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Eating disorders and autism

Home ~ Eating disorders A-Z ~ Eating disorders and autism

This page outlines the link between autism and eating disorders. It specifically looks at autism and anorexia nervosa, and autism and ARFID. We would like to thank EDNA and AMAZE for their support writing this webpage.

What is autism?

Autism is a neurotype or neurodevelopmental phenomenon that influences many aspects of living.

Autism can be experienced across a dynamic spectrum, impacting things like socialising, executive functioning, motor coordination, sensory processing, and language (i.e., speaking, non-speaking, partially-speaking, situational mutism).   

Around one in 100 Australians is diagnosed with autism – around three times as many males as females (as assigned at birth), (Amaze, 2021). Prevalence in the community is likely much higher due to inaccessibility and limitations around diagnosis.

Autism spectrum diagram

Autism is experienced across a dynamic spectrum.

Understand autism

Our friends at AMAZE have many resources to help autistic individuals and their families understand autism and find support.

Learn more

Autism, food and eating

It is common for autistic people to have atypical eating behaviours, with around 70% of autistic children having issues with food or eating (Mayes & Zickgraf, 2019).  

Autistic individuals may have highly selective eating requirements or be particularly sensitive to the textures, look, smell or sound of foods, which can lead to food aversions. The social aspects of eating (such as sitting at a table with others, waiting until others are finished) can also be challenging. There may also be physical difficulties such as oral problems (difficulties chewing or swallowing) or gastrointestinal problems, which make eating a non-pleasurable experience.  

Many of these symptoms and behaviours are commonly seen in people with eating disorders so researchers have sought to further understand the relationship and prevalence of autism in people with eating disorders (and vice versa) – especially in females who experience a higher rate of eating disorders and in whom autism may be under-diagnosed.   

All types of eating disorders are experienced by autistic people, with most research currently focused on  anorexia nervosa (including atypical anorexia) and ARFID, (Nimbly et al., 2022)

It is also worth noting that ADHD, another neurodevelopmental phenomenon that falls under the neurodivergent umbrella, frequently co-occurs with autism and vice-versa. ADHD is correlated with bingeing and purging eating disorder subtypes such as bulimia nervosa (Gesi et all., 2017, Bleck et al., 2015) ) and binge eating disorder (Levin et al., 2016, Curtin etc al., 2013) ). Therefore, it is important to keep in mind that the connection between different neurodivergent traits and eating disorders is complex and multidimensional. 

Autism and anorexia nervosa

In the early 1980s, a researcher named Christopher Gillberg first identified a possible link between anorexia nervosa and autism.  

It appears that up to 20-35% of women with anorexia nervosa meet the diagnostic criteria for autism, with many others exhibiting higher levels of symptoms characteristic of autism than the general population without actually meeting the threshold for a diagnosis (Brede et.al., 2020, Westwood & Tchanturia, 2017).   

Studies have also found that there may be a genetic or familial link between anorexia nervosa and autism and that the conditions have neurobiological links (Koch et.al., 2015).  

It may be that body image is less of a concern for autistic people with anorexia but more so diet restriction as a coping mechanism to mask emotions and anxiety (Brede et.al., 2020). While not yet been picked up in the research literature, many autistic women also report using food restriction to gain social acceptance by meeting our society’s emphasis on thinness. There may also be a tendency for repetitive behaviours taking the form of an intense interest (such as calorie counting or exercise) which develops into anorexia (Westwood & Tchanturia, 2017). Autistic people who restrict or avoid foods without a focus on weight or body image may be diagnosed with avoidant/restrictive food intake disorder (ARFID).   

“I misinterpret [emotions] as physical symptoms and I get very anxious about it: Am I unwell? Am I going to vomit? And that’s when I stop eating because I know that will dampen things down and calm them, so my emotions are feeding into my eating disorder behaviours, whereas I think my difficulties in perhaps coping with emotions stem perhaps more from the autism.” (Brede et.al., 2020)

Autism and avoidant/restrictive food intake disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is defined by the DSM-5 as an eating or feeding disorder characterised by a persistent and disturbed pattern of feeding or eating that leads to a failure to meet nutritional/energy needs. 

ARFID is similar to anorexia nervosa in that a person restricts their food intake but the intent or reason behind the restriction is different in that people with ARFID do not restrict food in order to avoid weight gain/control their body shape/size. People who are autistic who are underweight or struggle to meet nutritional needs from food may meet the diagnostic criteria for ARFID. 

ARFID is a fairly recent DSM-5 diagnostic category and specific research is limited. The prevalence rates of ARFID are currently unknown (estimates range from 5-60% of children being treated as an inpatient for an eating disorder) (Mayes & Zickgraf, 2019). ARFID is more commonly seen in children and adolescents but can occur in adults. There is no specific data on how many people with ARFID also have autism though there appears to be a strong correlation (Mayes & Zickgraf, 2019). 

Things to keep in mind for autistic people with an eating disorder

Sensory

Autistic people may have  reactions to what they see, hear, smell, touch or taste.  They often have heightened sensory issues regarding the textures, look, smell and sound of foods compared to non-autistic people. 

Routines, rituals and resistance to change

Autistic people may display repetitive behaviours, have a preference for routines and dislike change.  For example, routines and rituals around food such as eating times, places and types of food can be more inflexible and resistant to changes.

Interoception

Interoception is the process of perceiving senses inside the body, such as hunger, thirst, fullness and pain. Autistic people may experience interoception confusion, which can make intuitive eating challenging.   

Alexithymia

Alexithymia is having difficulty identifying and describing emotions and is common in autism. People with alexithymia may have a hard time pinpointing what emotion they are feeling and also not be able to communicate what they are feeling to others. This can make it hard for people to soothe themselves or get support from others and can make them more vulnerable to developing eating disorder symptoms as a coping mechanism (Vuillier et.al, 2020). 

“I’m not very good at judging my own emotions or physical sensations. I don’t really fully understand my thirst and hunger responses, or my fullness responses, so that really influences my eating because I can binge or miss meals very, very easily.” (Brede et.al., 2020)

Undernourishment and autism

It should be noted that undernourishment due to anorexia nervosa or ARFID can increase autistic people’s sensory-based difficulties, which has an impact on emotional responsiveness and mood swings. This can make it harder to accurately identify both autism and the eating disorder, due to the uncertainty as to the cause of the symptom. These behaviours may often resolve or improve significantly during recovery. Though there is a link, not all people with anorexia or AFRFID also have autism so it is important to consult professionals who can use a range of criteria for diagnosis of autism and can recommend specific treatment protocols

Autism as a consideration in the prevention of eating disorders

As our understanding of autism and eating disorders grows (and evidence that autistic traits appear in early childhood prior to the eating disorder (Solmi et.al., 2020)) there is opportunity for prevention and early intervention. Treating disordered eating in autistic people early and implementing support systems that are tailored to the needs of autistic people (i.e., neurodiversity-affirming care) is key. In addition, delivering psychoeducation education and training to caregivers and professionals who engage with autistic people (e.g., school wellbeing teams), will be an important factor in helping to prevent the occurrence of eating disorders for autistic people.   

Treatment and recovery for autistic people with eating disorders

Standard eating disorder treatments tend not to accommodate the specific needs of autistic people.

They may focus too heavily on weight or body image, involve overwhelming group settings, inpatient stays that disrupt routines and the need for in person visits to medical clinics that may be brightly lit, noisy and unfamiliar. Treatments that require a person to make dramatic changes to their eating routines in a short period of time may also be ineffective for people with autism who simply require more time and a more gradual process of change.  Autistic people may require less food choices and more clarification around rules and expectations in recovery.   

For this reason, identifying the presence of autism can make treatment and recovery of the eating disorder more effective.  Autistic people experiencing eating disorders may need access to a treatment plan that is not only aware of their autism, but actively understands it and allows treatment to be responsive to the needs of the individual.   

Overall, the recovery prospects and outlook are not any different to neuro-typical people but longer and more intensive treatment may be required. (Tchanturia et.al., 2019, Stewart et.al., 2017).  

What's next for autism and eating disorders?

Understanding autism and other neurodiverse conditions (for example learning disabilities, ADHD etc.) as not being an impairment, but instead a functioning difference in the brain, is crucial. This is especially important when supporting autistic people with eating disorders, as treatments for the eating disorder should be able to change depending on the needs of the individual.  There is research currently being conducted in this area and hopefully in time more evidence-based treatment protocols will become available. In particular, there is currently momentum growing around the concept of neurodiversity-affirming care.  

Support for autistic people with eating disorders

If you or someone you care about is needing further support, please reach out to us at EDV. We support autistic individuals and their loved ones to find treatment pathways that are suitable to their individual needs. 

EDV Telehealth Nurse 

Let our telehealth nurses support your treatment planning. Nurses can connect you with the right professionals suitable for your unique needs. 

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Other support options

Amaze website and free national autism helpline 1300 308 699 providing information, advice and referrals to help autistic people, their supporters and professionals. 

Eating Disorders Neurodiversity Australia (EDNA) is an advocacy organisation that supports neurodivergent Australians affected by eating disorders.

Eating Disorders Families Australia (EDFA) offers an ARFID support group. More information can be found here.  

Peace (Pathways for Eating Disorders and Autism developed from Clinical Experience) website has a great deal of information and resources for people with autism and eating disorders and their carers and clinicians.  

Other Autistic-led organisations

Further reading

References

Bleck JR, DeBate RD, Olivardia R. The Comorbidity of ADHD and Eating Disorders in a Nationally Representative Sample. J Behav Health Serv Res. 2015 Oct 1;42(4):437–51.

Brede, J., Babb, C., Jones, C. et al. (2020). For Me, the Anorexia is Just a Symptom, and the Cause is the Autism: Investigating Restrictive Eating Disorders in Autistic Women. J Autism Dev Disord 50, 4280–4296.

Curtin C, Pagoto SL, Mick E. The association between ADHD and eating disorders/pathology in adolescents: A systematic review. Open Journal of Epidemiology [Internet]. 2013.

Gesi C, Carmassi C, Luciano M, Bossini L, Ricca V, Fagiolini A, et al. Autistic traits in patients with anorexia nervosa, bulimia nervosa or binge eating disorder: A pilot study. European Psychiatry. 2017 Apr 1;41:S100.

Gillberg C (1983) Are autism and Anorexia Nervosa related? British Journal of Psychiatry 142: 428.

Kinnaird, E., Norton, C. & Tchanturia, K. (2017). Clinicians’ views on working with anorexia nervosa and autism spectrum disorder comorbidity: a qualitative study. BMC Psychiatry 17, 292.

Koch SV, Larsen JT, Mouridsen SE, Bentz M, Petersen L, Bulik C, Mortensen PB, Plessen KJ. (2015). Autism spectrum disorder in individuals with anorexia nervosa and in their first- and second-degree relatives: Danish nationwide register-based cohort-study. Br J Psychiatry. 206 (5):401-7.

Levin RL, Rawana JS. Attention-deficit/hyperactivity disorder and eating disorders across the lifespan: A systematic review of the literature. Clinical Psychology Review. 2016 Dec 1;50:22–36.

Mayes, SD, & Zickgraf, H. (2019). Atypical eating behaviors in children and adolescents with autism, ADHD, other disorders, and typical development. Research in Autism Spectrum Disorders, 64, 76-83.

Solmi, F F, Bentivegna, HB, William M, Radha K, Dheeraj R, David S, Glyn L. (2020). Trajectories of autistic social traits in childhood and adolescence and disordered eating behaviours at age 14 years: A UK general population cohort study. Journal of Child Psychology and Psychiatry,

Stewart CS, McEwen FS, Konstantellou A, et al. (2017) Impact of ASD Traits on treatment outcomes of eating disorders in girls. European Eating Disorders Review 25: 123–128

Tchanturia K, Larsson E and Adamson J (2016) How anorexia nervosa patients with high and low autistic traits respond to group Cognitive Remediation Therapy. BMC Psychiatry 16: 334.

Tchanturia, K, Adamson, J, Leppanen, J, & Westwood, H. (2019). Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme. Autism : The International Journal of Research and Practice, 23(1), 123-130.

Vuillier, L., Carter, Z., Teixeira, A.R. (2020). Alexithymia may explain the relationship between autistic traits and eating disorder psychopathology. Molecular Autism 11, 63

Westwood H, Mandy W and Tchanturia K (2017) Clinical evaluation of autistic symptoms in women with Anorexia Nervosa. Molecular Autism 16: 812.

Westwood, H., & Tchanturia, K. (2017). Autism spectrum disorder in anorexia nervosa: An updated literature review. Current Psychiatry Reports, 19(7), 41.

Need help?

Eating Disorders Victoria has put together a step-by-step guide take if you are concerned that you may be experiencing an eating disorder. It also covers how to talk to family or friends about what you’re going through. Remember that you have the best chance of success if you include people you trust on your journey.

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