Neurodevelopmental Differences and ARFID

The research on neurodevelopmental differences and ARFID shows:

Neurodevelopmental differences, such as autism _{(Watts et al 2023)}, attention deficit hyperactivity disorder (ADHD) _{(Nicely et al., 2014; Richmond et al., 2023)}, and learning difficulties _{(Kambanis et al., 2022)}, are co-occurring with ARFID presentations in paediatric populations.

In their seminal paper, Mayes & Zickgraf (2019) found prevalence rates of atypical eating behaviours among autistic children to be 70.4% compared with 4.8% among neurotypical children. Atypical eating behaviours were 4.2 times more common in the autism group than in the ADHD group. The clinically assessed sample comprised of N= 2,102 children: 1,462 with autism, 327 with other disorders (e.g., ADHD, intellectual disability, language disorder, and learning disability), and 313 neurotypical children.

Congruent with Mayes et al (2012), almost all autistic children had ADHD symptoms and were only assigned to the autism group. Notably, ARFID was not given as a co-occurring diagnosis as limited food preferences is a characteristic of autism. Most of the autistic children with restricted diets did not have food aversion and sensory sensitivity to foods. In addition, most children with limited food preferences were not underweight (from parent report), a prerequisite for ARFID.

An earlier study, investigating atypical eating behaviours in 1112 autistic children, who were also participants in Zickgraf & Mayes (2019), identified young age, increasing autism support needs, poor appetite, and constipation as having significant correlations with atypical eating behaviours _{(Mayes and Zickgraf, 2018)}.

Mayes and Zickgraf (2019), observed that among the autism group with atypical eating behaviours, the most common behaviour was:

• Limited food preferences (88%) - Grain products and/or chicken (usually nug gets) were the preferred foods for 92% of autistic children who had limited food preferences.

• Hypersensitivity to food textures (46%)

• Other peculiar patterns most often eating only one brand of food (27%)

• Pocketing food without swallowing (19%)

• Pica (12%)

Kozak et al (2023) showed that autistic children, when compared with neurotypical children have higher scores for 1) ARFID; 2) food neophobia; 3) eating-related behaviours such as, emotional undereating, desire to drink, food fussiness; and 4) feeding practices - more pressure to eat from their parents. Concerning “more pressure to eat”, carers should be made aware that applying pressure on their child to eat may be counterproductive.
It may affect their child’s relationship with food by increasing food aversion especially when new and unfamiliar foods are encountered (Kozak et al., 2023). The authors suggest that “pressure to eat” needs further investigation to understand the impact on autistic children.

“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” _{(Calisan Kinter et al., 2023)}.

Co-occurrence of autism with ARFID in adulthood

There is a paucity of research on adults with comorbid ARFID and autism.

However, Matsuzuka et al (2023) retrospectively reviewed 34 patients from a specialist eating disorder clinic with ARFID onset after the age of 18, whose diagnoses were confirmed by 3 psychiatrists. Two groups of patients, ARFID and autism (44%), or without co-occurring autism (54%) were formed.

In childhood, the co-occurring autism group reported significant sub-threshold eating disorder pathology, such as, picky eating, lack of interest in food and small appetite (53.3% versus 15.8%), compared to the group with no co-occurrence of autism. It seems that this sub-threshold eating disorder pathology may have evolved into ARFID eating behaviours following the increased stress from the demands of social functioning in adulthood _{(Polivy & Herman, 2002)}.

In contrast, autistic patients were prone to physical illness such as gastrointestinal disease as children (57.9% vs 20.0%), and as adults had higher levels of somatic symptoms (68.4% vs 33.3%) than those without co occurring autism. - In contrast to paediatric studies, see above, the three ARFID drivers were present in similar levels in both the groups with and without co-occurring autism: ‘aversive’, 22 (64.7%) patients, ‘limited intake’, 7 (20.6%), and ‘limited variety’ for 1 (2.9%). Five (14.7%) patients had multiple subtypes and the four (11.8%) patients with no subtypes, did not have co-occurring autism.

Results from the Eating Disorder Inventory _{(Garner, Olmstead & Polivy, 1983)} showed those with co-occurring autism having significantly higher values than the group without autism for ineffectiveness (p=0.03) and interoceptive awareness (p=0.04). Further, co-occurring autism had a significantly negative impact, slowing BMI gain during treatment (p=0.014), evidenced by slopes of BMI increase being 0.11 with co occurring autism and 0.19 for patients without autism. In all, the psychopathology of the ARFID group with co-occurring autism was more severe than that of the patients without autism, which may worsen their prognosis.

For a review of studies on ARFID and co-occurring autism, published in 2022 and first 6 months of 2023, Keski-Rahkonen & Ruusunen (2023) suggest that individuals being assessed for autism should be routinely screened for ARFID and that more research is needed on how to support individuals with this co-occurrence.

Calisan Kinter, R., Ozbaran, B., Inal Kaleli, I., Kose, S., Bildik, T., & Ghaziuddin, M. (2023). The Sensory Profiles, Eating Behaviors, and Quality of Life of Children with Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder. Psychiatric Quarterly, 1-22. doi: 10.1007/s11126-023-10063-6

Garner, D. M., Olmsted, M. P., & Polivy, J. (1983). The Eating Disorder Inventory: A measure of cognitive-behavioral dimensions of anorexia nervosa and bulimia. Anorexia nervosa: Recent Developments in Research, 3, 173-184. doi: 10.1002/1098-108X(198321)2:2<15::AID-EAT2260020203>3.0.CO;2-6

Kambanis, P. E., Harshman, S. G., Kuhnle, M. C., Kahn, D. L., Dreier, M. J., Hauser, K., Slattery, M., Beck- er, K. R., Breithaupt, L., Misra, M., Micali, N., Lawson, E. A., Eddy, K. T., & Thomas, J. J. (2022). Differential comorbidity profiles in avoidant/restrictive food intake disorder and anorexia nervosa: Does age play a role? International Journal of Eating Disorders, 55(10), 1397-1403. doi: 10.1002/eat.23777

Kozak, A., Czepczor-Bernat, K., Modrzejewska, J., Modrzejewska, A., Matusik, E., & Matusik, P. (2023). Avoidant/Restrictive Food Disorder (ARFID), Food Neophobia, Other Eating-Related Behaviours and Feeding Practices among Children with Autism Spectrum Disorder and in Non-Clinical Sample: A Preliminary Study. International Journal of Environmental Research and Public Health, 20(10), 5822. doi: 10.3390/ijerph20105822

Matsuzuka, T., Miyamoto, S., Harada, T., Yamauchi, T., Honda, M., Ohara, N., Mui, A., & Inoue, K. (2023). The Comorbidity of Autism Spectrum Disorder Slows Body Mass Index Gain in Adult-onset Avoidant/Re- strictive Food Intake Disorder. Osaka City Medical Journal, 69(1), 21-30.

Mayes, S. D., Calhoun, S. L., Mayes, R. D., & Molitoris, S. (2012). Autism and ADHD: Overlapping and discriminating symptoms. Research in Autism Spectrum Disorders, 6(1), 277-285. doi: 10.1016/j. rasd.2011.05.009

Mayes, S. D., & Zickgraf, H. (2019). Atypical eating behaviors in children and adolescents with autism, ADHD, other disorders, and typical development. Research in Autism Spectrum Disorders, 64, 76-83. doi: 10.1016/j.rasd.2019.04.002

Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of Eating Disorders, 2(1), 21. doi: 10.1186/s40337-014-0021-3

Richmond, T. K., Carmody, J., Freizinger, M., Milliren, C. E., Crowley, P. M., Jhe, G. B., & Bern, E. (2023). Assessment of Patients With ARFID Presenting to Multi-Disciplinary Tertiary Care Program. Journal of Pediatric Gastroenterology and Nutrition, 76(6), 743-748. doi: 10.1097/MPG.0000000000003774

Keski-Rahkonen, A., & Ruusunen, A. (2023). Avoidant-restrictive food intake disorder and autism: epidemiology, etiology, complications, treatment, and outcome. Current Opinion in Psychiatry, 36(6), 438-442. doi: 10.1097/YCO.0000000000000896

Watts, R., Archibald, T., Hembry, P., Howard, M., Kelly, C., Loomes, R., Markham, L., Moss, H., Munuve, A., Oros, A., Siddall, A., Rhind, C., Uddin, M., Ahmad, Z., Bryant-Waugh, R., Hübel, C. (2023). The clinical presentation of avoidant restrictive food intake disorder in children and adolescents is largely indepen- dent of sex, autism spectrum disorder and anxiety traits. eClinicalMedicine, 63:102190. doi: 10.1016/j.eclinm.2023.102190.