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Eating Disorders in Children | Participatory Awareness

Obesity and anorexia nervosa are two extremes of a spectrum of eating disorders and eating abnormalities that probably affect one in every third child. The prevalence of these disorders has increased greatly over the past decade especially in developed countries, and depending on their severity these disorders pose a serious health risk for the child and future adult. These are the malnutrition disorders of the developed world that in their outcomes are as serious as malnutrition in underdeveloped countries. In surveying the literature of these various conditions, I was struck by the distinct demarcation between them. They are characterised as separate eating disorders with no interconnection in any way. Yet common to them all is the activity of eating either too little or too much. In this article, I explore the possibility that these eating disorders may have some common generic origin that in different personality types manifest in different ways.

eating disorders in children

Obesity and anorexia nervosa are two extremes of a spectrum of eating disorders and eating abnormalities that probably affect one in every third child. The prevalence of these disorders has increased greatly over the past decade especially in developed countries, and depending on their severity these disorders pose a serious health risk for the child and future adult. These are the malnutrition disorders of the developed world that in their outcomes are as serious as malnutrition in underdeveloped countries. In surveying the literature of these various conditions, I was struck by the distinct demarcation between them. They are characterised as separate eating disorders with no interconnection in any way. Yet common to them all is the activity of eating either too little or too much. In this article, I explore the possibility that these eating disorders may have some common generic origin that in different personality types manifest in different ways.

Eating disorders in young children 
There are infants who persistently eat non-nutritive substances such as hair, cloth, paint, lime wash, plaster etc., and older children who eat pebbles, sand, animal faeces, insects, flowers, leaves, etc. This is a condition called pica. It usually occurs in the second or third year of life. Pica may occur in autistic and mentally impaired children. More often it is due to a specific nutritional deficiency such as calcium, iron or zinc. It may also be due to a neglectful or otherwise deficient mother-child relationship. Pica may be a risk factor for uncontrolled eating behaviour in adolescence.1,2

Food refusal and pickiness is common in children of all ages and has various causes. Functional digestive disturbances and food sensitivities cause digestive discomfort and resistance to eating. The parental-child relationship especially regarding food and mealtimes plays a major role. Some parents are misguided about what constitutes a healthy diet and impose rigid controls or anxiety-charged expectations on sensitive children. There may be no regular mealtimes when parents and children sit together. A mother may force-feed her child or demand that all food on the plate be finished. The mother who is over stressed, diet and weight conscious and irritable at mealtimes, imparts to the child an anxiety that he associates with eating. It is frequently the mother-child relationship that is at the root of the problem leading to the child’s unsatisfied oral needs. A 10-year follow up study of 6 to 16-year-old children found that food refusal, pickiness and digestive problems were risk factors for subsequent anorexia.2

Obese and overweight infants and toddlers are an every day sight in any supermarket. Obesity in early life is characterised by the increased number and size of fat cells. Once this has been established it is physiologically difficult to change and will predispose the child to adult obesity. A 6-year-old obese child has a 50% chance of becoming an obese adult.3 The tendency to put on weight may be genetic in origin (see below) or diet-related. Overfeeding of infants in the first year of life tends to occur more with artificial feeding as opposed to breastfeeding. Mothers tend to encourage infants to finish the bottle and the baby is unable to control milk intake to the same extent as is possible on the breast. However, psychological factors are invariably also implicated. For example, a mother who cannot bond with her child, who is overanxious or has misconceptions about food, will tend to overfeed her child. These children are prone to repeated respiratory and gastro-intestinal infections and their impaired sugar metabolism predisposes them to sugar diabetes.

Eating disorders in older children and adolescents 
Being overweight and obesity 
Obesity has reached epidemic proportions in the USA where at least 15% of children are obese and 1 in 3 or more children and adolescents are overweight. All population and socio-economic groups are affected and South Africa is no exception. Recent local studies show that in 13 to 19 year olds, over 30% of girls and 9% of boys are either overweight or obese.4 In black, white and Indian girls the prevalence was 30%, 34% and 41% respectively. Obesity is defined as excessive fat accumulation in the body that causes body weight to exceed 20% of standard weight as determined by height and weight tables. Being overweight is a 10% excess of the desired weight. Eighty per cent of obese people have a family history of obesity and identical twins raised apart can both be obese.

The environmental factor can be seen in the higher prevalence of obesity, unhealthy eating and lack of exercise found in industrialised countries, both among lower socio-economic sections as well as more affluent sectors. During the preschool and school years, obesity is promoted by the excessive intake of food, especially highly refined carbohydrates such as sugar, cold drinks, white bread, cakes and sweets, and high-fat diets such as those that include butter, fried foods and fatty meat. Fat moreover has a weak ability to satisfy appetite. The regular consumption of fast foods, sweetened drinks and even fruit juices also promotes obesity. Research indicates that children who eat lunch at tuck shops are at increased risk of gaining weight, those who eat supper with their family three or more times a week are at decreased risk, and children in high income neighbourhoods were half as likely to become overweight than their peers in low income areas.5 Decrease in physical activity restricts energy consumption and may contribute to increased food intake. In developed countries a clear relationship exists between low levels of physical activity and obesity. There is also a clear association between hours spent watching TV and obesity.

Psychosocial factors clearly play a central role. Children learn to use overeating or unhealthy eating habits as a means of coping with psychological problems such as boredom, frustration, insecurity, fear, loneliness and rejection. Parental and peer attitudes to the overweight child as well as parental overweight appear to be potent factors.

Excessive weight in children should be regarded as a serious disease that predisposes the child to a wide range of health problems: physical discomfort, the overtaxing of many organ systems, skeletal complications (e.g. flatfeet) and the rising incidence of juvenile diabetes are some of the physical consequences; feelings of low self-esteem and poor self-image, intensified by the social consequences of poor school performance, discrimination and loss of friends lead to self loathing and depression, all of which perpetuate the addictive eating tendency.

Obese children have a much greater chance of growing into obese adults who are at great risk of developing some of the most prevalent and life-threatening diseases of modern society. These include sugar diabetes, cardiovascular disease, high blood pressure, raised cholesterol, gallstones and cancer.

Controlled eating and anorexia nervosa 
Abnormal eating habits leading to controlled eating and weight loss with its extreme anorexia nervosa form are widespread in all developed countries, and are increasing among South Afri-
cans of all racial groups who follow a developing Western culture. A preliminary study in secondary school girls in South Africa suggests that 1 in 5 girls possess abnormal eating attitudes and up to 5% of young women will exhibit some anorexia symptoms.1 This tendency usually manifests in the mid-teens, but may appear any time between 10 and 30 years. Adolescent girls between 17 – 18 years are most at risk. It occurs 10 to 20 times more often in females than in males, with the greatest frequency occurring in professions and competitive activities that require thinness such as modelling, ballet, gymnastics and athletics. It is often associated with a past history of physical or sexual abuse and with parents who themselves have eating disorders or weight problems.

Anorexia nervosa is characterised by compulsive weight loss due to a morbid fear of gaining weight together with a misperception of body weight and shape. There is usually a preoccupation with food and dieting, weight control and body shape, a denial of the seriousness of the problem, and a restless pursuit of thinness often to starvation and even death from multiple organ failure. Anorexics usually refuse to eat with their families or in public places, abuse laxatives and diuretics to lose weight, and engage in compulsive exercising. They are usually anaemic, feel the cold intensely, often have low energy, feel dizzy or faint easily, are usually constipated and girls typically stop menstruating. Their growth may be stunted in puberty and they may develop osteoporosis later in life. They are moody, depressed and suicidal.

The cause seems likely to be multifactorial. The desire to lose weight clearly has a psycho-emotional basis. Anorexia occurs predominately in individuals with low self-esteem who are rigid, perfectionist, obsessive and compulsive in nature. They are often shy, studious and over-compliant, typically lack a sense of autonomy and selfhood, and are often unable to separate psychologically from an over-caring mother. Twin studies suggest that genetic/biological factors may predispose to the condition.2 Anorexic girls may be more influenced by advertising and media pressure that encourages slimming than non-anorexic girls of the same age.3,4

Uncontrolled eating and bulimia nervosa 
This condition is characterised by recurrent episodes of uncontrolled binge eating combined with inappropriate ways of preventing weight gain such as self-induced vomiting, laxative misuse, diuretics, enemas, fasting or excessive exercise. It is more prevalent than anorexia nervosa, occurring in 1 – 3% of young women, most commonly in late adolescence. As in anorexia nervosa, bulimic patients are over concerned about their body shape and weight, and find it extremely difficult to be objective about it. However, unlike anorexia they may maintain a normal body weight.

Their health risks are mainly due to the consequences of purging and laxative abuse, and include salivary gland swelling (characteristic chipmunk face), dental enamel erosion, dehydration, stomach tears with bleeding and sudden death. Genetic factors appear to be less impor-tant but low serotonin may play a part in the uncontrolled  appetite. They are also subject to the socio-cultural pres-sures to be slim but their psychological profile is different. They seem to lie somewhere between the extremes of anorexia and obesity. They try to gain self-control by restricting their eating, but then completely lose control by secret food bingeing. Purging may follow with subsequent shame, guilt, depression and suicide. Their lack of self-control makes them generally more outgoing and impulsive, leading them frequently into substance dependence, shoplifting, promiscuity and self-destructive sexual relationships. Their emotional lability allows them to feel and express their anger, frustration, guilt and self-disgust.

A preliminary study to determine factors influencing eating attitudes in high school girls in South Africa confirmed other research findings that maternal influences played an important role in these attitudes, e.g. communications concerning the daughter’s weight, food and dieting to lose or gain weight.5,6 Mothers of bulimic daughters more often perceived their daughters to be overweight, and encouraged dieting and exercise more than mothers of normal controls.7 Mothers of adolescents with eating disorders tend themselves to be more prone to eating disorders than mothers of adolescents without eating disorders.8

Towards an understanding of the nature and origin of eating disorders 
While the environment provides outer trigger factors and heredity promotes predisposition, the psycho-spiritual human component and its connection to the body may be seen as the starting point for all eating disorders. I have often referred in previous articles to a way of viewing the developing child as a physical and spiritual being.9,10 At conception the child’s psycho-spiritual nature unites with the inherited physical body, which can be regarded as the vehicle through which the former carries out its earthly tasks. During the developmental process the body is moulded by psycho-spiritual activities to become the most appropriate vehicle for its earthly work.

The child’s body is then an outcome of his psycho-spiritual nature and not a product of neuro-biochemistry and neuro-physiology as Western biomedicine views it, where the cause for all illness will logically be looked for in the body at a biochemical or genetic level. A holistic point of view does not imply that the body cannot influence the psyche. However it opens up the possibility that the psyche, as an independent entity, can influence the body. This must be theoretically possible if the body, soul and spirit components are in an interactive continuum that mutually influence each other. Previous articles have described the soul life in some detail.11,12 

As the child grows, the child’s life of soul develops through her contact with the surrounding world. She develops a particular disposition of feelings on the basis of what her 12 senses and her reflective capacities tell her. Her behaviour is then a natural outcome of this experience. A child may feel anxious and insecure as a result of ongoing parental conflict. She discovers that eating makes her feel better. She becomes obese and the resultant sluggish metabolism aggravates her depression.

Detect the warning signs 
Detecting the warning signs as early as possible may prevent serious developments and minimise long-term damage:
• Persistent weight gain, loss of self-esteem, withdrawal tendencies and depression.
• Sudden weight loss, fear of being overweight and weight loss denial, preoccupation with food and dieting, restricted eating pattern, unusual or ritualised eating habits, bathroom breaks during or after meals sug-gest vomiting, excessive exercising, baggy or full cover clothes to hide thinness or fatness, dry sallow skin with hair loss and fine hair growth, obsessive compulsive behaviour, evidence of binge eating, chip-munk cheeks from excess vomiting, mood changes including anxiety and irritability.

This way of viewing the child suggests that all eating disorders arise out of a specific soul disposition influenced by a specific bodily constitution. A child who refuses food or eats abnormally is usually a highly sensitive and vulnerable child who is using the body to express and control the discomfort she feels on an emotional level. Her eating behaviour is a reaction to this discomfort that over time becomes a learned coping mechanism that helps her to deal with her inner emotional difficulties and to find some level of inner equilibrium.

For instance, Thandi refuses to eat because of the inner anxiety that is triggered in her by her controlling or anxious mother. Her body shuts down to food. This helps to lessen her anxiety. She finds in this way she copes better with her anxious mother. Zolani with a similar controlling mother overeats when he senses the pressure. His body opens up to food. This relieves his inner tension. Some children crave food or specific kinds of foods whenever they feel insecure, lonely or unhappy. Food becomes a substitute for the lack of some emotional need such as love and attention. For a short period the inner discomfort melts away. In more severe forms, eating becomes addictive in the same way as a painkiller is continuously needed to block out pain.

Other children resist eating as a way of protecting their vulnerability and asserting their own autonomy. They notice they feel less vulnerable and more in control of their lives when they control their eating. The level of control expresses the degree of vulnerability and in its most extreme form – anorexia nervosa – it is as if a fundamentalist religious authority has taken charge of their lives, convincing them that what they are doing to themselves is right, even at the cost of their lives.

Sarah was a timid, highly anxious, diligent and religious 16-year-old girl who was always a fussy eater. Her mother herself was diet and weight conscious, and extremely protective and caring of her daughter. Her parents started noticing her greater preoccupation with food and with it her failure to gain weight. She started exercising compulsively, refusing food and dropped weight critically. She felt safe in the decisions she had made for herself.

The next intriguing question is to ask why these sensitive children choose specifically an eating disorder to clothe their soul experience? Since the activity of eating and the nutritional process is common to them all, it may be helpful to explore what these processes represent for the growing child. Food maintains and nurtures the body. The drive for food is one of the basic needs that the soul requires for preservation of the body.

In a previous article, the will activity of the soul working in the body was described as instinct and drive.13 The will drives the nutritional functions – one of seven basic life processes that maintain the healthy functioning of the human organism.10 Young and old we all feel physically and emotionally satisfied after a good meal, especially one prepared by a loving mother. There appears to be an innate connection between food, eating and maternal nurturing. The nutritional stream nurtures the child physically-etherically in the same way as the mother nurtures the child emotionally. One of the earliest associations a newborn baby has with her mother is the warm flow of milk that grows her body. The child feels with the inflow of food into her body something similar to the nurturing she receives from her mother. When this psycho-organic need has been fulfilled, the child will feel whole and complete. On a soul level one may say he tastes the mother. He has a feeling of wellbeing similar to that which he experiences when he rests in the loving arms of his mother or when he feels his mother is there for him, and when his mother is not there for him or is too present for him, this child may respond with some eating disorder. Eating disorders may well express some dysfunction between the child, its body, and the stream of nurturing with which the maternal spirit is intimately connected.

Research seems to indicate that the mother plays a crucial role in these eating disorders. Children who overeat may be expressing the longing for the mother, or the wish to identify with the mother who represents for them the protection and nurturing that they are not yet able to give themselves. Anorexia nervosa is often associated with a mother who is frequently absent, smothering or too controlling. These children may be making a conscious or unconscious attempt to distance themselves from the mother stream and to establish their own autonomy. They seem to have an aversion for everything that connects their body with the mother or womanhood: menstruation, sexuality, relationships and eating. They take on a more masculine and cerebral persona. They seem to disconnect from life and become more spiritual. In contrast the obese child has a more feminine and heartfelt nature. They hide behind an expanded body and become more earthy. Adolescents who overeat and then purge themselves may be expressing the struggle for separation from a maternal figure who they alternately wish to hold onto (overeating) and then wish to free themselves from (purging).

The eating disorders of older children manifest at a time when the child is faced with powerful developmental challenges – physically, emotionally and socially. Puberty awakens the child to the vulnerability of body and soul. Adolescence is characterised by the striving for a sense of identity and a new sense of self. There are healthy and less healthy responses to these challenges. These eating disorders may be an attempt to provide protection, autonomy and self definition in the face of these developmental challenges.

How can we help children with eating disorders?
Prevention is always better than cure. Parents and especially mothers (the usual food providers) need to be well informed in all aspects relating to food and eating. The following are some guidelines that will reduce the incidence of eating disorders:
• Exclusively breastfeeding for at least 6 months should be encouraged especially for mothers who have a family history of obesity.
• Acquire a clear understanding of the quality and quantity of a healthy balanced diet for each appropriate age from an expert in the field. Avoid unnecessary refined foods, fat and sugar products. Parents should demonstrate balance in eating. All foods can be enjoyed in moderation. Do not label food good or bad.
• Provide quality time for meals with children, free of anxiety or disharmony.
• Exercise should be balanced, recreational and fun for children. Exercise used competitively and to lose weight is harmful for young children.
• Examine your own attitudes towards eating and body image, especially mothers who serve as role models for daughters. A mother’s perception of physical appearance can and often does have a profound effect on a child’s belief system and actions. This is also important for fathers because their views of women profoundly affect their daughters’ self-image and understanding of what the opposite sex will expect of them.
• One of the most important times to identify and prevent potential obesity is at the age of 12 – 18 months since being overweight at this age seems to be an indicator for obesity in later life.
• Children with poor or fussy appetites should be carefully monitored without drawing attention to their food. Medical conditions that cause appetite loss obviously need to be excluded. Explore possible causes with an informed practitioner and find creative ways of encouraging eating. Using food as a punishment or reward is usually not effective.

Sensitive management
Sensitive management can make a huge difference to outcomes:11,12
• Understand and respect that these are highly sensitive and vulnerable children and that their eating response, although not healthy, is the best defence they have at their disposal. By supporting the child in her vulnerable place, you will gain her trust by convincing her that you understand her. Learn to communicate effectively with such children. Find out what their real needs are and what they are really missing.13,14 
• Each specific eating disorder requires a specific programme of management, the details of which go beyond the scope of this article. The programme offered by the Syringa Child Clinic (a holistic child clinic for sensitive children/adolescents and their reactive syndromes) includes individual dietary and nutritional interventions, individually prescribed natural and dynamic medication, and a range of therapeutic options such as body compresses, rhythmical massage, craniosacral therapy, art therapy, hippotherapy (horse riding), and most importantly, counselling both for family members and the affected child. Psychophonetic counselling is well suited for children with eating disorders. Its use of verbal as well as non-verbal expressive modalities of body sensing, gesture/movement, visualisation and sound work, allows the child to discover her vulnerability directly, what she is missing as well as new resources to provide herself with the protection and nurturing she is needing.

Eating disorders are an attempt by some sensitive children to cope with their internal struggles and their life challenges. The use of their bodies and the nutritional process may be an attempt to come to terms with maternal relationships and the mother/woman nature within them. Understanding their needs may help us to steer them into safer and healthier directions.

References
1. Szabo CP, Hollands C. Abnormal eating attitudes in secondary school girls in South Africa – a preliminary study. SAMJ 1997; 87.
2. Hebebrand J, Remschmidt, H. Anorexia nervosa viewed as an extreme weight condition: genetic implications. Human Genetics 1995; 95: 1-11.
3. Van der Linden J, Van der Reyken W. Guidelines for the family therapeutic approach to eating disorders. Psychotherapy and Psychosomatics 1991; 56: 36-42.
4. Toro J, Castro J, et al. Eating attitudes, sociodemographic factors and body shape evaluation in adolescence. Br J Med Psychol 1989; 62: 61-70.
5. Szabo CP. Factors influencing eating attitudes in secondary school girls in South Africa – a preliminary study. SAMJ 1997; 87.
6. Mukai T, et al. Eating attitudes and weight preoccupation among female high school students in Japan. J Child Psychol Psychiatry 1994; 35: 677-688.
7. Pike KM, Rodin J. Mothers, daughters and disordered eating. J Abnormal Psychol 1991; 97: 198-204.
8. Moreno A, Thelen MH. Parental factors related to bulimia nervosa. Addict Behav 1993; 18: 681-689.
9. Goldberg R. Enhance the developing child’s potential. South African Journal of Natural Medicine 2001; 3: 47-49.
10. Goldberg R. Protecting the heavenly years of childhood. South African Journal of Natural Medicine 2003; 10: 47-49.
11. Goldberg R. The three births of childhood. South African Journal of Natural Medicine 2003; 11: 44-46.
12. Goldberg R. Highly sensitive children Part 1. South African Journal of Natural Medicine 2005; 19: 65-68.
13. Goldberg R. Depressed children – hear their cry! South African Journal of Natural Medicine 2006; 22: 56-60.
14.Goldberg R. The psychosomatic connection in childhood. South African Journal of Natural Medicine 2004; 14: 44-47.

Further reading
1. Kaplan HI, Sadock MD. Synopsis of Psychiatry. Eighth ed. Baltimore, Maryland USA: Lippencott Williams and Wilkins, 1998.
2. Textbook of Psychiatry for Southern Africa. Edited by Robertson, Allwood and Gagiano. Cape Town: Oxford University Press, 2001.
3. Winston APW, Palmer RL. Eating Disorders. Medicine International, No. 3: The Medicine Publishing Company, 2000.