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Avoidant/restrictive food intake disorder (ARFID) is an eating disorder that involves extreme picky eating caused by sensory sensitivities or food-based fears, leading to severe malnutrition.
Much is still being discovered about ARFID, but research is increasingly finding connections between the condition and autism spectrum disorder (ASD).
And while there are methods to treat these mental health conditions separately—though comprehensively—additional research may soon uncover treatments or therapies that can address both conditions at once.
Autism and ARFID aren't the same thing, but the two conditions commonly occur together. One study found a comorbidity, or co-occurring, rate of 21%, while another noted that ASD was a predictor of ARFID developing in children.1,2
Evidence suggests the two may be genetically linked, with the first study identifying a particular gene that may play a role in both autism and ARFID. Parents of children with autism were also found to be at a heightened risk for developing ARFID, at a rate of 17%, suggesting the conditions may be inherited.1
But regardless of how they develop, the two frequently present with similar eating patterns, including:1,3
Eating from extremely narrow food selections
Being afraid to try new foods (neophobia)
High-frequency intake of a single type of food
Eating or avoiding foods with a specific sensory characteristic (e.g., smell, texture, or taste)
Rigid ritualistic eating behaviors (i.e., not wanting certain foods touching on their plate)
In fact, many people consider picky eating a sign of autism. And while that greatly simplifies the presentation, children with ASD are nearly five times more likely to have some type of eating concern than their neuronormative peers.1
Food aversion is perhaps a common feature of ARFID and autism, and frequently, they're driven by similar issues.
Sensory sensitivities and other sensory issues are common across both conditions, and frequently drive the disordered eating habits involved with both. Texture sensitivity is particularly common, but people with autism and ARFID may also have sensory sensitivity around food colors or scents.2,3
Sometimes, ARFID doesn't present as much as food selectivity as a general disinterest in food. And ASD can also manifest this way, as people with autism spectrum disorders sometimes have trouble interpreting internal cues for hunger.3
ARFID can also present as food aversion based on a fear of choking or vomiting. The overlap of this particular symptom with ASD hasn't been studied, but autism does sometimes lead to the same disruptive or difficult behavior around mealtime as ARFID frequently does.2,3
The disordered eating behaviors and common food texture sensitivity in autism and ARFID can lead to malnutrition. In fact, when it comes to ARFID, nutritional deficiency caused by eating behavior is part of the medical definition.
Similar vitamin deficiencies across the conditions include:5
Vitamin C: Foods rich in this mineral include green vegetables and citrus fruits.
Vitamin A: Carrots, eggs, cheese, and meat liver—particularly beef, lamb, and liver sausage—are foods high in this vitamin.
Thiamine (B1): B1 is naturally found in whole grains, vegetables, nuts, and seeds.
Vitamin B12: Red meat and green leafy vegetables provide rich sources of vitamin B12.
Vitamin D: This vitamin is commonly found in fish (salmon, cod, tuna), orange juice, and dairy products.
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 critical level.
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Treating autism and ARFID
Research on both autism and ARFID is ongoing, with new discoveries dictating treatment recommendations all the time. When treating ASD and ARFID, the treatment team must be aware of all conditions and how treatment will impact the individual.
ASD, when it becomes disruptive to someone's daily life, is generally addressed with therapy, including cognitive behavioral therapy (CBT) and nutritional therapy.6 The same therapeutic methods are also commonly recommended for people struggling with ARFID, with an ARFID-specific type of CBT recently developed to better help people with this condition.7
It may be possible for medications or other types of treatment or therapy to help in either case, as well. ARFID and autism are both very individualized disorders, which can manifest in any number of ways. A primary care physician, therapist, or dietitian should be able to help someone dictate the best course of treatment.
Remote treatment allows you recover from ARFID from the comfort of your home or wherever you are.
When food selectivity becomes extremely disruptive, or leads to malnutrition or other serious health issues, it may be necessary to utilize intravenous feeding methods or other more intensive types of care. These should only be issued by a doctor or other trained professional.
Other ways to promote healthy eating in people with ARFID and autism
In many cases, dietary changes, especially changes to a child's diet, are one of the most helpful ways to address issues caused by ARFID and autism, especially if someone is experiencing health issues tied to nutritional deficiencies.
When it comes to picky eaters, however, this can be a particular challenge. Many parents find themselves asking how to get an autistic child to eat, or how to help a child with ARFID get the proper vitamins and nutrients.
In this regard, there are a few tips that may be able to help parents of children with ARFID or autism improve what and how their child eats. And these tips can also be helpful for autism-related food aversions in adults.
While these suggestions fall short of a true treatment for ARFID and autism, they may be able to help alleviate some of the worse health-related issues that can arise from these conditions.
Rule out a medical problem
It's possible that, rather than being a "picky eater," a child with ARFID or autism may have a food sensitivity that causes pain, gas, or acid reflux. They may not be able to verbalize this issue and, instead, refuse a particular food.
Food sensitivity testing by a doctor is an excellent way to screen for gastrointestinal distress.8
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.8
Mixing a new food with an old favorite can also help warm them up to trying a new food.
Beware of textures
Texture sensitivity is one of the most common signs of ARFID and a frequent symptom of autism. But if a child doesn't like the natural texture of a food, it may be possible to alter that texture, by preparing it in a different way.8
To avoid the gelatinous feeling of a tomato, for example, you may be able to chop it into chunks or blend it into a salsa or tomato sauce.
Make eating fun
Autistic children and those with ARFID frequently have anxiety around mealtimes.8 Trying to make eating a fun adventure can help alleviate this fear.
You can play around with food by making fun shapes, like arranging vegetables on pizza into a smile. Letting the child join in on the fun may also be helpful, such as allowing them to finger paint with pasta sauce.
Modeling how food can be fun can also help show your child that eating is an experience to enjoy, rather than fear.
Offer choices and control
For many children who struggle with food selectivity, having a sense of control over what they eat can be important. Of course, allowing them too much control can result in the same type of picky eating that's driving the issue.
You can try splitting the difference.
When preparing dinner, you can present your child with options, showing them pictures of foods you can prepare or placing food in bowls. This gives them a choice in the matter, while keeping that choice within a range of healthy options.8
Avoid using food as a reward
It's a common practice for parents, especially those who are feeling frustrated or exhausted by constant issues around mealtime, but try to be wary of bribing the child to eat certain foods.
Bribing a child may confuse them, or deemphasize their autonomy in making these choices, which is actually what needs to be built. Rewarding good behavior with treats can also be a slippery slope, as this is not the best way to positively reinforce behavior change.8
Have patience
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.8
Of course, this is easier said than done, especially if this issue has been ongoing for some time. If you're dealing with regular disruptions of this kind, it's also important to be patient with yourself.
Giving back to yourself some time and space to breathe and recuperate is crucial, and can work wonders to help you maintain the strength, patience, and positive attitude that is often required in these difficult situations.
ARFID and autism-related malnutrition can be a serious problem. If you or someone you care about is looking for help with this issue or with overcoming an eating disorder, it's important to seek out help.
Your primary care physician or your child's pediatrician, therapist, or psychologist may be a good place to start. These experts can generally help write official diagnoses for these conditions or offer advice on next best steps.
Learn about our treatment program
If you don't live near an in-person treatment facility, have difficulties around transportation or mobility, or would rather receive treatment from your own home for any reason, you can also look into our program at Within Health.
Our clinical care team covers a comprehensive range of backgrounds and can help create tailored treatment plans for you or your loved one, which can be followed virtually, online or 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.
Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.
It can be equal parts heartbreaking and frustrating to watch your child refuse to eat, whether they struggle with autism or for any other reason. If your child has ASD and won't eat, you may want to try:9
Easing into mealtime. Have your child practice some deep breathing techniques before eating, or participate in other relaxing routines. This can help ease the stress or anxiety around mealtime, for both of you.
Build acceptance toward food with gradual exposure. Start by having them touch, smell, or lick food before introducing it into a meal.
Remove food from its branded box or bag. This can help reduce aversions to certain colors or associations that may cause food-related anxiety.
If your child continues to have trouble around mealtimes or refuses to eat, you may want to call a doctor, pediatrician, or specialist.
Is picky eating a sign of autism?
While it's true picky eating is very common among people with ASD, it's not a clear indication, on its own, that someone has autism spectrum disorder. Picky eating is common among both children with autism and those without the condition.
If picky eating is extreme, disruptive to everyday life, or occurs alongside other symptoms of ASD, it more likely points to someone having the condition.
How to get an autistic child to eat vegetables?
Getting an autistic child to eat vegetables or any other type of food they have an aversion to can be tricky, and there's no set of tips that will work across the board.
Aside from trying to make food more fun and enjoyable, you can slowly introduce different foods to the table. Start by having a bowl of the vegetable in question on the table, but away from your child's plate. Once that's been established, you can move it onto their plate, but not ask them to eat it. Finally, you can let them touch, smell, or lick the vegetable until they're comfortable enough to eat it.10
