Avoidant/restrictive food intake disorder and autism spectrum disorder: clinical implications for assessment and management

Abstract

Aim We examined clinical and neurodevelopmental presentations of children with avoidant/restrictive food intake disorder (ARFID) to inform clinical assessment and management. Method Five hundred and thirty‐six patients (mean age 6y 10mo, SD 3y 5mo, range 10mo–20y; 401 males, 135 females) seen by the tertiary multidisciplinary feeding service at the Evelina London Children’s Hospital between January 2013 and June 2019 were included in this case–control study. These children experienced significant feeding difficulties impacting nutrition, development, and psychosocial functioning requiring tertiary specialized input. Data on ARFID diagnosis, demographics, comorbidity, and nutrition was extracted from electronic patient records. Results Forty‐nine per cent of children met ARFID criteria. The remaining participants had other difficulties including feeding, medical, and/or neurodevelopmental conditions. ARFID is more prevalent among younger patients (4–9 years) and in children with comorbid autism spectrum disorder (ASD). Younger age, comorbid ASD, and male sex significantly predicted ARFID. Diet range and male sex significantly predicted nutritional inadequacy, while comorbid ASD did not. A trend was seen between younger age and nutritional inadequacy. Interpretation Young children with ARFID should raise suspicion for ASD. Although significant nutritional deficiencies are common in children with comorbid ARFID and ASD, they are correctable with nutritional supplementation. Specialty perspective potentially limits generalizability of findings to community feeding services. We also emphasize the importance of early identification of nutritional deficits and management.

Avoidant/restrictive food intake disorder and severe food selectivity in children and young people with autism: A scoping review

“…This can result in substantial limitations relating to the type and/or amount of food consumed, [11][12][13] which may mean that individuals with ASD are at an increased risk of significant feeding difficulties compared to those without ASD and may even meet the diagnostic threshold for ARFID. [14][15][16][17] It is important to note, however, that this continues to be investigated, with some research suggesting that autistic traits contribute to the exacerbation of severe feeding difficulties rather than their onset. 18 Evidence suggests that individuals with ASD are at a heightened risk of long-term physical health conditions and premature mortality, [19][20][21] but the reasons for this remain unclear.…”

“…The characteristic pattern of behaviours, needs, and sensitivities associated with autism can give rise to a limited food repertoire, specific sensory preferences, and rigid rules regarding mealtimes. This can result in substantial limitations relating to the type and/or amount of food consumed, 11–13 which may mean that individuals with ASD are at an increased risk of significant feeding difficulties compared to those without ASD and may even meet the diagnostic threshold for ARFID 14–17 . It is important to note, however, that this continues to be investigated, with some research suggesting that autistic traits contribute to the exacerbation of severe feeding difficulties rather than their onset 18 …”

Feeding and Swallowing Issues in Autism Spectrum Disorders

“… 11 , 12 , 39 Moreover, this also highlights the need to further assess children with a diagnosis of AFRID for ASD, to better understand the early identification of nutritional deficits and health outcomes. 40 …”

Integrating the Autistic Experience Into Existing Models for Disordered Eating

“…Autism-ED research is limited in acknowledging the nuances of the autistic experience in two ways: first, research lacks accounting for its heterogenic nature more generally and/or its entirety (e.g., development, presentation); second, despite it not being limited to a specific ED diagnostic category and/or severity level, research predominantly refers to restrictive eating pathology (Brede et al, 2020 ). Furthermore, existing ED theory has yet to be extended to feeding disorders such as ARFID, despite its prevalence among both neurotypical and neurodiverse groups – particularly children and adolescents (Nicely et al, 2014 ; Farag et al, 2021 ). Consequently, current understanding limits engagement and advancement of neurodiverse detection and intervention practices.…”

“…As a result, this perpetuates an axis of contention regarding limited generalisability among individuals with cognitive-behavioral variances, such as autistic individuals (Pennesi and Wade, 2016 ). Furthermore, existing models lack reference to other EDs commonly associated with autism – in particular, avoidant/restrictive food intake disorder (ARFID) (persistent avoidance/disturbance in feeding or eating due to sensory concerns and/or lack of interest; American Psychiatric Association [APA], 2013 ; Farag et al, 2021 ). For a more inclusive conceptualization of EDs, existing models should be adapted, or a parallel explanatory framework should be developed alongside existing practice, to better serve neurodivergent populations.…”