Brief report early intervention in children with <scp>ARFID</scp>/<scp>ARFID</scp>‐like symptoms

Avoidant restrictive food intake disorder (ARFID) is a DSM-V diagnostic term for disordered eating leading to children not being able to meet appropriate nutrition requirements, resulting in physical or psychosocial impairment. ARFID has three main overlapping drivers: apparent lack of appetite or interest in food, fear of aversive consequences, that is choking, and avoidance of food based on sensory characteristics.1 ARFID-like symptoms affect children to varying degrees, and often cause them and their family significant distress.2 International guidance recommends the clinical care involves assessment and support from a multidisciplinary team, including mental and physical healthcare professionals. Although a multidisciplinary team approach within Child and Adolescent Mental Health Service is recommended as optimal3 addressing medical, nutritional, skills-sensory based or behavioural aspects relating to the disorder,4 there is no consensus to which healthcare professionals are best placed to provide this support. This lack of consensus regarding the best clinical pathways for children affected by ARFID/ARFID-like symptoms may inadvertently lead to delays in receiving treatment, with anecdotal reports of children awaiting a formal diagnosis within national health services (NHS) are waiting for up to a year to receive support. In addition, as children with ARFID/ARFID-like symptoms present in numerous different settings across child-health services and within educational settings, little is known about whether early intervention or prevention strategies could reduce symptoms exacerbation or lead to earlier improvement in feeding. The aim of this service evaluation is to explore the characteristics of children referred with ARFID/ARFID-like symptoms to two NHS Child and Adolescent Mental Health Service teams in the north of England. Acceptance criteria for Group sessions; for carers of children awaiting a formal diagnosis of ARFID. An experienced mental healthcare practitioner screened referrals and triaged carers using parent-reported age-appropriate Pica, ARFID and Rumination Disorder Interview (PARDI-AR-Q) questionnaire.5 Children of all ages (≤18 years) were accepted onto the waiting list for group sessions if they presented with a rating of ARFID profile score or severity of impact of ≥3 in any of the four domains (e.g. severity of impact (range 0–6), sensory-based avoidance (range 0–6), lack of interest (range 0–6) or concerns about aversive consequences (range 0–6)), along with an affirmative score for diagnostic prediction (yes/no), and behaviours impacting on daily functioning (e.g. school-attendance, ability to socialise and increased stress in the family due to feeding difficulties). The group sessions were provided over 8 weeks with a weekly 90-min session led by a mental health practitioner or dietitian and supported by an occupational therapist, or family therapist. The structured sessions provided information on, what is ARFID/ ARFID-like symptoms, components of a healthy diet, mealtime habits, food strategies, motivation and change, young person's mental health, carers coping strategies and support networks, and keeping positive. Homework tasks were provided at the end of each session to complete with their child where appropriate. Acceptance criteria for individual sessions; a body mass index percentage <80%, or weight either static or ongoing recent weight loss, formal diagnosis of ARFID, previous unsuccessful interventions from dietitian or paediatric multidisciplinary team -, reliance on artificial nutrition, nutritional inadequacy arising from a very limited range of foods, or food intake or recent reduction in range of accepted foods, or high levels of distress reported by child or carers. Mental health practitioners provided individualised sessions using family-based treatment or cognitive behavioural therapy approaches. Sessions include components relating to psychoeducation and early change, treatment planning, addressing maintaining mechanisms and relapse prevention. A retrospective data extraction for children referred to Child and Adolescent Mental Health Services across two integrated care boards within a northern NHS mental health partnership was completed using Power-Bi (Microsoft, Redmond, WA, USA) between May 2023 and February 2024. Group sessions: Although there were no significant differences in pre- and post-group questionnaires of eating behaviour on mental health of carers 7.4 ± 2.0 vs. 8.2 ± 1.9 (p = 0.58) and children 7.7 ± 2.1 vs. 7.0 ± 2.0 (p = 0.37); following the group sessions carers felt significantly more confident in managing their child's eating 5.3 ± 1.9 vs. 7.8 ± 0.4 (p = 0.01). 10% (n = 3/32) of children in the group sessions were gastrostomy fed, with a further 32 children requiring oral nutrition support (ONS) of which 72% (n = 23/32) were compliant with the prescribed amount. Individual sessions: 60% (n = 3/5) of those accepted were receiving ONS with 100% (n = 3/3) compliance. None of the children receiving individual support required enteral tube feeds (Table 1). These results suggest children with ARFID/ARFID-like symptoms,5 whose carers received group-session support had similar PARDI-AR-Q scores compared to those requiring individual sessions. As waiting lists for specialist provision via tertiary MDT paediatric services and Child and Adolescent Mental Health Services teams within the NHS are long, early support for carers using group sessions may help to develop a better understanding of their child's eating and feel more supported by healthcare professionals. Although this is only a small service evaluation using group sessions, earlier intervention using a structured manualised approach may help prevent symptom exacerbation and distress in children and carers, decrease waiting times and reduce the health-economic impact on healthcare systems. There are several limitations of this study, including the retrospective nature and small sample size of children with ARFID/AFRID-like symptoms. A prospective longitudinal randomised-controlled study is required to explore the use of group sessions on important physical and mental health outcomes of children with ARFID/ ARFID-like symptoms and families. No funding is associated with this work. Luise V. Marino: Writing – original draft; writing – review and editing; formal analysis; data curation; supervision; methodology; investigation. Jessica Merrin: Methodology; investigation; writing – review and editing; data curation. Lizzie Dodd: Writing – review and editing; investigation; data curation; methodology. Vic Humble: Data curation; writing – review and editing; methodology. Clare Longfellow: Data curation; writing – review and editing; methodology; investigation. Elizabeth Barnsley: Conceptualization; writing – review and editing. Rosan Meyer: Writing – review and editing; supervision. Luise Marino has received honorarium to give lectures for Abbott Laboratories, Danone and Nestle, who had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. None of the other authors declare conflict of interest.