Treating ARFID and autism

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What is ARFID?

ARFID, which stands for avoidant/restrictive food intake disorder, is an eating disorder that involves eating less food than what is needed to nourish the body to function properly. Sometimes called extreme picky eating, ARFID is typically seen in children but can persist into adulthood if not treated. (1,2)

People with ARFID tend to avoid eating certain foods, because they don’t like the smell, texture, or taste of something or are afraid of choking, nausea, or vomiting. They may not like tomatoes, because they feel slimy in their mouths, or peaches because they feel prickly on their tongues. They may gag at the smell of fish. They may not eat meat, because they find it too hard to chew and swallow and think they’ll choke. They often have little interest in food and get full quickly.. 

While they may only eat a limited number or amount of foods, people who have ARFID do not have negative body image or fear of weight gain issues. (1,2)

How do ARFID and autism interact?

Most parents grow accustomed to their child being a picky eater or having neophobia, which is when the child refuses to try new foods. In fact, up to 46% of children struggle with picky eating, with one in ten having extreme picky eating. (2) But children with autism and other developmental disorders are five times more likely to have an eating concern than non-autistic developing peers. (2) Children with autism have sensory processing issues and often have aversions to certain textures, tastes, and smells. 

Autistic children are sometimes unable to properly interpret internal body states of hunger or fullness. This is called interoception. They may struggle with heightened anxiety surrounding food, but cannot properly express their feelings. This adds to their social-communication anxiety, which can make meal times even more stressful. (5)

There may be a genetic component, as well. A recent study published in Frontiers in Psychiatry revealed a strong genetic link between autism and ARFID. Their estimates revealed that up to 17% of parents with affected children also had ARFID, illustrating the lifelong risk of developing disordered eating. (2)

How does ARFID present in people with autism? 

 The most common presentations of ARFID in those who have autism include: (2,5) 

  • Eating a very narrow range of foods
  • Being afraid to try new foods, or neophobia
  • Refusing to eat food
  • High-frequency of single food intake
  • Eating or avoiding foods with a specific sensory characteristic (e.g., smell, texture, or taste)
  • Rigid ritualistic eating behaviors (i.e., not allowing foods to touch on their plate)

Vitamin deficiencies in ARFID and autism

As a result of all these factors, children with ARFID and autism most often present with vitamin deficiencies from eating a micronutrient poor diet. Some of the most common deficiencies include: (4) 

  • Vitamin C deficiency: results in scurvy. Symptoms can include swollen gums, excessive bruising and bleeding when injured, a swollen and inflamed tongue, tiredness and weakness, muscle and joint pain, and spots on their hands and legs that look like tiny red-blue bruises (perifollicular hemorrhage). Foods rich in vitamin C include green vegetables and citrus fruits. 
  • Vitamin A deficiency: results in eye disorders. Foods rich in vitamin A include carrots, eggs, cheese, and meat liver (beef, lamb, liver sausage, etc.). 
  • Thiamine (B1) deficiency: in severe cases can manifest as difficulty walking, muscle weakness, and confusion. B1 is naturally found in whole grains, vegetables, nuts, and seeds.
  • Vitamin B12 deficiency: results in feeling weak, tired, and irritable. Vitamin B12 is found in red meat and green leafy vegetables.
  • Vitamin D deficiency: results in fatigue, sadness, and irritability. Vitamin D is found in fish (salmon, cod, tuna), orange juice, and dairy. 

If a child with autism has ARFID, it’s important to have regular blood work performed to ensure they do not develop a serious vitamin deficiency. Symptoms can be difficult to detect until they reach a critically low level.

Ways to help children with autism eat

  1. Rule out a medical problem. The child may have a food sensitivity that causes belly pain, gas, or acid reflux. They may not be able to verbalize this pain and, instead, refuse a particular food. Food sensitivity testing by a doctor is an excellent way to screen for gastrointestinal distress.
  2. Be patient. Sometimes, children have to taste something numerous times before they will tolerate it. Avoid making the dinner table a battle ground. Roll with resistance and patiently introduce new foods without creating too much of a fuss.
  3. Involve the other senses. Children with autism approach new things cautiously. Sometimes, the child can benefit from touching and smelling the food a few times before tasting. They can practice touching it to their lips or simply licking it. Mixing a new food with an old favorite can also help warm them up to trying a new food.
  4. Beware of textures. The child, for example, may not be able to tolerate tomatoes because of the squishy texture. An alternative is to try mixing, chopping, or blending this into a salsa or tomato sauce. 
  5. Make eating fun. Autistic children can suffer from anxiety when trying new things. Try to make eating a fun adventure. Arrange vegetables on pizza into a smile, or allow them to finger paint with pasta sauce. This may help them be more receptive to trying new foods.
  6. Offer choices and control. Autistic children need to feel a sense of control over what they eat. Before preparing dinner, present them with options by showing them pictures or by placing food in bowels. 
  7. Do not use food as a reward. Try to be wary of bribing the child to eat certain foods. It’s important to reinforce their flexibility with food and willingness to try new things. Bribing may confuse them, so they won’t learn or understand it’s important to eat a balanced diet. Rewarding good behavior with treats can also be a slippery slope, as this is not the best way to positively reinforce behavior change.

If you or someone you care about is looking for help in overcoming an eating disorder, we are here to help. The clinical care team at Within Health have created a clinically-superior eating disorder treatment program that happens virtually, through our app. Call our admissions team today to get started.

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. Yager, J. Eating disorders: overview of epidemiology, clinical features, and diagnosis. UpToDate. Last updated Oct 8, 2020. Accessed Feb 25, 2022. https://www.medilib.ir/uptodate/show/2093 
  2. Koomar, T., Thomas, T. R., Pottschmidt, N. R., Lutter, M., & Michaelson, J. J. (2021). Estimating the Prevalence and Genetic Risk Mechanisms of ARFID in a Large Autism Cohort. Frontiers in Psychiatry, 12, 668297. https://doi.org/10.3389/fpsyt.2021.668297
  3. Autism and Food Aversions: 7 ways to help a picky eater. Autism Speaks. Oct 9, 2018. Accessed Feb 24, 2022. https://www.autismspeaks.org/expert-opinion/autism-and-food-aversions
  4. Yule, S., Wanik, J., Holm, E. (2021). Nutritional Deficiency Disease Secondary to ARFID Symptoms Associated with Autism and the Broad Autism Phenotype: A Qualitative Systematic Review of Case Reports and Case Series. Journal of the Academy of Nutrition and Dietetics, 121(3), 467-492. https://doi.org/10.1016/j.jand.2020.10.017
  5. ARFID & Autism. ARFID Awareness UK. Accessed Feb 24, 2022. https://www.arfidawarenessuk.org/the-link-with-autism-1

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