In children and adolescents, insufficient nutrition that results in weight loss or poor growth is associated with significant medical and psychological complications, and as such should be treated aggressively. This is especially true for a young person who has fallen off his or her growth curve. Using pediatric growth curves and working with families and health care providers to determine a child’s optimal goal weight is an essential step in the assessment and treatment of patients with ARFID.4
Limited published evidence exists to guide clinicians in the treatment of ARFID, although trials are presently underway in the US and abroad. Strandjord and colleagues5 undertook an open label trial and concluded that modified family-based therapy was helpful for adolescents with anorexia nervosa or with ARFID, although few adolescent ARFID patients took part in the family-based therapy sessions, thus limiting the study’s conclusions.
Family-based therapy, the gold-standard treatment for adolescent anorexia nervosa, seems well-suited to the treatment of a proportion of underweight youngsters with ARFID, given that family-based therapy focuses on lifting blame, raising the family’s anxiety about the dangers of low weight and malnutrition in young people, and empowering parents to take charge of nutrition and to focus on the goal of weight gain.
We recently published a case series of six young patients with ARFID.6 Two cases had histories of acute events that affected their nutrition (eg, fear of eating after seeing a dog choke on a bone), and the other four were mixed presentations. Although treatment was individualized to meet patient needs, modified family-based therapy was utilized in each case, along with adjunctive pharmacotherapy. For some, individual cognitive behavioral therapy was also added to address anxiety. Each patient reached his or her treatment goal weight (which is essential for reaching optimal physical and mental health), and family therapy played a major role in recovery.
The shared elements in these family therapy sessions included providing education to the families about the negative consequences of insufficient nutrition and low weight, lifting guilt in all family members, empowering parents to take charge of nutrition, providing compassion for the patient, and helping the parents to empathize with their child’s pain, fear, or discomfort while still being firm about the need to take the nutrition. The family was helped to focus on issues relating to intake and weight gain, often using detailed food diaries and the use of weekly weight graphs.
Four of the six patients required admission to hospital to help with weight gain. One 14-year-old girl with autism spectrum disorder plus severe anxiety at school was helped by staying home from school while her mother took time off from work to focus on feeding her; once the patient had gained sufficient weight, she returned to school part-time with additional supports in place.
Dr Spettigue is Associate Professor, Department of Psychiatry, University of Ottawa, Children’s Hospital of Ontario, Canada; Dr Norris is Associate Professor of Pediatrics, Adolescent Health Physician, Division of Adolescent Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario. The authors report no conflicts of interest concerning the subject matter of this article.
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