The SWedish Eating Assessment for Autism spectrum disorders (SWEAA)-Validation of a self-report questionnaire targeting eating disturbances within the autism spectrum

The clinical characteristics of autistic women with restrictive eating disorders

BACKGROUND

Autistic women are at high risk of developing restrictive eating disorders (REDs), such as anorexia nervosa.

AIMS

This study provides an overview of the clinical characteristics of autistic women with REDs to (i) enhance understanding of increased risk, and (ii) support the identification of autistic women in eating disorder services.

METHOD

We compared self-reported autistic and disordered eating characteristics of: autistic participants with REDs (Autism + REDs; n = 57); autistic participants without REDs (Autism; n = 69); and women with REDs who are not autistic (REDs; n = 80). We also included a group of women with high autistic traits (HATs) and REDs, but no formal autism diagnosis (HATs + REDs; n = 38).

RESULTS

Autism + REDs participants scored similarly to Autism participants in terms of autistic characteristics and to REDs participants in terms of experiencing traditional disordered eating symptoms. Autism + REDs participants were distinguished from both groups by having more restricted and repetitive behaviours and autism-specific eating behaviours related to sensory processing, flexibility and social differences. HATs + REDs participants showed a similar pattern of scores to Autism + REDs participants, and both also presented with high levels of co-occurring mental health difficulties, particularly social anxiety.

CONCLUSION

The presentation of autistic women with REDs is complex, including both traditional disordered eating symptoms and autism-related needs, as well as high levels of co-occurring mental health difficulties. In eating disorder services, the REDs presentation of autistic women and those with HATs should be formulated with reference to autism-specific eating behaviours and co-occurring difficulties. Treatment adaptations should be offered to accommodate autistic characteristics and related needs.

Psychometric evaluation of a revised version of the body appreciation scale-2 for autistic adults (BAS-2A)

Emerging evidence points to unique conceptualisations of positive body image in autistic individuals. However, there are no existing measures of positive body image that have been developed or validated for use with autistic adults. To rectify this, we developed a revised version of the BAS-2 - the BAS-2A - and examined its factorial validity and psychometric properties in a sample of autistic adults from the United Kingdom. Based on the results of exploratory factor analysis and scale purification, we extracted a 12-item, unidimensional model of BAS-2A scores in a first split-subsample (n = 273). Confirmatory factor analysis supported the unidimensional model of BAS-2A scores in a second split-subsample (n = 277). BAS-2A scores presented adequate composite reliability, measurement invariance across gender identity, and patterns of construct validity. For both women and men, BAS-2A scores correlated positively with self-esteem, well-being, quality of life, and adaptive coping, and inversely with dietary restraint, weight/shape overvaluation, body dissatisfaction, and depression. Finally, BAS-2A scores demonstrated incremental validity, predicting self-esteem over-and-above body dissatisfaction. However, temporal stability of the BAS-2A over three weeks was not supported. These results support the BAS-2A as a psychometrically robust measure of body appreciation for use in autistic adults from the United Kingdom.

Eating disorder in children: Impact on quality of life, with a spotlight on autism spectrum disorder

Eating behavior, which includes eating habits and preferences, frequency of eating, and other features related to diet, is a major characteristic not only of a person's nutritional status, but also of health in general. In recent years, the prevalence of eating disorders in children has tended to increase; they also require cross-system approaches in diagnosis by a variety of specialists and correction requires appropriate selection of optimal methods. Maladaptive eating attitudes formed at an early age can contribute to the formation of eating disorders, which can lead to or worsen various neuropsychiatric diseases, digestive diseases, and other related conditions. In children with autism spectrum disorder (ASD), eating disorders often appear earlier than other major symptoms of the condition. However, the clinical manifestations of eating disorders in children with ASD are varied and differ in severity and duration, whereas these disorders in neurotypical children might present as short-lived and may not lead to serious consequences. Nevertheless, cases of progressive eating disorders accompanied by a child presenting as under- or overweight and/or with macronutrient and micronutrient deficiencies cannot be excluded. Given the high prevalence of eating disorders in children, many researchers have highlighted the lack of a valid and universally accepted instruments to assess atypical eating behaviors in this population. Therefore, in this review, we wanted to highlight the problems and causes of eating disorders in children, and also to analyze the existing approaches to the validation of these problems, taking into account the existing behavioral features in children with ASD.

Autistic traits, sensory sensitivity and eating disturbances in a sample of young adults referring to a generalized mental health clinic

PURPOSE

The relationship between autistic traits and eating disturbances has been given considerable attention over the last decades. The rise of a dimensional approach to psychopathology has expanded the way we think about autism, acknowledging that subthreshold autistic manifestations span across the general population and are more pronounced in psychiatric patients. Here we investigated the prevalence of eating disorders and its potential relationship with autistic traits and sensory sensitivity in a group of patients who were referred for the first time to a mental health outpatient clinic, without a formal diagnosis yet.

METHODS

259 young adults (between 18 and 24 years old) completed: the Eating Attitude Test (EAT-26), the Swedish Eating Assessment for Autism Spectrum Disorders (SWEAA), the Autism Quotient (AQ), the Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R), and the Sensory Perception Quotient-Short Form 35 item (SPQ-SF35).

RESULTS

23.55% of participants scored above the cut-off at the EAT-26, suggesting that they presented a risk for eating disorders and should be assessed by a specialized clinician; associations emerged between hypersensitivity in the touch and vision domain and both the EAT-26 and the SWEAA; the presence of autistic traits was largely associated with eating disturbances.

CONCLUSIONS

This study underlines the significance of the eating domain as a central psychopathological feature in the distress experienced by young adults with general psychiatric symptoms and psychological suffering; it adds evidence to the association between autistic traits and eating disorders and opens to new research questions about the role of subthreshold autistic traits in general psychopathology.

LEVEL OF EVIDENCE

Level I: Evidence obtained from experimental studies.

Assessment Methods for Problematic Eating Behaviors in Children and Adolescents With Autism Spectrum Disorder

Autism spectrum disorder (ASD) can be associated with eating problems. However, currently, there is a lack of established guidelines for assessing and addressing eating behaviors in individuals with ASD. This gap in research exists due to the challenges associated with using traditional assessment methods, which may lead to discrepancies in responses and unintentional potential biases from caregivers. In this review, we provided a comprehensive overview of various eating behaviors commonly observed in individuals with ASD. These behaviors include 1) food neophobia, 2) selective eating, 3) binge eating, 4) food avoidance, 5) chewing and swallowing problems, 6) pica, 7) rumination, 8) rituals, and 9) problematic behaviors. Furthermore, we provide a perspective of utilizing digital tools: 1) augmentative and alternative communication; 2) ecological momentary assessment; and 3) video analysis, behavioral analysis, and facial expression analysis. This review explores existing assessment methods and suggests novel assessment aiding together.

Challenges and opportunities for conceptualizing intuitive eating in autistic people

Although intuitive eating (IE) has become an increasingly adopted intervention target, current conceptualisations of IE have yet to pivot away from (neuro)normative physiology and phenomenology. Autistic individuals commonly report disordered eating behaviours and/or poorer well-being but appear to benefit from adaptive interventions using an affirmative approach. This article uses autism as a case example to summarise challenges related to IE's prevailing conceptualisation, before proposing how future research and current practice can be extended to the autistic population. Scholars are encouraged to evaluate the full 10-principal IE framework while utilising a participatory-led approach. We argue that research using a mixed methods design is urgently needed to comprehensively explore the (re)conceptualisation of IE in autistic people. While IE shows promise for producing positive outcomes in the autistic population, we discuss the potential challenges for research and practice due to its current emphasis on accurate interoception, emotional awareness and processing, and executive functioning. This suggests the need for research and practice to integrate autistic needs and experiences into future developments with an affirmative approach. Public Significance: IE is an effective intervention for reducing disordered eating behaviours. Autistic individuals commonly present disordered eating behaviours and have unique nutritional needs which often require intervention. However, there is limited understanding of IE among the autistic population. Research-informed definitions involving autistic perspectives will support translating the IE framework to this underrepresented population.

Screening for Caregiver-Reported Feeding Concerns in Children with Autism Spectrum Disorder in a Tertiary-Care Clinic

OBJECTIVE

Feeding concerns, primarily food selectivity, are commonly observed in children with autism spectrum disorder (ASD). Prevalence rates suggest that at least half of autistic youth have feeding difficulties.

METHODS

A retrospective chart review examining records of a large cohort of autistic children (N = 746) referred for ASD evaluation was conducted. Families completed a survey regarding feeding concerns in their children before a diagnostic evaluation.

RESULTS

Post hoc analyses based on retrospective chart review revealed approximately 30% of caregivers reported significant difficulty feeding their child. Young age, food selectivity, and concerns about weight were associated with increased likelihood of reported feeding difficulties. There was clear overlap between overall feeding difficulties and specific food selectivity; however, 1 in 5 children whose caregivers did not report feeding difficulties endorsed food selectivity.

CONCLUSION

Findings highlight the need for multipronged approaches to screening to facilitate service prioritization by pediatric providers.

In search of environmental risk factors for obsessive-compulsive disorder: study protocol for the OCDTWIN project

BACKGROUND

The causes of obsessive-compulsive disorder (OCD) remain unknown. Gene-searching efforts are well underway, but the identification of environmental risk factors is at least as important and should be a priority because some of them may be amenable to prevention or early intervention strategies. Genetically informative studies, particularly those employing the discordant monozygotic (MZ) twin design, are ideally suited to study environmental risk factors. This protocol paper describes the study rationale, aims, and methods of OCDTWIN, an open cohort of MZ twin pairs who are discordant for the diagnosis of OCD.

METHODS

OCDTWIN has two broad aims. In Aim 1, we are recruiting MZ twin pairs from across Sweden, conducting thorough clinical assessments, and building a biobank of biological specimens, including blood, saliva, urine, stool, hair, nails, and multimodal brain imaging. A wealth of early life exposures (e.g., perinatal variables, health-related information, psychosocial stressors) are available through linkage with the nationwide registers and the Swedish Twin Registry. Blood spots stored in the Swedish phenylketonuria (PKU) biobank will be available to extract DNA, proteins, and metabolites, providing an invaluable source of biomaterial taken at birth. In Aim 2, we will perform within-pair comparisons of discordant MZ twins, which will allow us to isolate unique environmental risk factors that are in the causal pathway to OCD, while strictly controlling for genetic and early shared environmental influences. To date (May 2023), 43 pairs of twins (21 discordant for OCD) have been recruited.

DISCUSSION

OCDTWIN hopes to generate unique insights into environmental risk factors that are in the causal pathway to OCD, some of which have the potential of being actionable targets.

Oromotor skills in autism spectrum disorder: A scoping review

Oromotor functioning plays a foundational role in spoken communication and feeding, two areas of significant difficulty for many autistic individuals. However, despite years of research and established differences in gross and fine motor skills in this population, there is currently no clear consensus regarding the presence or nature of oral motor control deficits in autistic individuals. In this scoping review, we summarize research published between 1994 and 2022 to answer the following research questions: (1) What methods have been used to investigate oromotor functioning in autistic individuals? (2) Which oromotor behaviors have been investigated in this population? and (3) What conclusions can be drawn regarding oromotor skills in this population? Seven online databases were searched resulting in 107 studies meeting our inclusion criteria. Included studies varied widely in sample characteristics, behaviors analyzed, and research methodology. The large majority (81%) of included studies report a significant oromotor abnormality related to speech production, nonspeech oromotor skills, or feeding within a sample of autistic individuals based on age norms or in comparison to a control group. We examine these findings to identify trends, address methodological aspects hindering cross-study synthesis and generalization, and provide suggestions for future research.

Investigating the relationship between orthorexia nervosa and autistic traits in a university population

BACKGROUND

Orthorexia nervosa (ON) is an emerging condition featuring restrictive eating behaviors on the basis of subjective beliefs about food healthiness. Many authors have stressed the similarities between ON and anorexia nervosa (AN) in both cognitive and behavioral patterns. Despite that, while the link between AN and female autism presentations is well known in the literature, no study has yet investigated the relationship between ON and autism spectrum. This work aims to investigate the relationship between ON and autistic traits in a university population.

METHODS

An e-mail invitation was sent to all the students and University workers of University of Pisa. Subjects were asked to fulfill the ORTO-15 and the Adult Autism Subthreshold spectrum (AdAS spectrum) questionnaires.

RESULTS

A total of 2426 subjects joined the survey: 623 subjects (26.3%) reported a score associated with significant orthorexic symptoms according to ORTO-15 (ON group), while 1789 subjects (73.7%) did not report ON symptomatology and were considered as healthy controls (HC). The ON group scored significantly higher on almost all AdAS spectrum domains. Moreover, being female and scoring higher on AdAS spectrum were statistically predictive factors for the presence of ON symptomatology. Among AdAS spectrum domains, higher scores on AdAS spectrum inflexibility and adherence to routine and restricted interests and rumination domains, as well as lower scores on verbal communication domain, were statistically predictive of orthorexic symptoms.

CONCLUSIONS

Our findings highlight an overlap between ON and autism spectrum psychopathology. Further studies are needed to clarify the relationship between restrictive eating disorders and female autism phenotypes.

A comparison of the eating disorder service experiences of autistic and non-autistic women in the UK

Objective

Qualitative studies report that autistic women have poor experiences when being treated for an eating disorder (ED) and express that ED services are not appropriately tailored to meet their needs. It is unclear whether their experience differs to other women accessing ED services. The aim of the current study was to compare autistic and non‐autistic women's ED illness history and experiences in ED services.

Method

An online survey about ED illness history and their experience with ED treatment was completed by 46 autistic women with a restrictive ED and 110 non‐autistic women with a restrictive ED.

Results

Despite some similarities, there were three key differences in the experiences reported by autistic and non‐autistic women. First, autistic women reported a longer duration of ED and being diagnosed with an ED at a younger age than non‐autistic women. Second, autistic women reported accessing a broader range of healthcare settings and ED treatments than non‐autistic women when being treated for an ED. Finally, autistic women rated their experiences of inpatient care, dietetic input, and cognitive behavioural therapy (CBT) as significantly less beneficial than non‐autistic women when being treated for an ED.

Conclusion

These findings increase understanding of autistic women's ED experience and can help to shape ED services and treatments to better accommodate the needs of their autistic clients.

The current study is the first to compare the eating disorder (ED) illness history and treatment experiences of autistic and non‐autistic women.

Autistic women with EDs are diagnosed at a younger age and report longer illness duration than non‐autistic women.

Autistic women with EDs tend to access a broader range of healthcare settings and ED treatments than non‐autistic women, but report these to be less beneficial.

Problematic eating behaviours of autistic women-A scoping review

Aim

Eating and feeding behaviours of autistic individuals and related consequences have been mainly investigated in autistic children or in autistic adults with intellectual disabilities. Behaviours such as food selectivity or food neophobia have been shown to persist into adolescence and adulthood and are associated with aversive consequences. However, much less is known about the eating behaviours of autistic adults without intellectual disabilities, especially those of women. By means of a scoping review, we aim to assess the extent of the scientific literature on what is known about the eating behaviours of these women and the possible consequences of such eating behaviour.

Method

Medline, Cochrane, PubMed and PsycInfo databases were searched according to Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) guidelines.

Results

Five studies met the eligibility criteria and were included in this review. Autistic women not only reported high levels of eating behaviour frequently seen in autism spectrum disorders (ASD), but also high levels of disordered eating behaviour, similar to that of women with eating disorders.

Conclusions

Autistic women seem to exhibit high levels of eating behaviour frequently seen in ASD as well as disordered eating behaviour. Future research needs to shed light on what underlies these problematic eating behaviours, in order to help to adapt current treatment modalities to meet the unique needs of these women.

This scoping review indicates that autistic women exhibit both eating behaviours frequently seen in autism spectrum disorders (ASD) and disordered eating behaviours, similar to those of women with eating disorders.

The review also indicates that studies investigating these eating behaviours of autistic women are still very scarce, and those that are available often lack a comprehensive assessment of the ASD diagnosis.

Future studies are needed to confirm the findings and to further explore how and why autistic women eat the way they eat, in order to help to adapt current treatment modalities to meet the unique needs of these women.

A meta-analytic investigation of grey matter differences in anorexia nervosa and autism spectrum disorder

Recent research reports Anorexia Nervosa (AN) to be highly dependent upon neurobiological function. Some behaviours, particularly concerning food selectivity are found in populations with both Autism Spectrum Disorder (ASD) and AN, and there is a proportionally elevated number of anorexic patients exhibiting symptoms of ASD. We performed a systematic review of structural MRI literature with the aim of identifying common structural neural correlates common to both AN and ASD. Across 46 ASD publications, a meta‐analysis of volumetric differences between ASD and healthy controls revealed no consistently affected brain regions. Meta‐analysis of 23 AN publications revealed increased volume within the orbitofrontal cortex and medial temporal lobe, and adult‐only AN literature revealed differences within the genu of the anterior cingulate cortex. The changes are consistent with alterations in flexible reward‐related learning and episodic memory reported in neuropsychological studies. There was no structural overlap between ASD and AN. Findings suggest no consistent neuroanatomical abnormality associated with ASD, and evidence is lacking to suggest that reported behavioural similarities between those with AN and ASD are due to neuroanatomical structural similarities.

Findings related to neuroanatomical structure in AN/ASD demonstrate overlap and require revisiting.

Meta‐analytic findings show structural increase/decrease versus healthy controls (LPFC/MTL/OFC) in AN, but no clusters found in ASD.

The neuroanatomy associated with ASD is inconsistent, but findings in AN reflect condition‐related impairment in executive function and sociocognitive behaviours.

Eating disturbances in eating disorders and in high-functioning autism spectrum disorders: a preliminary study

PURPOSE

The relationship between autism spectrum disorders (ASDs) and eating disorders (EDs) has been widely studied in the last decades. We aimed to directly compare patients with EDs, individuals with high-functioning ASDs (HF-ASDs) and healthy controls (HC) at measures detecting: (1) symptoms of eating disorders, (2) eating disturbances known to be characteristic of autism.

METHODS

Thirty-four patients with EDs, 34 individuals with HF-ASDs and 35 HC, all females, completed the eating attitude test (EAT-26) and the Swedish eating assessment for autism spectrum disorders (SWEAA), two self-report questionnaires assessing, respectively, symptoms and concerns characteristic of eating disorders and ASD-related eating disturbances.

RESULTS

At the EAT-26, patients with EDs scored significantly higher than individuals with HF-ASDs, and both of them scored higher than HC (p < 0.05, η_p² = 0.283). Conversely, at the SWEAA, no differences between individuals with HF-ASDs and patients with EDs emerged (p = 901), but they both scored higher than HC (p < 0.05, η_p² = 0.247).

CONCLUSION

Individuals with HF-ASDs did not seem to reach the same level of EDs symptomatology as patients with EDs. Patients with EDs did not seem to present a different amount of autistic-eating behaviours than subjects with HF-ASDs. Patients with EDs and individuals with HF-ASDs scored higher than HC at both scales. Our results give further preliminary evidence of the overlap between autistic traits and EDs symptomatology, and should be taken into account in the definition of a shared model between EDs and ASDs.

LEVEL OF EVIDENCE

Level II; Evidence obtained from controlled trial without randomization.

Brief Report: Sensory Sensitivity is Associated with Disturbed Eating in Adults with Autism Spectrum Disorders Without Intellectual Disabilities

Aim of the present study was to evaluate the relationship between sensory sensitivity and autistic eating behaviours or Eating Disorders (EDs) symptomatology, in a group of 75 adults with Autism Spectrum Disorders (ASDs) without intellectual disabilities, through a series of self-report questionnaires. We found that, controlling for demographic and clinical features: (i) hypersensitivity in the vision domain predicted higher levels of both EDs symptoms and autistic eating behaviours; (ii) hyposensitivity in the taste domain predicted higher levels of EDs symptoms. This gives preliminary evidence that not only in children diagnosed with ASDs, but even in adult individuals, the threshold of sensory sensitivity is associated with dysfunctional eating behaviours.

Atypical Sensory Processing Is Associated With Lower Body Mass Index and Increased Eating Disturbance in Individuals With Anorexia Nervosa

BACKGROUND

Elevated autism spectrum disorder (ASD) traits are associated with anorexia nervosa (AN). Conversely, eating disturbances, which are core characteristics of AN, are common in ASD. Among individuals with ASD, atypical sensory processing is associated with eating disturbance. Because AN and ASD appear to overlap, it would be crucial to understand whether sensory processing atypicality exist also in AN. Further, it would be essential to find if atypical sensory processing is associated with eating disturbances in individuals with AN, since treatment modifications may be needed. We therefore aimed to examine whether atypical sensory processing is associated with AN and its core characteristics.

METHODS

Participants of the current study included 42 individuals with AN and 40 healthy controls (HCs). All participants were adult women. Sensory processing, other ASD traits, and eating disorder symptoms were assessed with self-report questionnaires.

RESULTS

Individuals with AN reported lower registration, decreased sensation seeking, increased sensory sensitivity, and increased sensation avoiding compared to HCs. When analyzing groups with restrictive AN (AN-R) and binge-purge type AN (AN-BP) separately, only individuals with AN-R exhibited decreased sensation seeking, and only those with AN-BP exhibited lower registration. After controlling for body mass index as a covariate, group differences remained significant only in sensory sensitivity between individuals with AN and HCs. Increased atypical sensory processing predicted lower body mass index and increased disordered eating.

CONCLUSION

Results suggest that sensory processing appears to differ between AN and HC women, and AN subtypes may exhibit distinct sensory processing atypicality. Sensory sensitivity may be stable traits whereas other aspects of atypical sensory processing may be related to acute AN. Atypical sensory processing may contribute to the severity of AN, and thus it is crucial to recognize sensory processing differences when treating individuals with AN.

Anorexia Nervosa and Autism Spectrum Disorder: A Systematic Review

BACKGROUND

Recent research has shown a growing interest in exploring the relationship between anorexia nervosa (AN) and autism spectrum disorder (ASD). Both conditions seem to share areas of cognitive, social and behavioural impairment, leading to relevant implications on treatment, especially when they are in comorbidity. This literature review aims to synthesise the latest studies on this topic to investigate the co-occurrence of AN and ASD, suggest future research directions and consider implications for treatment.

METHOD

Records were systematically (PRISMA guidelines) identified through PubMed, EBSCOhost, Scopus and Web of Science searching.

RESULTS

Thirteen studies met the eligibility criteria and were therefore included in the review. Results seem to confirm an overrepresentation of ASD symptoms in AN. Only few studies investigated the AN-ASD comorbidity in young people and report slightly lower rates than those conducted with adults.

CONCLUSIONS

Analysed studies suggest that while the comorbidity seems to exacerbate the severity of the condition, autistic traits appear to be rather stable over time and not related to body weight. Thus, future longitudinal studies and gender- specific assessment tools can help clarify the relationship between the two disorders, examine the onset of ASD symptoms and develop structured guidelines for treatment.

Evaluating the Use of Self-reported Measures in Autistic Individuals in the Context of Psychiatric Assessment: A Systematic Review

The current review examined the use of self-report measures in autistic individuals in the context of psychiatric assessments. It focused on inter-rater agreement, internal consistency, test-retest reliability, and criterion validity with clinical diagnoses. It also gathered information on constructs measured, the nature of the samples, and the quality of the studies. Thirty-six out of 10,557 studies met inclusion criteria. We found that the majority of studies (1) targeted young people with average or above average cognitive abilities, (2) measured anxiety symptoms, and (3) evaluated parent-child agreement. More studies are needed on individuals with lower cognitive abilities, adults, and other constructs. Studies assessing criterion validity and test-retest reliability are also needed.

Feeding and eating problems in children and adolescents with autism: A scoping review

LAY ABSTRACT

Feeding problems, such as picky eating and food avoidance, are common in youth with autism. Other, broader difficulties with feeding and eating (eating disorder symptoms such as restricting food intake or preoccupation with body shape or weight and insistence on specific food presentation) are also common in autistic individuals. Here, we describe the nature and extent of feeding and eating problems in youth with autism. We found no common characteristics (such as severity of autism symptoms) that best describe autistic youth who experience problems with feeding or eating. Almost all studies we reviewed focused on problems with feeding (selective or picky eating), and only a few studies focused on eating disorder symptoms (concern with weight, shape, and/or body image). However, some researchers reported that eating disorder symptoms may occur more often in autistic individuals compared to their peers without autism. Many studies used the terms "feeding" and "eating" problems interchangeably, but understanding the difference between these problems is important for researchers to be consistent, as well as for proper identification and treatment. We suggest future researchers use "eating problems" when behaviors involve preoccupation with food, eating, or body image, and "feeding problems" when this preoccupation is absent. We highlight the importance of understanding whether feeding or eating problems are separate from autism traits, and the role of caregivers and other adults in the child's treatment. Considerations for health-care providers to assist with diagnosis and treatment are also provided.

Eating Problems in Autistic Females and Males: A Co-twin Control Study

This study investigated the association between autism and self-reported eating problems and the influence of gender on the association, in a sample of adolescent and adult twins (N = 192). Autistic traits and autism diagnosis were associated with both total and specific eating problems, including selective eating and sensory sensitivity during mealtimes. Interaction effects indicated a stronger association between autistic traits and total eating problems in females, as well as more difficulties with eating in social contexts among autistic females. In within-pair analyses, where unmeasured confounders including genes and shared environment are implicitly controlled for, the association was lost within monozygotic pairs, which might further indicate a genetic influence on the relationship between autism and eating problems.

Eating Challenges in Children with Autism Spectrum Disorder: Development and Validation of the "Aut-Eat" Questionnaire (AEQ)

The Aut-Eat Questionnaire (AEQ) provides a novel and comprehensive assessment of eating problems and patterns in children with ASD. To establish the internal consistency and discriminant validity of the AEQ, parents of children with ASD (n = 105, M_age = 40.85, SD = 15.67 months) or typical development (TD; n = 98, M_age = 50.33, SD = 16.50 months) completed the AEQ. Questionnaire construction, content validity, factor analysis, internal consistency and discriminant validity are reported. The AEQ was reliable with high internal consistency in most domains. Significant differences were found between groups in all domains. The AEQ is a reliable and valid tool and may help to characterize eating difficulties in this population.

Eating disturbances in adults with autism spectrum disorder without intellectual disabilities

There is a growing interest in the relationship between autism spectrum disorders (ASDs) and eating disorders (EDs), two relatively common conditions lying on a spectrum from mild to severe clinical features. However, only limited data are available about pathological eating behaviors throughout adults on the autistic spectrum. The aim of the present study is to assess dysfunctional eating behaviors, including EDs manifestations and ASDs-related eating disturbances, in a population of adults with ASDs without intellectual disabilities. We recruited 106 adults on the autistic spectrum, without intellectual disability and 103 neurotypical adults (NAs). Participants completed the "Eating Attitude Test" (EAT-26), to measure symptoms and concerns characteristic of EDs, and the "Swedish Eating Assessment for Autism Spectrum Disorders" (SWEAA), to assess eating behaviors frequently observed within the autistic spectrum. Participants with ASDs scored significantly higher than NA at the EAT-26 and at the SWEAA. Moreover, participants with ASDs scored higher than NA at the EAT-26 subscales Dieting and Bulimia. The difference between groups remained significant after controlling for the effect of age, biological sex, and BMI. These results suggest that adults with ASDs without intellectual disability presented not only a higher prevalence of eating disturbances typical of the autistic spectrum, but also other symptoms of EDs in comparison to NA. LAY SUMMARY: For both scales assessing eating disturbances (EAT-26 and SWEAA), participants with ASDs scored higher than NA, presenting a higher prevalence both of eating disturbances typical of ASDs and of ED symptoms (distorted body image, tendency toward bulimic behaviors, and self-control of eating).

Correlates of Feeding Difficulties Among Children with Autism Spectrum Disorder: A Systematic Review

Feeding difficulties related to selective intake, or eating a limited variety of foods, are very common in children with autism spectrum disorder (ASD). A systematic search of PubMed, Embase, PsycInfo, and CINAHL identified 29 studies that evaluated eight correlates: age, ASD symptoms and severity, cognitive and adaptive skills, sensory processing and perception, challenging behavior, weight status, gastrointestinal symptoms, and parenting stress. Feeding difficulties related to selective intake are consistently correlated with impaired sensory processing and perception and tend to be positively associated with rigidity and challenging behavior. These feeding difficulties tend to persist with advancing age. Other correlates demonstrated inconsistent findings. A significant limitation of research reviewed is variability in terminology, definitions, and measurement of feeding difficulties.

Mealtime Behaviors and Food Preferences of Students with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by a lack of social communication and restrictive, repetitive behaviors or interests. This study aimed to examine the mealtime behaviors and food preferences of students with ASD. An online questionnaire on mealtime behavior and food preferences of ASD students was conducted by caregivers including parents, and the average age of ASD students was 14.1 ± 6.1. The analysis of mealtime behavior resulted in classification into three clusters: cluster 1, the "low-level problematic mealtime behavior group"; cluster 2, the "mid-level problematic mealtime behavior group"; and cluster 3, the "high-level problematic mealtime behavior group". Cluster 1 included older students than other clusters and their own specific dietary rituals. Meanwhile, cluster 3 included younger students than other clusters, high-level problematic mealtime behavior, and a low preference for food. In particular, there were significant differences in age and food preference for each subdivided ASD group according to their eating behaviors. Therefore, the content and method of nutrition education for ASD students' needs a detailed approach according to the characteristics of each group.

Impact of Selective Eating on Social Domains Among Transition-Age Youth with Autism Spectrum Disorder: A Qualitative Study

Food selectivity is a common feeding problem among autistic children. The objective of this qualitative study was to explore the impact of selective eating on key social domains-with family, peers, and in other social situations-of transition-age autistic youth who self-identified as being food selective. Interviews were conducted with 20 autistic youth ages 18-23 years. Data were analyzed using descriptive and thematic coding. Participants had developed a range of strategies to cope with their food selectivity, and although some expressed concerns, they did not feel that it had a major impact on social situations. A responsive approach to supporting such youth would likely involve recognizing the effort and skills that the youth have already developed around this issue.

Eating Problems in Men and Women with an Autism Spectrum Disorder

The presence of eating problems was assessed in 53 males and 36 females with an autism spectrum disorder (ASD), with and without housing and residential support. The results were compared to a neurotypical group of 30 men and 38 women. The results indicate that men and especially women with ASD experience various eating problems. Women with ASD also recognized symptoms of an eating disorder. Hence, it is important to be aware of eating problems and symptoms of an eating disorder in adults with ASD, to ensure they receive the care they need.

Pragmatic Sensory Screening in Anorexia Nervosa and Associations with Autistic Traits

BACKGROUND

Research suggests that people with anorexia nervosa (AN) experience subjective hypersensitivity to external sensations that may require consideration in treatment. These difficulties may be particularly pronounced in people with AN and high autistic traits. The purpose of this pilot study was to explore the use of a brief screening tool to assess sensory sensitivity in individuals receiving treatment for AN, and to assess if self-rated sensitivity in AN is related to autistic traits.

METHODS

47 individuals receiving treatment for AN completed a brief sensory screening tool and self-rated their autistic traits. Individuals were also asked to give qualitative feedback on the screening tool.

RESULTS

People with AN and high autistic traits rated themselves as more hypersensitive compared to people with AN and low autistic traits. Feedback surrounding the use of the screener was positive.

CONCLUSIONS

The results of this study suggest that the use of this screener may be beneficial in eating disorder settings to help adjust and calibrate treatment to personal needs, although further research and psychometric evaluation around the clinical use of the screener is required. The finding that people with AN and high autistic traits may experience elevated hypersensitivity also warrants further exploration in future research.

Autism, Gastrointestinal Symptoms and Modulation of Gut Microbiota by Nutritional Interventions

Autism spectrum disorder (ASD) is a complex behavioral syndrome that is characterized by speech and language disorders, intellectual impairment, learning and motor dysfunctions. Several genetic and environmental factors are suspected to affect the ASD phenotype including air pollution, exposure to pesticides, maternal infections, inflammatory conditions, dietary factors or consumption of antibiotics during pregnancy. Many children with ASD shows abnormalities in gastrointestinal (GI) physiology, including increased intestinal permeability, overall microbiota alterations, and gut infection. Moreover, they are "picky eaters" and the existence of specific sensory patterns in ASD patients could represent one of the main aspects in hampering feeding. GI disorders are associated with an altered composition of the gut microbiota. Gut microbiome is able to communicate with brain activities through microbiota-derived signaling molecules, immune mediators, gut hormones as well as vagal and spinal afferent neurons. Since the diet induces changes in the intestinal microbiota and in the production of molecules, such as the SCFA, we wanted to investigate the role that nutritional intervention can have on GI microbiota composition and thus on its influence on behavior, GI symptoms and microbiota composition and report which are the beneficial effect on ASD conditions.

Eating as an autistic adult: An exploratory qualitative study

Background

Although eating difficulties are known to be common in children on the autism spectrum, there is a lack of research on whether these behaviours persist or change into adulthood. Emerging evidence suggests that autistic adults may experience higher levels of disordered eating than the general population, indicating the impact of autism on eating in this adult population warrants further exploration.

Method

This study interviewed 12 autistic adults about their eating habits, with a focus on the continuing or changing presence of behaviours often seen in autistic children such as sensory sensitivity or a preference for routines. Interviews were transcribed and analysed using thematic analysis.

Results

Overall, participants suggested that autism did continue to impact their eating into adulthood, particularly in the areas of sensory sensitivity, medical difficulties, executive functioning difficulties, and rigidity, but that they had learned to adapt so that these issues no longer represented a problem. However, a minority of participants did feel that their autism had a negative effect on their eating, particularly those diagnosed with eating disorders. Additionally, eating behaviours associated with autism were identified as potentially contributing to having an unhealthy body weight.

Conclusions

Certain traits associated with autism, such as cognitive rigidity and sensory sensitivity, could potentially continue to influence the eating behaviours of autistic adults. These traits are typically experienced as differences which can be adapted around and managed, rather than specific problems. However, these traits can potentially contribute to difficulties such as disordered eating and weight gain, and the implications of these should be explored by future research.

Long-term follow-up study of low-weight avoidant restrictive food intake disorder compared with childhood-onset anorexia nervosa: Psychiatric and occupational outcome in 56 patients

OBJECTIVE

To compare long term outcome between childhood-onset Anorexia Nervosa (AN) and low-weight Avoidant/Restrictive Food Intake Disorder (ARFID) in regard to psychiatric diagnoses, social and occupational functioning.

METHOD

A consecutive series of 56 children originally treated for low-weight restrictive eating disorder (ED) were followed up after a mean of 15.9 years. ARFID-diagnoses were assigned retrospectively.

RESULTS

Thirty-seven patients originally had AN and 19 patients were diagnosed retrospectively with ARFID. At follow-up, in the AN-group 21.6% had a current ED, 24.3% had another psychiatric diagnosis, and 54.1% did not have any psychiatric diagnosis. In the ARFID-group, 26.3% had a current ED, 26.3% had another psychiatric diagnosis, and 47.4% had no psychiatric diagnosis. In the ARFID-group ED diagnoses at follow-up were all ARFID, whereas the AN-group showed heterogeneity. Morgan Russell Outcome Assessment Schedule indicated similar outcome in the AN- and ARFID-group. Occupational functioning did not differ significantly between the AN- and ARFID-group.

DISCUSSION

The AN-group showed high rate of ED at follow up. The ARFID-group had a similar outcome to AN. In the ARFID-group, all ED-cases at follow up had ARFID, possibly indicating symptomatic stability. Low-weight ARFID should be treated as seriously as childhood onset AN.

Do autism spectrum disorder and anorexia nervosa have some eating disturbances in common?

A possible overlap between autism spectrum disorder (ASD) and anorexia nervosa (AN), in terms of both behavioural and cognitive features, has led to new areas of research. The aim of the present study was to examine the occurrence of eating behaviours frequently seen in ASD among adolescents and young adults with AN. The participants were females within the age range 15-25 years: 36 with current AN (32 were followed up after 1 year), 19 with ASD, and 30 healthy females. The participants completed the SWedish Eating Assessment for Autism spectrum disorders (SWEAA) and the Autism Spectrum Quotient tool (AQ). AN groups had significantly higher SWEAA scores than the healthy comparison group, also when patients had gained weight. Typical autistic eating behaviours, such as selective eating, were more common in the AN groups than in the ASD group. This is the first time that SWEAA has been implemented in an AN population. Eating behaviours frequently seen in ASD seem to be frequent in AN and some remain also after weight gain.

An exploration of the association between matrix reasoning and eating disturbance behavior in girls with autism spectrum disorder

Background

Although there have been suggestions that central coherence may be associated with eating disturbances (EBD) in children with autism spectrum disorder (ASD), relatively little attention has been given to specific aspects of IQ and EDB.

Methods

The association between total IQ, perceptual and verbal composite scores and subtests was explored in a sample of 50 high-functioning girls with ASD (mean age = 9.7 years, SD = 2.4 years, range = 6 years to 14 years). Self-reports and mothers' reports were collected about the girls' EDB.

Results

There were only isolated associations between mothers' data and the girls' IQ. Selected aspects of the girls' self-reported EDB were significantly associated with matrix reasoning.

Conclusion

The role of IQ, particularly matrix reasoning, in the assessment and treatment of EDB in girls with ASD, is highlighted by these findings.

Using parent- and self-reports to evaluate eating disturbances in young girls with Autism Spectrum Disorder

BACKGROUND

Eating Disturbances (ED) often occur in Autism Spectrum Disorder (ASD) but most previous studies have relied on parent-reported data about males with ASD. Few studies have collected data from younger girls with ASD using self-reports and parents' reports.

AIMS

To compare self-reports and parents' reports of ED in a sample of 52 young girls with ASD, a standardised scale for ED was revised for use with younger girls with ASD.

METHODS

Mothers of 52 girls with ASD aged from 6 to 17 years completed the Swedish Eating Assessment for Autism spectrum disorders (SWEAA) on their daughters; the girls also completed the SWEAA as a self-report.

RESULTS

The prevalence of severe ED in the sample was low (about 11%). There were minimal significant differences between mothers' and daughters' SWEAA responses across most SWEAA subscales. Deletion of several of the original SWEAA items produced a scale that can be used as a self-report or a carer-report with young girls with ASD.

CONCLUSION

The clinical assessment of ED via self- or parent reports is suggested as a pathway to identify girls with ASD who also exhibit ED so that adequate treatment planning can be developed for them.

Using the Autism-Spectrum Quotient to Measure Autistic Traits in Anorexia Nervosa: A Systematic Review and Meta-Analysis

Interest in the link between Autism Spectrum Disorder (ASD) and Anorexia Nervosa (AN) has led to estimates of the prevalence of autistic traits in AN. This systematic review and meta-analysis assessed the use of the Autism-Spectrum Quotient (AQ) or abbreviated version (AQ-10) to examine whether patients with AN have elevated levels of autistic traits. Seven studies were identified and subsequent meta-analysis indicated that those with AN appear to have significant difficulties of a manner characteristic of ASD, relative to controls. Whilst this analysis supports previous indications of higher prevalence of ASD in AN, the aetiology of these traits remains unclear. Studies using more robust clinical measures of ASD within AN are needed to confirm what self-report measures appear to show.

Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive-compulsive spectrum

Eating disorders have been defined as "characterized by persistence disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs health or psychosocial functioning". The psychopathology of eating disorders changed across time under the influence of environmental factors, determining the emergence of new phenotypes. Some of these conditions are still under investigation and are not clearly identified as independent diagnostic entities. In this review, the historic evolution of the eating disorder concept up to the recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, has been evaluated. We also examined literature supporting the inclusion of new emergent eating behaviors within the eating disorder spectrum, and their relationship with anorexia, autism, and obsessive-compulsive disorder. In particular, we focused on what is known about the symptoms, epidemiology, assessment, and diagnostic boundaries of a new problematic eating pattern called orthorexia nervosa that could be accepted as a new psychological syndrome, as emphasized by an increasing number of scientific articles in the last few years.

Eating disorders and eating pathology in young adult and adult patients with ESSENCE

BACKGROUND

Little is known about the prevalence and incidence of traditional eating disorders (EDs, e.g., anorexia nervosa (AN), bulimia nervosa and binge eating disorder (BED)) in individuals with childhood onset neuropsychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD). The aim of the present study was to examine the prevalence of EDs and eating pathology in young adults and adults with ADHD and/or ASD, and to investigate the relationship between EDs and associated symptoms, on the one hand, and other psychiatric disorders, intelligence, and BMI, on the other hand, in this population.

METHODS

In an outpatient setting, 228 consecutively referred adults were neuropsychiatrically evaluated and assessed with regard to intelligence (WAIS-III), psychiatric comorbidities (SCID-I), personality disorders (SCID-II), eating disorders (SCID-I) and eating pathology (Eating Attitudes Test (EAT)).

RESULTS

For the entire sample, a total of 18 individuals (7.9%) had a current or previous eating disorder, with AN and BED being the most frequent. The male:female ratio was 1:2.5. According to EAT, 10.1% of the individuals scored within the range of severely disturbed eating behavior, and 13% moderately disturbed eating behavior. Individuals with ADHD more often affirmed eating pathology such as focusing on thoughts of calories and body dissatisfaction compared to individuals with ASD.

CONCLUSIONS

Eating disorder symptomatology seems to be overrepresented in adults with neuropsychiatric disorders compared with the general population. The gender ratio for EDs in adults with neuropsychiatric disorders is not nearly as skewed as in the general population.

Driving behaviors in adults with autism spectrum disorders

This pilot study investigated driving history and driving behaviors between adults diagnosed with autism spectrum disorders (ASD) as compared to non-ASD adult drivers. Seventy-eight licensed drivers with ASD and 94 non-ASD comparison participants completed the Driver Behavior Questionnaire. Drivers with ASD endorsed significantly lower ratings of their ability to drive, and higher numbers of traffic accidents and citations relative to non-ASD drivers. Drivers with ASD also endorsed significantly greater numbers of difficulties on the following subscales: intentional violations, F(1, 162) = 6.15, p = .01, η p (2)  = .04; mistakes, F(1, 162) = 10.15, p = .002, η p (2)  = .06; and slips/lapses, F(1, 162) = 11.33, p = .001, η p (2)  = .07. These findings suggest that individuals with ASD who are current drivers may experience more difficulties in driving behaviors and engage in more problematic driving behaviors relative to non-ASD drivers.

Early-onset anorexia nervosa in girls with Asperger syndrome

Eating disorders frequently occur in conjunction with autism spectrum disorders, posing diagnostic and therapeutic difficulties. The comorbidity of anorexia nervosa and Asperger syndrome is a significant clinical complication and has been associated with a poorer prognosis. The authors are presenting the cases of an eleven-year-old girl and a five-and-a-half-year-old girl with comorbid eating disorders and Asperger syndrome.

Exploring autistic traits in anorexia: a clinical study

BACKGROUND

The objectives of this study were to explore associations between autistic traits and self-reported clinical symptoms in a population with anorexia nervosa (AN). Experimental and self-report evidence reveals similarities between AN and autism spectrum condition (ASC) populations in socio-emotional and cognitive domains; this includes difficulties with empathy, set-shifting and global processing. Focusing on these similarities may lead to better tailored interventions for both conditions.

METHODS

A cross-sectional independent-groups design was employed. Participants with AN (n = 66) and typical controls (n = 66) completed self-report questionnaires including the Short (10-Item) Version Autism Spectrum Quotient (AQ-10) questionnaire (the first time this has been implemented in this population), the Eating Disorder Examination Questionnaire, the Hospital Anxiety and Depression Scale and the Work and Social Adjustment Scale. Group differences and the relationship between autistic traits and other questionnaire measures were investigated.

RESULTS

The AN group had a significantly higher AQ-10 total score and a greater proportion scored above the clinical cut-off than the control group. Seven out of ten AQ-10 items significantly discriminated between groups. In the AN group, levels of autistic traits correlated with a greater self-reported anxiety and depression and a lower ability to maintain close relationships; however, eating disorder symptoms were not associated with autistic traits.

CONCLUSIONS

Women with anorexia possess a greater number of autistic traits than typical women. AQ-10 items that discriminated between groups related to 'bigger picture' (global) thinking, inflexibility of thinking and problems with social interactions, suggesting that autistic traits may exacerbate factors that maintain the eating disorder rather than cause the eating disorder directly. Using screening instruments may improve understanding of patients' problems, leading to better tailoring of intervention. We conclude that further investigation of autistic traits in AN could inform new intervention approaches based on joint working between ASC and eating disorder services.