Overview of Eating Disorders
in Children

Often it is difficult for adults to recognize that a child is experiencing problems related to the intake of food and control of weight. It can be even harder for parents to believe that their own child might have such a problem. However, an increasing number of children in our culture are developing eating disorders, and, if left untreated, eating disorders can lead to serious physical and mental health problems, including death. Early detection and treatment of an eating disorder increases the likelihood of a full recovery and return to a healthier and fuller life.

What Are Eating Disorders?

The word "eating" in the term "eating disorders" refers not only to a person’s eating habits per se, but also to his/her weight-loss practices and attitudes towards body shape and weight. However, such habits, practices and beliefs do not, in themselves, constitute an eating disorder. A "disorder" results when these attitudes and practices are of such an extreme nature that one develops the following:

• An unrealistic perception of body weight and shape
• Anxiety, obsession and guilt related to weight and/or eating
• Potentially life-threatening physiological imbalances
• Loss of self-control in regards to eating and weight maintenance
• Social isolation

The development of an eating disorder may be caused by several factors, including biological or genetic susceptibility, emotional problems, problems in relationships with friends or family members, personality problems, and societal pressures to be thin. Such pressures include both blatant and subtle messages from the media, friends, athletic coaches and family members. While eating disorders tend to occur more often in females than in males, males are not immune. A growing number of young males are being diagnosed with eating disorders. Gay adolescents and certain types of athletes may be especially susceptible.

The diagnostic manual used by mental health practitioners currently recognizes two primary types of eating disorders: Anorexia Nervosa and Bulimia Nervosa. Consideration is also being given to officially recognizing a third type called Binge Eating Disorder.

Anorexia Nervosa

The essential features of Anorexia Nervosa are:

• A refusal to maintain a minimally normal or healthy body weight. An adolescent suffering with Anorexia Nervosa is literally capable of starving him or herself to death.
• An intense fear of gaining weight. Calories, food, and weight management are the controlling factors in the person’s life.
• A significant disturbance in the perception of the size and/or shape of his or her body. Where others may see a starving, emaciated body, a person with Anorexia Nervosa will see herself as "fat".
• A female with Anorexia Nervosa who would otherwise have regular menstrual periods will experience the cessation of her menstrual cycles.

While the term anorexia refers specifically to a loss of appetite, this is rarely the case with people suffering from this disorder. Those with Anorexia Nervosa actually experience extreme hunger and some may even engage in binge eating on occasion. However, eating binges are inevitably followed by some sort of "purge" activity that is intended to compensate for the earlier binge. A purge may be accomplished through a number of means including self-induced vomiting, overuse of laxatives or diuretics, or excessive exercise.

Bulimia Nervosa

Bulimia Nervosa is marked by binge eating, and excessive and inappropriate compensatory strategies to prevent weight gain. Also characteristic is an extreme concern about body weight and shape. Binge eating is defined as eating a quantity of food that is well in excess of what most people would eat during the same time period and under similar circumstances. In addition, there is a sense of lack of control over eating during the binge as well as an absence of the physical sensations that signal that the stomach is overly full. The binge may serve as an escape from unpleasant feelings, but eventually it ends and the person is left with an intense anxiety about weight gain. In order to compensate for the large quantities of food just ingested, the individual will "purge" the food by self-induced vomiting, excessive exercise, use of laxatives or diuretics, engaging in a highly restrictive diet, or some combination of these methods.

Other Eating Disorders

Many people with "eating problems" do not quite meet the criteria for Anorexia Nervosa or Bulimia Nervosa. Some people control their weight by vomiting and abusing exercise but never binge. Others may repeatedly binge or gorge without purging (Binge Eating Disorder). Even though these people do not purge, they may engage in repetitive diets or fasting in an attempt to control the weight gained from the repeated binges.

Who Develops An Eating Disorder?

Eating disorders are most commonly associated with adolescent females. While it is true that eating disorders of all types tend to be more common in this group, adolescent males are not immune to developing dysfunctional and dangerous eating habits and weight management strategies. Conservative estimates suggest that 5 to 10% of adolescents in the U.S. suffer from some form of eating disorder. About 1 in 10 of these adolescents are male.

A number of factors are associated with the prevalence of eating disorders among certain groups of adolescents:

Rates of Anorexia Nervosa are higher among those from a higher social economic status

Rates of Bulimia Nervosa tend to be highest among women at college, and may even be considered the "cool" or "in" way to control one’s weight in certain settings

Both male and female athletes who compete in certain sports may be at greater risk for developing eating disorders due to the extreme pressures to maintain a given body weight in order to be competitive. It is important to note, however, that weight control for the purpose of athletic success does not constitute an eating disorder unless the athlete develops some of the core psychological disturbances that mark the presence of an eating disorder. (For example, distorted body image or binge eating.) Some of the sports where pressures to maintain certain weights are especially high are:

• Dance
• Wrestling
• Gymnastics
• Swimming
• Running
• Body building
• Rowing

The prevalence of eating disorders tends to be lower among non-Caucasian populations. However, there is evidence to suggest that the more these populations become acculturated into American mainstream society, the higher the risk becomes.

Children who suffer from chronic diseases, such as diabetes, who have been required to modify their diets for medical reasons may be more likely to develop an eating disorder.

Eating disorders tend to run in families. Children with parents who have an eating disorder are at a much greater risk of developing a disorder themselves. A family history of depression and/or substance abuse has also been recognized as a risk factor for the development of some eating disorders.

A history of sexual abuse has been observed in a high percentage of those with eating disorders.

Negative self-evaluation, shyness and perfectionism are traits that may increase the likelihood of developing an eating disorder.

Girls who enter puberty early may be more likely to develop eating disorders, possibly due to teasing from their peers about the shapes of their developing bodies.

Overweight children may be more likely to develop an eating disorder as they enter puberty and appearance becomes more important. It is interesting to note that overweight girls are also likely to enter puberty earlier, making them subject to the additional pressures mentioned above.

Warning Signs

How does one know when a child’s eating habits have become dysfunctional? Given the extreme social pressures to be thin, dieting is not an uncommon occurrence among adolescents, and even children, in our society. In fact, researchers have found that as many as 46% of 9–11 year-olds are "sometimes" or "very often" on diets. Given this prevalence of "acceptable" patterns of restricted eating habits, it can be quite hard to distinguish between normal dieting behaviors and abnormal or destructive eating behaviors. The early stages of an eating disorder can be especially difficult to detect, because the behaviors can seem quite normal for a dieting, health conscious individual. However, early detection and treatment of dysfunctional eating patterns increases the likelihood of a full recovery. If dysfunctional eating patterns persist and develop into second-nature behaviors, the individual will have much more difficulty changing the behaviors later in life, and may suffer from serious health problems. People who have eating disorders do not necessarily present with all the behaviors and symptoms listed below, but they are likely to exhibit several of them.

Behaviors Involving Food

• Skips meals
• Eats only tiny portions of food
• Does not eat in front of others
• Develops ritualistic eating patterns
• Chews food and spits it out
• Cooks meals for others but will not eat
• Makes excuses not to eat (not hungry, just ate, ill, upset, etc.)
• Becomes a vegetarian
• Reads food labels religiously
• Goes to the bathroom after meals and spends an inordinately long time there
• Begins and ends diets repeatedly
• Large quantities of high-calorie foods are missing, but the child is not gaining weight
• Uses large quantities of laxatives or diuretics (money may even be stolen from family members to purchase these drugs or the large quantities of food needed for a binge).

Physical Changes

• Chipmunk cheeks (swollen salivary glands)
• Bloodshot eyes
• Tooth enamel decay
• Considerable weight changes not attributable to a medical condition
• Intestinal problems
• Dry, brittle hair, or hair loss
• Bad breath
• Calluses on knuckles
• Nose bleeds
• Constant sore throats
• Irregular or absent menstrual cycles

Body Image Concerns

• Constantly tries to lose weight
• Fears weight gain and obesity
• Wears over-sized clothing
• Obsesses about clothing size
• Complains of being fat when he or she is clearly not
• Criticizes body and/or body parts

Exercise Behaviors

• Exercises obsessively and compulsively
• Tires easily
• Consumes sports drinks and supplements

Thinking Patterns

• Lacks logical thinking
• Cannot evaluate reality objectively
• Becomes irrational
• Becomes argumentative
• Withdraws, sulks, throws tantrums
• Has difficulty concentrating

Emotional Changes

• Difficulty discussing feelings, especially anger
• Denies being angry, even when he or she clearly is
• Escapes stress by bingeing or exercising
• Becomes moody, irritable, cross, snappish, touchy
• Confrontations end in tears, tantrums, or withdrawal

Social Behaviors

• Socially isolates
• Demonstrates a high need to please others
• Tries to control what other family members eat
• Becomes needy and dependent

What Can A Parent Do?

If you’ve noticed behaviors in your child that may indicate an eating disorder, you should discuss your concerns with your child.

Plan to approach your child in a place that is private and stress free. Be sure you have set aside plenty of time to talk.

Tell your child what you have observed and what your concerns are in a caring, straightforward and non-judgmental way.

Do not focus on food and weight, but instead focus on feelings and relationships.

Give her plenty of time to talk and state how she is feeling. Accept what she says without passing judgment or reacting with anger.

Avoid commenting on appearance. This perpetuates the obsession with body image.

Know that anger and denial are often part of an eating disorder. If faced with these reactions, restate your observations and concerns in a caring way without accusing your child.

Do not engage in a power struggle over whether or not a problem actually exists.

Do not demand change or berate the child or adolescent.

Examine your own feelings about food, weight, body image, and body size. You do not want to convey a fat prejudice or exacerbate your child’s desire for thinness.

Do not blame the child for his or her struggle.

Treatment Of Eating Disorders

While it is often a long and difficult process, eating disorders are generally treatable. Depending on the severity of the disturbance and the physical health of the child or adolescent, an eating disorder may be treated in either an outpatient setting consisting of individual, family and/or group therapy, or, in more extreme cases, in an inpatient or hospital setting.

Individual counseling – Individual counseling usually takes place in a therapist’s office for 45-50 minutes, 1 to 3 times per week. It is critical to choose a therapist who has experience working with both children and adolescents, as well as eating disorders. Treatment philosophies will usually take one of three approaches, or, quite often, some combination of them.

Cognitive Behavioral – Cognitive behavioral therapy is a combination of cognitive therapy and behavioral therapy. Cognitive therapy deals primarily with identifying and changing problematic or distorted thoughts and beliefs, such as distorted body images and over emphasis on the importance of thinness. Behavior therapy works to change maladaptive behaviors such as binge eating.

Psychodynamic– The goal of a psychodynamic approach is to help the adolescent come to understand the connections between her past, her personal relationships, her current circumstances and the eating disorder. Psychodynamic theory holds that eating disorders may develop as a way of protecting one’s self from anger, frustration and pain one may experience in his or her life.

Disease/Addiction – This model views eating disorders as an addiction or disease similar to alcoholism and is modeled after the Alcoholics Anonymous program.

Family counseling – Family therapy not only benefits the person with an eating disorder, but the other family members as well. Living with a person with an eating disorder can be difficult for all involved. Good family therapy will address the concerns and problems of all the family members as well as teach the family how to assist in the healing of the family member with an eating disorder.

Group therapy – Group therapy may be effective for some, but harmful for others. Some people with an eating disorder are too withdrawn or anxious to effectively interact in a group setting. Others may benefit greatly from the support and acceptance they receive from other group members. It is critical that a group dedicated to the treatment of eating disorders be run by a qualified professional who can gauge individual members’ reactions to the group experience.

The Team Approach – For long-term treatment of, and recovery from, an eating disorder a multidisciplinary team approach with consistent counseling and support is essential. The team may consist of a physician, dietitians, therapists, and/or nurses. All of the individuals on the team should be specifically skilled in treating eating disorders.

Medication – Medications may be used to treat a number of aspects of eating disorders including:

• Treatment of depression and/or anxiety that may co-exist with the eating disorder
• Restoration of hormonal balance and bone density
• Encouragement of weight gain or loss by inducing or reducing hunger
• Normalization of thinking process

Hospitalization – People who suffer from extreme anorexia are most often admitted to a hospital for an extended period of time so they can be stabilized and treated for medical complications. People with bulimia are not usually admitted to a hospital unless their behaviors have developed into anorexia, they need medication to help them withdraw from purging, or they have developed major depression.

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Weight Gain – The most immediate goal in the treatment of an anorexic individual is often weight gain. A physician should strictly set the rate of weight gain, but the usual goal is 1 to 2 pounds per week. Initially the person is given 1,500 calories per day and eventually it may go as high as 3,500 calories per day. Individuals may require intravenous feeding if the amount of weight loss has become life threatening and he or she is still unwilling to consume adequate amounts of food.

Nutritional Therapy – A dietitian is often consulted to develop a strategy for planning meals and educate both the patient and the parents.

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