Eating disorders and neurodivergence

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Eating disorders commonly occur in neurodivergent individuals, such as those with autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD). But what is the link between the two? And how might eating disorder treatment be tailored to meet the unique needs of neurodivergent people?

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What is neurodivergence?

Neurodivergence is a term used to describe how someone’s brain functions, learns, behaves, and processes differently from what has previously been deemed “typical.”

There is not one way to be neurodivergent; rather, neurodivergence can manifest in many different ways, from internal processes no one can see to behaviors that depart from societal norms or standards. Being neurodivergent isn’t inherently bad or good—it’s just different, though many neurodivergent people experience stigma and discrimination due to their behaviors or brain functioning deviating from normative expectations.

The most common examples of neurodivergence include those who have:

  • Autism
  • Attention-deficit/hyperactivity disorder (ADHD)
  • Dyslexia

Other forms of neurodivergence may include:

  • Dyspraxia
  • Synesthesia
  • Dyscalculia
  • Tourette syndrome
  • Epilepsy
  • Down syndrome
  • Bipolar disorder
  • Borderline personality disorder
  • Depression
  • Anxiety
  • Obsessive-compulsive disorder

The connection between eating disorders and neurodivergence

There appears to be a connection between eating disorders and neurodivergence, particularly when it comes to autism and ADHD.

Autism and eating disorders

Individuals with anorexia nervosa (AN) are more likely to have autism than those without this eating disorder. Current research estimates autism prevalence among those with eating disorders to be as high as 37%. (1)

A common explanation for the connection between autism and anorexia nervosa is that of restrictive eating due to sensory aversions, but recent research has revealed a more complex relationship since binge eating disorder (BED), which involves episodes of eating extremely large amounts of food in a relatively short time, is also linked to autism. This may mean that the role sensory processing plays in eating disorder development goes beyond simple aversions. (1)

That said, some autistic people may develop an eating disorder due to food aversions while others may engage in disordered eating to manage distressing emotions or as a result of sensory seeking behaviors. Others yet may engage in disordered eating that began as an intense interest, such as exercising or counting calories.

One qualitative study of women with anorexia nervosa and autism revealed that some participants felt that the inflexibility and rigidity associated with their autism had contributed to food rituals and routines that progressed to disordered eating. They also found body image concerns and a desire to lose weight were less relevant to their eating disorder development than other motivations, such as social confusion, need for control, sensory challenges, organizational problems related to food shopping and cooking, exercise as stimulation, and the eating disorder becoming an intense interest. (2)

Avoidant/restrictive food intake disorder (ARFID) can also be common among people with autism. (5) This eating disorder is characterized by an extreme lack of interest in food, sensory issues such as strongly disliking the texture of food, and/or a fear of vomiting or choking. It goes well beyond simple “picky eating”—it involves severe restriction that can lead to significant malnutrition and health and growth problems. People with ARFID may experience significant anxiety related to certain foods, which causes them to avoid them.

It is important to note that while many autistic people have strong sensory preferences and dislikes or may prefer to eat a narrower range of foods than allistic (non-autistic people), that does not necessarily mean they have ARFID. Many autistic people enjoy eating their preferred foods and are able to eat enough of them to meet their nutritional needs. ARFID is considered a disorder because it involves a level of distress around eating some or all foods that is significant enough to prevent an individual from being able to meet their nutritional needs or causes substantial disruption to their life. 

ADHD and eating disorders

Less research exists on the link between eating disorders and ADHD, but recent research has suggested a significant connection. For instance, research indicates that people with ADHD are three to six times more likely to develop an eating disorder than the general population. (1)

Experts theorize that impulsivity may have something to do with the link between eating disorders and ADHD since this trait is typically associated with ADHD as well as disordered eating behaviors, such as binging or binging and purging through self-induced vomiting, laxatives, or excessive exercise. Research supports this assertion, as studies have shown that childhood impulsivity predicts bulimia nervosa symptom onset in adolescence. (3)

People with ADHD often struggle with executive function and keeping track of time, which can make remembering to eat regularly and completing tasks to prepare food more difficult. This can result in either restrictive eating patterns or a restrict-binge cycle. (5)

Treating eating disorders in neurodivergent people

Research indicates that women with autism tend to benefit less from eating disorder treatment and experience poorer treatment outcomes than non-autistic women with anorexia nervosa. (2)

This may be because there is no system-wide approach to treating eating disorder patients with autism—rather, treatment providers must rely on their own experience and knowledge and the unique needs of each patient. According to research, most eating disorder professionals recognized the importance of tailoring treatment to meet the needs of autistic patients, many expressed that they didn’t have the knowledge to provide comprehensive care for this population. Further supporting this are reports from autistic women in treatment for anorexia nervosa who have stated they felt their needs were not met during eating disorder treatment. (2) 

Overall, in-person eating disorder treatment may prove difficult for some patients with autism, especially if they have sensory sensitivities, such as an aversion to bright lights or loud sounds associated with patients eating meals together. Group therapy may also prove challenging, especially for autistic people with social anxiety. 

Accommodations may be necessary for neurodivergent people to benefit from treatment. These accommodations may be allowing patients to eat alone, if they wish. It may also involve adapting the treatment plan to reflect the underlying factors contributing to an individual’s specific eating disorder, such as disordered eating becoming an intense obsession or a means of reducing sensory distress, rather than always emphasizing body image and weight concerns.

It may be helpful if clinicians administered a sensory profile assessment at intake. This would allow them to better understand a patient’s sensory traits so they can tailor treatment to reflect these needs. Additionally, the area intended for eating should be sensory-friendly to reduce anxiety for neurodivergent individuals. 

Further, when someone has ADHD, treatment providers should view their eating disorder through an ADHD lens, considering all of the intersecting factors that influence the development of eating disorder behaviors in people with this form of neurodiversity. This may involve treating ADHD with medications that enhance focus and awareness of time, which can both make it easier to remember to eat consistently throughout the day and reduce executive dysfunction. Some commonly used ADHD medications can also impact appetite, so providers should be aware of monitoring both ADHD needs and eating disorder symptoms when designing a treatment protocol for each patient. 

Ultimately, treatment providers need to recognize the need for individualized treatment for all patients, but especially for those who are neurodivergent and require treatment adapted to their unique needs, traits, and challenges.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Cobbaert, L., Minkov, R., and Zadow, M. (2021). Neurodivergence & Eating Disorders: Through the Lens of Sensory Processing. Anzaed Conference.
  2. 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. Journal of Autism and Developmental Disorders 50, 4280–4296.
  3. Reinblatt S. P. (2015). Are Eating Disorders Related to Attention Deficit/Hyperactivity Disorder?. Current treatment options in psychiatry, 2(4), 402–412.
  4. Svedlund, N. E., Norring, C., Ginsberg, Y., & von Hausswolff-Juhlin, Y. (2019). Treatment of eating disorders with concurrent ADHD symptoms: knowledge, knowledge gaps and clinical implications. Lakartidningen, 116, FMUT.
  5. ADHD as a co-occurring disorder with eating disorders. Eating Disorder Hope. (2022, September 21). Retrieved November 1, 2022, from https://www.eatingdisorderhope.com/treatment-for-eating-disorders/co-occurring-dual-diagnosis/ocd-obsessive-compulsive-disorder/adhd-as-a-co-occurring-disorder-with-eating-disorders

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