Dear Editor,

A substantial addition to the DSM-5 Feeding and Eating Disorder category was the diagnosis of avoidant/restrictive food intake disorder (ARFID), which involves a reduction in nutritional intake resulting in failure to meet appropriate nutritional requirements, due to minimal interest in eating or food, disliking sensory characteristics of food, or fearing the potential consequences of eating (e.g., vomiting). Youth with ARFID are both clinically and demographically distinct from those suffering from classic eating disorders such as anorexia nervosa (AN) and bulimia nervosa [1]. Although the concomitant weight loss can be misattributed to AN, ARFID is unaccompanied by distress about body shape or size. Those individuals with ARFID often present with notable psychological comorbidities (e.g., anxiety, mood, and addictions) and considerably low weights that may have dangerous physiological and medical consequences and may impede their growth and development [1, 2].

Researchers have concluded ARFID is prevalent in community and clinical samples. However, the assessment and types of treatment received by those presenting with ARFID have been minimally investigated, and no study has examined which healthcare professionals are providing these services. This is critical as individuals with ARFID often seek help from various healthcare practitioners, many of whom do not specialize in mental health treatment and may be unfamiliar with ARFID. Below we describe a study we conducted to fill this knowledge gap.

We developed and administered a brief, semi-structured phone interview to clinicians from various disciplines who self-reported treating patients 5 to 24 years of age with symptoms of ARFID. We contacted 2089 Calgary clinicians from 13 disciplines who would (1) be likely to encounter patients with ARFID based on their scope of practice; (2) were currently practicing in our city as a registered allied health professional; and (3) had been independently practicing and seeing patients for more than 6 months; only 35 clinicians from 5 disciplines agreed to participate. Although initial contact with potential participants was initially sought via email or fax to ensure a wide reach for recruitment, it is possible that if initial contact had been attempted via telephone our recruitment rate would have increased. However, two subsequent attempts to contact participants were made via telephone, which still yielded a low recruitment rate. Therefore, we speculate that this low recruitment rate may be due to clinician unfamiliarity with ARFID and a reluctance to discuss their experience with the disorder, given the lack of ARFID-specific training and expertise. This lack of familiarity, which resulted in significant difficulties with recruitment, highlights a clear need for future investigations examining who is providing treatment to those with ARFID and which treatments are being provided. Although preliminary, we believe our findings provide valuable insight into these issues.

Two-thirds (65.7%) of participants reported they had seen patients with ARFID symptoms at some time during their career, but only half (48.6%) reported that they had heard of ARFID previously. Clinicians treating individuals with ARFID included mental health professionals (56.5%), occupational therapists (21.7%), dietitians (17.4%), and physicians (4.4%). Only 8.6% reported having received any specific training in treating ARFID. Clinicians reported using various therapeutic approaches to address ARFID symptoms, including the SOS Approach to Feeding, food exposure, hypnotherapy, nutritional counseling, integrative/assimilative psychotherapy, behavioural learning theory, emotion-focused therapy, and hypnotherapy. Overall, respondents reported feeling ill-equipped to assess or treat patients with ARFID, and unaware of resources for acquiring these skills.

Our participants reported a lack of training in the assessment of ARFID, with half of clinicians unfamiliar with the diagnostic label. We speculate there are several reasons why clinicians may not recognise the symptoms of ARFID in their practice. First, community clinicians, especially those outside the mental health profession, may not be familiar with changes to DSM-5 diagnoses, including ARFID, resulting in misdiagnosis and potentially inappropriate referrals for treatment. Second, ARFID symptoms may be overshadowed by symptoms of other disorders. For example, symptoms of both ARFID and autism include rigidity and obsessive or repetitive behaviours, which may make ARFID difficult to distinguish from symptoms of autism. That is, sensory sensitivities, a common issue in individuals with autism, significantly impact eating as individuals may be sensitive to the texture and taste of food. Clinicians should be acquainted with appropriate assessment tools (e.g., [3]) to increase diagnostic accuracy and referral to appropriate treatment.

Even when participants were able to accurately diagnose their patients with ARFID, they reported being unaware of any guidance regarding how to proceed with treatment. Over half (57.1%) of community clinician participants reported having provided treatment to ARFID patients without any training. Furthermore, almost all clinicians used unique treatment methods, achieving varying levels of perceived success. Although healthcare professionals have an ethical obligation to utilize best practices for all patients, the clinicians we surveyed communicated feeling pressured to balance their lack of training in ARFID with a perceived responsibility to provide treatment to their patients. Many clinicians also reported being unsure which clinics or services to refer their patients, so chose to treat them despite their lack of training. However, an obligation to provide effective treatment is particularly important when treating eating disorders. Individuals (and particularly children) with eating disorders are especially vulnerable given their complexity and the risk of medical complications, including death. Thus, it is critical for researchers to continue developing effective treatments for ARFID. Although there are currently no evidence-based treatment models for ARFID, Thomas and Eddy [4] have developed a cognitive-behavioural therapy protocol, CBT-AR, for individuals aged 10 and older with ARFID. It can be delivered in an individual or family-supported format, and preliminary results show increases in weight gain, dietary variety, and decreases in nutritional deficiencies [4].

Given the relative novelty of ARFID and the lack of resources available regarding how to assess and treat ARFID, clinicians in our study felt ill-prepared to assess or treat ARFID. The present findings highlight a marked need for training in assessment and treatment of ARFID to meet patient needs for effective care, as well as information on the range of clinicians providing services to ARFID patients.