Children with autism are more likely than typically developing children to meet criteria for being considered overweight or obese in early childhood through adolescence1,2. And these weight issues can have deleterious health effects: Obesity plays a role in the development of diabetes, cardiovascular disease and certain cancers in adulthood. These chronic conditions are all more prevalent among autistic adults than among their typical peers.
But admonishments to lose weight can backfire and may contribute further to weight gain. Pediatric primary care practitioners have a critical responsibility to provide guidance, information and resources for autistic children struggling with weight gain, and to advocate for them in accessing needed services and supports at home and school.
Unfortunately, many providers do not have the training to help special populations of children, who may have specific weight-related risks. Food selectivity, physical inactivity and elevated levels of screen time may all contribute to weight issues in autistic children, as may sleep problems, co-occurring medical conditions, family stress and antipsychotic medications.
To fill this training gap, we and our colleagues at the Healthy Weight Research Network developed a set of recommendations for primary care practitioners to guide them in working with children on the autism spectrum around weight-related concerns3. We modified and expanded the American Academy of Pediatrics’ helpful road map for managing childhood obesity for use with autistic children. Our recommendations encompass screening, evaluation, prevention and intervention. They also provide practitioners with targeted suggestions for working with autistic children and their families, therapists and school systems.
Guidance and motivation:
Practitioners can start to make a difference simply by assessing and discussing a child’s weight status. These conversations provide an opportunity to explore lifestyle-related behaviors and challenges for children and their families. They can be a way to identify issues related to food insecurity, a known risk factor for obesity, as well as social isolation and limited opportunities for physical activity and recreation4. Through these discussions, practitioners can begin to partner with children and their families to address concerns around eating habits, engagement in recreation and physical activity, and finding alternatives to sedentary pursuits such as excessive screen time.
It is imperative that providers serve as positive role models and approach these topics in an open, nonjudgmental way. Because of the stigma associated with obesity, children may be reluctant to discuss their weight. Parents may also feel they are to blame. Providers need to reassure autistic children and their families that there is no judgment involved. They should keep the conversation focused on health, wellness and well-being, and not on achieving some targeted number on a scale or growth chart.
Primary care providers can also deploy adapted motivational interviewing techniques, using simple, concrete, clear language. Verbal and nonverbal demonstrations of support and encouragement — for example, using positive reinforcement for improved dietary patterns or increased physical activity— can help individuals with developmental disabilities change behavior and make healthier choices5. Motivational interviews with parents can shed light on their concerns, values and readiness for change.
Primary care providers can also advocate for support within school systems, ensuring that children who have motor or coordination problems get adapted physical education, for example. Likewise, providers can ask that healthy eating and physical activity goals be included in a child’s Individualized Education Program. A written note or prescription from a physician holds great sway within educational and social institutions.
Although primary care providers can play a critical role for autistic children with weight issues, they need not work in isolation. They can also enlist the help of developmental specialists, such as developmental-behavioral pediatricians and behavioral psychologists. These professionals often possess autism-related expertise that can augment a provider’s ability to address lifestyle factors, especially if making changes in diet or increasing physical activity seem warranted and an autistic child needs additional support to make these changes. For example, if a child has sensory sensitivities that lead to a restricted diet, working with a feeding team that could include a behavioral psychologist, nutritionist or occupational therapist with expertise in oral sensory issues can help children expand their diet.
Pediatricians and primary care practitioners are often stable, long-term figures in a child’s life. The relationship that a pediatrician forges with a child and the child’s family, and the support and guidance she offers, can have a monumental impact on a child’s quality of life, health and well-being. It is paramount that primary care practitioners intervene promptly if an autistic child appears at risk for excess weight gain or has already reached criteria for being overweight or obese. These challenges may take time to address and may require a multi-level approach, but the many years that the provider has to follow the child and to support incremental but important changes in lifestyle behaviors can help promote optimal health and well-being in this important pediatric population.
Our hope is that our recommendations will enable primary care practitioners to intervene effectively and in supportive ways to help autistic children maintain a healthy weight.
Carol Curtin is associate professor of family medicine and of community health and psychiatry at the Eunice Kennedy Shriver Center at the University of Massachusetts in Worcester. Sarabeth Broder-Fingert is assistant professor of pediatrics at Boston University in Massachusetts.
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