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There is a paucity of validated diagnostic interviews for avoidant/restrictive food intake disorder (ARFID) to aid identification and classification of cases for both clinical and research purposes. To evaluate the factor structure, construct validity, and criterion validity of the Pica ARFID and Rumination Disorder Interview (PARDI; ARFID module), we administered the PARDI to 129 children and adolescents ages 9-23 years (M = 16.1) with ARFID (n = 84), subclinical ARFID (n = 11), and healthy controls (n = 34).We used exploratory factor analysis to examine the factor structure of the PARDI in children, adolescents, and young adults with an ARFID diagnosis, the Kruskal-Wallis analysis of variance and Spearman correlations to test the construct validity of the measure, and non-parametric receiver operating characteristic curves to evaluate the criterion validity of the PARDI.Exploratory factor analysis yielded a 3-factor structure: (1) concern about aversive consequences of eating, (2) low appetite/low interest in food, and (3) sensory sensitivity. Participants with ARFID demonstrated significantly higher levels of sensory sensitivity, low appetite/low-food interest, and concern about aversive consequences of eating symptoms relative to control participants. The construct validity for each PARDI subscale was supported and clinical cutoffs for the low appetite/low interest in food (1.1) and sensory sensitivity subscales (0.6) were established.These data present evidence for the factor structure and validity of the PARDI diagnostic interview for diagnosing ARFID in children, adolescents, and young adults, supporting the use of this tool to facilitate ARFID clinical assessment and research.Due to the paucity of validated diagnostic interviews for avoidant/restrictive food intake disorder (ARFID), we evaluated the factor structure and validity of the Pica ARFID and Rumination Disorder Interview (ARFID module). Findings suggest that the interview assesses 3 components of ARFID: concern about aversive consequences of eating, low-appetite, and sensory sensitivity, and that clinical threshold scores on the latter two subscales can be used to advance ARFID assessment.

OBJECTIVE: Previous literature shows an increased risk for eating disorders in autistic individuals. This study tested whether fussy eating contributes to the association between childhood autistic traits and adolescent eating disorder behaviours.METHOD: Using data from the Avon Longitudinal Study of Parents and Children, we estimated the intercept and slope of parent-rated autistic traits and fussy eating between 7 and 14 years (N = 8982) and their association with self-reported eating disorder behaviours at age 14 years, including the indirect path from autistic traits to eating disorder behaviours via fussy eating. Analyses were adjusted for child sex, maternal age at delivery, maternal body mass index and maternal education.RESULTS: Analyses found a small indirect pathway from autistic traits intercept to eating disorder behaviours via fussy eating slope (b = 0.017, 95% CI = 0.002-0.032, p = 0.026), with higher levels of autistic traits at age 7 years being associated with a shallower decline in fussy eating, which in turn was associated with greater eating disorder behaviours.CONCLUSION: Findings point towards fussy eating as a potential link between childhood autistic traits and later disordered eating. Addressing fussy eating patterns before they become entrenched may decrease risk for eating disorders later in development.

To assess the extent of the scientific literature on avoidant/restrictive food intake disorder (ARFID) in children and young people with autism in order to evaluate and synthesize the evidence on (a) the nature of feeding and eating difficulties in children and young people with autism; (b) the consequences of a severely restricted diet; and (c) what is known about effective treatment approaches.PubMed and PsycInfo databases were searched, identifying 56 studies and a narrative synthesis was effected.The literature suggested that ARFID-like presentations are common in children and young people with autism, with severe consequences for physical and mental health. The three drivers mentioned in the DSM-5 criteria, namely a sensory-based avoidance, fear- or phobia-based restriction, and a lack of interest in eating, are present in this population, although sensory sensitivities are currently the most commonly described. Research suggests that ARFID symptoms in children and young people with autism can be amenable to treatment, with evidence that behavioural interventions are feasible and potentially effective in this population.ARFID is a common and impactful problem among young people with autism but is currently under researched. Work is required to (a) identify the prevalence of ARFID in children and young people with autism; (b) uncover the key drivers of ARFID in this population; (c) adapt currently available interventions for use with children and young people with autism; and (d) rigorously test these interventions in clinical trials.Significant food restriction is common in children and young people with autism. Sensory sensitivities are frequently cited as a reason for food restriction. The prevalence and causes of avoidant/restrictive food disorders in children and young people with autism need further research.

ImportanceAvoidant restrictive food intake disorder (ARFID) is a newly recognised eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and in the International Classification of Diseases, Eleventh Revision which shows great heterogeneity in its clinical presentation.ObjectivesHere, we examined the clinical characteristics of ARFID and explored the associations between ARFID symptoms and traits of anxiety. We also investigated whether individuals with ARFID show a different clinical presentation based on their biological sex or comorbid autism spectrum disorder (ASD) diagnosis.Design, Setting, and ParticipantsWe recruited 261 consecutive patients from the specialised ARFID outpatient service at the Maudsley Centre for Child and Adolescent Eating Disorders, Michael Rutter Centre, Maudsley Hospital, London, United Kingdom.Main Outcomes and MeasuresThe parents of the patients completed the Pica, ARFID, Rumination Disorder – ARFID – Questionnaire (PARDI-AR-Q), the Revised Children’s Anxiety and Depression Scale (RCADS) and reported biological sex of their offspring. Age, height, and weight were obtained from medical records. Clinicians reported on comorbid ASD diagnosis and anxiety traits using the Current View Tool.ResultsThis cross-sectional study included 261 child and adolescent ARFID patients (133 [51%] female) with a median age of 12.7 years (IQR=9.2 to 15.8). Patients’ BMI-for-age z-scores ranged from −6.75 to 4.07 (median = −1.07, IQR = −2.25 to −0.01).Patients’ comorbid traits of anxiety had the highest correlations with symptoms on the concern about aversive consequences driver of ARFID: panic disorder correlated with physical feelings of panic and anxiety when eating (r=0.53, p=7.74 × 10−31) and being afraid to eat (r=0.42, p=5.13 × 10−21); generalised anxiety correlated with physical feelings of panic and anxiety when eating (r=0.44, p=7.72 × 10−23); and separation anxiety correlated with avoiding eating situations (r=0.36, p=2.01 × 10−15). Sensory sensitivity to the appearance of food positively correlated with separation anxiety (r=0.40, p=1.52 × 10−16) and generalised anxiety (r=0.36, p=7.16 × 10−18).The sensory sensitivities (RR = 0.96; 95% CI, 0.85 to 1.09;P= .53), lack of interest (RR = 1.14; 95% CI, 1.03 to 1.28;P= .02) and concern about aversive consequences (RR = 1.27; 95% CI, 1.03 to 1.56;P= .03) drivers were independent of patient sex. Comorbid ASD was reported in 74 (28%) ARFID patients. Their parents reported higher rates of food-related sensory sensitivities (RR = 1.26; 95% CI, 1.09 to 1.45;P=0.002) and lack of interest (RR = 1.19; 95% CI, 1.05 to 1.34;P=0.006) driving their child’s avoidant and restrictive eating than parents of ARFID patients without ASD (127 [49%]).Conclusions and RelevanceOur study highlights that ARFID patients present with varying combinations and severity of food-related sensory sensitivities, lack of interest and concern about aversive consequences which drive their avoidant and restrictive eating. ARFID does not discriminate between male and female children and adolescents or those with or without ASD. Anxiety and ASD can co-occur with ARFID, and ASD may accentuate food-related sensory sensitivities and lack of interest. Healthcare professionals should be aware of the multi-faceted and heterogenous nature of ARFID; it is important that comprehensive multidisciplinary assessments are administered to sufficiently understand the drivers of the eating behaviour and associated physical health, nutritional, and psycho-social risk and impact.Key PointsQuestionAre the clinical characteristics of avoidant restrictive food intake disorder (ARFID) associated with biological sex, comorbid autism spectrum disorder (ASD) and anxiety traits in patients who present to a specialist ARFID child and adolescent mental health outpatient service?FindingsIn our cross-sectional study, the clinical presentation of ARFID is largely independent of patient sex, comorbid ASD and anxiety.MeaningRegarding these patient characteristics, we detected no marked differences in our patient sample meaning that all patients should be comprehensively assessed by a multidisciplinary team regardless of comorbidity.

Avoidant Restrictive Food Intake Disorder (ARFID) is a condition characterised by a disturbance in eating behaviour that leads to a significant negative impact on physical, social and nutritional health. The diagnosis of ARFID relies on a comprehensive, multi-disciplinary assessment to understand the individual’s history, physical, social and mental health risk, and any co-occurring mental health difficulties. Consensus guidance suggests that psychological treatment, alongside medical and dietetic input is delivered with consideration of any appropriate adaptions to accommodate developmental stage and/or common co-occurring presentations. This paper has been authored by clinicians working in an out-patient setting for children and adolescents with ARFID, and focuses on the presentation and assessment of ARFID and cognitive behavioural therapy (CBT) approaches that can help children, young people and their families. After an introductory section, the paper is split into four sections: assessment of ARFID; drivers of avoidant restrictive eating behaviour; multi-disciplinary formulation and intervention planning; and treatment. The treatment section provides an overview of the available research on CBT for ARFID, and a brief summary of the broader evidence base for CBT in children and young people with anxiety. Following a review of the evidence base, three case descriptions are provided to illustrate the clinical application of CBT where fear-based avoidance is the main driver. The paper concludes with practice points for clinicians to take forward when working with children and young people with ARFID. Key learning aims (1) To be aware of the international consensus for the use of psychological interventions as a component of ARFID treatment alongside medical and dietetic input. (2) To understand that ARFID is characterised as a disturbance of eating behaviour, and as such, psychological intervention should target the drivers of this disturbance to promote behavioural change. (3) To gain an overview of the multi-disciplinary team assessment as an important tool to understand the contribution of each of the three drivers proposed to underpin an ARFID presentation. (4) To recognise when a CBT approach might be indicated, the current best evidence base for CBT for ARFID and how to adapt CBT to accommodate developmental stage and/or common co-occurring presentations.

Background Feeding and eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Low intensity psychological interventions have the potential to increase such access. Methods A systematic review and meta-analysis were conducted on the use of low intensity psychological interventions for the treatment of feeding and eating disorders. Studies comparing low intensity psychological interventions against high intensity therapies and non-eating disorder specific psychological interventions were included, as well as those with waiting list control arms. There were three primary outcomes: eating disorder psychopathology, diagnostic and statistical manual of mental disorders (DSM) severity specifier-related outcomes and rates of remission/recovery. Results Thirty-three studies met the inclusion criteria, comprising 3665 participants, and 30 studies were included in the meta-analysis. Compared to high intensity therapies, low intensity psychological interventions were equivalent on reducing eating disorder psychopathology (g = − 0.13), more effective at improving DSM severity specifier-related outcomes (g = − 0.15), but less likely to achieve remission/recovery (risk ratio (RR) = 0.70). Low intensity psychological interventions were superior to non-eating disorder specific psychological interventions and waiting list controls across all three primary outcomes. Conclusion Overall, findings suggest that low intensity psychological interventions can successfully treat eating disorder symptoms. Few potential moderators had a statistically significant effect on outcome. The number of studies for many comparisons was low and the methodological quality of the studies was poor, therefore results should be interpreted with caution. More research is needed to establish the effectiveness of low intensity psychological interventions for children and young people, as well as for individuals with anorexia nervosa, avoidant/restrictive food intake disorder, pica and rumination disorder.

PURPOSE OF REVIEW This article reviews available assessment instruments for three of the feeding and eating disorder diagnostic categories: avoidant restrictive food intake disorder (ARFID), pica, and rumination disorder (RD). It includes an overview of the current status of screening tools, questionnaire measures, and diagnostic instruments. RECENT FINDINGS Screening instruments are available for all three disorders; however, for pica and RD, these typically include single screening items only and do not cover any specific features of these presentations. Only one questionnaire suitable for clinical populations is included, covering ARFID only. Standardized diagnostic interviews are limited to two covering both pica and RD, only one of which provides further clinical information. Of the five diagnostic instruments for ARFID described here, two include diagnostic items as well as allowing more detailed assessment of clinical features. SUMMARY There are a limited number of assessment measures available for all three disorders, with instruments for ARFID being the greatest in number and widest in terms of scope. A commonly encountered difficulty is that many assessment instruments do not adequately cover diagnostic exclusion criteria, which raises the likelihood of false positive findings. All currently available measures require further study to determine their reliability and validity.

Despite growing research and clinical interest in avoidant restrictive food intake disorder (ARFID), robust, evidence-based guidance on optimal treatment interventions, appropriate clinic structures, and modes of service delivery remain absent. Current consensus recommendations include a multi-disciplinary, multi-modal approach to assessment and treatment, with out-patient care being appropriate for the majority of patients, yet to date there is no clear guidance on how this might best be organised or implemented. This lack of guidance is due to a number of factors, that include the time required to conduct the necessary controlled trials and other well-designed investigations and for the subsequent body of research evidence to build. Lack of specific treatment guidance may also be related to the heterogeneous nature of ARFID clinical presentations potentially limiting the likelihood of uniform recommendations. This situation presents a challenge for clinicians required to engage in evidence-based practice, and for health care planners, providers, and policy makers. We describe here a proposed evidence-informed framework for care, subjected to preliminary testing and currently in use in an out-patient eating disorders service for children and young people aged 2–17 years. The use of the simplified care pathway diagram is illustrated with three case examples, and intended to serve as a possible model for further testing in a range of settings. In the face of ongoing uncertainty and inconsistency in the clinical management of ARFID, our intention is to share our experience in the form of an evidence-informed, trialled approach to structuring and providing intervention for this patient population.

Eating behaviours may be expressions of genetic risk for obesity and are potential antecedents of later eating disorders. However, childhood eating behaviours are heterogeneous and transient. Here we show associations between polygenic scores for body mass index (BMI-PGS) and anorexia nervosa (AN-PGS) with eating behaviour trajectories during the first 10 years of life using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), n = 7,825. Results indicated that 1 s.d. increase in the BMI-PGS was associated with a 30–37% increased risk for early- and mid-childhood overeating. In contrast, 1 s.d. increase in BMI-PGS was associated with a 20% decrease in risk of persistent high levels of undereating and a 15% decrease in risk of persistent fussy eating. There was no evidence for a significant association between AN-PGS and eating behaviour trajectories. Our results support the notion that child eating behaviours share common genetic variants associated with BMI. Herle et al. provide evidence that common genetic variants associated with BMI are also associated with eating behaviour trajectories in childhood, supporting the behavioural susceptibility theory of obesity.

BackgroundAn overrepresentation of neurodevelopmental disorders (NDDs) has been observed in individuals with avoidant/restrictive food intake disorder (ARFID). Previous studies on the association between ARFID and NDDs are limited to cross-sectional data from clinical samples of small size. This study aimed to extend previous research by using prospectively collected data in children from a general population sample. We examined the occurrence and predictive power of early neurodevelopmental problems in 4–7-year-old children with suspected ARFID.MethodsData were collected via parent-report in 3,728 children born between 2011 and 2014 in Kochi prefecture, a sub-sample of the Japan Environment and Children’s Study (JECS). Neurodevelopmental problems were assessed with several instruments at different time points between 0.5 and 3 years of age as part of the JECS. In an add-on study, ARFID was identified cross-sectionally (between 4 and 7 years of age) using a newly developed screening tool.ResultsCirca 3% of children at high risk for NDDs in preschool age screened positive for ARFID between age 4 and 7 years, reflecting a three times increased risk of suspected ARFID. A fifth (20.8%) of children with suspected ARFID had likely NDDs, compared to 8.6% of children without suspected ARFID. Developmental delay trajectories of children with and without suspected ARFID started to divert after the age of 6 months. Only 2.2% of children with early feeding problems later screened positive for ARFID. The inclusion of neurodevelopmental problems improved the prediction of later ARFID.ConclusionsThe results mirror the previously observed overrepresentation of NDDs in ARFID populations, although to a weaker extent. In non-clinical populations, early feeding problems are common and rarely develop into ARFID, however, our findings imply that they should be monitored closely in children with high neurodevelopmental risk in order to prevent ARFID.

In order to create a short, internationally valid scale to assess eating behaviour (EB) in young children at risk of undernutrition, we refined 15 phrases describing avidity or food refusal (avoidance). In study one, 149 parents matched phrases in English, Urdu, Cantonese, Indonesian or Greek to videos showing avidity and avoidance, 82–100% showed perfect agreement for the avidity phrases and 73–91% for the avoidant phrases. In study two, 575 parents in the UK, Cyprus and Indonesia (healthy) and in Kenya, Pakistan and Guatemala (healthy and undernourished) rated their 6–24 months old children using the same phrases. Internal consistency (Cronbach’s α) was high for avidity (0.88) and moderate for avoidance (0.72). The best-performing 11 items were entered into a principal components analysis and the two scales loaded separately onto 2 factors with Eigen values &gt, 1. The avidity score was positively associated with weight (r = 0.15 p = 0.001) and body mass index (BMI) Z scores (r = 0.16 p = 0.001). Both high and low avoidance were associated with lower weight and BMI Z scores. These scales are internationally valid, relate to nutritional status and can be used to inform causes and treatments of undernutrition worldwide.

Introduction Prior to the COVID-19 pandemic, research in virtual care for young people with eating disorders was preliminary and implementation rare. This study explored the experience of young people, parents and clinicians when therapy was transitioned to virtual provision as a result of the UK lockdown in March 2020. Methods A mixed-method approach was used in this study. Online questionnaires that included a mixture of rating (Likert scale) and free-text response questions were completed by 53 young people with any eating disorder, 75 parents and 23 clinicians. Questions focused on the experience of online treatment as well as the impact on engagement, perceived treatment efficacy and preferences around treatment mode in the future. Likert scale questions were analysed using a summary approach. Free-text responses were analysed qualitatively using reflexive thematic analysis. Results Responses to rating scale questions indicate satisfaction with treatment, good engagement and ability to manage technology. Young people who had transitioned care, rather than started care virtually in lockdown, rated therapy as less effective. However, individual accounts of experience were more varied. Reflexive thematic analysis of free-text responses identified key themes of 1) Making it work, 2) Home as a therapeutic space, and 3) Disrupted connection and 4) Into the future. Conclusions These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and therapeutic engagement and depth and need for consideration of equal access to treatment in socially unequal societies. Supplementary Information The online version contains supplementary material available at 10.1186/s40337-021-00429-1., Plain English summary Due to the COVID-19 pandemic specialist eating disorder treatment needed to quickly adapt to new technologies. All but urgent and crisis appointments needed to be delivered online. This study looked at what that was like for the young people, their parents and clinicians engaged in treatment in a large specialist eating disorder service in London, UK. Fifty-three young people with an eating disorder, 75 parents and 23 clinicians completed anonymous online surveys about their experience. Results showed that generally people were satisfied with treatment, the therapeutic relationship was maintained and most managed technological issues well. Four main themes were identified from responses to open ended free-text response questions. All three groups wrote about 1) making it work, 2) home as a therapeutic space, and 3) disrupted connection. The fourth theme, 4) into the future, came from parent and clinician responses only. These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and the potential impact on the therapeutic relationship. There is also a need to make sure there is equal access to treatment in socially unequal societies. Supplementary Information The online version contains supplementary material available at 10.1186/s40337-021-00429-1.

Childhood eating behaviour contributes to the rise of obesity and related noncommunicable disease worldwide. However, we lack a deep understanding of biochemical alterations that can arise from aberrant eating behaviour. In this study, we prospectively associate longitudinal trajectories of childhood overeating, undereating, and fussy eating with metabolic markers at age 16 years to explore adolescent metabolic alterations related to specific eating patterns in the first 10 years of life. Data are from the Avon Longitudinal Study of Parents and Children (n = 3104). We measure 158 metabolic markers with a high-throughput (1H) NMR metabolomics platform. Increasing childhood overeating is prospectively associated with an adverse cardiometabolic profile (i.e., hyperlipidemia, hypercholesterolemia, hyperlipoproteinemia) in adolescence; whereas undereating and fussy eating are associated with lower concentrations of the amino acids glutamine and valine, suggesting a potential lack of micronutrients. Here, we show associations between early behavioural indicators of eating and metabolic markers.

Avoidant/restrictive food intake disorder (ARFID) is a relatively newly introduced diagnostic category within the feeding and eating disorders. This article summarizes current knowledge and clinical practice relating to ARFID in youth. It discusses epidemiology, diagnosis, clinical assessment, treatment interventions, prognosis, and outcome. Gaps in the existing research literature are highlighted, promising avenues of current research signposted, and potentially useful future directions proposed. The article is relevant to clinicians wishing to ensure their practice is based on up-to-date information, as well as researchers interested in furthering knowledge relating to ARFID.

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.

Many factors have been shown to impact treatment outcome in eating disorders, including illness related variables (e.g. symptom severity), and broader clinical features (e.g. personality pathology). Less is known about the potential impact of patient related variables, such as patients' views regarding treatment suitability and success. This study explored the impact of eating disorder severity, personality features and patient expectations regarding treatment suitability and success, on eating pathology at treatment end. Participants were 128 adults with diagnosed eating disorders who completed a course of evidence-based psychological therapy in a community eating disorders service in the UK. Patients completed measures of eating disorder psychopathology and personality features at treatment commencement, and a measure of patient expectations regarding change after session six. They repeated the measure of eating disorder psychopathology at treatment end. All patients had some level of positive expectations regarding the suitability and potential success of treatment after session six. Eating disorder severity significantly predicted eating pathology at treatment end. However, strength of positive expectations regarding treatment success significantly predicted eating pathology over and above baseline level of eating disorder severity. Personality features at baseline were not significantly related to treatment outcome. Findings suggest that patients' expectations regarding the likely success of therapy have a significant impact on treatment outcome. Patients who develop a strong belief that treatment will work may be more likely to actively engage in the process of therapy to achieve their recovery goals. These findings have important implications for the early phase of therapy and how patients are oriented towards treatment.

The prevalence of avoidant/restrictive food intake disorder (ARFID) in the general child population is still largely unknown and validated screening instruments are lacking. The aims of this study were to investigate the prevalence of children screening positive for ARFID in a Japanese birth cohort using a newly developed parent-reported screening tool, to estimate the prevalence of children with ARFID experiencing physical versus psychosocial consequences of their eating pattern, and to provide preliminary evidence for the validity of the new screening tool. Data were collected from 3,728 4-7-year-old children born in Kochi prefecture (response rate was 56.5%), Japan, between 2011 and 2014; a sub-sample of the Japan Environment and Children’s Study (JECS). Parents completed a questionnaire including the ARFID screener and several other measures to assess convergent validity. The point prevalence of children screening positive for ARFID was 1.3%; half of them met criteria for ARFID based on psychosocial impairment alone, while the other half met diagnostic criteria relating to physical impairment (and additional psychosocial impairment in many cases). Sensory sensitivity to food characteristics (63%) and/or lack of interest in eating (51%) were the most prevalent drivers of food avoidance. Children screening positive for ARFID were lighter in weight and shorter in height, they showed more problem behaviors related to mealtimes and nutritional intake, and they were more often selective eaters and more responsive to satiety, providing preliminary support for the validity of the new screening tool. This is the largest screening study to date of ARFID in children up to 7 years. Future studies should examine the diagnostic validity of the new ARFID screener using clinically ascertained cases. Further research on ARFID prevalence in the general population is needed.

The prevalence of avoidant/restrictive food intake disorder (ARFID) in the general child population is still largely unknown and validated screening instruments are lacking. The aims of this study were (1) to investigate the prevalence of children screening positive for ARFID in a Japanese birth cohort using a newly developed parent-reported screening tool, (2) to estimate the prevalence of children with ARFID experiencing physical versus psychosocial consequences of their eating pattern, and (3) to provide preliminary evidence for the validity of the new screening tool. Data were collected from 3728 4-7-year-old children born between 2011 and 2014 in Kochi prefecture, Japan (response rate was 56.5%); a sub-sample of the Japan Environment and Children's Study (JECS). Parents completed a questionnaire including the ARFID screener and several other measures to assess convergent validity. The point prevalence of children screening positive for ARFID was 1.3%; half of them met criteria for ARFID based on psychosocial impairment alone, while the other half met diagnostic criteria relating to physical impairment (and additional psychosocial impairment in many cases). Sensory sensitivity to food characteristics (63%) and/or lack of interest in eating (51%) were the most prevalent drivers of food avoidance. Children screening positive for ARFID were lighter in weight and shorter in height, they showed more problem behaviors related to mealtimes and nutritional intake, and they were more often selective eaters and more responsive to satiety, which together provides preliminary support for the validity of the new screening tool. This is the largest screening study to date of ARFID in children up to 7 years. Future studies should examine the diagnostic validity of the new ARFID screener using clinically ascertained cases. Further research on ARFID prevalence in the general population is needed.

Background: Psychotropic drugs are not recommended for child and adolescent eating disorders, though they are used empirically for symptomatic treatment and co-morbid conditions. Little is known about rates of prescribing or the beneficial and adverse effects. Objective: To ascertain rates and outcomes of psychotropic drug prescribing in child and adolescent eating disorder services. Method: Retrospective case note study of eating disorder cases (n = 308), seen in one year in seven specialist UK services, covering indications, response to treatment, beneficial and adverse effects. Results: Drugs were prescribed for 27%, (mainly anorexia nervosa), 12% before referral to specialist services. The most commonly prescribed drugs were fluoxetine and olanzapine, but 26 different drugs were used. The most common indications were depression, anxiety and 'pseudo-psychotic' concerns about weight. Drugs were generally well tolerated, but their effectiveness was uncertain. Conclusions: Non-specialists commonly prescribe psychotropic medication to this vulnerable group without reference to specialist services. Specialists prescribe regularly on empirical grounds, without apparent undue consequences, though these may be under-reported. A prospective clinical trial would further clarify risks and benefits. Key Practitioner Message: • Guidelines do not recommend the use of psychotropic drugs as first line treatments for child and adolescent eating disorders. • Nevertheless drugs are often prescribed on symptomatic grounds, in Primary Care and General CAMHS and more commonly by specialist eating disorder services. • Despite concerns about physical health, psychotropic drugs appear to be tolerated well, though adverse effects may be under-reported. • Antidepressants and major tranquillisers are considered by clinicians to often have beneficial effects on the symptoms they target, though other concurrent treatments may confound these impressions.

BackgroundDisordered eating (DE) is common and is associated with body mass index (BMI). We aimed to investigate if genetic variants for BMI were associated with DE.MethodsBMI polygenic scores (PGS) were calculated for participants of the Avon Longitudinal Study of Parents and Children (ALSPAC; N= 8,654) and their association with DE tested. Data on DE behaviors (e.g. binge eating, and compensatory behaviors) were collected at ages 14, 16, 18 years, and DE cognitions (e.g. body dissatisfaction) at 14 years. Mediation analyses determined whether BMI mediated the association between the BMI-PGS and DE.ResultsThe BMI-PGS was positively associated with fasting (OR= 1.42, 95% CI=1.25, 1.61), binge eating (OR=1.28, 95% CI= 1.12, 1.46), purging (OR= 1.20, 95% CI= 1.02, 1.42), body dissatisfaction (Beta= 0.99, 95% CI= 0.77, 1.22), restrained eating (Beta=0.14, 95% CI= 0.10, 1.17), emotional eating (Beta= 0.21, 95% CI= 0.052, 0.38), and negatively associated with thin ideal internalization (Beta= −0.15, 95% CI= −0.23, −0.07) and external eating (Beta= −0.19, 95% CI= −0.30, −0.09). These associations were mainly mediated by BMI.ConclusionsGenetic variants associated with BMI are also associated with DE. This association was mediated through BMI suggesting that weight potentially sits on the pathway from genetic liability to DE.

Individual-level longitudinal data on biological, behavioural, and social dimensions are becoming increasingly available. Typically, these data are analysed using mixed effects models, with the result summarised in terms of an average trajectory plus measures of the individual variations around this average. However, public health investigations would benefit from finer modelling of these individual variations which identify not just one average trajectory, but several typical trajectories. If evidence of heterogeneity in the development of these variables is found, the role played by temporally preceding (explanatory) variables as well as the potential impact of differential trajectories may have on later outcomes is often of interest. A wide choice of methods for uncovering typical trajectories and relating them to precursors and later outcomes exists. However, despite their increasing use, no practical overview of these methods targeted at epidemiological applications exists. Hence we provide: (a) a review of the three most commonly used methods for the identification of latent trajectories (growth mixture models, latent class growth analysis, and longitudinal latent class analysis); and (b) recommendations for the identification and interpretation of these trajectories and of their relationship with other variables. For illustration, we use longitudinal data on childhood body mass index and parental reports of fussy eating, collected in the Avon Longitudinal Study of Parents and Children. Electronic supplementary material The online version of this article (10.1007/s10654-020-00615-6) contains supplementary material, which is available to authorized users.

The introduction of a “new” diagnostic category is not something that happens on a whim or in response to demand. It is the result of thorough analyses of available evidence from a range of sources, careful scrutiny and testing of proposed criteria, and is intended above all else to be clinically useful. The introduction of ARFID as a diagnosis followed the same process and had a similar aim. Research is therefore crucial to the performance of any diagnostic category in the real world. Diagnoses are dynamic entities; our understanding of ARFID, its definition and diagnostic criteria, seem likely to evolve over time as more data are gathered. This final chapter highlights potentially useful areas for further investigation, highlighting some current studies underway.

Given the heterogeneity of ARFID presentations and the fact that the condition spans physical and psychological domains of functioning, a multi-modal approach to management is often recommended. This can be challenging for clinicians given the current limited body of evidence from research trials carried out with people with a confirmed ARFID diagnosis. This chapter provides guidance on how to determine what might constitute an appropriate treatment package for any one individual. The importance of comprehensive assessment and formulation of the presenting difficulties are emphasised as part of the process of determining an optimal approach, with practical guidance offered on steps the clinician can take to facilitate decision making around management. Basic principles of treatment and management, the currently available interventions toolkit, and suggested steps to aid treatment planning and selecting appropriate interventions are discussed in turn.

This chapter opens with a description of the background to the introduction ARFID as a diagnosis, to orientate the reader to the content of this and ensuing chapters. Given the variability in clinical presentation, and high rates of reported co-morbidities associated with ARFID, diagnostic practice can be complex. A certain amount of clinical judgement is inherent in the diagnostic criteria, which for clinical purposes may be appropriate, but represents a challenge in defining “cases” for research. As with any newly introduced category, the intention is that ARFID should prove to be useful and updated on the basis of emerging research. Current literature on diagnosis and clinical presentation is discussed, covering papers on clinical practice, published reviews, and research findings. Practical suggestions are made to assist clinicians in structuring the process of confidently confirming the presence or absence of a diagnosis of ARFID.

BackgroundEating behaviours in childhood are considered as risk factors for eating disorder behaviours and diagnoses in adolescence. However, few longitudinal studies have examined this association.AimsWe investigated associations between childhood eating behaviours during the first ten years of life and eating disorder behaviours (binge eating, purging, fasting and excessive exercise) and diagnoses (anorexia nervosa, binge eating disorder, purging disorder and bulimia nervosa) at 16 years.MethodData on 4760 participants from the Avon Longitudinal Study of Parents and Children were included. Longitudinal trajectories of parent-rated childhood eating behaviours (8 time points, 1.3–9 years) were derived by latent class growth analyses. Eating disorder diagnoses were derived from self-reported, parent-reported and objectively measured anthropometric data at age 16 years. We estimated associations between childhood eating behaviours and eating disorder behaviours and diagnoses, using multivariable logistic regression models.ResultsChildhood overeating was associated with increased risk of adolescent binge eating (risk difference, 7%; 95% CI 2 to 12) and binge eating disorder (risk difference, 1%; 95% CI 0.2 to 3). Persistent undereating was associated with higher anorexia nervosa risk in adolescent girls only (risk difference, 6%; 95% CI, 0 to 12). Persistent fussy eating was associated with greater anorexia nervosa risk (risk difference, 2%; 95% CI 0 to 4).ConclusionsOur results suggest continuities of eating behaviours into eating disorders from early life to adolescence. It remains to be determined whether childhood eating behaviours are an early manifestation of a specific phenotype or whether the mechanisms underlying this continuity are more complex. Findings have the potential to inform preventative strategies for eating disorders.

BACKGROUND: Child eating behaviors are highly heterogeneous and their longitudinal impact on childhood weight is unclear. The objective of this study was to characterize eating behaviors during the first 10 years of life and evaluate associations with BMI at age 11 years.METHOD: Data were parental reports of eating behaviors from 15 months to age 10 years (n = 12,048) and standardized body mass index (zBMI) at age 11 years (n = 4884) from the Avon Longitudinal Study of Parents and Children. Latent class growth analysis was used to derive latent classes of over-, under-, and fussy-eating. Linear regression models for zBMI at 11 years on each set of classes were fitted to assess associations with eating behavior trajectories.RESULTS: We identified four classes of overeating; "low stable" (70%), "low transient" (15%), "late increasing" (11%), and "early increasing" (6%). The "early increasing" class was associated with higher zBMI (boys: β = 0.83, 95% CI: 0.65, 1.02; girls: β = 1.1; 0.92, 1.28) compared with "low stable." Six classes were found for undereating; "low stable" (25%), "low transient" (37%), "low decreasing" (21%), "high transient" (11%), "high decreasing" (4%), and "high stable" (2%). The latter was associated with lower zBMI (boys: β = -0.79; -1.15, -0.42; girls: β = -0.76; -1.06, -0.45). Six classes were found for fussy eating; "low stable" (23%), "low transient" (15%), "low increasing" (28%), "high decreasing" (14%), "low increasing" (13%), and "high stable" (8%). The "high stable" class was associated with lower zBMI (boys: β = -0.49; -0.68-0.30; girls: β = -0.35; -0.52, -0.18).CONCLUSIONS: Early increasing overeating during childhood is associated with higher zBMI at age 11. High persistent levels of undereating and fussy eating are associated with lower zBMI. Longitudinal trajectories of eating behaviors may help identify children potentially at risk of adverse weight outcomes.

Eating disorders are severe illnesses characterized by both psychiatric and metabolic factors. We explored the prospective role of metabolic risk in eating disorders in a UK cohort (n = 2929 participants), measuring 158 metabolic traits in non-fasting EDTA-plasma by nuclear magnetic resonance. We associated metabolic markers at 7 years (exposure) with risk for anorexia nervosa and binge-eating disorder (outcomes) at 14, 16, and 18 years using logistic regression adjusted for maternal education, child&rsquo, s sex, age, body mass index, and calorie intake at 7 years. Elevated very low-density lipoproteins, triglycerides, apolipoprotein-B/A, and monounsaturated fatty acids ratio were associated with lower odds of anorexia nervosa at age 18, while elevated high-density lipoproteins, docosahexaenoic acid and polyunsaturated fatty acids ratio, and fatty acid unsaturation were associated with higher risk for anorexia nervosa at 18 years. Elevated linoleic acid and n-6 fatty acid ratios were associated with lower odds of binge-eating disorder at 16 years, while elevated saturated fatty acid ratio was associated with higher odds of binge-eating disorder. Most associations had large confidence intervals and showed, for anorexia nervosa, different directions across time points. Overall, our results show some evidence for a role of metabolic factors in eating disorders development in adolescence.

BackgroundChild eating behaviors are highly heterogeneous and their longitudinal impact on childhood weight is unclear. The objective of this study was to characterize eating behaviors during the first ten years of life and evaluate associations with BMI at age 11 years.MethodData were parental reports of eating behaviors from 15 months to age 10 years (n=12,048) and standardized body mass index (zBMI) at age 11 years (n=4884) from the Avon Longitudinal Study of Parents and Children. Latent class growth analysis was used to derive latent classes of over-, under-, and fussy eating. Linear regression models for zBMI at 11 years on each set of classes were fitted to assess associations with eating behavior trajectories.ResultsWe identified four classes of overeating; “low stable” (70%), “low transient” (15%), “late increasing” (11%), and “early increasing” (6%). The “early increasing” class was associated with higher zBMI (boys: β=0.83, 95%CI:0.65, 1.02; girls: β=1.1; 0.92, 1.28) compared to “low stable”. Six classes were found for undereating; “low stable” (25%), “low transient” (37%), “low decreasing” (21%), “high transient” (11%), “high decreasing” (4%), and “high stable” (2%). The latter was associated with lower zBMI (boys: β=-0.79; -1.15, - 0.42; girls: β=-0.76; -1.06, -0.45). Six classes were found for fussy eating; “low stable” (23%), “low transient” (15%), “low increasing” (28%), “high decreasing” (14%), “low increasing” (13%), “high stable” (8%). The “high stable” class was associated with lower zBMI (boys: β =-0.49; -0.68 -0.30; girls: β =-0.35; -0.52, -0.18).ConclusionsEarly increasing overeating during childhood is associated with higher zBMI at age 11. High persistent levels of undereating and fussy eating are associated with lower zBMI. Longitudinal trajectories of eating behaviors may help identify children potentially at risk of adverse weight outcomes.