DragLargOver the past few years, I have had an influx of young children with Anorexia Nervosa (AN) come to me for treatment.  When I tell friends and acquaintances about my work, they are shocked and horrified to learn that many of my AN patients are between 9-12 years old. The typical response is first incredulity, then a remark about how “sad” it is that little girls are under such pressure to be thin and perfect.   I am not sad about this at all – in fact, a very young child presenting for AN treatment represents an ideal scenario.

Let me explain. First, there are no good data to support the popular notion that the prevalence of AN has increased over the past few decades.  Most data in fact suggest that the incidence of AN has remained constant throughout recorded history. Second, 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 also 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 5th and 6th grade 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 later in adolescence, when it is more difficult to treat. Therefore, I view younger age of onset as a positive thing.

AN is triggered by an energy imbalance – that is, a period of time in which a person’s caloric intake is lower than her body’s energy needs.  My theory is that kids are developing AN at younger ages because there are more opportunities for energy imbalance to occur in younger children now compared to generations past.

Reasons for Earlier Onset

Several factors contribute to this trend of children developing AN at younger ages.  First is the national hysteria about the “obesity epidemic” and well-intentioned but misguided government programs aimed at young children.  Many of my pre-adolescent patients began restricting their diet after a nutrition lesson at school.   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) in favor of “healthy foods” (e.g., those low in calories and fat), thus creating a negative energy balance and triggering AN. The irony here is that it is very unhealthy for a growing child to eat a low-fat or restricted-calorie diet.

Second, this generation of children tends to enter puberty earlier than their parents or grandparents. The hormonal changes of puberty, 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 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. 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 to slip into a negative energy balance by accident.

Fourth, the modern lifestyle is fast-paced, rushed, overscheduled, and pressured for all of us, even children. Stress can cause a child to lose his appetite, which in turn can lead to weight loss and can potentially trigger an episode of AN.

Fifth, families are eating meals together less often now compared to a generation ago. If a young child is responsible for fixing her own breakfast, packing her own lunch, or microwaving her own dinner, it is much easier for her to restrict her food intake for a number of days or weeks without her parents 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, 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 and resistance, but they often cannot articulate why.

Young children are more likely to present with dehydration as well as malnourishment. Whereas teenage anorexics drink large quantities of water, diet soda, and black coffee, little kids sometimes cannot grasp the concept of calories. Many little kids with AN will fear and avoid anything that enters the mouth- including water, gum, vitamins, and medicine.

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. It is 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.

About the author:

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Dr. Sarah Ravin earned a BA from Smith College in 2001 and a Ph.D. in Clinical Psychology from American University in 2008.  Since 2009, she has maintained a private practice in Coral Gables, Florida.   An advocate for and practitioner of evidence-based treatments, Dr. Ravin specializes in Family-Based Treatment for children and adolescents with eating disorders as well as CBT for anxiety and depression.    Dr. Ravin is an active member of the Academy for Eating Disorders, a professional advisor for FEAST (Families Empowered And Supporting Treatment for eating disorders), and author of a popular blog on eating disorders and related topics in psychology.