Reviewing the Literature on Children and Eating Disorders

In the past few decades researchers have focused on eating disorders, the causes of these disorders and how the treatment of eating disorders. However, it has mainly been in the last decade that researchers have started looking at eating disorders in children, the reasons why these disorders are developing at such a young age, and the best recovery program for these young people. To understand this growing problem it is necessary to ask a few important questions:

1. Is there a relationship between family context and parental input and eating disorders?
2. What effect do mothers who suffer or have suffered from an eating disorder have on their children and specifically their daughters' eating patterns?
3. What is the best way to treat children with eating disorders?

Types of Childhood Eating Disorders

In an article focusing on an overall description of eating disorders in children, by Bryant-Waugh and Lask (1995), they claim that in childhood there appears to be some variants on the two most common eating disorders found in adults, anorexia nervosa and bulimia nervosa. These disorders include selective eating, food avoidance emotional disorder, and pervasive refusal syndrome. Because so many of the children do not fit all of the requirements for anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified, they created a general definition which includes all eating disorders, "a disorder of childhood in which there is an excessive preoccupation with weight or shape, and/or food intake, and accompanied by grossly inadequate, irregular or chaotic food intake" (Byant-Waugh and Lask, 1995). Furthermore they created a more practical diagnostic criteria for childhood onset anorexia nervosa as: (a) determined food avoidance, (b) a failure to maintain the steady weight gain expected for age, or actual weight loss, and (c) overconcern with weight and shape. Other common features include self-induced vomiting, laxative abuse, excessive exercising, distorted body image, and morbid preoccupation with energy intake. Physical findings include dehydration, electrolyte imbalance, hypothermia, poor peripheral circulation and even circulatory failure, cardiac arrythmias, hepatic steatosis, and ovarian and uterine regression (Bryant-Waugh and Lask, 1995).

Causes and Predictors of Eating Disorders in Children

Eating disorders in children, like in adults, are generally viewed as a multi-determined syndrome with a variety of interacting factors, biological, psychological, familial and socio-cultural. It is important to recognize that each factor plays a role in predisposing, precipitating, or perpetuating the problem.

In a study by Marchi and Cohen (1990) maladaptive eating patterns were traced longitudinally in a large, random sample of children. They were interested in finding whether or not certain eating and digestive problems in early childhood were predictive of symptoms of bulimia nervosa and anorexia nervosa in adolescence. Six eating behaviors were assessed by maternal interview at ages 1 through 10, ages 9 through 18, and 2.5 years later when they were 12 through 20 years old. The behaviors measured included (1) meals unpleasant; (2) struggle over eating; (3) amount eaten; (4) picky eater; (5) speed of eating (6) interest in food. Also data on pica (eating dirt, laundry starch, paint, or other nonfood material), data on digestive problems, and food avoidance were measured.

The findings revealed that children showing problems in early childhood are definitely at an increased risk of showing parallel problems in later childhood and adolescence. An interesting finding was that pica in early childhood was related to elevated, extreme, and diagnosable problems of bulimia nervosa. Also, picky eating in early childhood was a predictive factor for bulimic symptoms in the 12-20 year olds. Digestive problems in early childhood were predictive of elevated symptoms of anorexia nervosa. Furthermore, diagnosable levels of anorexia and bulimia nervosa were presaged by elevated symptoms of these disorders 2 years earlier, suggesting an insidious onset and an opportunity for secondary prevention. This research would be even more helpful in predicting adolescent onset of eating disorders if they had traced the origins and development of these abnormal eating patterns in children and then further examined alternative contributors to these behaviors.

Family Context of Eating Disorders

There has been considerable speculation regarding familial contributors to the pathogenesis of anorexia nervosa. Sometimes family dysfunction has proved a popular area for consideration for eating disorders in children. Often times parents fail to encourage self-expression, and the family is based on a rigid homeostatic system, governed by strict rules that are challenged by the child's emerging adolescence.

A study by Edmunds and Hill (1999) looked at the potential for undernutrition and links with eating disorders to the issue of dieting in children. Much debate centers around the dangers and benefits of dieting in children and adolescents. In one aspect dieting at an early age is central to eating disorders and has a strong association with extreme weight control and unhealthy behaviors. On the other hand, childhood dieting has the character of a healthy method of weight control for children who are overweight or obese. Especially important for children is the family context of eating and particularly the influence of parents. A question arises concerning whether highly restrained children receive and perceive parental control over their child's food intake. Edmunds and Hill (1999) looked at four hundred and two children with a mean age of 12 years old. The children completed a questionnaire composed of questions from the Dutch Eating Behavior Questionnaire and questions concerning parental control of eating by Johnson and Birch. They also measured the children's body weight and height and completed a pictorial scale assessing body shape preferences and the Self-Perception Profile for Children.

The research findings suggested that 12-year-old dieters are serious in their nutritional intentions. Highly restrained children reported greater parental control of their eating. Also, dieting and fasting were reported by nearly three times as many 12-year-old girls, showing that girls and boys differ in their experiences of food and eating. However, boys were more likely to be nurtured with food by parents than were girls. Though this study did show a relationship between parental control over eating and restrained children, there were several limitations. The data was collected from one age group in only one geographical area. Also the study was solely from the children's point of view, so more parental research would be helpful. This study does point to the fact that children and parents are both in desperate need for advice about eating, weight, and dieting.

A study also focusing on parental factors and eating disorders in children by Smolak, Levine, and Schermer (1999), examined the relative contributions of mother's and father's direct comments about child's weight and modeling of weight concerns through their own behavior on child's body esteem, weight-related concerns, and weight loss attempts. This study emerged because of the expressed concern about the rates of dieting, body dissatisfaction, and negative attitudes about body fat among elementary school children. In the long run early practices of dieting and excessive exercising to lose weight may be associated with the development of chronic body image problems, weight cycling, eating disorders, and obesity. Parents play a detrimental role when they create an environment which emphasizes thinness and dieting or excessive exercise as a way to attain the desired body. Specifically, parents may comment on the child's weight or body shape and this tends to become more common as the children get older.

The study consisted of 299 fourth graders and 253 fifth graders. Surveys were mailed to the parents and were returned by 131 mothers and 89 fathers. The children's questionnaire consisted of items from the Body Esteem Scale, weight loss attempts questions, and how much they were concerned with their weight. The parents' questionnaire addressed issues such as attitudes concerning their own weight and shape, and their attitudes about their child's weight and shape. The results from the questionnaires found that parental comments concerning the child's weight were moderately correlated with weight loss attempts and body esteem in both boys and girls. Daughter's concern about being or getting too fat was related to mother's complaints about her own weight as well as mother's comments about daughter's weight. Daughter's concern about being fat was also correlated with father's concern about his own thinness. For sons, only father's comments on son's weight was significantly correlated with concerns about fat. The data also indicated that mothers have a somewhat greater effect on their children's attitudes and behaviors than do fathers, especially for daughters. This study had several limitations including the relatively young age of the sample, the consistency of the findings, and the lack of a measure of body weight and shape of the children. However, despite these limitations, the data suggests that parents may certainly contribute to children's and especially girls', fears of being fat, dissatisfaction, and weight loss attempts.

Eating Disordered Mothers and Their Children

Mothers tend to have greater effects on their children's eating patterns and self image of themselves, especially for girls. The psychiatric disorders of parents may influence their child rearing methods and may contribute to a risk factor for the development of disorders in their children. Mothers with eating disorders may have a difficult time feeding their infants and young children and will further effect the child's eating behaviors over the years. Often the family environment will be less cohesive, more conflicted, and less supportive.

In a study by Agras, Hammer, and McNicholas (1999) 216 newborns and their parents were recruited for a study from birth to 5 years of age of the offspring of eating disordered and non-eating disordered mothers. The mothers were asked to complete the Eating Disorders Inventory, looking at Body Dissatisfaction, Bulimia, and Drive for Thinness. They also completed a questionnaire which measured hunger, dietary restraint, and disinhibition, as well as a questionnaire concerning purging, weight loss attempts, and binge eating. Data on infant feeding behaviors were collected in the laboratory at 2 and 4 weeks of age using a suckometer; 24 hour infant intake was assessed at 4 weeks of age using a sensitive electronic weighing scale; and for 3 days each month infant feeding practices were collected using the Infant Feeding Report by the mothers. Also infant heights and weights were obtained in the laboratory at 2 and 4 weeks, 6 months, and at 6-month intervals thereafter. Data on aspects of the mother-child relationships were collected annually by questionnaire from the mother on the child's birthday from 2 to 5 years of age.

The findings from this study suggest that mothers with eating disorders and their children, particularly their daughters, interact differently that non-eating disordered mothers and their children in the areas of feeding, food uses, and weight concerns. The daughters of eating disordered mothers appeared to have a greater avidity for feeding early in their development. Eating disordered mothers also noted more difficulty weaning their daughters from the bottle. These findings may be due in part to the mother's attitudes and behaviors associated with her eating disorder. The report of higher rates of vomiting in the daughters of the eating disordered mothers is interesting to highlight given that vomiting is so frequently found as a symptomatic behavior associated with eating disorders. Beginning at 2 years of age, the eating disordered mother expressed a much greater concern over their daughter's weight that they did for their sons or as compared to non-eating disordered mothers. Finally, eating disordered mothers perceived their children to have greater negative affectivity that do non-eating disordered mothers. Limitations to this study include the overall rate of the past and present eating disorders found in this study was high, compared with community sample rates, the study should also follow these children into the early school years to determine whether the interactions in this study do in fact lead to eating disorders in children.

Lunt, Carosella, and Yager (1989) also conducted a study focusing on mothers with anorexia nervosa and instead of looking at young children, this study observed the mothers' of adolescent daughters. However, before the study even started, the researchers had a difficult time finding potentially suitable mothers because they refused to participate, fearing deleterious effects of the interviews on their relationship with their daughters. The researchers felt that adolescent daughters of women with anorexia nervosa might be expected to have some trouble in dealing with their own maturational processes, tendencies to deny problems, and possibly an increased likelihood of developing eating disorders.

Only three anorexic mothers and their adolescent daughters agreed to be interviewed. The results of the interviews showed that all three mothers avoided talking about their illnesses with their daughters and tended to minimize its effects on their relationships with their daughters. A tendency on the part of both the mothers and daughters to minimize and deny problems was found. Some of the daughters tended to closely watch their mother's food intake and worry about their mother's physical health. All three daughters felt that they and their mothers were very close, more like good friends. This may be because while the mothers were ill the daughters treated them more like peers or some role reversal may have occurred. Also, none of the daughters reported any fears of developing anorexia nervosa nor any fears of adolescence or maturity. It is important to note that all of the daughters were at least six years old before their mothers developed anorexia nervosa. By this age much of their basic personalities had developed when their mothers were not ill. It can be concluded that having a mother who has had anorexia does not necessarily predict that the daughter will have major psychological problems later in life. However, in future studies it is important to look at anorexic mothers when their children are infants, the father's role, and the influence of a quality marriage.

Treatment of Childhood Eating Disorders

In order to treat children who have developed eating disorders it is important for the physician to determine the severity and the pattern of the eating disorder. Eating disorders can be divided into two categories: Early of Mild Stage and Established or Moderate Stage.

According to Kreipe (1995) patients in the mild or early stage include those who have 1) mildly distorted body image; 2) weight 90% or less of average height; 3) no symptoms or signs of excessive weight loss, but who use potentially harmful weight control methods or exhibit a strong drive to lose weight. The first stage of treatment for these patients is to establish a weight goal. Ideally a nutritionist should be involved in the evaluation and treatment of children at this stage. Also diet journals can be used to evaluate nutrition. Re-evaluation by the physician within one to two months ensures healthy treatment.

Kreipe's recommended approach to established or moderated eating disorders includes the additional services of professionals who have experience in treating eating disorders. Specialists in adolescent medicine, nutrition, psychiatry, and psychology each have a role in the treatment. These patients have 1) definitely distorted body image; 2)weight goal less than 85% of average weight for height associated with a refusal to gain weight; 3) symptoms or signs of excessive weight loss associated with a denial of the problem; or 4) use of an unhealthy means to lose weight. The first step is to establish a structure to daily activities that ensures adequate caloric intake and limits expenditure of calories. The daily structure should include eating three meals a day, increasing caloric intake, and possibly limiting physical activity. It is important that the patients and parents receive ongoing medical, nutritional, and mental health counseling throughout the treatment. The emphasis of the team approach helps the children and the parents realize that they are not alone in their struggle.

Hospitalization, according to Kreipe should only be suggested if the child has severe malnutrition, dehydration, electrolyte disturbances, ECG abnormalities, physiologic instability, arrested growth and development, acute food refusal, uncontrollable binging and purging, acute medical complications of malnutrition, acute psychiatric emergencies, and comorbid diagnosis that interferes with the treatment of the eating disorder. Adequate preparation for inpatient treatment can prevent some negative perceptions regarding hospitalization. Having direct reinforcement from both the physician and parents of the purpose of the hospitalization as well as the specific goals and objectives of the treatment can maximize the therapeutic impact.

CONCLUSIONS

Recent research on childhood eating disorders reveal that these disorders, which are very similar to anorexia nervosa and bulimia nervosa in adolescents and adults, do in fact exist and have multiple causes as well as available therapy. Research has found that observing eating patterns in young children is an important predictor of problems later in life. It is important to realize that parents play a huge role in children's self-perceptions of themselves. Parental behavior such as comments and modeling at a young age can lead to disorders later in life. Similarly, a mother who has or has had an eating disorder may rear daughters in such a way that they have a high avidity for feeding early in life, which may pose a serious risk for the later development of an eating disorder. Although having a mother who has an eating disorder does not predict the later development of a disorder by the daughter, clinicians should still assess the children of patients with anorexia nervosa to institute preventive interventions, facilitate early case finding, and offer treatment where needed. Furthermore, the treatment that is available tries to focus on the larger issues associated with weight loss in order to help patients complete treatment and maintain a healthy lifestyle in a culture of thinness. Future research should focus on more longitudinal studies where both the family and the child are observed from infancy to late adolescence, focusing attention on eating patterns of the entire family, attitude toward eating within the family, and how the children develop over time in different family structures and social environments.

References

Agras S., Hammer L., McNicholas F. (1999). A prospective study of the influence of eating-disordered mothers on their children. International Journal of Eating Disorders, 25(3), 253-62.

Bryant-Waugh R., Lask B. (1995). Eating Disorders in Children. Journal of Child Psychology and Psychiatry and Allied Disciplines 36 (3), 191-202.

Edmunds H., Hill AJ. (1999). Dieting and the family context of eating in young adolescent children. International Journal of Eating Disorders 25(4), 435-40.

Kreipe RE. (1995). Eating disorders among children and adolescents. Pediatrics in Review, 16(10), 370-9.

Lunt P., Carosella N., Yager J. (1989) Daughters whose mothers have anorexia nervosa: a pilot study of three adolescents. Psychiatric Medicine, 7(3), 101-10.

Marchi M., Cohen P. (1990). Early childhood eating behaviors and adolescent eating disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 29(1), 112-7.

Smolak L., Levine MP., Schermer R. (1999). Parental input and weight concerns among elementary school children. International Journal of Eating Disorders, 25(3), 263-

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