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The Obscure
“Eating” Disorders

Recognition and Response, The Challenge for Parents

By Abigail Natenshon, MA, LCSW, GCFP

The Challenge for parents: Recognition and Response
The task for parents of eating dysfunctional children is first to recognize the problem… next, to solve it. The responsibility for proper diagnosis rests solely with parents and caregivers. Behaviors connected with feeding problems are diffuse… with behavioral, neurological and emotional signs unique and variable from child to child. Pediatricians cannot be counted on to diagnose problems whose full spectrum of behaviors does not present itself in the medical evaluation or in laboratory testing. Too often, these diagnoses are missed.

Compounding the problem of under-diagnosing feeding disorders because of their complexity, the rampant existence of disordered eating in our society today is another major decoy, throwing parents and professionals off track. We live in a world where restrictive eating is considered to be "healthful" eating. Persuaded by the latest fad diet of the week and the belief that a person "can never be too rich or too thin," many believe that skipping meals; eating "substitute" foods and meals in the form of liquid diets or protein bars; restricting fats and sugars and/or becoming vegetarian; or ordering salad dressing "on the side," promises fitness, an attractive appearance and longevity. Many parents, who are themselves disordered eaters, fail to provide their children a consistent healthy eating lifestyle and/or exercise role modeling. Research shows that only 50 percent of American families sit down regularly with their children to eat dinners together. 

On college campuses today, 40 to 50 percent of girls are reported to be disordered eaters. 50% of girls in the first grade report having dieted or restricted foods. By the time they get to the eighth grade, 80 percent of girls have been on diets, feeling virtuous and accomplished when they can reject food and deprive themselves of nutrition. A behavior so commonplace as to have become a norm, dieting is a dangerous pastime. In genetically susceptible youngsters, dieting behaviors can trigger the onset of a clinical eating disorder, the most lethal of all the mental health disorders that kills and maims close to 15 percent of its victims. Ironically, it is, in fact, the worst possible way to lose weight and keep it off. It is a little known but important fact that dieting youngsters have a greater propensity to become overweight adults.

Recognizing signs of early childhood feeding problems
The following are signs of feeding problems according to the Colorado Pediatric Therapy and Feeding Specialists.
(Detroit Free Press, June 11, 2002):
  • Ongoing poor weight gain
  • Gagging during meals
  • History of eating and breathing coordination problems (which might cause problems with nursing)
  • Inability to transition to baby food purees by 10 months.
  • Inability to transition to baby food solids by 12 months of age.
  • Inability to transition from breast/bottle to a cup by 16 months of age.
  • Crying and arching the back and neck at meals.
  • Smell and food texture intolerance.
  • Parental history of an eating disorder.

People commonly believe that if children are hungry enough, they will eat; they will not starve themselves. Though this theory may be true for 96 percent of children, it does not apply to the 4 percent of kids with feeding problems who are, in fact, capable of inadvertently starving themselves. For these children, food smells, textures and feeding literally hurts, and no amount of hunger will overcome that fact. Through their efforts to protect themselves from pain, eventually the appetite becomes suppressed, and in time, they no longer respond correctly to appetite as a cue to eat. 

The preteen and young adult years: What these problems look like
Complicating the challenge of a feeding dysfunction diagnosis, a child may display a whole cluster of neurological or sensory traits, some of which occur at the lower end of a disorder's continuum, and others at the higher end. A child could typically be in the 90th percentile in areas such as working memory, but in the 27th percentile in organizational abilities and visual processing or motoric functions; this child might exhibit an academic performance that is typically average to poor through what appears to be a lazy, sloppy, disorganized, or unfocused work style. (Note that the child with sensory integration disorder will typically do his homework, and then lose it on the way to school.) Children with a non-verbal learning disorders are typically misdiagnosed as suffering from ADHD and are likely to be medicated improperly as such. 

Schools tend not to consider an eating dysfunctional child in need of special attention or accommodation if he or she is still managing to pull A's and B's ("So what's the big deal?"). If through standard psychological testing, the child does not meet all the criteria for learning disabilities and special education funding, the schools are apt to consider these problems merely a benign "shtick," to be disregarded. Why is it necessary to note subsidiary problems along with the feeding problem? Because without a proper diagnosis of feeding problems along with the full spectrum of their related disorders, these problems cannot be adequately and fully treated. Without an accurate diagnosis, parents tend to get blamed for their child's quirky behaviors, and kids get scolded and punished. It is hard to find expert professional help for problems that may at first glance appear to be considered nothing more than stubborn quirkiness. Despite misdiagnosis and lack of understanding, these are neurologically based problems that are hard wired into the central nervous system and that will not simply be outgrown. 

Treatments and Resources
The place to go for help with these disorders of the central nervous system may best be a properly trained occupational therapist, rather than a psychotherapist or medical doctor. Occupational therapists help children develop and hone motor skills through a variety of physical activities, such as obstacle courses, tumbling, rolling on balls and using tools and utensils. O.T. Kathy Dovey describes this active form of play therapy with a young child patient; "It's practice for his brain to talk to his muscles, to get around the roadblocks that come up for him because of this sensory integration disorder."

Aside from the importance of the O.T. as part of the child's team, there is a place and need for a multi-disciplinary team approach to serving the multi-dimensional, integrative needs of the eating dysfunctional child and family. The professional team optimally also includes a pediatrician, pediatric psychologist, speech pathologist, dietician and physical therapist capable of assessing and meeting the needs of the whole child beyond their own area of specialization. Once diagnosed, children with tactile/sensory problems can and should be supported by community resources such as the school, through educational and personal accommodations. Examples might include use of laptop computers to accommodate poor fine motor problems, shorter writing assignments, longer times for test taking, or special dispensation if the child is unable to wield a pencil sufficiently to complete an art assignment to satisfaction, or eat in the lunch room. 

The Feldenkrais Method
The Anat Baniel Method Based on the work of Dr. Moshe Feldenkrais
These mind/body holistic approaches to treatment access, reorganize and integrate the central nervous system, creating an empowered, more integrated perception of the self and a new repertoire of possibilities for neurological change. The power of these experiential treatments is in bypassing the area of the brain that relies on language alone to facilitate learning. Thus, the technique is designed and well-suited for children as young as new-born, a boon to the pre-mature population of babies who may be the most prone to developing these types of feeding difficulties.

For children and adults of all ages, these techniques integrate mind and body, reduce anxiety, and increase self confidence and enhanced well-being, while upgrading the quality of brain function. Kids access the gentle movements through song and play, through one-on-one work with a skilled practitioner. By facilitating self- and body-awareness, Feldenkrais techniques promote emotional versatility and integration. Offering a novel opportunity to seek and discover alternative solutions, it enhances coping skills and adept problem-solving, upgrading all aspects of physical and mental function. 

Other Practical solutions
Just Take a Bite: Effective Answers to Food Aversions and Eating Challenge (2004) by Lori Ernsperger and Tania Stegen-Hanson offers some suggestions for healing afflicted children. Adults who wish to make changes can also benefit from such techniques and practices.

  • Children with SID benefit from systematic desensitization programs offering short exposures to new textures and oral sensations in small, incremental doses. This requires the investment of time, initiative, and creative thinking, with the goal of introducing new foods that are similar to those the child already likes and is accustomed to.
  • The feeding team may alternately choose to reduce the demands for varied eating and focus instead on other ways to maintain a healthy diet… Parents are wise to utilize supplements and vitamins to achieve maximum nutritional balance.
  • Children, whose systems are continually in the "alert mode" have difficulty calming themselves; they need the right atmosphere for eating, so that mealtimes become pleasant, fun and stress-free social experiences. It is critical that there is no TV at mealtimes, lots of talk, and no threatening food discussions or forcing of foods.
  • Kids need to make friends with food by exploring and handling food, in many contexts and through all of the tactile senses.
  • Techniques for stimulating/exercising the tongue diminish the gag reflex. The side of the tongue, rather than the tip, is less sensitive to strange new tastes and is the best place to introduce new foods. 
    A treatment technique called "food chaining" involves "chaining" off the foods the child is willing to eat, and limiting availability to the child's favorite and most nutritious foods. Working within this context in small leaps, child and therapist search out increased numbers of barely acceptable (similar) foods, which became progressively more acceptable as the child eats more of them. As an example, pizza is a good food to chain off; pizza could be expanded to a grilled cheese by creating a pizza sandwich, toasting mozzarella cheese and pizza sauce instead of a more flavorful cheese. Or, by having hot pizza sauce served in a cup next to a child's macaroni and cheese, he could be encouraged to dip occasional bites of mac and cheese into the sauce, expanding his taste combinations.

If there is a "cure," there will certainly be no quick fixes. Treatment will invariably involve discomfort, albeit in a controlled environment. Problems are always easier to treat early on, before they have become too deeply rooted. Curative interventions let the individual know that he or she is not crazy, not alone, and not so misunderstood. The following are words of advice from a seasoned parent, "Once you start the ball rolling, you cannot stop, not even for a day, because otherwise the child will just slip backwards; going through the process with my son over the last two years has so very nearly broken me lots of times, but the rewards in the end are worth it. We can go to restaurants together now, and we can look at life together now with a new eye towards making adjustments and accommodating to change and towards solving problems that arise in the natural course of daily living." 

A Parent's Question
Should I wait until HE thinks his eating is a problem? Will trying some of these behavior modification strategies turn things into a more emotional issue? Will I do more harm than good?

Why would you assume that your young child is fully cognizant, or even capable of making a competent decision about whether or not his eating needs some attention? In some respects, leaving up to the child is a bit like asking the fox to guard the hen house. He is the most unlikely candidate to understand that change would be of benefit to him, and is least likely to feel motivated to change because in eating the way he does, he is maximizing his comfort, and minimizing his stress. It is counterintuitive, and in fact, incomprehensible for most kids to choose change once they recognize that an effective solution can (and will) feel worse than does the problem.
As a parent motivating change, you do take the risk of magnifying emotional ramifications of the problem, but at the same time, by so doing you must recognize that you are shielding the child from deeper and more far-reaching emotional problems as he grows older. There are no easy solutions to certain problems…particularly when they involve food, eating, and neurological function.
… Abigail Natenshon, MA, LCSW


Books and articles
1. Lask and Bryant-Waugh: Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence. Psychology Press 2000.
2. Lask and Bryant-Waugh: Eating Disorders- A Parents Guide Psychology Press 2004
3. Ernsperger and Stegen-Hanson. Just Take a Bite: Effective Answers to Food Aversions and Eating Challenges Publisher Future Horizons, 2004
4. Marcontell, D.K., Laster, A.E., & Johnson, J. (2002). Cognitive-behavioral treatment of food neophobia in adults, Journal of Anxiety Disorders, 16, 341-349.
5. Nicholls, D., Christie, D., Randall, L., & Lask, B. (2001). Selective eating: symptom, disorder or normal variant? Clinical Child Psychology and Psychiatry, 6, 257-270.
6. Seminars: http://www.sensoryresources.com/conf_details2.asp?cid=915

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