Autism 

There is no specific data on how many people with Avoidant Restrictive Food Intake Disorder (ARFID) also have autism, although there appears to be a strong correlation, particularly in women, where up to 20-35% of women with a diagnosis of Anorexia Nervosa (AN) also meet the criteria for Autism. 

During a ward admission it is important to distinguish between eating disorder behaviours and autistic behaviours. Both of these diagnoses can manifest in avoiding foods and behaviours around meals, mealtimes, and social situations. 

Taking a developmental and feeding history from parents or caregivers will help to determine if food avoidance and behaviours pre-dated the eating disorder. 

It is important to note that inadequate nutrition due to AN or ARFID can exacerbate experiences for autistic people such as social difficulties or differences with processing emotions. 

Medical and mental health wards can be overwhelming places, with bright lights, noise, and constant change of plans, staff, and patients. These factors can significantly increase distress and make it difficult for an autistic person, or someone with other neurodivergence (for example, ADHD), to cope.

Considerations 

• Sensory: Autistic young people may have heightened sensory sensitivities related to the textures, look, smell, and sound of foods as well as the sights, sounds, and smells on the ward. 

• Routines, Rituals, Resistance: Some autistic young people may display repetitive behaviours, have a preference for routines, and dislike change. This can include routines and rituals around food, such as eating times, locations, and types of food. 

• Interoception: Interoception refers to the ability to sense and interpret internal bodily signals, including hunger and fullness cues, thirst, and distinguishing the difference between anxiety or worry and physical sensations of fullness. An autistic young person may not be able to recognise the cues of hunger, thirst, and fullness accurately. 

• Alexithymia: Alexithymia is having difficulty identifying and describing emotions and is common in autistic young people. This can make it hard to pinpoint the emotion they are feeling, to soothe themselves, or get support from others. As a result, autistic young people may be more vulnerable to developing eating disorder behaviours as a coping mechanism. 

Tips for supporting autistic young people on the ward

• Provide clear explanations and advance notice for what is happening. Let the young person know when MDT meetings will occur, when you will be meeting with them or their parents, and adhere to the agreed times where possible. Uncertainty or last-minute changes can be highly unsettling.

• Provide the meal plan in advance (if this is the policy at your hospital) and let the young person know that this will not change until the next MDT meeting. Clearly outline expectations around meal completion and what support or interventions will occur if the young person is unable to complete meals.

• Discuss with parents or carers which foods the young person did not eat prior to the eating disorder and accommodate long-standing sensory preferences or food avoidances. This is not an appropriate time to challenge lifelong sensory sensitivities or established food avoidance patterns. If adequate calorie intake cannot be achieved using the limited range that the young person will eat, then discuss this together to work out a plan for achieving medical stability during admission.

• Explain the purpose of monitoring blood tests and observations, why this is important, and how frequently these will occur.

• Put everything in writing, including meal plans, expectations, and schedules.

• Keep staff consistent as much as possible. If this is not feasible, prepare the young person in advance for changes, such as another dietitian covering on the weekend or job-share arrangements.

• Discuss how best to support the person. Discuss individual sensory and environmental needs. For example, is the ward environment noisy or overwhelming? Is there a quieter space available for meals, or does the young person find having the television on during meals helpful?

• Develop clear goals or steps that need to be met prior to transition home.