The literature suggests that pediatric LOC eating is characterized by psychological distress and the development or maintenance of excess body weight, but that few children meet DSM-IV-TR (APA, 2000
) criteria for binge eating disorder. Thus the existing criteria do not adequately identify children with LOC eating behaviors (Marcus & Kalarchian, 2003
). To stimulate research on disordered eating in children, in 2003 Marcus and Kalarchian proposed provisional binge eating disorder research criteria for children 14 years and younger (Marcus & Kalarchian, 2003
The Marcus and Kalarchian criteria emphasized LOC eating (criterion A1) in combination with eating in the absence of hunger (criterion A2), a behavior that has been posited to be an early indicator of disinhibited eating in younger children (Faith et al., 2006
; Fisher & Birch, 2002
). Criterion B of the proposed criteria included correlates of LOC eating suggested by the research literature at that time including “food seeking in response to negative affect (Carper, Orlet Fisher, & Birch, 2000
), and sneaking food (30). To date, one study has tested Marcus and Kalarchian’s proposal using an interview specifically designed to assess for the provisional criteria (Shapiro et al., 2007
). Using a weight-loss treatment-seeking sample of 5–13 year-olds, the authors found that 30% of the sample met the provisional criteria for childhood binge eating disorder (Shapiro et al., 2007
). This study, however, is limited in that the methodology did not allow children to fully describe their behavioral and emotional experiences during LOC eating episodes.
In an attempt to characterize further the phenomenology of LOC eating in children and adolescents, researchers from multiple locations interviewed 445 youth about their eating patterns using the semi-structured Eating Disorder Examination (either the original or the child version), supplemented with additional probes to assess the circumstances surrounding a binge or LOC eating episode (Tanofsky-Kraff et al., 2007
). After determining the presence or absence of LOC during eating, each participant was queried about the contextual, behavioral, physical and emotional aspects of aberrant eating episodes during the past month. The results from a hierarchical cluster analysis revealed that adolescents reporting LOC eating behaviors have a presentation similar to adults with binge eating disorder (Tanofsky-Kraff et al., 2007
). However, in an examination of only middle childhood (6–12 years) participants, hierarchical cluster analysis revealed a somewhat different set of characteristics from adolescents. In addition to reporting LOC eating, children tended to report that the episode took place at a home other than their own and in the afternoon, and that they were eating more than others. These children reported experiencing a negative emotion and a trigger prior to the episode, eating in secret, and feeling numb. LOC eating was also associated with eating despite a lack of hunger and consuming more than others. Lastly, children 12 years and younger with LOC reported negative affect before and after the eating episode (Tanofsky-Kraff et al., 2007
). These data suggest that LOC eating in middle childhood may present differently in older children and adolescents.
Based upon the growing evidence base, we propose a revised set of criteria that extends Marcus and Kalarchian’s (2003)
provisional criteria to be empirically tested. lists provisional criteria for Loss of Control Eating Disorder (LOC-ED) in children age 12 years and younger. These preliminary criteria are proposed for the specified age group based upon findings from the recent multi-site study described (Tanofsky-Kraff et al., 2007
). In order to avoid re-defining the term “binge,” LOC eating is used to describe consumption of food while experiencing a lack of control over eating independent
of the amount of food consumed. We have retained Marcus and Kalarchian’s Criterion A1 and extended Criterion A2 to include “Food seeking in the absence of hunger or after satiation
.” Many children report that a LOC episode begins as a meal or snack when they are hungry (Tanofsky-Kraff et al., 2007
) and that LOC eating occurs after satiation. Furthermore, preliminary data suggest that children do not distinguish between eating in the absence of hunger and eating past satiation, but that both are associated with LOC eating (Ranzenhofer et al., 2007
). For Criterion B, we have modified the list of Marcus and Kalarchian’s associated features to incorporate findings from the recent multi-site investigation (Tanofsky-Kraff et al., 2007
). Finally, although current data suggest that episodes of LOC eating occurring once a month or more are associated with distress, we have chosen in criterion C a cutoff of two episodes per month to provide a more conservative estimate of the frequency of LOC eating required for a psychiatric diagnosis. As with the proposal as a whole, criterion C requires rigorous testing by multiple research groups. Similar to Marcus and Kalarchian’s (2003)
proposal and in concert with proposed modifications for DSM-V binge eating disorder criteria (Wilfley et al., 2007
), we have maintained a duration criterion of a least three months. However, the frequency and duration criteria require further investigation, as there are insufficient data establishing the optimal duration or length of LOC eating patterns for a child-specific diagnosis. Lastly, since some children may meet full DSM-IV-TR criteria for binge eating disorder (Morgan et al., 2002
), we have included in Criterion D that LOC-ED will not be diagnosed if binge eating disorder is present.
3.1 Future Directions
Research into the utility and clinical significance of LOC-ED is required. Specifically, 1. Studies of overweight children seeking weight-loss treatment as well as examinations of community samples are necessary to determine prevalence rates of LOC-ED and of each of the proposed diagnostic criteria. Such studies should include an examination of potential sex, racial and ethnic differences in prevalence rates. 2. Different statistical classification schemes should be considered; for example, should LOC-ED be considered a category (as proposed) or as a dimensional system? 3. Data are needed to determine whether LOC-ED is associated with greater levels of disordered eating attitudes, higher rates of co-morbid psychiatric distress, and increased problems in psychosocial functioning compared to children without the disorder or to those with LOC eating at sub-threshold levels. 4. The sensitivity and specificity of an LOC-ED diagnosis warrants investigation. For instance, it should be determined whether the components of LOC-ED co-occur in overweight children with LOC eating (but not LOC-ED), overweight children without LOC or non-overweight controls. 5. The relationship between LOC-ED and body weight warrants examination to determine if the diagnosis is associated with overweight and excessive weight gain prospectively. 6. Studies of prognosis and outcome are required to determine if LOC-ED is a stable condition potentially associated with the development of exacerbated eating problems. In the conduct of future investigations, refining the proposed criteria, in particular assessing the optimal frequency and duration criteria, should be taken into consideration. Lastly, although data supporting a relationship between LOC eating with emotional and eating-related distress have been established, further research is required to determine whether a diagnosis of LOC ED is associated with greater actual food intake and with weight gain over time, as has been found for children reporting binge eating episodes.