As parents, you want your children to be at their happiest and healthiest, and that includes their diet. Unfortunately, kids on and off the autism spectrum can have problems with food, appearance, and self-esteem.
Eating disorders are some of the most complex and dangerous mental health concerns. How common is it for autistic people to have an eating disorder? Are the two conditions related? In this article, we’ll explore these questions and more.
What is an eating disorder?
According to the American Psychiatric Association, eating disorders are “characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions.” In other words, they’re mental health conditions that produce unhealthy emotions and habits around food.
These behaviors include restricted eating, avoiding certain foods, excessive exercising, over-eating, and vomiting, or using laxatives to expel food.
It’s estimated that about 5% of the population struggles with an eating disorder. Female teenagers and young adults are most prone to disordered eating, but they can affect any age group or gender.
Is there a link between autism and eating disorders?
Psychologists have noted that people with autism spectrum disorder and people with eating disorders share many characteristics, including: inflexible thinking, repetitive behavior, sensory processing issues, insistence on routines, limited executive functioning, etc. It’s estimated that 20-30% of adults and 3-10% of minors with eating disorders have autism.
What’s less clear is whether the eating disorder produces traits similar to autism, or whether autism predisposes someone to eating disorders. Some research points to the latter—a 2020 study from the University College London (UCL) found that autistic traits in childhood predated an eating disorder.
UCL examined around 5,000 teenagers who had participated in a study called Children of the 90s since birth. They kept track of whether the young people showed autistic traits at ages seven, 11, 14, and 16, and whether they began to have disordered eating at 14. The participants weren’t necessarily diagnosed with autism, but similar traits had been reported by their parents.
Those who showed autistic traits at age seven were 24% more likely to have weekly disordered eating at 14. The eating disorders didn’t increase autistic traits by age 16, suggesting that autism—or difficulties similar to autism—may make developing an eating disorder more likely.
The researchers didn’t reach any conclusions about why but speculated that higher rates of depression and anxiety in autistic people may lead to unhealthy coping mechanisms like eating disorders.
What are the different types of eating disorders?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes seven eating disorders.
Anorexia Nervosa
Anorexia nervosa, often shortened to “anorexia”, is perhaps the most well-known eating disorder. People with anorexia have a compulsive desire to lose weight. It has the highest mortality rate of any mental condition besides opioid use disorder, as some patients reach the point of starvation.
The DSM-5 divides anorexia into two subtypes: restricting type and binge-eating/purging type. In the first type, people diet, fast, and exercise. In the second, they occasionally “binge”, or eat large amounts of food in a short time, then purge through vomiting, laxatives, or other medications.
Aside from weight loss, symptoms include:
- Dehydration
- Dizziness and fainting
- Muscle weakness
- Severe constipation
- Bloating after meals
- Bone thinning and possible stress fractures
- Fatigue and confusion
- Loss of menstrual periods in girls
- Brittle hair and nails
- Cold intolerance
- Cardiac problems
- Cognitive decline in long-term sufferers
Bulimia Nervosa
People with bulimia cycle between periods of dieting and periods of bingeing and purging. They may feel out of control when they binge and continue eating even if they become uncomfortable or nauseated.
According to the DSM-5, binges should occur at least once a week for the person to qualify for a bulimia diagnosis. Patients will usually try to “compensate” for their binges by fasting, exercising, or purging the food.
If someone with these behaviors is underweight, they’re considered to have the binge-eating/purging type of anorexia.
People with bulimia may have similar symptoms as people with anorexia, as well as symptoms more specific to purging such as:
- Sore throat
- Swollen salivary glands in the cheeks
- Heartburn and acid reflux
- Dental decay
- Diarrhea
- Esophageal tears
- Gastric rupture
Binge-eating Disorder
Bingeing also constitutes an eating disorder of its own. Like bulimia, this diagnosis requires a binge at least once per week. Unlike bulimia, patients don’t regularly try to compensate for the binges.
People with this disorder eat compulsively, even if they don’t feel hungry. They often feel depressed and ashamed afterward. The condition can cause obesity, diabetes, heart complications, and other health issues.
Pica
Pica is when someone regularly eats objects that have no nutritional value, such as hair, pebbles, carpet, etc. The behavior usually begins in childhood and is most often seen in people with autism, schizophrenia, or intellectual disabilities.
See our article Pica and Autism: What Should You Do? for more information about this eating disorder in kids on the autism spectrum.
Avoidant/Restrictive Food Intake Disorder
This disorder, also known by the acronym ARFID, involves extreme picky eating or general avoidance of food. People with ARFID may reject certain foods because of texture, smell, color, etc. They may also have unusual anxiety about choking, vomiting, constipation, or having an allergic reaction. Unlike people with anorexia, they aren’t preoccupied with their appearance.
The American Psychological Association notes that it’s normal for people with autism to be picky eaters because of sensory issues or difficulties with motor skills. Pickiness only reaches the level of ARFID if it has one or more of these consequences:
- Significant weight loss
- If they’re a child, they aren’t reaching weight milestones
- Significant nutritional deficiencies
- Need for nutritional supplements or a feeding tube
- Interference with social functioning—for example, the patient will be afraid to eat in front of others
Rumination Disorder
Rumination disorder is a rare problem in which undigested food will be regurgitated back into the mouth about an hour after eating. The person will either rechew and re-swallow the food, or spit it out.
Regurgitation is caused by relaxation of the diaphragm, which is similar to the belching reflex. Professionals think that rumination disorder occurs when diaphragm relaxation becomes a learned habit after eating.
This disorder can cause acid reflux and minor weight loss, but its effects aren’t as severe as others. Still, patients can work with a behavioral psychologist to relearn diaphragmatic breathing.
Other Specified Feeding and Eating Disorder
This category is for eating disorders that cause distress but don’t fit the other types. For example, the DSM-5 specifies that “low body weight” is crucial for an anorexia label. People who have anorexic behaviors but aren’t yet underweight may be diagnosed with Other Specified Feeding and Eating Disorder.
What causes eating disorders?
Eating disorders are complicated conditions. They’re usually caused by a combination of biological, environmental, and psychological factors.
Body image
Body image issues are a major risk factor, especially for bulimia and anorexia nervosa. It’s common for people to be insecure about their appearance, but when someone ties their self-worth to their weight, insecurities can spiral out of control into an eating disorder.
Girls traditionally face more pressure from society about their appearance, so it’s no surprise that disordered eating is more often reported by girls and women. However, boys and men aren’t immune to these difficulties or to eating disorders.
Family history
People whose family members have an eating disorder are more likely to develop one themselves. This is partially due to the environment—growing up around others with unhealthy attitudes about food will naturally influence someone.
Some research has also found that there may be a genetic component. However, the genes don’t necessarily cause eating disorders; they pass down anxiety and depression that may contribute to an eating disorder.
Trauma
Traumatic experiences, especially in childhood, are another risk factor for developing eating disorders. Bullying, neglect, emotional abuse, physical abuse, and sexual abuse could all be contributors.
An eating disorder may be a way for someone to manage the emotions caused by trauma and maintain a sense of control over their life. Victims of sexual abuse may eat too much or too little in an attempt to make their body less “attractive” to abusers.
In particular, people who have developed post-traumatic stress disorder (PTSD) have higher rates of eating disorders than the general population. Some autism research suggests that autistic people may be more predisposed to PTSD, which could further heighten the risk for an eating disorder.
Treatment for eating disorders
Traditionally, treatment for eating disorders includes two goals: restoring the patient to a healthy weight and addressing the psychological roots of the condition.
Professionals typically use therapy, such as cognitive-behavioral therapy (CBT), to help the patient change their thoughts and behaviors surrounding food. Family-based treatment is also one of the most evidence-backed methods. The family learns how to recognize eating disorder symptoms, understand the patient’s specific case, and monitor their recovery. Additional nutrition counseling teaches the patient how to maintain a balanced diet and restore normal eating habits.
Sometimes, people require treatment at a hospital or other in-patient facility. This may be the best choice for people who need daily supervision because of serious health complications or suicidal thoughts.
Treating eating disorders in autistic people
Autism can definitely affect one’s treatment options, because patients with autism may develop eating disorders for somewhat different reasons than non-autistic people.
The University College London is currently conducting a study of autistic women with anorexia. Though the research isn’t completed yet, interviews with participants have revealed that fear of fatness isn’t a major factor for them. Instead, their eating disorder is driven by…
- Sensory problems
- Difficulties telling when they’re hungry
- High anxiety
- Inflexibility in routines
When autistic people don’t respond to therapy that targets insecurities, doctors may perceive them as stubborn or in denial, when in reality their difficulties with food have a different underpinning. For some, the lesser-known ARFID may be a better fit than anorexia or bulimia.
Patients with anorexia, bulimia, or binge-eating disorder are also frequently told to attend support groups with peers—but autistic people are more likely to struggle in social situations, so a support group may be more stressful than helpful.
When Autism Spectrum Traits Complicate Eating Disorders Treatment, an article in the Eating Disorders Resource Catalogue, suggests the following modifications for the treatment of eating disorders in autistic people:
- Analysis of oral-motor skills and sensory issues
- Potential occupational therapy
- Gradually introducing a variety of foods
- Visual supports
- Lots of family involvement and support
- Additional social skills therapy
Wrap-up
Because of cognitive differences and possible mental health difficulties, autistic people may be at higher risk for developing an eating disorder than the general population.
Autistic people may also require different treatment approaches than non-autistic people with eating disorders. Ultimately, every person is different, so an individual’s strengths and weaknesses, alongside their autism, should be taken into account.
As a parent, the best thing you can do is seek out professional advice and give your child support. Loving families are often key to recovery from eating disorder symptoms, whether the patient has autism or not.
References
Ballas, P. (n.d.). Rumination Syndrome. Cedars-Sinai. https://www.cedars-sinai.org/health-library/diseases-and-conditions/r/rumination-syndrome.html
Cleveland Clinic. (2019, June). Anorexia Nervosa. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9794-anorexia-nervosa
Guarda, A. (2021, March). What Are Eating Disorders? American Psychiatric Association. https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders
Mandy, W. (2018). Treating anorexia in autistic women. Autistica. https://www.autistica.org.uk/our-research/research-projects/treating-anorexia-in-autistic-women
McCallum, K. (2019, January). When Autism Spectrum Traits Complicate Eating Disorders Treatment. Eating Disorders Resource Catalogue. https://www.edcatalogue.com/autism-spectrum-traits-complicate-eating-disorders-treatment/
Muhlheim, L. (2021, January). The Different Causes of Eating Disorders. VeryWell Mind. https://www.verywellmind.com/what-causes-eating-disorders-4121047
Ross, C. C. (n.d.). Eating Disorders, Trauma, and PTSD. National Eating Disorders Association. https://www.nationaleatingdisorders.org/blog/eating-disorders-trauma-ptsd-recovery
University College London. (2020, May 12). Children with autism face higher risk of eating disorders, study finds. ScienceDaily. Retrieved September 17, 2021 from www.sciencedaily.com/releases/2020/05/200512205555.htm
