Hidden Eating Disorders in Autism: Review Finds Pica and ARFID Often Overlooked in Children

Children and adolescents with autism spectrum disorder face a markedly elevated risk of three little-known feeding and eating disorders — pica, avoidant restrictive food intake disorder and rumination disorder — yet the evidence base for recognizing and treating these conditions remains strikingly thin. That is the central conclusion of a new systematic review published in the Journal of Eating Disorders, in which a Norwegian-Swedish research team combed through nearly 8,700 scientific records and found only 23 studies that met rigorous inclusion criteria. The scarcity of qualifying research, the authors argue, is itself a finding: some of the most dangerous eating-related conditions in autistic children are being chronically underrecognized, understudied and, as a result, undertreated.

The review, led by Gunhild Hodt of Innlandet Hospital Trust and the University of Oslo, together with colleagues from the University of Bergen, Haukeland University Hospital, Sahlgrenska University Hospital and the University of Gothenburg, was conducted in accordance with the PRISMA reporting guidelines, the international standard for systematic reviews in health research. The team searched five major databases — MEDLINE, Embase, the Cochrane Library, CINAHL and PsycINFO — with coverage extending up to January 12, 2026. Their search strategy initially surfaced 8,678 potentially eligible articles, a figure that underscores both the breadth of literature on autism and feeding and, by contrast, how few studies actually address formal eating disorder diagnoses in this population.

The inclusion criteria were deliberately strict. To qualify, studies had to be peer reviewed and published in English, include participants younger than 18 years, involve samples of at least three individuals, and apply recognized diagnostic frameworks — either the DSM-IV or DSM-5, the ICD-9 or ICD-10, or the forthcoming ICD-11. Importantly, the researchers excluded studies that described ARFID-like symptoms or phenotypes without a formal diagnosis, a decision that sharpened the review’s focus on clinically confirmed conditions but also revealed how rarely such diagnoses are formally made in autistic children. After screening, just 23 studies survived: ten examined the combination of autism and ARFID, twelve examined autism and pica, and a single study addressed autism and rumination disorder.

Pica, the most heavily studied of the three conditions in this population, involves the persistent ingestion of non-nutritive, non-food substances such as soil, hair, paper, plastic or metal objects. In typically developing children, the behavior is common in infancy but is considered pathological when it persists beyond a developmental window. In autistic children, particularly those with intellectual disability, pica can persist for years and carries serious medical consequences: lead poisoning from ingested paint chips, gastrointestinal obstruction or perforation, dental damage and parasitic infection. The studies included in the review indicated an increased risk of pica among children with autism, and the authors highlight that potentially severe adverse outcomes appear responsive to early detection and intervention — a point with immediate clinical implications, since a behavior that might be dismissed as a quirk of autism can instead signal a diagnosable, treatable and medically dangerous disorder.

Avoidant restrictive food intake disorder, or ARFID, presents a very different clinical picture. Introduced as a formal diagnosis in DSM-5, ARFID describes a restrictive eating pattern driven not by concerns about weight or body shape — the hallmark of anorexia nervosa and bulimia — but by sensory aversion to food textures, tastes and smells, fear of aversive consequences such as choking or vomiting, or a simple lack of interest in eating. The result can be weight loss, nutritional deficiency, dependence on supplements or tube feeding, and profound psychosocial impairment. The ten studies in the review that examined autism and ARFID together support a substantially increased co-occurrence of the two conditions, a finding that aligns with the broader clinical observation that sensory sensitivities and rigid, repetitive behaviors characteristic of autism frequently shape what, how and how much an autistic child will eat.

One of the review’s most important conceptual contributions is its confirmation that the eating disorders co-occurring with autism are fundamentally different in motivation from the classic eating disorders of adolescence. The authors state that the substantial co-occurrence of autism and these eating disorders involves concerns in which weight and body shape are not the primary drivers. This distinction matters enormously for clinical practice. Screening tools and treatment protocols developed for body-image-driven eating disorders may be poorly suited to an autistic child who restricts intake because of texture aversion, or who eats inedible objects because of sensory seeking. Misclassification can delay appropriate care, and the review’s authors emphasize that early detection of these eating disorders may improve clinical outcome.

Rumination disorder, the third condition examined, received by far the least scientific attention. The condition involves the effortless regurgitation of recently eaten food, which may then be re-chewed, re-swallowed or spit out, and it is not explained by gastrointestinal illness or another medical condition. In the entire body of literature screened by the review team, only one study met the criteria for examining rumination disorder in autistic children and adolescents. The authors conclude that rumination disorder may still be underrecognized and understudied in autism, a gap with real consequences: chronic regurgitation can cause dental erosion, esophageal injury, weight loss and malnutrition, and the behavior is frequently mistaken for reflux or vomiting, leading to ineffective medical workups rather than behavioral treatment.

Beyond the headline findings on occurrence, the review delivers a sobering assessment of the methodological quality of the existing evidence. The included studies, the authors report, have small cohorts and lack standardized diagnostic assessment and treatment protocols. In practical terms, this means that estimates of how common pica, ARFID and rumination disorder truly are among autistic children remain imprecise, that comparisons across studies are difficult, and that no evidence-based treatment pathway has been firmly established for any of the three conditions in this population. The abbreviations listed in the article — from the Brief Autism Mealtime Behaviour Inventory to the Food Frequency Questionnaire and the Gastrointestinal Symptom Inventory for ASD — hint at the patchwork of instruments researchers have used, none of which constitutes a gold-standard diagnostic tool for these disorders in autistic youth.

The clinical pathway from recognition to treatment emerged as another weak link. Because pica, ARFID and rumination disorder sit at the intersection of pediatrics, child and adolescent psychiatry, clinical psychology and gastroenterology, autistic children with these conditions may be seen — or missed — in any of several settings. A child with pica may present first to a pediatrician with lead poisoning; a child with ARFID may be referred to an eating disorder clinic built around adolescent anorexia; a child with rumination disorder may undergo repeated gastrointestinal investigations. Without standardized diagnostic criteria applied consistently across these pathways, the review suggests, the same underlying disorder can be interpreted very differently depending on which door the family walks through first.

The research team — which also included Gro Janne Henningsen Wergeland, Ola Skjeldal, Jørn Isaksen, Mads Holten-Andersen, Vesna Bryn and senior author Maj-Britt Posserud — calls implicitly for a new generation of studies: larger cohorts, validated diagnostic instruments adapted for autistic children, and controlled trials of interventions ranging from behavioral treatment for pica and rumination to graded food exposure for ARFID. Published open access in the Journal of Eating Disorders and supported by the Innlandet Hospital Trust, the review arrives at a moment of growing scientific interest in the intersection of autism and eating behavior. Its message to clinicians and researchers alike is clear: eating disorders in autistic children are real, common enough to matter, dangerous when missed, and responsive to early detection — but the field must first build the diagnostic and therapeutic foundations that other areas of eating disorder research have long taken for granted.

Subject of Research: Co-occurring feeding and eating disorders in children and adolescents with autism spectrum disorder

Article Title: Pica, avoidant restrictive food intake disorder and rumination disorder in children and adolescents with autism spectrum disorder: A systematic review

Article References: Hodt, G., Wergeland, G. J. H., Skjeldal, O., Isaksen, J., Holten-Andersen, M., Bryn, V., & Posserud, M.-B. (2026). Pica, avoidant restrictive food intake disorder and rumination disorder in children and adolescents with autism spectrum disorder: A systematic review. Journal of Eating Disorders, 14(1), Article 226. https://doi.org/10.1186/s40337-026-01772-x

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01772-x

Keywords: autism spectrum disorder, pica, ARFID, rumination disorder, eating disorders, systematic review, children, adolescents, feeding behaviour, diagnostic assessment, early intervention, Journal of Eating Disorders