Anorexia nervosa is serious mental health problem marked by extreme weight loss and an excessive fear of weight gain. In children and adolescents as well as extreme weight loss it can also be seen as a failure to make expected gains in weight and height. Although it only affects a small number of individuals it can have serious effects on physical health and serious psychological consequences. For some people it is a lifelong problem. What we understand from research is the longer it goes untreated the harder it is to get better from. Adolescence is the most likely time to develop anorexia nervosa. This illness is more commonly seen in girls but it appears it is becoming more frequent in boys. The negative consequences of eating disorders on physical health are much stronger in children and adolescents than in adults because the eating and exercise behaviours can disrupt normal physical development. The causes of Anorexia Nervosa are unknown or at the very least unclear. This is important to state because families often believe they are in some way to blame for their child becoming unwell.
The key to treating anorexia nervosa is catching it early.
We know that families are good at detecting the signs and symptoms of anorexia nervosa. If you are worried that your child may be developing an eating disorder, you should observe their behaviour for any warning signs. These warning signs can include
 Gradual changes in behaviour and appearance occurring over months or years
 Dieting behaviours ,e.g. fasting, counting calories

• A narrowing of food choices or changes in food preferences e.g. refusing to eat certain ‘fatty’ or ‘bad’ foods, cutting out whole food groups such as meat or dairy, or claiming to dislike foods previously enjoyed
 Increasing absences from family meals
 Excessive exercise patterns which may include exercising when injured or in bad weather
 Gradual withdrawal from social activities, particularly involving eating or drinking
 Behaviours focused on food, e.g. preparing and cooking meals for others but not actually eating or increased interest in cookbooks, recipes and nutrition
 There may be an attempt to conceal noticeable weight loss or the evading of questions about eating and weight

If you suspect that a child or young person is developing an eating disorder seek professional help. The South Island has a specialist eating disorders service based in Christchurch at Princess Margaret Hospital. They provide specialist support to other mental health professionals based throughout the South Island about eating disorders. They offer a wide range of treatments for those aged 14 years of age upwards. For those aged up to 19 they offer a treatment called Maudsley Family Based therapy. This treatment is based on work from the Maudsley Hospital in London, The University of Chicago, and Stanford University which has demonstrated that families can be an important resource for younger patients suffering from anorexia when they are included in the therapeutic work. In this treatment families are empowered to take charge of the illness. This treatment has a success rate of around 70% for those young people who have had the illness for less than 3 years. If you have concerns about your family member contact your GP who can refer you onto the service.

Ten-year old Mandy takes three times as long to finish her meal as the rest of the family; three-year old Cameron objects to eating meat and he protests loudly and gags when it is placed in his mouth; fourteen-year old Jackie will only eat very small amounts and refuses foods perceived to be high in fat or sugar; six-year old Cheryl dawdles through breakfast and is always late for school; and eight-year old Shamus will not eat his meal if the different food types have touched each other on the plate. In all of these cases, there is significant stress for parents and children at mealtimes.
Of these children, only Jackie is underweight, but all of the parents of these children are distressed by their children’s food refusal. There are few things that make parents more anxious than their child refusing to eat, and of all of the difficulties that parents face with their children, food refusal is near the top of the list in terms of parental distress. This is not surprising, given that one of the fundamental tasks of parenting is to ensure that one’s children thrive physically which obviously depends on adequate and appropriate nutrition.
There are many factors that contribute to food refusal in children. For the purposes of this article, we will concentrate on biological, learning, relationship and behavior management factors. Bear in mind that more than one factor may be at work in any one case.
On a biological level, children refuse food for a number of reasons. There may be difficulties with swallowing or chewing, resulting in choking easily, being unable to process food adequately before it is swallowed, or being able only to swallow very small amounts of food at a time. A number of medical conditions can result in abdominal discomfort after eating, and children who have been tube-fed for a long time may have to learn the basic skills of eating later than other children. Some children have high sensitivity to smell, taste, temperature and texture, resulting in resistance to particular foods or the mixing of food types, while others are cautious by nature, unwilling to try new eating experiences without a lot of gradual encouragement. Children who are particularly tired at the end of the day may not have the energy for the activities associated with eating, and those who have coordination problems may struggle to organize their eating activities in an orderly way.
Children also learn about food from their experiences with food and watching others’ reactions to food. So, a child who chokes easily may become anxious when it is time to eat and will try and avoid eating; a parent who expresses dislike of food or is anxious about weight gain or weight loss can induce anxiety about food in the child; or an adolescent whose peers are preoccupied with body shape may become preoccupied with hers (and consequently her food intake). In a home where food (or eating) has become a source of conflict, the level of tension at mealtimes is guaranteed to reduce people’s appetites; in a home where mealtimes are completely unstructured, children don’t learn to participate in the rituals and pleasure of preparing, eating and sharing food, missing out on the fun and enjoyment associated with mealtimes. Some children haven’t been taught about the importance of healthy nutrition and good eating patterns, depriving them of the knowledge necessary to make healthy eating choices. Of course, this assumes that the parent has no significant problems with food – eating difficulties in parents can result in eating difficulties in their children.
The parent-child relationship is critical to the development of healthy eating patterns. When the relationship is secure, the child is motivated to please the parent and keen to share activities with the parent. The child trusts that the parent knows and accepts him well enough that no unreasonable demands will be made of him, and that the parent will not expose him to unpleasant experiences. All of this means that the child is more likely to try new foods (when presented gradually), comply with parents’ requests to eat, and enjoy the rituals of food with the parent. From the moment of birth, food is a fundamental part of the parent-child relationship – it is by feeding the child that the parent ensures her survival – and it is primarily in the process of feeding that the child comes to trust that the parent will ensure that survival.
The way that parents manage their children’s eating behaviors have a significant impact on those behaviors. When mealtimes have become a battleground, eating is associated with unpleasant emotions, such as feelings of failure and anger in the parent, and feelings of inadequacy and fear in the child. Having said that, the battleground is usually perpetuated – negative attention is always better than no attention for children. They would rather have a parent sitting at the table with them for an hour and a half nagging them to eat, than only having fifteen minutes at the table with the parent’s attention shared with rest of the family. Making mealtimes rewarding (by including everyone in the event in a happy way; providing appropriate desserts as incentives for eating; ensuring that there is a period of pleasurable parent-child time after the meal) can go some way to reducing mealtime stress.
 In summary, food refusal is a complex issue, and it is important to address all of the factors discussed here. Parents can observe their children and make assessments of the four areas discussed here in order to highlight where the difficulties may be. Keeping a diary of mealtimes can help to pinpoint patterns of difficulty. Remember to note things like the time of day and everyone’s energy levels; the child’s eating behaviors, noting unusual features of the mechanical aspects of eating; and others’ reactions to those behaviors. Use the four categories outlined here – biological, learning, relationship and behavior management factors – to guide your observations. If you want professional advice about any of these areas, you can consult. A family doctor can assess any medical problems; a dietitian advises on nutritional issues; speech and language therapists and occupational therapists assess sensory and physical difficulties with eating; and a clinical psychologist will assess the relationship and behavior management issues.
The development of happy, healthy eating behaviors contributes to one’s individual and relationship satisfaction in significant ways throughout life.