TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 250 Sometimes the individual with ARFID restricts certain foods, and at other times, there is an inadequate intake of vitamins and minerals. The inadequacy of energy intake may result in a child’s poor growth, weight loss or low weight. In their study on picky eating among children, Jacobi, Schmitz, and Agras (2008) pointed out that the longer the duration of the pickiness, the more avoidant the child becomes to trying new foods. However, children with ARFID are more than just picky eaters, as they suffer from failure to meet nutritional and/or energy needs that may result in weight loss. As the criteria imply, some of these individuals must rely on enteral feeding. The clinical presentation of ARFID is quite variable (Bryant-Waugh & Kreipe, 2012). Over time, there may be evidence that subgroups of the disorder are present, requiring further classification. Bryant-Waugh and Kreipe (2012) describe several presentations that include some of the ARFID symptoms. For example, some children (and some adults) eat only certain-colored foods or foods with a particular texture, thus ingesting only a narrow range of foods. Others may avoid certain foods based on past negative experiences with them, usually gastrointestinal problems. While there is no specific assessment for ARFID, careful clinical interviewing, including parental observations and a medical evaluation, are necessary for diagnosis. Because ARFID and AN share many common symptoms in childhood and young adulthood (e.g., low weight, food avoidance), differential diagnosis may be difficult (APA, 2013a). The DSM-5 reminds counselors that in AN, the individual has a persistent fear of becoming fat and/or gaining weight, which is not present in ARFID. We refer readers to Bryant-Waugh (2013) for a case study of a child with ARFID, including assessment questions and treatment. Anorexia Nervosa The DSM-5 diagnostic criteria for AN reflect several significant changes from the criteria outlined in DSM- IV-TR . There are two particularly noteworthy changes to the first criterion for an AN diagnosis in DSM-5 . The first of these is that what was described as “refusal to maintain body weight” in the DSM-IV-TR (APA, 2000, p. 589) has been reframed as “restriction of energy intake relative to requirements” in the DSM-5 (APA, 2013a, p. 338). The removal of the word refusal , which has negative connotations, results in a more neutrally worded criterion. Moreover, the new phrasing of this criterion in DSM-5 focuses specifically on the central behavioral component of AN (i.e., restriction of intake), rather than upon the results of this behavior (i.e., body weight). The second key change to this first criterion is that the specific guideline provided in DSM-IV-TR as a definition of a less than “minimally normal” body weight (i.e., below “85% of that expected”; APA, 2000, p. 589) no longer appears in the DSM-5 . The new criterion instead highlights the essential role of context (e.g., age, sex, developmental status) in determining whether a particular individual is at a “significantly low weight” for his or her own body (APA, 2013a, p. 338). This change is particularly important because, while the DSM-IV- TR clarifies that 85% is intended as a guideline, once incorporated into the criteria, it became in many cases a requirement for insurance reimbursement (Hebebrand & Bulik, 2011). The second criterion for AN previously included only the cognitive symptom of “intense fear of gaining weight or becoming fat” (APA, 2000, p. 589). That same language appears in the DSM-5 , but the new criterion includes a behavioral component as well. Moreover, because the word or is used rather than and , the behavioral manifestation of this criterion can actually stand in for other, more overt expressions of the cognitive component. In other words, according to the DSM-5 , an individual engaging in “persistent behavior that interferes with weight gain” (APA, 2013a, p. 338) can now meet this second criterion even if he or she does not explicitly communicate anxiety around weight gain. This change may have particular relevance in pediatric cases, because some children with AN have not yet developed the cognitive abilities required either to have or to express this intense fear (Bravender et al., 2010; Reierson & Houlihan, 2008; Workgroup for Classification of Eating Disorders in Children and Adolescents, 2007).