21 - 31.9c AvoidantRestrictive Food Intake Disorde

31.9c Avoidant/Restrictive Food Intake Disorder

TREATMENT The treatment of rumination disorder is often a combination of education and behavioral techniques. Sometimes, an evaluation of the mother–child relationship reveals deficits that can be influenced by offering guidance to the mother. Behavioral interventions, such as habit-reversal are aimed at reinforcing an alternate behavior that becomes more compelling than the behaviors leading to regurgitation. Aversive behavioral interventions, such as squirting lemon juice into the infant’s mouth whenever rumination occurs, have been used in the past to diminish rumination behavior. Although aversive behavioral interventions have been reported anecdotally to be effective in some cases, current recommendations support the use of habit-reversal techniques. When features of child maltreatment of neglect may have contributed to rumination behaviors in an infant, treatments include improvement of the child’s psychosocial environment, increased tender loving care from the mother or caretakers, and psychotherapy for the mother or both parents. Anatomical abnormalities, such as hiatal hernia, are not uncommon, and must be evaluated, in some cases leading to surgical repair. In severe cases in which malnutrition and weight loss have occurred, placement of a jejunal tube may need to be inserted before other treatments can be utilized. Medication is not a standard part of the treatment of rumination. Case reports, however, cite a variety of medications that have been tried, including metoclopramide (Reglan), cimetidine (Tagamet), and even antipsychotics such as haloperidol (Haldol) have been cited to be helpful according to anecdotal reports. The treatment of adolescents with rumination disorder is often complex and includes a multidisciplinary approach consisting of individual psychotherapy, nutritional intervention, and pharmacologic treatment for the frequent comorbid anxiety and depressive symptoms. 31.9c Avoidant/Restrictive Food Intake Disorder Avoidant/restrictive food intake disorder, formerly known as feeding disorder of infancy or early childhood, is characterized by a lack of interest in food, or its avoidance based on the sensory features of the food or the perceived consequences of eating. This newly included DSM-5 disorder adds more detail about the nature of the eating problems, and has also been expanded to include adolescents and adults. The disorder is manifested by a persistent failure to meet nutritional or energy needs as evidenced by one or more of the following: significant weight loss or failure to achieve expected weight, nutritional deficiency, dependence on enteral feedings or nutritional supplements, or marked interference with psychosocial functioning. It may take the form of outright food refusal, food selectivity, eating too little, food avoidance, and delayed self-feeding. The diagnosis should not be made in the context of anorexia nervosa or bulimia nervosa, or if caused by a medical condition, by another mental disorder, or by a true lack of available food. Infants and children with the disorder may be withdrawn, irritable, apathetic, or

anxious. Because of the avoidant behavior during feeding, touching and holding between mothers and infants are diminished during the entire feeding process compared with other children. Some reports suggest that food avoidance or restriction may be relatively long-standing; however, in many cases, normal adult functioning is eventually achieved. EPIDEMIOLOGY It is estimated that between 15 percent and 35 percent of infants and young children have transient feeding difficulties. A study of restrictive eating difficulties in Swedish 9year-olds and 12-year-olds found that restrictive eating problems were present in 0.6 percent of their sample. However, another study of avoidant eating patterns in young children in Germany, found that some degree of avoidance was present in up to 53 percent of children. Thus, avoidant eating behaviors without impairment of nutritional state or psychosocial functioning must be separated from restricted eating disturbances leading to significant functional impairment. A survey of feeding problems in nursery school children revealed a prevalence of 4.8 percent with equal gender distribution. In that study, children with feeding problems exhibited more somatic complaints and mothers of affected infants exhibited increased risk of anxiety symptoms. Data from community samples estimate a prevalence of failure to thrive syndromes in approximately 3 percent of infants, with approximately half of those infants exhibiting feeding disorders. DIFFERENTIAL DIAGNOSIS The disorder must be differentiated from structural problems with the infants’ gastrointestinal tract that may be contributing to discomfort during the feeding process. Because feeding disorders and organic causes of swallowing difficulties often coexist, it is important to rule out medical reasons for feeding difficulties. A study of videofluoroscopic evaluation of children with feeding and swallowing problems revealed that clinical evaluation was 92 percent accurate in identifying those children at increased risk of aspiration. This type of evaluation is necessary before psychotherapeutic interventions in cases where a medical contribution to feeding problems is suspected. COURSE AND PROGNOSIS Most infants with feeding disorder who are identified within the first year of life and who receive treatment do not go on to develop malnutrition, growth delay, or failure to thrive. When feeding disorders have their onset later, in children 2 to 3 years of age, growth and development can be affected when the disorder lasts for several months. In older children, or adolescents, the feeding disorder typically interferes with social functioning, until treated. It is estimated that about 70 percent of infants who persistently refuse food in the first year of life continue to have some eating problems

during childhood. Jennifer was 6 months old when she was referred for a psychiatric evaluation because of feeding difficulties, irritability, and poor weight gain since birth. She was small and slight, but she did not appear to be lethargic or malnourished. Her parents were college-educated, and both had pursued their professional careers until Jennifer was born. Although Jennifer was full-term and weighed 7 pounds at birth, she had been unable to be breast feed due to turning away and not ingesting enough milk. When she was 4-weeks-old, Jennifer’s mother had reluctantly switched her to bottle feedings because Jennifer was losing weight. Although her intake improved somewhat on bottle feedings, she gained weight very slowly and was still less than 8 pounds at 3 months of age. Since then, she had gained a minimal amount each month to maintain a low but adequate weight. Jennifer’s mother appeared tired and described that Jennifer would drink only up to about 6 ounces at a time, or two bites of baby food, and then wiggle and cry; and refuse to continue with the feeding. But after a few hours, she might cry again as if she were hungry. However, she could not settle her into a good rhythm of feeding, and continued attempts to feed her would lead her to cry inconsolably. Jennifer’s mother described approximately 10 to 15 attempts at feeding her both liquids and solids in a 24-hour period. Jennifer was reported to be an irritable and fussy infant, who cried multiple times during the day and at night, and woke her family often during the night with her crying. Jennifer’s developmental milestones such as sitting up, tracking, and making sounds were within normal limits. The observation of mother–infant interactions during feeding and play revealed that Jennifer was a very alert and wiggly baby who had difficulty sitting still. While drinking from the bottle she would kick her feet and move around, and if the bottle slipped out of her mouth, she did not try to recapture it. When eating baby foods, she was not interested and her mother had to coax her to open her mouth. This upset Jennifer, and she would start crying. Jennifer’s mother reported that she was always anxious during meals, and would try to convince Jennifer to take spoonfuls of baby food while sitting in her high chair. After repeated unsuccessful attempts of adequate feeding, Jennifer and her mother both appeared exhausted and took a break. The history and examination revealed that Jennifer was a very active and excitable baby who had difficulty keeping calm during feedings. After reviewing the videotape with the mother, the therapist explored ways in which the mother could better facilitate calming Jennifer before and during meals. Using a quiet corner in the house, and singing to Jennifer before meals resulted in Jennifer remaining more calm during meals, and she was able to drink larger amounts of milk, eat more solid foods, and waited longer between meals. This, in turn, relieved her mother’s anxiety and helped both to have calmer interactions. (Adapted by Caroly Pataki, M.D.)

TREATMENT Most interventions for feeding disorders are aimed at optimizing the interaction between the mother and infant during feedings and identifying any factors that can be changed to promote greater ingestion. The mother is helped to become more aware of the infant’s stamina for length of individual feedings, the infant’s biological regulation patterns, and the infant’s fatigue level with a goal of increasing the level of engagement between mother and infant during feeding. A transactional model of intervention has been proposed for infants who exhibit the “difficult” temperamental traits of emotional intensity, stubbornness, lack of hunger cues, and irregular eating and sleeping patterns. The treatment includes education for the parents regarding the temperamental traits of the infant, exploration of the parents’ anxieties about the infant’s nutrition, and training for the parents regarding changing their behaviors to promote internal regulation of eating in the infant. Parents are encouraged to feed the infant on a regular basis at 3- to 4-hour intervals, and offer only water between meals. The parents are trained to deliver praise to the infant for any self-feeding efforts, regardless of the amount of food ingested. Furthermore, parents are guided to limit any distracting stimulation during meals and give attention and praise to positive eating behaviors rather than intense negative attention to inappropriate behavior during meals. This training process for parents is done in an intense manner within a short period of time. Many parents are able to facilitate improved eating patterns in the infant as a result. If the mother or caregiver is unable to participate in the intervention, it may be necessary to include additional caregivers to contribute to feeding the infant. In rare cases, an infant may require hospitalization until adequate nutrition on a daily basis is accomplished. If an infant tires before ingesting an adequate amount of nutrition, it may be necessary to begin treatment with the placement of a nasogastric tube for supplemental oral feedings. For older children with failure-to-thrive syndromes, hospitalization and nutritional supplementation may be necessary. Medication is not a standard component of treatment for feeding disorders; however, there are anecdotal reports of preadolescents with failure-to-thrive and feeding disorders who were comorbid for anxiety and mood symptoms and who received enteral nutritional interventions in addition to risperidone (Risperdal), and who were observed to have an increase in oral intake and accelerated weight gain. REFERENCES Araujo CL, Victora CG, Hallal PC, Gigante DP. Breastfeeding and overweight in childhood: Evidence from the Pelotas 1993 birth cohort study. Int J Obes. 2005;30(3):500. Berger-Gross P, Colettoi DJ, Hirschkorn K, Terranova E, Simpser EF. The effectiveness of risperidone in the treatment of three children with feeding disorders. J Child Adolesc Psychopharmacol. 2004;14:621. Bryant-Waugh R. Feeding and eating disorders in children. Curr Opin Psychiatry. 2013;26:537–542. Bryant-Waugh R. Avoidant restrictive food intake disorder: An illustrative case example. Int J Eat Disord. 2013;46:420–423. Call C, Walsh BT, Attia E. From DSM-IV to DSM-5: Changes to eating disorder diagnoses. Curr Opin Psychiatry.