Children & Young Adolescent Anorexia

Article Contributed by A. David Wall, Ph.D. of The Meadows Ranch

She is So Young

Walking into the center, she is easy to spot — she is 8 years old and she has anorexia nervosa. In my 17 years of working with eating disordered patients, I have seen many children ages 11 and under, and the emotional impact is always the same– she is so young.  Her head is pointed to the floor, her long brown hair covering her face.

She looks up for a few seconds and makes eye contact. Her sunken cheeks, lanugo hair growth, and protruding bones take my breath away, no matter how many times I’ve seen it.

Listless and sad, her behavior is also far from other girls her age.

A couple of weeks later, I walk into the same room to hear a loud voice call my name – “Dr. Wall!”  She rushes up to show me her drawing and asks me what I want her to draw for me.  Two weeks of nutrition and she is starting to come to life.

When it is time for her to leave, she has a spring in her step, laughter in her voice, and all of us who have worked with her experience an emotion that is 180 degrees from what we were feeling when she walked in the door.

How did she develop anorexia at such a young age – how do the others like her develop anorexia?  Historically, family problems were seen as the primary cause of anorexia.

Today, we have a better understanding of the role that genetic/biological and neurological factors play in the development of anorexia.  However, we are still far from fully understanding the complex interaction between the biologically based vulnerabilities and environmental factors.

In trying to understand adolescent anorexia, it is important to remember that anorexia is an evolving progressive disorder.  The development of the disorder runs parallel to the physical, psychological, and social development of the child.  The bio-genetic seeds of anorexia are there at the beginning of the child’s life. These seeds involve the propensity to develop neurological and psychological risk factors for the development of anorexia (there isn’t a single anorexic gene).

These seeds are fertilized by the environment, and may eventually give birth to the full-blown disorder, typically sometime after puberty. Once it develops, the course of anorexia continues to be shaped by an interaction between these biological and psychological vulnerabilities and the environment.

So what causes anorexia to develop before puberty?  There are probably multiple answers.  One answer may come from what is, in my experience, the most important risks in developing anorexia.

Dieting and Eating Healthy

A question that I ask patients of all ages is, “What was happening when your eating disorder started?” the most common answer has been, “I just wanted to lose a few pounds,” or “I just want to eat healthy foods.” While lots of kids want to drop a few pounds or improve the content of their diet, a very small minority develop an eating disorder.  Why?

Influenced by peer pressure, the mainstream media, or even due to the participation of certain sports that emphasize a particular body shape, more adolescents and teenagers are inclined to try a diet.  One research survey found that over 80 percent of ten-year-old’s are afraid of being fat, and 35-57 percent of adolescent girls engage in dangerous dieting behaviors, including fasting, diet pill use, laxative abuse, and more [ii].

However, far and away, the most common answer has been, “I just wanted to lose a few pounds,” or “I just want to eat healthy foods.” While lots of kids want to drop a few pounds or improve the content of their diet, a very small minority develop an eating disorder.  Why?

We know that children are dieting at young ages.  Given that dieting is a triggering event for the onset of anorexia for at least some children and adolescents, then early dieting would be a significant risk factor for early onset anorexia.

Increase in Childhood Dieting

There is no doubt that American children have problems with obesity.  Understandably schools, the media, and families are responding to this problem through education and the promotion of healthy eating.

Anorexia continues to be a misunderstood disorder, and those creating or teaching these programs often do not understand anorexia and the impact their message can have on a child who is at risk to develop anorexia.

The messages about food and weight gain can be emotional and sometimes seem moralistic (e.g.  good versus bad). The educational programs may show powerful videos about the risks of bad food/junk food. Many patients have told me that their road to dietary restriction began after these types of lectures or after watching a video about what happens to your body when you eat junk food / unhealthy foods.

Yet, what’s so bad about cutting out all junk food?  By temperament, most of the children at risk for anorexia are often focused on doing the right thing and doing it perfectly. They focus on the details (don’t eat bad foods) and miss the big picture (balanced diet and health).

They tend to think in black and white terms — food is either good food or bad food. “Why would I ever eat something that is bad?”  These children often start out by cutting out “junk food,” but that’s not where it ends. Their temperament involves high levels of anticipatory worry (what if) and fear of uncertainty.

“What if the food I am eating will make me fat/unhealthy?  I need to be certain.” They go on Internet searches and memorize the caloric and nutritional content of almost any food one can name.  In order to be safe, they cut out foods that share any characteristics with bad foods (e.g., any sugar, too many carbs, too many calories per serving, any fat whatsoever).  The list of bad foods grows as a number of calories they are consuming steadily decreases. They feel fear and guilt if they eat anything that could be a bad food.

Of course, these educational programs are needed, but those who write and deliver them must be educated about anorexia.  Anorexia is significantly more likely to take the life of a young person within the current or next decade of the student’s life than the diseases that are related to overeating.

Many programs that seek to educate about risks of overeating and obesity can be counter-effective by instilling a fear of eating “bad” foods and/or missing the opportunity to educate on the components of living a healthy, balanced lifestyle.  For a child who may predisposed to developing an eating disorder, such as anorexia, the presentation of this information can be triggering in and of itself.  

Families may also want to examine the environment of their own home and any potential dieting behaviors that may be present.  When a child susceptible to an eating disorder is around others who are chronically dieting or expressing body dissatisfaction, this can also become an influencing factor.  

It is important to note that families or any family members are not to blame for the development of an eating disorder.  However, reflecting on the home environment and the overall approach to food taken by family members can help understand the bigger picture of the eating disorder development.

The Role of OCD

These children are also much more likely than their peers to have OCD.  “Obsessive-compulsive disorder is an anxiety disorder that occurs in up to two-thirds of patients with anorexia.[i]  Some studies find the rates to be lower (35%), but the prevalence rate of OCD for anorexics is still far greater than for the general population.

OCD involves intrusive and persistent obsessive thoughts, impulses and/or images that are highly disturbing to the individual, and compulsions used to decrease this extreme anxiety.The content of the obsessions can vary widely – some may fear germs and illness, others fear that they left the stove on, resulting in a need to check it 30 times before they can leave their home.

No one really knows why one person develops a specific obsession versus another, but the environment clearly plays a significant role.  Returning to the child in the educational class dealing with the dangers of obesity, one of her risk factors for anorexia may be that she also has OCD or the susceptibility for the development of OCD. 

The content of the class may evolve from a concern about food and weight into an intrusive, pervasive obsession.

These obsessions are often referred to as the “eating disorder voice,” and include thoughts like: “I can’t believe you ate that; it’s going to make you fat.  You’re weak if you eat that food. Your stomach is so fat it jiggles.”  As the obsessions intensify, behaviors to decrease the anxiety are developed which ultimately become compulsions.

The compulsions can be behaviors such as, “I have to run 4 miles if I eat breakfast today. If I eat lunch I cannot have dinner.”  Other compulsive behaviors that can develop in counter to obsessions related to food, body, and weight include calorie counting, food rituals, frequent weighing, hoarding food, body checking, measuring food, and more.

The child also develops compulsive avoidance behaviors.  Just as people with a fear of germs avoid objects that might have germs, she avoids foods that have too many calories, or fat, etc.  In many respects, her OCD may morph or evolve into an eating disorder (see table below).

One of the focal points in this article has been on the impact of educational classes about obesity, but that doesn’t mean that these courses are bad, although many of the instructors need to be much more sensitive to the minority of children who are prone to eating disorders such as anorexia or bulimia, and adjust the content.

Taking an approach to health education that is weight-neutral can also support the idea that health can indeed be achieved at any size.  Hyper-focusing on a certain size, weight, and/or BMI is often detrimental to children in some way or form, even to those who may not necessarily be susceptible to developing an eating disorder.

Though considerably smaller in number, these children are at a much greater short-term risk for serious illness and even death.   The focus on these classes is related to the growing and pervasive concern about childhood obesity.  However, children with a predisposition to develop eating disorders are more likely to be influenced by their peers, the media and unknowingly by their families (e.g., a parent has a problem with being obese and his/her struggle with the problem becomes a concern for his/her sensitive child).

Vegetarianism and Anorexia

One other area related to dieting is worth mentioning – vegetarianism.  Again, the idea of vegetarianism must be understood in the context of those with a predisposition for anorexia.  Vegetarianism can be a healthy alternative for many people.

However, vegetarianism can be a problem for children and adolescents who have risk factors for anorexia.  A child may be interested in following this type of diet for various reasons, but it is important to understand the reasoning behind it.  Choosing to become vegetarian for weight-related reasons can be crossing into dangerous territory, as cutting out food groups is justified in the name of “health.”:

One study found, “Compared with controls, individuals with an eating disorder history were considerably more likely to ever have been vegetarian (52% vs 12%…) to be currently vegetarian (24% vs 6%…), and to be primarily motivated by weight-related reasons (42% vs 0%…).”[iii]  The relationship between vegetarianism and eating disorders is mostly one where the vegetarianism is a symptom of the eating disorder versus a cause.”

Apart from strong moral/religious convictions of the family, it is wise not to allow vegetarian practices.  

For many children, adolescents and teenagers, a vegetarian diet may not support the nutrient demands that are needed during this period of rapid growth in their life.  This may also trigger the perception that some foods are “good” and therefore acceptable to eat, while others are “bad” and should be avoided at all costs.  

This kind of thinking with food in general can create a chaotic eating experience for children, especially for those who may be biologically predisposed to developing an eating disorder.  

It is important for families not to blame themselves or their children.  Anorexia has a strong biogenetic foundation – but these disorders are not fated to occur.  Continue to learn about anorexia, seek help for your child and yourself.  Advocate for anorexia, making well-intended people aware of the serious risks that accompany this disorder.

Remember that you are not alone in this journey and that there are many different resources available to support both your child and your family through the recovery journey and process.  Consider connecting with a family group that specifically offers support to family members and loved ones of children and teenagers with an eating disorder.  By continuing to care for yourself through this process, you can ensure that supporting your child’s recovery.

Table 1:  OCD and Anorexia

Component	OCD	ED
What might they be afraid of	Doorknob	Hamburger
What makes object dangerous	Germs	Calories and Fat
Feeling after exposure to the object	Contaminated, gross, in danger	Contaminated, gross, in danger
Obsessive Fears	I could get sick or die	I could get fat and ridiculed
Passive Protective Compulsions	Avoid objects with germs	Avoid bad food — Restrict diet
Active Protective Compulsions	Wash constantly	Exercise. Self-Induced Vomiting