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Background ARFID (avoidant restrictive food intake disorder) is a relatively new diagnostic term covering a number of well‐recognised, clinically significant disturbances in eating behaviour unrelated to body weight/shape concerns. Its phenotypic heterogeneity combined with much about the condition remaining unknown, can contribute to uncertainties about best practice. While other reviews of the evidence base for ARFID exist, few specifically target health care professionals and implications for clinical practice. Methods A narrative review was conducted to synthesise the findings of ARFID papers in scientific journals focussing on four key areas relevant to clinical practice: prevalence, assessment and characterisation of clinical presentations, treatment, and service delivery. Freely available online databases were searched for case studies and series, research reports, review articles, and meta‐analyses. Findings were reviewed and practice implications considered, resulting in proposed clinical recommendations and future research directions. Results We discuss what is currently known about the four key areas included in this review. Based on available evidence as well as gaps identified in the literature, recommendations for clinical practice are derived and practice‐related research priorities are proposed for each of the four of the areas explored. Conclusion Prevalence studies highlight the need for referral and care pathways to be embedded across a range of health care services. While research into ARFID is increasing, further studies across all areas of ARFID are required and there remains a pressing need for guidance on systematic assessment, evidence‐based management, and optimal service delivery models. Informed clinical practice is currently predominantly reliant on expert consensus and small‐scale studies, with ongoing routine clinical data capture, robust treatment trials and evaluation of clinical pathways all required. Despite this, a number a positive practice points emerge. This paper reviews of the evidence base for ARFID specifically targeting health care professionals and implications for clinical practice. A narrative review was conducted to synthesise current evidence on four key areas relevant to clinical practice: prevalence, assessment and characterisation of clinical presentations, treatment, and service delivery. Findings are reviewed and practice implications considered, resulting in proposed clinical recommendations and future research directions.

Background An overrepresentation of neurodevelopmental problems (NDPs) has been observed in individuals with avoidant/restrictive food intake disorder (ARFID). Previous studies on the association between ARFID and NDPs have been limited by cross‐sectional data from clinical samples of small size. This study aimed to extend previous research by using prospectively collected data in a non‐clinical child cohort. We examined the occurrence of early NDPs in 4–7‐year‐old children with suspected ARFID and how predictive early NDPs are of ARFID. Methods Data were collected via parent‐report a sub‐sample of the Japan Environment and Children's Study (JECS) including 3728 children born 2011–2014 in Kochi prefecture. NDPs were assessed biannually between 0.5 and 3 years of age with the Ages and Stages Questionnaire‐3, at age 2.5 years with the ESSENCE‐Q, and at age 1 and 3 years via parent‐reported clinical diagnoses. ARFID was identified cross‐sectionally (at age 4–7 years) using a newly developed screening tool. Logistic regressions were used to test association of (1) a composite early NDP risk score, (2) specific early NDPs, and (3) neurodevelopmental trajectories over time with ARFID. Results Children in the highest risk percentiles of the NDP risk score had roughly three times higher odds of having suspected ARFID; the absolute risk of later ARFID for children above the 90th percentile was 3.1%. Early NDPs (excluding early feeding problems) were more predictive of later ARFID than were early feeding problems. Specific NDPs predictive of ARFID were problems with general development, communication/language, attention/concentration, social interaction, and sleep. Neurodevelopmental trajectories of children with and without suspected ARFID started to divert after age 1 year. Conclusions The results mirror the previously observed overrepresentation of NDPs in ARFID populations. In this non‐clinical child cohort, early feeding problems were common and rarely developed into ARFID; however, our findings imply that they should be monitored closely in children with high NDP risk to prevent ARFID. In our sample of 3728 Japanese children from a non‐clinical cohort, circa 3% of children with neurodevelopmental problems between age 0.5 and 3 years screened positive for avoidant/restrictive food intake disorder (ARFID) between age 4 and 7 years. This reflects a three times increased risk of ARFID in children with early neurodevelopmental problems and suggests that early neurodevelopmental problems might aid in the early detection of ARFID. Neurodevelopmental trajectories of children with and without suspected ARFID started to divert after age 1 year.

Family-based interventions are widely recommended as a first line treatment for children and young people with Anorexia Nervosa. There is clear evidence that model-adherent delivery of specific eating disorder focused family interventions has the potential to help adolescents with Anorexia Nervosa, who have typically engaged in extreme dietary restriction and lost a significant amount of weight over a relatively short period of time. Nevertheless, there remains a significant number of young people with restrictive eating disorders for whom family-based interventions for Anorexia Nervosa prove less effective, suggesting adaptations may be indicated for some. In this paper we provide a rationale and structure for considering a number of possible adaptations to the delivery of family-based therapy for anorexia nervosa specifically intended to enhance its relevance and potential effectiveness for children and adolescents on the autism spectrum; a subgroup known to represent a significant minority in eating disorder populations who have been identified as having relatively poor outcomes. Plain English summary Past research has shown that certain family-based treatments are effective for many children and adolescents who develop Anorexia Nervosa. At the same time this type of treatment approach in its current form does not work for everyone. Recent research has highlighted the overlap between anorexia and autism and the need for the development of adaptations to existing treatments to better meet the requirements of people on the autism spectrum who develop anorexia. With this in mind we propose a number of autism-related adaptations that could be made to family-based treatments for anorexia. We hope that these might be formally tested in the future to see if these adaptations improve outcomes for this group of individuals.

Prompt access to evidence-based treatment for children and young people with eating disorders is important for outcomes, yet the gap in service provision remains pervasive. Record levels of young people are waiting for eating disorder treatment and access to care is limited. Guided self-help interventions that are brief and require minimal clinician support have the potential to meet the unprecedented demand for treatment quickly and effectively. To examine the feasibility, acceptability and proof of concept of a novel, CBT guided self-help intervention for children and young people with threshold and subthreshold eating disorders. A single-arm, proof-of-concept pilot study of the CBT guided self-help intervention will be conducted. Children and young people (aged 11-19) with threshold and subthreshold eating disorders will receive a self-help intervention covering the core components of CBT, supported by 8 weekly guidance sessions delivered remotely. Clinical outcomes (eating-related psychopathology and associated impairment, changes in weight, depression, anxiety, and behavioural difficulties) will be assessed at baseline and post-intervention (12 weeks). Feasibility and acceptability of the intervention will be measured using various outcomes, including adherence to, and engagement with the intervention, rates of recruitment and retention, measure completion and treatment satisfaction. Qualitative data will also be collected for future intervention refinement. If the intervention is shown to produce clinical benefits in this pilot study, a fully powered randomised pilot study will be warranted with the ultimate goal of increasing access to psychological treatment for children and young people threshold and subthreshold eating disorders. This study protocol (S1 File) adheres to the guidelines outlined in the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist for trial protocols [1, 2] which can be found in S1 Checklist. The numbers in parentheses in this protocol correspond to the item numbers in the SPIRIT checklist. The order of items has been modified to group similar items.

Background Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial. Overview of paper This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people. Plain English summary Eating disorders are among the most serious mental health problems affecting children and young people. There has been accumulating clinical and research evidence that early expert outpatient treatment is effective and can also significantly reduce the need for costly inpatient care, indicating that investing in community-based eating disorder services is likely to be both clinically and economically beneficial. This paper describes a large-scale service transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in new services for eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community eating disorders services for children and young people.

Background The World Health Organization (WHO) International Classification of Diseases and Related Health Problems (ICD) is used globally by 194 WHO member nations. It is used for assigning clinical diagnoses, providing the framework for reporting public health data, and to inform the organization and reimbursement of health services. Guided by overarching principles of increasing clinical utility and global applicability, the 11th revision of the ICD proposes major changes that incorporate empirical advances since the previous revision in 1992. To test recommended changes in the Mental, Behavioral, and Neurodevelopmental Disorders chapter, multiple vignette-based case-controlled field studies have been conducted which examine clinicians’ ability to accurately and consistently use the new guidelines and assess their overall clinical utility. This manuscript reports on the results from the study of the proposed ICD-11 guidelines for feeding and eating disorders (FEDs). Method Participants were 2288 mental health professionals registered with WHO’s Global Clinical Practice Network. The study was conducted in Chinese, English, French, Japanese, and Spanish. Clinicians were randomly assigned to apply either the ICD-11 or ICD-10 diagnostic guidelines for FEDs to a pair of case vignettes designed to test specific clinical questions. Clinicians selected the diagnosis they thought was correct for each vignette, evaluated the presence of each essential feature of the selected diagnosis, and the clinical utility of the diagnostic guidelines. Results The proposed ICD-11 diagnostic guidelines significantly improved accuracy for all FEDs tested relative to ICD-10 and attained higher clinical utility ratings; similar results were obtained across all five languages. The inclusion of binge eating disorder and avoidant-restrictive food intake disorder reduced the use of residual diagnoses. Areas needing further refinement were identified. Conclusions The proposed ICD-11 diagnostic guidelines consistently outperformed ICD-10 in distinguishing cases of eating disorders and showed global applicability and appropriate clinical utility. These results suggest that the proposed ICD-11 guidelines for FEDs will help increase accuracy of public health data, improve clinical diagnosis, and enhance health service organization and provision. This is the first time in the revision of the ICD that data from large-scale, empirical research examining proposed guidelines is completed in time to inform the final diagnostic guidelines.

Introduction Prior to the COVID-19 pandemic, research in virtual care for young people with eating disorders was preliminary and implementation rare. This study explored the experience of young people, parents and clinicians when therapy was transitioned to virtual provision as a result of the UK lockdown in March 2020. Methods A mixed-method approach was used in this study. Online questionnaires that included a mixture of rating (Likert scale) and free-text response questions were completed by 53 young people with any eating disorder, 75 parents and 23 clinicians. Questions focused on the experience of online treatment as well as the impact on engagement, perceived treatment efficacy and preferences around treatment mode in the future. Likert scale questions were analysed using a summary approach. Free-text responses were analysed qualitatively using reflexive thematic analysis. Results Responses to rating scale questions indicate satisfaction with treatment, good engagement and ability to manage technology. Young people who had transitioned care, rather than started care virtually in lockdown, rated therapy as less effective. However, individual accounts of experience were more varied. Reflexive thematic analysis of free-text responses identified key themes of 1) Making it work, 2) Home as a therapeutic space, and 3) Disrupted connection and 4) Into the future. Conclusions These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and therapeutic engagement and depth and need for consideration of equal access to treatment in socially unequal societies. Plain English summary Due to the COVID-19 pandemic specialist eating disorder treatment needed to quickly adapt to new technologies. All but urgent and crisis appointments needed to be delivered online. This study looked at what that was like for the young people, their parents and clinicians engaged in treatment in a large specialist eating disorder service in London, UK. Fifty-three young people with an eating disorder, 75 parents and 23 clinicians completed anonymous online surveys about their experience. Results showed that generally people were satisfied with treatment, the therapeutic relationship was maintained and most managed technological issues well. Four main themes were identified from responses to open ended free-text response questions. All three groups wrote about 1) making it work, 2) home as a therapeutic space, and 3) disrupted connection. The fourth theme, 4) into the future, came from parent and clinician responses only. These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and the potential impact on the therapeutic relationship. There is also a need to make sure there is equal access to treatment in socially unequal societies.

Background Feeding and eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Low intensity psychological interventions have the potential to increase such access. Methods A systematic review and meta-analysis were conducted on the use of low intensity psychological interventions for the treatment of feeding and eating disorders. Studies comparing low intensity psychological interventions against high intensity therapies and non-eating disorder specific psychological interventions were included, as well as those with waiting list control arms. There were three primary outcomes: eating disorder psychopathology, diagnostic and statistical manual of mental disorders (DSM) severity specifier-related outcomes and rates of remission/recovery. Results Thirty-three studies met the inclusion criteria, comprising 3665 participants, and 30 studies were included in the meta-analysis. Compared to high intensity therapies, low intensity psychological interventions were equivalent on reducing eating disorder psychopathology ( g  = − 0.13), more effective at improving DSM severity specifier-related outcomes ( g  = − 0.15), but less likely to achieve remission/recovery (risk ratio (RR) = 0.70). Low intensity psychological interventions were superior to non-eating disorder specific psychological interventions and waiting list controls across all three primary outcomes. Conclusion Overall, findings suggest that low intensity psychological interventions can successfully treat eating disorder symptoms. Few potential moderators had a statistically significant effect on outcome. The number of studies for many comparisons was low and the methodological quality of the studies was poor, therefore results should be interpreted with caution. More research is needed to establish the effectiveness of low intensity psychological interventions for children and young people, as well as for individuals with anorexia nervosa, avoidant/restrictive food intake disorder, pica and rumination disorder. Plain English summary Feeding and eating disorders can significantly impair health and psychosocial functioning. However, demand for eating disorder services is greater than services’ ability to deliver effective treatment. Low intensity psychological interventions, which are brief in nature and require less therapist input than standard treatments, have the potential to bridge this demand-capacity gap. The current review examined the effectiveness of low intensity psychological interventions for the treatment of feeding and eating disorders. Overall, findings suggest that low intensity psychological interventions can successfully treat eating disorder symptoms, particularly binge eating-related symptoms. Given their relatively low costs and ease of accessibility, such interventions can help people to access treatment at a time when this is so desperately needed. More research is needed to determine the value of low intensity psychological interventions for children and adolescents, and people with feeding and eating disorders that are not characterised by recurrent binge eating, such as anorexia nervosa, ARFID, pica and rumination disorder.

Background The Pica, ARFID, and Rumination Disorder Interview (PARDI) is a structured interview that can be used to determine diagnosis, presenting characteristics, and severity across three disorders, including avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate the psychometric properties of a questionnaire focused specifically on ARFID (PARDI-AR-Q), which has the potential to provide related information with less participant burden. Methods Adolescents and adults ( n  = 71, ages 14–40 years) with ARFID ( n  = 42) and healthy control participants (HC, n  = 29) completed the PARDI-AR-Q and other measures. A subset of the ARFID group ( n  = 27) also completed the PARDI interview. Results An exploratory factor analysis of proposed subscale items identified three factors corresponding to the ARFID phenotypes of avoidance based on the sensory characteristics of food, lack of interest in eating or food, and concern about aversive consequences of eating. Further analyses supported the internal consistency and convergent validity of the PARDI-AR-Q subscales, and subscale ratings on the questionnaire showed large and significant correlations (all p -values < 0.001; r ’s ranging from 0.48 to 0.77) with the corresponding subscales on the interview. The ARFID group scored significantly higher than HC on all subscales. Furthermore, 90% of the ARFID group scored positive on the PARDI-AR-Q diagnostic algorithm while 93% of the HC scored negative. Conclusions Though replication in larger and more diverse samples is needed, findings provide early support for the validity of the PARDI-AR-Q as a self-report measure for possible ARFID in clinical or research settings. Plain English summary Few measures are available for detecting avoidant/restrictive food intake disorder (ARFID) in clinics or research settings. This makes it difficult for individuals with the disorder to be identified and offered appropriate care. We developed the Pica, ARFID, and Rumination Disorder Interview ARFID Questionnaire (PARDI-AR-Q), a brief self-report measure of possible ARFID, and evaluated how well it worked in the current study. In our preliminary study of 71 adolescents and adults, most individuals with ARFID (90%) scored positive on this measure, whereas most healthy control participants (93%) scored negative. Our findings provide early support for the PARDI-AR-Q as a promising new measure for detecting possible ARFID when a full clinical interview is not possible.