ChtldAhu.se& Neglect, Vol. 15, pp. 77-88, 1991 0145-2134/91 $3.00 + .00 Printed in the U.S.A. All rights reserved. Copyright © 1991 Pergamon Press plc

REPORTED HYPERPHAGIA IN FOSTER CHILDREN

JANET M. DEMB

Department of Psychiatry, Albert Einstein College of Medicine and Foster Boarding Home Program, St. Dominic's Home, New York

Abstract--In evaluating a large group of foster children from biological families with a high incidence of alcohol and/or drug abuse, there emerges a subsample of children with both atypical eating patterns as well as atypical behavior patterns. Their physical and behavioral characteristics are described. These children are neither obese nor "failure to thrive." They display an excessive appetite for food, a driven quality to their eating, an apparent lack of satiety, and frequent eating to the point of vomiting or gastric pain if food intake is not limited externally. All of these children have psychiatric disorders. Hyperphagia appears to be a marker for significant psychopathology.

Key Words--Hyperphagja, Psychopathology, Foster care.

INTRODUCTION

ABUSED AND/OR NEGLECTED CHILDREN have been observed to display a variety of behaviors which reflect their abuse/neglect. Disturbed eating and disturbed growth have been reported in such children. Spitz and Wolf (1946) described neglected children in hospitals who were apathetic, did not gain weight normally, and whose developmental milestones were delayed. More recently, Ferholt et al. (1985) and Powell and colleagues (1967, 1972) have reported psychosocial dwarfism, in which height growth and weight growth were dramatically slowed as a result of emotional factors.

In contrast to abused/neglected children with apparently reduced food intake, stands a group of previously unreported abused/neglected foster children with apparently increased food intake. Their eating patterns closely resemble hyperphagia as defined and reported by Danford and Huber (1981) in their study of institutionalized, retarded adults.

The present study compares foster children who are reportedly hyperphagic with foster children who are not to see what behaviors are characteristic of hyperphagic foster children and to see what effect their hyperphagia has upon their height and weight growth.

METHOD

The records of 200 foster children ranging in age from 8 weeks to 14 years of age were reviewed. This group included all children who were referred for mental health evaluations in a foster care agency during a 28-month period, and represented 22% of the entire population of 924 children served by this agency during this period of time. A subsample of children (n = 10) was identified who were reported by foster mothers as having an excessive appetite for

Received for publication January 3, 1989; final revision received December 5, 1989; accepted December 8, 1989.

Reprint requests may be addressed to Janet M. Demb, Ph.D., Children's Evaluation and Rehabilitation Clinic, Rose F. Kennedy Center, Albert Einstein College of Medicine, 1410 Pelham Parkway South, Bronx, NY 1046 I.

77

78 Janet M. Demb

food, a driven quali ty to its consumpt ion , an apparent lack o f satiety, and frequent eating to the point o f vomi t ing or gastric pain if food intake was not limited externally. These behaviors were reported by foster mothers to the au thor in the course o f menta l health evaluat ions o f their foster children, and these reports serve to define hyperphagia in this s tudy and qualify a child for inclusion in the subsample o f reportedly hyperphagic children (HC). In each case, children were referred by social workers to the au thor for a problem other than hyperphagia, and the abnormal eating was an accidental finding at the t ime of the menta l health evaluation. All o f the foster mothers l imited the a m o u n t o f food these children were allowed to eat so that they only rarely actually ate to the point o f d i scomfor t or vomiting.

Height and weight o f children in the subsample were based on growth charts in medical records, and psychiatric diagnoses o f the mothers came f rom psychiatric records. Intellectual status was based on s tandardized tests adminis tered by a licensed psychologist using the Merrill Palmer, the Stanford Binet, or the Wechsler. Psychiatric diagnoses were made by a single child psychiatrist using criteria o f the Diagnostic and Statistical Manual of Mental Disorders. II1 (1980). Psychot rophic medica t ion was prescribed by the same child psychia- trist. Evidence o f a need for educat ional assistance was based on a child 's enro l lment in special educat ion. Evidence o f m a n a g e m e n t problems was based on a child having been designated as having "special needs" by New York City 's Special Services for Chi ldren because o f danger to themselves or others.

The 190 referred foster children (RFC) were c o m p a r e d to the subsample o f 10 hyperphagic children (HC) for intelligence, psychiatric diagnosis, the need for psychot ropic medicat ion, the need for special educat ion, and the incidence of"spec ia l needs." A normal approx imat ion to the b inomial was used to establish statistical significance.

R E S U L T S

Food Intake

W h e n they entered foster care, seven boys and three girls between the age o f six mon ths and six and a half years satisfied the criteria for hyperphagia. They remained in care for an average o f 24 m o n t h s with hyperphagia reported within 3 m o n t h s o f entry for 3 children and no t for over 4 years for one child (Table 1).

The foster mo the r o f Child #1 reported:

He eats like there's no tomorrow. He eats and eats and eats. Since he's been in my house, his appetite has never changed. I buy him a pound of potato salad in the deli, and he eats it all. He must be sick. Why does he eat so much? Is there something wrong with his insides? He eats so much it just gets you disgusted.

The foster mo the r o f Child #8 reported:

She does not know when she has enough, but she never eats until she vomits. Last Tuesday I gave her a whole steak. I don't eat a whole steak! She finished it with a large helping of mashed potatoes and licked the plate clean. I gave her more steak, and she ate that too and then ices. My neighbor brought ices for the children because she didn't know they already had dessert. A. ate that and then the bag of potato chips my husband brought home. Before she went to bed she had a peanut butter and jelly sandwich, and then she vomited. I think she would always eat this way, but I don't let her.

W h e n asked to record all the food her HC would eat in a 24-hour period if not limited, one foster mo the r responded incredulously, " Y o u m e a n you want me to let h im eat until he vomits?" Ano the r described how she feared for her H C ' s safety when food was s teaming hot or frozen. " W h e n he eats ice cream, he gets froze up, and I a m scared he will choke on me."

Hyperphagia in foster children

Table 1. Hyperphagia in 10 Foster Children

79

Age/Entry Age/Report Child Sex (Months) (Months) Report of Hyperphagia

1 M 6 58 2 M 39 50

3 M 51 54 4 M 7 19

5 M 13 29 6 F 78 78

101

7 F 71 82

8 F 43 58

63

9 M 78 81

94

l0 M 48 57

"Eats like there's no tomorrow." "He will eat all I can give h i m . . , he will somet imes eat until he

vomits ." "He eats until he v o m i t s . . , eats mucous . " "(Mrs. R.) feeds h im until she feels his s tomach to be hard and

protruding then stops." "He eats like a m o n s t e r . . . R. will keep eating until I stop h im." "Her appetite seems to be insatiable, with T. eating to the point o f

regurgitation." "At this point she is said to have no limit to the a m o u n t of food

she will consume ." "M. is said to eat all day l o n g . . , never refuses f o o d . . .

occasionally eats until vomits ." "She is said to have an eno rmous appetite and will eat on and on if

not l imited." "'She will keep eating as long as you give h e r . . , does not know

when she has enough." "R. eats too m u c h . . , until I stop h im or until he huffs and puffs

in distress." "R. is said to have no control over his e a t i n g . . , eats until he has

trouble breathing." "L. will overeat unless food intake is l i m i t e d . . , he sneaks food

away and gets sick."

Accounts of hyperphagia were communicated with revulsion, anxiety, and disbelief (See Table 1).

Physical Parameters

All HC received physicals within one month of entry into foster care and were found to be without chronic illnesses. Heights and weights were recorded at entry into foster care and prior to discharge with placements ranging from seven months to four and a half years. Children #3, #5, #6, #7, and #8 showed height and weight stability, although #6 had stunted growth. Another, Child (#4), also with stunted growth, showed a drop in weight relative to height. Child #9 showed an increase in height relative to weight, while Child #2 and Child # 10 increased in weight relative to height. A single child (#1) showed marked increase in both height and weight (see Figures 1-6).

Diagnosis and Management

Mental retardation was diagnosed for children whose IQ was below 70 on a standardized intelligence test. Three HC (30%) were mentally retarded (Table 2). Mental retardation was found in 31% of RFC, indicating no statistically significant difference in intellectual function- ing (z = .146, NS).

Other psychiatric disorders were also present. Two had Pica, three had Atypical Conduct Disorders, four had Attention Deficit Disorders with Hyperactivity, and five children were diagnosed as having pervasive developmental disorders (Infantile Autism and Atypical Perva- sive Developmental Disorder) (see Table 2). Of the HC, 50% were diagnosed as having perva- sive developmental disorders compared to 21% of RFC (z = 1.86, p < .05).

Among HC, 4 (40%) received psychotropic medication, with 2 receiving antipsychotic

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medication and 2 receiving medication to reduce activity level. Three more HC were felt to need psychotropic medication, but natural parents refused permission for its administration (Table 2). Of the RFC, 7% received psychotropic medication (z = 3.57, p < .01).

In the HC group, nine (90%) were designated as having "special needs" (Table 2) with reasons for this designation including three setting fires, one breaking a teacher's hand, and

Hyperphagia in foster children 81

cm 50 55 60 65 70. 751 80, 85 . 90 9'5 100 J in 19202! 222324. 2 5 2 6 2 7 2 8 2 ' 9 3 0 3 1 3 2 3 3 3 4 3 5 3 6 3 7 ' 383'94'0

Figure 2. Child #1 (A) and #4 (O): Physical growth, National Center for Health Studies, weight/height ration, boys, birth to 36 months.

one being severely self-abusive. Special needs designation was given to 8% o fRFC (z = 8.98, p < .01).

Among the HC group, 9 (90%) received either special education in public school or in a therapeutic nursery (Table 2), and 50% of RFC required special education (z = 2.15, p < .02).

Natural Mothers

Four natural mothers of HC received psychiatric evaluations. All suffered from some form of depression, and three were additionally diagnosed as having a personality disorder. Of the

82 Janet M. Demb

nine often mothers with psychosocial histories available, five were known to be alcoholic, one to be on methadone maintenance, and two to have unspecified drug abuse problems. Material was not available on RFC's mothers.

DISCUSSION

The disordered eating displayed by the children in this study did not fall into the traditional eating disorders of Anorexia Nervosa, Bulimia Nervosa, or Rumination Disorder of Infancy (see DSM-III-R, 1987). They had a constellation of behaviors characterized by hyperactivity, impulsivity, attention deficits, poor interpersonal skills and poor communication skills, in- cluding poor articulation. Distortions of development of social skills and language were so severe that half of these children were diagnosed as having a pervasive developmental dis- order. They required psychotropic medication, special education, and an extraordinary de- gree of supervision, significantly more often than other children referred for mental health service.

Although hyperphagia was reported in only 5% of children referred for mental health evaluations at a foster care agency, it is possible that the prevalence of this symptom is somewhat higher. Children who appear well nourished, are not obese, and whose appetite is reported to be "good" seldom have a detailed account taken of their eating habits. Two children in the subsample had notations of "good appetite" interspersed with accounts of grossly deviant eating. Once having established that a child's appetite is good, one must ask if a child would eat too much. A positive response to this probe would then lead to relevant questions such as:

• How much food does he eat before seeming full? • What does he do about food between meals? • What does he do if you continue to offer him food? • Does he eat from the garbage? • Does he eat until satisfied or until uncomfortable? • Would he eat until he vomits?

Although this study included only foster children, there is no reason to believe that reports of hyperphagia are restricted to foster children. One child (# 10), whose father was available for questioning, identified his son as having been hyperphagic prior to foster care. It is very tempting to explain the reports of hyperphagia as simply being an effect of early deprivation, but it should be emphasized that such reports were rare even in a group of neglected/abused foster children. One might argue that these children were being emotionally deprived while in foster care, but evidence from social workers does not suggest this. In fact, foster parents of HC were repeatedly described as tolerant and nurturing and chosen because they were adept at meeting needs of difficult foster children.

Children in this study had eating characteristics almost identical to those described by Danford and Huber (1981) in their study of institutionalized adults, but these were children who lived in the community, and most were not retarded. These children had eating charac- teristics similar to autistic children described by Kanner (1937), but only one was autistic. Although these children were reported to be hyperphagic, they were not obese, and they did not suffer from Prader-Willi syndrome commonly associated with childhood hyperphagia or from other serious illness. Unlike the children studied by Ferholt et al. (1985) or by Powell

Hyperphagia in foster children 83

2 ~ 3 4 - - 5 6 ~ 7 ~ 8 ' -' 9 ~ ' ~ 1 0 ~ T l ~ 1 2 ~ 1 3 ~ 1 4 - . - ~ - l S ~ Z ~ 1 7 ~ 1 , q

Figure 3. Child #6 (O), #7 (A), and #8 (D): Physical growth, National Center for Health Studies, percentiles for height and weight, girls, 2 to 18 years.

and associates (1967, 1972), half of the children in this study did not have a surge in height or weight upon environmental change.

In the absence of deprivation as a sufficient explanation for hyperphagia, other possibilities suggest themselves. The mothers of HC characteristically were substance abusers. Prenatal exposure to alcohol or other drugs may have resulted in central nervous system deficits in these children.

Recently, hormones have received much attention in connection to feelings of satiety after meals as well as to the lack of these feelings in bulimics. HC were noted to seldom appear to be satiated but rather they seemed to maintain an inner experience of hunger despite eating even

84 Janet M. Demb

Figure 4. Child #6 (O), #7 (A), and #8 ([]): Physical growth, National Center for Health Studies, weight/height ratio, girls, prepubescent.

to the point of vomiting. Lowered levels of the hormone cholecystokinin has been implicated by Geracioti and Liddle (1988) as an explanation for bulimia, while Geary (1981) found that injecting natural peptides have resulted in normal eaters eating smaller meals. These findings may have relevance for mechanics underlying hyperphagia in children.

These preliminary clinical observations of hyperphagic children open the way for much speculation. In order to provide necessary data to illuminate this observed phenomenon, it would be helpful to ask questions which identify hyperphagic children, collect longitudinal data, study such children in a controlled setting where accurate records of intake and output can be kept, study rates of metabolism of these children, and study such children in a setting where the quality of caregiving can be documented.

Hyperphagia in foster children 85

2 - - 3 - - - - 4 - - 5 - - - 6 - 7 - 8 9 10 - 11 - 1 2 - 1 3 - 1 4 - 1 5 - 1 6 - - 1 7 - - - 1 8

Figure 5. Child #2 (A), #3 (R), #5 (O), #9 (V) and #10 ()): Physical growth, National Center for Health Studies, percentiles for height and weight, boys, 2 to 18.

Janet M. Demb

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Figure 6. Child #2 (A), #3 ([~), #5 (©), #9 (V) and #10 (~'~): Physical growth, National Center for Heal th Studies, weight/height ratio, boys, prepubescent.

SUMMARY

Hyperphagia was reported to be present in a subsample of ten foster children referred for mental health evaluations. These children displayed disordered behavior characterized by

Hyperphagia in foster children

Table 2. Diagnoses and Management of HC

87

Mental Psychotropic Special* Special Child Retardation Diagnoses Medication Needs Education

1 No Attention Deficit Disorder with Permission Refused Yes Yes Hyperactivity, Atypical Conduct Disorder

2 No Atypical Pervasive Developmental No No No Disorder

3 No Atypical Pervasive Developmental Thioridizine Yes Yes Disorder, Pica, Functional Encopresis

4 No Attention Deficit Disorder with Permission Refused Yes Yes Hyperactivity, Pica

5 Yes Atypical Pervasive Developmental Dextroamphetamine Yes Yes Disorder, Pica

6 Yes Infantile Autism Thioridizine, Yes Yes Haloperidol

7 No No Yes Yes

8 No No Yes Yes

Atypical Pervasive Developmental Disorder

Adjustment Disorder with Mixed Disturbance of Emotion and Conduct, Borderline Personality Dis.

9 No Atypical Conduct Disorder, Methylphenidate Yes Yes Attention Deficit Disorder with Hyperactivity, Borderline Personality Disorder, Stuttering

10 Yes Atypical Conduct Disorder, Permission Refused Yes Yes Attention Deficit Disorder with Hyperactivity

* City of New York designation for foster children requiring extraordinary care.

hyperac t iv i ty , p o o r impu l se cont ro l , p o o r in t e rpe r sona l skills, a n d p o o r c o m m u n i c a t i o n . T h e y were f requen t ly d i agnosed as hav ing pervas ive d e v e l o p m e n t a l d isorders . The m o t h e r s o f these ch i ld ren were r epo r t ed to have an ex t r eme ly high inc idence o f d rug a n d a lcoho l abuse. Repo r t s o f h y p e r p h a g i a migh t be m o r e c o m m o n i f specific ques t ions were asked a n d such ques t ions w o u l d lead to m o r e accura te r epor t ing o f hyperphag ia . R e p o r t e d h y p e r p h a g i a shou ld a ler t p rofess iona ls to the poss ib i l i ty o f assoc ia ted psychopa tho logy .

Acknowledgement--The author thanks Gary Diamond, M.D., Ruth Kaminer, M.D., and Bea Soles, C.S.W. of the Rose F. Kennedy Center for their helpful input.

R E F E R E N C E S

Diagnostic and statistical manual of mental disorders (3rd ed.). (1980). Washington, DC: American Psychiatric Association.

Diagnostic and Statistical manual of mental disorders (3rd ed. rev.). (1987). Washington, DC: American Psychiatric Association.

Danford, D., & Huber, A. M. (1981) Eating dysfunctions in an institutionalized mentally retarded population. Journal for Intake Research, 2, 281-292.

Ferholt, J. B., Rotnem, D. L., Genel, M. Leonard, M., Carey, M., & Hunter, D. E. K. (1985). A psychodynamic study of psychosomatic dwarfism: A syndrome of depression, personality, and impaired growth. Journal of the American Academy of ChiM Psychiatry, 24(1 ), 45-57.

Geary, N. ( 1981 ). Injected peptide produces satiety. The Monitor (American Psychological Association), 20(3), 8. Geracioti, Jr., T. D., & Liddle, R. A. (1988). Impaired cholecystokinin secretion in bulimia nervosa. The New

England Journal of Medicine, 319( 11 ), 683-688.

88 Janet M. Demb

Kanner , L. (1937). Child psychiatry (pp. 213-218, 340, 351). Springfield, IL: Charles C. Thomas . Powell, G. F., Brasel, J. A., & Blizzard, R. M. (1967). Emotional deprivation and growth retardation simulat ing

idiopathic hypopituitarism: Clinical evaluation of the syndrome. New England Journal of Medicine, 276, 1271- 1278.

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R6sum6- -Lors de l '6valuation d ' u n grand nombre d 'enfants en famille d'acceuil, issus de families biologiques pour la plupart alcooliques ou toxicomanes, un sous-groupe d 'enfants a 6t6 identifi6: ceux-ci pr6sentaient ~ la fois un compor- tement et des habitudes alimentaires atypiques. Leurs caract6ristiques physiques et compor tementa les sont d6crites. Les enfants ne sont atteints ni d'ob6sit6 ni de nan isme affectif, lls pr6sentent une attirance excessive pour la nourri ture et une pulsion ~ manger avec une apparente absence de sent iment de sati&6, lls mangent f r6quemment jusqu '~ vomir ou d6velopper des douleurs abdominales si personne ne limite leurs apports alimentaires. Tous ces enfants pr6sentent des troubles psychiatriques. La boulimie semble un marqueur d ' une pathologie psychiatrique significative.

R e s u m e n - - D u r a n t e la evaluaci6n de un grupo grande de nirios adoptivos provenientes de familias biol6gicas con una alta incidencia de abuso del alcohol y/o las drogas, surge una submues t ra de nirios tanto con patrones de comer anormales como con patrones anormales de conducta. Se describen sus caracterlsticas fisicas y conductuales. Estos nirios no son ni obesos ni con "'fracaso para el crecimiento" ("failure to thrive"). Demuest ran un excesivo apetito por la comida, una forma obsesionada de comer, una falta aparente de saciedad, y comen con frecuencia hasta el punto de vomitar o sufrir dolor de e s t rmago a menos que el consumo de al imentos no se limite externamente. Todos estos nirios padecen desordenes psiquiStricos. La hiperfagia parece sera una serial significativa de psicopatologia.