There are no dedicated Irish services for the treatment of eating disorders in children, yet cases are increasing, and those affected are getting younger. Nuala Macklin reports
The days of childhood are becoming ever fewer. This is evident in the growing number of children who are increasingly worrying about how they look. Recent studies in the US found 40 per cent of six-year-old girls wish they were thinner, and half will have tried dieting by the age of eight. The International Journal of Eating Disorders reported that by fourth grade (age 10), 80 per cent of American girls have been, or are currently on a diet.
Not so very long ago, generously proportioned female icons such as Marilyn Monroe and Jane Russell who were reportedly a size 16, personified the ideal female form. Nowadays, the MTV generation is fed a constant diet of tanned and chiselled male and impossibly thin and child-like, female images that don't measure up to any normal standards. This all-pervasive imagery places disproportionate emphasis on the importance of appearance for easily influenced children.
Some would argue that this cultural trend has played a significant part in the genesis of eating disorders (EDs) in both children and adults. Possibly the strongest influence on a child's body image is parental body image. A child whose parent is continuously dissatisfied with his or her own body image and tries to change it, may also be dissatisfied with that of their child and encourage certain restrictive eating patterns. This is seen in the rise in cases of second and third generation eating disorders, particularly from mothers to daughters.
On a proportional basis, while not as common as major depression or schizophrenia, the percentage of patients that die from anorexia is the highest with a reported 15 per cent mortality rate.
There were 12 admissions for the treatment of severe EDs to Our Lady's Hospital for Sick Children in Dublin during 2003. "Despite the fact that EDs pose a considerable threat to the health and wellbeing of children and adolescents, there are as yet, no dedicated services for the treatment of EDs in children in Ireland," explains Prof Fiona McNicholas, a child psychiatrist working at Our Lady's Hospital in Crumlin, where many children with EDs present in a medically compromised state.
Early identification and aggressive treatment is associated with an improved outcome, hence the importance of adequate services in childhood, Prof McNicholas notes.
Of all the reported EDs in under 12s within a given decade, 5 per cent will die - based on US indications. "Eating disorders accounts for the highest rate of mortalities within the range of psychiatric disorders. Some of these deaths will have been due to medical complications. A significant number will have be attributable to suicide."
EDs in childhood are not a new phenomenon. "The prevalent rate of anorexia nervosa in adolescent girls may have increased in recent years. There has been no epidemiological study carried out in Ireland. A recent survey of child psychiatrists' active case load suggested that on average, consultants saw five new cases per year," Prof McNicholas adds.
While this would suggest a very low prevalence rate, it is not clear if in fact Ireland has a much lower prevalence rate of ED than other western countries. Or, it may be that many cases are not being referred or identified, or are being referred to other services.
"Body image is a fundamental part of the diagnosis of anorexia," she says. "Together with a morbid fear of fatness and severe calorie restriction, this has its peak age of onset in adolescents. Bulimia nervosa, characterised by overeating and vomiting or purging, is rare before adolescence. The ratio of females to males is 9:1 in older cases, but increasing number of boys are found in pre-pubertal presentations, where the ratio reduces to 3-4:1."
Not all children presenting with restricted eating patterns have anorexia. Some present with selective eating patterns, and others with an emotional disorder in which food avoidance is a prominent symptom but without the associated body and weight distortions characteristic of an ED. Pervasive Refusal Disorder, potentially a life threatening condition, is associated with a profound refusal to eat, drink, communicate, and engage in every day activities. EDs include conditions in which a child will present with overeating, either as part of a medical syndrome or comfort eating, leading to the risk of obesity.
The profile of the family of a child with an eating disorder can sometimes be characterized as one where there is either over, or under-involvement by the parents in the child. Some therapists say there tends to be a failure, or inability to deal with conflict openly and verbally within the family.
The ED can be a response or perceived as a means of gaining control over their lives by the child. These children tend to be very determined, bright, perfectionist and high-achievers. Paradoxically, it's these very attributes which can contrive to make recovery for the child more difficult.
Dr Collette Halpin, a consultant psychiatrist based in the midlands, highlights key aspects of the treatment and some of the physical findings associated with eating disorders. "These can include dehydration, electrolyte imbalance, hypothermia, poor circulation, slow heart rate and even cardiovascular shutdown. There are serious implications resulting in the early development of osteoporosis due to calcium deficiency. If a child presents in a dangerous physical condition, they will be hospitalised.
"The big problem is that there are no specialised psychiatric services for children in this region. When required, I must look to units in Dublin or Galway or the paediatric hospitals for a bed for a child.
"Part of the treatment relies on agreeing a contract with the child in order to develop a normal eating pattern and getting their weight back to a normal level. We then work at an emotional level through cognitive behaviour and psychotherapy," Dr Halpin says. "Parallel work with the family is a vital part of the treatment. Unless they agree to be involved, it is extremely difficult to achieve a good result. Some will achieve a full recovery, while others will develop other mental health problems in adulthood such as depression or obsessive disorders."
In addition to highly influential teen and pre-teen magazines which purvey the "thin equals happy" allegory, there is another alarming threat to children's health. This comes in the form of dedicated websites promoting anorexia/bulimia as a lifestyle or popular culture, as opposed to the life-threatening illnesses they are.
While dolls like Barbie and GI Joe, and MTV's unrealistically thin images of young adults are presented to the young as the ideal, parents and society have an uphill battle. They might start by challenging those with a vested interest in promoting a tyrannical myth which brags that "happiness, love and success" are synonymous with being thin. These include advertising-courting media, the multi-billion dollar diet industry and the fashion industry. Perhaps one day, children might be permitted to accept their bodies exactly as they are, and to get on with the fun business of being a child.