Childhood Sleeping Problems and Eating Disorders

New Years Day – Happy New Year Everybody!

Apologies for the un-festive post, I cannot help it- I have been thinking about a subject and find it so interesting that I cannot wait to write about it. Mostly, I await the opinions of readers that I have found are often forthcoming when I post a blog. In this subject area I thrive off the thought provoking notions that other people present me with. Especially the ones conflicting to my own opinion and experience.

Childhood sleeping patterns and the predictive quality that they present for adolescent onset of eating disorders……..correlational observations, personal experience and many questions!

What started me off on this topic was reading an interesting  ongoing study by Helping to Outline Paediatric Eating Disorders (HOPE). The HOPE project gathers information on children and adolescents with eating disorders. The registry database to date contains 941 assessments, of whom 685 met DSM-IV diagnostic criteria for an eating disorder at admission. The majority of the sample were females (91%) from metropolitan Perth (83%). The cases with eating disorders consist of eating disorders not otherwise specified (EDNOS) (68%), anorexia nervosa (25%) and bulimia nervosa (7%). Among those with eating disorders, a history of weight loss since illness onset was almost universal (96%) with fear of weight gain (71%) common, and the median duration of illness was 8 months.

Obviously I have some issues with the catchment area of this database being so small, with 83% of the participants coming from Perth. I also think that there should be more of an effort to sample males and diagnose eating disorders in males. I always internally sigh when I see  anorexia being grouped in with eating disorders in general because I think that it is so different from bulimia or EDNOS. Most patients in the HOPE Project registry met the criteria for EDNOS. I am surprised that the mean duration of the illness was only 8 months.

On average, patients presented symptoms of weight loss at  14 years of age with a recent history of weight loss and parental reports of a change in behavior around food and eating. Intense exercise was present in 45% of the sufferers, self-induced vomiting in 28%, and objective binge eating in 19%.  HOPE has found that similar to observations in other pediatric studies , laxative and diuretic misuse among children and younger adolescents is rare, perhaps because these are harder to access for this age group and require financial resources. Also prevalence may be higher than self-report. Personally I think this is probably because children do not think of laxatives as an option and are more inclined to use things that they know are in their control, over- exercising being the first option.

((Going off on a bit of a tangent here- I would also like to comment that observations like this highlight the problems that occur when different types of eating disorder are lumped into one. I personally thing that anorexics are less inclined to use laxatives. As in my own self I considered any outside help as….. rather like cheating. If one is going to use the term eating disorder I think that one could be referring to anyone that has affected behavior around food, which is inclusive of overeating, binge eating and obsessive eating. Its just impossible to find anything conclusive when all these disorders are grouped.))I am keeping an eye on the HOPE study, but so far I have not found anything reported that I think is particularly helpful, nonetheless unless we continue to watch, observe and record we cannot expect to learn, so I am all about praising the effort. 

Back to eating disorders in children, reading this HOPE study got me wondering about the predictive aspect of childhood eating habits. I find it interesting that studies show mixed results as to what is a likely indication of eating disorder potential. One might assume that early signs of problematic eating patterns in childhood may develop to more serious eating problems during adolescence but that is not my personal experience. To speak of my direct personal experience with anorexia; Of all of my sisters, I was the least fussy eater as a child. My younger sister on the other hand was very picky. I was the only sister to develop anorexia. In fact, my picky sister was in adolescence the most unaffected of all of us in terms of disordered eating. (Incidentally she also slept the best as a child) To speak of my experience with other anorexics, I have not noticed a trend between picky eater children and anorexic teens  when I have asked for parental reports on childhood behavior.

Looking at the scientific research as I like to do, so far, only a small number of prospective studies have assessed eating behavior in younger children (under the age of 10 years) and followed the respondents into adolescence. In one of these studies, ((Kotler, et al. (2001)) showed that  mealtime struggles with food, and eating conflicts in early childhood predicted eating problems in adolescence, but other types of problematic eating behaviors – such as picky eating – were not predictive.( I wonder if this was more to do with defiant behavior? I have seem correlation’s between defiance in childhood and anorexia in some research studies)

No longitudinal association was reported between childhood picky eating and eating concerns at age 14 in another study ((conducted by Martin et al (2000)).  Wertheim et al (2002) concluded that picky eating as a child was predictive of adolescent eating disorders. As usual, the scientific studies and reviews are not conclusive, measuring and recording eating disorders and attitudes toward food are tricky at best. I have found that there is no conclusive anything in any field of research that involves eating disorders and one can find a study to support ones particular interest or point of view. Relating to studies with children this gets even more like a shot in the dark. Reports are generally taken from parents, and with that comes the filter of the parents own attitude to food being projected onto the child. That is not to say that any parent would wish an eating disorder on their child, but just that it is natural to interpret behavior to ones own tendencies, experience and fears. For example, I do it all the time. I am very geared to assume that any act of food avoidance or lack of appetite spells an eating disorder. In reality there are many other conclusions that could be had. Stomach upsets and taste aversion are not conclusions that I naturally jump to, but they are valid considerations. I worked with one lady who was convinced that her 5 year old had an eating disorder, every time the child turned her nose up at food her mother concluded that she was showing signs of an eating disorder. I found this not to be the case, and on further investigation it turned out that the mother had suffered bulima and was terrified that her daughter would too. To this day the child still seems very healthy and thankfully her mother has learnt not to assume that her picky eater child had an eating disorder. On the flip side, I think many parents overlook eating disorders.

I just like to point out that parental ratings are not always going to be objective. But that said, we have to rate somehow and its the best measure that we have in this sort of situation.

All of that is not to say that the studies are not very useful as they are. We need to try and understand all forms of eating disorders with greater accuracy . I like this study that Hafstad et al conducted in 2013 which looked at early childhood precursors for eating problems in adolescence. It was a 15 year longitudinal study that interviewed parents via a questionnaire when their children were 1.5 years old and then again a year later. Of the 921 parents interviewed, 373 of the children were found and given the EAT (Eating Attitudes Test) at age 16. Whilst this study did not conclude that picky eating in childhood resulted in eating problems in later life (it seems that the majority of studies that I have come across agree with this- not all, but most) what it did find was that early childhood sleeping problems (rated by the mother) predicted self -rated eating problems in the 16 year old when questioned.

Due to my opinion that research on eating disorders is largely flawed due to the lack of understanding of the generic category “eating disorders” I dislike concluding anything from studies. Rather I prefer to use the information to question what I know about my own experience with anorexia and those that I have had the pleasure to work with. I did not sleep well as  a child. I slept better as a teen and them suffered hideous insomnia when I was anorexic. I think that there is something worth questioning in this. Only in full recovery have I seemed to of mastered the art of “sleeping like a baby” which is ironic when you consider that as a baby I did not sleep well at all 😉

One can only look at correlation as an interesting point for further investigation.

Is there something in the pattern of children who have difficulty sleeping and adolescents that go on to develop eating disorders?

Is this true only for anorexia as it was in my personal experience or does it also hold for bulimia and EDNOS?

Do other anorexics suffer insomnia as I did? I know a few that sleep very well indeed and some that do not.

What are they opinions from those of you that have experience with bulimia or EDNOS?

How about overeating or binge eating and sleep patterns?

All comments very welcome! In fact this is the reason that I have left this blog so vague and open. I could just read research papers, and I will do that anyway, but I want some personal opinions and thoughts.  If you have an opinion which is without any scientific basis or backing please feel free to comment as I am very interested in intuition and experience over quoting research studies alone. Likewise if you have an academic opinion without experience of eating disorders your voice is welcome also. I like to learn from all.

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