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.
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.
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.