Introduction: Avoidant/restrictive food intake disorder (ARFID) is a heterogeneous eating disorder characterized by sensory sensitivity, low appetite/interest, and fear of aversive consequences. Associations of subthreshold ARFID-related symptoms with anxiety, psychosocial difficulties, and neurodevelopmental traits remain unclear. We examined these symptoms dimensionally in a diagnostically subthreshold pediatric outpatient sample.
Methods: This multicenter cross-sectional study included 350 participants aged 6-18 years from five child and adolescent psychiatry outpatient clinics in Türkiye. The K-SADS-PL confirmed that no participant met DSM-5 criteria for a full-threshold psychiatric disorder; some had non-impairing subthreshold symptoms. Parents completed the Nine-Item Avoidant/Restrictive Food Intake Disorder Screen-Parent Version (NIAS-P), Revised Child Anxiety and Depression Scale-Parent Version (RCADS-P), Strengths and Difficulties Questionnaire (SDQ), and Social Responsiveness Scale-Parent Version (SRS-P). Body mass index (BMI) z-scores were age- and sex-standardized; developmental consistency was tested with age-stratified analyses (6-12/13-18 years) and age interaction terms.
Results: Based on published NIAS-P cutoffs, 101 participants (28.9%) screened positive and scored higher on most clinical domains, most markedly SRS-P restricted and repetitive behaviors (RRB; r=0.258). RRB was the strongest correlate of NIAS-P total (ρ=0.435) and was independently associated with all subscales in sensitivity analyses (β=0.214-0.309). Fear of aversive consequences was independently associated with both anxiety and RRB, whereas low appetite/interest was associated with social responsiveness but not anxiety. Weight status did not differ by screening status (98.0% ≥5th BMI percentile); associations were similar across age bands, and no age interaction survived correction.
Conclusion: ARFID-related symptoms were common in diagnostically subthreshold pediatric outpatients, with RRB as their most consistent correlate across all NIAS-P subscales. These findings support integrating neurodevelopmental evaluation with routine, dimensionally differentiated restrictive eating screening. Given the cross-sectional design, positive screens warrant comprehensive nutritional, psychiatric, and neurodevelopmental assessment rather than inferences about intervention.
Keywords: Anxiety; Autism Spectrum Disorder; ARFID; Child Psychiatry; Feeding