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Kid's 'Finicky' Eating: Food Phase or Eating Disorder?

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Maggie Baumann, MA:It's not uncommon for children to be "picky" eaters, but how can you tell if your child's eating issues are associated with a life-threatening illness such as anorexia or bulimia?

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While the majority of eating disorder cases are seen in teenage girls and young-adult women, it's becoming more common to see them in prepubescent children -- mostly girls aged 8 to 12. (Boys can also be affected, though it's less common.)

Psychiatrist Barton Blinder, MD, a specialist in treating eating disorders, has observed anorexia in children as young as 4. In "The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment" (the textbook Dr. Blinder edited), it says that childhood anorexia generally has the same diagnostic criteria as adolescent and/or adult-onset anorexia -- except that, in children, a 15 percent reduction in body weight issufficient for diagnosis, instead of the25 percent required for older age groups. (Prepubertal children -- especially girls -- have less body fat than their adolescent counterparts.)

Here are some quick definitions:

Childhood-onset anorexia nervosa:These children are preoccupied with weight and body size. Generally they have a distorted view of their body and ingest an abnormal or inadequate amount of food. They usually have a strong desire to lose weight, and if they eat more than what is acceptable to them, they may take laxatives and/or exercise to get rid of the extra calories.They may experience delayed sexual maturation and growth impairment. They are at an increased vulnerability to emaciation and dehydration. Rapid weight loss is often seen, which can bring about many serious medical complications, including heart or electrolyte problems that can be fatal.

Childhood-onset bulimia nervosa:Children with bulimia frequently engage in binges (eating excessive quantities of food at one time). The binging usually causes the child to feel guilt and then choose to make herself/himself vomit or use laxatives in order to get rid of the food. They have a strong preoccupation with weight and body size. Their weight can be low, normal or high, so sometimes it's difficult to diagnose bulimia just by looking at them. Like anorexia, bulimia can be fatal due to the serious medical conditions associated with it.

One psychological feature associated with both childhood-onset anorexics and bulimics is that the children tend to be concrete thinkers and lack little insight to describe their psychological issues and feelings. Also, most are black-and-white thinkers -- a characteristic they share with adolescent and adult eating-disorder patients.

The main behavioral feature associated with children who have eating disorders is that their actions are more focused on refusing to eat and selective eating. However, somechildren do struggle with binge-eating disorder, another type of eating disorder wherein the child ingests excessive amounts of calories without any compensatory behaviors such as purging, taking laxatives or excessively exercising. This type of emotional eating can contribute to childhood obesity and all of its medical complications.

Other Childhood Eating Disturbances

London-based medical researchers Rachel Bryant-Waugh, Ph.D., and psychiatrist Bryan Lask, MD, describe other eating problems in children (in addition to anorexia and bulimia):

Food-avoidance emotional disorder:These children have emotional problems -- such as sadness, worrying or obsession -- that interfere with their appetite and eating. They are not preoccupied with weight or body size. The emotions tend to be so intense, food intake isn't a priority.

Food refusal:
Commonly found in preschool children, food refusal can be used as a means to obtain other things. The child may refuse to eat in the presence of certain people or in certain situations. They are not preoccupied by weight or size. Worry and unhappiness may underlie the food refusal.

Pervasive refusal:Children with this serious condition tend to have a profound refusal to eat, walk, talk or self-care. Physical examination often shows no organic explanation for the symptoms. The children are often very resistant, angry or frightened.

Selective eating:
This is commonly seen in preschool children. They eat a very narrow range of foods -- maybe just five or six, usually carbohydrate-based -- and do not like to try new foods. These children tend to be normal weight and height and have no preoccupation with weight or height.

Appetite loss due to depression:
When depression strikes a child, one of the symptoms can be the loss of appetite. The loss of appetite is usually corrected with successful treatment of the depression.

Food phobia:Generally, these children are fearful of eating -- particularly eating lumpy or solid foods. Some fear the food will poison them or cause them to gag, choke or vomit. They are not preoccupied with weight or body size and don't want to lose weight. In many cases, a traumatic event -- such as a previous choking incident --led to the phobia. Others may just have an illogical association in their mind that leads them to develop the phobia.

Restrictive eating/poor appetite:These children will eat a normal range of foods, but in small portions, due to a small appetite or disinterest in the food. They are not preoccupied with weight and are generally happy children. The restrictive eating is not associated with an emotional problem.

Inappropriate texture of food for age:Some children will only eat pureed or semi-solid foods (those appropriate for a 6- to 10-month-old infant), when they should be eating a normal diet of solid food that requires biting and chewing. They can be at normal weight or low weight. There is no preoccupation with body size or weight issues.

The Diagnostic and Statistical Manual (DSM), a common reference tool used by mental health clinicians, describes these additional feeding disorders in children:

Pica:When infants and children eat nonedible substances such as paint, bugs or dirt.

Rumination disorder:
The repeated regurgitation of food. This can be potentially fatal for infants, who may develop malnourishment and delayed development as a result.

Any of the above-listed childhood feeding disorders can eventually turn into an eating disorder if it interferes with normal growth and development and is used to compensate for emotional issues the child is experiencing.Before any feeding or eating disorder can be diagnosed, a complete medical work-up must be performed by a physician in order to rule out any medical reasons for the behavior.

According to therapist Ann Gerberry, MA, director of clinical services at Remuda Ranch, a residential facility in Arizona that treats eating disorders in adults, teens and children as young as 8, children with anorexia may show the following symptoms:

  • Classic self-starvation behavior.
  • Severe anxiety.
  • Depression.
  • Obsessive thoughts related to a fear of eating and a fear of getting fat.
  • Tremendous psychological torment.
  • A desire to please their parents, but an inability to eat the food their parents' request.
  • Persistent food avoidance and weight loss connected to emotional reasons.
  • Some may not show body-image concerns or obsessions.
  • Eating disorders in children need to be distinguished from feeding disorders that might cause growth problems and failure to thrive.
  • Disturbed parent-child relationships often manifest with food and eating problems.

The children's program at Remuda Ranch treats children aged 8 to 12. Once the patient reaches high school (at approximately 13 years of age), he or she enters the Ranch's adolescent program. Each program offers age-appropriate treatment, since children and adolescents can struggle from different stressors and are in need of individualized treatment techniques and education.

Common Causes of Eating Disorders in Children:

  • Genetics. There is a higher chance of getting anorexia if you have a first- or second-degree relative with anorexia.
  • Perfectionism.
  • Inability to self-soothe or tolerate distress.
  • OCD.
  • Low self-esteem.
  • Anxiety disorder, including separation anxiety disorder.
  • Depression.
  • Maturation fears.
  • Somatic issues -- physical complaints such as headaches and/or stomachaches.
  • Oppositional defiant disorder -- a child with a pattern of disobedience, negativity and opposition to authority figures.
  • Relational issues such as attachment disorder, teasing, bullying or social phobia.
  • Family issues of neglect.
  • Trauma issues: child abuse, sexual abuse, physical abuse or bullying due to obesity-related issues.

Typically, treatment centers like Remuda Ranch begin treatment with a two- or three-day assessment phase with the child and parents. This is followed by consultations with the child's treatment team, which includes a registered dietitian (RD), primary-care medical doctor, psychiatrist, psychologist/therapist, nurse and education coordinator. The team then presents a treatment plan to the child and parents.

Treatment may include:

  • Regular appointments with a medical doctor.
  • Many patients are seen daily by a psychiatrist.
  • Weekly RD and nutrition therapy.
  • Individual and group therapy.
  • Family therapy/intensive family week.

All meals, activities and restroom visits are supervised so staff can intervene on any eating-disorder behaviors that may present during treatment.

The goal of treatment is to get the child to return to his or her ideal body weight, resolve any medical complications and stop the eating-disorder behaviors. Of course, treatment is also focused on resolving any emotional disturbances that may have triggered the child to use eating (or not eating) as a coping tool to manage life. Not only is the child offered emotional support, the families are, too -- so when the child returns home, the family can work together for continued recovery.

If you suspect that your child has an eating issue, consult his or her doctor promptly for help.For more resources on eating disorders in children, visit www.mirror-mirror.org/child.htm. To locate treatment centers that provide care to children, visit www.edreferral.com.

Does your child have any unusual eating behaviors -- including feeding and/or eating disorders? If so, how have you managed to help him or her?


next: Postpartum Psychosis and Terri Moulton Horman
3 comments so far | Post a comment now
Kristen July 13, 2010, 4:44 AM

You know the article should be talking about picky eating and food allergies, NOT eating disorders. Good grief.

anonymous July 13, 2010, 1:25 PM

I agree with Karen. This should be about picky kids and getting them to eat.

On another note, a kid eating a bug is not pica. It’s just a little kid eating a bug.

Tiffani July 15, 2010, 12:24 PM

Actually, kudos to the person that wrote this article. Unfortunately, many people don’t take eating concerns with children seriously enough and are uneducated such as those who commented above. This issue is becoming more common and more concerning. As a mother of a child with an eating disorder I am pleased that the word is getting out there. We need to start paying attention to our children’s needs and stop brushing everything off as “just being kids” or we will end up with a generation of adults with some serious problems.


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