Jo Li, Project Manager at PEACE Pathway and Professor Kate Tchanturia, both from Kings College London, discuss how to support autistic people with eating disorders

Research suggests that an estimated 23% of patients with anorexia nervosa (AN) are also autistic (Westwood and Tchanturia 2017; Wentz et al 2005; Anckarsäter et al 2012).

However, autism is often overlooked in standard eating disorder treatment programmes. This makes recovery more complex and challenging for these patients, who tend to benefit less in treatment programmes, with poorer outcomes, heightened presentation, and longer in-patient admissions.

The PEACE (Pathway for Eating disorders and Autism developed from Clinical Experience) project has developed a range of resources and treatment recommendations for autistic people with eating disorders, since it began in 2019.  PEACE pathway is led by Professor Kate Tchanturia and her research and clinical team at King’s College London, in partnership with the South London and Maudsley NHS Foundation Trust. 

Screening

One practical and helpful way to identify those who would benefit from adapted treatment, is to assess for autistic characteristics. Therefore, a screening process on admission was set up as part of the pathway. All admissions receive an initial screening using the Short (10-Item) Version Autism Spectrum Quotient (AQ-10) (Allison et al. 2021), which assesses autistic characteristics. Patients who score above clinical cut-off on the AQ-10 immediately have access to all PEACE pathway psychoeducation resources and adapted therapies. 

Where appropriate, they were also followed up with the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2) (Lord 2012) which provides a more in-depth assessment of autistic characteristics. The results provide valuable information for clinicians to consider when creating individualised treatment plans for autistic patients. The PEACE team is aware of the limitations of screening with these brief measures, but receiving a full autism diagnostic assessment is a lengthy process, with long waiting lists in specialist services and a lack of resources and training.

Adaptations to sessions

Therapeutic interventions can be a very overwhelming experience for patients, especially those who are autistic. The team has found that having a flexible approach, such as adapting the length and pace of sessions, can have a significant effect on the outcome. Patients who find it difficult to process information can really benefit from slightly longer sessions that include visuals, with regular short breaks. 

Autistic people can find motivational interview techniques and cognitive behavioural therapy (CBT) extremely challenging. These therapies use open-ended questions and metaphors which are intended to probe exploration and allow flexibility in responses. For autistic people this approach can be much more difficult (Spain et al. 2015). The PEACE team avoids using motivational interviewing in favour of simple, concrete and literal language. 

PEACE have also introduced a communication passport, a document completed by the patient to identify their sensory differences and preferred means of communication. This information helps the team provide more individualised support, and makes it easier to build rapport with the patient. 

Dietary needs

Eating difficulties are not only central to eating disorders, but are commonly seen in autistic people without a formal diagnosis of eating disorder - they are often linked to sensory sensitivities. Autistic people with co-existing eating disorders may experience more complex needs and nutritional needs that call for a more individualised dietary plan. 

An alternative PEACE menu was therefore introduced to all patients, in addition to the standard menu in the national clinical service at South London and Maudsley. The PEACE menu was designed with sensory sensitivities in mind, consisting of items with low sensory stimulation:

• bland flavour
• low odour
• neutral colour
• similar textures.

As far as possible, foods that would be very consistent and predictable were used, for example pre-packaged items. Photographs of the meals as served were also provided on the menu, to be predictable and thus less anxiety-provoking for autistic patients. All patients are given the choice between standard and alternative menus.

Environmental adaptations

The PEACE pathway introduced changes to the ward environment to address potential sensory differences in patients with autistic characteristics. Experts from the National Autistic Society were invited for advice on building an autism-friendly environment.

• Dining room was decluttered and redecorated to create a more calm, relaxing space. 
• Walls were repainted with pale neutral colours. 
• Soft furnishings were then chosen to match the colour scheme. 
• Sensory soothing aids were made available to all patients. 
• Wellbeing workshops were also introduced to enhance social communication and sensory wellbeing.

Community

PEACE Pathway has developed a support network where resources, tips and knowledge can be shared. The aim was to create a community that supports autistic people with eating disorders, their family/carers’ and clinicians.

Carers’ workshops and coffee mornings were also held regularly by clinicians of the PEACE team throughout the pandemic. These provided psychoeducation and peer support for carers of autistic people with eating disorders. 

Further information

Stay up to date by following the PEACE pathway on X @PEACE_Pathway
Find helpful resources on our website.
For more information on the PEACE approach, please read Tchanturia, K. (Ed). (2021) Supporting Autistic People with Eating Disorders: A Guide to Adapting Treatment and Supporting Recovery. Jessica Kingsley Publishers