Received: 20 July 2020 Revised: 26 November 2020 Accepted: 27 November 2020

DOI: 10.1002/eat.23438

ORIGINAL ARTICLE

Health professionals' familiarity and experience with providing

clinical care for pediatric avoidant/restrictive food intake
disorder

Jennifer S. Coelho PhD1,2 | Mark L. Norris MD, FRCPC3,4 |

1,5 1,5
Stephen C. E. Tsai MD | Yuwei J. Wu MD |
Pei-Yoong Lam MBBS, FRACP, FRCPC1,5

1
Provincial Specialized Eating Disorders
Program for Children and Adolescents, BC Abstract
Children's Hospital, Vancouver, British Objective: The current study explored the experience and familiarity of pediatric
Columbia, Canada
2 health professionals with avoidant/restrictive food intake disorder (ARFID), and
Department of Psychiatry, University of
British Columbia, Vancouver, British Columbia, assessed the application of diagnostic criteria in a series of clinical vignettes.
Canada
Method: Pediatric health professionals were invited to complete an online survey.
3
Children's Hospital of Eastern Ontario,
Ottawa, Ontario, Canada Data from 93 health professionals from medical and allied health roles who com-
4
Department of Pediatrics, University of pleted the survey were analyzed.
Ottawa, Ottawa, Ontario, Canada
Results: Respondents providing care for pediatric feeding/eating disorders were
5
Department of Pediatrics, University of
British Columbia, Vancouver, British Columbia,
more likely to report familiarity with ARFID than those not typically providing care
Canada for feeding/eating disorders. Clinicians who had provided care for pediatric ARFID

Correspondence
reported more confidence in clinical management of ARFID than did those who had
Jennifer S. Coelho, Provincial Specialized not yet provided care for ARFID, though there were overall relatively low levels of
Eating Disorders Program for Children and
Adolescents, BC Children's Hospital, Box
confidence in providing care for ARFID. Respondents to the clinical vignettes were
150, 4500 Oak St., Vancouver BC, Canada more likely to confer a diagnosis of ARFID when there were symptoms of both psy-
V6H3N1.
chosocial impairment and weight loss than when there was psychosocial impairment
Funding information alone.
British Columbia Mental Health and Substance
Use Services
Discussion: The results suggest variability in current application of diagnostic criteria
for ARFID, low confidence in clinical management of ARFID, and ambiguity in clini-
Action Editor: Guido Frank
cians' judgments regarding whether psychosocial impairment is sufficient to meet a
diagnosis of ARFID.

KEYWORDS

avoidant restrictive food intake disorder, clinical care, clinical impairment, confidence,
diagnosis, DSM-5, eating disorders, familiarity, feeding disorders, pediatric

1 | I N T RO DU CT I O N make expected weight gains, nutritional deficiencies, dependency

Avoidant/restrictive food intake disorder (ARFID) is a new diagnosis
included in the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5; APA, 2013). ARFID is characterized by a
lack of adequate food intake leading to weight loss or failure to
on nutritional supplements or enteral feeding, and/or psychosocial
interference. Given the recent inclusion of ARFID in the DSM-5
(APA, 2013), there is relatively limited published research on the prev-
alence and characteristics of individuals with this diagnosis. Although
data are emerging both from community and clinical settings,

Int J Eat Disord. 2021;54:587–594. wileyonlinelibrary.com/journal/eat © 2020 Wiley Periodicals LLC 587
588
community samples have largely utilized screening instruments to
assess prevalence, and clinical settings have been generally represen-
ted by patients from tertiary care eating disorder (ED) programs
(Cooney, Lieberman, Guimond, & Katzman, 2018; Fisher et al., 2014;
Kurz, Van Dyck, Dremmel, Munsch, & Hilbert, 2015; Nicely, Lane-
Loney, Masciulli, Hollenbeak, & Ornstein, 2014; Norris et al., 2014;
Ornstein et al., 2013). A recent systematic scoping review reported
prevalence estimates of ARFID (Bourne, Bryant-Waugh, Cook, &
Mandy, 2020), which demonstrated a large range in estimates, both in
pediatric treatment settings (1.5–64%; Eddy et al., 2015, Krom
et al., 2019), and non-clinical samples recruited from the community
and schools (0.3–15.5%; Hay et al., 2017, Gonçalves et al., 2018). Var-
iability in the definitions of ARFID diagnostic criteria (i.e., nutritional
deficiency, dependence on nutritional supplements or enteral feeding,
and significant weight loss/faltering growth) may be contributing to
differences in prevalence estimates across studies (Eddy et al., 2019).
Furthermore, structured tools to assess symptoms of ARFID have only
recently been published (Bryant-Waugh et al., 2019; Schmidt, Kirsten,
Hiemisch, Kiess, & Hilbert, 2019).
Given the relatively high prevalence of complex feeding issues
in community and clinical settings, pediatric health professionals are
likely to encounter youth with ARFID in clinical practice. In a recent
paper that summarized diagnostic and treatment challenges associ-
ated with ARFID, an international group of ED experts suggested
that such individuals are likely to present to various settings outside
of mental health, and that any heath professional can screen for and
identify individuals who have symptoms consistent with ARFID
(Eddy et al., 2019). Shortly after the publication of the DSM-5, an
ARFID-specific survey of Canadian pediatricians demonstrated that
63% of respondents were not familiar with the diagnosis (Katzman,
Stevens, & Norris, 2014). Similarly, a study of Yogo teachers in
Japan (health educators who are also responsible for weighing stu-
dents and reviewing medical records to screen for medical concerns)
found that 13.0% of Yogo teachers had encountered youth with
symptoms consistent with ARFID. The majority of Yogo teachers
indicated they had limited knowledge about ARFID—58.8%
reported not knowing the diagnosis well, and 15.4% reported not
knowing anything about the diagnosis (Seike et al., 2016). In con-
trast, less than 1% of the sample reported an absence of knowledge
concerning the diagnosis of anorexia nervosa (AN) or bulimia
nervosa (BN), suggesting a discrepancy in knowledge across ED
diagnoses.
Although understudied, one of the potential challenges that
may impede health professionals in accurately identifying and pro-
viding clinical care for individuals with ARFID may relate to varying
presentations and heterogeneity among cases. A number of studies
have highlighted the existence of different ARFID presentations,
which vary according to the inherent mechanism that influences
food avoidance and restriction (Bourne et al., 2020; Norris
et al., 2018). Challenges with the validity of the diagnosis of ARFID
have been highlighted across studies, especially in the context of
co-occurring psychiatric or medical diagnoses (Strand, von
Hausswolff-Juhlin, & Welch, 2019). In addition to these
COELHO ET AL.
considerations, experts in the field have suggested there is a lack of
consensus in the field of how to apply the DSM-5 diagnostic criteria
(APA, 2013) that involves psychosocial impairment. The Radcliffe
ARFID Working Group reported that most (but not all) members
were applying a diagnosis of ARFID in the context of psychosocial
impairment alone (Eddy et al., 2019).
With all of these considerations in mind, the current study was
designed to better understand health professionals' experience and
familiarity in working with children/adolescents with ARFID. There
were two aims of the study: (a) to elucidate health professionals'
familiarity and experience in working with ARFID in a broad sample of
multi-disciplinary pediatric health professionals and (b) to assess the
ability of health professionals with experience in working with ARFID
to differentiate between different clinical presentations of restrictive
eating. Given potential inconsistencies in the way in which practi-
tioners are applying diagnostic criteria for ARFID in the context of
psychosocial impairment alone (Eddy et al., 2019), we sought to
explore what proportion of health professionals would view weight
loss/nutritional deficiency as necessary for a diagnosis of ARFID. We
assessed clinicians' knowledge of each of the individualized diagnostic
criteria for ARFID. We also evaluated whether individuals with previ-
ous experience in working with a pediatric ARFID population would
report more confidence in providing clinical care for this condition rel-
ative to those who had not provided care for ARFID. We expected
those with clinical experience to report higher confidence than those
without ARFID clinical experience, but anticipated low levels of confi-
dence in providing clinical care overall, given previous research
demonstrating professionals' lack of familiarity with this diagnosis
(e.g., Seike et al., 2016). Finally, we evaluated the application of diag-
nostic criteria of ARFID in a series of case vignettes, to explore the abil-
ity of health professionals with experience working with ARFID to make
diagnostic judgments across differing clinical presentations (including
psychosocial impairment alone, without weight loss/nutritional
deficiency).
2 | METHOD
Study information letters were distributed throughout the province of
British Columbia (BC), with the goal of capturing a multi-disciplinary
group of pediatric health professionals who worked in mental health
or medical settings. Recruitment included an email with study infor-
mation to clinical departments across the only pediatric tertiary care
hospital in the province. Efforts were made to broadly disseminate
study information to professionals across the hospital, including those
who were not specialized in feeding/EDs. Study information was sent
to all professionals working in the Healthy Minds Centre (who provide
outpatient and inpatient mental health care), as well as to staff in the
department of pediatrics, adolescent medicine, and all medical resi-
dents. Allied care health professionals across hospital departments
were also targeted, including psychology, dietetics, occupational ther-
apy, social work, and speech-language pathology. Professionals who
specialize in treatment of ARFID and feeding/EDs were also recruited,
COELHO ET AL.
with information letters sent to health professionals across hospital
departments who were part of an ARFID working group, and to staff
in the provincial ED program. Study information was also dissemi-
nated through the BC Children's Hospital Research Institute website
and newsletter, which distributes information to affiliated pediatric
health professionals.
Outside of the hospital, information letters were distributed
through provincial associations of health professionals (including the
Pediatric Society, Psychological Association, and Association of Clini-
cal Counsellors), Divisions of Family Practice (community-based
groups of family physicians across the province), and a provincial email
distribution list to dietitians. The study was also advertised through
the provincial ED Community of Practice, which is associated with
community-based ED programs across the province, through a news-
letter to all members and as well as through the website. Individuals
were encouraged to pass on the information letter to colleagues who
work with children and youth, to widen distribution. The survey was
available for three months.
Any English-speaking health professional who was working in
health care and/or mental health in British Columbia, and who had pro-
vided care in the past two years to children or adolescents ages 18 and
under was eligible to participate. Potential participants were provided
with a link to a web-based survey in the information letter, with the
survey and study database maintained using Research Electronic Data
Capture (REDCap; Harris et al., 2009), which was hosted by the BC
Children's Hospital Research Institute. Given the high proportion of
participants in previous studies who have reported a lack of familiarity
with the diagnosis of ARFID (Katzman et al., 2014; Seike et al., 2016),
to reduce selection bias study recruitment materials did not include the
term ARFID, and instead referred to a survey about familiarity with
challenges relating to “picky eating”, and experiences in working with
children and youth who may struggle with feeding or nutrition, or have
anxiety related to food or eating. This wording was employed to include
clinical presentations that the participants outside of specialized feed-
ing or eating disorder programs may have encountered. Informed con-
sent was obtained from all participants. No personally identifying
information was collected from participants as part of the study. Indi-
viduals who completed the survey were provided with the option to
enter a draw for one of four $25 gift cards—the contact information for
those who chose to enter the draw was stored separately from the sur-
vey, to maintain the anonymity of participants.
2.1 | Survey
A 15-item survey was designed to assess participants' familiarity and
experience in working with children/adolescents with ARFID. Partici-
pants were asked if they provide clinical care (e.g., assessment, treat-
ment) for children or adolescents with feeding and/or EDs
(participants were provided with a dichotomous response option,
yes/no). All participants were also asked whether they were familiar
with the DSM-5 diagnosis of ARFID, and whether they had provided
care for a child/adolescent with ARFID, with dichotomous response
589
options (yes/no). Participants were asked to rate their confidence in
providing clinical care for children/adolescents with ARFID on a
5-point Likert scale (anchors were given for the response end points,
1 = Not at all; 5 = Very much). Participants were asked to identify
DSM-5 (APA, 2013) diagnostic criteria for ARFID from a checklist (see
Supporting Information, Appendix 1 for details). Demographic ques-
tions (e.g., professional role, practice setting, gender identity) were
also included.
The subgroup of respondents who had provided care for a child
or adolescent with ARFID were presented with four case vignettes,
and asked whether the signs and symptoms in the case were consis-
tent with a diagnosis of ARFID, using the broader definition of
ARFID in which marked psychosocial interference due to avoidant or
restrictive eating is sufficient to meet criteria (Eddy et al., 2019).
Each of the vignettes tested understanding of restrictive eating
behavior, excessive exercise, and consequences of food restriction
(e.g., weight loss, psychosocial interference). Case 1 described
longstanding food avoidance in the absence of medical concerns or
psychosocial interference (not consistent with ARFID), Case
2 described longstanding food avoidance with psychosocial interfer-
ence (consistent with ARFID), Case 3 described longstanding food
avoidance with both medical and psychosocial interference (consis-
tent with ARFID), and Case 4 described an acute exacerbation in
restrictive eating in the presence of excessive exercise (not consis-
tent with ARFID). Case 4 aimed at providing a differential diagnosis
between ARFID and AN, and details regarding body image concerns
were deliberately excluded. Details of the vignettes are available in
Supporting Information (Appendix 2).
2.2 | Planned analyses
2.2.1 | Evaluation of confidence in providing
clinical care for ARFID
A Mann–Whitney test was performed to assess for differences in con-
fidence ratings between those who had or did not have previous
experience in working with pediatric ARFID, given that there was a
non-normal distribution of confidence ratings in the sample.
The effect size estimate, r, was calculated by dividing the z-score of
the Mann–Whitney test by the square root of the sample size
(as recommended by Field (2009)).
2.2.2 | Assessment of correct identification of
diagnosis in case vignettes
Cochran's Q test was conducted to compare the percentage of
appropriate classification of the four case vignettes in a within-subject
analysis (assessing whether the proportion of appropriate diagnostic
classification was different for at least one of the vignettes; signifi-
cance was set at p < .05). Bonferroni-corrected McNemar tests were
employed to follow-up on a significant test (alpha set at .05/6 = .008).
590
Given the low proportion of missing data, analyses were
performed on available data for each separate analysis. Details of
missing data are provided where relevant.
3 | RESULTS
3.1 | Participants
A total of 123 individuals provided consent for the study and went on
to complete at least the first question of the survey; of these partici-
pants, 93 completed the survey. Analyses were performed on the data
from respondents who completed the survey.
The majority of respondents (n = 79, 84.9%) indicated that they
provided care for children or adolescents with feeding and/or EDs in
their work. Participants represented a variety of roles, including: dieti-
tian (n = 25, 26.9%), pediatrician/adolescent health physician (n = 18,
19.3%), nurse/psychiatric nurse (n = 10, 10.8%), medical/pediatric res-
ident (n = 9, 9.7%), primary care provider/family physician (n = 8,
8.6%), psychologist (n = 8, 8.6%), social worker (n = 5, 5.4%), thera-
pist/clinical support (i.e., registered clinical counselor, child, and youth
worker; n = 5, 5.4%), and other (n = 5, 5.4%; i.e., psychiatrist, internist;
occupational therapist, speech-language pathologist).
Participants worked in a range of clinical practice settings, with
55 (59.1%) in a tertiary, hospital-based treatment setting, 20 (21.5%) in
secondary, community-based settings, 11 (11.8%) in private practice,
and 7 (7.5%) in primary care. A total of 92 participants reported their
gender (1.1% missing data), with 21 male (22.8% of the 92 individuals
for whom gender was available) and 71 female (77.2%) respondents.
3.2 | Familiarity, experience, and confidence in
providing care for ARFID
The majority of participants (n = 73, 78.5%) reported familiarity with
the diagnosis of ARFID. Familiarity varied as a function of whether
respondents provided care for pediatric feeding/EDs in their clinical
practice, with 84.8% (n = 67/79) of those who provide care for
feeding/EDs reporting familiarity with ARFID, and 42.9% (n = 6/14)
of those not providing care for pediatric feeding/EDs reporting
familiarity with ARFID, χ 2 (1, N = 93) = 12.40, p < .001. Overall,
61 participants (65.6%) had provided care for pediatric ARFID.
Although a portion of those who reported that they did not provide
regular care for pediatric feeding/EDs acknowledged providing care
for someone with a diagnosis of ARFID (n = 4/14, 28.6%), a larger
proportion of those who provide care for feeding/EDs had provided
clinical care for an individual with ARFID (n = 57/79, 72.2%), χ (1, 2
N = 93) = 10.01, p = .002.
Ratings of confidence in providing clinical care for ARFID were
available for 90 participants (3.2% missing data for this variable, cases
with missing data were excluded from this analysis). Respondents
who had provided care for ARFID (n = 60) reported higher confidence
in providing clinical services for pediatric ARFID than those who had
COELHO ET AL.
not provided care for ARFID (n = 30), U = 655.5, p = .028, r = 0.23. It
is noteworthy that both groups had relatively low confidence ratings.
Those who had provided care for ARFID reported mean confidence
ratings of 2.77 (SD = 0.87, 95% confidence interval 2.54–2.99;
median = 3.0, interquartile range = 1), and those who had not pro-
vided care for ARFID reported mean confidence of 2.33 (SD = 1.09,
95% confidence interval 1.93–2.74, median = 2.0, interquartile
range = 1). The distribution of confidence ratings demonstrated a pos-
itive skew, with very few participants from the overall sample
reporting confidence above the mid-point of the scale (13.3% had a
rating of 4, and 3.3% had a rating of 5).
3.3 | Application of DSM-5 diagnostic criteria
In a screening of respondents' understanding of DSM-5 diagnostic
criteria, 92 participants responded to the questions about ARFID
criteria (1.1% missing data for this variable, cases with missing data
were excluded from analysis). The majority (n = 72/92 participants;
78.3%) indicated that ARFID manifests as a persistent failure to
meet nutritional or energy needs. Furthermore, 50% of respondents
(n = 46) indicated that ARFID must be associated with significant
weight loss, failure to achieve expected weight gain, or faltering
growth. Only 34 participants (37.0%) identified all DSM-5 diagnostic
criteria (APA, 2013; see Supporting Information, Appendix 1 for list of
criteria assessed). Respondents who had provided care for a child or
adolescent with ARFID had a higher proportion of participants who
identified all diagnostic criteria (47.5%; n = 29) in comparison to
16.1% (n = 5) of those who had not provided care for ARFID identify-
ing all criteria, χ 2 (1, N = 92) = 8.71, p = .003.
3.4 | Case vignettes
All participants who had provided clinical care for a child/adolescent
with ARFID (n = 61) responded to the vignettes (including 57 partici-
pants who provide care for pediatric feeding/EDs, and 4 participants
who reported that they do not provide regular care for feeding/EDs).
There was a high proportion of appropriate classification for the eat-
ing vignette without an ARFID diagnosis (Case 1) and the vignette
with both psychosocial interference and medical complications (Case
3), and a lower proportion of respondents who appropriately classified
the cases with only psychosocial interference (Case 2) and with
restrictive eating and excessive exercise (Case 4; see Table 1 for
details). Cochran's Q test was conducted to test differences amongst
the four categories, which demonstrated a significant difference
among the four proportions, χ 2 (3) = 40.18, p < .001. Bonferroni-
corrected comparisons demonstrated that there were no significant
differences in the proportion of respondents who appropriately classi-
fied cases 1 and 3, nor were there differences in the proportion of
appropriately classified responses between cases 2 and 4 (p = 1.0). All
other classifications were significantly different (p < .001; see
Table 1).
COELHO ET AL.
TABLE 1 Proportion of respondents (n = 61) who appropriately classified the diagnosis for each of the case vignettes presented
Case 1 Case 2
Case description Longstanding food Longstanding food
avoidance without avoidance with
psychosocial or medical psychosocial interference
interference (no ARFID (ARFID diagnosis)
diagnosis)
Proportion of cases 95.08% 62.30%
classified
appropriately
McNemar tests* 1 > 2, 4 2 < 1, 3
*All differences significant at p < .001.
Participants' response to the question regarding weight loss/
growth differentiated whether they identified case 2 (psychosocial
interference only) as having ARFID—76.7% of respondents (n = 23)
who did not agree that ARFID must be associated with weight loss/
failure to gain weight identified this case as having an ARFID diagnosis,
whereas 48.4% of respondents (n = 15) who agreed with this criterion
identified the case as having ARFID, χ 2 (1, N = 61) = 5.19, p = .023.
4 | DISCUSSION
This is the first study that we are aware of that examined clinicians'
application of diagnostic criteria for ARFID across varying clinical
vignettes. Participants were more likely to endorse an ARFID diagno-
sis for a case vignette of a youth presenting with both psychosocial
interference and medical impairment (i.e., weight loss) than for a
vignette presenting psychosocial impairment alone. Our results sug-
gest ambiguity in the interpretation of DSM-5 (APA, 2013) diagnostic
criteria across varying case presentations. Of relevance, the majority
of the sample (78.3%) indicated that there must be persistent failure
to meet nutritional or energy needs as part of the ARFID diagnosis,
and 50% of the sample considered that ARFID must be associated
with significant weight loss, failure to achieve expected weight gain,
or faltering growth. Further, our results suggest discordance of clini-
cians' application and understanding of the DSM-5 criteria with that
reported by the Radcliffe ARFID working group, which indicated that
most of the experts in this working group apply the diagnosis of
ARFID in the context of psychosocial impairment alone (Eddy
et al., 2019). The tendency to view weight loss or failure to gain
weight as necessary may reflect participants' familiarity with the prior
DSM-IV-TR diagnosis of Feeding Disorder of Infancy and Childhood,
which included these factors in the diagnostic criteria (APA, 2000).
Approximately, 15% of the sample who provided regular clinical
care for pediatric feeding/EDs reported that they were not familiar
with the diagnosis of ARFID. This lack of familiarity with the diagnosis
has also been reported in Yogo teachers in Japan (Seike et al., 2016).
We believe that this finding is reflective of varying diagnostic classifi-
cation systems presently utilized in the field of complex pediatric
feeding disorders (Goday et al., 2019; Sharp & Stubbs, 2019).
591
Case 3 Case 4
Longstanding food Restrictive eating with
avoidance with excessive exercise (no
psychosocial interference ARFID diagnosis)
and weight loss (ARFID
diagnosis)
96.72% 60.66%
3 > 2, 4 4 < 1, 3
However, the majority of the overall sample of participants (78.5%)
reported familiarity with ARFID, which is an improvement from previ-
ous research conducted shortly after the publication of the DSM-5
(APA, 2013) that indicated that 63% of pediatricians and pediatric
subspecialists were not familiar with this diagnosis (Katzman
et al., 2014).
Health professionals who had provided care for ARFID reported
higher confidence levels than did those who had not yet provided
clinical care for a child/adolescent with ARFID. However, mean and
median ratings of confidence in providing care for patients with
ARFID were at or below the mid-point of the 5-point Likert rating
scale, and the distribution of confidence ratings was positively
skewed, suggesting relatively low levels of confidence even within the
group of health professionals who provide clinical care for ARFID.
Although the current study did not explore predictors of confidence,
we speculate the absence of evidence-based treatments for ARFID
may play a role in the overall lack of confidence of health profes-
sionals in the area. Furthermore, the heterogeneity and complexity of
clinical presentations of ARFID can lead to challenges in identifying
appropriate care pathways (Norris, Spettigue, & Katzman, 2016). The
gap between the evidence and clinical practice has been reported pre-
viously for adolescent medicine specialists, who report rarely using
ARFID-specific protocols for nutritional rehabilitation (Guss, Rich-
mond, & Forman, 2018). Of interest, Sharp and Stubbs (2019) high-
light that pediatric feeding disorder specialists have well-established
interventions for feeding disorders that could be applied to ARFID,
and suggest the utility of bridging between the feeding disorder and
ED communities.
Heterogeneity of ARFID presentations may also have contributed
to a lack of confidence in providing clinical care for ARFID. Emerging
evidence suggests that there are varying presentations of ARFID
(Bourne et al., 2020). Thomas et al. (2017) suggest that the heteroge-
neous presentation of ARFID may be dimensional as opposed to cate-
gorical. Based on the dimensional model of ARFID, a cognitive-
behavioral treatment for ARFID has been developed and manualized
(Thomas & Eddy, 2019). Family-based therapy, cognitive-behavioral
therapy, and adjunctive pharmacological treatment are promising
approaches in the treatment of ARFID (Bourne et al., 2020). Further
research on the effectiveness of psychological treatments, and the
592
development of etiological models of ARFID is likely to bolster confi-
dence of health professionals in providing clinical care for this
population.
Responses to the case vignettes suggest that health professionals
are skilled in differentiating restrictive eating that does not warrant
clinical care from presentation of ARFID symptoms with both medical
and psychosocial interference. However, we noted greater ambiguity
in responses to a case scenario in which the differential diagnosis
included AN and ARFID (Case 4), as well as a scenario in which psy-
chosocial interference was the predominant case feature (Case 2). It is
notable that nearly half of the respondents who indicated that ARFID
must be associated with weight-related concerns (e.g., weight loss or
failure to gain weight) endorsed Case 2 as having an ARFID diagnosis,
despite the fact that this case highlighted only psychosocial interfer-
ence in the clinical presentation. Therefore, there appears to be incon-
sistency in the application of ARFID criteria, even for those who
report the importance of weight-related features as part of the
diagnostic criteria.
One of the limitations in the field has been a lack of validated
assessment tools; however, recently the Pica, ARFID, and Rumination
Disorder Interview (PARDI) has been developed with preliminary evi-
dence supporting the feasibility, validity and reliability of this measure
(Bryant-Waugh et al., 2019). Similarly, an ARFID module has been
developed for the children's version of the Eating Disorder Examina-
tion (Bryant-Waugh, Cooper, Taylor, & Lask, 1996), which has prelimi-
nary support for the validity and reliability (Schmidt et al., 2019).
Given the observed differences in the application of DSM-5
(APA, 2013) criteria in the current study, the use of validated mea-
sures to confirm an ARFID diagnosis is needed to advance clinical
research.
A proposal to clarify the criteria to allow for psychosocial impair-
ment alone to meet criteria for ARFID has been presented to the
American Psychiatric Association (Eddy et al., 2019). This proposal
was recently approved by the American Psychiatric Association, and
the updated criteria will be published in the upcoming DSM-5-TR
(text revision; B.T. Walsh, personal communication, August 27, 2020).
A challenge in distinguishing clinical presentations of ARFID that are
associated with psychosocial impairment alone is the lack of measures
of clinical impairment that are specific to ARFID, though the PARDI
(Bryant-Waugh et al., 2019) includes several items that assess psycho-
social impairment. Heterogeneous presentations of ARFID, with
varying types of restrictive eating, are likely to be associated with
impairment across different domains. Further empirical validation
of assessment tools for ARFID can help guide clinicians with the
upcoming clarification to the diagnostic criteria.
Strengths of the current study include a multi-disciplinary sample
of health professionals working across a range of treatment settings,
from private practice to hospital-based treatment programs for feed-
ing/EDs. The initial aim of recruitment was to capture health profes-
sionals who may not specialize in treatment for feeding/EDs in their
clinical practice. However, a small sample of individuals who did not
provide care for feeding/EDs completed the survey, suggesting selec-
tion bias toward those working in feeding/EDs in the participants
COELHO ET AL.
who responded. Furthermore, the methodology precludes a determi-
nation of response rate to the study invitation. Other significant
limitations included our overall conservative sample size, and the con-
sideration that our sample was drawn from a single province in
Canada. Inclusion of health professionals from general mental health
settings in future research is recommended, to elucidate the experi-
ences of non-specialists in feeding/EDs. The current study also
focused on pediatric ARFID presentations. The decision to have a
pediatric focus allowed for comparisons with previous research on
pediatric health professionals' familiarity with ARFID (Katzman
et al., 2014; Seike et al., 2016). However, the inclusion of only pediat-
ric health professionals in the current study limits the generalizability
of the results to health professionals outside of pediatric settings. Fur-
ther research on clinical care for ARFID across the lifespan is needed.
The current study focused on a single presentation of ARFID
(longstanding food avoidance), and therefore the vignettes do not
address the ability of health professionals to detect ARFID in youth
with heterogeneous presentations. Furthermore, the vignette aimed
at differential diagnosis between AN and ARFID (Case 4) included
ambiguity regarding the motivations for exercise, and the types of
foods being excluded by the youth. It is possible that some health pro-
fessionals may have interpreted some of the listed symptoms as con-
sistent with a diagnosis of ARFID. Furthermore, the representation of
a male in the vignette may have also contributed to variability in the
interpretation of the case information, given that males are more likely
than females to be diagnosed with an “other” ED (Murray
et al., 2017). Therefore, the results regarding differential diagnosis
between ARFID and AN need to be interpreted with caution. As
research progresses, it will important to better delineate how specific
clinical presentations of restrictive eating behavior evolve into ARFID
or AN diagnoses (Norris et al., 2020). Becker et al. (2019) suggest the
utility of assessing mood, anxiety, and eating symptoms in differenti-
ating between ARFID and AN, and indicate that when allowing for
psychosocial impairment to be sufficient for a diagnosis, the mean
percentage of median body mass index for individuals with ARFID fell
within the normal weight range.
5 | CONC LU SIONS
Our findings highlight ongoing ambiguity regarding application of
ARFID criteria. In contrast to clinical practice reported by an interna-
tional group of experts in ARFID (Eddy et al., 2019), only a minority of
clinicians from our sample considered that it was not necessary to
demonstrate deficits in nutrition or energy intake in order to meet
criteria for ARFID. Similarly, fewer clinicians endorsed a case with psy-
chosocial impairment alone as having ARFID in comparison to a case
with both weight loss and psychosocial impairment. Our study also
demonstrates that health professionals who provide care for children/
adolescents with ARFID report relatively low levels of confidence in
providing clinical services for ARFID, revealing the need for education
of health professionals in the diagnosis and management of ARFID as
recommended by Norris et al. (2016). Further development and study
COELHO ET AL.
of validated diagnostic measures and continued clarification of diag-
nostic criteria is needed to better support clinical care for individuals
with ARFID.
ACKNOWLEDGMENTS
This research was supported in part by funds from BC Mental Health
and Substance Use Services awarded to the first author. We would
like to thank Sheila Marshall for consultation on the study, and Janet
Suen for assistance with study administration.
CONF LICT OF IN TE RE ST
Mark Norris received speaker fees from Takeda in 2019. The other
authors have no conflicts of interest to declare.
DATA AVAI LAB ILITY S TATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Jennifer S. Coelho https://orcid.org/0000-0001-9907-8067
Mark L. Norris https://orcid.org/0000-0002-6651-5803
RE FE R ENC E S
American Psychiatric Association. (2000). Diagnostic and statistical manual
of mental disorders (4th ed., Text Revision.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual
of mental disorders (5th ed.). Washington, DC: Author.
Becker, K. R., Keshishian, A. C., Liebman, R. E., Coniglio, K. A., Wang, S. B.,
Franko, D. L., … Thomas, J. J. (2019). Impact of expanded diagnostic
criteria for avoidant/restrictive food intake disorder on clinical com-
parisons with anorexia nervosa. International Journal of Eating Disor-
ders, 52, 230–238. https://doi.org/10.1002/eat.22988
Bourne, L., Bryant-Waugh, R., Cook, J., & Mandy, W. (2020). Avoid-
ant/restrictive food intake disorder: A systematic scoping review of
the current literature. Psychiatry Research, 112961, 112961. https://
doi.org/10.1016/j.psychres.2020.112961
Bryant-Waugh, R., Micali, N., Cooke, L., Lawson, E. A., Eddy, K. T., &
Thomas, J. J. (2019). Development of the Pica, ARFID, and Rumination
Disorder Interview, a multi- informant, semi-structured interview of
feeding disorders across the lifespan: A pilot study for ages 10–22.
International Journal of Eating Disorders, 52, 378–387. https://doi.org/
10.1002/eat.22958
Bryant-Waugh, R. J., Cooper, P. J., Taylor, C. L., & Lask, B. D. (1996). The
use of the eating disorder examination with children: A pilot study.
International Journal of Eating Disorders, 19, 391–397. https://doi.org/
10.1002/(SICI)1098-108X(199605)19:4<391::AID-EAT6>3.0.CO;2-G
Cooney, M., Lieberman, M., Guimond, T., & Katzman, D. K. (2018). Clinical
and psychological features of children and adolescents diagnosed with
avoidant/restrictive food intake disorder in a pediatric tertiary care
eating disorder program: a descriptive study. Journal of Eating Disor-
ders, 6, 1–8. https://doi.org/10.1186/s40337-018-0193-3
Eddy, K. T., Harshman, S. G., Becker, K. R., Bern, E., Bryant-Waugh, R.,
Hilbert, A., … Thomas, J. J. (2019). Radcliffe ARFID Workgroup:
Toward operationalization of research diagnostic criteria and direc-
tions for the field. International Journal of Eating Disorders, 52,
361–366. https://doi.org/10.1002/eat.23042
Eddy, K. T., Thomas, J. J., Hastings, E., Edkins, K., Lamont, E., Nevins, C. M.,
… Becker, A. E. (2015). Prevalence of DSM-5 avoidant/restrictive food
intake disorder in a pediatric gastroenterology healthcare network.
593
International Journal of Eating Disorders, 48, 464–470. https://doi.org/
10.1002/eat.22350
Field, A. (2009). Discovering statistics using IBM SPSS statistics (3rd ed.).
London, UK: Sage Publications Ltd.
Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K.,
Rome, E. S., … Walsh, B. T. (2014). Characteristics of avoid-
ant/restrictive food intake disorder in children and adolescents: a
“new disorder” in DSM-5. Journal of Adolescent Health, 55, 49–52.
https://doi.org/10.1016/j.jadohealth.2013.11.013
Goday, P. S., Huh, S. Y., Silverman, A., Lukens, C. T., Dodrill, P.,
Cohen, S. S., … Kenzer, A. (2019). Pediatric feeding disorder: consen-
sus definition and conceptual framework. Journal of Pediatric Gastroen-
terology and Nutrition, 68, 124–129. https://doi.org/10.1097/MPG.
0000000000002188
Gonçalves, S., Vieira, A. I., Machado, B. C., Costa, R., Pinheiro, J., &
Conceiçao, E. (2018). Avoidant/restrictive food intake disorder symp-
toms in children: Associations with child and family variables. Children's
Health Care, 48, 1–13. https://doi.org/10.1080/02739615.2018.
1532796
Guss, C. E., Richmond, T. K., & Forman, S. (2018). A survey of physician
practices on the inpatient medical stabilization of patients with avoid-
ant/restrictive food intake disorder. Journal of Eating Disorders, 6, 22.
https://doi.org/10.1186/s40337-018-0212-4
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G.
(2009). Research electronic data capture (REDCap)—a metadata-driven
methodology and workflow process for providing translational
research informatics support. Journal of Biomedical Informatics, 42,
377–381. https://doi.org/10.1016/j.jbi.2008.08.010
Hay, P., Mitchison, D., Collado, A. E. L., Gonzalez-Chica, D. A.,
Stocks, N., & Touyz, S. (2017). Burden and health-related quality of life
of eating disorders, including avoidant/re- strictive food intake disor-
der (ARFID), in the Australian population. Journal of Eating Disorders, 5,
1–10. https://doi.org/10.1186/s40337-017-0149-z
Katzman, D. K., Stevens, K., & Norris, M. (2014). Redefining feeding and
eating disorders: What is avoidant/restrictive food intake disorder?
Paediatrics & Child Health, 19, 445–446. https://doi.org/10.1093/pch/
19.8.445
Krom, H., van der Sluijs Veer, L., van Zundert, S., Otten, M., Benninga, M.,
Haverman, L., & Kindermann, A. (2019). Health related quality of life
of infants and children with avoidant restrictive food intake disorder.
International Journal of Eating Disorders, 52, 410–418. https://doi.org/
10.1002/eat.23037
Kurz, S., Van Dyck, Z., Dremmel, D., Munsch, S., & Hilbert, A. (2015). Early-
onset restrictive eating disturbances in primary school boys and girls.
European Child & Adolescent Psychiatry, 24, 779–785. https://doi.org/
10.1007/s00787-014-0622-z
Murray, S. B., Nagata, J. M., Griffiths, S., Calzo, J. P., Brown, T. A.,
Mitchison, D., … Mond, J. M. (2017). The enigma of male eating disor-
ders: A critical review and synthesis. Clinical Psychology Review, 57,
1–11. https://doi.org/10.1016/j.cpr.2017.08.001
Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., &
Ornstein, R. M. (2014). Prevalence and characteristics of avoid-
ant/restrictive food intake disorder in a cohort of young patients in
day treatment for eating disorders. Journal of Eating Disorders, 2, 1–8.
https://doi.org/10.1186/s40337-014-0021-3
Norris, M. L., Robinson, A., Obeid, N., Harrison, M., Spettigue, W., &
Henderson, K. (2014). Exploring avoidant/restrictive food intake disor-
der in eating disordered patients: A descriptive study. International
Journal of Eating Disorders, 47, 495–499. https://doi.org/10.1002/eat.
22217
Norris, M. L., Santos, A., Obeid, N., Hammond, N. G., Valois, D. D.,
Isserlin, L., & Spettigue, W. (2020). Characteristics and clinical trajecto-
ries of patients meeting criteria for avoidant/restrictive food intake
disorder that are subsequently reclassified as anorexia nervosa.
594
European Eating Disorders Review, 28(1), 26–33. https://doi.org/10.
1002/erv.2710
Norris, M. L., Spettigue, W., Hammond, N., Katzman, D. K., Zucker, N.,
Yelle, K., … Obeid, N. (2018). Building evidence for the use of descrip-
tive subtypes in youth with avoidant restrictive food intake disorder.
International Journal of Eating Disorders, 51(2), 170–173. https://doi.
org/10.1002/eat.22814
Norris, M. L., Spettigue, W. J., & Katzman, D. K. (2016). Update on
eating disorders: current perspectives on avoidant/restrictive
food intake disorder in children and youth. Neuropsychiatric Dis-
ease and Treatment, 12, 213. https://doi.org/10.2147/NDT.
S82538
Ornstein, R. M., Rosen, D. S., Mammel, K. A., Callahan, S. T., Forman, S.,
Jay, M. S., … Walsh, B. T. (2013). Distribution of eating disorders in
children and adolescents using the proposed DSM-5 criteria for feed-
ing and eating disorders. Journal of Adolescent Health, 53, 303–305.
https://doi.org/10.1016/j.jadohealth.2013.03.025
Schmidt, R., Kirsten, T., Hiemisch, A., Kiess, W., & Hilbert, A. (2019). Inter-
view-based assessment of avoidant/restrictive food intake disorder
(ARFID): A pilot study evaluating an ARFID module for the Eating Dis-
order Examination. International Journal of Eating Disorders, 52,
388–397. https://doi.org/10.1002/eat.23063
Seike, K., Nakazato, M., Hanazawa, H., Ohtani, T., Niitsu, T., Ishikawa, S. I.,
… Takamiya, S. (2016). A questionnaire survey regarding the support
needed by Yogo teachers to take care of students suspected of having
eating disorders (second report). BioPsychoSocial Medicine, 10, 28.
https://doi.org/10.1186/s13030-016-0079-z
Sharp, W. G., & Stubbs, K. H. (2019). Avoidant/restrictive food intake dis-
order: A diagnosis at the intersection of feeding and eating disorders
COELHO ET AL.
necessitating subtype differentiation. International Journal of Eating
Disorders, 52, 398–401. https://doi.org/10.1002/eat.22987
Strand, M., von Hausswolff-Juhlin, Y., & Welch, E. (2019). A systematic
scoping review of diagnostic validity in avoidant/restrictive food
intake disorder. International Journal of Eating Disorders, 52, 331–360.
https://doi.org/10.1002/eat.22962
Thomas, J. J., & Eddy, K. T. (2019). Cognitive-behavioral therapy for avoid-
ant/restrictive food intake disorder: Children, adolescents, and adults.
Cambridge: Cambridge University Press.
Thomas, J. J., Lawson, E. A., Micali, N., Misra, M., Deckersbach, T., &
Eddy, K. T. (2017). Avoidant/restrictive food intake disorder: a three-
dimensional model of neurobiology with implications for etiology and
treatment. Current Psychiatry Reports, 19, 54. https://doi.org/10.
1007/s11920-017-0795-5
SUPPORTING INF ORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of this article.
How to cite this article: Coelho JS, Norris ML, Tsai SCE,
Wu YJ, Lam P-Y. Health professionals' familiarity and
experience with providing clinical care for pediatric avoidant/
restrictive food intake disorder. Int J Eat Disord. 2021;54:
587–594. https://doi.org/10.1002/eat.23438