• Eating disorders in mid-childhood can be a continuation of feeding
• The symptoms and diagnostic criteria for the above mentioned eating disorders are presented.
• It is important to differentiate these eating disorders because affected
• The younger the child, the more important it is to use family therapy to provide a family environment in which the child can learn to regulate eating in accord with hunger and fullness and learn more effective ways of dealing with his or her emotions.
Most literature on the subject of eating and feeding disorders has focused primarily on feeding difficulties in infants and young children and on eating disorders in adolescents and young adults. This article examines eating disorders in mid-childhood, specifically during the preadolescent elementary school age, an area that has undergone relatively little scrutiny. Specific symptoms and diagnostic criteria for infantile anorexia, sensory food aversions (both starting during infancy or early childhood), and posttraumatic eating disorder are described, and the presentation of anorexia nervosa and bulimia nervosa in children is discussed. The specific treatment for each of these five eating disorders is outlined and the need for family therapy for children with eating disorders is emphasized.
Although most attention has been directed toward feeding disorders in infants and young children and toward anorexia nervosa and bulimia nervosa during adolescence and early adulthood, it is well known that eating disorders occur in preadolescent elementary school children as well. However, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),1 does not provide diagnostic criteria for most eating disorders that present during mid-childhood. The DSM-IV introduces the diagnosis of feeding disorder of infancy and early childhood, which addresses food refusal and growth deficiency in infants and young children, and it contains diagnostic criteria for anorexia nervosa and bulimia nervosa. However, these criteria frequently do not fit the presentation of eating problems during mid-childhood. Consequently, several authors have confusingly described eating disorders in children using different terms to describe the same symptomatology or the same terms to describe different eating disorders.2-5 The lack of clear diagnostic criteria has also hampered epidemiological research on the frequency of eating disorders in mid-childhood.
This review categorizes eating disorders during mid-childhood into three groups: eating disorders that begin during infancy or early childhood and continue to present with serious problems for children during school age, including infantile anorexia and sensory food aversions; posttraumatic eating disorder, which can occur at any age from infancy to adulthood; and early onset of the classic eating disorders anorexia nervosa and bulimia nervosa (Algorithm). The diagnostic criteria, symptom patterns, possible etiologies, and interventions for each eating disorder are described. Finally, the differentiation of these various eating disorders is emphasized because an intervention that may be helpful for one eating disorder may be ineffective or counterproductive for another eating disorder.
Eating Disorders with Onset During Infancy or Early Childhood
The continuation of early feeding difficulties into childhood is highlighted by a longitudinal study from Sweden by Dahl and colleagues,6-8 who found that 1% to 2% of infants presented with severe feeding problems and growth deficiency during the first year of life; 70% of these children continued to have eating problems at home and at school when followed up during school age. In the authors’ experience, the following two feeding disorders, infantile anorexia and sensory food aversions, can be seen during school age if affected children do not receive appropriate intervention during the early years.
Chatoor and Egan9 first described this feeding disorder as a separation disorder because it usually becomes apparent in the first 3 years of life during the developmental phase of separation and individuation. Later, it was renamed “infantile anorexia” to emphasize the onset of this disorder during infancy and the lack of appetite that accompanies it.10 Infantile anorexia usually presents during the first 3 years of life with food refusal and growth deficiency. When these infants are transitioned to spoon and self-feeding at 9–18 months of age, the parents frequently report that they take only a few bites of food and then refuse to eat any more. The children do not open their mouths for feeding, they throw food and feeding utensils, and they frequently try to climb out of the high chair or leave the table to play. Many parents report that these children hardly show any signals of hunger. The parents usually become worried about the infants’ poor food intake, and they try to increase the infants’ eating by coaxing, distracting, bribing, offering different foods, offering food constantly, threatening, and by force feeding when they become desperate. As time goes on, the children’s feeding becomes increasingly dependent on the interactions with their parents, who end up feeling frustrated and helpless because the harder they try, the less the children seem to eat.
Chatoor and colleagues11 explored the mother-toddler interactional patterns associated with infantile anorexia and found that toddlers with infantile anorexia and their mothers demonstrated less dyadic reciprocity, more conflict, engaged in more struggle for control, and engaged in more talk and distractions during feeding than did healthy eaters and their mothers. In addition, mothers whose toddlers exhibited infantile anorexia rated them as more emotionally intense, negative, irregular in feeding and sleeping patterns, dependent, unstoppable, and difficult than did mothers with healthy eaters.12 Physiological measures of heart rate showed that toddlers with infantile anorexia experience a higher level of arousal and have more difficulty shifting into a calmer, less-aroused state than healthy eaters.13 This physiological pattern may explain the difficulty anorexic toddlers experience in settling down in order to eat or to sleep.
In summary, these studies indicate that toddlers with infantile anorexia demonstrate a special temperament constellation that is characterized by intense interest in play and interaction with their caretakers, higher physiological arousal, and difficulty in calming themselves in order to eat or sleep. As these children get older, they verbalize their disinterest in eating by stating that they do not feel hungry, that they are bored with eating, that they do not want to stop their activities in order to eat, and that they want to get up from the table and play.
Initially, children with infantile anorexia fail to gain weight at a normal rate for their age. Then they slow down in their linear growth and may end up as small and thin children. Children 3–4 years of age with infantile anorexia may look like 2-year-olds, and 10-year-olds may have the bone age and the appearance of children 6–7 years of age. However, in most cases, their heads grow at a normal rate for age, and their intellectual development is usually average and may even be superior despite their growth failure.14
This eating disorder seems to occur with the same frequency in boys as in girls.11 However, as the children get older, boys seem to suffer emotionally because they are subjected to teasing by their peers, and they are often excluded from team sports because of their small size. Girls seem to be less bothered by their small size, and some girls seem to be quite confused about their body and experience body image distortions, complaining of a big stomach or big thighs, not unlike adolescents with anorexia nervosa. However, there are no longitudinal studies of infantile anorexia, and the relationship between infantile anorexia and anorexia nervosa is not known at this time.
The diagnostic criteria for infantile anorexia, sensory food aversions, and posttraumatic feeding disorder in infants and young children were recently revised with the help of a national task force in order to follow the pattern of the DSM-IV.1,3,15 In this article, the diagnostic criteria for these feeding disorders are modified where necessary to characterize the symptoms in elementary-school–age children (Table 1).1,15
The first step of the intervention is a thorough evaluation of the affected children’s eating history, developmental history, medical history, psychiatric history, and the family’s history of eating habits, medical disorders, and psychiatric disorders. It is important to grasp the children’s understanding of their eating and growth problems, especially their awareness of hunger and fullness; whether they are bothered by their poor growth; or whether they purposefully restrict food intake out of fear of becoming fat.
Should affected children confirm that they do not feel hungry most of the time and prefer to play or talk to their friends instead of eating, but are worried about their small size, they can be told that the therapist will help them to recognize hunger, eat more, and grow better. The intervention consists of helping the parents schedule regular meals and snacks, spaced at least 3–4 hours apart, without any snacking or drinking (except water) in between. Anorexic children should be given small portions and encouraged to ask for second and third helpings until they feel satiated. The parents are to abstain from praise for eating more or coaxing or threatening for eating less than expected. Affected children must learn to read their inner hunger and fullness signals and should be encouraged to speak about hunger and fullness instead of complaining about not having any time to eat or wanting to do something else other than sitting at the table. Although the intervention is rather simple, many families need help in dealing with the children’s behavior around mealtime.
Sensory Food Aversions
Children with sensory food aversions selectively refuse to eat certain foods related to the taste, texture, smell, and/or appearance of these particular foods. However, they eat better if they are offered preferred foods. This feeding disorder usually becomes apparent during the early years, when infants are introduced to various types of baby food and table food (Table 2).1,15 Typically, when specific foods are placed in the mouth, the aversive reactions range from grimacing and spitting out the food to gagging and vomiting. After an initial aversive reaction, the children often refuse to eat any more of that particular food and frequently they generalize to other foods that seem to remind them of the aversive food (eg, refusing to eat any green vegetables after having had an unpleasant experience with spinach). However, since most children experience these aversive reactions when they are young and preverbal, they only express reluctance and fear to try certain foods, and they are often unable to explain why they are scared. Although many children may refuse to eat a few foods, some children generalize to the point that they refuse whole food groups (eg, vegetables, fruits, meats). Parents often report that these children are limited to very few foods, that they refuse to try any new foods, and in extreme cases, that they insist that one food should not touch another food on the plate, or that they accept food only if it is prepared by a certain company (eg, McDonald’s chicken nuggets or Domino’s pizza).
If children refuse many foods or whole food groups, their limited diet may lead to specific nutritional deficiencies (eg, protein, vitamin, zinc, or iron deficiencies). If children refuse foods that require significant chewing (eg, meats, hard vegetables, or fruits), they may fall behind in their oral motor and language development. The children’s refusal to eat various foods may also create conflict within their families, and, as the children get older, they may avoid social situations because of their embarrassment that they cannot eat various foods like their peers. Since sensory food aversions are common and occur along a spectrum of severity, the diagnosis of a feeding disorder should only be made if the food aversions result in either nutritional deficiencies, oral motor delay, family conflict, or social anxiety.
In addition to their sensitivity to certain foods, many of these children experience problems in other sensory areas as well. Parents may recall that as toddlers these children did not like to walk barefoot on sand or grass, that they did not like their hands to get “messy,” that they objected to labels in their clothing, that they were reluctant to change from long pants to short pants, or that they were very sensitive to odors or loud noises. Frequently, these difficulties in other sensory areas improve with age, but some children continue to struggle with these hypersensitivities as they get older.
Other authors have referred to this eating disorder as “selective eating,”5,16 “choosy eaters,”17 “picky eaters,”18 and “food neophobia.”19 Some studies have explored whether taste sensitivities are heritable, and various models of genetic transmission have been suggested, such as multilocus and multiallele models,20 a two locus model,21 and specific changes on gene 7.22 Other studies have postulated that certain aspects of the eating environment, such as exposure and the social affective context in which the food is offered, can have a strong influence on food preferences and shape-selective food refusal.23,24 In summary, these studies suggest that both genetic predispositions and the eating environment have an effect on children’s food preferences.
The first priority of treatment has to be directed toward the nutritional adequacy of the children’s diet. If the diet is deficient in specific nutrients (eg, protein, vitamins, zinc, or iron), supplementation with these specific nutrients should be initiated. However, these children often have difficulties in taking specific supplements and it may be necessary to explore different flavors or start with a small amount to allow them to get used to the taste or texture of the supplement. This supplementation is very important in order to alleviate the parents’ anxiety about the children’s poor diet, and to allow the behavioral program to proceed.
Since these children are usually fearful of trying new foods, making them hungry, coaxing them, threatening them, or punishing them are usually ineffective in helping them overcome their fear of new foods. On the contrary, these interventions usually make them more anxious and more reluctant to try new foods. Although many children cannot explain why they are scared to try new foods, they express fear verbally and in body language, and some of them become combative if they are forced to eat new foods. Consequently, treatment needs to address their fearfulness. In clinical practice, several children have responded well to being rewarded with points for their courage in trying each bite of a new food of their choosing. When reaching 10, 30, and 50 points, the children earn increasingly larger rewards. The emphasis on having courage distracts from the food itself and increases the confidence and self-esteem of these children. However, some children are so anxious that medication should be considered to manage their anxiety and to facilitate the behavioral intervention. Unfortunately, no controlled treatment studies for this eating disorder are available.
Posttraumatic Eating Disorder
The term posttraumatic eating disorder was first coined by Chatoor and colleagues2 in an article on food refusal in five latency-age children who experienced episodes of choking or severe gagging and later refused to eat any solid food. These children were afraid to eat any solid food that had to be chewed out of fear that the food would get stuck in their throat and cause them to choke and die. In addition, the children clung to their parents and reported getting very anxious in anticipation of mealtimes, having fears of choking in their sleep, and having frightening dreams about dying. As a result of their fear of choking and dying, most of the children restricted themselves to liquids or smooth foods (eg, ice cream and pureed foods). Hunger did not seem to overcome their fear of eating, and many of these children lost weight while on their self-imposed liquid diet.
Several other authors have reported that children can develop fears of swallowing after choking on food and have described this eating disorder as food phobia,4 functional dysphagia,5 choking phobia,25 or dysphagia and food aversion.26 Chatoor3 previously described a posttraumatic feeding disorder in infants and young children; that diagnostic criteria has been modified for school-age children for this article (Table 3).1,15
Some case reports2,4 have described treatment of this eating disorder, but no empirical studies are available at this point in time. Considering the children’s conviction that any solid food will get stuck in their throat, an initial cognitive approach of explaining the anatomy of the trachea, the esophagus, and the stomach through a drawing with the child’s participation seems to help to clarify some of the children’s cognitive distortions. The children will be reassured that that the “little door” between the esophagus and the trachea will close each time they swallow, and all they have to do is to eat slowly, chew their food well, and then swallow. Then they are encouraged to practice chewing and swallowing by eating softer, less-frightening foods first, and then working their way up to harder, chewier foods (eg, apples, meats). Some children can learn relaxation exercises and visual imagery to help them in this gradual desensitization process. Other children respond well to earning points for courage and getting special rewards for overcoming their fear and trying to eat frightening foods. However, some children are so anxious that they seem immobilized by their fears. These children benefit from anxiolytic medication, which controls their excessive worries and fears and allows them to engage in the gradual desensitization process described above. In general, most children overcome their fear of choking and resume a normal eating pattern.
Early Onset of Classic Eating Disorders
The onset of anorexia nervosa and bulimia nervosa is most commonly observed during the adolescent and early adult years. However, children as young as 7–8 years of age have been reported to present with symptoms of these two eating disorders.27 Weight and body image concerns can develop early in children. Maloney and colleagues28 reported that up to 45% of elementary school children want to be thinner than they are and 6.9% scored in the pathological range on an adapted version of the Eating Attitude Test. The expression of anorexia nervosa and bulimia nervosa in prepubertal children is discussed below.
Children diagnosed with anorexia nervosa are often intensely afraid of gaining weight, attempt to lose weight, and exhibit a significant disturbance in the perception of the shape or size of their body (Table 4).1 Prepubertal children have less body mass and may enter a state of starvation rather quickly. In their effort to diet and lose weight, children also fail to drink adequately and may not maintain their hydration. In addition, when children eat inadequately for months and years, they stunt their linear growth, though they may not appear as malnourished because of their compromised height. However, there is a prolonged delay of puberty and failure of catch-up growth affecting breast development. Interestingly, whereas studies of anorexia nervosa in adolescents and adults consistently have shown that the ratio of girls to boys is generally 9:1, early-onset anorexia nervosa in children has been reported to occur in 19% to 30% of boys.5
Although twin and family studies have demonstrated that there is a high heritability to anorexia nervosa, several other risk factors have been identified. Sharpe and colleagues29 identified a significant correlation between anxious attachment and eating concerns. Other studies30 have identified affective lability and maternal preoccupation with diets as risk factors of eating disturbances in children. Whereas the psychobiological challenges of puberty have been seen as triggering factors for anorexia nervosa during the adolescent years, prepubertal children have been shown to experience more stressful life events, which act as alternative precipitating factors to puberty in triggering anorexia nervosa.31 Some studies have described premorbid depressive symptoms that usher in anorexia nervosa, and several studies have reported on the high comorbidity of anorexia nervosa and depression.32 Many children experience depression as their nutritional state deteriorates.
The initial goal of treatment is the restoration of physical health. Some children may require hospitalization for refeeding and weight restoration. Early discharge with low discharge weight has been shown to confer high risk for relapse and a poor prognosis.33 A large variety of outpatient approaches to individual, family, and group therapy are used in the treatment of anorexia nervosa.34 A study by Russell and colleagues,35 which compared family therapy that encouraged the family to take charge of the patient’s eating with individual therapy that emphasized support, education, and problem solving, found that family therapy was superior for younger patients, whereas individual therapy had a better outcome for older adolescents. Generally, outcome studies of anorexia nervosa have reported good results in 50% to 67% of patients. Some studies have reported that onset at <11 years of age is associated with poor outcome,36 whereas other studies found that the older the age of onset, the poorer the outcome.37
The essential features of bulimia nervosa are binge eating and inappropriate compensatory methods to prevent weight gain. To qualify for the diagnosis, the binge eating and the inappropriate compensatory behaviors must occur, on average, at least twice/week for 3 months. The binge is defined as eating in a discrete period of time an amount of food that is larger than most individuals would eat, and is associated with a sense of loss of control. The compensatory behaviors can include vomiting, abuse of laxatives, fasting, and excessive exercise (Table 5). The most common onset of bulimia is during late adolescence and early adulthood, although some cases of bulimia have been reported in preadolescent children.38 Binge eating usually begins in the context of dieting and once purging begins, patients are often resistant to treatment and tend to keep their bingeing and purging secret. Although children with bulimia nervosa usually do not approach the low weights associated with anorexia nervosa, they may experience other medical complications, such as hypokalemia, gastric disturbances, and dehydration that may require hospitalization. The course of bulimia nervosa usually fluctuates with remissions and relapses. However, early onset of the disorder is associated with an increased risk for late adolescent and adult bulimia nervosa.39
Although the successful treatment of bulimia nervosa in young adults with cognitive therapy and with various medications has been well documented, the treatment of adolescents with bulimia nervosa (as with anorexia nervosa) through family therapy seems to be most promising.40 There are no treatment studies of children with bulimia nervosa. However, it appears that the younger the child the more critical the involvement of the family becomes.
Eating disorders in mid-childhood are diverse and can be carried over from feeding difficulties during infancy or early childhood, or may signal fears of fatness and early struggles to control one’s weight. In addition, some children develop fears of choking and dying after they have experienced a traumatic event or witnessed someone else choking, and they avoid any foods that they fear would get stuck in their throat. In order to help affected children to overcome their fears, it is important to understand the factors that are troubling to them: is it the fear of being “fat,” the fear of eating new foods, or the fear of choking? In addition, the family needs to provide an environment in which these children can learn to regulate eating in accord with hunger and fullness and deal
with their emotions more effectively. PP
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Dr. Chatoor is vice chair and director of the Infant and Toddler Mental Health Center in the Department of Psychiatry at Children’s National Medical Center, and is professor of psychiatry and pediatrics at George Washington University, both in Washington, DC.
Ms. Surles is a doctoral student in clinical psychology at Argosy University in Washington, DC.
Disclosure: The authors report no financial, academic, or other support of this work.
Please direct all correspondence to: Irene Chatoor, MD, Department of Psychiatry, George Washington University Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010-297; Tel: 202-884-2118; Fax: 202-884-5039; E-mail: email@example.com.