For many people, eating is an act full of positive emotions: it nourishes us, brings up memories, and gives us a rewarding avenue through which we can go out and explore other cultures. Cooking and sharing meals between our friends and loved ones, for our children and families, is an activity that bonds people and communities together the world over. We tend not to think about them so explicitly, but our eating behaviours are intimately tied in both supportive and destructive ways to many aspects of our emotional, physical, and mental health.
However, while it is not a universal rule, it is common for individuals with autism to experience greater challenges when it comes to eating. These difficulties alone do not necessarily cause concern, but in some cases, food limation related to autism can mirror and develop into a separate condition called avoidant restrictive food intake disorder.
Avoidant Restrictive Food Intake Disorder
Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterised by a complete unwillingness to consume certain foods. The fifth diagnostic and statistical manual (DSM-5) lists 3 core motivators for this eating disturbance:
- Apparent lack of interest in food.
- Fear of negative consequences connected to eating specific foods (often based on a past traumatic experience, such as a fear of choking or vomiting).
- Sensory sensitivities to particular textures or flavours, or foods with certain appearances.
ARFID is not a harmless example of typical picky eating, it is a restrictive and persistent eating disorder, sometimes even involving entire food groups. With time, the refusal of food can produce the following ARFID symptoms and side effects:
- Significant weight loss, or when it comes to children, failure to achieve expected growth.
- Severe nutritional deficiency.
- Supplementation dependence, either by enteral feeding or oral supplements.
- Fatigue and weakness.
- Brain fog and trouble concentrating.
- Psychosocial functioning issues, and mood effects related to malnutrition.
- Isolation and avoidance of social situations that may involve eating in public.
Unlike other common eating disorders, such as anorexia nervosa or bulimia nervosa, ARFID is not typically connected to a fixation on weight gain or weight loss.
What Is Autism?
Autism, or autism spectrum disorder (ASD), is one of a few common developmental disorders identifiable in early childhood. We understand ASD as a spectrum condition that ranges from mild to severe, and the term now encapsulates several diagnoses that were previously considered separate autism spectrum disorders, including Asperger’s syndrome and childhood disintegrative disorder. According to the DSM-5, individuals who meet the diagnostic criteria for autism must show difficulty with all of the following:
- Social-emotional reciprocity.
- Nonverbal social communication.
- Understanding, developing and maintaining relationships.
As well as at least two of the following:
- Repetitive behaviours, movements, use of objects, or speaking.
- Specific “special interests” that cause preoccupation or hyperfocus when they’re brought up.
- Insistence on routine and patterns of repetitive ritual, and rigidity or distress when those routines are disrupted.
- Sensory sensitivity or hyporeactivity: abnormal responsiveness to stimuli like textures, sounds, lights, smells, and tastes.
Autism Spectrum Disorder and Food Avoidance
Parents of autistic children and teens alike may recognise something called “food selectivity” – a pattern of eating whereby the autistic person will only find it acceptable to eat foods that fall within a very narrow range. This kind of “picky eating” is not inherently dangerous and doesn’t necessarily mean that the individual has a clinical case of ARFID.
If these eating issues develop to become too restrictive, have resulted in eating fear, or are contributing to a loss of body weight or slowed weight gain in growing children, a treatable eating disorder may be present.
ARFID and Autism: Connection and Co-occurrence
People with autism spectrum disorder are at a lifelong risk of developing avoidant restrictive food intake disorder. Something between one in eight and one-third of individuals with ARFID also have co-occurring autism – statistics that have caused many professionals to call for eating disorder screens to accompany diagnoses for ASD.
Effectively treating ARFID in these individuals requires us to tailor our approach with an understanding of how autism may be contributing to eating problems – and broadly, we have identified two key themes.
Need for Sameness and Routine in Autism and ARFID
Repetitive behaviours and/or a need for routine are critical traits associated with ASD. While these can manifest in many different ways, for many, food is one of the arenas of routine. In practice, this can mean rigid adherence to a particular schedule of eating, or of eating foods in particular orders, or only wishing to eat products from particular brands or stores.
The individual may have an active fear of foods that don’t align with the specificities of these rituals – consuming other items may seem disruptive, stressful, “unsafe” or simply gross. With time, the aversive consequences of eating these things reinforce the restrictive behaviour, and can, in turn, lead to symptoms of ARFID.
Sensory Issues in Autism and ARFID
It is very common for individuals with autism to experience sensory sensitivity issues, as well as sensory overload. People with autism are more likely to be sensitive to sensory experiences, which can lead to the individual feeling more quickly overwhelmed or distressed by things in the environment that assail their senses, such as particular clothing fabrics, loud or out-of-place noises, or in the case of food, textures, tastes, and scents.
This, on its own, may be enough to trigger the disrupted eating behaviours in children with ARFID and autism. However, young people with ASD and food sensitivity are also far more likely to struggle to communicate their challenges. Difficulties verbalising the nature of the food rejection doesn’t make things any easier and can contribute to eating anxiety when the adults or other people around fail to understand the issue.
Other Co-occurrent Mental Disorders
It’s important to understand that children and young adults with autism are at risk of more than ARFID. Developmental disorders such as autism and frequently comorbid attention deficit hyperactivity disorder (ADHD), especially when they are not well understood or coped with, put young people at risk of high levels of stress and anxiety. In adolescents, shifts in academic and social pressures, as well as puberty itself, can lead to a persistent sense of overwhelm and dysregulation – feelings that can be more intense and more likely to trigger co-occurring conditions such as anxiety disorders in autistic teens.
The development of other patterns of disordered eating is common in autistic teens, especially young women and girls, who seek to assert control over the onslaught. Early intervention is the best practice for young people that are living with eating disorders connected to distorted body images, such as anorexia nervosa and bulimia nervosa.
Treatment for ARFID and Autism
Autism is not a curable condition, but it can be made more manageable through early intervention and treatment of connected or co-occurring conditions. Meanwhile, ARFID is treatable, and effective recovery from this eating disorder requires treatment teams to take a compassionate, informed approach to the overlap between the two.
Sensory issues are unlikely to go away entirely, but through therapy and holistic wellness interventions, adolescents and teenagers can sustainably build up their comfort and skills, ultimately recovering their physical health and joy in eating.
Safe Daily Exposure
Food refusal and food avoidance can be effectively treated in part by safe exposure to the objects of fear on a daily basis. Engaging the treatment centre as a safe, affirming environment and using it as a place to start introducing new foods that include the various sensory characteristics that are feared or avoided is a common practice in recovery for eating disorders that works well for ARFID.
Gastronomic and Nutritional Education
When a young person is living with both Autism and ARFID, food can become a source of fear, making it very hard (and unappealing) for the individual to learn much about the processes involved with selecting and preparing food for themselves. Beyond our initial reactions to their sensory characteristics, foods become total unknowns – and the easiest way to protect oneself from these unknowns seems to be to limit or avoid them entirely.
However, becoming educated in the basics of these processes explicitly combats this fear. Learning to understand labels, monitor nutrient intake, select foods, cook, and even enjoy cooking demystifies self-nourishment and fleshes out the concept of food far beyond its sensory properties, removing many sources of fear that drive anxiety.
Treating Nutritional Deficiency
Proper nourishment is one of the fundamentals of physical and mental health and one of the more obvious objectives of treating eating disorders. That said, it is both an end and a means, and there are benefits to making these changes when in treatment.
When our brains and bodies are well-nourished, we are more mentally resilient, flexible, and open to learning. When a client comes to us for treatment for co-occurring ARFID and autism, we may ask for tests screening for nutritional deficiencies. We aim to resolve any deficits present through whole-food meal planning, tailored to individual needs and wants, and with space for supplementation when medically necessary.
Like all eating disorders, ARFID is a condition that begins in the mind, and psychotherapy remains a cornerstone of all treatment programmes. Psychotherapy for ARFID is centred around the underlying mental and emotional processes that lead to the pattern of disordered eating. It generally involves therapeutic processing, both one-on-one with a therapist and together in a group, with both familiar and new foods – ultimately focused on learning to taste, communicate, unpack and address concerns, and eventually recover the ability to eat comfortably.
Reach The Wave
When a loved one or child begins rejecting food, exhibiting “extreme picky eating,” or when we notice our food restrictions are out of control, we rapidly feel something is amiss. At The Wave, we specialise in problems related to eating disorders and eating patterns in teens, taking a holistic approach informed by trauma, co-occurrent mental health conditions, and the unique stresses faced by adolescents and teens. We treat young people, with an eye to their lifelong well-being and development: there is no better time to learn to take your health into your own hands.
To learn more about our approach, treatment for co-occurring ARFID and autism, or how to get started with The Wave, reach out to us today.