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

The current clinical approach to feeding and eating disorders aimed to increase personalization of management

Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind-body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first-line treatments for FEDs are mainly psychological and/or nutrition-focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine-grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients' illness and recovery trajectories and facilitate development of novel intervention approaches.

Emotional and Behavioral Impacts of the February 6, 2023 Earthquake on Children with Autism Spectrum Disorder: An Evaluation from the Parental Perspective

PURPOSE

Earthquakes have serious psychosocial and emotional effects on children diagnosed with autism spectrum disorder (ASD) and their parents. The limited number of studies investigating the earthquake experience of children with ASD and their parents indicates a need to improve existing research in this area. The aim of this study was to assess parents' experiences with their children after the earthquake and their reactions to the earthquake.

METHODS

This study was subjected to analysis via both phenomenological and thematic analysis methods on the basis of the results of semistructured interviews with the parents of 21 children with ASD who were receiving their education in special education and rehabilitation centers.

RESULTS

Two principal themes were discerned: the first theme, entitled Post-Eartquake Responses in Children and the second, entitled Parents' Earthquake Experiences and Coping Strategies, were identified. Earthquakes had a significant effect on children's bodily, behavioural and emotional responses. In addition, parents were compelled to devise a range of coping strategies to manage their emotional responses to the earthquake and to facilitate their children's access to constrained educational opportunities and adapt to evolving social dynamics.

CONCLUSION

In disaster situations, access to multidisciplinary support programs for children diagnosed with ASD and their families is highly important. These programs, designed through collaboration across various fields of expertise, can offer comprehensive solutions to the emotional, social, and physical challenges faced by children and their families.

A systematic review and meta-analysis of the relationship between sensory processing differences and internalising/externalising problems in autism

There is evidence to suggest that sensory processing differences (SPDs) to external stimuli are a plausible underlying mechanism for mental health problems among autistic people. In the current systematic review, we examined the associations between, on the one hand, eleven types of SPDs and, on the other hand, internalising and externalising problems. The literature search was conducted on five databases (MEDLINE, PsycINFO, Web of Science, EMBASE, and CINAHL) between 1990 and August 2024. Studies with autistic people aged under 65 years-old that reported correlations between SPDs and internalising/externalising problems were included. Three-level and random-effects meta-analyses and narrative synthesis were conducted. In total, we included 63 articles (11,659 participants) in the current review. Overall, higher levels of all SPD subtypes were found to be associated with greater internalising/externalising problems. Hypersensitivity, visual, auditory, and tactile sensitivities were strongly associated with internalising/externalising problems, while smaller effects were observed for unusual processing of smell and taste. Sensation seeking was highly linked with externalising problems, whereas it was the least associated sensory subtype with internalising problems. Future studies could address the limitations in the extant literature (e.g., heterogeneity in the estimates of associations, a lack of externalising problem investigations and longitudinal studies) to further advance our understanding of the role of SPDs in the aetiology, development, and treatment of internalising/externalising problems in autism.

Empirical Approaches to the Classification of Avoidant/Restrictive Food Intake Disorder

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) is a relatively new formal diagnosis for which empirical classification research (defined here as studies using latent class/latent profile analysis-type methods) is still emerging. Such research focused on ARFID is an important gap to fill given questions about (1) the boundaries between ARFID and phenotypically similar presentations (e.g., eating disorders [EDs] such as anorexia nervosa [AN], and pediatric feeding disorder [PFD]), and (2) within-ARFID heterogeneity. These questions have practical implications, including diagnostic reliability and treatment selection.

METHOD

This forum synthesizes the limited empirical classification literature seeking to quantitatively distinguish ARFID from non-ARFID EDs or from PFD, and/or characterize within-ARFID heterogeneity.

RESULTS

To our knowledge, only five studies in clinical samples have used empirical classification methods to delineate ARFID from non-ARFID EDs and/or characterize within-ARFID heterogeneity; no studies have used such methods to delineate ARFID from PFD. Existing studies are mixed in determining how well ARFID can be distinguished from other EDs (particularly AN), but converge in identifying several potential ARFID subclasses (i.e., sensory sensitivity, low appetite, feared eating-related consequences, and subclass representing a combination of these) with some overlapping features.

DISCUSSION

The existing ARFID empirical classification literature should guide future ARFID classification research priorities (e.g., incorporating mechanistic variables as classification indicators, incorporating longitudinal variables as classification validators) to inform differences between ARFID and other disorders and between ARFID presentations. Dimensional approaches to conceptualizing, studying, and modeling psychopathology (namely, the Hierarchical Taxonomy of Psychopathology [HiTOP] and the Research Domain Criteria [RDoC]) may offer useful insights.

Food selectivity in children and adolescents with autism spectrum disorders - a systematic literature review

Background

Autism spectrum disorders involve problems with social communication and interaction as well as restricted, repetitive patterns of behaviour and interests. Food selectivity is common among individuals with autism spectrum disorders when their average intellectual ability is below the normal range. This literature review examines the degree to which the same applies for children and adolescents with an intellectual ability level in the normal range.

Knowledge base

We undertook searches in the MEDLINE and PsycInfo (Ovid) databases until June 2024 for original papers on the prevalence, characteristics and somatic consequences of food selectivity in autism spectrum disorders. We restricted our searches to studies that included individuals with an intellectual ability in the normal range and/or an autism spectrum disorder for which this is a prerequisite, and with an average age of 6-18 years. The GRADE system was used to rate the quality of the studies. We gave emphasis to consistency between findings, the number of studies and their sizes.

Results

The inclusion criteria were met by 20 studies. There was a high prevalence (21-76 %) of food selectivity in those with autism spectrum disorders and an intellectual ability level in the normal range. Sensory sensitivity to food texture and taste were key characteristics (approximately 2-10 times more frequent in children with autism spectrum disorders than in control individuals). While the intellectual ability level was of little importance, autism symptoms were of some significance in respect of the prevalence of food selectivity patterns. The somatic consequences tended to be obstipation and overweight/obesity. Our level of confidence in the studies varied from high (prevalence) to low (somatic consequences).

Interpretation

Food selectivity patterns should be surveyed whenever individuals are examined for autism spectrum disorders, irrespective of their intellectual ability level.

A Mixed Method Systematic Review Into the Impact of ED Treatment in Autistic People and Those With High Autistic Traits

OBJECTIVE

Our understanding of the impact of eating disorders (ED) treatment in Autistic people remains elusive. Research has begun to explore ED treatment outcomes and experiences in this population, however current understandings are poorly integrated. The current review therefore sought to explore the impact of ED treatment on Autistic people and those with higher Autistic traits.

METHOD

A convergent, segregated approach was used, independently evaluating quantitative then qualitative studies before integrating findings into a coherent narrative synthesis.

RESULTS

Autistic people and people with higher Autistic traits report poorer experiences of treatment and may be at increased risk of inpatient admission and prolonged inpatient treatment, possibly explained by difficulties with treatment timeframes and a lack of autism-informed support. Both groups reported similar improvements in ED symptoms and BMI. Higher rates of psychosocial difficulties pre-and post-treatment were reported in those with higher Autistic traits, and emotion-focused interventions were felt to be particularly relevant to Autistic presentations of EDs. Concerns were reported as to how well aligned group-based programs and cognitive-based interventions are for Autistic individuals and those reporting higher Autistic traits.

DISCUSSION

Future research in diagnosed autism samples is urgently needed to develop a more robust understanding of Autistic outcomes and experiences. Review findings demonstrate the need for increased understanding of ED presentations and the possible need for treatment adaptations, for Autistic people or those with higher Autistic traits.

Conceptualizing avoidant/restrictive food intake disorder via an executive functioning lens

Avoidant/restrictive food intake disorder (ARFID) is a heterogeneous disorder wherein restrictive eating is primarily attributed to non-shape/weight-based reasons (e.g., sensory sensitivity) that empirical research continues to explore. Mounting evidence suggests that ARFID often presents alongside neurodevelopmental diagnoses (NDs) or divergent neurodevelopment broadly. Executive functioning (EF) differences often characterize divergent neurodevelopmental trajectories. Additionally, restrictive eating in anorexia nervosa has been conceptualized as related to EF factors (e.g., set shifting). Given the neurodevelopmental phenotype that may be associated with ARFID and the role of EF in anorexia nervosa, this paper proposes EF as a potentially important, yet understudied factor in ARFID pathology. We posit that various observed ARFID behavioral/cognitive tendencies can be conceptualized in relation to EF differences. We contextualize commonly observed ARFID presentations within "core" EF components (i.e., cognitive flexibility, working memory, inhibitory control), leading to hypotheses about EF in ARFID. Finally, we offer additional considerations/directions for future research on EF in ARFID. Increased research on EF in ARFID is needed to consider this potential common factor in the etiology and maintenance of this heterogeneous disorder. We aim to promote further consideration of EF in ARFID etiology, maintenance, and treatment-outcome research. PUBLIC SIGNIFICANCE: This article proposes that aspects of executive functioning (EF) may play a role in the onset and maintenance of avoidant/restrictive food intake disorder (ARFID), although this notion is largely untested by existing research. Further research on the role of EF in ARFID may assist with refining models and treatments for this heterogeneous disorder.

Investigating the utility of the AQ-10 in children and adolescents assessed in an outpatient ARFID clinic

The high co-occurrence of autism and eating disorders is well established, including for those with Avoidant Restrictive Food Intake Disorder (ARFID). It is therefore important to consider autism and identify possible autism when people present to eating disorder services to ascertain whether further assessment is indicated, to support clinical formulation and to make appropriate adaptations during interventions. This paper explores the utility of a validated autism screening measure, the AQ-10, in a population of children and adolescents who presented to an outpatient eating disorders clinic for an assessment of possible ARFID. Over 19 months, 335 young people were assessed and 246 families with children aged between 4 and 17 years completed one of three versions of the AQ-10 (Child, Adolescent, and Adult), as part of a battery of routinely administered pre-assessment questionnaires. Results indicated that 80.2% (n = 69) of those with an existing autism diagnosis scored above clinical threshold of ≥6 (M = 7.2, SD = 1.9), 43.9% (n = 43) of those queried to be autistic scored above clinical threshold (M = 5.2, SD = 2.5), and 6.5% (n = 4) of non-autistic individuals scored above clinical threshold (M = 2.8, SD = 1.8). Additionally, the AQ-10 satisfactorily discriminated between those with a known autism diagnosis and those who are not autistic across all age groups and sex. We conclude that the AQ-10, alongside a comprehensive clinical assessment and clinical judgment, is a useful screening tool that can support clinicians to identify appropriate onward referrals for autism assessments, aid clinical formulation, and consider appropriate adaptations and reasonable adjustments during ARFID interventions.

Anorexia nervosa with comorbid autism spectrum disorder: Optimizing care for youth, caregivers, and health care providers

Youth with anorexia nervosa (AN) have been reported to have high levels of comorbid autism spectrum disorder (ASD) and ASD-like traits suggesting a potential shared underlying neurodevelopmental or genetic link between the disorders. Youth with comorbid AN and ASD symptomatology generally require more intensive treatment and have worse psychological outcomes following treatment. To date, no Canadian national guidelines exist for the treatment of this comorbidity. An informal survey of tertiary paediatric eating disorder programs across Canada revealed that centres do not routinely screen for ASD at intake and few offer any treatment modifications for youth with AN and suspected/diagnosed comorbid ASD. This represents a significant care gap for this clinical sub-population and an important area for future study and healthcare provider training.

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.

Cortical thickness and childhood eating behaviors: differences according to sex and age, and relevance for eating disorders

PURPOSE

This study investigated the association between childhood eating behaviors and cortical morphology, in relation to sex and age, in a community sample.

METHODS

Neuroimaging data of 71 children (mean age = 9.9 ± 1.4 years; 39 boys/32 girls) were obtained from the Nathan Kline Institute-Rockland Sample. Emotional overeating, food fussiness, and emotional undereating were assessed using the Children's Eating Behavior Questionnaire. Cortical thickness was obtained at 81,924 vertices covering the entire cortex. Generalized Linear Mixed Models were used for statistical analysis.

RESULTS

There was a significant effect of sex in the association between cortical thickness and emotional overeating (localized at the right postcentral and bilateral superior parietal gyri). Boys with more emotional overeating presented cortical thickening, whereas the opposite was observed in girls (p < 0.05). Different patterns of association were identified between food fussiness and cortical thickness (p < 0.05). The left rostral middle frontal gyrus displayed a positive correlation with food fussiness from 6 to 8 years, but a negative correlation from 12 to 14 years. Emotional undereating was associated with cortical thickening at the left precuneus, left middle temporal gyrus, and left insula (p < 0.05) with no effect of sex or age.

CONCLUSIONS

Leveraging on a community sample, findings support distinct patterns of associations between eating behaviors and cortical thickness, depending on sex and age.

Potential mechanisms underlying the association between feeding and eating disorders and autism

There is a reliable association between autism and Feeding and Eating Disorders. Concerningly, where these two conditions co-occur, clinical outcomes of Feeding and Eating Disorders are significantly worse, and treatment less effective, than when the Feeding and Eating Disorders occur in neurotypical individuals. Problematically, the reason for the association between autism and Feeding and Eating Disorders is poorly understood, which constrains advances in clinical care. This paper outlines several possible mechanisms that may underlie the observed association and suggests ways in which they may be empirically tested. Mechanisms are split into those producing an artefactual association, and those reflecting a genuine link between conditions. Artefactual associations may be due to conceptual overlap in both diagnostic criteria and measurement, Feeding and Eating Disorders causing transient autistic traits, or the association being non-specific in nature. A genuine association between autism and Feeding and Eating Disorders may be due to common causal factors, autism directly or indirectly causing Feeding and Eating Disorders, and Feeding and Eating Disorders being a female manifestation of autism.

Avoidant restrictive food intake disorder: recent advances in neurobiology and treatment

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by persistent insufficient nutritional and/or energy intake. ARFID, before referred to as "selective eating disorder", was introduced recently in the DSM-5 as a replacement for and expansion of the previous diagnosis. Individuals with ARFID may limit food variety and intake due to avoidance based on the sensory characteristics of the food or related to any adverse consequences of eating without the intention of losing weight and concerns of body image. The limited understanding of avoidant and restrictive eating poses challenges to effective treatment and management, impacting directly on the growth and development of children and adolescents. The ARFID neurobiological concept has not yet been clearly defined to clinical practice for nutritionists, thereby hindering screening and impeding the development of treatment recommendations. This narrative review provide useful practical information to consult the pathophysiology, the neurobiology, the clinical features, the assessment and the treatment for healthcare professionals seeking to enhance their clinical knowledge and management of this disorder.

Synthetic Colors in Food: A Warning for Children's Health

This study addressed the harmful effects of artificial colors in pediatric populations, including children diagnosed with Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD), as well as those without behavioral disorders. There is a consensus that synthetic food colorings have several impacts on consumers, especially pediatrics, due to their influence on sensory appeal, which can encourage preference for certain foods. The results revealed that these color additives are directly linked to a series of health problems, with a greater impact on children, including a predisposition to pathological conditions such as carcinogenic, allergenic, mutagenic, cytotoxic, and clastogenic activities, as well as gastrointestinal and respiratory problems, in addition to behavioral changes in children with and without diagnosed disorders. The harms of synthetic dyes in children with or without comorbidities are worrying and require a careful and proactive approach from parents, caregivers and public authorities.

Autism Spectrum Disorder at Home and in School

The diagnosis of autism spectrum disorder (ASD) brings a lifetime of considerations for individuals and their families. The core symptoms of ASD vary in severity and influence behavior and function across all environments. Co-occurring medical, mental health, cognitive, language, learning, and behavioral differences add challenges to those associated with core symptoms. Navigating the preschool, school, and transition ages in the educational setting requires continual reassessment of the strengths, weaknesses, and needs of the student to provide appropriate placement and services.

Co-existing mental and somatic conditions in Swedish children with the avoidant restrictive food intake disorder phenotype

Background

Avoidant restrictive food intake disorder (ARFID) is a feeding and eating disorder, characterized by limited variety and/or quantity of food intake impacting physical health and psychosocial functioning. Children with ARFID often present with a range of psychiatric and somatic symptoms, and therefore consult various pediatric subspecialties; large-scale studies mapping comorbidities are however lacking. To characterize health care needs of people with ARFID, we systematically investigated ARFID-related mental and somatic conditions in 616 children with ARFID and >30,000 children without ARFID.

Methods

In a Swedish twin cohort, we identified the ARFID phenotype in 6-12-year-old children based on parent-reports and register data. From >1,000 diagnostic ICD-codes, we specified mental and somatic conditions within/across ICD-chapters, number of distinct per-person diagnoses, and inpatient treatment days between birth and 18th birthday (90 outcomes). Hazard ratios (HR) and incidence rate ratios (IRR) were calculated.

Findings

Relative risks of neurodevelopmental, gastrointestinal, endocrine/metabolic, respiratory, neurological, and allergic disorders were substantially increased in ARFID (e.g., autism HR[CI95%]=9.7[7.5-12.5], intellectual disability 10.3[7.6-13.9], gastroesophageal reflux disease 6.7[4.6-9.9], pituitary conditions 5.6[2.7-11.3], chronic lower respiratory diseases 4.9[2.4-10.1], epilepsy 5.8[4.1-8.2]). ARFID was not associated with elevated risks of autoimmune illnesses and obsessive-compulsive disorder. Children with ARFID had a significantly higher number of distinct mental diagnoses (IRR[CI95%]=4.7[4.0-5.4]) and longer duration of hospitalizations (IRR[CI95%]=5.5[1.7-17.6]) compared with children without ARFID. Children with ARFID were diagnosed earlier with a mental condition than children without ARFID. No sex-specific differences emerged.

Interpretation

This study yields the broadest and most detailed evidence of co-existing mental and somatic conditions in the largest sample of children with ARFID to date. Findings suggest a complex pattern of health needs in youth with ARFID, underscoring the critical importance of attention to the illness across all pediatric specialties.

Funding

Fredrik and Ingrid Thurings Foundation, Mental Health Foundation.

Functional contribution of the intestinal microbiome in autism spectrum disorder, attention deficit hyperactivity disorder, and Rett syndrome: a systematic review of pediatric and adult studies

Introduction

Critical phases of neurodevelopment and gut microbiota diversification occur in early life and both processes are impacted by genetic and environmental factors. Recent studies have shown the presence of gut microbiota alterations in neurodevelopmental disorders. Here we performed a systematic review of alterations of the intestinal microbiota composition and function in pediatric and adult patients affected by autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and Rett syndrome (RETT).

Methods

We searched selected keywords in the online databases of PubMed, Cochrane, and OVID (January 1980 to December 2021) with secondary review of references of eligible articles. Two reviewers independently performed critical appraisals on the included articles using the Critical Appraisal Skills Program for each study design.

Results

Our systematic review identified 18, 7, and 3 original articles describing intestinal microbiota profiles in ASD, ADHD, and RETT, respectively. Decreased Firmicutes and increased Bacteroidetes were observed in the gut microbiota of individuals affected by ASD and ADHD. Proinflammatory cytokines, short-chain fatty acids and neurotransmitter levels were altered in ASD and RETT. Constipation and visceral pain were related to changes in the gut microbiota in patients affected by ASD and RETT. Hyperactivity and impulsivity were negatively correlated with Faecalibacterium (phylum Firmicutes) and positively correlated with Bacteroides sp. (phylum Bacteroidetes) in ADHD subjects. Five studies explored microbiota-or diet-targeted interventions in ASD and ADHD. Probiotic treatments with Lactobacillus sp. and fecal microbiota transplantation from healthy donors reduced constipation and ameliorated ASD symptoms in affected children. Perinatal administration of Lactobacillus sp. prevented the onset of Asperger and ADHD symptoms in adolescence. Micronutrient supplementation improved disease symptomatology in ADHD without causing significant changes in microbiota communities' composition.

Discussion

Several discrepancies were found among the included studies, primarily due to sample size, variations in dietary practices, and a high prevalence of functional gastrointestinal symptoms. Further studies employing longitudinal study designs, larger sample sizes and multi-omics technologies are warranted to identify the functional contribution of the intestinal microbiota in developmental trajectories of the human brain and neurobehavior.

Systematic review registration

https://clinicaltrials.gov/, CRD42020158734.

The Sensory Profiles, Eating Behaviors, and Quality of Life of Children with Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder

Eating disorders frequently accompany autism spectrum disorder (ASD). One such novel eating disorder is avoidant/restrictive food intake disorder (ARFID). This study compares the eating attitudes, quality of life, and sensory processing of typically developing children (TDC), autistic children, and autistic children with ARFID. A total of 111 children aged 4-10 with a diagnosis of ASD and ARFID (n = 37), ASD without ARFID (n = 37), and typical development (n = 37) were recruited. After an interview in which Childhood Autism Rating Scale (CARS) was administered, Child Eating Behavior Questionnaire (CEBQ), Pediatric Quality of Life Inventory (PedsQL), Social Responsiveness Scale (SRS) and Sensory Profile (SP) were completed by caregivers. Autistic children with ARFID had higher scores in CEBQ subscales relating to low appetite and lower scores on the subscales associated with weight gain. Both groups of autistic children scored lower than TDC on all PedsQL subscales and autistic children with ARFID had lower social QL scores than both groups. SRS scores were highest in autistic children with ARFID, followed by autistic and typically developing children. CARS scores were similar in both groups of autistic children, but higher than TDC. Auditory, vision, touch, multi-sensory, oral processing scores; as well as all quadrant scores, were significantly lower in autistic children with ARFID. Oral sensory processing scores were found to be the most significant predictor of ARFID comorbidity in ASD and reliably predicted ARFID in autistic children in the clinical setting. Autistic children with ARFID demonstrate differences in social functioning, sensory processing, eating attitudes, and quality of life compared to autistic and TD children.

Off-label psychopharmacological interventions for autism spectrum disorders: strategic pathways for clinicians

The prevalence of autism spectrum disorder (ASD) continues to see a trend upward with a noticeable increase to 1 in 36 children less than 8 years of age in the recent MMWR. There are many factors linked to the substantially increased burden of seeking mental health services, and clinically these individuals are likely to present for impairments associated with co-occurring conditions. The advances in cutting-edge research and the understanding of co-occurring conditions in addition to psychosocial interventions have provided a window of opportunity for psychopharmacological interventions given the limited availability of therapeutics for core symptomatology. The off-label psychopharmacological treatments for these co-occurring conditions are central to clinical practice. However, the scattered evidence remains an impediment for practitioners to systematically utilize these options. The review collates the crucial scientific literature to provide stepwise treatment alternatives for individuals with ASD; with an aim to lead practitioners in making informed and shared decisions. There are many questions about the safety and tolerability of off-label medications; however, it is considered the best practice to utilize the available empirical data in providing psychoeducation for patients, families, and caregivers. The review also covers experimental medications and theoretical underpinnings to enhance further experimental studies. In summary, amidst the growing clinical needs for individuals with ASD and the lack of approved clinical treatments, the review addresses these gaps with a practical guide to appraise the risk and benefits of off-label medications.

Subtypes of avoidant/restrictive food intake disorder in children and adolescents: a latent class analysis

Background

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) describes three primary avoidant/restrictive food intake disorder (ARFID) subtypes including sensory sensitivity, lack of interest in food or eating, and fear of aversive consequences. Studies exploring these subtypes have yielded varying results. We used latent class analysis (LCA) based on the psychopathology of ARFID in a sample of children and adolescents to empirically identify classes.

Methods

We carried out a surveillance study of ARFID in collaboration with the British Paediatric Surveillance Unit (BPSU) and the Child and Adolescent Psychiatry Surveillance System (CAPSS) in the United Kingdom and the Republic of Ireland from 1st of March 2021 to 31st of March 2022. Paediatricians and child and adolescent psychiatrists were contacted monthly to report newly diagnosed cases of ARFID electronically and complete a detailed clinical questionnaire. Cases aged 5-18 years were included. LCA was performed specifying 1-6 classes and likelihood-based tests for model selection. The Bayesian Information Criterion (BIC), the Akaike Information Criterion (AIC) and the Sample-Size Adjusted BIC were used to determine the most parsimonious model. Analysis of variance (ANOVA) and χ2 tests were used to compare the characteristics of the identified classes. A multinomial logistic regression (MLR) was performed to investigate predicting factors for the latent classes.

Findings

We identified 319 children and adolescents with ARFID. LCA revealed four distinct classes which were labelled as Fear subtype, Lack of Interest subtype, Sensory subtype, and Combined subtype. The probability of being classified as these were 7.2% (n = 23), 25.1% (n = 80), 29.5% (n = 94) and 38.2% (n = 122), respectively. Age at diagnosis, sex, weight loss, distress associated with eating, and autism spectrum disorder diagnosis were identified as predictors of class membership.

Interpretation

LCA identified four different classes in a sample of children and adolescents with ARFID. The Combined Subtype, a mixed presentation was the most common. The other three classes resembled the subtypes described in the literature. Clinicians should be aware of these different presentations of ARFID as they may benefit from different clinical interventions.

Funding

This study was funded by the Former EMS Ltd (charity number 1098725, registered October 9th 2017).

Expanding considerations for treating avoidant/restrictive food intake disorder at a higher level of care

Existing descriptions of the treatment of avoidant/restrictive food intake disorder (ARFID) at higher levels of care (HLOC) for eating disorders are limited, despite HLOC settings frequently serving patients with ARFID. The purpose of this commentary is to expand on the preliminary literature that describes pediatric ARFID treatment at HLOC by describing two specific components of our approach to treating pediatric ARFID that may not yet have traction in the current literature. Specifically, we highlight the utility of (1) treatment accommodations that appropriately account for patients' neurodevelopmental needs (e.g., executive functioning, sensory processing) and (2) the adjunctive use of Dialectical Behavior Therapy (DBT) elements within family-based pediatric ARFID treatment. We also describe necessary future directions for research in these domains to clarify if incorporating these considerations and approaches into pediatric ARFID treatment at HLOC does indeed improve treatment outcomes.

A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID)

OBJECTIVE

This scoping review identifies and describes psychological interventions for avoidant restrictive food intake disorder (ARFID) and summarizes how outcomes are measured across such interventions.

METHOD

Five databases (Cochrane, Embase, Medline, PsycInfo, Web of Science) were searched up to December 22, 2022. Studies were included if they reported on psychological interventions for ARFID. Studies were excluded if participants did not have an ARFID diagnosis and if psychological interventions were not delivered or detailed.

RESULTS

Fifty studies met inclusion criteria; almost half were single-case study designs (23 studies) and most studies reported on psychological interventions for children and adolescents with ARFID (42 studies). Behavioral interventions (16 studies), cognitive-behavioral therapy (10 studies), and family therapy (5 studies), or combinations of these therapeutic approaches (19 studies) were delivered to support patients with ARFID. Many studies lacked validated measures, with outcomes most commonly assessed via physical health metrics such as weight.

DISCUSSION

This review provides a comprehensive summary of psychological interventions for ARFID since its introduction to the DSM-5. Across a range of psychological interventions and modalities for ARFID, there were common treatment components such as food exposure, psychoeducation, anxiety management, and family involvement. Currently, studies reporting on psychological interventions for ARFID are characterized by small samples and high levels of heterogeneity, including in how outcomes are measured. Based on reviewed studies, we outline suggestions for clinical practice and future research.

PUBLIC SIGNIFICANCE

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by avoidance or restriction of food due to fear, sensory sensitivities, and/or a lack of interest in food. We reviewed the literature on psychological interventions for ARFID and the outcomes used to measure change. Several psychological interventions have been developed and applied to patients with ARFID. Outcome measurement varies widely and requires further development and greater consensus.

Autism Spectrum Disorder and Eating Problems: The Imbalance of Gut Microbiota and the Gut-Brain Axis Hypothesis

This review explores the complexities of autism spectrum disorder (ASD), primarily focusing on the significant eating challenges faced by children and adolescents with this neurodevelopmental condition. It is common for individuals with ASD to exhibit heightened sensitivity to various sensory aspects of food such as taste, texture, smell, and visual appeal, leading to restricted and less diverse diets. These dietary limitations are believed to contribute to an imbalance in the gut microbiota. This review elaborates on how these eating problems, coupled with the distinctive characteristics of ASD, might be influenced by and, in turn, influence the gut-brain axis, a bidirectional communication system between the gastrointestinal tract and the brain. This discussion aims to shed light on the multifaceted interactions and potential implications of diet, gut health, and neurological development and function in children and adolescents with ASD.

A Review of the Nutritional Approach and the Role of Dietary Components in Children with Autism Spectrum Disorders in Light of the Latest Scientific Research

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects several areas of mental development. The onset of ASD occurs in the first few years of life, usually before the age of 3 years. Proper nutrition is important to ensure that an individual's nutrient and energy requirements are met, and it can also have a moderating effect on the progression of the disorder. A systematic database search was conducted as a narrative review to determine whether nutrition and specific diets can potentially alter gastrointestinal symptoms and neurobehavioral disorders. Databases such as Science Direct, PubMed, Scopus, Web of Science (WoS), and Google Scholar were searched to find studies published between 2000 and September 2023 on the relationship between ASD, dietary approaches, and the role of dietary components. The review may indicate that despite extensive research into dietary interventions, there is a general lack of conclusive scientific data about the effect of therapeutic diets on ASD; therefore, no definitive recommendation can be made for any specific nutritional therapy as a standard treatment for ASD. An individualized dietary approach and the dietician's role in the therapeutic team are very important elements of every therapy. Parents and caregivers should work with nutrition specialists, such as registered dietitians or healthcare providers, to design meal plans for autistic individuals, especially those who would like to implement an elimination diet.

Vitamin D and hypophosphatemia in patients with anorexia nervosa and avoidant/restrictive food intake disorder: a case control study

BACKGROUND

Refeeding hypophosphatemia (RH) is a common complication of nutritional restoration in malnourished individuals, yet clear risk stratification remains elusive. Individuals with anorexia nervosa (AN) and avoidant/restrictive food intake disorder (ARFID) may be deficient in vitamin D, an important component of dietary phosphorus absorption in the gut. The relationship between vitamin D and RH in AN and ARFID is unknown. Therefore, the aims of this study were to (1) report rates of low serum 25-hydroxy vitamin D and RH in AN and ARFID; (2) describe associations between phosphorus and variables associated with RH identified in extant literature; (3) examine the relationship between 25-hydroxy vitamin D and RH and (4) investigate moderation by vitamin D between variables of interest and phosphorus level.

METHOD

Analyses included retrospective chart review of 307 individuals admitted to the ACUTE Center for Eating Disorders and Severe Malnutrition with a diagnosis of AN or ARFID. Variables of interest included admission laboratory values (vitamin D level, comprehensive metabolic panel, hemoglobin, point-of-care blood glucose), anthropometric measures (weight, body mass index [BMI], % ideal body weight [IBW]), age, duration of illness, length of stay, feeding method, and serum phosphorus nadir. Pearson and Spearman rank correlation, one-way ANOVA, and regression analyses were used to determine the relationship between variables and serum phosphorus.

RESULTS

Over 1/3 of the sample (35.3%) had serum phosphorus levels ≤ 2.9 mg/dL. There were no significant differences between groups in phosphorus nadir (p = .17, η2 = 0.12) or hypophosphatemia (p = .16, ϕc = 0.11). Thirty-five (35%) of individuals with ARFID were either deficient or insufficient in vitamin D, compared to 29% of individuals with AN. Individuals with AN had significantly higher mean vitamin D levels compared to those with ARFID (p = .03; η2 = 0.015). Nadir phosphorus showed a positive association with weight, BMI, %IBW, potassium, and calcium on admission, and a negative association with length of stay, hemoglobin, and total number of tube-fed days. Higher levels of 25-hydroxy vitamin D moderated the relationship between serum phosphorus nadir and weight on admission (p = .0004).

CONCLUSION

Individuals diagnosed with ARFID are as nutritionally fragile as those with AN regarding vitamin D and RH. The negative feedback loop involving vitamin D that maintains phosphorus homeostasis may play a role in the development of RH in AN and ARFID.

Exploring the intersection of autism spectrum disorder and eating disorders: understanding the unique challenges and treatment considerations for autistic women with eating disorders

PURPOSE OF REVIEW

Autistic women struggle with high levels of both autistic eating behaviours and disordered eating behaviours , which might make them particularly vulnerable to develop eating disorders. Research investigating the presence and characteristics of eating disorders in autistic women is however limited, as is research examining the role of autism in the treatment and recovery of an eating disorder in autistic women.

RECENT FINDINGS

The link between autism and eating disorders has mainly been investigated from the field of eating disorder research, with studies finding an overrepresentation of autism or autistic traits in eating disorders populations. Findings also suggest that autism or autistic traits are associated with a more serious presentation of the eating disorders, including a higher chance of a chronic course of the eating disorders. Most studies however lack comprehensive autism assessments, making it difficult to determine the actual prevalence of autism and its role in women with eating disorders.

SUMMARY

Autistic women with an eating disorder seem to suffer from more complex eating disorders and seem to not benefit from current treatment modalities. This could be partly related to specific autism characteristics such as sensory sensitivities, which are not being considered by current treatment protocols. Future research needs to shed light on what underlies the eating behaviours of autistic women with an eating disorder, in order to help to adapt current treatment modalities to meet the unique needs of these women.

Avoidant-restrictive food intake disorder and autism: epidemiology, etiology, complications, treatment, and outcome

PURPOSE OF REVIEW

There is considerable overlap between the features of avoidant-restrictive food intake disorder (ARFID) and autism. The purpose of this scoping review is to provide an overview of studies published on ARFID and autism in 2022 and the first half of 2023.

RECENT FINDINGS

ARFID and autism are highly heritable conditions that often co-occur. In a large autism cohort, 21% of participants and 17% of their parents presented with avoidant-restrictive features. Of children diagnosed with ARFID, 8.2-54.8% are autistic. More than half of individuals with ARFID also have other neurodevelopmental, psychiatric, or somatic diagnoses. Anxiety, depression, sleep disorders, and learning difficulties are particularly common co-occurring issues. Various strategies have been developed to support autistic children with feeding difficulties. It appears that their feeding difficulties, particularly sensory sensitivities, food preferences, and mealtime rituals and routines frequently persist into adolescence and adulthood, but research on optimal support for adults and adolescents is still scarce. Untreated ARFID in autistic individuals may lead to serious complications.

SUMMARY

Individuals seeking specialist care for autism, eating disorders, or gender dysphoria should be screened for ARFID. More research is needed on how to support autistic adolescents and adults with features of ARFID.

Mental health challenges faced by autistic people

Mental health challenges impede the well-being of autistic people. This Review outlines contributing neurodevelopmental and physical health conditions, rates and developmental trajectories of mental health challenges experienced by autistic people, as well as unique clinical presentations. A framework is proposed to consider four contributing themes to aid personalized formulation: social-contextual determinants, adverse life experiences, autistic cognitive features, and shared genetic and early environmental predispositions. Current evidence-based and clinical-knowledge-informed intervention guidance and ongoing development of support are highlighted for specific mental health areas. Tailored mental health support for autistic people should be neurodivergence-informed, which is fundamentally humanistic and compatible with the prevailing bio-psycho-social frameworks. The personalized formulation should be holistic, considering physical health and transdiagnostic neurodevelopmental factors, intellectual and communication abilities, and contextual-experiential determinants and their interplay with autistic cognition and biology, alongside resilience. Supporting family well-being is integral. Mutual empathic understanding is fundamental to creating societies in which people across neurotypes are all empowered to thrive.

Disgust Processing and Potential Relationships with Behaviors in Autism

PURPOSE OF REVIEW

While there are reports of differences in emotion processing in autism, it is less understood whether the emotion of disgust, in particular, plays a significant role in these effects. Here, we review literature on potential disgust processing differences in autism and its possible associations with autistic traits.

RECENT FINDINGS

In autism, there is evidence for differences in physical disgust processing, pica behaviors, attention away from other's disgust facial expressions, and differences in neural activity related to disgust processing. In typically developing individuals, disgust processing is related to moral processing, but modulated by individual differences in interoception and alexithymia. Autistic individuals may experience atypical disgust, which may lead to difficulty avoiding contaminants and affect socio-emotional processing. In autism, such outcomes may lead to increased occurrences of illness, contribute to gastrointestinal issues, diminish vicarious learning of disgust expression and behaviors, and potentially contribute to differences in processes related to moral reasoning, though further research is needed.

The clinical presentation of avoidant restrictive food intake disorder in children and adolescents is largely independent of sex, autism spectrum disorder and anxiety traits

Background

Avoidant restrictive food intake disorder (ARFID) is a new eating disorder with a heterogeneous clinical presentation. It is unclear which patient characteristics contribute to its heterogeneity.

Methods

To identify these patient characteristics, we performed symptom-level correlation and driver-level regression analyses in our cross-sectional study in up to 261 ARFID patients (51% female; median age = 12.7 years) who were assessed at the Maudsley Centre for Child and Adolescent Eating Disorders, London between November 2019 and July 2022.

Findings

Symptoms across the three drivers 1) avoidance based on sensory characteristics of food; 2) apparent lack of interest in eating; and 3) concern about aversive consequences positively correlated with each other. Patients' anxiety traits showed the greatest positive correlations with symptoms of concern about aversive consequences of eating. Patient sex was not significantly associated with any of the three ARFID drivers. Patients with comorbid autism spectrum disorder (ASD; 28%) showed more food-related sensory sensitivities (RR = 1.26) and greater lack of interest in eating (RR = 1.18) than those of patients without ASD (49%).

Interpretation

In our clinical sample, the ARFID drivers occurred together and did not show clinically meaningful differences between the sexes. ASD may accentuate food-related sensory sensitivities and lack of interest, but may not drive a completely different symptom presentation. ARFID is multi-faceted and heterogenous, requiring a comprehensive multidisciplinary assessment to sufficiently understand the drivers of the restrictive eating behaviour. Results need replication in larger samples with more statistical power.

Funding

None.

Priorities, barriers, and facilitators for nutrition-related care for autistic children: a qualitative study comparing interdisciplinary health professional and parent perspectives

Introduction

Children with autism spectrum disorder often face nutrition-related challenges, such as food selectivity, gastrointestinal issues, overweight and obesity, and inadequate nutrient intake. However, the role of routine nutrition-related screening or care by interdisciplinary health professionals is not well understood. This study aimed to compare the beliefs of health professionals with those of parents of autistic children regarding high-priority nutrition-related challenges, barriers and facilitators to care, and desired education and resources related to nutrition for autistic children.

Participants

Interdisciplinary health professionals (n = 25) (i.e., pediatricians, occupational therapists, speech-language pathologists, board certified behavior analysts, registered dietitians) and parents of autistic children (n = 22).

Methods

The study used semi-structured phone interviews, which were recorded, transcribed, verified, and double-coded using the Framework Method.

Results

Thematic analysis of transcripts revealed that while health professionals and parents of autistic children shared some perspectives on nutrition-related challenges and care, they also had distinct viewpoints. Parents emphasized the importance of addressing food selectivity, behavioral eating challenges, sensory issues, and sleep disturbances affecting appetite. Both groups acknowledged the need for tailored support, access to an interdisciplinary care team, and reasonable expectations. Some health professionals perceived parents as lacking motivation or the ability to make changes. In contrast, many parents felt that health professionals lacked the knowledge and motivation to take nutrition or growth concerns seriously. Health professionals acknowledged that their lack of knowledge or capacity to provide nutrition education or referrals was a common barrier to care, particularly given limited community resources.

Discussion

Health professionals who serve autistic children are motivated to address nutrition-related challenges but lack resources related to nutrition. To promote better health outcomes for autistic children, professionals should identify and support parent motivations around nutrition-related care. Both groups expressed interest in accessing autism-specific resources for education, referral, and screening guidance. Future research could explore the development of healthcare training models that improve the competency of health professionals in providing nutrition care and referral for autistic children.

Vitamin D and Hypophosphatemia in Patients with Anorexia Nervosa and Avoidant/Restrictive Food Intake Disorder: A Case Control Study

Background

Refeeding hypophosphatemia (RH) is a common complication of nutritional restoration in malnourished individuals, yet clear risk stratification remains elusive. Individuals with anorexia nervosa (AN) and avoidant/restrictive food intake disorder (ARFID) may be deficient in vitamin D, an important component of dietary phosphorus absorption in the gut. The relationship between vitamin D and RH in AN and ARFID is unknown. Therefore, the aims of this of this study were to 1) describe the prevalence of low serum 25-hydroxy vitamin D levels and RH in AN and ARFID 2) report associations between nadir phosphorus level and variables associated with RH in extant literature and 3) examine the relationship between 25-hydroxy vitamin D levels and serum phosphorus nadir in AN and ARFID.

Method

Analyses included retrospective chart review of 307 individuals admitted to the ACUTE Center for Eating Disorders and Severe Malnutrition with a diagnosis of AN or ARFID. Variables of interest included admission laboratory values (vitamin D level, comprehensive metabolic panel, hemoglobin, point-of-care blood glucose), anthropometric measures (weight, body mass index [BMI], % ideal body weight [IBW]), age, duration of illness, length of stay, feeding method, and serum phosphorus nadir. Pearson and Spearman rank correlation, one-way ANOVA, and regression analyses were used to determine the relationship between variables and serum phosphorus.

Results

Over 1/3 of the sample (35.3%) had serum phosphorus levels ≤ 2.9 mg/dL. There were no significant differences between groups in phosphorus nadir (p = .17, η2 = 0.12) or hypophosphatemia (p = .16, ϕc = 0.11); 44% of individuals with ARFID and 33% of individuals with AN had hypophosphatemia. Nadir phosphorus showed a positive association with weight, BMI, %IBW, potassium, and calcium on admission, and a negative association with length of stay, hemoglobin, and total number of tube-fed days. Higher levels of 25-hydroxy vitamin D moderated the relationship between serum phosphorus nadir and weight on admission (p = .0004).

Conclusion

Individuals diagnosed with ARFID are as nutritionally fragile as those with AN regarding vitamin D and RH. The negative feedback loop involving vitamin D that maintains phosphorus homeostasis may play a role in the development of RH in AN and ARFID.

Early-life differences in the gut microbiota composition and functionality of infants at elevated likelihood of developing autism spectrum disorder

Evidence from cross-sectional human studies, and preliminary microbial-based intervention studies, have implicated the microbiota-gut-brain axis in the neurobiology of autism spectrum disorder (ASD). Using a prospective longitudinal study design, we investigated the developmental profile of the fecal microbiota and metabolome in infants with (n = 16) and without (n = 19) a family history of ASD across the first 36 months of life. In addition, the general developmental levels of infants were evaluated using the Mullen Scales of Early Learning (MSEL) test at 5 and 36 months of age, and with ADOS-2 at 36 months of age. At 5 months of age, infants at elevated-likelihood of ASD (EL) harbored less Bifidobacterium and more Clostridium and Klebsiella species compared to the low-likelihood infants (LL). Untargeted metabolic profiling highlighted that LL infants excreted a greater amount of fecal γ-aminobutyric acid (GABA) at 5 months, which progressively declined with age. Similar age-dependent patterns were not observed in the EL group, with GABA being consistently low across all timepoints. Integrated microbiome-metabolome analysis showed a positive correlation between GABA and Bifidobacterium species and negative associations with Clostridium species. In vitro experiments supported these observations demonstrating that bifidobacteria can produce GABA while clostridia can consume it. At the behavioral level, there were no significant differences between the EL and LL groups at 5 months. However, at 36 months of age, the EL group had significantly lower MSEL and ADOS-2 scores compared to the LL group. Taken together, the present results reveal early life alterations in gut microbiota composition and functionality in infants at elevated-likelihood of ASD. These changes occur before any behavioral impairments can be detected, supporting a possible role for the gut microbiota in emerging behavioral variability later in life.

Current evidence for avoidant restrictive food intake disorder: Implications for clinical practice and future directions

Background

ARFID (avoidant restrictive food intake disorder) is a relatively new diagnostic term covering a number of well-recognised, clinically significant disturbances in eating behaviour unrelated to body weight/shape concerns. Its phenotypic heterogeneity combined with much about the condition remaining unknown, can contribute to uncertainties about best practice. While other reviews of the evidence base for ARFID exist, few specifically target health care professionals and implications for clinical practice.

Methods

A narrative review was conducted to synthesise the findings of ARFID papers in scientific journals focussing on four key areas relevant to clinical practice: prevalence, assessment and characterisation of clinical presentations, treatment, and service delivery. Freely available online databases were searched for case studies and series, research reports, review articles, and meta-analyses. Findings were reviewed and practice implications considered, resulting in proposed clinical recommendations and future research directions.

Results

We discuss what is currently known about the four key areas included in this review. Based on available evidence as well as gaps identified in the literature, recommendations for clinical practice are derived and practice-related research priorities are proposed for each of the four of the areas explored.

Conclusion

Prevalence studies highlight the need for referral and care pathways to be embedded across a range of health care services. While research into ARFID is increasing, further studies across all areas of ARFID are required and there remains a pressing need for guidance on systematic assessment, evidence-based management, and optimal service delivery models. Informed clinical practice is currently predominantly reliant on expert consensus and small-scale studies, with ongoing routine clinical data capture, robust treatment trials and evaluation of clinical pathways all required. Despite this, a number a positive practice points emerge.

Bone health in avoidant/restrictive food intake disorder: a narrative review

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is an eating/feeding disturbance characterized by severe food avoidance or restriction that results in faltering growth, nutritional deficiencies, dependence on formula supplementation, and/or significant psychosocial impairment. Compared to other eating disorders, ARFID is observed to have an earlier childhood onset and chronic course without intervention. Childhood represents a sensitive period for longitudinal growth and bone accrual, setting the stage for long-term health outcomes associated with longevity and quality of life, including risk for fracture and osteoporosis.

RESULTS

This narrative review discusses published scientific literature on bone health in individuals with ARFID by describing the current understanding of ARFID's effect on bone health, how common dietary constraints characteristic of ARFID may present unique risks to bone health, and the current clinical recommendations for bone health assessment. Reviewing what is known of clinical data from anorexia nervosa (AN) and similar cohorts, the chronicity and etiology of dietary restriction observed in ARFID are hypothesized to compromise bone health significantly. Although limited, examination of bone health in ARFID patients suggests children with ARFID tend to have shorter stature compared to healthy reference datasets and have lower bone density compared to healthy individuals, similar to those with AN. There remains a substantial knowledge gap in how ARFID may interrupt bone accrual during childhood and adolescence, and subsequent impact on attainment of peak bone mass and peak bone strength. The longitudinal effects of ARFID may be subtle and overlooked clinically in the absence of severe weight loss or growth stunting. Early identification and remediation of threats to bone mass accrual have significant personal and population-level implications.

CONCLUSION

For patients with ARFID, delayed identification and intervention to address feeding disturbances may have a long-lasting impact on various body systems and processes, including those relating to longitudinal growth and bone mass accrual. Further research employing rigorous prospective observational and/or randomized study designs are required to clearly define effects of ARFID, as well as clinical interventions aimed at addressing ARFID-related feeding disturbances, on bone accrual.

Food Selectivity in Children with Autism: Guidelines for Assessment and Clinical Interventions

Autisms Spectrum Disorders (ASD) are characterized by core symptoms (social communication and restricted and repetitive behaviors) and related comorbidities, including sensory anomalies, feeding issues, and challenging behaviors. Children with ASD experience significantly more feeding problems than their peers. In fact, parents and clinicians have to manage daily the burden of various dysfunctional behaviors of children at mealtimes (food refusal, limited variety of food, single food intake, or liquid diet). These dysfunctional behaviors at mealtime depend on different factors that are either medical/sensorial or behavioral. Consequently, a correct assessment is necessary in order to program an effective clinical intervention. The aim of this study is to provide clinicians with a guideline regarding food selectivity concerning possible explanations of the phenomenon, along with a direct/indirect assessment gathering detailed and useful information about target feeding behaviors. Finally, a description of evidence-based sensorial and behavioral strategies useful also for parent-mediated intervention is reported addressing food selectivity in children with ASD.

Effects of a mobile health nutrition intervention on dietary intake in children who have autism spectrum disorder

Background

Children who have Autism Spectrum Disorder (ASD) show preferences for processed foods, such as salty and sugary snacks (SSS) and sugar-sweetened beverages (SSB), while healthier foods, such as fruits and vegetables (FV), are consumed less. Innovative tools are needed that can efficiently disseminate evidence-based interventions and engage autistic children to improve their diet.

Aim

The aim of this 3-month randomized trial was to test the initial efficacy of a mobile health (mHealth) nutrition intervention on changing consumption of targeted healthy (FV) and less healthy foods/beverages (SSS, SSB) in children who have ASD, ages 6-10, who were picky eaters.

Methods

Thirty-eight parent-child dyads were randomly assigned to either an intervention (technology) group or a wait list control (education) group. The intervention included behavioral skills training, a high level of personalization for dietary goals, and involved parents as "agents of change." Parents in the education group received general nutrition education and the dietary goals but did not receive skills training. Children's intake was assessed at baseline and at 3 months using 24-hour dietary recalls.

Results

While there were no significant group-by-time interactions (P > 0.25) for any of the primary outcomes, we found a significant main effect of time for FV intake (P = 0.04) indicating that both groups consumed more FV at 3 months (2.58 ± 0.30 servings/day) than at baseline (2.17 ± 0.28 servings/day; P = 0.03). Children in the intervention group who consumed few FV at baseline and showed high engagement with the technology increased their FV intake by 1.5 servings/day (P < 0.01). Children's taste/smell sensitivity significantly predicted their FV intake (P = 0.0446); for each unit of lower taste/smell sensitivity (indicating greater sensory processing abnormalities), FV intake increased by 0.13 ± 0.1 servings/day.

Discussion

This mHealth intervention did not yield significant between-group differences for changing consumption of targeted foods/beverages. Only children who consumed few FV at baseline and highly engaged with the technology increased their FV intake at 3 months. Future research should test additional strategies to expand the intervention's impact on a wider range of foods while also reaching a broader group of children who have ASD. This trial was registered at clinicaltrials.gov as NCT03424811.Clinical Trial Registration: This study was registered at clinicaltrials.gov as NCT03424811.

Case report: Pulmonary hypertensive crisis leading to cardiac arrest during endoscopic evaluation in a 6-year-old boy with autism, severe malnutrition, and undiagnosed scurvy

Pediatric gastroenterologists are often responsible for the evaluation of malnutrition in the setting of selective eating. Endoscopic evaluation for conditions including eosinophilic esophagitis and celiac disease can help to identify and treat mucosal disease contributing to food selectivity. However, undiagnosed micronutrient deficiencies can cause cardiovascular derangements that significantly increase a patient's anesthetic risk. Vitamin C deficiency in particular, alone or in combination with severe malnutrition, is associated with a severe but reversible form of pulmonary arterial hypertension that, while life threatening in the acute phase, may significantly improve within days of starting ascorbic acid replacement therapy. Here we present a case of a 6-year-old boy with autism spectrum disorder (ASD), severe malnutrition, and undiagnosed chronic vitamin C deficiency who developed a pulmonary hypertensive crisis after induction of general anesthesia leading to cardiac arrest during endoscopic evaluation. While the association between food selectivity among youth with neurodevelopmental differences and vitamin C deficiency is well-described, and pulmonary hypertension is a recognized rare complication of scurvy, extant literature has not addressed next steps to improve patient outcomes. Using this case report as a foundation, we discuss specific patient populations to screen and treat for micronutrient deficiencies prior to anesthesia and propose a novel clinical algorithm for pre-anesthesia risk stratification and mitigation in patients specifically at risk for scurvy and associated pulmonary hypertension.

Sensory processing and eating behaviours in autism: A systematic review

OBJECTIVES

The aim of this study was to assess the relationship between sensory processing and a broad range of eating behaviours across the lifespan.

METHODS

Five electronic databases of published and unpublished quantitative studies were systematically searched, evaluated for risk of bias and synthesised according to identified eating outcomes.

RESULTS

Across 25 studies, there was consistent evidence of a relationship between sensory processing and a range of eating behaviours. There was early evidence for the particular role of taste/smell sensitivities, as well as hypersensitivities, although future research is needed looking at different sensory patterns and modalities. There was also tentative evidence to suggest this relationship extends across development.

DISCUSSION

Study findings are discussed in relation to implications for sensory-based eating and feeding interventions and the development of eating disorders. Methodological and conceptual limitations are discussed and suggestions for future research are made to address these limitations. A broader investigation of multi-sensory issues and clearly defined eating behaviours, including disordered eating in clinically diagnosed samples, will allow for a more comprehensive and robust understanding of the relationship between sensory processing and eating behaviours in autism.

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 Personalized Multidisciplinary Approach to Evaluating and Treating Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder without a known cure. Current standard-of-care treatments focus on addressing core symptoms directly but have provided limited benefits. In many cases, individuals with ASD have abnormalities in multiple organs, including the brain, immune and gastrointestinal system, and multiple physiological systems including redox and metabolic systems. Additionally, multiple aspects of the environment can adversely affect children with ASD including the sensory environment, psychosocial stress, dietary limitations and exposures to allergens and toxicants. Although it is not clear whether these medical abnormalities and environmental factors are related to the etiology of ASD, there is evidence that many of these factors can modulate ASD symptoms, making them a potential treatment target for improving core and associated ASD-related symptoms and improving functional limitation. Additionally, addressing underlying biological disturbances that drive pathophysiology has the potential to be disease modifying. This article describes a systematic approach using clinical history and biomarkers to personalize medical treatment for children with ASD. This approach is medically comprehensive, making it attractive for a multidisciplinary approach. By concentrating on treatable conditions in ASD, it is possible to improve functional ability and quality of life, thus providing optimal outcomes.

How to support adults with anorexia nervosa and autism: Qualitative study of clinical pathway case series

INTRODUCTION

Previous research has explored the overlapping presentation between autism and eating disorders (ED). This study aims to summarize the clinical challenges associated with co-occurring autism and anorexia nervosa (AN) based on clinicians' case notes and minutes from case discussions, to understand how to better support people with the comorbidity.

METHOD

Thematic analysis was conducted on de-identified notes on 20 cases with AN and autistic characteristics and minutes from case discussions. Themes relevant to clinical challenges in supporting those with the comorbidity were identified, and a thematic map was produced to visually represent the results.

RESULTS

The key challenges faced by clinicians when treating patients with AN and autism included: communication difficulties, maintaining boundaries, autism screening, presence of other comorbidities, sensory difficulties, atypical presentation of eating difficulties, cognitive rigidity, and emotional difficulties. Adaptations to resolve some of these difficulties included exposure-based food experiments, keeping a record of patients' self-reported communication preferences, individual-level modification of communication style, and providing tools for patients to identify emotions.

CONCLUSIONS AND IMPLICATIONS

Further exploration to establish the effectiveness of the adaptations is warranted. Furthermore, tools for differentiating between ED, autism and other comorbidities are needed to help clinicians clarify the cause of a presenting symptom, and help them to best support and maintain boundaries with patients.