Autism

Autism

Autism is a neurodevelopmental condition meaning the nervous system has developed differently to that of most people. It is a naturally occurring form of neurodiversity. Autism affects how minds and bodies work with patterns of differences in movement, sensory processing, social communication, routines, thought processes, learning, working memory and awareness. These differences can impact many areas of eating and feeding with research finding that 70% of autistic children demonstrate ‘atypical’ eating behaviours. Individuals with autism may experience the world in a unique way, often noticing details that others might overlook. This can lead to strengths such as deep focus and passion in specific areas of interest.

Common eating challenges seen in autism: 

People with autism (which can also co-occur with ADHD) are more likely to face mealtime challenges and eating difficulties that can vary in severity and presentation. Some common eating challenges that can have a significant impact on individuals and their families include:

• Low interest in eating, food refusal and food neophobia
• Slow eating pace or difficulty focusing on one task for an extended period making it hard to finish a meal or snack
• Fast eating pace which may include loss of control around food
• Sensitivity to certain textures, smells, tastes, temperature or visual aspects of food, resulting in strong food dislikes and often extreme food selectivity
• Seeking sensory input resulting in strong preferences for certain textures e.g. crunchy, salty or spicy foods, carbonated beverages limiting food variety impacting nutritional adequacy
• Strong preference for ‘same foods’ eaten for prolonged periods to provide a sense of safety and regulation through consistency and predictability e.g. a particular brand or type of processed ‘beige’ foods such as nuggets, crackers, potato crisps, white bread, noodles
• Sensory processing differences related to the eating environment (at the table, school or a restaurant) e.g. lighting, crowded/busy/noisy/confined eating areas, visual clutter, hard uncomfortable chairs, social interaction pressures and extreme sensitivity to chewing sounds, making it difficult to eat with others
• Dysregulation and overwhelm due to neurotypical expectations at mealtimes such as must sit down, use cutlery, not stimming, not using fidgets or headphones
• Sensory processing differences making food shopping or preparing food challenging
• Executive functioning differences impacting the ability to plan meals, food shop, follow recipes, prepare food and clean up
• Aversions to specific foods due to feeding-related trauma, such as choking, gagging, or vomiting due to coercive/force-feeding at home or in feeding therapy
• Insistence on sameness and ritualistic mealtime behaviours to reduce uncertainty, uncontrollability and dysregulation e.g. same foods, wanting bread cut in triangles instead of squares, refusing certain foods to touch on a plate, requiring specific utensils, cups or plates, arranging food in a certain way
• Reduced interoception or interoceptive confusion affecting the ability to notice and respond to signals of hunger, thirst and fullness or issues with body mistrust negatively impacting body image
• Difficulties identifying, differentiating and expressing feelings and emotional states resulting in emotional and/or impulsive eating
• Hyperfocus on areas of interest or difficulties transitioning from one task to another which can impact regularity of eating
• Demand avoidance where eating or responding to hunger feels like a ‘demand’
• Oral motor difficulties such as low muscle tone making it difficult or tiring to chew, swallow, or coordinate their mouth muscles during mealtimes, limiting the range of foods and textures consumed e.g. only consuming liquid or puree foods
• Gastrointestinal issues such as constipation, diarrhoea, bloating, reflux, Coeliac Disease, Crohn’s Disease or IBS leading to food restriction or avoidance  
• Chronic poor sleep (in up to 80% of autistic people) impacting energy levels, sensory regulation, executive functioning and gut symptoms

How our dietitians can help with eating challenges in autism: 

• Providing a safe, non-judgemental, neurodiversity-affirming space to talk openly and share concerns about food and eating difficulties
• Providing neurodiversity-affirming psychoeducation on potential sensory, social, and executive functioning differences that can impact food intake
• For children and adolescents, providing a thorough assessment of weight and growth and whether it is tracking normally for age
• Providing individualised strategies to restore appropriate growth trajectory in children and adolescents. This may include taste testing of medical nutrition supplements and scripts to purchase them at a reduced price if required
• Conducting a nutritional analysis of current food intake alongside a review of medications and blood tests to provide a personalised vitamin and mineral supplementation plan to correct or prevent deficiencies. This may include liquids, chewables, powders, sprays, tablets, or drops depending on personal preference while considering sensory sensitivities
• Reviewing impact of medications (type and timing) on food intake and educating on interactions with food or supplements if relevant
• Providing strategies to expand the diet that are aligned with the individual’s goals g. restore weight and growth, prevent deficiencies, improve energy levels, sleep and concentration, eat socially
• Identifying individual’s unique food sensory profile and providing practical advice to successfully expand on ‘safe’ foods to meet nutrition requirements
• Exploring and supporting sensory needs around food and mealtimes to manage anxiety and dysregulation to help build safety, trust, confidence, and a positive relationship with food
• Creating a structured and predictable mealtime routine and environment to set up for success
• Understanding and challenging neurotypical expectations around eating and food
• If appropriate, providing strategies to improve interoceptive awareness of hunger, thirst and fullness cues
• Assisting with the management of food sensitivities and gastrointestinal symptoms which can impact food intake, behaviour, attention, sleep patterns and emotional regulation
• Providing in-session meal support with the optional support of our Dietwise dogs Ella and Reggie
• Providing practical low-spoon (quick and easy) tips, guides and hacks for meal planning, food shopping, cooking, food storage and clean-up
• Reducing overwhelm and confusion by helping navigate the plethora of conflicting nutrition information and myth busting informed by the latest research
• Advocating for support, accommodations and autonomy around food and eating at kindergarten, school, university, the workplace, family or friends
• Referring to and collaborating with other members of the interdisciplinary team where required such as a GP, Paediatrician, Occupational Therapist, Speech Pathologist, Psychologist and Psychiatrist

As every autistic person’s eating and feeding experience is different, no one approach, diet, or supplement will suit everyone. Our dietitians approach their work with compassionate curiosity and embrace creative and collaborative problem-solving. We also understand the importance of working in a way that encourages the development of a positive neurodivergent identity for the individual and the family.

A special note on autism, eating disorders and neurodiversity-affirming care 

Autistic people are at increased risk of developing an eating disorder due to some crossover traits such as rigidity (black-and-white thinking), intense interests and repetitive behaviours. In addition, dietary restriction may be a form of ‘masking’ to fit in with neurotypical eating behaviours or a coping mechanism for anxiety/burnout or difficult emotions. 

The most common eating disorders amongst autistic people are Anorexia Nervosa and ARFID- Avoidant/Restrictive Food Intake Disorder. Up to 20-35% of women with Anorexia Nervosa meet the diagnostic criteria for autism. ARFID prevalence is estimated to be 21% of autistic individuals. In ARFID, food is not restricted to avoid weight gain or control body shape/size, but rather due to sensory sensitivities, low interest and/or fear of aversive consequences. Read more about ARFID here.  

“When a flower doesn’t bloom, you fix the environment in which it grows, not the flower.” Alexander Den Heijer

In terms of treatment, our experience is that compliance-based behavioural-based ED interventions such as CBT-E, CBT-AR and FBT are not neurodiversity-affirming and may not be a good fit for some people with autism and/or ADHD. In these cases, we challenge neuronormative beliefs, assumptions, norms, goals and expectations related to food, eating and body to prevent trauma and minimise harm. We prioritise self-determination and autonomy, and use a client-centred, strengths-based approach, adapting nutrition care accordingly. In addition, our Dietitians work alongside our clients with compassionate curiosity and respect neurodivergent ways of being, versus seeking to eradicate or cure it to support a positive neurodivergent identity.