It is widely accepted that eating disorders do occur in children. There is a growing literature on childhood-onset AN, and it seems that the core behavioral, psychologic, and physical features are similar to those in adults. The differences between children and adults also must be taken into account, however. Because children have lower levels of body fat, they tend to become emaciated and suffer the effects of starvation for more quickly than adults, which must be taken into account when considering treatment. Although cases of childhood-onset BN have been reported, they are so rare that empirical research is difficult. Clinical features reported regarding the atypical childhood-onset eating disorders generally concur, although empirical testing of these features has yet to be developed. Theories as to why children develop these disorders need further development. The general consensus is that all childhood-onset eating disorders must be considered using a multidimensional model that takes into account physical, psychologic, social, and family factors in origin, assessment, and treatment. Psychological, behavioral, and medical assessments indicated that the boys were of average intelligence, without other significant psychological or medical disorders.
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, functional dysphagia, choking phobia, or dysphagia and food aversion.
Choking phobia is characterized by fear and avoidance of swallowing food, fluids, or pills. Most individuals with this phobia suddenly acquire their fear after an episode of choking on food. Fear of choking appears to occur somewhat more often in females than in males, and has a variable age of onset ranging from childhood to old age. Its prevalence is unknown. Choking phobia appears responsive to antipanic medication and to certain cognitive and behavioral therapies.
The eating disturbances were conceptualized as phobic disorders maintained by family factors reinforcing the children’s avoidant behaviors. Cognitive-behavioral treatment consisted of an individualized combination of contingency management, shaping, desensitization, relaxation training, education, and cognitive restructuring. Generalization and maintenance were promoted by training parents to implement treatment at home before discharge.
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.
- Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
- Chatoor I. Feeding disorders in infants and toddlers: diagnosis and treatment. Child Adolesc Psychiatr Clin N Am. 2002;11(2):163-183.
- Watkins B, Lask B. Eating disorders in school-aged children. Child Adolesc Psychiatric Clin N Am. 2002;11(2):185-199.
- Singer LT, Ambuel B, Wade S, Jaffe AC. Cognitive-behavioral treatment of health-impairing food phobias in children. J Am Acad Child Adolesc Psychiatry. 1992;31(5):847-852.
- McNally RJ. Choking phobia: a review of the literature. Compr Psychiatry. 1994;35(1):83-89.
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