Food selectivity in children and

adolescents with autism spectrum

disorders – a systematic literature review
REVIEW ARTICLE

MARIANNE MØRDRE
[email protected]
Division of Mental Health and Addiction
Oslo University Hospital
Author contribution: idea, review and selection of literature, interpretation of
data, writing and revising the manuscript and approval of the submitted version.
Marianne Mørdre, PhD, child and adolescent psychiatrist and senior consultant.
The author has completed the ICMJE form and declares no conflicts of interest.

BEATE ØRBECK
Division of Mental Health and Addiction
Oslo University Hospital
Author contribution: literature review, interpretation of data, writing and
revising the manuscript and approval of the submitted version.
Beate Ørbeck, PhD, specialist psychologist and researcher.
The author has completed the ICMJE form and declares no conflicts of interest.

R AGNHILD ELISABE T HOEL

Division of Mental Health and Addiction
Oslo University Hospital
Author contribution: interpretation of data, revising the manuscript and approval
of the submitted version.
Ragnhild Elisabet Hoel, specialty registrar and PhD student.
The author has completed the ICMJE form and declares no conflicts of interest.

KRISTIN ROMVIG ØVERGA ARD

Division of Mental Health and Addiction
Oslo University Hospital

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
Author contribution: idea, review and selection of literature, interpretation of
data, writing and revising the manuscript and approval of the submitted version.
Kristin Romvig Øvergaard, PhD, child and adolescent psychiatrist and
researcher.
The author has completed the ICMJE form and declares no conflicts of interest.

Background
Autism spectrum disorders involve problems with social communication and
interaction as well as restricted, repetitive patterns of behaviour and interests.
Food selectivity is common among individuals with autism spectrum disorders
when their average intellectual ability is below the normal range. This literature
review examines the degree to which the same applies for children and
adolescents with an intellectual ability level in the normal range.

Knowledge base
We undertook searches in the MEDLINE and PsycInfo (Ovid) databases until
June 2024 for original papers on the prevalence, characteristics and somatic
consequences of food selectivity in autism spectrum disorders. We restricted our
searches to studies that included individuals with an intellectual ability in the
normal range and/or an autism spectrum disorder for which this is a
prerequisite, and with an average age of 6–18 years. The GRADE system was
used to rate the quality of the studies. We gave emphasis to consistency between
findings, the number of studies and their sizes.

Results
The inclusion criteria were met by 20 studies. There was a high prevalence (21–
76 %) of food selectivity in those with autism spectrum disorders and an
intellectual ability level in the normal range. Sensory sensitivity to food texture
and taste were key characteristics (approximately 2–10 times more frequent in
children with autism spectrum disorders than in control individuals). While the
intellectual ability level was of little importance, autism symptoms were of
some significance in respect of the prevalence of food selectivity patterns. The
somatic consequences tended to be obstipation and overweight/obesity. Our
level of confidence in the studies varied from high (prevalence) to low (somatic
consequences).

Interpretation
Food selectivity patterns should be surveyed whenever individuals are examined
for autism spectrum disorders, irrespective of their intellectual ability level.

Main findings

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
We found a high prevalence of food selectivity in children and adolescents with
autism spectrum disorders and an intellectual ability level in the normal range.
Sensitivity particularly to food textures and taste, and a high degree of autism
symptoms, were of significance to the prevalence and characteristics of the food
selectivity patterns.
Individuals with autism spectrum disorders present with persistent difficulties
with social communication and interaction as well as restricted, repetitive
patterns of behaviour and interests (1). The international diagnostic
classification standard ICD-10 splits the condition into subtypes (childhood
autism, Asperger syndrome, atypical and unspecified) based on the time of
debut, symptoms and whether there is delayed language and cognitive
development (intellectual ability level). Asperger syndrome is used when the
child's language and intellectual ability is normal (intelligence quotient (IQ)
≥ 70). In Norway, those whose intellectual ability level is assumed to be in the
normal range tend to be assessed by the Child and Adolescent Mental Health
Services.
Food selectivity includes refusing food intake, fear of new foods (neophobia), a
strong preference for certain types of food and/or a severely restricted food
repertoire (2). Such eating patterns can have a serious impact on children's
somatic health (3). Food selectivity is not a formal diagnosis; the literature
provides a variety of slightly different definitions as symptoms are measured in
different ways. Nevertheless, the severity of these symptoms has been
recognised in the US diagnostic system (DSM-5) through the diagnosis
'Avoidant/Restrictive Food Intake Disorder' (ARFID) (4). The ARFID criteria
requires the restrictive eating patterns to have growth-related, nutritional and
psychosocial consequences, without a desire to lose weight.
Seven studies were identified in the first review article on food selectivity in
children and adolescents with autism spectrum disorders, and a high prevalence
(46–89 %) was established (5). The considerable variation can be explained in
part by the fact that the studies measured eating patterns in different ways
(questionnaires, direct observation of the child, and eating difficulties as a
reason for referral). One meta-analysis reported a prevalence that was
approximately five times higher in children with autism spectrum disorders than
in the general child population (2). However, the prevalence was assessed for all
diagnostic subgroups combined.
The last ten years have seen increasing interest in food selectivity in children
and adolescents with autism spectrum disorders, and several review articles
have recently been published (6–8). One of these summarised findings from 56
original papers and concluded that food selectivity patterns similar to those used
in the DSM-5 diagnostic criteria occur frequently in children and adolescents
with autism spectrum disorders (6).

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
The eating patterns were particularly associated with sensory sensitivity (hyper
and hypo sensitivity to food textures and taste, etc.), but also neophobia and a
lack of interest in food. Included in the review were 38 separate case studies of
severe avoidant restrictive food intake disorders that had considerable somatic
consequences in the form of low weight/weight loss, impaired growth or
development, and deficiencies (anaemia, rickets), but also overweight due to an
intake of high-energy foods only (6).
Two review articles that primarily investigated the characteristics of food
selectivity, but that did not require the ARFID criteria to be met, found an
association between sensory sensitivity and food selectivity (7, 8). Only one of
them (8) reported on somatic consequences, and these were less severe
(primarily obstipation and weight impact) than those described in the review
article about avoidant/ restrictive food intake disorder (6). All the review
articles included studies of heterogenous autism groups (which meant large
variation in intellectual ability levels), and all the articles included pre-school
children, who at group level have proved to display clearer autism symptoms (as
in childhood autism) and a lower intellectual ability level (9). The broad
inclusion obscures whether the findings apply equally to those with an
intellectual ability level in the normal range (like for Asperger syndrome).
This systematic review article maps the prevalence, characteristics and somatic
consequences of food selectivity in children and adolescents with autism
spectrum disorders, focusing on those with an intellectual ability level in the
normal range.

Knowledge base

The MEDLINE and PsycInfo (Ovid) databases were searched until the end of
June 2024. We used the databases' own subject headings (Medical Subject
Headings, MeSH) as well as various variants and combinations of truncated (*)
search terms and proximity operators (ADJ) (for detailed information on search
strings, see Table 1 and Appendix 1). We included original papers, including
case studies, that examined the prevalence, characteristics and/or somatic
consequences of food selectivity in children and adolescents with autism
spectrum disorders and that involved participants with an intellectual ability
level in the normal range and with a mean age of 6–18 years. The inclusion and
exclusion criteria are described in more detail in Table 1 (see also Appendix 2).

Table 1

The search terms, inclusion criteria and exclusion criteria of our literature review.

Population Autism spectrum disorder OR asperger OR PDD-NOS OR autism OR

autistic OR ASD OR highfunctioning autism OR high-functioning ASD

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
 Definition of eating Avoidant/restrictive food intake disorder OR ARFID OR restrictive
patterns eating OR restrictive intake disorder OR neophobia OR select eating
OR picky eating

Age Child OR adolescent OR youth OR young OR juvenile OR teenage OR

teen-age

Period Until the end of June 2024 (going as far back as possible)

Inclusion criteria Original papers (including case studies) in English on the prevalence,
characteristics and/or consequences of food selectivity (broadly
defined: eating a small selection of foods/or refusing to taste new
foods (neophobia) and ARFID (avoidant/restrictive food intake
disorder) in children and adolescents with autism spectrum disorders,
involving participants with an intellectual ability level in the normal
range and/or with Asperger syndrome, not limited to young children
(mean age 6–18 years)

Exclusion criteria Articles that do not discuss the prevalence or characteristics or

consequences of food selectivity in autism spectrum disorders and an
intellectual ability level in the normal range, or that are generally
restricted to young children (mean age < 6 years)

The articles' relevance was assessed independently by two of the authors (MM
and KRØ) based on their title and abstract; any disagreement was resolved by
consensus. Out of 503 articles, full-text versions of 96 were read by both
authors; 20 were included in the literature review (Figure 1). In order to rank the
included studies, one author (BØ) applied the GRADE system's four confidence
ratings: very low, low, moderate and high (10). These were then considered by a
different author (KRØ), and any ranking disagreement was resolved by
consensus. For our descriptive study, which is not suitable for calculating effect
sizes, we opted to assess consistency between findings, the number of studies
and their size.

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
Figure 1 Flow chart of our literature review's inclusion and exclusion process.

Results

We identified a total of 20 articles (Table 2) (11–30), of which twelve specified

prevalence. The others included only other findings (characteristics and somatic
consequences).

Table 2

Included studies on food selectivity in autism spectrum disorders (ASD). Studies that specified
prevalence are highlighted in bold, case studies are highlighted in italics. ARFID =
Avoidant/Restrictive Food Intake Disorder.

Design and
participants.
Number (n),
age and Prevalence of food selectivity (%)
Studies, intellectual and other study findings
year of ability level Food selectivity (characteristics and somatic
publication (IQ) measure consequences)

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
 Design and
participants.
Number (n),
age and Prevalence of food selectivity (%)
Studies, intellectual and other study findings
year of ability level Food selectivity (characteristics and somatic
publication (IQ) measure consequences)
Bandini, 2010 Clinical study, The Food Refusal of certain types of food in 42 %
(16) N = 53 ASD + frequency of ASD individuals versus 19 % in control
58 control questionnaire individuals.
individuals (FFQ) and
Mean age 7 food diary
years
Mean IQ > 70

Bandini, 2017 Clinical The FFQ & the 47 % at 7 years and 31 % at 13 years.
(27) progress Meals in Our
study, Household
N = 18 with Questionnaire
ASD Mean (MIOH)
age 7 and 13
years
respectively
at two
different
times
Mean IQ > 70

Chistol, 2018 Clinical study, FFQ & The Sensory Atypical oral sensitivity that was also
(21) N = 53 ASD + Profile associated with food selectivity was
58 control displayed by 64 % in ASD individuals
individuals versus 7 % in control individuals.
Mean age 7
years
Mean IQ > 70

Dominick, Clinical study, The Atypical 76 % in ASD individuals versus 15 % in

2007 N = 67 ASD + Behavior individuals with language impairments.
(14) 39 with Patterns Non-verbal IQ was lower among those
language Questionnaire with food selectivity (87 versus 92).
impairments (ABPQ)
Mean age 7
years
Mean IQ > 80

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
 Design and
participants.
Number (n),
age and Prevalence of food selectivity (%)
Studies, intellectual and other study findings
year of ability level Food selectivity (characteristics and somatic
publication (IQ) measure consequences)
Harris, 2021 Population The Stanford Prevalence not specified but saw an
(25) study, N = Feeding association between autistic traits and
2 818, of Questionnaire obstipation and found that food
whom 39 selectivity mediates this.
score over the
ASD symptom
threshold
Mean age 6
and 10 years
respectively
at two
different
times. Mean
of whole
population
non-verbal IQ
= 105

Hubbard, Clinical study, FFQ and interview

2014 N = 53 ASD + questions (food
(18) 58 control texture, mixing of 36 % of ASD individuals versus 16 % of
individuals foods, control individuals had > 3 of 7
Mean age 7 temperature, investigated problems associated with
years separating foods, food characteristics.
Mean IQ > 70 colour, brand and Food selectivity was associated with
shape) sensory sensitivity.

Kamal Nor, Clinical study, Brief Autism Assessed the consequence of ASD:
2019 N= Mealtime Obesity 11 % and overweight 22 %.
(26) 151 ASD Behavior Inventory Found association with food selectivity.
Median age 7 (BAMBI)
years
3 % with IQ <
70

Kazek, 2021 Clinical study, The Child's Current 63 % in ASD individuals versus 26 % in
(12) N = 41 ASD + Nutritional Status, control individuals. Food selectivity was
34 control 20 associated with sensory sensitivity.
individuals Questions
Median age 7
years
IQ > 70 (all
with an IQ <
70 were
excluded)

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
 Design and
participants.
Number (n),
age and Prevalence of food selectivity (%)
Studies, intellectual and other study findings
year of ability level Food selectivity (characteristics and somatic
publication (IQ) measure consequences)
Calisan- Clinical study, Child Eating Prevalence not specified but association
Kinter, 2024 N = 37 ASD Behavior found between food selectivity and ASD
(22) with ARFID, 37 Questionnaire symptoms, lower intellectual ability
without ARFID (CEBQ) level and increased sensory sensitivity.
+ 37 control
individuals
Median alder
6 years IQ =
80 (with
ARFID) and
100 (without
ARFID)

Koomar, 2021 Population Nine-item ARFID 21 % diagnosed with ARFID.

(11) study, Screen (NIAS) and Food selectivity was associated with
ASD cohort, N additional sensory sensitivity, ASD symptoms and
= questions about obstipation.
5 157 food selectivity
Mean age 11
years
17 % with IQ <
70

Kuschner, Clinical study, The self-report 57 % neophobia in ASD individuals

2015 N = 65 ASD + Adult/ versus 32 % in control individuals Food
(15) 59 control Adolescent selectivity was associated with sensory
individuals Sensory sensitivity.
Mean age 16 Profile (AASP)
years
All
participants
with
IQ > 75

Mayes, 2019 Clinical study, Checklist for 70 % in ASD individuals, 13 % in

(13) N = 1 462 ASD Autism individuals with other diagnoses and
+ 327 with Spectrum Disorder 5 % in control individuals.
other (CASD) Food selectivity was associated with
diagnoses + sensory sensitivity, but no difference in
313 control food selectivity
individuals at IQs in and below the normal range.
Mean age 7
years
70 % with IQ
> 80

Nadon, 2011 Clinical study, N The Eating Prevalence not specified, found
(19) = 95 ASD Profile & The association between food selectivity
Mean age 7 years Short Sensory and sensory sensitivity, but not
23 % with IQ < 70 Profile intellectual ability level.
(SSP)

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
 Design and
participants.
Number (n),
age and Prevalence of food selectivity (%)
Studies, intellectual and other study findings
year of ability level Food selectivity (characteristics and somatic
publication (IQ) measure consequences)
Planerova, Case study, boy Clinical Consequence: Severe vitamin C
2017 with Asperger interview deficiency
(28) syndrome
Age 10 years
IQ not specified

Postorino, Clinical study, N The revised FFQ 50 % had food selectivity.

2015 = 158 ASD, of Lower non-verbal IQ among those with
(20) whom 79 with food selectivity.
food selectivity Food selectivity was associated with
Mean age 7 years sensory sensitivity and a higher ASD
Non-verbal IQ = symptom score.
87 and 99,
respectively for
those with and
without food
selectivity

Rajendram, Case study, boy Clinical Consequence: Severe malnutrition

2021 Age 14 years interview
(30) IQ > 100

Roth, 2010 Case study, boy Clinical Consequence: Severe malnutrition

(29) with Asperger interview
syndrome
Age 16 years
IQ not specified

Valicenti- Clinical study, N Childhood 60 % in ASD individuals, 36 % in

McDermott, = 50 ASD + 50 Autism individuals with other development
2006 with other Rating Scale disorders and 33 % in control
(17) diagnoses + 50 (CARS) individuals.
control & No difference in the prevalence of food
individuals Gastrointestinal selectivity in those with an IQ in or
Mean age 8 Questionnaire below the normal range.
years
40 % with IQ > 70

Van't Hof, Population- Children's Prevalence not specified, but ASD

2020 (24) based cohort Eating symptom scores at 6 years of age were
study, N = Behaviour associated with later food selectivity.
3 559 Questionnaire
Mean age 10 (CEBQ)
years
Median non-
verbal
IQ = 102

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
 Design and
participants.
Number (n),
age and Prevalence of food selectivity (%)
Studies, intellectual and other study findings
year of ability level Food selectivity (characteristics and somatic
publication (IQ) measure consequences)
Zickgraf, 2018 Clinical study, N Checklist for Food selectivity in 71 % of ASD
(23) = Autism individuals
1 112 Spectrum No difference in intellectual ability level
Mean age 6 Disorder between those with and without food
years (CASD) selectivity.
70 % with IQ > 80 ASD symptom scores were associated
with food selectivity. Obstipation
occurred more frequently among those
with food selectivity.

Prevalence
While there was a considerable spread in prevalence rates for food selectivity in
those with autism spectrum disorders, from 21 % to 76 %, these rates were
consistently higher than in the control individuals in the respective studies. A
large questionnaire-based cohort study (N = 5 157, mean age 11 years) showed a
relatively low prevalence (21 %), which may have been caused by the authors'
use of ARFID criteria (11). This study showed that avoidant/restrictive food
intake disorder occurred similarly when a majority (83 %) of the sample had an
intellectual ability level in the normal range, but the study did not correct for
intellectual ability level.
Seven studies compared the prevalence of food selectivity in children and
adolescents with autism spectrum disorders to the prevalence in control
individuals (12–18). These studies reported that food selectivity was displayed
by 42–76 % of the children with autism spectrum disorders compared to 5–33 %
of the control individuals (Table 2). One of these studies asked young people
between 12–28 years of age to self-report on a few questions. The results
indicated that those with autism spectrum disorders and an intellectual ability
level in the normal range (IQ > 75) (n = 65) suffered from neophobia and food
selectivity more frequently than the control individuals (n = 59) (15). Another
study that similarly asked a few specific questions showed that 70 % of those
with autism spectrum disorders (n = 1 462, of which 70 % had IQ > 80)
declared that they had food selectivity, compared to 5 % of the control
individuals (13). There was a high proportion of boys (68–92 %) in all the
above-mentioned study populations. Overall, we had high confidence in this
finding due to consistency in the reported high prevalence of food selectivity in
individuals with autism spectrum disorders and an intellectual ability level in
the normal range.

Sensory sensitivity
Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
A total of eight studies explained food selectivity by pointing to a high level of
sensory sensitivity in children with autism spectrum disorders and intellectual
abilities in the normal range (11–13, 15, 18–21). Several studies related sensory
sensitivity to food textures, but in the above-mentioned large cohort study,
sensitivity to taste was the clearest cause of avoidant/restrictive food intake
disorder (11). Two studies compared children with autism spectrum disorders
with and without food selectivity. One of them found that sensitivity to textures,
smell/taste and visual/auditive impressions was associated with food selectivity,
but a majority of the children in this study had childhood autism (61 % of 95
children), although 67 % had an intellectual ability level in the normal range
(19). The average intellectual ability level of participants in the other study was
in the normal range, and here it was found that 68 % of those with food
selectivity were sensitive to the texture of food, approximately half (53 %) to
taste, while fewer were sensitive to other factors (such as colour, shape, smell)
(20).
In five studies, children with autism spectrum disorders were compared to
control individuals without this condition (12, 13, 15, 18, 22). It was found that
sensory sensitivity to the texture and taste of food was a key characteristic
(approximately 2–10 times more frequent in the children with autism spectrum
disorders than in the control individuals). Two of the studies included only
children and adolescents with autism spectrum disorders and an intellectual
ability level in the normal range (12, 15). Both studies reported that sensitivity
to texture was a cause of food selectivity, but one of them also found that
neophobia and sensitivity to taste were key (15). One study compared a group
of children with an average intellectual ability level in the lower parts of the
normal range to control individuals. This study also showed that sensitivity to
texture was the most common cause of food selectivity among those with
autism spectrum disorders, but this was also frequently reported by the control
individuals (77 % versus 36 %, with a standardised questionnaire) (18).
Other reasons for sensory sensitivity in the five studies were related to 'the
mixing of foods', which was common both among those with autism spectrum
disorders and the control individuals (45 % versus 26 %). The question 'does the
child avoid the taste and smell of certain types of food' clearly distinguished
between the groups. This was rarely reported among the control individuals
(5 %), while it was present in nearly half of those with autism spectrum
disorders (49 %).
A large study (n = 1 462 with autism spectrum disorders, 70 % IQ > 80) showed
that restricted food preferences was the most common trait (88 %) (13). This
was followed by sensitivity to texture (47 %), but more niche phenomena also
occurred, like eating only one brand of particular foods (31 %), hiding food in
the mouth without swallowing (20 %) and an urge to eat non-digestible
substances (pica). One weakness of this study was that only five questions about
food selectivity were included and that no questions were asked about
sensitivity to smell and taste.

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
A study of children with autism spectrum disorders from 2024 found that those
who also had avoidant restrictive food intake disorder had significantly higher
sensory sensitivity (visual, auditive, tactile and oral) than those who did not
(22).
It proved challenging to find studies that only examined children with an
intellectual ability level in the normal range. As this reduced the number of
studies included, our confidence in these findings were rated as moderate.

Intellectual ability level

In general, food selectivity does not appear to be explained by intellectual
ability level (13, 14, 17, 19, 20, 23). Intellectual ability levels were found to be
equally good in children with autism spectrum disorders whether they displayed
food selectivity (n = 784) or not (n = 328) (IQ 91 versus 92) (23). There was
also no significant difference found when comparing the prevalence of food
selectivity in those with an intellectual ability level in the normal range with
those with an intellectual ability level below the normal range, neither in a large
study (n = 1 443) (13) nor in a smaller study (n = 50) (17). Yet there was one
exception: One study (n = 74) found that a group with autism spectrum
disorders and avoidant/restrictive food intake disorder had a significantly lower
average intellectual ability level (IQ = 80) than those with autism spectrum
disorders without this food intake disorder (IQ = 100) (22). Another study (n =
95) that used a multivariable regression model to examine factors that might
explain food selectivity, found that intellectual ability level did not contribute
significantly to the model (19). However, while some studies of children and
adolescents with autism spectrum disorders with an intellectual ability level in
the normal range reported small differences, there were significantly lower non-
verbal intellectual ability levels reported for those with food selectivity
compared to those without (14, 20). Despite the low number of studies, the
consistency of the findings gave us a moderate level of confidence.

Autism symptoms
Out of seven studies that investigated the association between food selectivity
and autism symptoms, four showed a higher symptom score for autism
spectrum disorders for those with food selectivity, measured using a
standardised survey instrument (11, 20, 23, 24), and one for those with
avoidant/restrictive food intake disorder (22). The largest of the studies (11)
described a particular association between these and stereotypical and repetitive
behaviours, which is a core symptom of autism spectrum disorders. A study of a
large birth cohort also found an association between autism symptoms and food
selectivity; the strongest correlation was between the symptom 'restricted,
repetitive patterns of behaviour' and the study's ARFID score (ρ = 0.30; 95 %
confidence interval 0.28 to 0.32) (24). Another study that made use of
diagnostic subgroups, showed no difference between food selectivity rates
among those with childhood autism and the other subgroups of autism spectrum

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
disorders, but the number of participants was low (n = 37) (19). We assessed our
confidence in these findings as moderate, although we cannot exclude a certain
association due to measurement overlap between autism symptoms (restricted
repetitive patterns of behaviour and interests) and food selectivity.

Somatic consequences
Six studies discussed the somatic consequences of food selectivity in children
and adolescents with autism spectrum disorders. Obstipation occurred more
frequently among those with food selectivity (11, 23, 25). Overweight and
obesity were reported to be associated with food selectivity in a clinical study of
151 children and adolescents with autism spectrum disorders (2–18 years) (26),
while this was not found in two smaller studies (20, 27). Three separate case
studies of boys with Asperger syndrome (10, 14 and 17 years) described
gingivitis, scurvy (28) and severe malnutrition as having developed as a
consequence of food selectivity (29, 30). Given the low number and small size
of these studies, our overall confidence in these findings was considered to be
low.

Discussion

This review article has identified a total of 20 articles on the topics of

prevalence, characteristics and consequences of food selectivity in children and
adolescents with autism spectrum disorders and an intellectual ability level in
the normal range, i.e. the group of individuals who in Norway tend to be
assessed by the Child and Adolescent Mental Health Services. We found a high
prevalence of food selectivity in this group. In several studies these eating
patterns were associated with a high degree of sensory sensitivity, particularly
sensitivity to the texture and taste of food.

Prevalence
The prevalence of food selectivity was consistently higher in children and
adolescents with autism spectrum disorders and an intellectual ability level in
the normal range than in the control individuals, and it was similar to the level
that has been reported for the overall group of autism spectrum disorders (2).
However, prevalence figures varied considerably between studies, which is in
line with what has been previously reported in literature reviews (5, 6). In part,
this may be due to the studies' age range and gender distribution.
The most uneven gender distribution was found in a sample of 18 participants of
whom 16 were boys (27). The high proportion of boys in most of the studies can
be explained by a higher prevalence of autism spectrum disorders among boys
(4:1) (31). This limits the extent to which findings may be generalised to apply
to girls. Furthermore, the studies measured food selectivity in different ways.
While some used the strict ARFID criteria (11), others applied a broader

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
definition of food selectivity (14), or they focused on specific issues (15).
Nevertheless, the study that used the ARFID criteria found a high prevalence, as
approximately one in five individuals with autism spectrum disorders met the
criteria. Unfortunately, this study did not include a control group. However, the
studies that did, found considerable variation in the prevalence of food
selectivity among control individuals (5–33 %). This may reflect the lack of
consensus associated with the use of survey instruments, as shown in Table 2.

Sensory sensitivity
In line with the review articles that did not distinguish between different
intellectual ability levels in children with autism spectrum disorders (6–8), we
found several studies that associated a high degree of sensory sensitivity with
food selectivity, including among those with autism spectrum disorders and an
intellectual ability level in the normal range. Sensitivity to food textures and
taste were particularly important causes of food selectivity. In several studies,
only a certain proportion of participants had an intellectual ability above a
certain level (e.g. 70 % IQ > 80 (13)), and this may have influenced the results.
Two studies that exclusively included children and adolescents with autism
spectrum disorders and an intellectual ability level in the normal range, found
that food selectivity was caused by sensitivity to textures (12, 15). One of them
also reported that neophobia and hypersensitivity to taste played a part (15).

Intellectual ability level

The studies we found do not suggest that food selectivity can be explained by
the intellectual ability level of children with autism spectrum disorders, possibly
because there was little difference between the intellectual ability levels of the
groups that were compared. Several also involved small group sizes, although
one large study (n = 1 112) found that the level of intellectual ability was
virtually the same among children with autism spectrum disorders whether or
not they displayed food selectivity traits (23). Interestingly, two studies showed
significantly lower non-verbal intellectual ability levels in those with food
selectivity than in those without (14, 20). However, the differences were small,
and it is important to be cautious when interpreting findings until further studies
are available.

Autism symptoms
Several studies indicate that children and adolescents with autism spectrum
disorders and food selectivity have more autism symptoms than those who have
no such eating patterns (11, 20, 23, 24). The largest study (11) described a
special association between these eating patterns and stereotypical and repetitive
behaviours, which is a core symptom of autism spectrum disorders.

Somatic consequences

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
We found somatic consequences of food selectivity also among those with
autism spectrum disorders and an intellectual ability level in the normal range.
Obstipation was the most common (11, 23, 25), but we also found overweight
and obesity (26). Instances of severe malnutrition that gave somatic
consequences, were described in some case studies (28–30).

Limitations
This study had several limitations. It proved to be difficult to include only
studies on food selectivity in children and adolescents with autism spectrum
disorders and an intellectual ability level in the normal range. Nevertheless, all
the studies that were included in this literature review involved, either
exclusively or generally, participants who had an intellectual ability level in the
normal range (table 2). There is therefore reason to assume that the findings are
representative of children and adolescents who are examined for autism
spectrum disorders by the Child and Adolescent Mental Health Services.
Similarly, several studies had a wide age range and included young children,
even if they were in a minority as we requested a mean age no lower than six
years. The ratings of confidence levels had to be based on discretion, and this
invited interpretive caution. The studies that were identified through the
literature search, varied considerably in respect of design, participants,
measurements etc., and detailed information was frequently not specified. We
cannot therefore rule out that we have failed to include some articles that may
have been relevant. Furthermore, we included only articles published in
English-language peer-reviewed journals and may have overlooked knowledge
from conference presentations, books or material in other languages. There were
few studies on the individual themes, which dictated a cautious approach to
interpreting findings. Overall, these limitations emphasise the importance of
further research on food selectivity in autism spectrum disorders.

Conclusion

The high prevalence of food selectivity in children and adolescents with autism
spectrum disorders and an intellectual ability level in the normal range
demonstrates that it is important to survey diet and nutrition whenever autism
spectrum disorders are diagnosed by the Child and Adolescent Mental Health
Services. Clinicians should not overlook food selectivity traits that can be
interpreted as part of the autism symptoms. Instead, it is essential that they
examine what it is that drives the eating patterns in each individual, such as
sensory sensitivity. This knowledge may well be important to the treatment.
Both cognitive behaviour therapy and a family/ parent-led approach to
increasing food intake variation have proved to be effective in the treatment of
food selectivity (6, 7). There is a need for standardised survey instruments
designed to uncover food selectivity in clinical settings as well as in research.

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening
There is also a demand for longitudinal studies (7). Moreover, studies that can
increase our understanding of the mechanisms behind food selectivity, are
important, e.g. with a focus on sensory experiences.

We are grateful to specialist librarian Ellen Bjørnstad for her work on the
literature searches. The article has been peer reviewed.

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Publisert: 25 November 2024. Tidsskr Nor Legeforen. DOI: 10.4045/tidsskr.24.0193

Received 7.4.2024, first revision submitted 11.7.2024, accepted 15.9.2024.
Published under open access CC BY-ND. Downloaded from tidsskriftet.no 27 February 2025.

Food selectivity in children and adolescents with autism spectrum disorders – a systematic literature review | Tidsskrift for Den norske legeforening