The clinical presentation of avoidant restrictive food intake disorder is largely independent of sex, autism spectrum disorder and anxiety traits
Authors: Watts Rosie , Archibald Tanith , Hembry Pippa , Howard Maxine , Kelly Cate , Loomes Rachel , Markham Laura , Moss Harry , Munuve Alfonce , Oros Anca , Siddall Amy , Rhind Charlotte , Uddin Mohammed , Ahmad Zain , Bryant-Waugh Rachel , Hübel Christopher 
Published: February 2023

Importance

Avoidant 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.

Objectives

Here, 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 Participants

We 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 Measures

The 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.

Results

This 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 Relevance

Our 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 Points

Question

Are 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?

Findings

In our cross-sectional study, the clinical presentation of ARFID is largely independent of patient sex, comorbid ASD and anxiety.

Meaning

Regarding 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.