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Cited by 88Eating Disorders and BehaviorsChild Nutrition and Feeding IssuesAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder

Open access
Thomas, Jennifer J., Becker, Kendra R., Breithaupt, Lauren, Murray, Helen Burton, Jo, Jenny H., Kuhnle, Megan C., Dreier, Melissa J., Harshman, Stephanie +6 more·2021·Journal of Behavioral and Cognitive Therapy
DOI 10.1016/j.jbct.2020.10.004PMC PMC8375627
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Abstract

There are currently no evidence-based treatments for adults with avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate the acceptability, feasibility, and proof-of-concept of cognitive-behavioral therapy for ARFID (CBT-AR) for adults. Males and females (ages 18–55 years) were offered 20-30 outpatient sessions of CBT-AR delivered by one of five therapists. Of 18 eligible adults offered CBT-AR, 15 chose to participate and 14 completed treatment. All patients endorsed high ratings of treatment credibility and expected improvement after the first session, and 93% of completers provided high ratings of satisfaction at the conclusion of treatment. Therapists rated the majority (80%) of patients as “much improved” or “very much improved.” Based on intent-to-treat analyses, ARFID severity on the Pica, ARFID, and Rumination Disorder Interview (PARDI) showed a large and significant decrease from pre- to post-treatment; and patients incorporated a mean of 18.0 novel foods. The underweight subgroup (n = 4) gained an average of 11.38 pounds, showing a large and significant increase in mean BMI from the underweight to the normal-weight range. At post-treatment, 47% of patients no longer met criteria for ARFID. To our knowledge, this is the first prospective treatment study of ARFID in adults. The findings of this study provide preliminary evidence of feasibility, acceptability, and proof-of-concept of CBT-AR for heterogeneous presentations of ARFID in adults. Randomized controlled trials are needed to confirm these findings. ClinicalTrials.gov Identifier: NCT02963220.

AI snapshot

Written from the paper’s full text.

TL;DR

This first prospective treatment study of adults with avoidant/restrictive food intake disorder (ARFID) found that cognitive-behavioral therapy for ARFID (CBT-AR) was feasible, acceptable, and showed preliminary proof-of-concept. Of 15 adults who initiated treatment, 14 completed, with significant reductions in ARFID severity and 47% no longer meeting ARFID criteria at post-treatment.

Key findings

  • Of 18 eligible adults offered CBT-AR, 15 chose to participate and 14 completed treatment; 93% of completers rated high satisfaction on the CSQ.
  • Therapists rated 80% of patients as “much improved” or “very much improved” on the CGI.
  • Intent-to-treat analyses showed a large and significant decrease in PARDI ARFID overall severity (p < .001); patients incorporated a mean of 18.0 (SD = 13.2) novel foods.
  • The underweight subgroup (n = 4) gained an average of 11.38 (SD = 7.47) pounds, with a significant increase in mean BMI (p = .04) and all four achieving BMI > 18.5; 47% (n = 7) no longer met ARFID criteria at post-treatment (p = .01). Anxiety (p = .78) and depression (p = .26) did not change.

Methods

  • Open pilot/proof-of-concept study of adults ages 18–55 years recruited from an observational neurobiology study (ages 18–23) and consecutive clinical referrals for ARFID treatment at Massachusetts General Hospital.
  • Patients received 20–30 outpatient CBT-AR sessions delivered by one of five doctoral or master’s level therapists; treatment was manualized, with high fidelity (M = 6.96, SD = 0.21 on a 7-point scale) and competence (M = 4.99, SD = 0.11 on a 5-point scale).
  • Intent-to-treat analyses used paired t-tests, McNemar’s chi squared tests, and Cohen’s d; post-treatment assessments were conducted on all patients except one dropout, for whom baseline assessment was carried forward.

Limitations

  • The authors state the sample size was small, effect size estimates may be unstable, and p-values require cautious interpretation.
  • The authors state there was no control group, so alternative explanations such as therapist attention or passage of time cannot be ruled out.
  • The authors also state possible recruitment/payment effects on low dropout, a mostly non-Hispanic white sample, use of the KSADS with a subset of young adults, and limited ability to draw conclusions about family-supported CBT-AR for adults.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.jbct.2020.10.004

Cites

27 of 27 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 25 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    All patients endorsed high ratings of treatment credibility and expected improvement after the first session.

    “All patients endorsed high ratings of treatment credibility and expected improvement after the first session”
    Quote in the paperSubstantial claim
  • Findingown data

    Of 18 eligible adults offered CBT-AR, 15 chose to participate.

    “Of the 18 patients offered CBT-AR, 15 chose to participate.”
    Quote in the paperSubstantial claim
  • Findingown data

    PARDI fear of aversive consequences decreased at trend level (p = .06) with a small effect size.

    “PARDI fear of aversive consequences decreased at trend level with a small effect size (p = .06).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The underweight subgroup (n = 4) gained an average of 11.38 (SD = 7.47) pounds.

    “The underweight subgroup (n = 4) gained an average of 11.38 (SD = 7.47) pounds”
    Quote in the paperSubstantial claim
  • Findingown data

    Approximately half of the sample received some or all CBT-AR sessions via video.

    “Approximately half of our sample received some or all CBT-AR sessions via video.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 11
  • Classified as probably not a substantial claim. 12

  • May combine two claims.

    Findingown data

    The underweight subgroup showed a trend-level increase in weight (p = .06) with a large effect size.

    “representing a trend-level increase in weight (p = .06) and a significant increase in BMI (p = .04), both with large effect sizes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    One patient dropped out after two sessions.

    “One patient dropped out after two sessions in the setting of flu-like and gastrointestinal symptoms.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    47% (n = 7) of patients no longer met criteria for ARFID at post-treatment, a significant change from pre-treatment when 100% met criteria (p = .01).

    “Using the PARDI diagnostic algorithm, 47% (n = 7) of patients no longer met criteria for ARFID at post-treatment, representing a significant change from pre-treatment when 100% met criteria (p = .01).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The underweight subgroup showed a significant increase in BMI (p = .04) with a large effect size, moving from the underweight to the normal-weight range.

    “moving from an average BMI in the underweight range to an average BMI in the normal-weight range, representing a trend-level increase in weight (p = .06) and a significant increase in BMI (p = .04), both with large effect sizes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In a 2014 Australian sample of 3005 people ages 15 and older, the point prevalence of ARFID was 0.3%, compared to 0.4% for anorexia nervosa.

    “In a recent study of 3005 Australians ages 15 and older, the point prevalence of ARFID in 2014 was 0.3%, compared to 0.4% for anorexia nervosa (Hay et al., 2017).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hay et al., 2017

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    The sample size was small, rendering effect size estimates potentially unstable and requiring cautious interpretation of p-values.

    “First and most importantly, the sample size was small, rendering effect size estimates potentially unstable and requiring cautious interpretation of p-values.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    CBT-AR showed preliminary evidence of feasibility, acceptability, and proof-of-concept for adults with ARFID.

    “In our initial study of 15 patients, CBT-AR showed preliminary evidence of feasibility, acceptability, and proof-of-concept.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The Clinical Impairment Assessment (CIA) measures functional impairment related to eating, shape, and weight in adults with eating disorders.

  • May combine two claims.

    Interpretationown data

    Children and adolescents may respond more fully than adults to ARFID treatment, or perhaps have a better overall prognosis.

    “The finding that children and adolescents may respond more fully than adults to ARFID treatment, or perhaps have a better overall prognosis, mirrors the literature for anorexia nervosa (e.g., Jagielska & Kacperska, 2017; Kass, Kolko & Wilfley, 2013).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Jagielska & Kacperska, 2017

      Not checked in the free run.

    • cites Kass et al., 2013 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The trial was registered at ClinicalTrials.gov prior to data collection.

    “The trial was registered at ClinicalTrials.gov (Identifier: NCT02963220) prior to data collection.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Significance level was set at p < .05 and no correction for family-wise error was made given the preliminary nature of the study.

    “We set the significance level at p < .05 and did not correct for family-wise error given the preliminary nature of the study.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Intent-to-treat analyses were used.

    “To test our proof-of-concept hypotheses, we considered responses from both therapists and patients using intent-to-treat analyses.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    ARFID symptoms in adults are severe and impairing.

    “The few studies that have examined ARFID and associated psychopathology in adults suggest that its symptoms are severe and impairing (e.g., Nakai, Nin, Noma, Teramukai, & Wonderlich, 2016); Zickgraf, Franklin, & Rozin, 2016)”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Nakai et al., 2016 source

      Not checked in the free run.

    • cites Zickgraf et al., 2016 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The KSADS (originally designed for children and adolescents) was used with a subset of young adults.

    “Fifth, we used the KSADS (originally designed for use with children and adolescents) with a subset of young adults in the current study who were drawn from a neurobiology study with a younger age range.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Video delivery had benefits including immediate accessibility of food in the home and increased convenience of attending sessions.

    “However, video delivery had many of the benefits previously noted for other forms of behavioral treatment for eating disorders (Matheson et al., 2020; Waller et al., 2020), including the immediate accessibility of food in the home (which facilitated the completion of in-session food preparation and exposures), and the increased convenience of attending sessions (which may have contributed to low”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Matheson et al., 2020 source

      Not checked in the free run.

    • cites Waller et al., 2020 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Independent assessors who were not study therapists conducted all PARDIs.

    “Independent assessors who were not study therapists conducted all PARDIs.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    ARFID may be just as common as the better-known eating disorders.

    “and that ARFID may be just as common as the better-known eating disorders.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hay et al., 2017

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Recruiting participants from those already willing to take part in an intensive longitudinal neurobiology study and paying them for completing assessments may have contributed to the low rate of treatment dropout.

    “Third, it is possible that recruiting participants from those who were already willing to take part in an intensive longitudinal neurobiology study, and then paying them for completing assessments, may have contributed to the low rate of treatment dropout.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    CBT-AR is a promising new treatment worthy of further evaluation for adults with ARFID.

    “suggest that CBT-AR is a promising new treatment worthy of further evaluation for adults with ARFID.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Findings suggest that CBT-AR is a potentially efficacious treatment for adults with ARFID that requires more rigorous evaluation.

    “Taken together, findings suggest that CBT-AR is a potentially efficacious treatment for adults with ARFID that requires more rigorous evaluation.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The Clinical Impairment Assessment (CIA) measures functional impairment related to eating, shape, and weight in adults with eating disorders.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Most of the sample was non-Hispanic white.

    “Fourth, most of the sample was non-Hispanic white.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Post-treatment assessments were conducted on all patients except one dropout, for whom baseline assessment was carried forward.

    “We conducted post-treatment assessments on all patients, except for our one dropout, for whom we used baseline assessment carried forward.”
    Quote in the paperSubstantial claim
21 of 21

  • The paper relies on this without support.

    The majority of research on ARFID has focused on children.

    “However, the majority of research has focused on children.”

  • The paper relies on this without support.

    The Clinical Impairment Assessment (CIA) measures functional impairment related to eating, shape, and weight in adults with eating disorders.

    “The CIA is a self-report questionnaire that measures functional impairment related to eating, shape, and weight in adults with eating disorders.”
2 of 2

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Cites

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Research works printed but not linked: 1

  1. Sheehan, 1998, The Mini International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview, Journal of Clinical Psychiatry, 59, 22

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Authors
Thomas, J. J., Becker, K. R., Breithaupt, L., Murray, H. B., Jo, J. H., Kuhnle, M. C., Dreier, M. J., Harshman, S., Kahn, D. L., Hauser, K., Slattery, M., Misra, M., Lawson, E. A., & Eddy, K. T.
Affiliations
  • Harvard University (US)
  • Massachusetts General Hospital (US)
Corresponding author
Thomas, Jennifer J.
ORCID
Venue
Journal of Behavioral and Cognitive Therapy
Publisher
Elsevier BV
Published
2021-03
Volume
31
Issue
1
Pages
47-55
ISSN
2589-9791 (ISSN-L)
DOI
10.1016/j.jbct.2020.10.004
PMC
PMC8375627
OpenAlex
W3135691280
Semantic Scholar
9a69a37bf1912771611b54af400743b1fd3e315e
Cited by
88
References
27
Citations by year
2026: 15 · 2025: 18 · 2024: 25 · 2023: 16 · 2022: 11 · 2021: 3
FWCI
9.38
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Behavioral and Cognitive Therapy (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion, cc-by-nc-nd)
Funders
  • Hilda and Preston Davis Foundation
  • Massachusetts General Hospital (K24 MH120568, R01 MH108595)
  • Global Foundation for Eating Disorders
  • National Institute of Mental Health
  • American Psychological Foundation
Topics
  • Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
avoidant/restrictive food intake disorder, cognitive behavioral therapy, adults, treatment acceptability, treatment feasibility, proof of concept, weight gain, underweight, eating disorders

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