Ownership and Apology: The Reality of Neurodivergence in Eating Disorder Care
I recently attended the International Conference on Eating Disorders (ICED), an annual interdisciplinary conference that brings together attendees from around the world.
I never attended my high school prom, and I jokingly think of ICED as my yearly prom because it is both fun and exhausting. Additionally, I get to wear cute outfits and see colleagues in person rather than on a screen. The conference brings together many of the field’s leading voices — the people who conduct the research and write the treatment manuals — so yes, I nerd out. By the end of the conference, I am usually overstimulated and worn out, and I often leave early.
This year, however, I stayed for the final session, which was the sociocultural plenary. The talk featured several prominent clinicians, and the topic was on the intersection of eating disorders (EDs) and neurodivergence.
Why Are We Talking About This?
EDs and neurodivergence are developing areas of study in the ED field. Autistic people and those with attention-deficit hyperactivity disorder (ADHD) are more likely than those without neurodivergence to develop an ED. About one in three people with anorexia nervosa (AN) are autistic, as are one in every two people with a diagnosis of Avoidant Restrictive Food Intake Disorder (ARFID) diagnosis.
A recent meta-analysis on autism and AN support this, showing that AN frequently overlaps with both autistic traits and autistic symptomatology1. Strikingly, the study showed that approximately 22-23% of people with EDs show comorbid autism spectrum features, with one research group estimating that around 35% of people with an ED may be autistic or show high levels of autistic traits — significantly above the 1% autism prevalence in the general population2.
My colleagues who work in developmental medicine often see children with picky eating presentations or ARFID. They seem to recognize and understand the overlap between autism and ARFID, which is estimated to be about 16% across ARFID groups, and an ARFID prevalence of about 11% across autistic groups3. But things aren’t always so clear cut.
Rigid Categories Versus Real-World Clinical Presentations
There are evidence-based models to treat these individuals that include interventions from occupational and behavioral therapy. Additionally, many pediatric hospitals have feeding clinics that specialize in these types of feeding and eating challenges that occur in younger children with neurodevelopmental diagnoses.
According to the DSM-5 criteria, there is no body image disturbance with ARFID, making the diagnostic criterion different from other EDs. And yet, what we are currently seeing in my clinic is an overlap of individuals with ARFID type presentations who do have body image disturbances.We also see autistic individuals presenting with restrictive eating, as well as clients who exhibit behaviors of ARFID, AN, and autism.
The DSM-5 treats these conditions as mutually exclusive, leaving clinicians without a clear diagnostic framework for these complex cases. I often worry that I am missing the mark or failing to support clients who fall outside these rigid boxes—which is precisely why attending this presentation was so critical.
Eating Disorder Behaviors? Or Traits of Neurodivergent Individuals…
All the talks in the plenary were excellent, as was the moderator. However, it was the second talk — titled “Integrating Neurodivergence into Eating Disorder Frameworks” — that hit me with a gut punch. Dr. Laurence Cobbaert (she/they) from the University of New South Wales discussed how neurodivergent individuals experience EDs, presenting from the perspective of their lived experience with both neurodivergence and an ED.
Some of the things highlighted in the talk were:
● Sensory processing differences experienced by neurodivergent individuals.
● The presence of alexithymia (difficulty identifying feelings).
● The challenges with executive functioning.
● The use of food restriction as a form of masking to gain social acceptance.
● Autistic people may prefer eating the same specific foods because familiar “safe” foods can support self-regulation; a similar “hyperfixation” on certain foods may also occur in people with ADHD.
Dr. Cobbaert also explained that these processing and cognition differences can make it harder to remember to eat, while executive functioning challenges may create difficulties with deciding what to eat, getting ingredients, and preparing meals.
Listening to her map out these experiences, a sense of shame began to settle in as I realized exactly where the presentation was heading.
The Best Treatment Is the One That Fits the Person
Research indicates that most mental health interventions are not tailored to the needs of autistic adults but tailored to the needs of neurotypical individuals4. Dr. Cobbaert discussed how ED treatment failed them and often failed others like them.
She spoke to her difficulty in navigating treatment and her invalidating treatment experiences. She noted that no one had ever apologized to her for the way she was treated, and the way the system failed her. Dr. Cobbaert did not find the treatment helpful; in fact, they found it harmful.
I have worked in several residential treatment centers over the years, and in my experience — sadly — we did not offer individualized treatment for those with neurodiversity. In fact, we did not even assess ADHD or autism, and it wasn’t factored into a care plan at all unless someone came to us with the existing diagnosis. At most, we sometimes would tailor treatment for someone with severe trauma or OCD; however, this was not customary as the focus was typically on managing the milieu.
Although treatment is changing and clinicians today are more aware of individual differences, this has not always been the case. It sounds — and is — awful. Although I can speak only from my own experience and not for every treatment center, conversations with colleagues suggest that my experience was fairly typical.
I clearly remember an interaction with a client in a higher level of care program where I worked that illustrates this. I had prompted a male client to stop mixing jelly in his yogurt because it was deemed to be a “condiment”, and the rule was that it was not to be used for this purpose. His response was that it was not an ED behavior but a taste preference. He became upset over my re-direction and my reasoning and ended up leaving the table. Instead of listening, considering his history outside of the ED, and perhaps validating how difficult it must have been to be the only male in a program full of women — as was often the case at the time (over 20 years ago) - I chose to focus on the yogurt.
I wish I could have re-do. Because maybe it was not an ED behavior, but a safe food that was self-regulating. And maybe individuals who were deemed ‘resistant’ to the treatment were simply misunderstood and being asked to participate in a treatment that did not understand their needs and differences. I don’t know, because I did not ask. At the time, the established approach was that we did not ask those questions, and even if we had tried, most of us did not yet know how to ask them effectively.
Looking back, I can think of several people who likely met criteria for neurodivergence. And in our efforts to help them, we may still have been missing what they needed most.
Changing the Way We Treat Eating Disorders
To bring us back to the ICED conference, Dr. Cobbaert has also co-authored an excellent call to action with Anna Rose (née Millichamp), on behalf of Eating Disorders Neurodiversity Australia (EDNA): Eating Disorders and Neurodivergence: A Stepped Care Approach. Their central message is that effective eating disorder treatment must be neurodiversity-affirming rather than one-size-fits-all. By educating stakeholders to recognize how autism, ADHD, and other neurodevelopmental differences influence eating behaviors, they believe that clinicians can provide more accessible, compassionate, and effective care. Rather than expecting all patients to fit traditional treatment models, the authors advocate for flexible, individualized care delivered through a stepped care framework, where treatment intensity matches the person's current needs. It is an excellent, comprehensive report.
The discussant for the conference talk was Dr. Kate Tchanturia, another leader advancing this work, and an esteemed professor, researcher, and psychologist at King's College London. Under her leadership, the Pathway for Eating Disorders and Autism developed from Clinical Experience2 (The PEACE Pathway) has become a London-based clinical and research initiative and an international leader in adapting ED treatment for autistic and neurodivergent populations. The PEACE Pathway has helped shift ED care from a "one-size-fits-all" model toward personalized, neurodiversity-affirming treatment. By integrating research, clinical innovation, and lived experience, PEACE has become one of the leading models in the world for improving outcomes for neurodivergent people with EDs. 2
The great news is times have changed, thanks to the excellent work of dedicated clinicians, researchers, and those with lived experience like Dr. Cobbaert and so many others. It is my hope that their work will be disseminated to those who run and create programming for treatment centers in the United States.
First Do No Harm
Finally, to Dr. Cobbaert. I know you did not receive an apology when you deserved it. Please accept a heartfelt apology from me. I am sorry you suffered and that you were not treated with the care, dignity, compassion, and skill you needed during one of the most vulnerable times in your life.
To the young man I carelessly invalidated when he was seeking treatment, I am so sorry for not understanding, or for taking the small step of simply asking about the function of your behavior.
To anyone else I may have encountered over the years where I missed the mark (and your neurodiversity) by talking more than I listened, I am genuinely sorry.
We cannot change the care people received in the past, but we can acknowledge where we fell short, listen with greater humility, and continue building a system that is responsive to the people it is meant to serve.
Citations
Inal-Kaleli, I., Dogan, N., Kose, S. and Bora, E. (2025), Investigating the Presence of Autistic Traits and Prevalence of Autism Spectrum Disorder Symptoms in Anorexia Nervosa: A Systematic Review and Meta-Analysis. Int J Eat Disord, 58: 66-90. https://doi.org/10.1002/eat.24307
About PEACE." PEACE Pathway, https://peacepathway.org/about-peace. Accessed 12 July 2026.
Koomar T, Thomas TR, Pottschmidt NR, Lutter M, Michaelson JJ. Estimating the Prevalence and Genetic Risk Mechanisms of ARFID in a Large Autism Cohort. Front Psychiatry. 2021 Jun 9;12:668297. doi: 10.3389/fpsyt.2021.668297. PMID: 34177659; PMCID: PMC8221394.
Curnow E, Rutherford M, Maciver D, Johnston L, Prior S, Boilson M, et al. (2023) Mental health in autistic adults: A rapid review of prevalence of psychiatric disorders and umbrella review of the effectiveness of interventions within a neurodiversity informed perspective. PLoS ONE 18(7): e0288275. https://doi.org/10.1371/journal.pone.0288275.
Rose, A., & Cobbaert, L. (2023). Eating disorders and neurodivergence: A stepped care approach. National Eating Disorders Collaboration. https://nedc.com.au/eating-disorders/types/neurodivergence