eating dysfunctions in an institutionalized mentally retarded population

Appetite: Journal for Intake Research 1981, 2, 281-292

Eating Dysfunctions in an Institutionalized Mentally Retarded Population

DARLA ERHARD DANFORD Clinical Nutrition Research Center, University of Chicago Medical School

AGNES M. HUBER Department of Health Sciences, Sargent College, Boston University

Frequencies of eating dysfunctions (pica, rumination, aerophagia, hyperphagia, and anorexia) were determined in a survey of 991 institutionalized mentally retarded individuals. Of the group, ranging in age from 11 to 88 years with a mean age of 32 years, 41'6% had some form of eating dysfunction. Eating dysfunctions were distributed in the total population as 25·8% pica, 13-7% hyperphagia, 7'2% anorexia, 5'5% rumination and 2'7% aerophagia. With increasing age there was a marked decrease in incidence of eating dysfunctions. Since these dysfunctions are most frequent in the profoundly retarded population, the age-related change is accounted for by a reduction in number of profoundly retarded individuals in the older population. Eating dysfunctions were observed among all population subgroups identified. These dysfunctions were most significantly correlated with level of mental deficit, constipation, seizures, and certain medications (anticonvulsants, psycho tropics, food supplements, antacids, and iron), with certain physical characteristics (ambulation, sleep disturbance, abnormal weight, and place of eating), and with behavioral problems and food-related behaviors including food cravings and refusals. Eating dysfunctions tended to be coincident (e.g. individuals with pica frequently also had rumination and/or hyperphagia). Since a significantly high percentage of the population had some form of eating dysfunction, the nutritional consequences of these dysfunctions merit further investigation.

Appetite is a complex psychophysiological phenomenon affected by physical need, emotional state, habit, fatigue, and cultural and ethnic background. In the mentally retarded, observations indicate that appetite disorders occur frequently and warrant attention (Palmer & Ekvall, 1978).

Kanner (1937) described a variety offeeding problems in 20% ofthe mentally ill and retarded. These included "regurgitation and rumination, aerophagia, lack of appetite, ravenous (hyperphagia) and perverted appetite (pica)". Since then many cases of anorexia, multiple food dislikes, "bizarre food habits" leading to growth retardation, weight loss and malnutrition have been described (Bartlett, 1928; Coffey & Crawford, 1971; Palmer & Ekvall, 1978; Schwartz, 1958). Rumination (Ball, Hendricksen & Clayton, 1974; Cadman, Richards & Feldman, 1978; Sondheimer & Morris, 1979), anorexia (Bartlett, 1928), and pica (Halsted, 1968; Kanner, 1937; Oliver & O'Gorman,

This work was done in partial fulfilment of the requirements for the Doctor of Science degree at the Harvard School of Public Health.

From the Department of Nutrition, Harvard School of Public Health, Boston, MA and the Eunice Kennedy Shriver Center for Mental Retardation, Inc., Waltham, MA.

Requests for reprints should be sent to: Dr Agnes Huber, Department of Health Sciences, Sargent College, Boston University, 38 Cummington St., Boston, MA 02115, U.SA.

0195-6663/81/040281 + 12 $02·00 © 1981 Academic Press Inc. (London) Limited

282 D. E. DANFORD AND A. M. HUBER

1966; Verga, 1849) are described in the mentally retarded and have serious nutritional consequences. Growth retardation and emaciation in the adult may be the result of chronic rumination or anorexia (Coffey & Crawford, 1971; Palmer & Ekvall, 1978). The practice of pica may interfere with food intake (Palmer & Ekvall, 1978) or require surgical intervention (pers. obs.).

Reports on the frequency of such problems are scarce and only address pediatric populations (Coffey & Crawford, 1971; Palmer & Ekvall, 1978). Reports of feeding problem frequency in the pediatric mentally retarded have been as high as 40%. Bicknell (1975) estimated that 45% of children with Down's Syndrome had pica. Several investigators (Kanner, 1937; Oliver & O'Gorman, 1966) report an even higher frequency of 50-60% pica in mentally retarded children. Pica also occurs in the nonretarded. Children under six years of age and pregnant women have been reported with pica occurring in 10-50% of the population (Cooper, 1957; Edwards et ai., 1959; Ferguson & Keaton, 1950; Halsted, 1968). In these populations pica has been related to iron deficiency anemia (Mohan, 1968).

Rumination has been associated with psychological factors, cerebral dysfunction and digestive problems (Biox-ochoa, 1979). It is estimated that 10-15% of the institutionalized mentally retarded children chronically vomit or ruminate (Ball et aI., 1974; Cadman et aI., 1978; Sondheimer & Morris, 1979).

The frequencies of other eating dysfunctions in the mentally retarded such as aerophagia (excessive swallowing of air), hyperphagia (excessive appetite for food), and anorexia (lack of appetite) are not known. Aerophagia has been related to immaturity of development of esophageal muscle control and may occur in nervous individuals (Ganong, 1977). Hyperphagia and anorexia have been extensively explored in relation to hypothalamic appetite control and to a variety of psychological factors (Groover, 1978).

In view of the general under-reporting in the adult mentally retarded and the nutritional implication of such eating dysfunctions, a survey was undertaken to document the type and frequency of eating dysfunctions in an entire institutionalized adult mentally retarded population. The population surveyed consisted of 991 predominantly white adult retarded individuals, which consisted of approximately equal numbers of males and females. The specific purpose of the survey was to document the types of eating dysfunction as they relate to sex, age, mental deficit, etiological factors, medications and a variety of behaviors and nutrition-related factors. This study was important in that it identified problems and provided a basis for developing better nutritional care.

METHODS

Population

A population of991 individuals residing in an institution for the mentally retarded was surveyed over a two-year period (1977-79) for characteristics related to eating dysfunction. The population was a stable, diverse group ranging in age from 11 to 88 years, the majority being adults. The individuals resided in 20 buildings in a residential school-like environment. Some residents were bedridden, consuming their food in their residential buildings, while the others, all ambulatory, ate in a centrally located cafeteria.

EATING DYSFUNCTIONS IN MENTAL RETARDATION 283

Definitions of Eating Dysfunction

For this survey, pica was defined as the frequent consumption of non-food items such as soil, paper, leaves. Individuals who had an isolated incidence of non-food consumption or who ate food off the floor are not included in this group.

Rumination can include self-induced vomiting but we chose a more conservative definition wherein the individual repeatedly exhibited reverse peristalsis and then chewed and reingested the vomitus.

Aerophagia is identified as spasmodic swallowing of air, often accompanied by gastric distention and usually followed by oral expulsion of the swallowed air.

Hyperphagia 'is defined as excessive appetite for food accompanied by constant searching for food resulting in grossly excessive food intake. In some cases, individuals consumed up to 30 servings at one meal. Some individuals would eat to the point of hospitalization for gastric pain and/or vomiting.

Anorexia consists of persistent lack of appetite for food, and the need for others to encourage any food consumption. Only small amounts offood were tolerated by these individuals.

Some individuals vaciIlate between periods of anorexia and hyperphagia throughout the year. Such cases are categorized by the eating dysfunction which was observed at the time of the survey.

Survey Techniques

Survey data were collected over a period of two years. Observations of eating dysfunction were made by one person throughout this period. Once a patient was identified with pica or any other eating dysfunction, it was verified by interviews with the direct care staff. Some of these cases had been previously identified in the review of medical records. In general, pica was under-reported and rumination was overreported.

Most individuals with pica were further observed for eating behavior over a total period of30 hours per subject, occasionally less. (Several individuals could be observed simultaneously.) This was in order to exclude those individuals who exhibited mouthing or smearing behavior but who did not practice pica. Mouthing is defined tS the habit of putting objects in one's mouth to suck or chew but not to swallow them (e.g. hands, rags). Smearing is defined as the habit of spreading saliva, feces, etc. over one's bod y with the hands. If there was a difference of opinion whether a patient had a specific eating dysfunction, it was verified by direct observation at least twice.

Demographic data (age, race, sex, etc.) were obtained from each individual's medical record. The validity of these data was checked by observation and in general correlated well.

Etiology, current mental deficit (IQ), medical problems, and current medications were obtained from the medical records. For the majority of the individuals, etiology was unknown. Those individuals with a specific diagnosis were classified according to Holmes (1972). Only those individuals with IQ scores that were consistent from year to year were classified according to the degree of mental deficit.

Ambulation, activity level, weight, and place of eating were determined by observation. Ambulatory meant that the individual had the ability to walk independently and the non-ambulatory individuals were those confined to bed or wheelchairs. Sedentary individuals sat all day and/or exhibited little motion except


when encouraged. Moderately active individuals displayed a normal variety of activity, while very active individuals were in constant motion.

It was not possible to measure height and weight of all individuals since many buildings did not have accurate scales. Such measurements would have been complicated by the fact that height and weight standards do not exist for mentally retarded adults (Rosenthal, 197£). Over and underweight was ascertained visually using a classification on a 7-point scale from grossly obese to grossly underweight. Since our primary interest was in extreme differences ofweight, these individuals could be classified without any uncertainty. Verification by skinfold measurement was used in cases that were difficult to categorize visually (Seltzer & Mayer, 1965).

Behavior problems such as hyperactivity, self-abuse, and aggressive behavior were obtained from medical records as determined by staff physicians and psychologists. Food-related behaviors such as skipping meals, stealing food, food cravings, and food refusals were determined by observation during the mealtime and had to be present in at least two out of three consecutive meals observed. Again, these observations were verified with direct-care staff. Only when findings were verified by these two independent sources were they included.

Computer Analysis and Statistical Evaluation

The observations in this survey constitute a database of 375 variables, mostly binary (yes-present/no-absent), for each of the 991 individuals. The data were entered using a specially written interactive program (for rapid entry and efficient checking and error correction). Statistical analysis was performed using MAXI-SPSS (Nie et ai., 1975). Given the difficulty of comparing binary and continuous variables, frequencies and chi-square analysis were used to discover outstanding features of the data and significant associations between variables.

RESULTS

Table 1 summarizes the frequency of eating dysfunctions in the total population and their relationship to demographic data (sex, race, and age). Among the total population of991 mentally retarded residents in the institution, 42% had at least one form of eating dysfunction. Pica was the most frequent of these (26%), followed by hyperphagia (14%), anorexia (7%), rumination (6%), and aerophagia (3%). Since some subjects exhibited more than one eating dysfunction, the total of 42% is less than the sum of the incidences of individual dysfunctions.

The results show that eating dysfunctions were not related to sex or race, except that rumination occurred predominantly among males (p < 0·05), and aerophagia was absent from the black population (p < 0·001).

The population ranged in age from 11 through 88 years with a mean age of 32 years and a median age of 27 years. There was a decrease with age in the incidence of pica (p < 0·01), rumination (p < 0·01), aerophagia (p < 0·05), anorexia (p < 0·00 1) and one or more eating dysfunctions (p<O·OOl). However, pica seemed to increase in the population after age 60 and those over 70 showed the highest incidence of 39%.

Table 2 relates eating dysfunction to mental deficit, etiology of the mental retardation, medical problems, and current medications. With more severe mental


TABLE 1 Relationship of eating dysfunctions to sex, race and age

Percentage of subjects showing:

Population No. of One or more characteristics subjects Pica Rumination Aerophagia Hyperphagia Anorexia dysfunctions

Total population 991 25·8 5·5 2·7 13-7 7·2 41·6 Sex

Male 560 23·8 6'8* 2'5 14'6 6·6 40'5 Female 431 28·5 3·7 3·0 12·5 7·9 42·9

Race White 953 25·8 5·1 2'7*** 13-4 6'7** 40'9* Black 36 25·0 13-8 0 19·4 19·4 55·6

Age 11-20 129 30'2** 10·1 ** 7'0* 11·6 17'8*** 58·1 *** 21-30 436 27·3 7·8 3-4 14'7 6·7 44·5 31-40 226 29·2 2·7 1·3 17·7 5·8 42·5 41-50 93 16·1 1·1 0 9'7 3·2 25·8 51-60 73 12·3 0 0 8·2 4·1 20·5 61-70 21 14·3 0 0 4·8 0 14·3 71+ 13 38'5 0 0 8·0 0 38'5

Chi-square tests show that the subgroups of Sex, Race and Age display significant variations of incidence: *p<0'05; **p<O'Ol; ***p<O·OOl.

deficits all eating dysfunctions [pica (p < 0'001), rumination (p < 0'01), aerophagia, hyperphagia and anorexia] tended to show a higher frequency than in less retarded subjects. Rumination, hyperphagia and pica were observed to be equally distributed among all etiologies, whereas anorexia was notably higher in the category of central nervous system diseases and acquired etiology (p<O·Ol). Eating dysfunctions were uniformly observed in practically all categories of medical problems. Constipation showed a high association with rumination (p < 0'01), aerophagia (p < 0'001), anorexia (p<O'OOl) and One or more eating dysfunctions (p<O·OOl). A comparatively lower incidence of pica was observed in the blind population (p < 0'05), while anorexi~ was significantly higher in blind and deaf subjects (p < 0'05). It was interesting that an excessively high proportion (half) of the individuals with seizures had eating dysfunctions, notably pica (p < 0'05), anorexia (p < 0'001), and one or more eating dysfunctions (p<O·OOl).

More than half the institutionalized population received medications including prescription vitamins and food supplements. A disproportionately greater number of individuals with pica received anticonvulsant (p < 0'05) and psychotropic (p < 0'001) drugs. Rumination was associated with food supplements (p < 0'001), antacids (p<0'05) and iron (p < 0'001), while aerophagia was significantly associated with iron (p<O·OOl). Anorexia correlated with anticonvulsants (p<O'OOl), vitamins (p<O'OOl), food supplements (p < 0'001) and iron (p<O·Ol).

Table 3 summarizes the relationship of eating dysfunctions to physical status. While 25% of sedentary individuals had pica, this figure increased to 50% in the very

286 D. f:. DANFORD AND A. M. HURER

TABLE 2 Relationship of eating dysfunctions to degree of mental deficit, to etiology of the deficit, to other

medical characteristics and to current medications


Medical No. of One or more characteristics subjects Pica Rumination Aerophagia Hyperphagia Anorexia dysfunctions

Total population 991 25·8 5·5 2·7 n7 7·2 41·6

Mental deficit (I.Q.) Borderline (> 68) 9 11·1 *** 0 ** 0 11·1 0 11'1*** Mild (68-52) 42 9·5 0 2-4 7·1 4·8 21A Moderate (51-36) 82 11'0 1·2 0 11·0 2·4 no Severe (35-20) 254 16·5 2-4 1·2 no 4·3 29·1 Profound ( < 20) 579 33·7 7·9 4·0 15·0 9·7 52·2

Etiological factors Chromosomal 195 16A 7·2 1·0 12·3 1'5** 30'3* Acquired 122 25A 9·0 2·5 11·5 1J9 46·7 Central N.S. 31 32·3 6·5 6·5 19A 16·1 54·8 Congenital 19 31-6 5·3 5·3 15·8 5·3 47-4 Othera 24 31·8 4·5 0 18·2 4·5 39·1 Unknown 600 28·5 4·2 3·2 14·2 7·3 43·5

Medical problems Constipation 288 28·8 8'7** 6'3*** n5 13'9*** 52'8*** Cerebral palsy 40 20·0 7·5 5·0 2·5 15·0 45·0 Heart disease 59 27-1 11'9* 0 n6 0 37·3 Hypothyroid 29 17-2 3-4 3-4 10·3 3-4 31·0 Diabetes 17 35·3 0 0 11-8 0 41·2 Blind 57 14'0* 7·0 5·3 8·8 17'5** 40A Deaf 39 30·8 7-7 0 12·8 17'9* 51·3 Seizures 316 30'7* 6·3 J5 12·7 12'0*** 49A***

Medications All medications 563 29'0** 6'7* 3-4 14·0 10'8*** 48·1 *** No medications 428 21'7 3·7 1·9 n3 2·3 32·9 Anticonvulsants 281 30'6* 7·1 J9 n2 1J2*** 50'9*** Psychotropic 211 38'9*** 4·3 2·8 23'2*** 6·6 55'5*** Vitamins 112 27·7 3·6 5-4 6'3* 17'0*** 46A Food supplement 96 24'0 15'6*** 4·2 8·3 33· 3*** 65'6*** Antacids 14 35·7 21-4* 14·3 14·3 14·3 71-4* Thyroxine 20 25·0 0 0 15·0 0 35·0 Iron 32 28'0 21'9*** 15'6*** 15·6 21'9** 71'9*** Other medications 144 17-4* 2·1 2·1 9·7 9·7 35A

aThis includes Metabolic-Endocrine. Progressive and Neurocutaneous Etiologies. The significance of variations in incidence in subgroups of Mental Deficit and Etiological Factors was

tested by chi-square. The significances under Medical Problems and Medication are between individual subgroups and the total population. *p<0'05; **p<O'OI; ***p<O·OOl.

active individuals (p<O'Ol), whereas rumination was independent of activity level. Aerophagia, hyperphagia, and anorexia were inversely related to activity. Particularly high incidences of pica and one or more eating dysfunctions (p <0'001) were observed in individuals with sleep disturbances.

EATING DYSFUNCTIONS IN MFNT AL RFT ARDA TION 287

TABLE 3 Relationship of eating dysfunctions to physical status and place of eating


Physical No. of One or more characteristics subjects Pica Rumination Aerophagia Hyperphagia Anorexia dysfunctions

Total population 991 25·8 5·5 2·7 13-7 7-2 41·6

Mobility Ambulatory 804 27'5* 5·0 1'2*** 15-4*** 5·1 *** 40·8 Non-ambulatory 187 18·7 7·5 9·1 6-4 16·0 44·9

Activity characteristics

Sedentary 497 25'3** 4-4 1-4 13-5 4·2 38'0* Moderately active 204 29-4 5·9 1·9 17-2 4·4 36·8 Very active 45 46·6 4-4 0 6·7 2·2 57·8 Sleep disturbance 40 62'5*** 20·0 10'0* 30'0* 16·7 72'5***

Weight Grossly obese 118 16'9* 0** 1·7 24'6*** 0'8** 36-4 Moderately obese 172 28·5 3·5 1·2 17-4 0'6** 39·0 Normal 401 24·3 5·3 2·0 10-8* 1'5*** 31·5 Moderately underweight 145 35·9** 5·5 2·8 13-1 11-0 53·1 **

Grossly underweigh t 155 24·5 12'3*** 7·1 *** 9·7 30'3*** 63'9***

Place of eating Central cafeteria 448 18·1 *** 1· 3*** 0-4*** 14·1 3·1 *** 30·1 *** Residential building 543 32·2 8·8 4·6 13-4 10·5 51·0

Occasionally elsewhere 120 11·7 0·8 0 12·5 0·8 24·2

The significance of variations in incidence in subgroups of Mobility and Place of Eating was tested by chi-square. The significances under Activity Characteristics and Weight are between individual subgroups and the total populations. *p<0'05; **p<O'Ol; ***p<O·OOl.

Approximately 25% of the population were either obese or underweight. Pica was found in every weight group but was particularly high in the moderately underweight group (p < 0'01), while rumination and aerophagia were highly correlated with gross underweight (p <0'001). As expected, hyperphagia showed a positive and anorexia an inverse relationship with weight (p<O·OOl).

Table 4 relates eating dysfunctions to various behavioral parameters. Hyperactivity, self-abusive, and stereotypic behavior were associated with a high incidence of pica (p<O'OOl), hyperphagia (p<O'Ol) and one or more eating dysfunctions (p < 0'001), while rumination correlated with self-abusive behavior (p<0·05).

Outstanding correlations were found between pica as well as hyperphagia and the food-related behaviors (aggressive pursuit of food items, ritualistic, smearing, food eaten from the floor, and stealing of food) (p<O·OOl). Rumination was significantly associated with stealing food (p<O'Ol), mouthing foreign objects (p<O'OOl) and


TABLE 4 Eating dysfunctions in relation to behavioral problems and associations between eating dysfunctions


Behavior No. of One or more characteristics subjects Pica Rumination Aerophagia Hyperphagia Anorexia dysfunctions

Total population 991 25·8 5·5 2·7 n7 7·2 41-6

Behavior problems Hyperactive 226 38-9*** 8·0 2-7 23-9*** 5·3 55-3*** Self-abusive 161 39·1 *** 9·3* 3·7 20'5** 5·6 55'3*** Stereo typic 61 52'5*** 8·2 4·9 27'9** 8·2 68'9*** Aggressive 64 31-3 3·1 1·6 15·6 6·3 45-3 Psychotic-like 56 26·8 1·8 0 10-7 12·5 46-4 Hoarding 43 37·2 2·3 7·0 lO'9 0 55·8 All behaviors 438 38'4*** 7'3* 3·0 19'2*** 5·7 53-9*** No behaviors 553 15-9 4'0 2·5 9·4 8·3 31-8

Food-related behaviors Finicky eater 129 17-1 5·4 2·3 3·1 41-1*** 64'3*** Aggressive for more 65 60'0*** 6·2 6·2 58'5*** 1-5 86-2***

Throws food 23 47'8* no 0 39·1 *** no 69-6*** Spits food out 14 28·6 14·3 21-4** 21·4 0 50'0 Ritualistic 24 62'5*** 4·2 4·2 37'5** 4·2 79'2*** Eats food off floor 63 73-0*** 9·5 4·7 42'9*** 1·6 88'9*** Steals food at table 283 50'2*** 9'5** 3·5 32'5*** 3-2 68'9*** Skips meals 193 25-4 8·3 3·6 8'8* 26-4*** 56'5*** Mouthing foreign objects 83 73-5*** 14'5*** 8-4** 12·0 8-4 86-7***

Smearing 50 74'0*** 18'0*** 2·0 30·0 10·0 84-0*** Smoking cigarettes 26 26·9 0 0 3·8 0 30-8

Eating dysfunction Interrelationships

Pica 256 11'3*** 4·3 25'0*** 5·5 Rumination 54 53-7*** 7-4 20·4 no Aerophagia 27 40·7 14·8 18·5 11-1 Hyperphagia 136 47'1*** 8·1 3·7 5·1 Anorexia 71 19·7 9·9 4·2 9·9

Individual subgroups under the categories of Behavior Problems, Food-related Behaviors and Eating Dysfunction Interrelationships show significant differences from the total population in the frequency of an eating dysfunction: *p<0'05; **p<O'Ol; ***p<O-OOl.

smearing (p<0·001). Aerophagia was significantly associated with spitting food out and mouthing foreign objects (p < 0·001). Anorexia, as expected, was significantly associated with finicky eating and skipping meals (p < 0·00 1). One or more eating dysfunction was significantly associated with aggressive pursuit of food, ritualistic, smearing, eating food from the floor, and stealing food (p < 0'001).

IQ. some individuals more than one eating dysfunction was observed. Rumination and hyperphagia each were significantly associated with pica (p<0·001).


Table 5 summarizes the findings of dysfunctions associated with food cravings and food refusals. Out of the total population of991 individuals, 128 individuals exhibited food craving alone, 99 individuals food refusal alone, and 35 individuals craved at least one food and refused another. A high incidence of pica was associated with fluid (p<0·001), milk and coffee craving (p<0'01), and color-related food refusal (p< 0'05). Rumination was especially associated with fluid craving (p <0'001) and milk aversion (p < 0'01). Hyperphagia was often found in association with a craving for fluid (p< 0'01), desserts (p <0'05), and bread (p <0·01). Conversely, anorexia was associated, as expected, with refusal offluid (p <0'001), animal and vegetable foods (p <0'05), and fruits and desserts (p < 0'001). Finally, as a general rule, the entire categories of food cravings and food refusals showed a significant inverse relationship (p < 0·002).

TABLE 5 Eating dysfunctions in relation to food cravings and refusals


No. of One or more Food category subjects Pica Rumination Aerophagia Hyperphagia Anorexia dysfunctions

Total population 991 25·8 5·5 2·7 13-7 7·2 41·6

Food cravingsa

All fluids 24 79'2*** 25'0*** 8·3 33'3** 16·7 91'7*** Milk 13 53'8* 15-4 7-7 HI HI 76'9* Coffee 80 36'3* 0'0* 1-3 17-5 }8 52'5* Desserts 24 29·2 4·2 0 29'2* 4·2 45·8 Bread 24 29·2 12·5 0 37'5** 12-5 70'8** Other foods 16 33-3 0 0 16·7 8·3 56·3

Food refusals· All fluids 25 24·0 4·0 8·0 4·0 40'0*** 64'0* Milk 17 35·3 2J5** 0 17·6 11-8 58'8* Coffee 6 50·0 0 0 16·7 0 66·7 Animal foods 16 18·8 6·3 0 6·3 25'0* 37·5 Vegetables 24 25·0 8·3 8·3 8·3 20'8* 45·8 Fruits & desserts 15 20·0 6·2 6·7 6·2 40'0*** 46·7 Color-related 5 80'0* 0 0 0 0 80·0 Texture-related 16 25·0 6·3 6·3 18·8 12·5 50·0 Other foods 49 34·7 8·2 0 10·2 14·3 53·1

aExtreme food refusal or craving present in at least two out ofthree meals observed. Individual subgroups under the categories of Food Cravings and Food Refusals show significant differences from the total population in the frequency of an eating dysfunction: *p<0'05; **p<O'Ol; ***p<O·OOl.

DISCUSSION

Eating dysfunctions are well described in developmentally delayed children (Kanner, 1937; Palmer & Ekvall, 1978). This study indicates that eating dysfunctions are comparatively frequent in the institutionalized mentally retarded adult population. The frequency of all eating dysfunctions was 42%. Thus, such problems extend far beyond the pediatric population. Of the five eating dysfunctions observed, pica was the most common (26%).


Pica was observed to correlate with level of mental deficit. With increase in age, the incidence of eating dysfunctions generally decreased, with the notable exception of pica which increased in individuals older than 70 years. It is consequently possible that the progressive decline in all eating dysfunctions with increase in age is related to the survival of fewer profoundly retarded individuals.

The etiology of pica is at present obscure. In animals, pica is known to occur in response to specific nutrient needs (e.g. salt licks for wandering animals). Pica in mentally retarded children has been suggested to reflect a developmental lag of oral behavior which is considered normal in children under 18 months of age (Bicknell, 1975). The fact that in this survey pica was most prevalent in individuals with the lowest IQ may support the idea that pica in these adults also reflects extreme developmental delay. The suggestion that mentally retarded individuals with pica cannot distinguish between food and non-food items was not verified by our observations. Most individuals were deliberate and quite specific in the choice of non-food item consumed and they were consistent in their choice.

Pica has been extensively documented in pregnant women and non-retarded young children. Many etiologies have been suggested which include cultural factors and nutrition (Grivetti, 1978; Vermeer & Frate, 1979), the latter which relates pica to iron deficiency (Mohan, 1968). Pica among pregnant women is so diverse in choice of substances consumed that there is no basis for relating all cases to nutrient needs (e.g. consumption of coal or newspaper).

Some eating dysfunctions may be related to organic brain damage. Lesions in the lateral and ventromedial hypothalamous in man are associated with extreme anorexia and hyperphagia (Groover, 1978). Brain lesions in the amygdala in cats and the left temporal lobe of monkeys results in the indiscriminate ingestion of non-food items (Holden, 1979; KlUver & Bucy, 1939). Whether one or several of these are related to pica in this survey is at present not known.

The Kluver-Bucy syndrome described in 1939 is a left temporal lobe manifestation, and one individual in our survey with this diagnosed syndrome as well as seizures had a persistent history of paint ingestion. In this connection, Bicknell (1975) reported that 40% of individuals with pica had seizures, which is almost the same proportion as that observed in our population (38%). A study of pica in relation to type of seizures may help to characterize the relationship of brain damage to pica.

While Bicknell (1975) reported a high incidence of pica in blind mentally retarded children, our study did not verify this (14%). This may be related to access to non-food items and differences in the environment.

It is interesting to note the association of pica with anticonvulsant and other drugs. This may possibly relate to more severe brain damage, consequently more profound retardation. Also, as previously mentioned, those with seizures may have left temporal lobe involvement.

Our survey demonstrates many behavioral and other abnormalities associated with eating dysfunctions. Bicknell (1975) found that 37% of her cases of pica had several behavioral disorders, an association earlier described by Cooper (1957). In our population with pica the frequency of other behavior disorders was high (39%). Sleep disturbance, notably nocturnal activity, was observed to be associated with pica, probably representing individuals who were up at night looking for pica substances.

Weight trends are as expected in our population. Hyperphagia correlated with obesity and anorexia with gross underweight. However, it was interesting to note that pica correlated with being moderately underweight.


In our population, food-related behaviors as well as food cravings and refusals were associated with a high frequency of eating dysfunctions. In our survey, 15% of the total population had multiple food cravings and/or refusals. Coffee craving 'was the most frequently observed food craving in our population. Podboy (1977) reported extensive caffeine use by 15 institutionalized mentally retarded females. Others have reported high consumption of coffee in the mentally retarded but the actual frequency has not been described before (Stephenson, 1977). As one would expect, hyperphagia was correlated with food cravings, while anorexia was associated with food refusal. The fact that food cravings and refusals were inversely related indicates that individuals tended to either crave items or refuse them but rarely did they have a combined food refusal and craving pattern.

The eating dysfunctions described in this survey are at present not well understood in terms oftheir etiology and prevention. It is not possible to discern a cause and effect relationship between the parameters described in relation to these eating dysfunctions. The survey clearly has shown that eating dysfunctions are comparatively frequent, even in an adult mentally retarded institutionalized population, and more frequent than expected from isolated reports in the literature. Further studies are necessary to elucidate etiologies and nutritional consequences, as well as the treatment and prevention of the dysfunctions.

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Ball, T. S., Hendricksen, H., & Clayton, 1. A special feeding technique for chronic regurgitation. American Journal of Mental Deficiency, 1974, 78,486-493.

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Received 13 February, 1981; revision 5 June, 1981

eating dysfunctions in an institutionalized mentally retarded population

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