Autism and its links to anorexia - Dandelion Training & Development

Please note the information in this article is not medical advice and should not be taken as such. If you have a concern about a child’s eating behaviours please ensure that you speak with a medical professional

Autism

In my therapy work, I frequently work with young people with anorexia. Many, but not all clients are female, although over recent years I have seen an increase in male clients. A proportion of these clients have subsequently received an autism diagnosis, but why are they so often missed?

Autism is often detected by parents by the time children are 2-3 years, however, where symptoms are mild, this may not be identified until late adolescence or adulthood. One of the greatest challenges, is that autism can be observed differently in boys and girls. Traditionally autism has a higher male presentation with 4 males diagnosed to every 1 female. However, autism in girls is often harder to recognise and later to diagnose. Further, the traits that many professionals are looking for when considering an autism diagnosis are based on male presentation. Further, it has been identified that there is a bias that work against females being diagnosed, even if they present with the same or similar levels of autistic traits as males, they are less likely to be diagnosed. Females are found to present, more frequently with internalising issues, such as anxiety and depression, whilst males have more externalising issues such as hyperactivity and conduct disorders, which may influence the approach or diagnosis of a practitioner. This can lead to a misdiagnosis with other mental health conditions such as anxiety disorders and personality disorders.

It has been identified that girls are better able to mask (or camouflage) symptoms and mimic social behaviours of other children, which can appear to look like they are coping better with social situations. For instance, girls are often perceived as being able to imaginatively play – when watched more closely, they will often order, organise or set up imaginative play, or mimic carrying dolls like their peers, but are not seen to be actively ‘playing’. Camouflage is an exhausting process, and it has been found that those who use it as a frequent coping strategy often have higher levels of depression, low mood, anxiety and low self-esteem. Females are often at the higher end of IQ presentation and females with higher IQ have increased social behaviours. Further, females have less repetitive behaviours, show less hyperactivity and aggression and tend to have a higher language ability .

Autism and Anorexia

Some research suggests between 4% to 23% of people with an eating disorder are also autistic. Some research suggests anorexia is the most common eating disorder amongst autistic people. The Maudsley Hospital found that 35% of the women they see – often women with the most challenging and long-standing eating disorders meet the diagnostic criteria for Autism Spectrum Disorder (ASD). Because of changes in how autism is diagnosed, some participants met the criteria for a diagnosis at one time point and not at others, but those with anorexia still tend to score higher on a test of social-communication difficulties than controls do.

Research has found that children with social difficulties at age 7 and 11 are more likely than their peers without such difficulties to engage in disordered eating behaviours, such as fasting or using diet pills, at age 14, according to data from more than 5,000 children born in the U.K. Among 1.7 million people in Denmark’s national health registry, the likelihood of having autism is more than 15 times higher among people with anorexia than among those without; likewise, autistic people are more than five times as likely to have anorexia as non-autistic people.

An issue with this overlap between the two conditions is complicated by the fact that starvation can cause brain changes that result in autism-like behaviours, such as social difficulties and problems with emotion processing. William Mandy, professor of clinical psychology at University College London in the U.K discusses that it can therefore be difficult to accurately diagnose autism in people with severe anorexia.

Anorexia involves a damaging focus on weight and body image, but people with autism may restrict their eating for other reasons, such as coping with difficult emotions or having certain food aversions. For some autistic people, eating disorders may originate in restricted and repetitive behaviours that take the form of an intense interest such as calorie-counting, exercise or an insistence on a limited diet.

In a qualitative study of autistic women with anorexia published in April, few participants reported their eating behaviors as being primarily driven by body image, although some used a goal of thinness as a way to fit in with peer groups from which they felt excluded. This sort of emotional driver may be particularly common among girls with undiagnosed autism, who can experience painful inner lives without adequate support. Difficulties with identifying emotions (alexithymia) — and understanding physical sensations, such as hunger, may also contribute to the overlap between the two conditions. Alexithymia is common in both autism and anorexia.

So, what other factors may contribute to eating disorders?
*Being misunderstood or not accepted by non-autistic people may also lead to autistic people feeling socially isolated. For some, focusing on weight might feel like a way to fit in and reduce their social anxiety.
*Sensory differences related to food (including not recognising hunger or fullness, known as interoception)
food, counting calories and exercise becoming an intense interest/obsession, or being used to manage general anxiety levels
*Developing strict routines and rules around food and exercise that are very difficult to change a need for control and familiarity (such as restricted eating)
*Using food to manage difficult emotions – made harder if you have alexithymia (difficulty recognising and understanding emotions).
*Therapy for eating disorders often involves in-person doctor’s appointments and inpatient stays. People in treatment often need to eat meals in group settings, which can be noisy and overwhelming, making eating even more difficult.

Considerations

When working with children and young people, we therefore want to ensure that we are always practicing professional curiosity. Where there are concerns about an overlap in symptoms being an advocate for those young people and providing clear information to professionals involved in their cases is therefore paramount to ensuring that diagnosis is accurate and treatment plans are therefore appropriately executed.

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