With gold standard treatment yet to be defined, Avoidant/Restrictive Food Intake Disorder (ARFID) represents a lesser known and lesser understood eating disorder diagnosis. Clients present with a wide range of ages, symptoms, subtypes, etiologies, and therapeutic experiences, leading many providers to feel uncertain about working with this population. We’ve heard:
- “ARFID clients are so different from those with Anorexia Nervosa. Why do we treat them together in the same tracts?”
- “Mainstream eating disorder treatment emphasizes refeeding and weight restoration, but this does not feel relevant for my ARFID clientele.”
- “Food exposures don’t seem to help.”
- “I was relieved to have a protocol, but it doesn’t feel right. I’m not even sure what to ask about.”
What would it look like to consider the variation we see in ARFID as an invitation to explore instead of an obstacle to fear? Responsive Feeding Therapy (RFT) embraces such an approach.
According to a recently published white paper by Rowell, Wong, Cormack, and Moreland, RFT is an intervention that “facilitates the (re)discovery of internal cues, curiosity, and motivation, while building skills and confidence. It is flexible, prioritizes the feeding relationship, and respects and develops autonomy.” This framework honors the individuality of each client, recognizing eating behaviors as a response to a person’s past or present environment rather than as pathology to amend.
Another component of RFT is the acknowledgment that early eating experiences set the stage for our relationships with food and body, which spans interoception, self-regulation, neural and emotional pathways, and more. One outpatient ARFID study, for instance, found that the onset of eating challenges occurred before the age of three in almost all participants (Zickgraf 2019). These first years matter. Thus, a thorough history of feeding and eating challenges – as well as of previous treatment and response – is a key piece of the healing puzzle.
In addition to sensory, oral-motor, metabolism, temperament, disgust, trauma, aversive experiences, anxiety, and other factors, the impact of feeding dynamics should be considered in the development of avoidant, selective, and anxious eating. Crying or gagging, for instance, may harken back to years of childhood mealtimes rife with anxiety, conflict, and pressure to eat (which often stems from well-intentioned caregiver concerns around low-weight or nutritional deficiencies). It is unlikely that feeding difficulties will resolve without addressing these broader contexts.
Regardless of the root cause(s), RFT-trained practitioners maintain that both caregiver and child are doing the best they can, avoid placing shame or blame, and approach therapeutic goals with the following values front of mind (as overviewed by Rowell et al. 2020):
- “Autonomy pertains to agency and respect for personal space and bodily integrity, enabling a person to be in control of their own actions
- Relationship refers to warm and attuned interpersonal connections
- Internal motivation describes a desire to act that is self-driven rather than brought about by external forces
- Individualized care refers to personalized interventions with a focus on the whole person, in the context of their families, communities, and cultures
- Competence means the individual’s perceived (as opposed to objectively assessed) sense of having sufficient skills to manage a situation”
As a whole, RFT opens opportunities for clinicians to utilize a variety of skill sets for optimal care. The therapeutic toolkit may include motivational interviewing, Dialectical Behavior Therapy, somatic healing, Cognitive Behavioral Therapy, nutrition counseling, emotion coaching, interoception support, and therapeutic relationships – to name just a few. This individualized process improves both outcomes for the client and personal satisfaction for the dietitian.
Hungry for further learning? EDRD Pro is pleased to produce ARFID for Dietitians: A Responsive Feeding Therapy Approach, a virtual course launching January 2021! You’ll learn from five experts in eating and feeding disorders on the complexities of selective and avoidant eating, with an emphasis on ARFID and RFT. Along with a thorough exploration of ARFID etiology, subtypes, and treatment, this 3-part 12-hour workshop-style series includes panels and Q&As for learning how to best support clients with avoidant/selective eating across the lifespan.
Dietitians earn 19 CEs upon completion. Details and registration at https://edrdpro.com/arfid-for-dietitians-a-responsive-feeding-therapy-approach/