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Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Friday, August 23, 2013

Child Starvation Death in Qatar: Intentional, Accidental, or Ill-Advised?

A reader kindly suggested that I should comment about a recent case in which an 8-year-old girl died of apparent starvation in Qatar (http://www.nydailynews.com/news/world/u-s-couple-jailed-qatar-starving-daughter-article-1.1418610). Gloria had been adopted from Ghana at age 4 by a Los Angeles couple, Matthew and Grace Huang; they had been living in Qatar for about a year while Matthew worked as an engineer on preparations for the 2022 World Cup. Their case is briefly discussed by supporters at www.freemattandgrace.com, where it is stated that the California Innocence Project, an organization that defends wrongly imprisoned persons, is working in support of the Huangs, and a law firm is taking their case pro bono. They have sought the testimony of a pathologist well known for working with parents accused of child abuse. The Huangs have been described as “Christian” at www.worldmag.com/2013/08/american_christian_couple_accused_of_killing_adopted_child_in_qatar, and this presumably means that they are members of an evangelical group rather than, say, Roman Catholics or Presbyterians.

Did Gloria literally starve to death? Probably not, at least in the exact sense. She was said to have been without food for four days--  not long enough to produce death in and of itself, but perhaps sufficient to do some organ damage in a child with a history of potentially damaging undernourishment. It is also possible that her death occurred as a result of ingesting food after a period of starvation. Refeeding syndrome (see www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/) can result after five days of starvation, especially in those who are chronically undernourished.  

Newspaper reports described Gloria as periodically refusing food from her parents and then (depending on the report) either going through several days of anorexia or eating from garbage cans. Between these events, she was said to eat normally. The reports presented the anorexic periods as occurring spontaneously.

I have been unable to find any reference to such spontaneous alterations of eating behavior in searches of Google, Academic Premier Search, PSYCinfo, or PubMed. I’ve asked the Spoon Foundation (www.spoonfoundation.org), a reputable source for information on feeding adopted children, for a comment about this sort of eating behavior but have not heard back from them yet (I will report what they say if I hear from them.) [See comments below this post for responses from SPOON.]

It is certainly true that individuals who have experienced starvation can remain fragile in their appetites, responses to food, and rates of weight gain, when plenty of appropriate food is available to them. Children who were in rough-and-ready group care early in their lives may have experienced being fed as frightening or even painful and may be reluctant to eat. Gloria is said to have been small in size even several years after her adoption, and may have been somewhat difficult to nourish. However, these lingering problems, insofar as they were a continuing feature of Gloria’s life, would ordinarily be expected to be about the same from day to day, rather than showing the intermittent difficulty as it is described.

However, it is true that in some cases where there has been a period of poor nutrition, either a child or an adult who seems to have recovered can respond to an experience by loss of appetite. For instance, someone who has been anorexic for psychological reasons but has recovered may be thrown into a new anorexic episode by an infection that causes gastrointestinal problems. In children who are anxious about eating, an increase in general anxiety could affect the fragile appetite. For example, being pressured to eat a particular food, or other distress surrounding eating, could lead to a period of anorexia.

There are thus some possible explanations for Gloria’s periodic failure to eat--  although the implication that these events “just happened” is probably not correct. It is less easy, though,to explain the reported eating from garbage cans or accepting food from strangers (and surely this would have to mean begging food from strangers or at least watching them eat in a hungry way). Some references have been made to pica, the eating of unusual non-food substances like clay, in some cases in response to dietary insufficiencies, in others simply to cultural practices. However, the most parsimonious explanation for getting food in these ways is that food is not readily available to the child. When children in the U.S. are seen to take food from the garbage, the most likely situation is that they are not being fed at home.

Speculating with very few facts, I would put forward the following hypothesis: Gloria periodically did not eat what her parents offered her because of circumstances that made the food itself inappropriate for her, and/or other circumstances that made it too difficult for her to behave in ways that would give her access to the food.  

Why would this happen? Why would the parents create such circumstances, and why would they then fail to seek expert advice about unusual and potentially life-threatening problems?

Were the Huangs’ actions intended to starve Gloria and bring about her death? This seems most unlikely. Even sadistic parents do  not generally mean their ill-treatment to kill a child, although they may fail to give normal care or seek medical care, in ways that common sense would predict would be fatal.

Were the Huangs’ actions an accidental cause of death? This might be the case if the last anorexic episode was the only one, and the parents simply did not realize that there was a serious problem. But the reported history of eating problems, dating back to early malnutrition, surely indicates that they were aware of her difficulties.

Were the Huangs’ actions ill-advised? Please note that this is a very different question from asking whether they are culpable in Gloria’s death.  I’m simply considering whether the Huangs had a belief system that would lead them to act in ways that made it difficult for Gloria to get the food she needed, or that triggered her food aversion; I name both of these because the reports make it difficult to know whether Gloria did not eat at all or whether she sought food outside the family table.  

There are belief systems in the United States that recommend manipulation of food as a tactic of child-rearing. Such beliefs rarely become public knowledge, although the case of Roxanne Heiser in Texas about ten years ago showed that a child who was eating from the garbage can at school was actually being deprived of food at home by a stepmother who demanded that the 7-year-old hold weights over her head for minutes at a time before she was allowed to eat.  The stepmother believed that such treatment would cause Roxanne to form an emotional attachment to her. Advice to this effect continues to be given by the “parent educator” Nancy Thomas, who stresses that children should not be allowed to get their own food, but must receive it from the hand of the parent in order to cause attachment; she also recommends limitation of the amount and variety of the child’s diet in order to bring about complete compliance by adopted and foster children.  (Once infamous for having declared that peanut butter and jelly sandwiches with milk are a perfectly balanced diet, Thomas has now softened her views slightly.)

At the beginning of this post, I mentioned that the Huangs had been described as “Christian” in a context that suggested that the real meaning was “evangelical”. I alluded to their personal beliefs because there appear to be connections between the acceptance of Nancy Thomas’ advice and membership in evangelical groups, especially those of Pentecostal or charismatic flavor. (I have discussed the broader issues elsewhere http://thestudyofnonsense.blogspot.com/2013/06/religious-beliefs-and-alternative.html.) For these groups, as for some religious thinkers in the U.S. even during the colonial period, a parent’s duty is to make a child obey at all costs; those who disobey as children will be disobedient to God later and will be damned. In addition, evangelicals have in recent years identified adoption as part of the Great Commission (see Kathryn Joyce’s book The Child Catchers) and have focused their energies on supporting adoptive families in ways congruent with evangelical beliefs. These views presumably made the Huangs more likely to adopt Gloria, and may have made them more likely to use her diet as a control measure.

Obviously, I am in no position to say how the Huangs behaved toward Gloria or exactly how she died. I am simply putting forward some possible explanations other than accident or deliberate cruelty.








11 comments:

  1. Responsible parents would have, at a minimum. consulted a pediatrician about the child's troubling eating habits. (They apparently did see a physician when the girl was first adopted, because giardia was diagnosed at that time.) Usually there is mention by the defendents if the child had been evaluated any time prior to death; we don't see that here.

    A pediatrician would have given the parents, if not advice about how to feed the child, then surely when to seek medical attention before the child's condition might get critical.

    Either the child was severely emaciated and dehydrated at the time of death, or she was not. Is there another option other than concluding that someone is lying here? The family photos do not show an emaciated child. Certainly she seems no thinner than her adoptive mother.

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  2. Thanks for reaching out to SPOON. SPOON Foundation has a wealth of information on feeding challenges from food aversions to food hoarding behaviors, both of which are described as present in this complex case. However, we do not feel comfortable commenting or speculating on this case without more background information or consent from the family.

    Our advisors may be willing to connect with you about general feeding issues. We also recommend our website www.adoptionnutrition.org as well as "Love Me, Feed Me: the Adoptive Parent's Guide to Ending the Worry About Weight, Picky Eating, Power Struggles and More"
    for background and help for families struggling with feeding and weight worries.

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    1. Dear Mishelle--

      Thanks for your response and for the information that SPOON makes available.

      Of course, I did not ask you to comment about this particular family, or in any way to breach professional ethics. What I asked was whether the alternation of normal eating and unusual eating behaviors described in news reports has been thought to occur spontaneously, as opposed to occurring in response to events in the environment. I have not been able to find descriptions of this kind of alternation in the literature.

      Best regards,
      Jean Mercer

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    2. Jean, please look forward to a response from one of SPOON's medical advisors, Dr. Katja Rowell, on the above question regarding eating patterns. Thanks again for engaging us in this discussion.

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    3. Thank you very much. I will be most interested in Dr. Rowell's comments.

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  3. I’m one of the advisers for SPOON. In general, to the spontaneous vs. a reaction to environmental factors question, the answer is of course, both to varying degrees. It can help to think of initial feeding challenges in two somewhat artificial categories, primary (coming from the child) or secondary (coming from the environment) though all is related. http://thefeedingdoctor.com/the-worry-cycle-of-feeding-part-i-for-adoption-month/
    Feeding challenges often wax and wane from any number of factors. I usually don't see “normal” eating interspersed with periods of extreme presentation unless other factors are present. Most of the time what I see is gradual improvement— first in anxiety and how the child relates to food, and second in intake and self-regulation.
    Particularly with our current panic over obesity, one of the biggest problems I see is that food anxious children are restricted or put on portion controls from day one. So, they continue to feel anxious and not trusting they will get enough, and that anxiety can develop into an entrenched food obsession, rather than improving slowly over time as the child is reassured she will get fed. (See my NACAC article on hoarding here…)http://www.nacac.org/adoptalk/beyondthestash.html
    Aversive feeding disorders or selective eating, are increasingly common, I estimate from various studies that it’s about 10-15% of the general population, and it’s likely higher in foster and adopted children. Up to 80% of children with special needs will struggle with feeding.
    Children with a history of adversity have a higher chance of struggling with eating and self-regulation.
    I hope that my “Worry Cycle” series can shed some light on possible factors that can affect intake and behaviors at mealtimes, from challenges the child presents with, to how parents may respond to those challenges (often with little support or misguided advice).
    For example, one family I worked with had a preschooler adopted internationally. She was not gaining weight, was anxious, gagging and vomiting daily at meals, had normal medical, speech therapy and swallow eval. GI and psych eval were 6 weeks away. The parents were terrified she wouldn’t eat, so there was a lot of pressure on her eating, and pressure backfired. They also had a rule that the child couldn’t spit out food, since it was felt to be rude. That is one relatively simple thing we addressed. If a child has a food aversion, or history of gagging or vomiting, she has to have a way to safely get food out of her mouth other than gagging or vomiting. Within a weekend of no pressure, and more responsive feeding, the vomiting had completely stopped, and within ten weeks she had gained more weight than in a previous year. (This is “Bethany’s” story in my book, Love Me, Feed Me.)
    Generally, the harder parents and caregivers push and try to make a child comply, the worse things go. (Journal of Nutrition 2011 has a great supplement on the responsive feeding literature.) Hope that helps...

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    1. Thanks so much for providing these general but detailed comments. I have many more questions, but will start by looking at the readings you suggest.

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    2. After a dip into the suggested literature on responsive feeding, another issue related to possible belief systems of the parents occurred to me. This has to do with the recommendation of some unconventional therapists that adopted children not be allowed to obtain food or drink on their own, so that they will feel completely dependent on their caregivers, and that young children should not be allowed to hold their own bottles or to feed themselves by hand or spoon, but must receive food from the hand of the caregiver. These actions are claimed to facilitate attachment of the child to the caregiver, but they are clearly at odds with the child's need for developing autonomy and mastery.

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  4. Jean,
    I would not make that a general recommendation at all. If the child welcomes and is comforted by being fed, that is one thing. If the child resists, and this tactic increases battles and conflict, I believe it can be harmful. Clients with very young children have reported that their adopted children were self-feeding completely at very young ages, which makes sense if they had to fend for themselves. Forcing a child who wants to do it themselves to be spoon or bottle fed doesn't seem like a good strategy to build trust and closeness. I do think that the parents can and should provide regular and safe meals and snack, and that whenever possible, parents should provide the food (vs simply having a drawer in the pantry or food out so the child is still left to fend for herself...) I get into this a little in the beyond the stash article. Responsive feeding is critical, and if it increases stress and battles, it is likely to decrease appetite and make any feeding challenges worse.

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    1. Thanks so much for this comment. In terms of general recommendations, I don't think one can say more than that each family has to work out the best approach to feeding with their unique child, using the general idea that feeding needs to be responsive. Certainly providing the meals and snacks (rather than just putting food where a child can get it) helps eating act as the interactive social event that it can be-- just as feeding a baby or sitting by and socializing as a baby self-feeds make the process a pleasurable communicative event.

      All these ideas would also argue strongly against the practice (proposed by some "adoption educators") of insisting on bottle-feeding older children, even adolescents.

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  5. Agreed! Some children will literally not eat if there is too much pain/conflict/stress/trauma around meals. (Counter to what many pediatricians still say, "No child will starve himself.") I think it is very dangerous, particularly if the child is already marginally nourished to force and invite more stress/conflict.

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