Pushing Past the Extinction Burst: Extreme Dysregulation in Inpatient Treatment of ARFID

Abstract

The treatment of children with avoidant restrictive food intake disorder (ARFID) can be challenging and complicated by severe mood and behavior dysregulation. Here we present the case of an 11-year-old girl who was transferred to our facility after she had developed a fear of eating due to abdominal pain and who had been nasogastric tube dependent for four months without any oral intake. During treatment on the inpatient level of care, severe behavior problems and mood dysregulation complicated achieving the treatment goals of all nutritional intake by mouth. Multiple medication adjustments were necessary to help regulate behavior and mood and facilitate psychotherapy that used family-based therapy together with motivational and reward-based interventions. The treatment process was long and protracted, with a 62-day hospitalization, but despite the various hurdles, led to an excellent short and long-term outcome. This was accomplished by maintaining consistent goals of care, utilizing behavioral principles to move through an extinction burst, and using psychiatric medication as a support to regulate mood and break the maladaptive behavioral pattern of avoiding nutrition. This case report further highlights the importance of interdisciplinary collaboration and remaining steadfast in setting and pursuing treatment goals to address severe psychopathology.