CHAPTER 23 Eating and Feeding Disorders in Early Childhood Miri Keren Eating and sleep problems are among the most Brief Historical Considerations common for referral of infants and toddlers to pediatricians and to infant mental health units, Spitz, as early as 1946, observed a link between including our own (Keren, Feldman, & Tyano, severe food refusal and “anaclitic depression.” 2001). This is not surprising, as eating and Kreisler (1981) introduced the concept of devi- sleeping are the main daily activities during ant eating behaviors in the first year of life as the first year of life, and both are dependent on a psychosomatic disorder, like sleep problems, the interplay between an infant’s characteristics breath-holding spells, and infant colic, thus em- and a caregiver’s behaviors. phasizing the now well-accepted mind–body In this chapter, after reviewing some histori- interplay. Later, describing “psychogenic fatal cal considerations about the concept of eating vomiting,” Kreisler (1999) reminded us of how and feeding problems in infancy, I emphasize severe an eating disorder in the first year of life the distinction between eating and feeding pro- can be. Green (1985), drawing on the work of cesses and problems, then follow with a review Powell, Brasel, and Blizzard (1967), noted a of the parental risk factors and the role of the special category of reactive attachment disorder quality of the parent–infant relationship in the of infancy, “psychosocial dwarfism,” character- development of eating disorders. Regarding ized by growth retardation and mood distur- the classification of eating disorders in infan- bance associated with a reversible hypopituita- cy, I describe the similarities and differences, rism and low growth hormone levels. Through as well as the contributions and shortcomings, the 1980s, feeding disturbances were often of DC:0–3R (Zero to Three, 2005), DC:0–5 conflated with reactive attachment disorder, in- (Zero to Three, 2016), and DSM-5 (American cluding in DSM-III (American Psychiatric As- Psychiatric Association, 2013). I then provide sociation, 1980), but it is now clear that although a clinical description and treatment of each of eating disorders and attachment disorders may the three main categories—overeating disorder, co-occur, they are distinct disorders. undereating disorder, and atypical eating dis- Chatoor and Egan (1983), for example, re- order—with short, illustrative case vignettes. I ported their own observation that a disturbed end with a section on the different aspects of parent–infant primary caregiving relationship the evaluation of infants referred for an eating may be the underlying cause of a significant behavior problem. eating disorder, even in the absence of the ex- Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 392 EBSCO : eBook Collection (EBSCOhost) - printed on 7/2/2019 3:14 PM via TUFTS UNIV AN: 1843598 ; Zeanah, Charles H..; Handbook of Infant Mental Health, Fourth Edition Account: s3579704.main.ehost 23. Eating and Feeding Disorders 393 treme condition of reactive attachment disorder. procedures or conditions. On the other hand, Both Chatoor, Hirsch, Ganiban, Persinger, and disturbed eating may be observed only in the Hamburger (1998) in the United States and Kre- context of a specific feeding relationship, as it isler (1999) in France defined infantile anorex- reflects the disturbed dyadic or family relation- ia nervosa as clinical feeding disturbances in ship of which the eating problem is only one of which a very serious battle around control and its manifestations. separation–individuation takes place between an infant and mother, and often leads to forced feeding. In pediatric textbooks, the traditional Parental Risk Factors distinction between “organic failure to thrive” and “nonorganic failure to thrive” led to a di- Maternal eating disturbances, including buli- chotomous approach that did not fit the clinical mia and anorexia nervosa, are risk factors for reality. Currently, the most accepted approach all types of eating disorders in infancy. In the is the multifactorial one that integrates the Avon Longitudinal Study of Parents and Chil- physical and psychological aspects of normal dren (ALSPAC), women with lifetime eating and abnormal eating behaviors (Benoit, 2009; disorders have been compared with women Bryant-Waugh, Markaham, Kreipe, & Walsh, without any lifetime psychiatric disorder (Mi- 2010). cali, Simonoff, Stahl, & Treasure, 2009, 2011). The authors’ main finding was that lifetime eat- ing disorder and active eating disorder during Eating and Feeding Disorders pregnancy increased the risk for infant feeding difficulties, while maternal distress (depression Beyond their nutritional aspect, meals are so and/or anxiety) was the main mediating factor. central in the very young child’s daily life that A controlling parenting style during mealtimes the quality of the feeding and eating experience and play was observed among mothers with affects the child’s sense of security and basic eating disorders of all kinds, while their infants trust, inner sense of self, mastery, autonomy, suffered from eating problems (Cooper, Whel- and initiative. Metaphorically, we may define an, Woolgar, Morrell, & Murray, 2004; Micali the optimal value of a meal as the sum of its et al., 2009, 2011; Stein et al., 2001). calories and its related emotional experience. A longitudinal study of mothers and fathers The term “feeding” reflects the interaction with binge-eating disorder and their children at that takes place between the caregiver and the 18 and 36 months of age (Cimino et al., 2016) infant, whereas “eating” reflects the infant’s showed that the presence of this diagnosis in autonomous handling of food (e.g., reaching for one or both parents influences the severity of food, opening the mouth, swallowing). Obvi- maladaptive parent–infant feeding interactions ously, the younger the child, the more depen- and the children’s emotional–behavioral prob- dent he or she is on the caregiver’s attitudes lems over time. Sherkow, Kamens, Megyes, and on the quality of their relationship in the and Loewenthal (2009) observed mother–infant development of his or her eating patterns. Birch dyads at a therapeutic play nursery for mothers and Doub (2014) have described the process of with eating disorders and their children, and infants learning to eat in the first 2 years of life, suggested a developmental pathway, as well as and have shown how parenting and feeding ap- several mechanisms that help in understanding proaches may facilitate or impede the child’s the pathogenesis of the intergenerational trans- development of self-regulation of hunger and mission of eating disorders from mothers to food preferences. For instance, feeding prac- daughters. tices that encourage eating for soothing may Maternal depression and anxiety have been promote a dysfunctional habit of eating in the consistently associated with feeding difficul- absence of hunger. ties in young children (Benoit, 2009; Blissett, Not all eating problems are relational. In- Meyer, & Haycraft, 2007; Chatoor, Hirsch, et deed, on the one hand, the very young child’s al., 1998; Coulthard, Blissett, & Harris, 2004). eating disturbance may be a reflection of his Stein and colleagues (2001) have further char- or her own characteristics, such as constitu- acterized the feeding styles of these mothers as tional difficulties of state regulation, difficul- nonresponsive (i.e., too controlling, too indul- ties in making changes and transitions, sensory gent or underinvolved). Noncontingent feeding, Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. aversions, and reactions to traumatic medical in turn, has been related to under- or overweight EBSCO : eBook Collection (EBSCOhost) - printed on 7/2/2019 3:14 PM via TUFTS UNIV AN: 1843598 ; Zeanah, Charles H..; Handbook of Infant Mental Health, Fourth Edition Account: s3579704.main.ehost 394 IV. Psychopathology conditions among young children (Micali et al., toms on the Edinburgh Postnatal Depression 2009). A relatively recent study (Braden et al., Scale. In another study of 219 fathers of infants 2014) has shown that mothers with binge eating ages 1–24 weeks, Cockshaw, Muscat, Obst, and and depression tend to offer food to soothe their Thorpe (2014) found a link between paternal child’s negative emotions, which leads the child depressive symptoms and infant feeding dif- to develop “emotional eating.” ficulties. Similar findings about the impact of Parents who have conflicts about control of parent depression and parenting stress on the their own food intake often adopt controlling young child’s eating behavior (both undereating child-feeding practices in an attempt to prevent and overeating) have been reported (Hughes, the child from becoming overweight (Birch Power, Liu, Sharp, & Niklas, 2015). General & Davison, 2001), instead of promoting their risk factors, such as low parental education, child’s ability to self-regulate intake. Sonnev- low income, and young maternal age, have been ille and colleagues (2013) have found a strong found to be relevant both for undereating and link between parental control and overeating, overeating (Dubois, Farber, Girard, Peterson, & and food sneaking,