduction of new
foods, combined with anxiety management like progressive relaxation
[11,14,19,37]. In child and adolescent ARFID patients the parents’ involve-
ment in the treatment plan and psychoeducation is essential [37,38]; and a suc-
cessful family-based treatment can be combined with anxiety and feeding
management [36]. Chandran and colleagues [43] referred a case about a 17-
year-old mage ARFID patient with selective eating since many years with
comorbid subacute spinal cord degeneration managed with combined inpatient
treatment: 1. standard inpatient eating disorder treatment. 2. Nasogastric feed-
ing. 3. Varied diet with supplements. 4. Pharmacotherapy (Quetiapine). 5.
Routine psychotherapy for anxiety management. 6. Family therapy was also
applied to help the individuation process. 7. Individual psychotherapy sup-
ported the outpatient management. The evidence-based treatment methods of
ARFID are shown in Table 2.
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Szalai T. D. Treatment methods of avoidant/restrictive food intake disorder…

Table 2. Applied therapy methods in ARFID

Therapy Main intervention Indication Efficacy Reference

method
Nutritional Nutritional Most cases: No data; [15,16,19,
management supplements, undernourished, low part of 34,36,37]
vitamins, body weight weight
nutri drinks, restoration
calcium, probiotics
Psychoeducation Treatment step and General / No data; [37,40]
goals, consequences anxiety / part of CBT
of nutritional experiencebased and FBT
deficiency, avoidance
symptoms’
misinterpretations,
psychoeducation
for family members
Behavior Standard phobia Anxiety or Good; most [11,14,19,
therapy and CBT treatments, gradual sensory-based often used 20,37]
exposure therapy avoidance/
(often restriction,
combined with aversive
other modalities) experiences, chock-
ing phobia
Behavioral experi- Sensory-based re- Often used [8,19]
ments (e.g., intro- striction, negative
duction of new experiences or emo-
foods with similar tions
sensory features) related to eating
Changing Lack of interest in No data [14,34]
sensory qualities of eating or sensory-
the food or based avoidance
the patient’s attitude
Self-monitoring, nu- Aversive good; [14,19,
tritional risk assess- food-related experi- often used or 37,40,44]
ment, increasing re- ences, emotional combined
sponsibility, factors contribute to with
cognitive restructur- avoidance other
ing, invivo – and in- or restriction, chock- methods
teroceptive exposi- ing
tions, systematic and vomiting
desensitization with phobia
anxiety
management
Self-regulation Breathing and pro- Aversive experi- Partial; [19,34,
and anxiety gressive relaxation ences, part of 37,40]
management: techniques, guided anxious, desensitiza-
relaxation, imagery selfrelaxa- phobic or sensory- tion
imagination, bio- tion prior to eating based food aversion
feedback (parts of the CBT or / avoidance
desensitization)
Biofeedback, Traumatic Good [34]
self-regulation experiences with
xercises food, phobias
18 Psihijat.dan./2017/49/1/5-24/
Szalai T. D. Treatment methods of avoidant/restrictive food intake disorder…

Family-based Changing feeding Feeding anxiety, Good or as [9,15,36,

treatment and interactional deficient interac- efficient as 40,43]
patterns, tions, pressure other
anxiety and feeding to eat parents’ methods;
management, pathology, need parental
supporting for individuation involvement
individuation, is necessary
reinforcements in children
of healthy behavior
Pharmacotherapy Antidepressants, contributing emo- low; better, [15,19,
SSRIs, tional factors (e.g., if combined 34,35,36]
benzodiazepines depression, anxiety) with
psychother-
apy

Predictors of treatment outcome

The efficacy of the above mentioned therapeutic approaches is hetero-
geneous, and only reflected from case studies. Most authors have reported
about combined treatments, just as the only randomized control pilot trial that
have successfully used specific behavioral interventions like gradual exposure
combined with parental training [20]. However, Forman and colleagues [15]
found that ARFID patients have 2-4-times lower odds for weight restoration
than anorectic or atypical anorectic patients; and often have higher drop-out
rates because of their different and more complex treatment needs. Males
overrepresented in ARFID may have worse treatment responses in settings
where they are in minority. The type of intervention was not a significant pre-
dictor of treatment outcome without large differences between the pharma-
cotherapy, nutritional therapy, individual therapy, family based treatment and
“higher level of care”. According to their results the median body mass index
predicted weight restoration, suggesting weight recovery as the primary aspect
of any ARFID treatment.

Conclusions
The manuscript aimed to review the current case reports and studies on
the risk factors, assessment facilities, and to synthesize the available infor-
mation about the treatment of ARFID with the primary goal to draw therapeu-
tic implications.
Multifaceted reasons behind the restricted or avoidant eating pattern
suggest using different treatment methods according to the individual back-
ground factors. Food refusal can be associated with qualitatively different
feeding or eating patterns of diverse origins such as avoidance based on sen-
sory qualities, negative experiences related eating, parental interactions or the
lack of interest in eating. Selective food refusal can be originated in sensory
food aversion; unpredictable refusal is often related to infantile anorexia ner-
vosa, while fear-based refusal is mostly associated with traumatic feeding [25].
These different subtypes commonly indicate different approaches [25]. The
Psihijat.dan./2017/49/1/5-24/ 19
Szalai T. D. Treatment methods of avoidant/restrictive food intake disorder…

various comorbid states of ARFID also require attention in the treatment

choice and in the course of the therapies. Kenney and Walsh [14] suggested
applying any methods that treat the underlying conditions of ARFID in an ev-
idence-based way. Therefore, the efficacy of heterogenic therapy methods can
be suspected in its different presentations [19], suggesting a complex treatment
with different modalities that aim to treat each component of the disorder. This
suggests distinguishing general and specific treatment recommendations in the
different subtypes of ARFID.

General treatment recommendations

Each therapy of ARFID shall be implemented according to the pa-
tients’ and their families’ individual needs, and should respond to the biopsy-
chosocial aspects of the disorder requiring interdisciplinary approach. Patients
require individualized treatment plans according to their complex histories
[45]. Exact treatment plans should be set up as soon as possible based on the
symptoms’ severity, with the primary step to stabilize the severe somatic status
[15]. Therapeutic needs can be assessed according to the impact of food avoid-
ance or restriction on nutritional withdraw, the weight loss, growth deficiency,
associated distress, and the decrease in social and emotional functioning [19].
Treatment procedures shall start with risk assessment, setting goals, and
health- or psychoeducation. Psychoeducation shall focus on both the physical
and psychological consequences of ARFID [40]; while most treatments in-
clude medical and psychological interventions as well as nutritional advice
[46]. As in many cases achieving an eating pattern without any avoidance or
restriction is neither realistic nor desirable, therefore therapist should above all
aim to minimize the physical or nutritional risk by changing the individuals
behavior through anxiety management, trying new foods and extending the
dietary intake [19]. Norris and colleagues [36] warned, that some of the
ARFID patients are at risk to evolve into AN as treatment progresses, thus
therapist must beware of the symptom changes or other implications of the
therapy. As except case reports and one pilot trial no exact guidance is availa-
ble for ARFID, treatment shall be based on most responsible areas for the
avoidant or restricted food intake [19]. This may mean that symptom charac-
teristics can be determining in the exact treatment choice beside the primary
aim of weight restoration [15]. Most treatment shall necessarily include: 1.
medical monitoring, 2. nutritional management, and 3. psychological interven-
tions [46]. Dependent on the initial presentation of the patient even intensive
treatment can be required [5]. However, choosing the right psychotherapeutic
intervention and planning its steps seem to be the most complex question in
the treatment of ARFID.
20 Psihijat.dan./2017/49/1/5-24/
Szalai T. D. Treatment methods of avoidant/restrictive food intake disorder…

Summary of the most effective treatments of ARFID

Although no evidence-based treatments could have been identified till
the end of 2015; case studies, clinical reports and pilot trials suggest the utility
of an individualized combination of: 1. medical treatment with the primary
focus on the stabilization of the patient’ somatic status. This is often combined
with 2. nutritional management and 3. psychotherapeutic interventions
[2,45,46]. Pharmacotherapy seemed alone less effective in ARFID, or showed
heterogeneous results when combined with other modalities, but nutritional
management was unavoidable in most of the cases [15,19,34,36]. Each treat-
ment that aims to be effective shall fit the patients’ and their families individual
needs, and should react on the different presentations or subtypes of ARFID
with their diverse symptomatic characteristics. This can include: 1. selective
eating based on the foods’ sensory qualities, 2. avoidance owing to traumatic
experiences like in chocking phobia and emetophobia 3. restriction triggered
by emotions, 4. or avoidance because of interactional difficulties [1,11,14].
General psychotherapeutic implications are to start the treatment with psy-
choeducation [40] - if adult for the patient, if child for the parents -, and to
involve the parents in the treatment of children [36,41]. The most effective
psychotherapy methods can be:
1. Behavior therapy with exposure and systematic desensitization includ-
ing gradual introduction of new foods in most cases of avoidance, pri-
marily when the restriction is based on the foods sensory qualities
[11,14,19,20,34,37].
2. CBT, where the therapeutic process is supported by cognitive restruc-
turing of the irrelaistic consequences of eating, and self-regulation
strategies like anxiety management (e.g. biofeedback, breathing or re-
laxation techniques). CBT can be especially suggested in emotionally
triggered restriction (e.g., mood disorders) or avoidance based on trau-
matic events (e.g., in chocking or vomiting phobia) [14,19,37,40,44].
3. Family based treatments are specially recommended when interac-
tional patterns, familiar reinforcement, parental pathologies or the in-
dividuation process shall be supported [15,36,40,43].
4. However, most cases can require combined treatments involving med-
ical (if needed pharmacotherapeutic) care, nutritional management,
psychoeducation, and an individualized mixture of specific behavior
therapy, CBT and FBT methods [11,14,19,7,43].

Final conclusion and outlook

This paper shall be read in the light of limitations, as we could only
review cases published after the introduction of ARFID, synthesized according
to our own clinical experiences; but no interventions were involved to conduct
this paper. Authors of this review share the opinion of Norris and Katzman
[47], who concluded that studies should start assessing the effectiveness of
Psihijat.dan./2017/49/1/5-24/ 21
Szalai T. D. Treatment methods of avoidant/restrictive food intake disorder…

different treatment approaches based on manualized interventions. Longitudi-

nal researches are urged [40] to describe strict evidence-based guidelines for
each presentations of ARFID.

Abbreviations
ARFID: Avoidant/Restrictive Food Intake Disorder
ASD: autism spectrum disorder
CBT: cognitive behavior therapy
FBT: family based treatment
SSRI: selective serotonin reuptake inhibitor

Competing interests
The authors declare that they have no competing interest, and received
no financial support to prepare this paper. Present paper is based on the review
of literature evidences; no participants were involved to conduct this manu-
script.

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________________________
Tamás Dömötör SZALAI, Semmelweis University, Institute of Behavioural
Sciences, 1089 Budapest, Nagyvárad tér 4., Hungary

E-mail: [email protected]