Written by Marley Kamin.
Once, when working with a toddler diagnosed with autism spectrum disorder (ASD), he squirmed at the idea of eating the mac and cheese I had prepared for lunch. I had no idea why—kids love mac and cheese! When I asked his mom about it, she explained that her son went through phases with food. One month, he only ate things cut into a circle. Another month, he would only eat pasta. This month, he needed all his food to be green.
I never considered this to be a feeding or eating disorder. I chalked it up to a behavioral expression of his autism. People with ASD, kids especially, tend to experience sensory fixations. These are often a manifestation of the rigidity and high detail orientation characteristic of the disorder. Working here at the Columbia Center for Eating Disorders, I started to wonder about the connection between this child’s eating behavior, his autism, and eating disorders.
Shared Traits
Until now, most of my practical experience in psychology has involved working with neurodivergent children. I thought that I was decently well-versed in this topic. But a cursory search on Reddit introduced me to many instances of co-occurring autism and disordered eating behavior. Posters talked about
- “sensory bingeing,”
- difficulties understanding hunger cues (much like their difficulties recognizing emotions),
- specific foods causing “whole body shudders,” and
- the complete avoidance of certain food groups.
The connection between autism and eating disorders can clearly be highly individual, complex, and at times difficult to parse.
A look into the academic literature on this topic confirmed my suspicions. Individuals with ASD share many traits typically associated with eating disorders. For example, people in both diagnostic groups can experience cognitive (i.e., “thinking”) styles marked by:
- High detail-orientation, referred to as weak central coherence, or more commonly described as “missing the forest for the trees”
- Rigidity that makes it difficult to flexibly shift ways of thinking, termed impaired set shifting
- A tendency to focus intensely on a few interests at a time, known as monotropism
How often does autism spectrum disorder overlap with eating disorders?
Among people with ASD, the presence of unusual eating behaviors, such as food refusal, food selectivity, or abnormalities in diet and nutrition, is rather high, with rates ranging between 44-96%. Considering my own experience, coupled with what I found on Reddit, I can’t say this shocked me.
Two of the most common eating disorders in individuals with ASD are avoidant restrictive food intake disorder (ARFID) and anorexia nervosa.
Since its introduction into the diagnostic manual of psychiatric disorders over a decade ago, the eating disorders field has learned a lot about ARFID. There is significant diagnostic crossover between ARFID and autism. Studies estimate that between 8.2-54.8% of children with ARFID also have ASD. According to one study, 61% of children with co-occurring ARFID and ASD had inadequate nutrition, which can potentially lead to serious medical complications.
While limited, research on anorexia nervosa and autism hints at a potentially intriguing connection between the two disorders. When questionnaires assessing for self-report autism are used, up to one-third of those with anorexia nervosa endorse elevated ASD symptoms. Estimates for the number of people with anorexia nervosa who meet the clinical cutoff for ASD diagnosis vary widely. Ranging from as low as 4% to as high as 52.5%, these numbers are difficult to interpret.
Scientists interested in the co-occurrence of ASD and anorexia nervosa are curious about how features of one disorder may negatively influence the other. For example, if an individual with ASD struggles with their body image and finds a new “special interest” in dieting and body enhancement, they may be at risk of subsequently developing an eating disorder. As is the case with other instances of co-occurring psychiatric problems, having both ASD and a restrictive eating disorder has implications on symptom severity and treatment outcome.
How can treatments that help with eating disorders be applied for those with autism spectrum disorder?
Outpatient treatments for ARFID include cognitive-behavioral therapy (CBT) and family-based treatment (FBT). In both CBT and FBT for ARFID, parents and caregivers of children with ARFID may be trained in a variety of interventions, such as repeated taste exposure and positive reinforcement. Guidelines for applying these outpatient approaches for individuals with ASD emphasize the use of a multidisciplinary team, in which occupational therapists, medical doctors, autism services, local social networks, and mental health day services collaborate to deliver adequate care.
For low-weight, medically unstable ARFID patients, hospital-based refeeding programs may be helpful, much like for those with acute anorexia nervosa who are unable to restore weight on an outpatient basis.
Normalization of eating may require some special considerations for those with co-occurring ASD. Clinicians must recognize and work with, rather than against, sensory sensitivities when facilitating weight restoration and maintenance. Additionally, some specialists in this area propose that individuals with anorexia nervosa and ASD may benefit more from individual therapy and cognitive remediation therapy (a psychotherapy that includes exercises to increase flexibility in thinking style), rather than the more popular group therapy and CBT approaches.
We need better research across the board, as eating disorder treatment that considers autistic individuals is vital. These topics are understudied, and much of the available research uses less-than-ideal measures for autism, such as study-specific questionnaires, rather than well-tested screening tools or clinician-provided diagnoses.
Going forward, I hope that there will be more effective screening tools, allowing clinicians working with one clinical population to enhance their awareness of the other. As with all psychiatric disorders, ASD and EDs do not, and cannot, exist in isolation.
As my time at the Columbia Center for Eating Disorders finishes and I prepare to continue working with autistic individuals back at school, I am feeling grateful for this new perspective and knowledge to better understand their eating behaviors.
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