Autism Spectrum Disorder (ASD) and Childhood Obesity

• Professor Linda Bandini’s slides on The Link Between Autism and Obesity in Children
• Dr Kajsa Järvholm’s slides on the Practical Approaches for Obesity Management in Children with ASD, with additional content added

Key Takeaways

Autism and Obesity Risk Factors:

Tailored Approaches to Management:

Exploring New Treatment Options:

Next Steps and Future Research

• Train healthcare providers in managing ASD within primary care settings
• Implement ASD-friendly features, such as calm waiting areas, in obesity clinics
• Investigate the relationship between food selectivity and obesity in children with autism
• Research combining lifestyle and medical interventions for better health outcomes in obesity management

Transcripts are auto generated, if you spot an error, please email enquiries@easo.org

Welcome everyone to this monthly IASO Collaborating Centre for Obesity Management webinar. Thank you for joining us. Today we will discuss about the intersection of autism spectrum disorder and childhood obesity.

We have two excellent speakers who will provide us with some insight on the prevalence of obesity and risk factors in children with autism spectrum disorder. And also our speakers will provide us with insight on practical approaches for the management of these children living with both autism and obesity, focusing in particular on individualised care plans for personalised treatment of these patients. I’m Melania Manco, I’m a paediatric endocrinologist at the Bambino Gesù Children’s Hospital in Rome, and I’m co-chair of the IASO COMS Working Group.

And it is really a pleasure for me to introduce the first speaker who is Linda Bandini. Linda Bandini is a professor of paediatrics at the Shiver Centre at the Massachusetts Chan Medical School in the US. Professor Bandini will give us a talk on the link between autism and obesity in children.

Please, Professor Bandini, the floor is yours. As anticipated in the chat before, we will manage questions at the end of the webinar. So, I have also a few other info for our attendees.

The first one is indeed, please put your question on the Q&A section, I mean in the chat, and we will manage at the end. Also for attendees, all the material, including this webinar that is being recorded, will be available to all of you on the IASO platform. These webinars are free, and so please pay attention also to the programme, to the upcoming webinars.

And you will be invited at the end to complete an anonymous feedback form. I mean, your feedback and suggestions are really appreciated because we can improve, of course, our programme. And before moving to the second speaker, I want also to remind you that some deadlines are approaching for IASO members.

The first one is the deadline for the IASO Novo Nordisk Foundation Award. The deadline is December 16. And then also, we have a deadline for the application to the Early Career Network Best Thesis Award.

The deadline is January 12. And we also have a deadline for the abstract submission to our annual meeting, European Congress on Obesity, that this year will be in Malaga, Spain, in May 11 to 14. And now, thank you for the patience.

It is really a pleasure to introduce the second speaker, who is Professor Kajsa Harvolm, who is a clinical psychologist and associate professor at the Department of Psychology of the Lund University in Sweden. And Professor Harvolm will give us a talk on practical approaches for obesity management in children with the autism spectrum disorder. Please, Kajsa, the floor.

Thank you so much. I will start sharing my slides with you. So, do you see them correctly? Yeah, hopefully you do.

Otherwise, please let me know. Fine. Yeah, great.

Thank you. Good afternoon, everyone. It’s a pleasure to talk to you after the excellent presentation of Professor Bandini.

And I’m going to say a little bit about how we can approach obesity management in children with autism disorder. First of all, I think it’s very important to acknowledge that there is a great variation in how autism is presented. We need to think about autism as the spectrum disorder that it is.

So, when you see in the referral or in the chart that the next patient you are going to meet has an autism disorder, you cannot assume anything at all, because there is such a great variation in how autism is presented. So, you can either meet a young child with very many difficulties that it’s even hard for the parents to get the child to get in to the clinic. And you can meet adolescents with autism that you need to meet them several times before you understand that this young person might have an autism spectrum diagnosis.

So, we should not assume so much when we read about autism. We also need to consider does this patient have an intellectual impairment, language impairment, other coexisting neurodevelopmental disorder, because if the child has many different impairments, the sum is more than one plus one. So, in general, when we meet children with autism, we can ask the parents, because the parents or the caregivers, they are the ones who know the child the best.

And if we are meeting our next patient, it’s Sam, we could just ask the parents, is there anything specific we should keep in mind when meeting Sam, or how can we tailor this visit to make it as good as possible for Sam? Because then they can tell you there might be some easy small things that we can do to make the visit much more easy for the child. As always, with any patients, but even more important with children with autism, it’s important to be calm, because they are even more receptive when we are stressed, with distress. And of course, we should be friendly.

For when we meet children and adolescents with autism, we should avoid using metaphors and irony. It’s really hard for many children, not all children, but for many children with autism to understand irony or metaphors. And we can also try to use more statements and prompts, like please step on the scale instead of asking questions, would you mind stepping on the scale? Because such questions can be confusing for the child.

Can they say, yes, I mind stepping on the scale, so should they not do that then? So use more statements and prompts when talking to children with autism. Again, a diagnosis can be very helpful, but it can also make professionals feel insecure and doubt their abilities to care for the patients. And few have had any formal training in treating people with autism when they were educated.

And when we are insecure, it makes us feel less open and less flexible. And we need to be open and flexible when we meet children with autism. So a good thing can be to prepare in general at the clinic to meet children with autism, so we don’t need to invent the wheel every time we see we are supposed to meet a child with autism.

Because as Professor Bandini said, autism is rather common, and obesity is more common among children with autism. So this means that we will meet many children with obesity and autism in our clinics. And we can think in general if it’s possible to make our clinics more autism friendly.

And if we adapt our clinics to be better suited to meet children with autism, those adaptations will be beneficial for children without autism too, but it’s not necessary for those children, but many of them will also benefit from adaptations. So we can make our obesity clinics more autism friendly by using visual support, like I show here. It’s always beneficial to prepare children before the visit.

Can we send out information about the visit where we clearly structure what is going to happen during the visit? How will it start? How will it end? That can give a lot of security to the child. And some need these kind of pictures as a help, and adolescents, they might just need a written description about what is going to happen. We can also think about our clinics from a sensory sensitivity perspective.

Is it very noisy? Can we have a calm waiting room, etc.? Is it a visible, visual, busy place they are coming to? Can we do something to make the environment more calm? Sometimes we can also ask ourselves, is it necessary that the child is taken to the visit, or is it better to just meet with the parents or caretakers and have the measurements taken somewhere else that the child is more comfortable being? Like asking a school nurse to do the measurements in school and then meet the parents instead. We should always try to personalize treatment, but it’s even more important to personalize treatment when we meet children and adolescents with autism. And if we want to personalize treatment, we need to talk less ourselves and listen more to the situation of the child and the family.

And as Professor Bandini said, things that are typical for children with autism that we should consider in the treatment is that sensory information can be processed differently. Children with autism often have a preference for what is already known, and there is also a preference for what is perceived as secure. And stress and unpredictable situations can cause meltdowns, especially in younger children.

So when we meet children with autism at our clinics, there are some specific areas that we should try to cover. And as Professor Bandini told us, it’s more common to see picky or selective eating in children with autism than typically developing children. And we need to ask parents or the child about mealtime challenges.

And I chose this picture with pasta because for many of us, this is just like different versions of pasta. But if you look at it from the perspective of a child with autism, this can be completely different things. And eating one of these pastas won’t mean that you’re willing to try another one.

As I said, security is important for many children with autism and for many processed food seem more secure than raw food or uncooked food. And we could discuss with the parents whether this knowledge can be used to help to try new food. So can the food be served more cooked and processed? And I think it’s a good thing to think about, because many people say that children with autism have this tendency to eat unhealthy, but we might rather perceive it as a tendency to eat like processed food.

And could we in some way help them to process more healthy food? Many parents describe that their children with autism have what you can call neophobia. They are unwilling to try new types of food. And then it’s wanted that they learn to eat more different kinds of food.

You can use food shaming to approach new food step by step. So if you have a child liking chicken nuggets, you might be able to try to take a step to fish nuggets, et cetera. So can nuggets be like a food shaming? But also parents to children with autism say that my child eat this.

Right now, he or she is restricted to eating like five different kinds of food. And all of a sudden it can change. And then we need to have a plan.

So how to move with the child when the preferred food changes? As I said before, children with autism can be very sensitive, but they can also be under sensitive. And we need to discuss satiety with the parents or with the child. Does the child recognize when he or she is hungry, when he or she is full, or is he or she eating in the absence of hunger? And then why is he or she eating in the absence of hunger? Is it boredom, stress, anything else? We need to have a good understanding of what the eating stands for.

I found this hunger satiety scale online, which I think is a good example of a tool that can be used. And again, this is very good for children with autism. But I think this could be used for many children, not just children with autism, when you discuss satiety and hunger and learn how hunger and satiety can feel like and get more words to describe hunger and satiety.

And as Professor Bandini also said, it’s very common with behavioral problems among children with autism and also around mealtimes. And it’s important to learn what happens when the parents restrict the child and set boundaries around food. Are they expecting their child to have a meltdown? Sometimes children can have such bad meltdowns, so the parents are afraid of restricting food.

And we need to know that, because if you ask a parent to restrict a child and the parent is afraid, we don’t get a very good treatment or connection with that family. And also, as Professor Bandini said, we need to ask where the food and snacks are used to avoid behavioral problems. So is it used as a way to get out of problems? So is food used to help the child calm down, etc.? And also food and sedentary behaviors like using the computer or tablet can be the only reinforcers with real value for the child.

And then we need to discuss how should this be handled. We can’t just tell the parents that this should not be the way when it is this way. Then we need to help them navigate.

I met one family once, a boy with autism, and the only way that they could get him get out for a walk was when they said that he could get out and go to a fast food restaurant. And then we need to discuss, okay, is it better to go out and have a walk and end up in a fast food restaurant, or how should they approach this? And it’s also very important to remember that the parents can be exhausted, and we need to know more about the family. What does the family look like? Are there siblings? How are they doing? They might have special needs, too.

So the parents might have a lot on their plate. What does the support system look like? Is the child spending time at a preschool school? How can they help? And it’s a good thing to ask about the greatest. If you sense that there are struggles, then you can ask what are the greatest struggles at the moment to get a feeling whether obesity and eating is the biggest problem at the moment, or is it just a tiny problem, and there is another more major problem.

And it’s also important to know what the parents are worried about the child’s nutritional status. They might give overfeed them because they were underweight when they were younger, or they are in some way afraid that the child is not getting enough energy. And of course, the child can have too little nutrition, but still too much energy.

And as Professor Bandini said, we need to cover medications. Is the child taking any medication that increases their appetite? And also, as Professor Bandini said, physical activity. Many activities for children are social, loud, and unpredictable, and they also require motor skills.

And that are things that children with autism, they don’t tend to like social, loud, and unpredictable activities. So maybe we can start with everyday activities, make them a routine, not trying to go to a club at the beginning, but like walking to school, to the preschool, etc. And then try to find an activity tailored for children with autism.

And important things are that there is at least someone there with knowledge about autism, that they use perhaps visual support, and it’s more focused on a routine rather than novelty. Good tools to be used in the treatment is like for all children when we treat obesity, out of sight, out of mind. If the parents don’t want the child to eat something, it’s much better to not have it at home.

And in the same vein, it’s like it’s talk less, do more. So take things away that the child is not supposed to eat, and present things that you want the child to eat. And it’s of course important to work for sustainable routines in small, very small steps, and that there should be a focus on what’s predictable, and repeat a lot.

And don’t forget, don’t think that all children with autism can’t be a part of their own treatment. Of course, many of them can, and involve them as much as possible. And sometimes when you get it right, children with obesity and autism can be better at following rules than children without autism.

I think the most important things that when we meet children and adolescents and the family with obesity is that we try our best to understand the child’s perspective. When we understand the child’s perspective, we can be of much more help, and also understand the parent’s perspective. And we need to do realistic plans based on the current situation, and not the preferred situation.

Sometimes the situation is not good at all, and then we have to start there and make small, tiny steps in a better direction. We need to validate the caregivers in their struggles, and we need to involve the extended family and school. Families with children with autism need external support.

And we should also cooperate with other specialists. It’s so easy just to be in our own silo, but we need to think about, does the family need more overall support? Can we cooperate with the habilitation clinic? Many children with autism and other neurodevelopmental disorder, they have a higher risk for mental health problems. Maybe we should offer mental health assessment.

And if the child is in applied behavior analysis, we need to discuss with them, are they using food as reinforcers? Can ABA also be used to set good routines around mealtimes and eating? Yes. Thank you very much. Thank you, Kajsa.

I mean, a really amazing talk. We had really two excellent talks. We have a first question for Professor Bandini.

It’s about the prevalence also of overweight. If we consider overweight together with obesity, of course, prevalences are going to rise. Do you want to comment on this? Yes, I think if, let me just share my screen for a second, and I can, yeah.

So in this, you can see the slide on by the global prevalence. So you can see here, you’re correct. If this, the overweight is in the yellow and obesity is in the red, if you add those together, yes, the prevalence is going to be quite high in the group of children with autism.

Yeah. And what is impressive is that the prevalence of underweight, as you highlighted during your talk, parents often are afraid that children are underweight because of their selectivity, but in many cases is not as they are afraid of. Okay.

Waiting for other question. I’m wondering, and this is a question for both of you. If there is any kind of parent training also, I mean, in our hospital, we run a parent training since the beginning for parents of these children, but parent training should also involve dietary habits and strategies to cope with the selectivity.

Do you think so? I mean, it’s something that you do in your practice? No, but it would be great if we did. I think that the habilitation service in Sweden, it’s really focused on underweight and they say that obesity is not a part of what they should work with. And I think that we need to change that and also help parents with the right strategies to tackle obesity.

Colleagues ask also for a practical example, how help parents when they are afraid of behavioral change about food? How you can really help these parents to deal with the changes? Yes, again, I think it’s, you need first to analyze the situation and get a better understanding of what is happening, what is the child reacting to? And then it’s possible to see, is it possible to do small, small changes over time and start with the things that are most easy to change and prepare the child? And sometimes it’s easier to start in another environment. For example, if you want to introduce something, can the school start? It might be easier to start in school and then transfer it to the home. But I think that you have to look into the situation first and then, and most important is that you don’t suggest things to the parents that they are not able to do at home because then they will feel left.

Thanks. Sometimes it is quite hard to understand if the child is able to feel the anxiety and anger. How you can help this child to learn how to recognize the anxiety and anger? I mean, it’s really difficult.

Do you have any suggestions for clinical practice? Kajsa? As I showed you, it might be valuable to use the scale and talk to the child and show such scales. But sometimes it’s just also like that the parents or caregivers need to talk to the child and say things and use a broader range of words if it’s possible. Like you’re not hungry.

So talk about hunger when it’s supposed to be hunger, but then talk more about that you feel like eating in other times. Or if the child is eating when bored, for example, then it’s good to learn to perceive that as boredom and not as hunger. But it can be quite tricky.

Okay. Another thing that I think came clearly out from your talks, I mean both talks, is the need also to provide the training for health care providers because autism is a very prevalent condition. Do you think that this condition can be managed also in primary health care? I mean, in Italy, for instance, they are managed in the very specialized centers and this is really a problem because there are so many.

What about your experience, your country? I mean, do you have trained specialists also in primary care? Again, I think it’s important to think about autism as a spectrum disorder that a lot of children with autism can go to primary care and it works out very well. But if they have additional diagnosis and problems, you might need more specialized care and a more holistic approach. But we meet children with autism that they do as fine in obesity treatment as children without autism.

So I think it depends on how serious the problems are and if they have intellectual problems too. Again for you, Kezia, how can you discriminate neophobia from selectivity? I mean, they are different constructs, of course, but when you have a child in your clinic, do you have to ask for support from the psychologist or you can try to understand if there is some neophobia behind selectivity? Yeah, in the clinic, I think it’s not always that useful to try and figure out what is exactly selective eating and what is neophobia. They can look quite like each other, but rather try to understand what is the struggle with this child? Is it trying new things or is it that you just have a tendency to eat? So if you have a selective eating, you only eat white food, that’s quite common.

Then you need to approach that and say, okay, your child just eats white food. Is it possible to introduce other white foods to that menu? And then from that, try to learn to eat new things and eventually you can like jump to yellow food or something. But I think it’s important to accept how is it here and now and then try to make small changes over time.

Okay. So by a practical point of view, if you have a child living with severe obesity and also, I mean, this child is going to eat continuously, can you, for instance, also, I mean, hypothesize that there is some genetics in the background of these patients, for instance, a form of obesity, syndromic obesity associated with the, I mean, autism. Is that something that you do in your clinic? Go, for instance, to genetics? Yeah.

It’s, I think it’s really, it’s always important to be a team around children with obesity so they can see the professional that is most relevant to them. And I guess that if you, when you think that there might be a genetic disorder, then it’s up to the pediatrician. I think, but I think it’s also important to, not to discriminate children with autism from new treatments.

And if we look at the guidelines for obesity surgery for adolescents, at least the surgical associations, they don’t say that autism is a definite contra indication to be referred to periatric surgery. So I think it’s also important that if, to include them and offer new treatments. And I’m not putting children on medications because I’m not a physician, but I hear from colleagues that they think that children with autism are doing very well with the new anti-obesity medications.

So you suggest, I mean, to, you consider also pharmacological treatment and surgical treatment. A question to Professor Bandini, which can be a reason for different prevalences of obesity and overweight in the European population of children with obesity respect to United States is, I mean, do you have any insight about different rates that we can observe between Europe and US? Yeah, the different prevalence, the different prevalence rates among the different countries. I don’t know that the different risk factors actually.

Okay. Can be related to a different parent training, a different social support to parents? Likely all of those things are among different countries and there are different approaches. There are some parent training programs I know of that are used in the US, but there is a need for so much more to meet the needs of all these kids that are food selective.

Thank you. The last question before we end, because we have still two minutes left, is from Eva Larsson. Any tips on how to involve the child with autism to set treatment goals again for Keisha, I guess? Yes.

Thank you. I think it’s, you can use a lot of support, like if you want the child to try or adolescent to try new vegetables, for example, you can use like pictures of different vegetables and say, so which is the next one you want to learn and try and involve them so they can choose. And I think it’s important always just to involve the children in behavioral treatment goals that they can actually achieve by themselves, like not setting a goal about how much weight should they lose or not increase.

So try something new for physical activity, for example. So what would they be most interested in trying and what is important to them when they try it and what is the next step? Do they think that they would like to try something new or what do they think is most helpful? And it’s always, of course, like at what kind of level you can talk about it. But I think you should always try to involve the child in one way or another, but you can also check with the parents.

So I would like to involve this child in setting a goal. Do you think it would be a good thing to do? And then the parents can say, no, I think it will fly over his or her head or they can say yes. So just one final anecdote.

We had this family coming to our clinic and at the end, the mother said to the nurse, it was such a good thing to come here because you talked to my children like they were usual children or how to express that. But she said that when people read that my children have autism, they get so hesitant to talk to them. And I think it’s as important to talk and listen to children with autism as it is to every child.

Thank you. Well, I thank you, both of you, Professor Linda Bandini and Professor Cassia Jarmusch. I mean, really excellent, excellent talks.

And I thank you all the attendees for taking part to this event. And I remind you that these are monthly events and our activity is not limited to webinars, but includes a lot of activities. So please follow us on socials and take a look at our website.

I thank you for, I thank you again, the speakers and all of you for having attended this event. So see you next time.