ARFID (Avoidant/Restrictive Food Intake Disorder) is an eating disorder characterized by highly selective eating habits, disturbed feeding patterns or both. It often results in significant nutrition and energy deficiencies, and for children, failure to gain weight.
As a parent of a child with Avoidant/Restrictive Food Intake Disorder (ARFID), you may have struggled for years to help your child increase their range of acceptable foods. Perhaps your child’s struggle with a limited range of foods is more recent, following a choking or vomiting episode. Whichever pathway ARFID has taken, it can be challenging and overwhelming to ensure your child meets their nutritional needs on a daily basis.
Cognitive Behavioral Therapy for ARFID (CBT-AR) has shown promise as an intervention for children (ages 10 and up), adolescents, and adults with ARFID. CBT-AR consists of four treatment stages across 20-30 sessions. For younger patients, the treatment will incorporate parent/family involvement and support.
Stage One: The first stage of CBT-AR involves education about ARFID, highlighting factors that are keeping the person stuck in restrictive or avoidant patterns. The therapist may explore past experiences around food-related discomfort (i.e. pain), difficulty swallowing, or traumatic experiences of choking or vomiting. In this stage, weight restoration is addressed first (if necessary), through learning to eat at regular intervals (3 meals + 2-3 snacks) throughout the day, focusing on preferred foods at first, before introducing novel foods.
Stage Two: The second stage focuses on setting goals and outlining the specific targets for Stage Three of the treatment. During this phase, it’s important for the patient and therapist to explore barriers to treatment progress.
Stage Three: The third stage of CBT-AR varies in content and length of time. During this stage, the patient is systematically and actively working through their food fears and aversions. Using exposure, patients slowly acclimate to new food experiences and begin to increase their tolerance to accommodate a wider range (and in some cases, a continued increase in volume). For example, patients with sensory sensitivity identify a list of new foods to learn about and practice describing foods in a neutral way, trying small tastes of the foods during therapy sessions, and later incorporating full portion sizes of these foods into their diet outside of sessions. Patients who have lack of interest will work on exposures to bodily sensations that prevent them from eating enough, including feeling overly full, nauseous, or bloated. Finally, patients who have a fear of aversive consequences will work on a fear hierarchy to become more comfortable with the foods and eating-related experiences that they fear. Young patients as well as older patients who are underweight will typically work with their families to bring about these important changes!
Stage Four: The fourth and final stage sets the patient up for long-term success by developing plans to prevent relapse. The patient has gained tools to continue their exploration and expansion into new foods once treatment has ended.
FBT for ARFID
Family-based treatment (FBT) has been effective in the treatment of anorexia nervosa. Using a similar rationale for ARFID, families are educated and taught to support their children in increasing dietary volume and dietary variety through repetitive exposure to new foods. In FBT for ARFID, the main principles of FBT—agnosticism, externalization, parental empowerment, and emphasis on the serious medical and developmental consequences of persistent ARFID are applicable. FBT for ARFID enlists parental support in helping the patient overcome their food restrictions and avoidances. The specific strategies used, and the goals of treatment will differ depending on the patient’s symptoms. For selective eaters, parents work with the therapist to gradually expand the patient’s variety of foods. For those who have lost weight or failed to gain weight due to ARFID, parents are empowered to ensure that their child increases caloric intake, gains sufficient weight, and begins to grow as expected. For individuals who have a fear of vomiting or swallowing, parental support is enlisted to help the patient challenge the thoughts, beliefs, and behaviors that perpetuate the illness.