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Autism, Feeding, and Eating Disorders

Photo credit: Amy Shamblan for Unsplash

The connection between eating disorders and Autism has been on the radar since at least the 1980s. Here's what Autistic individuals, parents, and professionals need to know. *This article talks about eating and food issues, please consider this a blanket content warning.* Please note that feeding and eating disorders are complex. This post can only act as an overview and a starting point for more research. Please contact a health professional if you have concerns about eating for yourself or your child.

Autistic children and adults are known to have patterns of restrictive eating. In some cases, it can be extreme where a child or adult only eats a handful of foods. First, it's important to understand the difference between being a selective or "picky" eater and having an eating disorder.

Where is the line between selective eating, eating disorders, and feeding disorders?
The most important factor to consider here is an individual's health, comfort with eating and, in the case of a child, growth. Feeding and eating disorders impact a child's nutrition and growth. If a child or adult is having health concerns, vitamin deficiencies, or is not growing and gaining weight on a glide path, this is cause to seek medical intervention. If an adult is having health concerns or vitamin deficiencies or is having distress around body image or eating, this is cause to seek intervention. I don't include weight here because this is highly variable and may not be linked to health. Please see Health at Every Size for more information about this. If a child or adult is highly selective in what they eat but are growing, are getting enough nutrition (this can be determined through testing or a food analysis by a registered dietician), and are healthy, the selective nature of their eating habits may be a common part of their makeup as an Autistic person.

Common feeding disorders seen in Autistics include Avoidant Restrictive Food Intake Disorder (ARFID) and pica (the ingestion of non-food items). Pica is always a concerning issue that requires vigilance to prevent injury. ARFID was referred to in the DSM as selective eating disorder in the past. ARFID might sound like Autistic eating because most Autistics are avoidant and/or restrictive in their eating habits, but what makes the difference--what makes it disordered--is the impact on health and growth, and internal distress. Feeding disorders differ from eating disorders in motivation. Both selective eating and feeding disorders are often about sensory issues. Eating disorders are coping methods with internal states of distress such as body dysmorphia

If you aren't sure about your or your child's health (or growth in the case of a child), ask your physician.

ARFID might sound like "Autistic eating" because most Autistics are avoidant and/or restrictive in their eating habits, but what makes the difference--what makes it disordered--is the impact on health and growth and internal distress.

The overlap between Autism, feeding disorders, and eating disorders
Autistic teens and adults, parents of Autistic children, and professionals who serve Autistics and their families need to be aware of the commonality of feeding and eating disorders for Autistic people.

In 1983, a clinical researcher working with Autistic boys found that each boy had a girl cousin with anorexia.

As much as 30% of adults with eating disorders are Autistic. However, there also appears to be either undiagnosed Autistics or those who do not meet "severity" criteria for diagnosis because other studies find that those with eating disorders and feeding disorders are more likely to have Autistic traits but not be diagnosed as Autistic. This is the Broader Autism Phenotype category. Estimates of the rate of feeding disorders in Autistic children range from 12.5-33%. These rates are significant. Though anorexia nervosa is most often studied in association with Autism, binge eating and bulimia are associated with ADHD. There is a high degree of co-occurrence of ADHD and Autism.

Eating disorders are more common in girls and women. This is the same for Autistic women and girls. However, Autistics are more likely to be gender diverse. Gender should not be a barrier to diagnosis or treatment. Feeding disorders are slightly more common in males. Gender socialization impacts eating disorders and women and girls who are Autistic tend to mask symptoms more than boys and men do.

It should also be noted that obesity in more common in Autistics than in the general population. The cause for this connection is not known. However, it may be a combination of factors including a genetic component, medications, and early eating patterns carried into adulthood.

Contributing factors in feeding and eating disorders for Autistic children and adults
There are a number of factors that influence the formation, continuation, treatment and recovery in feeding and eating disorders for Autistics. Some include those that affect non-Autistic individuals with these conditions like body image and dysphoria, and coping and control.

However, there are other factors that are at play for Autistic and neurodivergent individuals that are less often in play for non-Autistic individuals. these include:

Masking, fitting in, and perfectionism: masking is actions taken by a neurodivergent person to hide their differences. Masking is done in an attempt to fit in or at least not stand out. Perceptions of weight or size contributing to standing out can influence a decision to restrict eating. Perfectionism is a common trait for neurodivergent individuals including Autistics. A desire to attain physical perfection can also lead to disordered eating.

Sensory issues: Autistic children and adults have sensory systems that are highly sensitive and/or highly hyposensitive, which can have a direct impact on food choices. Food textures, smells, tastes, and appearance can be factors in restrictive diet choices. Sensory issues are valid reasons for avoidance.

Alexithymia: alexithymia is difficulty interpreting feelings. In the context of eating and feeding conditions. Autistic children and adults may be unable to discern the difference between physical sensation and somatic responses to emotional states. For example, an anxious feeling of "butterflies" in the stomach may be interpreted as nausea causing the individual not to eat until feeling better.

Interoception: Interoception is the sense of what is happening inside the body. Many Autistic people do not have a typical relationship with the internal organs compared to non-Autistic people. They may not sense being thirsty until their mouth is dry. They may forget to eat or eat twice forgetting that they have already eaten. The may not sense a need to use the bathroom until it's an urgent need.

Special Interests and a preoccupation with the numbers: A less common but still important factor contributing to the eating disorders in Autistic people is taking a special interest in nutrition and health such as in orthorexia or a preoccupation with measuring and calculating nutrition, calories, or weight.

Treatment implications
Before embarking on treatment, it's important to determine if the eating issues meet the threshold for being a disorder. This is especially applicable to children whose parents may wish to change their habits to fit norms or ideals. Being a selective eater may not need intervention.

Treating eating and feeding disorders is complex. Parents and providers should use a light touch and preferably a trauma informed approach.

Exposures may backfire leading to further entrenched aversions--essentially food based trauma. Behavior based approaches may require caution. Understanding the factors for a particular person should inform the treatment plan. Acceptance and openness on the part of the parents and clinician to help minimize masking of symptoms and allowing authenticity are likely to increase the quality of the therapeutic relationship and outcomes.

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