Not just small adults: eating disorders in young children
More and more researchers and clinicians are becoming aware of the presence of eating disorders in young children (defined here and in most of the research literature as ED onset at less than 13 years). I have known five-year-olds with full-blown anorexia nervosa. Whether this awareness is due to people developing EDs at an earlier age (a study by Favaro et al., 2009 seems to indicate a small but significant decrease in age at diagnosis), a greater number of parents and physicians on the lookout for ED signs and symptoms, or some combination thereof is still unclear. This doesn’t stop clinicians and newspapers from blaming skinny models, however.
Regardless, when the diagnostic criteria for eating disorders was developed, scientists really only thought about eating disorders as occurring in late adolescence and early adulthood. When they were looking to define the characteristic signs and symptoms of an eating disorder, this is the population they looked at. These same criteria are applied to everyone who might have an eating disorder, regardless of whether they were 5 or 95. An eating disorder is an eating disorder is an eating disorder. Or so the thinking went.
The problem is that no one had actually looked to see whether these criteria were actually useful in pediatric cases. Do children with eating disorders have the same symptoms as adolescents and adults? Despite the growing awareness of pediatric EDs and the slew of media articles on the subject, there have really only been two studies published comparing pediatric EDs with adolescent EDs. The first was published in 2006 by Rebecka Peebles and colleagues. The other was just published in the International Journal of Eating Disorders (Walker et al., 2014)
Children vs. adolescents
Researchers at the Eating Disorders Program, Princess Margaret Hospital for Children in Perth, Australia compared various measures of eating disorders on young children (<13 years) and adolescents (13-17 years). They collected the data over nearly two decades on 656 individuals, including 104 young children (the youngest was 8 years old) and 552 adolescents. All individuals were diagnosed with DSM-5 eating disorders.
I created the table below to outline and summarize what the researchers found.
The highlights of what’s in the table:
- Adolescents are significantly more likely to have bulimia or bulimia-spectrum disorders, as well as binge/purge behaviors
- Children are more likely to be male
- Adolescents had lost a higher percentage of their body weight at presentation than children
- Children and adolescents had a similar rate of weight loss
- Children and adolescents had similar rates of medical problems arising from malnutrition
Interestingly, some of this data was different from what was discovered in the 2006 study by Peebles et al. In that first study, the researchers found that children lost a higher percentage of their body weight more rapidly than adolescents, and were more likely to experience medical issues relating to their eating disorder. Although the current study did find that children tended to lose weight more rapidly, they didn’t find that children presented at a lower body weight or had more medical problems.
One reason for the finding of less weight loss in children was that it didn’t appear (as far as I could tell) that the researchers accounted for growth potential. In growing children, a stagnant weight is equivalent to lost weight in adults. So while children may look like they’ve lost less weight, when you look at where there weight currently is vs where it should be had they not developed an ED, you can often see big discrepancies that wouldn’t be accounted for if you just measured the % body weight lost.
What they didn’t consider
One of the things that I found interesting was that how the researchers looked for symptoms were still largely constrained by our ideas of “typical” adolescent eating disorders. For instance, they assessed “strenuous exercise to control weight and shape” rather than something like motor restlessness, as described by pediatric eating disorder expert Julie O’Toole of the Kartini Clinic. This isn’t to say that children’t can’t exercise to control weight and shape, just that it might not be what’s motivating them, nor is it necessarily stereotypical “exercise.” It could be constant movement, leg jiggling, etc.
Nor did the researchers look at potential co-occurring disorders or the presence of body dysmorphia. Again, there have been some clinical reports that many young children with EDs have anxiety and OCD, as well as less expression that they’re “feeling fat” or afraid of becoming so. From what I’ve seen in that age group, I see more of a fixation on “healthy eating” or more of a food phobia situation, where the child can’t quite articulate why they are afraid of eating.
Write the authors:
Worth considering is the idea that professionals and adults in general have applied a weight- and shape-centric model to the explanation of EDs, whereas presentations such as avoidant/restrictive food intake disorder or those undocumented may genuinely be free of or involve limited shape- and weight-related disturbance. Alternative explanations that may account for lower scores on eating pathology measures among children are stronger need for social approval, children’s tendency toward more positive self-appraisals, more egosyntonic presentations among children with EDs, and lower desire for help as younger people are often compelled to treatment by their parents.
Other things to think about
I’m curious if there’s a difference down the line in outcome or later ED symptoms based on age of onset. Take two 20-year-olds with an eating disorder, one of whom had symptoms begin at age 10, one of whom had symptoms begin at 18. Obviously, there’s the duration-of-the-ED effect (since Person A has had an ED for 10 years, whereas Person B had an ED for 2), but there’s also the age of onset effect. Do people whose EDs begin as young children have less body dysmorphia down the line? Are they more or less likely to become chronic cases? Are they more likely to have co-morbid anxiety disorders? Do they have different motivators for their eating disorder? These are things we just don’t know.
What we also haven’t assessed is EDs in older adults. This is another population in whom there has been a growing awareness and interest in by both ED professionals and the media. What do the symptoms and medical sequelae here look like?
There is so much we just don’t know. But as studies are beginning to make clear, we can’t think of children with EDs as just “small adults.” They seem to have a unique presentation of EDs that differentiates them from adolescents and adults.
Favaro A, Caregaro L, Tenconi E, Bosello R, and Santonastaso P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa. Journal of Clinical Psychiatry, 70(12):1715-21. doi: 10.4088/JCP.09m05176blu.
Peebles, R., Wilson, J. L., & Lock, J. D. (2006). How do children with eating disorders differ from adolescents with eating disorders at initial evaluation?.Journal of Adolescent Health, 39(6), 800-805. DOI: 10.1016/j.jadohealth.2006.05.013
Walker, T., Watson, H. J., Leach, D. J., McCormack, J., Tobias, K., Hamilton, M. J., & Forbes, D. A. (2014). Comparative study of children and adolescents referred for eating disorder treatment at a specialist tertiary setting. International Journal of Eating Disorders, 47(1), 47-53. DOI: 10.1002/eat.22201