This paper (Assignment 5.3) which I developed for CNS 762: Issues in Clinical Mental Health Counseling describes the diagnosis of Avoidant/Restrictive Food Intake Disorder, summarizes literature on the topic, outlines a hypothetical case study, and provides suggestions for how counselors can be advocates in relation to this issue. This paper shows that I can identify both the individual impact of mental illness, and the larger societal factors related to those disorders. Click here to download a PDF version.
Avoidant/Restrictive Food Intake Disorder (ARFID)
Introduction This look into the diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) is important because as a new diagnosis, there has been little research conducted on the topic. However, up to nearly a quarter of clients presenting with eating disorders may meet the criteria for ARFID (Nakai, Nin, Noma, Teramukai, & Wonderlich, 2016). The symptoms, which include nutritional deficiencies and severe weight loss are very serious, which is why attention must be paid to the topic. Additionally, most of the research that has been conducted is in regards to how ARFID manifests in children. Research needs to include adults with this diagnosis to establish best treatment practices for clients of all ages with ARFID.
Literature Review Diagnosis & Characteristics. ARFID is a relatively new diagnosis that replaced the former DSM-IV diagnosis of feeding disorder in infancy or early childhood (Nakai et al., 2016). It is different from picky eating, but more research needs to be conducted to discover the nuances between the two (Ellis, Schenk, Galloway, Zickgraf, Webb, & Martz, 2018). In the most basic sense, ARFID can be differentiated from picky eating due to “clinically significant failure to meet requirements for nutrition or insufficient energy intake through oral food intake” (Kohn, 2016). To meet the DSM-V criteria for ARFID, clients must present with at least one of the following: “significant weight loss (or failure to achieve expected weight gain or faltering growth in children); significant nutritional deficiency; dependence on enteral feeding or oral nutritional supplements; or marked interference with psychosocial functioning” (Kohn, 2016, p. 1874). One of the unique factors of ARFID is that although clients are likely to be underweight, they do not present with a “preoccupation with body image or weight” (Kohn, 2016, p. 1874). Clients with ARFID often avoid foods due to sensory concerns, such as “their appearance, small, or texture” (Kohn, 2016, p. 1874).
Clients with ARFID have been shown to have a high instance of comorbidity with other mental health diagnoses including: attention deficit disorders, anxiety disorders, autism spectrum disorders, and obsessive compulsive disorders (Kohn, 2016 and Kenney & Walsh, 2013). Norris, Robinson, Obeid, Harrison, Spettigue, and Henderson (2014) found there was an especially high incidence of Generalized Anxiety Disorder in their adolescent research participants with ARFID. Common symptoms associated with ARFID include “abdominal pain, a history or fear of vomiting or choking, and gastroesophageal reflux disease” (Kohn, 2016). ARFID has been primarily believed to have an onset during childhood, although it can continue through adulthood and adults can have a later onset of the disorder. AFRID has also been believed to be more common in males, which differentiates it from other eating disorders. Unfortunately, as Kenney and Walsh (2013) explain, “The course of illness for individuals who develop ARFID is, at the moment, relatively unknown” (Kenney).
Prevalence. As Kohn (2016) puts it, ARFID’s “prevalence has been minimally investigated” (p. 1874). Since most of the research on ARFID has been centered on children, there have been reports citing anywhere between 5 and 22% of pediatric clients seeking eating disorder treatment presenting with ARFID (Nakai et al., 2016). Nakai et al.’s (2016) study found that 9.2% of the adults in an eating disorder treatment program met the criteria for ARFID (p. 530). Clearly more research needs to be done to narrow down this range, but it is clear that many people are struggling with this disorder and therefore, effective treatments should be identified.
Treatments. Another unfortunate result of the little research on this diagnosis is that there are “currently no evidence based guidelines for treatment specific to ARFID” (Kohn, 2016). That being said, generalizations can be made based on other eating disorders which would suggest that Cognitive Behavioral Therapy and exposure therapy may be useful (Kenney & Walsh, 2013). However, research has yet to support the effectiveness of these approaches in working with clients with ARFID. Orstein, Essayli, Nicely, Masciulli, & Lane-Loney (2017) also suggest the use of an “intensive, multidisciplinary approach” (p. 1068). Furthermore, Orstein et al. (2017) found that in a partial hospitalization program (PHP) clients with ARFID restored weight faster than those with other eating disorder diagnoses. This provides hope that structured treatment of this kind might be an effective intervention for clients with ARFID.
Case Study Fletcher is a 13-year-old Caucasian male who is finishing 8th grade at a local public middle school. He is slightly under the normal height rage for his age group. Fletcher is part of the soccer team, but does not spend much time outside of school with friends. He mostly keeps to himself in his room and draws comics. He has been struggling academically and is at risk of having to repeat his 8th grade year if he cannot bring his grades up by the end of the semester. His mom has brought him to therapy as she is concerned about his “picky eating” and recent weight loss. She reports that her son has always refused to eat certain foods, but recently has begun saying he is afraid foods will cause him to vomit. He reports frequent stomach aches. He has been restricting his intake even more, mostly just to chicken, and has lost about 5 pounds over the last 3 months. His mother gives him nutritional supplements such as Pedialyte to help him maintain weight. This is Fletcher and his mother’s first time coming to a counselor, although Fletcher has been diagnosed with ADHD by his primary care physician. Fletcher’s parents divorced one year ago and he has reported handling the transition okay, but his mom says he has been more tearful than usual. Fletcher has not had any major medical issues or hospitalizations. Besides taking Ritalin for his attention deficit disorder, he takes no other medications. Fletcher and his mom both report no prior trauma.
Case Conceptualization(Based on Sperry & Sperry, 2012) Fletcher’s worsening symptoms seem to be due to anxieties related to his parents’ recent divorce and academic challenges. The client reports that his previous diagnosis of ADHD has always made him feel “different,” and he is very concerned that being “held back” or accidentally vomiting at lunch would isolate him even more. The goals of our work together are to reduce Fletcher’s fear associated with food, introduce new coping skills to manage stress, and restore his weight. The focus will be on helping Fletcher identify new outlets to express himself besides using food. Based on the suggestion by Kenney and Walsh (2013), we will utilize a Cognitive-Behavioral framework and will use exposure therapy interventions. Fletcher will be encouraged to continue taking Ritalin as long as it is overseen by a psychiatrist and a coach that specializes in executive function struggles will be suggested to help Fletcher manage his schoolwork. One challenge to treatment may be the father’s absence at the counseling sessions, as he may not be as understanding of ARFID and helpful when Fletcher is staying at his house. We will begin with two sessions each week over the course of three months and then will evaluate any progress or continuing obstacles.
Treatment Formulation Diagnosis. Fletcher’s diagnosis is ADHD, based on prior diagnosis, and ARFID, based on his reliance on nutritional supplements to maintain functioning.
Objectives. Goal 1: Gain knowledge on ARFID
Objective 1: Keep journal to track fear foods, times of day when food is avoided, and other details related to appetite and food consumption.
Objective 2: Read literature as a family about the symptoms, causes, and potential dangers of ARFID.
Goal 1: Reduce fear of vomiting due to eating
Objective 1: Participate in exposure therapy to consume fear foods in a supportive environment
Objective 2: Utilize reality testing exercises to counter the thought “I know I will vomit if I eat that.”
Goal 1: Restore weight (based on a healthy BMI)
Objective 1: Consume additional nutritional supplements while engaging in counseling
Objective 2: Client will challenge himself to eat one difficult or new food each day
Assessment. The Beck Anxiety Inventory will be administered to assess for a co-occurring anxiety disorder. Additionally, the Eating Disorder Inventory-3 and the Eating Attitudes Test- 26 will be administered to assess for current thoughts, beliefs, and symptoms related to disordered eating. These assessments will also be able to rule out other eating disorders such as Anorexia Nervosa and Bulimia Nervosa.
Clinician Characteristics. An appropriate therapist for Fletcher would be someone with a Cognitive Behavioral theoretical framework and experience working with eating disorders.
Location of Treatment. Since Fletcher’s mother has reliable transportation, the recommendation would be that they attend outpatient therapy nearby his school. However, counseling should not take place at the client’s school as it does not feel like a safe place for him and may lead to bullying.
Interventions. Interventions will include cognitive behavioral therapy including tackling negative self-talk, practicing mindfulness, and keeping thought records. Additionally, exposure therapy will be used to have Fletcher slowly experience eating the foods that cause him the greatest levels of discomfort and anxiety.
Emphasis. The emphasis of therapy will be to foster self-worth and self-efficacy in the client by utilizing reality testing techniques and helping establish new coping skills.
Numbers. The client will attend both individual counseling and family counseling with his mother over the course of 3 months.
Timing. The client will attend two sessions per week (one individual and one family session) for the duration of 12 weeks.
Medication. The client will continue taking Ritalin under the care of his psychiatrist. If an anxiety disorder is identified through the assessments mentioned above, then SSRI’s and other anti-anxiety medications may be discussed.
Adjunct Services. The client will also see an executive functioning coach and a tutor, while his mother will attend a support group for parents of children with ARFID.
Prognosis. Since research has shown that those with ARFID tend to restore their weight quickly during treatment and Fletcher has the support of his mother, his prognosis for recovery is good. The fact that this was caught early is also a sign that it may be effectively improved through treatment.
Advocacy and Multicultural, Legal, and Ethical Considerations In Schermbrucker, Kimber, Johnson, Kearney, & Couturier’s (2017) case study, they discuss how many cultures discourage seeking mental health treatment as the family is seen as the appropriate source of support. They also talk about how highly academic language can isolate clients with lower levels of education and may prevent them from seeking or continuing to participate in treatment. Furthermore, there remains in many cultures a stigma against mental illness which keeps people from getting help. In their case study specifically, the authors reported that the ARFID client did not improve through typical North American treatment techniques, which they attribute in part to a “socio-cultural mismatch between the treatment team” that “created a sense of mistrust” (Schermbrucker et al., 2017, p.111). Their conclusion was that “a strengths-based approach that demonstrates socio-cultural competency and challenges negative misperceptions concerning those living with mental illness is an important part of [the counseling] process.” (Schermbrucker et al., 2017, p. 111). Ethically speaking, clinicians working with clients who present with ARFID should continue monitoring them to ensure that they are medically stable, as the disorder often leads to malnutrition. Since many clients with ARFID are children, their parents must be included in any decision-making and any abuse would need to be reported. Unfortunately, there is not much additional information on the legal/ethical issues related to this diagnosis as it is so new and under-researched. Clinicians and individuals with an interest in enhancing treatments for ARFID should work with groups such as NAMI and the ACA to advocate for funding for additional research on this topic.
References: Ellis, J. M., Schenk, R. R., Galloway, A. T., Zickgraf, H. F., Webb, R. M., & Martz, D. M. (2018) A multidimensional approach to understanding the potential risk factors and covariates of adult picky eating. Appetite, 125, 1-9.
Kenney, L. & Walsh, B. T. (2013). Avoidant/restrictive food intake disorder (ARFID): Defining ARFID. Eating Disorders Review, 24(3), 1.
Kohn, J.B. (2016). What is ARFID? Journal of the Academy of Nutrition & Dietetics, 116 (11), 1874.
Nakai, Y., Nin, K., Noma, S., Teramukai, S., & Wonderlich, S. A. (2016). Characteristics of avoidant/restrictive food intake disorder in a cohort of adult patients. European Eating Disorders Review, 24(6), 528-530.
Norris, M. L., Robinson, A., Obeid, N., Harrison, M., Spettigue, W., & Henderson, K. (2014). Exploring avoidant/restrictive food intake disorder in eating disordered patients: A descriptive study. International Journal of Eating Disroders, 47(5), 495-499.
Ornstein, R. M., Essayli, J. H., Nicely, T. A., Masciulli, E. & Lane-Loney, S. (2017). Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders. International Journal of Eating Disorders, 50(9), 1067-1074.
Schermbrucker, J., Kimber, M., Johnson, N., Kearney, S., & Couturier, J. (2017). Avoidant/restrictive food intake disorder in an 11-year-old South American boy: Medical and cultural challenges. Journal of the Canadian Academy of Child & Adolescent Psychiatry, 26(2), 110-113.