Family-Based Treatment for Avoidant/Restrictive Food Intake Disorder Is About More Than Weight Gain.

We appreciate the many supportive and complimentary comments included in the editorial by Eddy and Thomas1 about our recently completed randomized clinical trial (RCT) comparing family-based treatment (FBT) to an individually focused psychoeducational motivation therapy (PMT) for avoidant/restrictive food intake disorder (ARFID) in underweight children.2 There are, however, several comments that were included in the editorial that we feel require additional clarification. The first is the impression that FBT is focused exclusively on weight gain. As with FBT for anorexia nervosa (AN) and bulimia nervosa (BN), in FBT-ARFID weight gain is often an important early goal for underweight children. However, cognitive, emotional, and developmental improvements are also crucial treatment aims of FBT.3 RCTs have confirmed that improvements in these domains are superior in FBT vs individual comparison treatments (adolescent focused treatment for AN and cognitive-behavioral therapy for BN).4,5 Second, the editorial suggests that FBT for ARFID does not include the child's perspective and wishes. This is not the case. In all manualized FBT treatments including FBT for AN, BN, or ARFID, the child or adolescent's perspective is part of family work and is always considered, from the first session to the last, although parents make the final decisions about how best to use these perspectives. Including the child's input on how to improve dietary range is clearly described in the published treatment manual for FBT-ARFD that was basis of treatment delivered in this RCT.6 The editorial also suggests that FBT-ARFID improved weight but not dietary range. Because of space limitations in this primary outcomes paper, we did not report detailed data related to how much and what kinds of foods were increased among the participants, but changes in severity ratings indicate an improved dietary range following FBT-ARFID. Baseline severity of ARFID symptoms also moderated the treatment effect on changes in severity, meaning that those individuals with the greatest severity improved significantly more in FBT than in PMT, suggesting that, in addition to weight gain, FBT improved other restrictive behaviors in those most affected. Future publication of secondary outcomes will provide more granular data on many clinical outcomes, including improvements in dietary range associated with both FBT and PMT. Finally, the comments in the editorial focused primarily on FBT, whereas PMT was effective in significantly improving ARFID symptoms except weight, especially for those who were not as severely affected. PMT is modeled in part on the non-confrontational model that Eddy and Thomas ascribe to Satter, and our findings suggest that this approach is useful as long as weight gain is not needed. We hope that these comments will help JAACAP readers better appreciate the outcomes of the RCT. Much work remains to be done to improve treatment for young people with ARFID, and we anticipate that this study will stimulate others to continue efforts to find novel approaches for treating this complex and challenging disorder.