"A high prevalence of disordered eating in individuals with ADHD was observed"

The quote heading this post - "A high prevalence of disordered eating in individuals with ADHD [attention-deficit hyperactivity disorder] was observed" - comes from the study results published by Louis Jacob and colleagues [1].

Drawing on information derived from the 2007 Adult Psychiatric Morbidity Survey (APMS) here in Blighty (an initiative that has been talked about previously on this blog), researchers looked at the data for 'screened for' ADHD signs and symptoms using the Adult ADHD Self-Report Scale (ASRS) Screener as well as data derived from "the five-item SCOFF screening instrument" relevant to eating disorders (ED) completed by over 7000 adults.

Researchers reported that: "The prevalence of possible eating disorder (ED) was much higher among those with ADHD symptoms (ASRS score ≥14) compared to those without ADHD symptoms (19.2 vs. 5.7%)." They also noted that issues such as anxiety and the presence of borderline personality disorder (BPD) also might have an important influence on disordered eating as measured by the SCOFF. ADHD plus anxiety linked to a heightened increased risk of another condition presenting? I've heard that before (see here).

Accepting the fact that use of the ASRS in initiatives such as the APMS is not without potential 'limitations' (see here), and the important word 'possible' when it comes to the presence of an eating disorder based on SCOFF results alone, these are potentially important results. I say that on the basis that a connection between food/diet and ADHD has a long history from many different perspectives (see here and see here and see here for examples). I should also add that this is not the first time that ADHD and eating disorders have been talked about in the peer-reviewed research literature (see here and see here).

Other implications aside from the potential need for preferential screening for eating disorders as and when ADHD or ADHD-type behaviours feature? Well, I'd be minded to suggest that including another label/diagnosis/constellation of symptoms into future research proceedings might be useful. I speak of autism or autistic traits and the ideas that: (i) autism and ADHD occurring together is not unheard of (see here) and (ii) there is some increasing interest regarding the presence of autistic traits in relation to those diagnosed with an eating disorder (see here and see here).

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[1] Jacob L. et al. Attention deficit hyperactivity disorder symptoms and disordered eating in the English general population. Int J Eat Disord. 2018 Sep 6.

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The strengthening relationship between eating disorders and ADHD

The results from Loretta Sala and colleagues [1] confirms a recent trend in research circles observing a potentially important relationship between various types of eating disorder and the presence of traits/behaviours consistent with a diagnosis of attention-deficit hyperactivity disorder (ADHD).

It's something that has been covered on this blog previously (see here) and represents an extension to the idea that the presentation of autistic traits might not be the only relevant comorbidity when it comes to eating disorders (ED) (see here).

Sala et al report results based on a sample of some 70 female inpatients "all with longstanding histories of eating disorder (ED)." Various scales and instruments were used to assess both ED and ADHD traits/symptoms including the "presence of a diagnosis of ADHD." Accepting the rather nebulous term ED, participants were divided up into specific groups based on the type of eating disorder present: anorexia nervosa restricting type (AN-R), anorexia nervosa binge-eating/purging type (AN-BP) and bulimia nervosa (BN).

Results suggested that ADHD comorbidity is not necessarily an uncommon feature among quite a few cases of ED: "13 patients reported comorbidity with ADHD; three in the AN-R subtype, nine in the AN-BP and one in the BN." Findings also suggested that further research efforts might need to be directed into how ADHD traits/symptoms correlates with other features in cases of ED; specifically in relation to scores on the EAT-40 and the presence of anxiety as measured by the Hamilton scales for Anxiety (HAM-A).

It can only be a good thing that science and clinical practice is beginning to understand that various behavioural/psychiatric labels are rarely observed in isolation to other comorbidity. Not only does this offer potential new avenues for screening/prevention/treatment (see here for one example) but could also provide some much-needed clues as to why conditions such as ED might come about and indeed, who might be particularly at risk for such conditions.

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[1] Sala L. et al. Attention-deficit/hyperactivity disorder symptoms and psychological comorbidity in eating disorder patients. Eat Weight Disord. 2017 May 22.

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Sala L, Martinotti G, Carenti ML, Romo L, Oumaya M, Pham-Scottez A, Rouillon F, Gorwood P, & Janiri L (2017). Attention-deficit/hyperactivity disorder symptoms and psychological comorbidity in eating disorder patients. Eating and weight disorders : EWD PMID: 28534123

Could an "ill-state" associated with anorexia nervosa mimic the symptoms of autism?

The question posed in the title of this post 'Could an "ill-state" associated with anorexia nervosa mimic the symptoms of autism?' stems from the findings reported by Heather Westwood and colleagues [1] (open-access).

They continued a research theme looking at the potential 'overlap' when it comes to autism and eating disorders such as anorexia nervosa (AN) (see here). Notably, researchers questioned whether the finding that some 50% of their cohort "scored above the clinical cut-off on the ADOS-2" but "when developmental history was obtained, only 10% met diagnostic criteria for ASD [autism spectrum disorder]" could be due to "the ill-state associated with AN."

The Westwood paper is open-access so doesn't need any further grand explanations from me. The research caveats alongside relying on quite a small cohort - "40 females aged between 12 and 18" - were that this was a snapshot study not a longitudinal one and whilst relying on data other than that just linked to the presence of autism traits, they did not control for things like social anxiety "which could lead to high scores on the ADOS-2." Interesting.

On the question of whether 'active AN' (please pardon my lack of knowledge on this topic) might have the ability to 'provoke' autistic traits, I have to say that I'm quite intrigued. This might have a few, quite important, implications not least that (a) autistic traits can be 'acquired' as per what has been noted under other different circumstances (see here and see here for examples) and (b) the potential stability of said traits might not be particularly stable for everyone at every time (see here). On that last point, we do need a lot more data as to what happens/happened when AN is treated/managed or goes into remission for example and any subsequent impact on autistic traits.

It's too early to start talking mechanisms when it comes to AN and autistic traits in light of this data alone. I might also venture into the idea that other comorbidities than can appear alongside AN might also have some impact on clinical presentation (see here) and are also in need to further investigation in the context of any eating disorders - autism correlation. Indeed, there are potentially lots of variables that need to be kept in mind (see here and see here) before any sweeping generalisation are made...

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[1] Westwood H. et al. Assessing ASD in Adolescent Females with Anorexia Nervosa using Clinical and Developmental Measures: a Preliminary Investigation. J Abnorm Child Psychol. 2017 Apr 17.

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Westwood, H., Mandy, W., Simic, M., & Tchanturia, K. (2017). Assessing ASD in Adolescent Females with Anorexia Nervosa using Clinical and Developmental Measures: a Preliminary Investigation Journal of Abnormal Child Psychology DOI: 10.1007/s10802-017-0301-x

Coeliac disease, autism and more

"Compared with the general population, children with celiac disease had a 1.4-fold greater risk of future psychiatric disorders. Childhood celiac disease was identified as a risk factor for mood disorders, anxiety disorders, eating disorders, behavioral disorders, ADHD [attention-deficit hyperactivity disorder], ASD [autism spectrum disorder], and intellectual disability."

So said the study findings reported by Agnieszka Butwicka and colleagues [1] who, yet again, relied on one of those oh so important Scandinavian nationwide [research] registries to look at potential extra-intestinal comorbidity associated with a diagnosis of coeliac (celiac) disease. This research group have been pretty active in 'mining' the Swedish population databases in relation to various aspects potentially linked to labels like autism (see here and see here for examples). Importantly, at least one of the authors has also talked about how any connection specifically between coeliac disease (CD) and autism is likely to be rather complicated (see here).

OK, back one step. Coeliac disease (CD) is the premier autoimmune condition - that's autoimmune condition not allergy - where dietary gluten is the [mostly modifiable] baddie. There is a growing realisation in the peer-reviewed science community that aside from the gastrointestinal (GI) manifestations of CD, it looks like extra-intestinal 'effects' are not uncommon too (see here for example) including those affecting early years development (see here). Of the myriad of other diagnoses/labels that have been mentioned alongside CD down the years, autism or ASD has cropped up more than once; leading some to suggest that there may be a connection between the two diagnoses and onward, the need for additional screening (see here). I might add that the gluten connection to CD also overlaps with 'some' research hinting that dietary gluten might have 'effects' for some on the autism spectrum too (see here).

The current Butwicka results represent something quite important. No, they do not infer that everyone diagnosed with autism or ADHD or mood disorder or anxiety disorder has CD but rather that these labels are not protective against the development of CD. Indeed, something else important is mentioned by the authors: "In contrast, siblings of celiac disease probands were at no increased risk of any of the investigated psychiatric disorders." This implies that the relationship, in general terms, seems to be quite specific to the biology / genetics and clinical course of CD and those other developmental/behavioural/psychiatric labels.

Then a tantalising question: what happens to these extra-intestinal labels/conditions when CD is managed/treated via a gluten-free diet? Well, we'll have to wait and see for the science to catch-up but I daresay for some, treating CD might be an important step to managing other labels too (see here)...

Music to close: and double-denim never really went out of fashion y'know...

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[1] Butwicka A. et al. Celiac Disease Is Associated with Childhood Psychiatric Disorders: A Population-Based Study. J Pediatr. 2017 Mar 7. pii: S0022-3476(17)30153-1.

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Butwicka A, Lichtenstein P, Frisén L, Almqvist C, Larsson H, & Ludvigsson JF (2017). Celiac Disease Is Associated with Childhood Psychiatric Disorders: A Population-Based Study. The Journal of pediatrics PMID: 28283256

High frequency of (self-reported) ADHD symptoms in eating disorders

"There is a high frequency of ADHD [attention-deficit hyperactivity disorder] symptoms in patients with binge eating/purging eating disorders that motivates further studies."

That was the conclusion reached in the study by Nils Erik Svedlund and colleagues [1] (open-access) who, among other things, set out to "explore the prevalence and types of self-reported ADHD symptoms in a large, unselected group of ED [eating disorder] patients assessed in a specialized ED clinic." Participants (over 1100 of them) were "seeking help at the Stockholm Centre for Eating Disorders (SCED) from 4 February 2013 through 18 September 2015" and as well as being confirmed to have an eating disorder were also screened for ADHD-type behaviours using the WHO ADHD Self-Rating Scale for Adults (ASRS-screener). Notice the 'self-rated' part of that last sentence...

Based on a ASRS screener score of 14 or above, researchers reported that some 30% of females (N=1094) self-reported 'issues' associated with a diagnosis of ADHD. Some 34% of men included for study (N=47) reported similar ADHD traits (31.3% of the total group including those diagnosed with 'Eating Disorder Not Otherwise Specified (EDNOS) type 5' were on or above the ASRS screener score of 14).

Bearing in mind the presence of various types of different eating disorders in their cohort, researchers also looked at how those self-reported ADHD traits might correlate with sub-groupings. They report that: "The highest frequency of possible ADHD was found in BN [Bulimia Nervosa] and in AN-BP [Anorexia Nervosa bingeing/purging subtype], respectively." They also noted that specific symptoms of ED correlated with the ASRS-screener scores: binge eating, purging, loss of control over the eating and BMI [body mass index] > 17.5. I might add that based on responses to another schedule - the Comprehensive Psychiatric [Psychopathological] Rating Scale (CPRS) - included as part of the study, authors noted something of a link between the ASRS trait scores and "the CPRS scales for depression..., anxiety... and obsession-compulsion." But: "Psychiatric comorbidity correlated to ADHD symptoms without explaining the differences between eating disorder diagnoses."

Keeping in mind that answering 6 questions on a screener questionnaire does not an ADHD diagnosis make, I am rather interested in these and other findings. I am by no means an expert on eating disorder but I have previously been interested in the suggestion that autistic traits may be 'over-represented' when it comes to ED (see here). Combined with the idea that autism and [diagnosed] ADHD might not also be unstrange diagnostic bedfellows (see here) and you can perhaps see that there is potentially more research to do in this area in these times of overlap and ESSENCE. And speaking of ESSENCE [2]...

With a word or two of caution, I note the authors also talked about potential 'treatment' options given the overlap between ADHD traits (self-reported) and ED. So: "This motivates further randomized trials with stimulant treatment for bingeing/purging ED-patients with and without a concomitant ADHD diagnosis." Certain stimulants have quite a good track record when it comes to ADHD (see here) but the authors rightly note that 'appetite suppression' is a potential side-effect of such pharmacotherapy and something perhaps not ideal if someone is already underweight. More studies are indicated to disentangle what is linked to what.

And while I'm on the topic, the link between autism traits and anorexia nervosa might actually be a little more tenuous that you perhaps think [3]...

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[1] Svedlund NE. et al. Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) among adult eating disorder patients. BMC Psychiatry. 2017; 17: 19.

[2] Karjalainen L. et al. Eating disorders and eating pathology in young adult and adult patients with ESSENCE. Compr Psychiatry. 2016 Apr;66:79-86.

[3] Postorino V. et al. Investigation of Autism Spectrum Disorder and Autistic Traits in an Adolescent Sample with Anorexia Nervosa. J Autism Dev Disord. 2017. Jan 24.

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Svedlund, N., Norring, C., Ginsberg, Y., & von Hausswolff-Juhlin, Y. (2017). Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) among adult eating disorder patients BMC Psychiatry, 17 (1) DOI: 10.1186/s12888-016-1093-1

Gut dysbiosis in anorexia nervosa

"Collectively, these results clearly indicate the existence of dysbiosis in the gut of AN [anorexia nervosa] patients."

That opening sentence comes from the paper by Chihiro Morita and colleagues [1] (open-access available here) who "compared the fecal microbiota of female patients with AN (n = 25), including restrictive (ANR, n = 14) and binge-eating (ANBP, n = 11) subtypes, with those of age-matched healthy female controls (n = 21)." Stool and blood samples were analysed for various potentially important markers, and some interesting results were forthcoming.

So: "AN patients had significantly lower amounts of total bacteria, C. coccoides group, C. leptum subgroup, B. fragilis, and Streptococcus than age-matched healthy women." Although I am a little wary of zooming in on just one bacterial finding, the suggestion that this relatively small participant group diagnosed with AN showed something akin to a decrease in levels of B. fragilis (Bacteroides fragilis) caught my eye. My reasoning: well, lets just say that research on a certain mouse model applied to another diagnosis frequently discussed on this blog has mentioned B. fragilis before; particularly what happened when this stuff was offered as an oral treatment: "Bacteroides fragilis corrects gut permeability, alters microbial composition, and ameliorates defects in communicative, stereotypic, anxiety-like and sensorimotor behaviors." Now apply all that to the idea that there may be some 'overlap' when it comes to autistic traits and AN (see here) and hopefully I'm not getting too carried away.

One other detail from the Morita study also caught my eye specifically with C-reactive protein (CRP) in mind. We are told that: "The ANR group exhibited significantly lower serum levels of C-reactive protein than the control group." Again accepting the small participant numbers included for study, I was a little surprised that nothing too much was made of this finding in the paper discussion and conclusions. If one assumes that CRP levels might be a rough-and-ready response indicator to something like inflammation, the idea that there may be 'issues' with either systemtic inflammation or the response to inflammation is something than I'd like to see a little more investigation into.

There is a small but growing interest in the possible role of the gut microbiota in relation to AN. Accepting that the issues with food (restriction and in some cases "abnormal eating or purging behaviors") that define the condition are probably going to play some role in the make-up of the gut microbiome, I do think are some interesting routes for future study. That intestinal dysbiosis when present in cases of AN may have some possible psychological repercussions as per the findings reported by Kleiman and colleagues [2] for example, is one area of interest that could lead to some important discussion points.

Oh and whilst we're on the topic of gut bacteria, yes, we might have to redefine what 'the common knowledge' on numbers of bacteria that call us home vs. cells, but don't downplay what important role(s) they play (see here).

Music: Me First and the Gimme Gimmes - Sweet Caroline.

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[1] Morita C. et al. Gut Dysbiosis in Patients with Anorexia Nervosa. PLoS One. 2015 Dec 18;10(12):e0145274.

[2] Kleiman SC. et al. The Intestinal Microbiota in Acute Anorexia Nervosa and During Renourishment: Relationship to Depression, Anxiety, and Eating Disorder Psychopathology. Psychosom Med. 2015 Nov-Dec;77(9):969-81.

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Morita C, Tsuji H, Hata T, Gondo M, Takakura S, Kawai K, Yoshihara K, Ogata K, Nomoto K, Miyazaki K, & Sudo N (2015). Gut Dysbiosis in Patients with Anorexia Nervosa. PloS one, 10 (12) PMID: 26682545

Autoimmune disease risk and eating disorders

"We were set up. The cops were waiting for us."

"We observed an association between eating disorders and several autoimmune diseases with different genetic backgrounds. Our findings support the link between immune-mediated mechanisms and development of eating disorders".

So said the paper by Anu Raevuori and colleagues [1] (open-access) based on an analysis of over 2300 people "treated at the Eating Disorder Unit of Helsinki University Central Hospital between 1995 and 2010" compared with nearly 10,000 control participants (so yes, this was quite a well-powered study).

The Raevuori paper is open-access but if you want a few choice details, here goes...

• Based on a body of research literature looking at a possible association between eating disorders and autoimmune conditions like type 1 diabetes [2], authors set about testing the hypothesis on a large scale on whether "the risk of autoimmune diseases would be increased in individuals with eating disorders both prior and after the onset of the treatment for an eating disorder".
• Having already mentioned how large a scale the authors' participants groups were, various eating disorder diagnoses were confirmed based on ICD-10 criteria [3] and both research and control populations were assessed for some 30 autoimmune conditions based on existing hospital discharge registry. "Period and lifetime prevalences" were calculated from the data. 
• Results: "Participants with BN [bulimia nervosa] made up the largest patient group (54.0%), followed by those with AN [anorexia nervosa] (38.8%), and those with BED [binge eating disorder] (7.3%)". Over 5% of those diagnosed with an eating disorder had been diagnosed with one or more autoimmune conditions compared with just under 3% of controls when it came to looking at period prevalence (at the onset of treatment). Long quote coming up... "The risk of prior diagnosis of endocrinological autoimmune diseases (OR 3.3, 95% CI 2.4–4.6, P<0.001), of gastroenterological immune-mediated diseases (OR 2.0, 95% CI 1.3–3.1, P = 0.002), and of autoimmune diseases combined (OR 2.1 95% CI 1.7–2.7, P<0.001) was significantly higher among patients than among matched controls".
• With regards to lifetime prevalence (over the whole study period) "8.9% (N = 209) of patients and 5.4% of control individuals (N = 509) had ever been diagnosed with one or more autoimmune disease". 

Whilst only looking like a relatively small percentage difference in the rates of autoimmune conditions between the groups, it is the scale of the Raevuori study in terms of participant numbers which gives the data some 'edge'. As the authors also note, their use of the category BED - binge eating disorder - is also another plus to their study given it's recent inclusion into DSM-5 (see here).

As I always seem to be about papers mentioned on this blog, I was really quite interested in the results presented by Raevuori et al and their potential implications for how we describe eating disorders and the potential mechanisms involved in onset. Research into autoimmune conditions has recently been producing some rather important associations as per my covering of things like a [possible] link between autoimmune disorders following trauma and PTSD (see here) and even a suggested connection with some epilepsy (see here).

Raevuori and colleagues discuss several pertinent mechanisms potentially linking their findings including the ever-present issue of inflammation and: "Pro-inflammatory cytokines and antibodies/autoantibodies against neuronal antigens". They also mention some possible role for "intestinal microflora contributing to the development of cross-reactive neuronal autoantibodies [providing] a link between gut and brain" and the growing fascination with all-things gut microbiome. Their finding of a greater frequency of the inflammatory bowel disease (IBD), Crohn's disease in their eating disorder cohort offers some evidence for this assertion as a function of the growing interest in gut bacteria and IBDs [4].

Without hopefully going too far off tangent from the Raevuori paper, I started to think about how these results might also fit in with some of the research done on autism and whether there may be a bigger picture here. Eating disorders have been mentioned alongside the label autism quite a few times in the research literature [5]. My previous discussions on signs of autism in cases of eating disorders (see here) is one example. Likewise, autoimmune conditions and autism also seem to have something of a connection (see here) alongside presented data on markers of autoimmunity in cases of autism (see here and see here). One can perhaps see how the various elements - immune function, inflammation, gut bacteria, gut permeability? - might be intertwined, albeit in a rather complex fashion...?

Music then, and Naive by The Kooks.

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[1] Raevuori A. et al. The increased risk for autoimmune diseases in patients with eating disorders. PLoS One. 2014 Aug 22;9(8):e104845.

[2] Young V. et al. Eating problems in adolescents with Type 1 diabetes: a systematic review with meta-analysis. Diabet Med. 2013 Feb;30(2):189-98.

[3] Herpetz S. et al. The Diagnosis and Treatment of Eating Disorders. Dtsch Arztebl Int. Oct 2011; 108(40): 678–685.

[4] Manichanh C. et al. The gut microbiota in IBD. Nat Rev Gastroenterol Hepatol. 2012 Oct;9(10):599-608.

[5] Huke V. et al. Autism spectrum disorders in eating disorder populations: a systematic review. Eur Eat Disord Rev. 2013 Sep;21(5):345-51.

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Raevuori A, Haukka J, Vaarala O, Suvisaari JM, Gissler M, Grainger M, Linna MS, & Suokas JT (2014). The increased risk for autoimmune diseases in patients with eating disorders. PloS one, 9 (8) PMID: 25147950

Signs of autism in eating disorders?

To mention 'food and autism' in the same sentence can conjure up images of quite a few associations made in the peer-reviewed research literature over the years. You have for example, the growing body of work talking about how certain dietary interventions might be useful for some people on the autism spectrum (see here) and all the accompanying science on potentially why which seems to follow (see here).

Your differential analyser or mine? @ Wikipedia 

In another vein, issues with food and feeding behaviours, present in quite a few cases of autism, represent a far more practical issue to contend with; something which I've talked about before on this blog (see here).

Outside of the various sensitivities to things like taste, texture and smell which can affect a person's relationship with food (see here for a great overview* with autism in mind), questions are being asked about whether there may be more pathological issues to contend with as a result (see here**). I refer readers to the question asked by Prof. Gillberg 30 years ago on whether autism and familial anorexia might be linked (see here).

With this in mind, and slightly reversing the nature of any relationship, I want to discuss the paper by Baron-Cohen and colleagues*** (open-access) which suggested that females diagnosed with anorexia nervosa (AN) might being more likely to present with a cognitive style reminiscent of that seen in autism. Quite a nice overview of the study and its findings can be found here and due credit should be given to the article by Clare Allely which recently appeared in The Psychologist.

In essence (no, not that ESSENCE) we are talking about a group of adolescent females diagnosed with AN (n=66) compared with a control group of similarly aged young women without AN (n=1609). Based on the previous work looking at empathising and systemising (see here) styles in autism, participants completed questionnaires (EQ --- SQ-R --- AQ) to report on these attributes.

The results: "As predicted, the patients with anorexia has a higher AQ and SQ". In other words, the distribution of AN cases scoring higher on the AQ (see here for some more chatter about this instrument) was greater than that seen in the non-AN controls (see Figure 1 of the paper here). Ergo, more autistic traits in the AN group as per earlier research****. That also the AN group seemed to be better systemisers was another finding.

Whilst I have had my doubts about some of the earlier manifestations of the whole empathising-systemising theory (think the sweeping generalisations of Theory of Mind and autism) I have to say I am really interested in these recent results. I note also that another review study looking at the presence of autism in eating disorder populations***** likewise suggests that this might be a relationship which requires much further investigation.

If I had to throw a few spanners into the works outside of the study limitations already talked about by the authors, it would have to be that we should be cautious of making too many over-generalisations from this work. The recent 'mixed' findings by Courty and colleagues****** need to be considered. Although I am not an expert on eating disorders, it's still possible that we might also consider some shared comorbidity outside of autism as potentially accounting for some of the results at least in a sub-group. So for example, are features such as anxiety or obsessionality potential links between AN and the autism spectrum disorders particularly when talking about being better systemisers? The paper by Morsanyi and colleagues******* might be relevant here: [the systemising quotient] "was correlated with statistics-related attitudes, self-efficacy, and anxiety". I tip my hat also to the findings reported by Coombs and colleagues********. I'd also like to see more data on whether the described relationship between eating disorders and autistic traits holds for other kinds of eating disorders such as bulimia too?

Without also wishing to cause any offence, I do wonder about these results potentially being extended following in the tracks of the Gillberg letter. Take for example the paper by Grove and colleagues********* who talked about the empathising-systemising results being extended to other family members where autism is present. Does this therefore imply that we should be thinking about eating disorders potentially being more prevalent in other family members where autism is present? Indeed should we consider the possibility that the presence of a maternal (or paternal) eating disorder could be [another] subsequent risk factor for offspring autism?

To close, an Elvis track for you... His Latest Flame. I'd also like to mark the passing of David Barker (see here for his obituary) and his insightful contribution to science discussed in an earlier post (see here) which in an odd sort of way might also be relevant to today's discussions.

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* Cermak SA. et al. Food selectivity and sensory sensitivity in children with autism spectrum disorders. J Am Diet Assoc. 2010 February; 110(2): 238–246.

** Råstam M. et al. Eating Problems and Overlap with ADHD and Autism Spectrum Disorders in a Nationwide Twin Study of 9- and 12-Year-Old Children. Scientific World Journal. 2013; 2013: 315429.

*** Baron-Cohen S. et al. Do girls with anorexia nervosa have elevated autistic traits? Mol Autism. 2013; 4: 24.

**** Hambrook D. et al. Empathy, systemizing, and autistic traits in anorexia nervosa: a pilot study. Br J Clin Psychol. 2008 Sep;47(Pt 3):335-9. doi: 10.1348/014466507X272475.

***** Huke V. et al. Autism spectrum disorders in eating disorder populations: a systematic review. Eur Eat Disord Rev. 2013 Sep;21(5):345-51.

****** Courty A. et al. Levels of autistic traits in anorexia nervosa: a comparative psychometric study. BMC Psychiatry. 2013 Sep 10;13(1):222.

******* Morsanyi K. et al. Are systemizing and autistic traits related to talent and interest in mathematics and engineering? Testing some of the central claims of the empathizing-systemizing theory. Br J Psychol. 2012 Nov;103(4):472-96.

******** Coombs E. et al. An investigation into the relationship between eating disorder psychopathology and autistic symptomatology in a non-clinical sample. Br J Clin Psychol. 2011 Sep;50(3):326-38.

********* Grove R. et al. Empathizing, systemizing, and autistic traits: latent structure in individuals with autism, their parents, and general population controls. J Abnorm Psychol. 2013 May;122(2):600-9.

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Baron-Cohen S, Jaffa T, Davies S, Auyeung B, Allison C, & Wheelwright S (2013). Do girls with anorexia nervosa have elevated autistic traits? Molecular autism, 4 (1) PMID: 23915495