During her senior year of college, Sonell's coursework became overwhelming and required increasing amounts of her attention. This led her to avoid components of her life that were hard or required extra effort. In light of her food restrictions, meal preparation fell into that "not so easy to do" category, and she ended up eating just one meal per day. “The resultant weight loss was really exciting to me,” Sonell says. "It became addicting." Along with food aversions, autism traits such as cognitive rigidity (needing to do things a certain way) can lead to this kind of restriction around one’s diet.
Research suggests an overlap exists between autism and eating disorders: Around 20 to 35 percent of women with anorexia, compared to just one percent of the general population of women, meet the criteria for autism. (One in every hundred women may sound like a lot, but autism in women has been traditionally underdiagnosed and may actually be even more common than that.) Similar correlations exist between autism and other eating disorders, like bulimia and binge eating disorder. People with autism are also more likely to end up diagnosed with avoidant/restrictive food intake disorder (ARFID), which involves highly restricted or selective eating that is not motivated by body image issues.
Research suggests an overlap exists between autism and eating disorders: Around 20 to 35 percent of women with anorexia, compared to just one percent of the general population of women, meet the criteria for autism.
“What we've found in autism is that potentially disordered eating often starts during childhood years, and if not rectified then, it typically continues into adulthood,” says registered behavior technician Sunny Cash, a therapist for children and teens with autism and community director at the neurodiversity-focused supplement brand Bened Life. Children may start off avoiding certain foods simply because they find these foods distasteful, but if this isn’t managed early, it can turn into an eating disorder.
Eating disorders are common among people with autism, and may present differently than they do for people who are neurotypical. In order to provide the best care and tools to people who have both autism and disordered eating or eating disorders, it’s important to understand those differences, because it's crucial for effective treatment and recovery.
Causes and vulnerability: What the research says about people with autism and eating disorders
In addition to food aversions and difficulties with body awareness, a number of other traits associated with autism may contribute to eating disorders. Some people with autism, for instance, are prone to body-image distortions due to differences in how they process visual information. While people who are neurotypical are more likely to look at themselves and see all of their features together, people with autism may be prone to fixating on a singular body part.
People with autism are also susceptible to feelings of overwhelm and overstimulation due to their sensory sensitivity and difficulty in processing emotions. "This can lead to feelings that are difficult to manage, and disordered eating can become a way to get a hold on these emotions," says Corrie Goldberg, PhD, a licensed clinical psychologist who works with people who are neurodiverse.
"Autistic people are more likely than non-autistic people to have experienced subtle and direct feedback throughout their lifetime that they should behave in ways that feel unnatural to them, known as masking, in order to better fit in with peers or with broader society,” says Dr. Goldberg. “This pressure to deny their own instincts and prioritize the comfort of others can contribute to a decreased ability to notice and respond to their own needs in a healthy way, which can extend to their relationship with food and their bodies.”
“This pressure to deny their own instincts and prioritize the comfort of others can contribute to a decreased ability to notice and respond to their own needs in a healthy way, which can extend to their relationship with food and their bodies.” —Corrie Goldberg, PhD
This is one of the many reasons why people with autism benefit from seeing providers who are open to them expressing themselves however feels natural to them, rather than expecting them to act like people who are neurotypical. “I have a client who tends to ‘giggle’ when stating thoughts from the eating disorder,” says Michelle Hunt, LMHC, NCC, a licensed therapist with Empower Your Mind Therapy. “While this could be assumed to mean that she is not taking the eating disorder seriously, as stated by other providers, what it actually means is that the eating disorder thoughts create sensory overload, which in turn needs to be expelled. In this case, the expulsion of the energy is giggling.”
Finally, another common feature of autism is “over-reliance on routines and more rigid thinking, which usually comes with 'rules,'” explains licensed clinical psychologist Jephtha Tausig, PhD. This, she says, can translate to rigid behaviors around food.
The powers of early intervention and professional help
"For a person with autism at any age, developing a healthy relationship with food may involve finding healthy meals to eat that don’t trigger dietary aversions or cause digestive issues, which are also common in people with autism," says Cash. You might slowly introduce foods into your diet that are similar to ones you already like, and then, eventually, you'll end up with a diversified diet and fewer aversions. For instance, Cash worked with one four-year-old who almost exclusively ate chicken nuggets and would have meltdowns when their parents tried to serve vegetables. This child had more success learning to eat mozzarella sticks and fish sticks before tackling broccoli and brussels sprouts.
Some signs of eating disorders resemble signs of autism, making it easy to unintentionally overlook certain symptoms in people with autism. “Weight fluctuations, menstrual irregularities, dizziness, syncope [fainting], feeling cold all the time, weakness, and fatigue should not be ignored in any person who also has autism spectrum disorder," says Anna Tanner, MD, FAAP, FSAHM, CEDS-S, vice president for the Department of Child and Adolescent Medicine at Veritas Collaborative eating disorder treatment center and The Emily Program. "They should instead be evaluated by an experienced professional with a background in eating disorders.”
With that in mind, it's ideal for those with autism and eating disorders to work with professionals who thoroughly understand both. “I strongly encourage autistic people who are struggling with their eating to seek support and treatment from neurodiversity-affirming health-care providers who are familiar with the unique complexities of eating and the autistic neurotype,” says Dr. Goldberg. “The experience of eating disorders and eating disorder treatment can be highly interwoven with other aspects of the autistic experience.”
For instance, people with autism may need to pace or move around to discharge feelings of overwhelm after eating, says Hunt. “Splitting therapy sessions in half—half of the time dedicated to food, the other half processing—can be beneficial, as is adding more sessions throughout the week at varying times,” Hunt says. “Find providers who can empathize with the sensory processing needs.”
A road to recovery
About two years after her one-meal-a-day routine began, Sonell realized her eating was disordered and began trying to eat in a more balanced manner. She left school to reduce her stress, and her eating improved as well. “Recovery had a lot to do with leaving school and having way less [responsibility] on my plate, which left more space for proper meal planning and grocery shopping,” Sonell says. While she didn’t work with a therapist on her disordered eating habits at the time, Sonell plans to start doing so next month—a strong example of the fact that recovery should be seen as an active, ever-evolving process rather than an end-all, be-all moment in time.
While she didn’t work with a therapist on her disordered eating habits at the time, Sonell plans to start doing so next month—a strong example of the fact that recovery should be seen as an active, ever-evolving process rather than an end-all, be-all moment in time.
Sonell also learned to lean in to one of her autism traits: her desire for order. “I have a brain that craves and thrives in strict structure, so I've actually started planning roughly the same times for breakfast, lunch, and dinner,” she says. “I'm also really careful to always keep some of my 'safe' foods around—things that, taste and texture-wise, are basically universally pleasant for me.” This way, Sonell says that she always has something that she finds palatable and comfortable to eat.
“The foods I most readily turn to are the same foods I've been drawn to most of my life, but I really, really enjoy cooking. I've found that the older I've gotten and the more control I have over my kitchen, the easier it's been to try new recipes and take more risks with food," Sonell says. Stress management was also important, she adds.
Recovery for anyone, whether they have autism or not, is not just about normalizing eating: It’s an emotional and spiritual journey. Recovery is also an ongoing process, which means it may require a caregiver to forgive moments of relapse as well as celebrate small victories along the way. “I definitely still held on to some really harmful ideas about the supposed ‘health’ of delaying my meals for a long time, and it's only in the last couple of years I've really been able to unpack that,” says Sonell. “I don't know that I can say I'm ‘recovered,’ but rather that I'm happier and healthier—and more able to choose food and fullness over weight loss.”
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