Tweens, Teens & Anorexia

Young girls are routinely exposed to a media that promotes thinness, an older generation of chronic dieters, and a peer group that finds fault with the slightest of imperfections. Overwhelmed by pressures of their world, adolescents choose excessive dieting to control their lives and act out their frustrations of never being perfect enough. There is a tendency to want to see anorexia as a disorder of choice and the struggles associated with it as issues of discipline. Yet when 200 girls go on a diet, only one will develop anorexia (Kaye ‘08; Am Acad Ped ‘03). Why is this? The answer has to do with one’s gene pool. Studies on twins suggest anorexia is highly inheritable. A young girl having a mother or sister with an eating disorder increases her chances twelve fold (Bulik ’07; Pinheiro ‘09). The gene codes for personality traits that persist even in individuals after recovery include perfectionism, obsessiveness, harm avoidance and anxiety.  Variable gene expressions alter the brain’s chemistry, structure and circuitry that influence the characteristic behaviors (body image disturbances, rigidity, low reward dependence, suppression of the feeding response and persistence) of an eating disorder. But the gene pool only accounts for 50% of the likelihood of developing anorexia (Bulik ’07). It is the exposure to stressful life events, distorted media messages, pressure to fit in, parental influences, puberty (hormones) and dieting that trigger the emotional gauges (temperament) and dysfunctional brain of these young girls. This latent vulnerability is often described as the “loaded gun theory”:  your parents provide the ammunition (genes), and life’s experiences (nature) pull the trigger. You do not “get” anorexia and parents do not “cause” the eating disorder. Anorexia is a multifaceted disorder where biological, psychological and social factors play a role in its development. It has a physiological cause that creates an emotional response (Herpertz-Dahlmann ‘11ab; Erwin-Grabner ‘06).

Only a select few are genetically capable of deliberately starving themselves. This genetic vulnerability reinforces the drive for thinness and extreme dieting. Caloric restriction, malnutrition and weight loss produce physical complications (low body weight, low temperature, slow heart beat, amenorrhea, electrolyte imbalances and bone loss) as well as defective behavioral responses (depression, food phobias, obsessions, compulsivity, neuroticism and distorted thinking). Anorexia is perpetuated as starvation and deprives the brain cells of energy, produces nerve cell death and changes the way young girls process information. In some respects these changes parallel foraging (compulsive exercising and fidgeting) and hoarding (rituals and preoccupation with food), which are characteristic of both anorexia and primitive survival mechanisms in times of famine (Negardh ’07; Beck ’06; Bartnass ’11). The continuum of the disease process is predisposed by genes and neurological differences, which are precipitated by behaviors (dieting, life pressures, puberty and the media messages) and perpetuated by starvation. 

Disordered eating occurs most frequently in females (10 times more often than males) and most often at the onset of puberty (Procopio ‘07). Estrogen triggers the expression of genes that alter the brain in vulnerable anorectics (Young ‘10). The effect is most pronounced in girls with gene variants that cause anxiety, perfectionism and obsessiveness (Burghy ’12). The psychosocial challenges and transitions that take place during puberty create fears during this maturation phase. Right before a growth spurt, it is normal for young females to look a little chunky as their activity decreases and height has not yet caught up with their additional weight. Add breast buds, body hair and widening of the hips and you have a recipe for negative self-consciousness. Over the next four years female adolescents generally gain 40 pounds and go from 8% to 21% body fat (Klump ‘07). Such challenges demand flexibility to manage this transition into adulthood. Flexibility is not the anorectic’s strong suite as most anorexics are characteristically rigid and persistent. 

The average age of a girl’s first menarche is 12.5 with the beginning of secondary female sexual characteristics (breast budding and pubic hair) having fallen significantly since 1970 (with secondary sexual charateristics emerging as early as 7 years of age) (Weil ’12; Biro ‘10, ’12; Herman-Giddens ‘07; Euling ‘08). Several factors can disrupt the timing of puberty, but stress and anxiety rank high along with excess fat tissue, estrogen mimickers (BPA), and possibly meat and dairy hormones. 

The number of preteens struggling with eating disorders is a disconcerting phenomenon. Not so long ago, the average age for the onset of anorexia was 13 to 17. Today, children start showing clear symptoms of the condition between 9 to 12 years of age (Natenshon ’12). There are reports of children as young as six being diagnosed with anorexia, and 10% of adult anorectics reporting clear symptoms of the disorder before they were 10 (ANAD 12; Nicholls ‘11). The Agency for Healthcare Research and Quality reported that between 1999 and 2006, the number of children hospitalized for eating disorders has doubled (Rosen ’10). More that 60% of elementary and middle school teachers reported that eating disorders are a problem in their schools (ANAD 12). According to David S. Rosen, MD, MPH, of the American Academy of Pediatrics Committee on Adolescence:

“The incidence and prevalence of eating disorders in children and adolescents has increased significantly in recent decades, making it essential for pediatricians to consider these disorders in appropriate clinical settings, to evaluate patients suspected of having these disorders, and to manage (or refer) patients in whom eating disorders are diagnosed” (Rosen ’10).  

The DSM-IV criteria dictates that to be diagnosed with anorexia a female must experience amenorrhea for three consecutive cycles, maintain a body weight of <85% expected for age and height and have a distorted body image (AP ’94). Anorexia is hard to diagnose in children because most children below the age of 12 are not typically experiencing a regular menstrual cycle. Also, few have extremely low weights because they are still in the early stages of development. It is difficult to determine ideal body weight (IBW) when there is no threshold for body weight or basal mass index (BMI) at which medical compromises occur (APA ’00). Children experience symptoms at an average of 5% below IBW because they have less body mass to begin with and enter a starvation state rather quickly (Nielsen ‘97). 

In addition, children may not believe they are overweight or have a distorted body image but simply fear that they will gain weight as their body changes (Nielsen ’97). The consensus is that the DSM-IV has limitations and does not provide appropriate diagnostic criteria for most eating disorders that present themselves during mid-childhood. To establish a criterion that will include preteens, the DSM-IV would need to omit body weight and amenorrhea in the diagnosis of anorexia (Nicholls ’00; Peebles ’10; Bravender ’10). Without a clear guideline for diagnosis, the condition will not be taken seriously enough, and children with anorexia will continue to be under recognized, under referred and have limited access to specialized care (Knoll ‘11). 

There are several important reasons to diagnose anorexia at an early age and provide immediate treatment (Lantzouni ’02; Peebles ’06; Lask ’92; Romeo ’96). Children lose weight more rapidly, have a lower body mass to begin with and enter a state of starvation rather quickly. Failure to treat children with anorexia in a timely fashion could result in irreversible effects on organ development (heart, liver, kidney), stunt linear growth; impede the natural progression of puberty, cause detrimental brain alterations and lead to severe bone loss. The longer an individual has anorexia the more challenging it is to intervene. Optimal assessment requires paying attention to a child’s distorted body image, her failure or refusal to gain weight, her strong desire to lose weight despite being at or below a healthy weight, her harmful weight control methods (food avoidance and refusal to eat), and a prolonged delay at reaching puberty. In addition, clinicians should also seek input from the child’s parents. 

Eating disorder advocacy groups, feminist authors, and outspoken experts are the watchdogs who attempt to expose the media, the fashion industry and advertisers that promote thin at any cost (Maine ’11; NEDA ’12). Professionals in the field are also concerned that schools, in their enthusiasm to address the war on childhood obesity, may wrongly endorse dieting, establish inappropriate weight goals and trigger food and weight obsessions. In one study, nearly one-third of 3 to 6 year old girls said they would change something about their physical appearance (Hayes ‘10). Forty percent of elementary school children want to be thinner, 81% of ten year olds are afraid of becoming fat, and 40% of nine year olds have already dieted (Maloney ‘89). Children are internalizing the idea of not being okay with themselves and dieting in an attempt to change that poor self-concept. 

In the meantime, the percentage of overweight children in the United States is growing at an alarming rate. One out of three children and adolescents are now considered overweight or obese. Why is so much energy placed on the small percent of children who might become anorectic (<1%) when the obesity crisis (>33%) is so much more severe? When children are insecure in their bodies and dissatisfied with their weight and looks they often feel inadequate, doubt they are loveable, and believe they don’t deserve happiness. The stigmatization begins early and the scars are long lasting. With low self-esteem comes social anxiety, school failures, depression and violence. All too often this poor self-concept can lead to substance abuse or eating disorders. 

What Parents Can Do  

What is desperately needed is to shift the focus away from weight loss to improvements in health and self-esteem (Costin ’10). For children, the approach should be to maintain their current weight or to keep their weight stable as linear growth proceeds (most importantly avoid dieting). Through these developmental years it is important for parents to reassure their child they are important, valuable and loved unconditionally regardless of weight. Parents should encourage children to express their feelings and emotions and listen to what their children are telling them. When appropriate, parents need to provide education about the media’s intent, social biases and peer pressure. It is important to treat weight as a delicate and private issue out of the public eye. Children know if they are heavy and being honest with them about their weight issues is important. Parents should not try to pretend it is not an issue. There should be an open dialogue. Do not play the blame game and avoid yelling, nagging, criticizing, bribing, threatening or punishing. Children should be complemented for their successes such as eating healthy snacks, spending time in physical activities, watching less television and practicing healthy eating.  Moderation is the key with emphasis on participation in enjoyable activities, healthy food choices and limited TV time. It is necessary to avoid power struggles, constant policing and over monitoring of what is consumed. At the same time parents need to strive to introduce boundaries, set limits and delegate responsibility. All parents should be involved in their child’s life and provide them with the attention they need and crave. The youth of today should be raised to believe in themselves. The underlying message should always be that it’s what is on the inside that counts, not what they look like. 

By eating together as a family, parents are capable of discerning significant variations in eating habits (dieting, counting calorie) and observing alterations in mood and attitudes around food. Equally important is the need to stay cued into words and phrases their young girls use to describe their bodies (“I’m fat”). Eating regular, balanced meals will set a good precedent and provide the opportunity to see food as a powerful source of energy for growth and development. If there is reason to believe that a child has symptoms of an eating disorder, the key is to begin treatment early, involve the family and institute permanent change in a stepwise fashion. It is critical that the intervention be age appropriate (do not simply lower the age range of existing adolescent services) and that parents take an active role with the assistance of a therapist. Most psychosocial interventions are started with the parents whom should serve as the mediators of change. Parents should always serve as appropriate role models and communicate to with their children. The eating disorder should be blamed as the common adversary. By taking this approach, the parents and child are removed from the problem and form a unified front. With children, it is often wise to turn autonomy over to the parents and progressively give it back to the child as the condition improves. 

When low body weight is the issue, a pediatrician, dietician and therapist should be brought into the picture. The immediate goal is to restore weight to 95% of ideal weight. The popular phrase in recovery is, “first we eat, then we talk.”  The first order of business is to get past the phobia of gaining weight to a weight threshold, reintroduce forbidden foods, and to resume normal menstrual cycles (depending on age). The needs of each child should be considered separately. The basics are for parents to establish (with the help of professionals) a weight goal, keep a food journal and evaluate nutrition, establish structure (3 meals per day), increase caloric intake, limit physical activity and correct cognitive distortions. Many times there is a need to receive ongoing medical, nutritional and mental health counseling (social skills, coping mechanisms, problem solving, emotional regulation etc). When warranted, a family therapist should be brought in to educate the parents, address family conflicts, improve parent-child relationships, and provide marriage counseling.

There may come a time when placing the child into a treatment facility is advisable and often necessary (Hodes ’93; Kreipe ‘95). Medical indications for acute care and immediate hospitalization would include cardiac dysrhythmia (ECG abnormalities), dehydration, electrolyte disturbances, severe bradycardia (heart rate <50 beats/min daytime; <45 beats/min at night), hypotension (<80/50 mmHg); hypothermia (body temperature <96◦F), orthostatic changes in pulse (>20 beats/min) or blood pressure (>10 mmHg), acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis), acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis), self-injurious behavior and comorbid diagnosis that interferes with the treatment of the eating disorder (e.g., severe depression, obsessive-compulsive disorder, severe family dysfunction). Inpatient treatment should be seriously considered if family-based/outpatient treatment is failing or not progressing appropriately (Goldin ’03). Indicators might include refusal to eat, uncontrollable binging and purging, continued weight loss, or gaining less than 1 to 2 pounds per week over a 4 to 6 week period.

There are several additional advantages to placing the child in a specialized residential program.  It is often therapeutic to get the child away from her stressful setting and family environment. Being away from home for the first time and in an environment with others who are struggling provides insight to the reality of the dangers of the disease. The child can focus on recovery 24-7, interact with peer groups, and immerse herself in a safe place to practice new behaviors. The time in treatment potentially could motivate young anorectics to become more amenable to following their parent’s guidance to eat and gain weight. It is best to look for a facility that has a holistic, multidiscipline approach and is well versed in addressing children differently than adolescents. But the time away in treatment is only part of the journey. Complete recovery and maintenance will require a qualified eating disorder therapist, dietitian, and an educated family support system during post hospital or residency care. 

The primary steps in dealing with preteen eating disorders are prevention, assessment, refeeding, parenting, referral, recovery and maintenance. Focus first on refeeding and eating problems by implementing nutritional support (food as medicine). Refeeding to 100% weight restoration has been shown to reduce relapse rates, decrease hospitalizations and prevent complications such as growth retardation, osteopaenia and pubertal delays. Then, either concomitantly or after weight restoration, it will be necessary to concentrate on therapeutic issues such as negative behaviors (restrained eating), affect regulation (anxiety); phobias (weight gain; fatty foods), obsessions (rituals; exercise) and distorted thinking (perfectionism). Carefully monitored, treatment outcomes should produce recovery rates of 70% after 12 months and 90% after 5 years. Treating early and at a young age may go a long way in reducing the 20% to 30% of cases that are reported to be chronic and unremitting. Without treatment, 10% to 18% of people with anorexia will die within 20 years of diagnosis. 

References:   

American Psychiatric Association Diagnostic and statistical manual of mental health disorders (4th ed). Washington DC (1994)

American Psychiatric Association Task Force on DSM-IV Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR 4th rev ed Washington, DC: American Psychiatric Association: 2000

American Academy of Pediatrics Committee on Adolescence: Identifying and treating eating disorders Pediatrics (2003) 111: 204 -211

Anorexia Nervosa and Associated Disorders (ANAD) 2012 http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/

Bartness TJ et al Neural and hormonal control of food hoarding Am J Physiol Regul Integr Comp Physiol (2011) 301:R641-55

Beck B Neuropeptide Y in normal eating and in genetic and dietary induced obesity Phiolo Trans R Soc Lond B Biol Sci (2006) 361: 1159 – 1185

Biro FM et al Pubertal Assessment Method and Baseline Characteristics in a Mixed Longitudinal Study of Girls Pediatrics (2010) 126: e583

Biro FM, Greenspan LC and Galvez MP Puberty in girls of the 21st century J Pediatr Adolesc Gynecol (2012) 25: 289 – 294

Bravender T et al Classification of eating disturbance in children and adolescents: proposed changes for the DSM-V European Eating

Bulik C et al The Genetics of Anorexia Nervosa Annual Review of Nutrition (2007) 27: 263 – 227

Costin C Tricks of the Trade: Things We’ve Learned Along the Way 3rd Annual Rocky Mountain Eating Disorder Conference, Denver, CO (August 20, 2012)

Erwin-Grabner T Beyond the DSM: A Biopsychocosial Model of Anorexia Nervosa ProQuest (2006)

Euling SY, Herman-Giddens ME Examination of US puberty-timing data from 1940 to 1994 for secular trends: panel findings Pediatrics (2008) 121 (Suppl 3): S172 – S191

Golden NH et al Eating disorders in adolescents Position paper of the Society for Adolescent Medicine J Adolesc Health (2003) 33: 496

Hayes S and Tantleff-Dunn S Am I too fat to be a princess? Examining the effects of populatr child’s media on young girls’ body image British Journal of Developmental Psychology (2010) 28: 413 – 426

Herman-Giddens ME The decline in the age of menarche in the United States: should we be concerned? J Adolesc Health (2007) 40: 201-203

Hodes M Anorexia nervosa and bulimia nervosa in children Int Rev Psychiatry (1993) 5: 101

Herpertz-Dahlmann B et al Etiology of anorexia nervosa: from a “psychosomatic family model” to a neuropsychiatric disorder? Eur Arch Psychiatry Clin Neurosci (2011a) 261(Suppl 2): S177 – 181

Herpertz-Dahlmann B  et al Anorexia nervosa in childhood and adolescence: course and significance for adulthood Nervenarzt (2011)b 82: 1093 – 1099

Kaye W Neurobiology of anorexia and bulimia nervosa : Purdue Ingestive Behavior Research Center Symposium Influences on Eating and Body Weight over the Lifespan: Children and Adolescents Physiol Behav (2008) 94:121–135

Klump KL et al Puberty moderates genetic influences on disordered eating Psychological Medicine (2007) 37: 627 – 634

Knoll S et al Do the currently proposed DSM-5 criteria for anorexia nervosa adequately consider developmental aspects in children and adolescents? Eur Child Adolexc Psychiatry (2011) 20: 95 – 101

Kreipe RE and Palomaki A Beyond picky eating: avoidant/restrictive food intake disorder Curr Psyciatry Rep (2012) 14: 421 – 431

Lantzouni E et al Reversibility of growth stunting in early onset anorexia nervosa: a prospective study J Adoles Health (2002) 31: 162 – 165

Lask B and Bryant-Waugh R Early onset anorexia nervosa and related eating disorders J Child Psycho Psychiatry (1992) 22: 281 – 300

Maloney MJ et al Dieting behavior and eating attitudes children Pediatrics (1989) 84: 482 – 489

Natenshon AH  Doing What Works: an Integrative System for the Treatment of Eating Disorders from Diagnosis to Recovery Eating Disorders: The Journal of Treatment and Prevention (2012) 20: 380 pages

NEDA (National Eating Disorder Association) Statistics 2012 http://www.nationaleatingdisorders.org/uploads/file/Statistics%20%20Updated%20Feb%2010,%202008%20B.pdf

Negardh R et al Neuropeptide Y facilitates activity based anorexia Psychoneuroendocrinology (2007) 293 – 502

Nicholls DE et al Children into DSM don’t go: a comparison of classification systems for eating disorders in childhood and early adolescence Int J Eat Disord (2000) 28: 317 – 324

Nicholls D et al Managing anorexia nervosa Arch Dis Child (2011a) 96: 977 – 982

Nicholls DE and Lynn R Childhood eating disorders: British national surveillance study The British Journal of Psychiatry (2011b) 198: 295 – 301

Nielsen GB et al Three cases of severe early onset eating disorder: Are they causes of anorexia nervosa? Psychopathology (1997) 30: 49 – 52

Peebles R et al How do children with eating disorders differ from adolescents with eating disorders at initial evaluation? J Adolesc Health (2006) 39: 800 -805

Peebles R et al Are Diagnostic Criteria for Eating Disorders Markers of Medical Severity? Pediatrics (2010) 125:e1194

Pinheiro AP, Root T and Bulik CM The Genetics of Anorexia Nervosa: Current Findings and Future Perspectives Int J Child Adolesc Health (2009) 2: 153 – 164

Procopio M and Marriott P Intrauterine hormonal environment and risk of developing anorexia nervosa Archives of General Psychiatry (2007) 64: 1402 – 1408

Romeo F Educators and the Onset of Anorexia Nervosa in Young Education (1996) 117: 55 – 60

Rosen DS et al Identification and management of eating disorders in children and adolescents Pediatrics (2010) 126: 1240 – 1253

Weil, E Puberty before age 10: a new normal? The New York Times (May 30,2012)

Young JK Anorexia nervosa and estrogen: current status of the hypothesis Neruoscience and Biobehavioral Reviews (2010) 34: 1195 – 1200