2/27/18. But. What if this doesn t work?

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1 Hillary Mamis, MS, RD, LDN Nutrition Factory Amanda Smith, LICSW Walden Behavioral Care Lori Goodrich, OTR/L OTA The Koomar Center Children (toddlers) can be picky eaters. Well-known RD, Ellyn Satter s method for feeding: But. What if this doesn t work? Challenges: Picky eating is common in toddlers. How do you differentiate picky eating from a feeding disorder? No agreed upon criteria Gradations of picky eating Differentiating developmental v. organic Eating disorders (AN, BN, BED) well studied and criteria agreed upon. Could an eating disorder be a feeding disorder? Can look similar impaired physical and cognitive development Picky Eating: Is It Serious? (2015) Medscape Pediatrics 1

2 The Oxford Dictionaries defines eating disorder in adults or children as: any of a range of psychological disorders characterized by abnormal or disturbed eating habits. DSM-IV v. DSM-V DSM-IV: only feeding disorder diagnosis: Feeding Disorder of Infancy and Early Childhood (FIDEC) Rarely used in practice Did not generate research Many cases assigned eating disorder not otherwise specified (EDNOS) Problem: difficulty obtaining appropriate and timely treatment DSM-V: eliminated FIDEC, introduced ARFID ARFID criteria from the DSM-V: 1. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). Significant nutritional deficiency. Dependence on enteral feeding or oral nutritional supplements. Marked interference with psychosocial functioning. 2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. 3. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one s body weight or shape is experienced. 4. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. Examples: identifying the ARFID case Case 1: 8 yo boy, underweight and concern for continued growth. - Avoidance of many meats and vegetables - History of reflux and gagging as an infant - Gets visibly upset if foods are put in front of him Case 1: 9 yo girl, recent history of weight loss. - Recently adopted vegetarian diet - Avoidance of processed and calorically dense foods - Gets visibly upset if feared foods are presented. - Not comfortable with weight gain Case 2: 6 yo girl, underweight and concern of continued growth. -Avoids many foods presented by parents. Parents will often make a separate meal that includes preferred foods -History of being a picky eater since infancy Case 2: 19 yo male unable to finish freshman year of college due to anxiety around foods served in the dinning hall. - c/o not being hungry and feeling nauseous if forced to eat and 160# - Desire to gain weight In other words. individuals who are diagnosed with ARFID had developed a problem with eating, irrespective of their age, that has led to their inability to consume adequate calories and/or nutrition, requiring independent attention or treatment. 2

3 What does ARFID look like? Initial criticism around this diagnosis due to the complexity of feeding disorders From the American Psychiatric Association : insufficient information about these conditions (feeding disorders) to document their clinical characteristics and validity or to provide definitive diagnostic criteria. From Ellyn Satter: Diagnosing may catastrophize. Doesn t agree with feeding disorder being psychiatric disorder. Psychosocial distortion lies in the relationship with the parent * Goal: ARFID might lead to further research and eventually bring consensus about how to diagnose and treat these disorders Thomas et al, 2017 * Current ARFID population: 3 independent studies used retrospective chart reviews in ED clinics Studies found ARFID patients to be demographically and clinically distinct from those with AN or BN Larger percentage male Tended to be younger Tended to have symptoms lasting a longer period of time Tended to have higher rates of co-morbid anxiety disorders One study identified symptoms associated with ARFID: abdominal pain, fear of vomiting, feeling full, nausea, generalized anxiety around eating, and unpleasant sensory experiences associated with eating Nicely et al, 2014; Norris et al,2014; Fisher et al, 2014 Potential for over diagnosis: Some have expressed concern that an ARFID classification could contribute to over diagnosis and overtreatment because it is not yet supported by an extensive empirical literature Study conducted in GI clinic setting v. ED treatment center Prevalence found to be low (2.4%) Study suggested using broader criteria was better/easier to identify cases Example: not all cases were FTT, underweight or had significant weight loss Conclusion: Because cases meeting full criteria were rare, the ARFID diagnosis is not overinclusive even in a population where eating/feeding difficulties would be expected. Conceptualizing ARFID Recently published three dimensional model by Thomas et. al. Hypothesis: could inform understanding of etiology, longitudinal persistence, and treatment response. Introduction on Cognitive Behavioral Therapy for ARFID (CBT-AR) Currently being tested Direction for future research: Agreement on what defines recovery: Amount of weight restored Dietary diversity Guidelines for level of care Eddy et al, 2014 Thomas et al,

4 Minimal research to date for the treatment of ARFID. Currently no randomized controlled trials have evaluated the efficacy of any type of ARFID treatment. What is available: Current treatment in ED clinic, OT clinic, outpatient setting Pending research on Cognitive Behavior Therapy for ARFID from group at MGH Combined with general ED population with individualized treatment goals. Utilized a food hierarchy to introduce challenge foods while completing full portions of preferred foods Especially important if weight restoration is necessary Utilize the FBT treatment model (at Walden) for children and adolescents. Access to higher LOC if significant weight restoration needed (inpatient and residential) and support integrating challenges into daily life activities (PHP and IOP). Group therapy to focus on increase use of coping skills (CBT, DBT) throughout exposures. Individual and small group therapy provided in an outpatient center All ages of clients seen from young children to adults Intervention provided in an environment that has Sensory Integration Equipment that allows for the provision of targeted sensory input that is adjusted to meet individual client s needs in a physically and emotionally safe environment Eating and mealtime space 4

5 Sensory Integration - The organization of information from the senses for use in adapting to environmental demands. Motor - A coordinated pattern of movements and muscle activation acquired through practice resulting in effectively achieving intended outcomes. Psychosocial The complex interrelation of psychological and social factors that impact a wide range of one s interactions and behaviors. Intervention focuses on Remediation of sensory and motor foundations through sensory integration therapy Combining bottom up sensory integration with top down approaches (i.e. education, framing challenges) Home support, programing and accommodations Therapy progression Address underlying sensory processing problems Address oral functioning sensory, motor Once sensory and motor systems functioning, move into food exploration (start with noneating, move towards eating) Collaboration with other professionals Typically has been with an individual therapist and/or dietitian in an outpatient setting. Up until now, no structured treatment protocol therefore each practitioner takes a different approach. MGH s Eating Disorders Clinical and Research Program has developed a 20 session outpatient CBT protocol for the treatment of ARFID. Sessions are weekly. The beginning sessions involve education on ARFID and sets up the use of exposures during treatment. By session 5 participants will be trying 5 exposures in office. Participants continue exposures in between sessions. Focus on setting expectations and maintaining appropriate expectations throughout treatment. There is agreement across disciplines that expectations for treatment of ARFID are different than traditional eating disorders. There is some disagreement about the rate at which exposures should happen depending upon discipline, but overall all would agree that the length of time before foods are fully accepted is longer. Families and practitioners benefit from progress being framed individually for each child and discussed in relation to where the child s aversions began. More traditional eating disorder treatments may set the bar too high for outcomes when it comes to those struggling with ARFID. 5

6 Food Hierarchy Food Chaining Chaser Foods Exposure rating scales Systematic desensitization ARFID needs to continue to be researched and new treatments validated. MGH s CBT treatment will be published in OTA The Koomar Center continues to develop and implement The FOCUS Program, a manualized systematic program used by occupational therapists. 6

7 Thank you! 7