Particularities of eating disorders in autism spectrum disorder. Clinical & Therapeutic approach in a Romanian Center of Child and Adolescent Psychiatry- clinical case series

GROZAVESCU Raluca1,2, LEȚI Maria-Mădălina1, POP Anca Lucia 2, 3

1Clinical Hospital of Psychiatry”Prof. Dr. Alexandru Obregia”, Romania

2University of Medicine and Pharmacy “Carol Davila” Bucharest, Romania

3National Institute of Diabetes, Nutrition and Metabolic Diseases “Prof. Dr. N. Paulescu” Romania

Corresponding author: mariamadalinaleti@gmail.com

Abstract

Autism spectrum disorder (ASD) is a very wide pathology and affects more and more children in the latest years. Even if certain situations do not always meet the ICD or DSM diagnostic criteria described for a particular eating disorders (ED), the manifestations can be severe and can significantly affect the child’s health. The restrictive aspects of the autism disorder will amplify a particular eating behaviour. Clinicians must identify and observe the particular ED and the restrictive autistic feeding limitation in order to implement the appropriate forms of therapy and in the parent-child relationship. There is a reverse hypothesis that the ED are an important comorbidity in Autism and it needs a special attention. Methods: In this paper we intend to present the main data that exist so far about the association of autism spectrum disorder and eating disorders and present nine relevant cases from The Clinic of Child & Adolescent Psychiatry in the Clinical Hospital of Psychiatry “Professor Doctor Alexandru Obregia” in Bucharest, to capture the defining elements of these patients. Results: Our results support the hypothesis that if an eating disorder overlaps with the autism spectrum disorder, the characteristics are much more severe, often overlaps with an acute eating requiring and drug treatment. Certain particularities of eating behaviour will remain throughout life and therefore it is important to work as much as possible on these aspects in the therapy program. Studies on larger populations and relevant groups are needed to certify statistical data and find the most effective solutions for this niche of patients.

Keywords: autism spectrum disorder, eating disorders, Anorexia Nervosa, restrictive behaviour, autism eating behaviours

Introduction

According to DSM IV TR the autism is a developmental disorder that occurs before the age of three, characterized by deviant and / or delayed functioning in one of the following areas: social interaction, verbal or nonverbal communication, behaviour. DSM V narrows the areas of manifestations to two – deficiency in relationship and social communication together with restrictive, repetitive patterns of behaviour and interests [1, 2].

Other features that we have to consider when we talk about autism spectrum disorder are the resistance to change and restricted areas of interests: any change in their environment and in their stereotypes can trigger an accentuated emotional state, with screams and bizarre agitation, insists that he eat from the same plate or be dressed in the same clothes; some children with autism insists that the food must always be prepared and placed on the table in the same way; the child insists on following the same behaviour, otherwise appears catastrophic reactions[3,4].

Patients with autistic spectrum disorders frequently have sleep disorders, restricted or bizarre food preferences, hypersensitivity to certain stimuli (auditory, olfactory, tactile or visual), fascination with rotating objects and certain toys with complicated mechanisms, higher pain threshold, chronic anxiety with intense manifestations [1,5].

Particularities of the eating disorders in ASD

Atypical eating behaviours and frequent difficulties in the child with ASD are represented by limited acceptance of diverse food types, colours and textures; systematic rejection of novel foods; restrictive and unbalanced diet for long periods of time –their food must be placed in the same order on the plate and use the same plates and cutlery; sometimes they cannot stand to touch food or, surprisingly, eat only by hand, without accepting cutlery [6]. In other cases, they refuse to chew uncoordinated swallowing, regurgitation and vomiting spike (ingestion of inedible substances: paper, pebbles, lint, etc.) Another inappropriate behaviours during the meal includes the need of watching TV, tablet or telephone; otherwise a fit of anger will appear [7].  It is important not to neglect the detection of any digestive disorders, food intolerances or allergies that may be present [8,9]. In the latest years it has been studied more a more the correlation between eating disorders and autism spectrum disorder. Persons with anorexia nervosa can associate a form of mental rigidity, difficulties with empathy and interpreting the relationships with others [10,11].

In adolescence ED may be maintained or even worsened the childhood condition – often in childhood appears selective eating behaviours; the most encountered diagnostics in these periods are Anorexia nervosa Bulimia nervosa Mixed forms Excessive eating [18,30]. Anorexia nervosa is a pathology characterized by restrictive eating behaviours, intense fear of gaining weight and the use of specific behaviours to lose weight according to American Psychological Association in 2013. Persons with Autism Spectrum Disorder (ASD) can frequently associate eating disorders, especially Anorexia Nervosa, but also the persons with AN can associate traits of ASD. About 20-35% of persons with AN meet the criteria for ASD [10]. Westwood described that the onset of starvation in anorexia nervosa is accompanied by cognitive rigidity and poor metallizing ability that appears to attenuate once recovery is achieved [12,13]. Less is known about the association between autism spectrum disorders and eating disorders, given the selective and restrictive appetite of those with ASD, which is part of the spectrum disorder and is not a separate diagnosis [14]. The purpose of this study is to analyse a series of cases from the Clinic of Child and Adolescent Psychiatry from the Clinical Hospital of Psychiatry Professor Doctor Alexandru Obregia Bucharest and observe the main characteristics of eating behaviours in children with a diagnostic of Autism Spectrum Disorder. 

Materials and methods

Review of the literature

In the first part, we reviewed the recent studies about the correlations between ED and ASD and we systematically searched the databases. We have systematically searched in the literature for studies that address and describe the chosen topic and presented the main ideas. Data sources: we made an accurate search in the main sources of Databases (PubMed, BMC Public Health, Global Health, Cross Ref, Scopus, Web of Science, Google Scholar and Medline with the keywords: “autism spectrum disorder”, “Anorexia Nervosa”, “eating disorders”, “restrictive behaviours”, ”autism eating behaviours”. 

Clinical case series

On the second part we made a retrospective observational clinical case analyse; we integrated the clinical data from the clinical record of 9 patients with AED and ED admitted in our clinic during a period of 1 year. We considered the following items: gender, age, diagnoses, psychiatric and somatic characteristics and methods of intervention – Table I. The data was collected anonymously, respecting the confidentiality and we obtained the consent of the patients to present the cases.

Results

Review of the recent clinical studies regarding correlations between AED and ED

Huke & al. (2013) reviewed the literature to observe the cognitive deficits in eating disorders overlapping with ASD. From a total of eight studies, a high prevalence of autism spectrum disorder in ED population was found compared with the healthy population. This aspect may indicate the need for a conventional treatment for these areas and adapted intervention methods [15].

A pilot study suggest that  pre-existing – childhood onset – neuropsychiatric disorder like autism spectrum disorder, attention deficit/hyperactivity disorder, tic disorders are often associated with the severe eating disorders [16]. Nevertheless, gastro-intestinal symptoms/dysfunction can be found in ASD patients so it is very important for the clinician to exclude the somatic pathology before considering that the dysfunction is due to the psychiatric affection exclusively [17,18]. Feeding difficulties represent a characteristic of ASD. Specific forms of psychotherapy and sometimes pharmaceutical approach must be done in order to improve the health status of more patients and improve their quality of life (QoL). Besides cognitive behavioural, therapy, it has been proved that operant conditioning is the best form to use in these cases [19, 20, 21, 22]. Particularities like neophobia and food selectivity in these patients are frequently met and we have to get the tools to know how to handle this pathology and how to eliminate them [23, 24]. 

Clinical case series

Table I. Clinical Cases

General data Diagnostic Psychiatric characteristics Somatic characteristics   Intervention
Case 1, male

3 years and 6 months

 ASD Excessive eating, no food selectivity but with preferences for sweets and flour preparations Obesity (weight – 35kg, height – 110 cm) collaboration psychiatrist, psychotherapist, paediatrician and family Parent training, proper diet, finding other ways to reward and reward
Case 2, 

Female, 5 years

 ASD Selectivity: refuse fruits and vegetables, the only fruits accepted are bananas; eat very small amounts of other foods, only on TV or phone  Stature-weight hypotrophy (G-11.5kg, I-102cm) collaboration psychiatrist, psychotherapist, paediatrician and family Parent training, proper diet, nutritional supplements, Behavioural therapy
Case 3, Male, 

6 years

 ASD Eat only liquid and semi-liquid foods (past), refuse any solid food, bite into a food and do not chew (swallow directly) Severe difficulty chewing behavioural therapy, collaboration psychiatrist, psychotherapist, speech therapist and family
Case 4, Female, 

4 years

 Infantile Autism

Pica

 eat paper, soap, lint Extreme selectivity: from the age of about 3 years, accept only solid foods such as pretzels, bread, breadsticks. Rarely accepts meatballs, prepared only with meat and egg  physical behavioural therapy, collaboration psychiatrist, psychotherapist, family
Case 5, 9 years ASD Deficit of social interaction

Severe anxiety

 Altered physical condition and total food refusal Gavage, treatment with risperidone 0.5mg / day, behavioural therapy collaboration psychiatrist, paediatrician, psychotherapist, family
Case 6, Male, 

11 years

 ASD, ADHD with severe hyperactivity, Obsessive-compulsive disorder He developed a severe anorexic syndrome: he systematically refused to swallow, even his own saliva – fear of swallowing. Chew food and then spit it out, do not accept liquids Various diets were kept in the family, semi-solid food, on evaluation the child accepted only certain kind of food  Treatment with Risperidone 0.75mg / day and Fluvoxamine 50mg / day, behavioural therapy collaboration psychiatrist, paediatrician, psychotherapist, family
Case 7,

Female, 

15 years 

 ASD Severe difficulties in social interaction, of understanding jokes

Social inadequacy

 She lost 17 kg in 3 months, BMI-13, amenorrhea Treatment with Risperidone 1mg / day and Sertraline 50mg / day, cognitive-behavioural therapy collaboration psychiatrist, paediatrician, psychotherapist, family
Case 8,

Male,

17 years

 Asperger Syndrome, Obsessive-Compulsive Disorder He lost 24 kg in 4 months eating 250g of pretzels with bran per day and drinking 3l of plain water. Refuse to eat at home saying he ate in the city overweight 

(W-92kg, H-185cm) 

 treatment with escitalopram 10 mg / day and risperidone 0.5 mg / day, cognitive-behavioural therapy collaboration psychiatrist, paediatrician, psychotherapist, family
Case 9,

Male,

17 years

 Asperger Syndrome He began to systematically refuse foods he considered unhealthy, refusing meat, fish (except catching salmon), eggs and dairy products, as well as sweets and fats, being initially encouraged by his family as well.  She lost weight from 62 to 45kg (I-174cm) in 6 months. treatment with olanzapine 10mg / day and sertraline 50mg / day, cognitive-behavioural therapy collaboration psychiatrist, paediatrician, psychotherapist, family

DISCUSSIONS

Deficit of sensory integration, resistance to change, stereotypical and repetitive behaviour. Difficulty understanding and emotional self-regulation (eg understanding and managing anxiety; eating gratification, etc.) Lack  of clear self-perception and significant deficit in self-analysis deficit of integration of self-image in the process of confrontation and interaction. Behaviours learned through imitation The metallization deficit is accentuated by the lack of processing or poor processing of information from others [25,26].

According to Practice Parameter for the Assessment and Treatment of Children and Adolescents with Autism Spectrum Disorder The clinician must help the family to obtain a structured therapeutic intervention based on scientific evidence adapted to each case Ensuring access to the multidisciplinary therapeutic team (psychiatrist, paediatrician, nutritionist, psychologist, psychotherapist) The family and caregivers have a very important role in the therapeutic process.

It is very important to fallow the next steps in order to improve this children outcome and to prove there is something that can do for these kind of patients like family counselling – information on ASD, associated disorders, eating disorders; preparation and training of the family on the adaptation of educational methods, therapeutic plan, possible effects of therapeutic interventions; psychotherapeutic intervention for ASD and associated disorders (including eating disorders) behavioural and cognitive-behavioural techniques are most effective; in older children and adolescents metallization (theory of mind) social group; ensuring as much as possible a balanced diet; possibly the administration of nutritional supplements; specific approach to digestive disorders, allergies or food intolerances if any; association of drug treatment (if necessary): antipsychotics, antidepressants, anxiolytics, mood stabilizers may be used. The treatment scheme is adapted to the particularities of each case. Also it is essential to treat the hydro-electrolytic disequilibrium and other associated comorbidities and dysfunctions [27].

 Data from the literature and our clinical experience show that eating disorders occur frequently in children and adolescents with ASD. Although they do not always meet the ICD or DSM diagnostic criteria for a particular eating disorder, eating disorders can be severe in this context and can significantly affects the health of the child or adolescent. Therapeutic intervention for eating disorders must be included in the general plan of therapy and must be adapted to the particularities of each case, after a rigorous evaluation Access to the multidisciplinary team has a very important role [28].

In the cases presented, we noticed the following features, sometimes the parents apply the modified eating behaviour because they do not impose limits and accept that the child eats only what he wants. Eating behaviour is shaped in the family and when food is eaten in excess, habitual obesity occurs. The child will not try to find new methods of emotional regulation and will eat when he feels discomfort. Given the rigidity of people with autism, this behaviour can be amplified and becoming stereotype.

Food restriction in terms of quality and quantity causes growth disorders and stature-weight hypotrophy. Some children agree to eat only if they look at a screen, usually the phone. Thus, the act of eating becomes a passive, automatic behaviour, without realizing the sensation of hunger and satiety, the texture. So, they do not even want to try new foods, to diversify their diet, facts that amplifies the deficiencies of essential nutrients, vitamins, minerals [29]. In the case of severe forms, childhood autism frequently associates cognitive deficit, which makes restrictive eating behaviour even less controllable, frequent association with pica, need for supervision.  The comorbidity with somatic disorders amplifies the development of an eating disorder, especially respiratory and digestive infections, fever, gastrointestinal disorders, but also side effects of medication, like extrapyramidal symptoms [30].

Teenagers are very suggestive and influential. The bullying phenomenon is very common during adolescence and those with autism spectrum traits are the most vulnerable. Often in clinical practice, not enough attention is paid to the presence of eating disorders that can worsen and cause complications.

CONCLUSIONS

Both in literature and in clinical experience there is a very high frequency of eating disorders in children and adolescents with autism spectrum disorder. These disorders can be severe and the particularities can be very difficult to address and both active detection of these disorders and early intervention are necessary. Therapeutic intervention for comorbid eating disorders with autism spectrum disorder can be extremely difficult and requires the development of treatment lines structured and adapted to the particularities of each case.

DISCLOSURE. The authors have no commercial relationships to disclose and no conflicts of interest. 

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