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Evolution From Feeding Disorders to Avoidant/Restrictive Food Intake Disorder


Introduction

Eating disorders in young children and infants are generally referred to as “feeding disorders,” to emphasize the relationship between caregiver and child that may be strained or dysregulated in these conditions. This term includes a variety of conditions ranging from food refusal and disinterest to food aversions, overeating, undereating, fear of eating, pica (or the eating of nonfood substances), and rumination. Approximately 20%–30% of infants and young children have been perceived to have feeding problems that encompass a broad range, from mild (so-called picky eating) to severe as may be seen in autism. One difficulty in pinpointing the incidence and prevalence of these disorders lies in their naming and categorization. The definitions and diagnostic classifications of feeding disorders have varied greatly among clinicians. However, identifying feeding disorders in infants and young children is critical because the disorders adversely affect the entire family, not just the individual. In addition, if left untreated, these disorders can persist into adolescence and adulthood.

Definitions of Feeding Disorders

There has been much controversy over the appropriate categorization of Feeding Disorders of Infancy and Early Childhood. DSM-IV-TR criteria were too restrictive, leading to many young children going undiagnosed and untreated. For these reasons, alternative classifications have been used to increase the specificity of the DSM-IV-TR diagnosis, most notably the “Feeding Behavior Disorder” section in DC: 0-3R (2005), which defined six different feeding disorders based on the classifications by Chatoor. The DSM-5 then grouped these feeding disorder subtypes under one heading, “Avoidant/Restrictive Food Intake Disorder” (ARFID). Of note, the ARFID diagnostic criteria can be applied to individuals of all ages, which is key as this psychopathology can persist from childhood and early infancy into adolescence and even adulthood, as previously mentioned.

The DSM-5 describes three main types of ARFID: those with an apparent lack of interest in food and eating, those with sensory aversions to specific food characteristics, and those with a conditioned negative association and fear of eating due to or in anticipation of an aversive experience. These DSM-5 varieties are also described in DC: 0-3R (2005). The DSM-5 ARFID subtype, “apparent lack of interest in food or eating” is described in DC: 0-3R as “Infantile Anorexia”; the DSM-5’s “avoidance based on the sensory characteristics of food” is described in DC: 0-3R as “Sensory Food Aversions”; the DSM-5’s “concern about aversive consequences of eating” is described in DC: 0-3R as “Feeding Disorder Associated with Insults to the Gastrointestinal Tract” and was termed “Posttraumatic Feeding Disorder” by Chatoor in 2002.

The DSM-5 classification also allows for the diagnosis of the three remaining DC: 0-3R Feeding Disorder subtypes, including those of state regulation, those of caregiver-infant reciprocity, and those associated with concurrent medical condition. The DSM-5 differentiates ARFID from more common feeding difficulties by requiring at least one 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, and (4) marked interference with psychosocial functioning.

History and Comparative Nosology

Previously, there was much confusion over the criteria for the diagnosis of feeding disorders in infants and young children. There were no recognized standards resulting in naming and criteria variability among clinicians, researchers, and authors. Some of the terminology utilized in the past included: “picky,” “choosy,” “selective,” or “problem” eaters, food “refusal,” “selectivity,” or “aversion,” and dysphagia. With the inclusion of “Feeding Disorders of Infancy or Early Childhood” in DSM-IV in 1994, the classification of feeding disorders began to clarify.

To further complicate issues, the terms “feeding disorder” and “failure to thrive” (FTT) have been used interchangeably for several years. FTT refers to weight gain that is inadequate based on standardized growth charts. It generally is broken down into organic and nonorganic causes. Organic causes are due to a diagnosable medical condition, such as heart disease, milk allergy, reflux, cerebral palsy, Down syndrome, and metabolic disorders. Nonorganic causes of FTT have historically been blamed on maternal deprivation or neglect. While these causes certainly can cause FTT, there are several other nonorganic causes of FTT that have since been recognized. The last category of FTT (which was added later) is due to a combination of organic and nonorganic contributing factors. The use of the term FTT as an overarching diagnosis for all patients with feeding disorders is misleading, as not all patients with feeding disorders have FTT and vice versa. In addition, the term “failure to thrive” does not describe the underlying feeding disturbance, but rather indicates the symptomatology only. Despite the agreement among many clinicians, researchers, and authors that FTT should be used to describe symptoms only, rather than used as a diagnostic term, “failure to thrive” persists as a diagnosis in both the psychologic and pediatric literature.

Given the limitations of the DSM-IV diagnostic criteria for Feeding Disorders of Infancy or Early Childhood, DC: 0-3R diagnostic criteria served as a template for the updated DSM-5 classification, ARFID. This classification system was initially published by Chatoor in 2002 and then modified in 2003 by the Task Force for Research Diagnostic Criteria for Infants and Preschool Children. The six Feeding Disorder subtypes were then published in the 2005 DC: 0-3R. In addition, an American Psychiatric Association supported work group further revised the criteria that were then published in “Age and Gender Considerations in Psychiatric Diagnosis” in 2007.

The six subtypes include (1) feeding disorder of state regulation, (2) feeding disorder of caregiver-infant reciprocity, (3) infantile anorexia , (4) sensory food aversions , (5) feeding disorder associated with a concurrent medical condition, and (6) feeding disorder associated with insults to the gastrointestinal tract . Numbers 1 through 4 have onset at specific times in a child’s development (arranged chronologically), whereas the last two may have onset at any time. Those in bold will be discussed in further detail in this chapter. For the sake of clarity, these subtypes will be described using both the DSM-5 and DC: 0-3R classifications.

Specific Feeding Disorders Subtypes of Avoidant/Restrictive Food Intake Disorder (DSM-5)

I. ARFID Subtype: “Apparent Lack of Interest in Eating or Food” (DSM-5)

Infantile Anorexia (DC: 0-3R)

DC: 0-3R criteria : Requires all six of the following:

  • 1.

    The infant/young child refuses to eat adequate amounts of food for at least 1 month.

  • 2.

    Onset of the food refusal occurs before 3 years of age.

  • 3.

    The infant/young child does not communicate hunger cues or lacks interest in food but shows strong interest in exploration, interaction with caregiver, or both.

  • 4.

    The child demonstrates significant growth deficiency.

  • 5.

    Food refusal does not follow a traumatic event.

  • 6.

    Food refusal is not due to an underlying medical condition.

Clinical features

Infantile anorexia (IA) is characterized by poor appetite, lack of interest in eating, and poor growth in an otherwise active and engaged child. Chatoor first described this clinical picture in the 1980s after treating malnourished patients, following their medical hospitalization, who had been diagnosed with FTT nonorganic type with the assumption of maternal neglect, despite having fully engaged mothers who were desperate to get their children to eat and gain weight. IA was later described as a subtype of Feeding Behavior Disorder in DC: 0-3R (2005). Onset of IA is usually within the first 3 years of life, most commonly between ages 9 and 18 months. This is the time when infants are becoming more physically independent, learning to talk and walk, and beginning the transition to spoon and self-feeding. These children tend to be quite active and engageable. They are often interested in everything but eating, which may appear to bore them. They are resistant to stopping their activities to be placed in their high chairs and often refuse to even open their mouths to be fed, many times throwing their food and utensils. Parents of these infants and young children become worried by the poor food intake and growth. They try a variety of things in an attempt to coax the children into eating, including distraction, bribes, feeding on the go (i.e., offering bites of food while the child is playing, running by, or otherwise engaged in noneating activities), and sometimes even resorting to force feeding. These parents become fixated on getting food into their children, feeling that every calorie counts. This raises the tension between the child and parent, which increases the distress for all parties and often results in making meal times almost unbearable for the entire family.

Risk factors

Chatoor and Lucarelli et al. independently identified risk factors for the development of IA. These include both risk factors related to the infant or young child (i.e., the identified patient) and those related to the primary caregiver (generally the patient’s mother). Difficult temperament in the infant may result in irregular sleeping and feeding patterns, high physiologic arousal and poor regulation, and intense stress responses, such as severe temper tantrums. The risk factors related to the mother’s psychopathology include an insecure or disorganized attachment style, maternal eating disorder, and maternal depression and/or anxiety. In addition, both overly controlling and overly permissive parenting styles are also risk factors for the development of IA. The transactional model of feeding disorders demonstrates the negatively reinforcing interactions between the child who is refusing food and the caregiver who becomes distressed by this food refusal and therefore attempts to become more controlling of the child’s food intake, which further results in the child’s refusal to eat, thereby further increasing the caregiver’s anxiety and distress, etc.

Differential diagnosis

IA must be differentiated from other feeding disorders that result in food refusal. The ARFID subtype “concern about aversive consequences” generally has a more sudden onset and follows a traumatic event to the gastrointestinal tract or oropharynx. Such traumas may result from choking, gagging or severe vomiting, or placement of endotracheal or nasogastric tubes. Depending on the type of traumatic experience, these children may refuse all foods, only solids, or only liquids/the bottle. The ARFID subtype “avoidance based on the sensory characteristics of food” results in children refusing specific foods, but eating well when offered foods they prefer.

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