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Intensive, Manual‐based Intervention for Pediatric Feeding Disorders: Results From a Randomized Pilot Trial
Abstract
Objectives: The aim of this pilot study was to investigate feasibility and preliminary efficacy of an intensive, manual‐based behavioral feeding intervention for children with chronic food refusal and dependence on enteral feeding or oral nutritional formula supplementation. Methods: Twenty children ages 13 to 72 months (12 boys and 8 girls) meeting criteria for avoidant/restrictive food intake disorder were randomly assigned to receive treatment for 5 consecutive days in a day treatment program (n = 10) or waitlist (n = 10). A team of trained therapists implemented treatment under the guidance of a multidisciplinary team. Parent training was delivered to support generalization of treatment gains. We tracked parental attrition and attendance, as well as therapist fidelity. Primary outcome measures were bite acceptance, disruptions, and grams consumed during meals. Results: Caregivers reported high satisfaction and acceptability of the intervention. Three participants (1 intervention; 2 waitlist) dropped out of the study before endpoint. Of the expected 140 treatment meals for the intervention group, 137 (97.8%) were actually attended. The intervention group showed significantly greater improvements (P < 0.05) on all primary outcome measures (d = 1.03–2.11) compared with waitlist (d = −1.13–0.24). A 1‐month follow‐up suggested stability in treatment gains. Conclusions: Results from this pilot study corroborate evidence from single‐subject and nonrandomized studies on the positive effects of behavioral intervention. Findings support the feasibility and preliminary efficacy of this manual‐based approach to intervention. These results warrant a large‐scale randomized trial to test the safety and efficacy of this intervention.
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“Early medical conditions and/or somatic symptoms such as abdominal pain may lead some with ARFID to experience somatic sensations as aversive.”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Sharp et al., 2016
In the citing paper
“in a pilot treatment study for children with ARFID, 60% had gastroesophogeal reflux, a condition whereby pain follows eating (Sharp et al., 2016).”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Sharp et al., 2016
In the citing paper
“several case studies have demonstrated the success of core ARFID treatments, particularly behavioural interventions, in a non-autistic population, [87][88][89]”
From Avoidant/Restrictive Food Intake Disorder and Severe Food Selectivity in Children and Young People with Autism: A Scoping Review (2022) · cites this paper as [89]
In the citing paper
“There are currently a number of promising psychosocial treatments for ARFID in children and adolescents (e.g., Dumont, Jansen, Kroes, de Haan, & Mulkens, 2019); Lock, Sadeh-Sharvit, & L’Insalata, 2019; Sharp et al., 2016; Thomas et al., in press).”
From Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder (2021) · cites this paper as Sharp et al., 2016
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Self-citationAvoidant/restrictive food intake disorder: A systematic scoping review of the current literature
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“…of outpatient therapy, the patient was fully weight restored, experienced a substantial improvement in appetite and decreased oppositional behaviour Sharp et al. (2016) USA (Treatment interventions) To investigate the feasibility and preliminary efficacy of an intensive, manual-based behavioural…”
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“34 In general, treatment is individualised on the basis of the main feeding or eating dif fi culty and the factors contributing to aetiology.”
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“Only three small randomized controlled trials have been published, and all have focused on young children ages 13 months to 12 years (Sharp et al., 2016; Sharp et al., 2017; Lock et al., 2019a).”
BackgroundEvaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents
Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018) · Current Pediatrics Reports · doi:10.1007/s40124-018-0162-y · Cited by 138
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“That is, studies focused particularly on pediatric feeding disorders (e.g., Sharp et al., 2016), and many concern feeding problems before they were named ARFID; fear of eating is usually treated by systematic desensitization techniques where escape extinction, distraction, and/or relaxation…”
BackgroundCognitive–behavioral treatment of avoidant/restrictive food intake disorder
Thomas, J. J., Wons, O. B., & Eddy, K. T. (2018) · Current Opinion in Psychiatry · doi:10.1097/yco.0000000000000454 · Cited by 97
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“For example, in a pilot treatment study for children with ARFID, 60% had gastroesophogeal reflux, a condition whereby pain follows eating (Sharp et al., 2016).”
Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder
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., et al. (2021) · Journal of Behavioral and Cognitive Therapy · doi:10.1016/j.jbct.2020.10.004 · Cited by 88
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Pehlivan, M. J., Miskovic-Wheatley, J., Lê, Â. H., Maloney, D., National Eating Disorders Research Consortium, Touyz, S., & Maguire, S. (2022) · Journal of Eating Disorders · doi:10.1186/s40337-022-00671-1 · Cited by 71
“Further, piloting of a 5-day program for ARFID involving an MDT resulted in positive changes in meal-time behaviours and amount of food consumed in a small group of young children, compared to wait-list controls [78].”
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“The youngest participant was aged 13 months (Sharp et al., 2016) and the oldest participant was 55 years (Thomas et al., 2021).”
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Strand, M., von Hausswolff‐Juhlin, Y., & Welch, E. (2018) · International Journal of Eating Disorders · doi:10.1002/eat.22962 · Cited by 68
Assessment and Treatment of Avoidant/Restrictive Food Intake Disorder
Kambanis, P. E., & Thomas, J. J. (2023) · Current Psychiatry Reports · doi:10.1007/s11920-022-01404-6 · Cited by 76
Becker, K. R., Mancuso, C., Dreier, M. J., Asanza, E., Breithaupt, L. E., Slattery, M. J., Plessow, F., Micali, N., Thomas, J. J., Eddy, K. T., et al. (2021) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2021.105243 · Cited by 61
“Individuals with low-weight ARFID tend to present in childhood or early adolescence due to a younger age of onset (often in infancy or early toddlerhood; Sharp et al., 2016).”
Mammel, K. A., & Ornstein, R. M. (2017) · Current Opinion in Pediatrics · doi:10.1097/mop.0000000000000507 · Cited by 56
Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years
Clark, G. F., & Kingsley, K. L. (2020) · American Journal of Occupational Therapy · doi:10.5014/ajot.2020.743001 · Cited by 66
“The use of a manualized behavioral intervention via a tablet signi fi cantly increased accepted bites and decreased mealtime disruptions after 14 meal blocks (40 min each) over 5 days compared with controls (Sharp et al., 2016).”
Avoidant Restrictive Food Intake Disorder
Katzman, D. K., Norris, M. L., & Zucker, N. L. (2018) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2018.10.003 · Cited by 50
“Although the important proximal goal is to increase the mental and physical health of the child, interventions that deliberately attempt to create pleasant associations with the family eating environments and that attempt to decrease caregiver burden and distress are critical components of intervention strategies.(37)…”
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Peterson, K. M., Piazza, C. C., Ibañez, V. F., & Fisher, W. W. (2019) · Journal of Applied Behavior Analysis · doi:10.1002/jaba.650 · Cited by 48
Sharp, W. G., Volkert, V. M., Stubbs, K. H., Berry, R. C., Clark, M. C., Bettermann, E. L., McCracken, C., Luevano, C., McElhanon, B. O., & Scahill, L. D. (2020) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2020.04.034 · Cited by 48
Self-citationAvoidant/Restrictive Food Intake Disorder
Bryant‐Waugh, R. (2019) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2019.05.004 · Cited by 47
Avoidant/restrictive food intake disorder: what do we know so far?
Coglan, L., & Otasowie, J. (2019) · BJPsych Advances · doi:10.1192/bja.2018.48 · Cited by 45
“Sharp et al (2016), in a pilot trial, developed an intensive manual-based behavioural feeding intervention for chronic severe food refusal in children aged between 13 and 72 months.”
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Sharp, W. G., Allen, A. G., Stubbs, K. H., Criado, K. K., Sanders, R., McCracken, C. E., Parsons, R. G., Scahill, L. D., & Gourley, S. L. (2017) · Translational Psychiatry · doi:10.1038/tp.2017.126 · Cited by 39
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“A hunger provocation program (Hartdorff et al., 2015) and an outpatient behavioral program (Sharp et al., 2016) both reported signi fi cant improvements in the achievement of full oral feeds, increased volume consumed orally, and body mass index – height ratio and weight gain compared with a…”
Anderson, R., Taylor, S. A., Taylor, T., & Ortega, J. V. (2021) · Behavioral Interventions · doi:10.1002/bin.1832 · Cited by 37
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“While only a minority of group studies used randomized assignment (Benoit et al., 2000; Hartdorff et al., 2015; Sharp et al., 2016), the outcomes of the RCTs included in the review did not demonstrate distinctive departures from the overall outcomes observed in non-randomized and uncontrolled group…”
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Treatment of avoidant/restrictive food intake disorder: a systematic review
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“…further confirmation, because the outcomes were evaluated only in four studies (Bryson et al., 2018; Dumont et al., 2019; Lange et al., 2019; Sharp et al., 2016), is that weight recovery is maintained at follow-up in a fair percentage of participants and treatments tend to lead to an…”
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“Clinically, individuals with ARFID report uncomfortable somatic experiences after eating, such as gastroesophageal reflux or gastric discomfort with satiety [24].”
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“ARFID is present throughout development, from very young children (Sharp et al., 2016; Zucker et al., 2019), midchildhood, and adolescents (Dumont, Jansen, Kroes, de Haan, & Mulkens, 2019; Lock, SadehSharvit, & L’Insalata, 2019; Ornstein, Essayli, Nicely, Masciulli, & Lane-Loney, 2017) to adults…”
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“Before 2020, few randomised controlled trials had been conducted, which had focused on integrative behavioural (Sharp et al., 2016) or family-based treatments (Lock et al., 2019) in children ages 13 months to 12 years with feeding and eating disorders.”
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“…across studies; however, many of the clinical outcomes found in the current study appear to be relatively comparable to multidisciplinary treatment approaches in the literature (Sharp et al. 2016; Ornstein et al. 2017; Shimshoni, Silverman, and Lebowitz 2020; MacDonald, Liebman, and Trottier 2024).”
Intervention for Feeding Difficulties in Children With a Complex Medical History
Marshall, J., Hill, R. J., Wallace, M., & Dodrill, P. (2017) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/mpg.0000000000001683 · Cited by 14
“Intervention based on operant conditioning (OC) is commonly used (9,10), and can involve a range of OC techniques broadly including reinforcement, punishment, and escape extinction.”
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“…in working with children and adolescents with ARFID have also shown promising preliminary outcomes across case studies and pilot randomised control trials (Dahlsgaard and Bodie, 2019; Eckhardt et al., 2019; Sharp et al., 2016; and Shimshoni et al., 2020, as described by Breiner et al., 2021).”
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“…behavior and related targets, such as decreases in tube dependence and increases in oral intake, were improved at discharge (Brown et al., 2014; Byars et al., 2003; Clawson et al., 2007; Cornwell et al., 2010; Greer et al., 2008 ; Sharp et al., 2016; Silverman et al., 2013; Williams et al., 2007).”
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“Currently, there are no specific guidance for assessment, diagnostic tools are in their infancy (Eddy et al., 2019) and the evidence base for treatment of ARFID remains limited (Sharp et al., 2016, 2017).”
Breiner, C. E., Miller, M. L., & Hormes, J. M. (2024) · International Journal of Eating Disorders · doi:10.1002/eat.24269 · Cited by 9
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“Intervention followed a manualized sequence of behavioral strategies developed through clinical practice and a review of the literature (see Sharp et al., 2016 for randomized clinical trial).”
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“[31] also observed improved food acceptance in children between 13 and 72 months of age with chronic refusal of food and dependence on enteral feeding or oral supplementation in relation to the control group after a five-day nutritional intervention.”
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“Two of the reviewed studies assessed social validity after the children had transitioned to follow-up services to assess for maintenance (i.e., 2 weeks or 1 month; Flanagan et al., 2021; Sharp et al., 2016).”
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Home and Parent Training Strategies for Pediatric Feeding Disorders: The Caregivers’ Perspective
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Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery
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Multidisciplinary Treatment of Avoidant/Restrictive Food Intake Disorder
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Social Validity of Paediatric Feeding Treatment across Goals, Processes, and Outcomes
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Atypische und nicht näher bezeichnete Essstörungen
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“For younger children, the field largely describes behavioral interventions delivered in US-based programs (e.g., Sharp et al. 2016, 2020, 2024; Volkert et al. 2021).”
InfluentialTaylor, T., & Taylor, S. A. (2023) · European Journal of Behavior Analysis · doi:10.1080/15021149.2023.2259219 · Cited by 5
“…have been conducted describing aspects of treatments for paediatric feeding problems, such as those covering intensive multidisciplinary programmes (Sharp et al., 2017), group design studies (Lukens & Silverman, 2014), treatments for tube dependency (Taylor et al., 2019), specific treatment…”
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Interdisciplinary Treatment for Pediatric Feeding Disorders
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Caregiver Impressions of Clinical Effectiveness of an Intensive Behavioral Feeding Program
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Intensive Multidisciplinary Feeding Intervention for High-Risk Infants
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Self-citationTreatment methods of avoidant/restrictive food intake disorder: Review with therapeutic implications
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“Behavior therapy with exposure and systematic desensitization including gradual introduction of new foods in most cases of avoidance, primarily when the restriction is based on the foods sensory qualities [11,14,19,20,34,37].”
BackgroundInfluentialMiles, S., Phillipou, A., Neill, E., Newbigin, A., Kim, H. W., Eddy, K. T., & Thomas, J. J. (2024) · Contemporary Clinical Trials · doi:10.1016/j.cct.2024.107756 · Cited by 2
Desai, H., Lauridson, S., Nguyen, M., Ornelas, E., & Schomberg, J. (2022) · Perspectives of the ASHA Special Interest Groups · doi:10.1044/2022_persp-21-00331 · Cited by 2
“The outcomes of multi-disciplinary intensive feeding programs are frequently reported in terms of bite acceptance, behaviors, and volumes consumed using empirically researched behavioral strategies (Sharp et al., 2016).”
Akyürek, G., & Koca, R. B. (2025) · Appetite · doi:10.1016/j.appet.2025.108271 · Cited by 1
Lukens, C. T., Dempster, R. M., Eddy, K. T., Estrem, H., Menzel, J. E., Noel, R. J., Pederson, J. L., Ramirez, A. L., Romeo, C., Sharp, W. G., et al. (2026) · International Journal of Eating Disorders · doi:10.1002/eat.70101 · Cited by 1
Self-citationAvoidant/Restrictive Food Intake Disorder
Menzel, J. E., & Luo, T. J. (2021) · Springer eBooks · doi:10.1007/978-3-030-67127-3_6 · Cited by 1
Avoidant/Restrictive Food Intake Disorder in Children
Shimshoni, Y., & Lebowitz, E. R. (2022) · Springer eBooks · doi:10.1007/978-3-030-67929-3_74-1 · Cited by 1
Non-Pharmacological Interventions for Feeding Disorders in Pediatrics: A Scoping Review
Franchinotti, R., Moler, M., Paulenas, E., Saura, J. P., & Andreu, M. F. (2024) · Occupational Therapy In Health Care · doi:10.1080/07380577.2024.2401732 · Cited by 1
“Furthermore, an analysis of the studies with the highest level of evidence (Adamson et al., 2013; Benoit D et al., 2000; Garcia Coll et al., 1996; Mlinda et al., 2018; Sharp et al., 2016) reveals a tendency to study interventions of this type.”
Masciulli, E. (2018) · ScholarlyCommons (University of Pennsylvania)
Blank, L. A., Hoffmann, G. F., & Blank, R. (2022) · Research Square · doi:10.21203/rs.3.rs-2105537/v1
(2023) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9780890424865.eatingdisorder07
Avoidant/Restrictive Food Intake Disorder in Children
Shimshoni, Y., & Lebowitz, E. R. (2023) · Springer eBooks · doi:10.1007/978-3-031-16691-4_74
Mulkens, S., Neimeijer, R. A. M., Dumont, E. L. M., & Kroes, D. (2024) · doi:10.1007/978-90-368-3033-1_1
Behandeling met gedragstherapie of toegepaste gedragsanalyse bij kinderen van één tot zes jaar
Mulkens, S., Neimeijer, R. A. M., Dumont, E. L. M., & Kroes, D. (2024) · doi:10.1007/978-90-368-3033-1_4
Chen, D., Peng, W., Liu, X., Xiong, F., Luo, Y., Luo, H., Tang, M.-Y., Guo, X., Fu, X., Feng, Q., et al. (2025) · Frontiers in Pediatrics · doi:10.3389/fped.2025.1595641
Dietary intake and risk of nutrient inadequacy among children with pediatric feeding disorders
Brown, J., Brown, S., Childs, K., & Aguilar, R. (2025) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1002/jpn3.70100
Neurobiological Model of Avoidant/Restrictive Food Intake Disorder
Thomas, J. J., Holsen, L. M., & Lawson, E. A. (2025) · Oxford University Press eBooks · doi:10.1093/9780197675212.003.0024
A behavior-analytic approach to the assessment and treatment of pediatric feeding disorders
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Selective Review of Empirically Supported Psychological Treatments for Pediatric Health Problems
Cuéllar‐Flores, I., Basterra, I., Barrio, S. C., Orduña, B. E., Fuentes-Casany, D., González-Riesco, L., Izquierdo, A., Cid, M. D. P. M., Salcedo, E., Gómez, R. S., et al. (2025) · Psicothema · doi:10.70478/psicothema.2025.37.25
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Dempster, R. M., Evenson, E., Gentile, M., Arand, B., Ahmed, R., Garbacz, L. L., Peters, B., Neary, M. J., Stefan, B., Schellhaas, S. M., et al. (2026) · Nutrition in Clinical Practice · doi:10.1002/ncp.70121
A systematic review of mealtime training for caregivers: effectiveness and social validity
Tereshko, L., Magrauth, M., & Weiss, M. J. (2026) · Frontiers in Child and Adolescent Psychiatry · doi:10.3389/frcha.2026.1758507
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FEEDSETUP: feeding difficulties spectrum evaluation and treatment up-to-date proposal
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“…receive different labels depending on the specialist who evaluates him, whether it is a psychiatrist (Avoidant/Restrictive Food Intake Disorder - ARFID), pediatric gastroenterologist (eating disorder), behavioral psychologist (food selectivity), or developmental specialist (food neophobia) [4,5].”
McLennan, J. D. (2026) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2026.09.016
Metadata
- Authors
- Sharp, W. G., Stubbs, K. H., Adams, H., Wells, B. M., Lesack, R. S., Criado, K. K., Simon, E. L., McCracken, C. E., West, L. L., & Scahill, L. D.
- Affiliations
- Emory University (US)
- Marcus Autism Center Atlanta GA
- Georgia Institute of Technology (US)
- Corresponding author
- Sharp, William G.
- Venue
- Journal of Pediatric Gastroenterology and Nutrition
- Publisher
- Wiley
- Published
- 2016-04
- Volume
- 62
- Issue
- 4
- Pages
- 658-663
- ISSN
- 0277-2116 (ISSN-L)
- 1536-4801
- OpenAlex
- W2323571464
- Semantic Scholar
- 158e0a3d34daec642f2889568ab1c3ac77e5b05b
- Cited by
- 102
- References
- 16
- Citations by year
- 2026: 10 · 2025: 8 · 2024: 16 · 2023: 12 · 2022: 9 · 2021: 10 · 2020: 12 · 2019: 8 · 2018: 10 · 2017: 5 · 2016: 2
- FWCI
- 4.59
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Pediatric Gastroenterology and Nutrition (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Keywords
- pediatric feeding disorders, avoidant/restrictive food intake disorder, food refusal, meal ingestion, parent training, intervention fidelity, feasibility
- MeSH terms
- Diet, Healthy, Behavior Therapy, Child Behavior, Child, Preschool, Combined Modality Therapy, Feasibility Studies, Female, Follow-Up Studies, Food Preferences, Georgia, Humans, Infant, Male, Manuals as Topic, Parents, Patient Acceptance of Health Care, Patient Care Team, Patient Compliance, Pilot Projects, Practice Guidelines as Topic, Feeding and Eating Disorders of Childhood, Meals
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