By Sarah Ravin, Ph.D. Licensed Psychologist
Over the course of my career, I’ve observed a dramatic increase in the number of pre-adolescent children presenting for treatment of Anorexia Nervosa (AN). When I tell friends and acquaintances about my work, they are shocked and horrified to learn that many of my patients with AN are between 8-12 years old. The typical response is first incredulity, then a remark about how sad it is that little girls are exposed to the thin ideal at such a young age. While it is undoubtedly sad to witness a young child suffering, I have a different perspective on the matter. I believe that a very young child presenting for AN treatment represents an ideal scenario.
Let me explain. We do not yet know how to prevent AN, nor do we know whether AN is possible to prevent. We do know that children are being diagnosed with and treated for AN at much younger ages now compared to a generation ago. Research has shown that the prognosis for AN is inversely correlated with age and duration of illness prior to the start of effective treatment. In other words, the younger the patient, the better her chance for full recovery. The elementary school-aged boys and girls who are diagnosed with AN today would most likely have developed AN anyway, but in previous generations the illness would not have been triggered, diagnosed, or treated until late adolescence, when it is more difficult to treat. Therefore, I view younger age of onset as a positive thing.
Reasons for Earlier Onset
AN is triggered by an energy imbalance: a period of time in which a person’s caloric intake is lower than his or her body’s energy needs. I believe that more pre-adolescent children are developing AN because there are more opportunities for energy imbalance to occur in younger children now compared to generations past.
Several factors contribute to this trend of children developing AN at younger ages. First is the national hysteria about the “obesity epidemic,” which has resulted in well-intentioned but misguided government programs aimed at preventing or reversing obesity in children. Many of my pre-adolescent patients began restricting their diet after a nutrition lesson at school, or after they were publicly weighed during gym class and given a “BMI report card.” Kids who are predisposed to AN tend to be anxious, sensitive, perfectionistic, rigid, and overly compliant with rules. These are the kids who actually take the obesity prevention messages to heart and follow them to the letter. They avoid “unhealthy foods” (e.g., those high in calories and fat) in favor of “healthy foods” (e.g., those low in calories and fat), thus creating a negative energy balance and triggering AN in those who are genetically vulnerable.
Hysteria over the obesity epidemic has also influenced pediatricians’ attitudes about children’s weight. In many cases, pediatricians are the first healthcare professionals to spot (or miss) early signs of an eating disorder. Falling off one’s historic growth curve (e.g., dropping to a lower percentile for weigh, height, or BMI) is often the first sign of an eating disorder. Ideally, a healthcare provider would express concern and make a referral for an eating disorder evaluation when a child falls off of his or her historic growth curve, regardless of whether a child has historically lived in a large, average, or slim body. Unfortunately, many healthcare providers are so consumed with fighting childhood obesity that they fail to recognize that weight loss in a growing child or adolescent of any size is neither normal nor healthy.
Second, this generation of children tends to enter puberty earlier than their parents or grandparents. The hormonal changes of puberty cause dramatic alterations in brain chemistry. Hormonal and neurobiological changes, combined with the increased energy needs of the pubertal growth spurt, provide a perfect opportunity for a negative energy balance. Add to that the tendency of girls to begin dieting to counteract their body’s pubertal changes to conform to the thin ideal, and boys’ tendency to begin working out and “eating clean” to achieve a leaner physique, and you have a perfect storm.
Third, children nowadays are participating in intense athletics at younger ages. It used to be that athletically-inclined kids did not begin intense athletic training until high school. These days, kids in elementary school begin practicing for their sport multiple nights per week and traveling to games on the weekends (often, incidentally, disrupting family mealtimes). These kids have extremely high energy needs, as they must consume enough food to fuel their sports in addition to keeping up with normal growth and development. It is very easy for a young competitive athlete or dancer to slip into a negative energy balance by accident.
Fourth, the modern lifestyle has become fast-paced, competitive, overscheduled, and pressured for all of us, even young children. Many kids are overwhelmed with academically rigorous classes at school, hours of homework, and multiple extracurricular activities. Evenings and weekends are consumed by athletic training, sporting events, and other structured activities, many of which are competitive in nature. Families are eating meals together less often now compared to a generation ago. This change in daily life reflects our collective priorities: success in academics, athletics, and other extracurricular activities, and gaining admission to a highly competitive middle school, high school, or college, has become a priority. Stress can cause a child to lose his appetite, and pressure to succeed can make stopping to eat with his family feel like a luxury he cannot afford. Without the staple of daily family meals, changes in a child’s eating habits can easily go unnoticed by parents. A child who is responsible for fixing his own breakfast, packing his own lunch, and microwaving his own dinner and eating it in the car between soccer practice and piano lessons, can restrict food intake for weeks or months without a parent noticing.
Different Presentation
Like many diseases, AN in children presents differently than in teens or adults. Dieting is the most common trigger for an episode of AN in teenagers, but AN in young children is more likely to result from unintentional weight loss through illness, stress, growth spurts, getting braces, athletic training, or “healthy eating.”
Fear of fat, drive for thinness, and body dysmorphia – which are considered the hallmark cognitive symptoms of AN – are often absent in young children. Eating provokes extreme fear, rage, and/or resistance, but these children often cannot articulate why. Whereas a teenager is likely to verbalize his or her desire to lose weight, fear of weight gain, anxiety about eating high-calorie foods, and body image distress to therapists, friends, and family members, a young child is more likely to become overwhelmed by strong emotion and fly into a rage, or simply curl up into a ball and stop talking.
Young children are more likely to present with dehydration as well as malnourishment. Whereas teenagers with anorexia drink large quantities of water, diet soda, and black coffee, little kids sometimes cannot grasp the concept of calories. Many children with AN will fear and avoid anything that enters the mouth- including water, gum, toothpaste, vitamins, medicine, or even their own saliva.
Teens and adults with AN usually have a list of “safe foods” which are low calorie and low fat – such as salads, fruit, rice cakes, and nonfat yogurt – and they tend to fear high calorie foods such as ice cream and pizza. However, sometimes young children’s food rules and food fears make no caloric sense. For example, I have worked with children who will willingly consume any beverage, including milkshakes, but who refuse to take a bite of solid food, even a carrot stick. Other kids will have a narrow list of safe foods which are familiar but not low-calorie (e.g., chicken nuggets, pop tarts, and grilled cheese sandwiches).
Young children become medically and mentally unstable much more quickly than teenagers. Post-pubescent teen girls and women, even slender ones, start out at a higher body mass and have reserves of fat. Prepubescent children are already light and very lean. A loss of even a few pounds is enough to cause severe medical problems and extreme cognitive distortions in a child. It is not uncommon for a child to go away to summer camp completely healthy and return three weeks later in grave danger.
Swifter Recovery
In my experience, young children tend to make a full recovery more quickly and more easily than teens or young adults. Because they fall into AN so quickly and because they are still so dependent on their parents, they are often brought into treatment very early in the course of the illness. Their AN thoughts and behaviors are not as engrained as, say, a 16-year-old who has suffered from AN for two years.
It is easier for young children to externalize their illness. They often describe feeling “taken over” by a voice or by some evil force beyond their control. They love to name their illness and refer to it in the third person, unlike teenagers who tend to balk at this exercise, or who experience their illness as more ego-syntonic. My young patients have come up with various names for their illness – the monster, the dragon, the devil, Scary Larry, and Voldemort are a few that come to mind. Externalizing the illness is helpful to parents because it allows them to fight against the AN, rather than fighting against their child. Children benefit from externalizing their illness because they tend to be concrete thinkers, so it makes more sense to them to be fighting against some other entity.
Young children are more dependent on their parents than teens. Thus, it is far easier for both parent and child to adjust to the “magic plate” technique of parents preparing and supervising all meals and snacks. This is not so different from what most parents do for their healthy 10-year-olds anyway. In contrast, it can be extremely difficult for teens and especially young adults to accept the amount of parental support and supervision required for successful re-feeding.
I love treating preadolescent children with AN. Each time I get a call from a terrified parent whose child is showing signs of AN, I breathe a sigh of relief, grateful that they have come to my attention so early in the course of the illness. Although these children and their families are in for a harrowing journey, I have confidence that we can work together to slay this dragon. These kids can enter their teen years fully recovered and able to enjoy high school and college unencumbered by this horrible illness.
I would also add the fact that gender non-conforming kids are coming out sooner- some use ED behaviors to cope with distress induced by a “wrong puberty”. Education on gender identity is essential and necessary for pediatricians, along with ED education, so that gender dysphoria can be ruled out. If and ED and GD are co-occuring, both can be simultaneously treated, and when medically safe with weight restoration, hormone blockers/hormone replacement therapy should be discussed.
So true about catching AN disorder early. My daughter was leaving the 6th grade when she was first diagnosed. She went through many years of treatment. She did well at first, unfortunately had a relapsed last summer, during this pandemic. She is back in therapy and eating 6 meals a day. She is now 17 and a senior. It has been much more difficult to support her of course, as she is very defiant and closed off to her dad and I. We will never give up on our beautiful and smart young lady. We just pray that when she turns 18 this September she won’t sign herself out of treatment completely. Thank you for your great article.
My son is 13 and your article describes precisely what he is experiencing. The “experts” here in the UK have said that they don’t think it’s anorexia because he doesn’t have any of the body image issues so we can’t get any help from the eating disorder team at all 🙁
I’d suggest you look into PANS/PANDAS , it happens mostly with boys, develops anorexia at a rate 30% , and at this age no image issues.
So much harder when they are dx older
My d was 17 when she first got ill and not dx till 17.5 YO (waitlists for expert help are disgraceful IMO)
5 years of hell and only now I’m seeing my beautiful d back to “normal” again yay!!!
Our daughter was dx at the age of 11 with AN after she started to restrict in January and despite receiving in patient treatment for 14 weeks in August of the same year and follow up care by a team of health care professionals for many years, she has never recovered. The illness has consumed her life for the past 14 years and today while being well educated she lives at home, has no social life, and no hope for the future. It is beyond heartbreaking to witness the suffering imposed by the illness. Wishing all parents courage, determination, and support to deal with the illness.
Young people can get eating disorders get hold of them when they feel things are ALL out of control in their lives – “I’ll quit eating. That, I can control”, quote from a young girl who got very thin and admitted about her problem when she was mid twenty. Things spiral to bad from this thought in a young person’s mind.
Young people can get eating disorders when they have a genetic predisposition to them. Very prevalent, indeed. One family I heard of had five in it with eating disorders.
Parents can save their child’s life from anorexia nervosa. Just have to not give up and to focus to their child that professional treatment works, rooting for them every step of the way. Focus on the anxiety and depression part usually diagnosed with eating disorders hence, scared to eat behavior gets hold of child.
“I want to be involved in your life” in a note form to child helps them realize a lot as they struggle, as mom is xed out of child’s life by child. It’s all about to sweep away from anorexia nervosa. It’s a most difficult experience for parents and all along, mom and dad must take care of themselves.
A lot remains to be understood about anorexia nervosa, Professor Janet Treasure, UK.
Thank you for writing this article! My daughter exhibited brewing ED symptoms at the age of about 9 after a possible reaction from a flu mist vaccine. She was diagnosed with asthma & swollen lymph nodes. In addition, she had a replicating fatigue. This medical situation coupled with her type A driven student personality, a best friend moving away and redistricting at school made the perfect storm. An abrupt downslide off the growth curve at age 10 was the final straw. Sadly, although she was continually not well from age 9-age 14 her ED continued to brew with symptoms never recognized by the medical community. Finally at the age of 14 she was diagnosed by “Dr. Mom” and by then it was so much more severe and entrenched. I am thankful for FEAST for the updated information they provide about eating disorders to both parents and the pediatric community. It would indeed by better to deal with recovery from an eating disorder at a young age instead of figuring it out by adolescence. Thank you Dr. Ravin for your expertise.
Hi, thank you for this article. Would you please annotate with your sources? We’re dealing with a difficult case, we’re told and I’m doing a lot of research.
Such a great article and makes sense to me. My daughter was diagnosed with AN at 13, hospitalised with dehydration and malnutrition after losing 20 kgs. A few doctors and a psychologist did not even investigate her weight loss even though I repeated this visit after visit. Her heart was so strained by the time she got to hospital. Even though I work in mental health, I didn’t know much about ED’s until then! Phew what a journey. However, as she was 13 I felt grateful she was young and I had so much say and influence in the re-feeding. I have reflected on how much harder it would have been if she was older. Her AN was diagnosed within 6-8 months of her restrictive eating, she got sick really quickly, but her recovery, although extraordinarily hard, has not looked back . We are now celebrating 12 months of reaching her goal weight and gaining more still, but as the saying goes, it’s state not weight so even better her thinking shows so much recovery too. She no longer has ‘the voices’ and she is the happy, beautiful young woman I’ve always known. AN is harrowing and so is re-feeding for that matter and I know the door has been opened and there are no guarantees but there is hope for full recovery.
Thank you for writing this article. You could be describing our 11 year old daughter to the letter. She was diagnosed with AN in November. It’s reassuring that there is so much hope for recovery. Since starting treatment quickly, thanks to our GP, we have seen improvement. However living in the UK we are now going in to a third lockdown which is a blow as we believe it was one of the causes. It may be too early for you to comment on the impact, but do you think something like lockdown can delay or even reverse recovery? With treatment moving to Zoom calls and memories of the first lockdown we are feeling anxious about progress.
Hi Jeff,
Research has shown that there has been a dramatic increase in mental health problems such as depression, anxiety, suicidal ideation, and insomnia, since the COVID-19 pandemic began. I, and many of my colleagues, have observed an increase in the number of people presenting for eating disorder treatment during this time as well.
https://www.eatingdisorderhope.com/blog/impact-covid-19-pandemic-eating-disorders
For most of my newer patients with AN, the pandemic marked the start of their restrictive eating or exercise behaviors. I absolutely believe that the pandemic has triggered the onset of eating disorders, delayed recovery, or triggered relapse in many people.
On the other hand, the pandemic has offered unique opportunities for recovery to move along more swiftly in kids who have already been diagnosed. Most of the families I work with who were beginning Phase I of FBT at the start of the pandemic have been able to supervise their children’s meals and snacks much more closely, and focus more intensively on re-feeding and weight restoration, given that most activates are cancelled and everyone is doing school or work from home. Kids who were fortunate enough to begin FBT right around March or April 2020 were able to progress through re-feeding and weight restoration rapidly, and with no more disruption to their day-to-day lives than their healthy peers were also experiencing due to the pandemic.
Thank you for this informative post. It helps me to see that we are not complete outliers in our daughter’s situation.
We are struggling with the recent and sudden onset of AN with our 12 y/o daughter. It has been quite a few weeks. It was fascinating to read her what she described to us as the same thing – that there is a person that talks in her head and who she calls, “The Devil.”
We currently have her seeing a dietician and a therapist and are in the first week of FBT. Meal times are struggling, mostly at night, but she is eating, albeit with anger and tears and heartbreaking struggles. I still can’t believe how fast it came on. It went from what we thought was a nice change in early November in her wanting to eat more wholesome natural foods and exercising more, to drastic weight loss by the end of December, whereby we began insisting that she eat more. Only then came her confession to us what’s going on in her head. I never imagined someone so young would be subject to this.
One of the hardest things has been sleep as well. Since we started FBT and dietician organized meals and mealtimes, she wakes up every few hours with nightmares etc. I assume this is “the devil” that is trying to fight our efforts and pray that in time this will abate as we gain ground in winning against this horrible disease.
An inspiring article I clung to when our daughter through fast height growth and social anxiety at school fell down the rabbit hole. Pre Covid hospitalised for 4 months gave us a kick start and post Covid it’s true easier to accompany and support all meals and snacks over a long time. We’ll use as much time between now and whenever she becomes more independent to cement the nourishment habit. She knows it nearly killed her and doesn’t want to go back, eats well but not totally naturally I.e. still structured and has to work at it a bit. I agree this is about energy imbalance and also mental health issue are caused by that and melt like snow as weight restores and 6mths plus stays on. We remain vigil why but she and we her parents agree in long run hopefully a blessing she had this close call so young as she’s better prepared than had it not come out to get her priorities firmly in place – nourishment and well being ahead of other things always. Recovery is possible and for now, hopefully forever, things are so much better and my prayers to those who go on similar and especially later journeys. Stay strong and tackle it head on, in the open, one meal and snack at a time x