Being a parent can often feel like wading through a seemingly never-ending list of concerns. Is your child safe? Are they happy? Are all their needs being met? With all of these questions playing on a constant loop, it may seem unfathomable to consider bigger questions around mental and physical health issues, like eating disorders. But eating disorders like anorexia can and do affect people of all ages, including children. In fact, a recent study found a massive increase—about 40%—in eating disorders among kids ages 6 to 18 since the beginning of the COVID-19 pandemic, and another study found that about 22% of children worldwide show signs of disordered eating.

While noticing changes in your child's eating or weight can be scary, there are highly successful evidence-based treatment strategies that work in children with anorexia. Read on to learn the facts about anorexia in children, how to spot the signs, and what the path to recovery looks like.

What is anorexia nervosa in children?

Anorexia nervosa, commonly referred to as anorexia, is an eating disorder characterized by extreme food restriction and fear of weight gain. While many people with anorexia are at a low weight and appear extremely thin, the illness can affect those in “average-size” or larger bodies as well. It’s important for parents to know that a child does not need to be visibly emaciated to have anorexia; in pediatrics, brighter red flags are things like stalled weight gain or deviation from the growth curve.

“Anorexia nervosa is a serious eating disorder characterized by an intense fear of gaining weight, distorted body image, and severe restriction of food intake, often leading to dangerously low body weight,” says Equip Dietitian Lead Tanya Hargrave-Klein MS, RDN. “While the core diagnostic criteria are similar for both adolescents and adults, there are important distinctions in how the disorder presents and is treated in younger individuals.”

While many people associate anorexia with simply not eating, it’s important to note that there are actually two different subtypes: restricting type and binge-eating/purging type. “Young people with the restricting type of anorexia primarily achieve weight loss through dietary restriction and excessive exercise,” Hargrave-Klein says. “They might meticulously count calories, avoid certain food groups, or develop rigid rules around eating. In the binge-eating/purging type, children restrict food intake, but also engage in recurrent episodes of binge eating—consuming a large amount of food in a short period, often feeling a loss of control—followed by compensatory behaviors such as self-induced vomiting, or misuse of laxatives, diuretics, or enemas.”

Equip Therapist Carol Brown, LCSW, notes that these subtypes aren’t fixed, and can change over time. She also explains that, while anorexia at any age carries risks, the health risks for children with anorexia can be greater: “While the diagnostic criteria in both children and adults are the same, there are heightened medical risks for children, as they are not yet fully developed.”

Signs and symptoms of anorexia in children and teens

While there are important distinctions in how the illness is treated in young people versus adults, the signs and symptoms of anorexia in children can often resemble those of older patients. “Parents might hear ‘I’m not hungry’ or ‘I already ate’ frequently, and might also notice that their child prepares food for others but doesn’t eat it themselves,” Brown says. “The child may have a new or sudden preoccupation with food and recipes, or have detailed questions about how food is prepared—for instance, asking parents if they used oil, lean meat, low calorie dressing etc.” Parents may also notice their child avoiding social situations due to body image or appearance distress, according to Brown.

The most obvious sign of anorexia in children is weight loss, but it’s crucial to understand that weight loss won’t always be obvious—and that it’s not necessary for a child to be underweight for them to be struggling with anorexia. “While weight loss can be a concern and sign of anorexia, this is more complicated in youth since they are developing and their bodies are changing,” explains Brown. “This makes it easier to miss, especially since anorexia is just as risky for youth even if they are ‘within normal BMI,’ which is why it’s important to pay attention to other signs.”

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Behavioral signs

According to Hargrave-Klein and Brown, behavioral signs of anorexia often include:

• Calorie counting
• Meticulous food preparation
• Skipping meals
• Hiding food
• Developing rigid food rituals
• Eating alone
• Making excuses to avoid eating
• Preoccupation with calories/”healthiness” of food
• Fixation with weight (weighing self frequently)
• Focus on perceived appearance flaws
• Extended bathroom time before/immediately after meals
• Preoccupation with exercise
• Excessive fluid or caffeine consumption
• Excessive laxative use
• Sudden changes in food preferences and restriction of foods that they previously enjoyed

Additionally, young people with anorexia may also:

• Engage in body checking
• Avoid social events involving food
• Wear baggy clothing
• Chew and spit out food
• Bake without eating
• Exercise excessively outside of organized sports

Emotional and psychological signs

“Emotional and psychological indicators of anorexia in a child can manifest as an intense preoccupation with food, eating habits, or exercise,” Hargrave-Klein says. “You might observe heightened irritability during meal and snack times, and a palpable fear of weight gain.”

Additionally, Hargrave-Klein says that the emotional and psychological signs of anorexia may include:

• Extreme mood swings
• Withdrawal from previously enjoyed activities and friendships
• An increasing tendency towards secretiveness
• Social isolation

Physical signs

“The physical toll of anorexia on young individuals can present in striking ways,” Hargrave-Klein says, noting that common physical signs may include:

• Dramatic weight loss
• Persistent gastrointestinal issues like constipation and bloating
• Irregular or absent menstrual cycles
• Chronic coldness
• Hair loss
• Sleep disturbances
• Episodes of fainting or dizziness

“A telltale sign can also be the appearance of fine, downy hair (lanugo) on the body, along with a compromised immune system,” Hargrave-Klein adds

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What causes anorexia in children? Understanding the risk factors

There is no single cause of anorexia in children or adults, but rather a combination of genetic, psychological, and environmental factors. “When I work with families, one of the first truths I share as an eating disorder registered dietitian is that parents are not the cause of their loved ones' eating disorders,” Hargrave-Klein says. “There is no single cause.”

There are, however, certain risk factors that may increase the chance of developing anorexia, including a family history of eating disorders or other mental health conditions, perfectionistic personality traits, and anxiety disorders. “For children, a close relative with an eating disorder is a significant risk factor for anorexia,” Hargrave-Klein says. “Additionally, low energy availability, or burning more calories than you eat, can increase risk. This is often seen in young athletes who unintentionally burn more calories than they consume, particularly when intense sports training is coupled with inadequate fueling.”

According to Brown, additional risk factors for anorexia in children may include a history of bullying (especially if its weight- or appearance-related), dieting, or trauma. “Youth specifically are very easily influenced by their peers, so having peers that are dieting or highly focused on appearance, or following dieting/fitness/’health’ trends on social media,” she says. “Social media usage—specifically following body-focused/diet-focused/appearance-focused content—can have a significant impact on young people’s body dissatisfaction, and children have a more difficult time discerning true vs. false claims related to health and nutrition.”

Mental health challenges like depression, trauma, obsessive compulsive disorder (OCD), or generalized anxiety can all also contribute to the likelihood of a child developing anorexia. “Further fueling the fire is weight stigma—the prejudice people face due to their body shape or size,” Hargrave-Klein says. “Constant exposure to damaging messages about weight can breed body dissatisfaction in young people, significantly increasing their risk of developing anorexia. Tragically, young individuals battling eating disorders are up to three times more likely to have endured bullying or teasing about their appearance than their peers.”

Brown also notes that another anorexia risk factor for children is engaging in a sport or activity that is appearance- or weight-focused, such as dance, running, gymnastics, or swimming. “All that said, eating disorders are complex mental health conditions with no single known cause,” she adds.

Diagnosis: how to get a professional anorexia assessment

In order to get a proper diagnosis for children with anorexia, it’s essential to identify signs and symptoms as soon as possible and seek guidance and support from a trained professional. “Early detection of anorexia is crucial; it can significantly reduce the duration of treatment and mitigate the physical ramifications of the illness,” Hargrave-Klein says. “Discuss your observations and concerns with your loved one's primary care provider. Request an eating disorder assessment and, if needed, seek a second opinion. Don't delay.”

If you observe any of the aforementioned signs or have any concerns about your child’s eating, it’s essential to listen to your gut and take action. As with all eating disorders, anorexia only tends to get worse over time, and it does not go away on its own. “Early intervention is key, and the earlier it is caught the easier it is to treat!” Brown says. “Do not hesitate if you notice any concerns—early intervention can be life saving.”

One small first step toward a diagnosis is Equip’s free, 5-minute eating disorder screener. You can also set up a call with an Equip team member to talk through your concerns, get a professional opinion on whether your child may have anorexia, and discuss potential treatment options.

Treating anorexia in children

Although anorexia can often present similarly in children and adults, the most effective treatments for both groups are distinct. Family-based treatment (FBT) is considered the gold standard for treating eating disorders in children, adolescents, and young adults. It was specifically developed to treat anorexia, but has shown to be effective for bulimia, binge eating disorder (BED), and other specified feeding or eating disorder (OSFED) as well, and can also be used in conjunction with other treatment modalities to treat ARFID.

“While conventional adult-focused treatments have limitations, FBT is an evidence-based approach and is considered the leading treatment for children with anorexia,” Hargrave-Klein says. “Historically, treating anorexia in children involved adapting methods developed for adults. These traditional approaches, which prioritize a child's development of insight and motivation, can be inefficient and risky. Valuable time is lost while the physical effects of the eating disorder worsen. FBT addresses this by offering a more rapid and often more economical route to recovery.”

Working with a multidisciplinary treatment team

To effectively treat anorexia in children, experts agree on the importance of working with a multidisciplinary treatment team including a doctor, therapist, registered dietitian, and other clinicians. While one or more medical providers may be necessary to help stabilize a patient’s health, a dietitian can provide nutritional rehabilitation to not only support weight gain, but to restore brain and body function in children with anorexia. In the context of FBT, a therapist is essential in helping to target eating disorder symptoms and behaviors first, and then moves on to address psychological, emotional, and relational aspects later.

The importance of family support

“When a child is battling an eating disorder, it's as if a terrorist has seized control of their mind, making healthy eating choices impossible,” Hargrave-Klein says. “FBT empowers parents to guide their child toward recovery by ensuring proper nutrition until the child is fully weight- and nutritionally-restored. This active family involvement significantly increases the likelihood of recovery.”

FBT utilizes a three-phase model that empowers families to actively manage their child's recovery at home. The three phases of FBT are:

1. Reduction of symptoms and weight restoration (when needed)
2. Development of skills and independence
3. Identity formation and relapse prevention

“The initial phase focuses on caregivers supervising re-nourishment at home,” Hargrave-Klein says. “This is essential for the child to regain weight, which is a fundamental step in recovery. As the child improves, FBT then assists them in resuming control over their eating and other eating disorder symptoms, providing them with coping strategies for the challenges of recovery.”

Brown adds that family support is always valuable in the mental health field and it is even more crucial in pediatric eating disorder recovery, as family support is the main driver of change. “This differs from adult eating disorder treatment, which utilizes an enhanced cognitive behavioral approach to treat eating disorders,” she says. “While supports are very valuable in adult eating disorder treatment, in treating eating disorders in children, the supports are the primary change agents.”

One of the unique challenges of anorexia is that it’s egosyntonic, meaning the eating disorder behaviors feel aligned with the person’s beliefs, making it extremely challenging to fight disordered urges. “This only worsens as the child becomes more and more malnourished, creating a cycle that’s really difficult to break,” Brown says. “Our patients often describe the eating disorder urges as a ‘voice’ telling them what to do; these voices become louder and more fixed with malnourishment, and it becomes more and more difficult to differentiate the eating disorder voice from rational thoughts. This is where supports become so valuable; they can provide a supportive counter-messaging voice when the child has difficulty accessing their own internal voice.”

Above all, family support in the context of anorexia treatment in children allows patients to maintain some semblance of normalcy as they navigate recovery. “Keeping children at home keeps them with their families,” Hargrave-Klein says. “It keeps them in their real lives. It keeps them developing and on track with peers. It keeps them connected to things that motivate them: basketball practice, school, theater tryouts, and friends.”

Anorexia in children: recovery is possible

Although anorexia in children can be frightening to consider or alarming to confront, recovery is possible. And remember that you don’t need to go it alone: there are experts available to offer comprehensive, evidence-based, effective treatment, and they can support you as you help your child restore their health and return to themselves.. Because anorexia can have long-term health complications, including bone density issues, heart problems, and more, early intervention and comprehensive treatment are essential.

You can also support your child’s anorexia recovery—and help protect against eating disorders in general—by practicing prevention strategies like fostering healthy eating habits and promoting a positive body image at home. Anorexia in children is scary, but it is treatable; and with your help, your child can achieve lasting, lifelong recovery.

FAQ

How is anorexia different from just being a "picky eater" or not having an appetite?

“Eating disorders can be deceptive,” Hargrave-Klein says. “It's easy to attribute changes in a child's eating habits to a passing phase of pickiness or a low appetite. However, there are key distinctions. Picky eaters generally consume sufficient calories by eating larger quantities of their preferred foods. In contrast, children with anorexia restrict both the variety and amount of food they eat, and this rigidity often intensifies as the illness progresses. Furthermore, a child experiencing a loss of appetite simply doesn't feel hungry. A child with anorexia, on the other hand, may feel hunger but actively chooses to restrict food intake due to an intense fear of weight gain and a distorted body image.”

Can my child recover from anorexia at home, or do they need to be hospitalized?

“Children with anorexia have the best recovery odds at home, rather than in traditional treatment centers,” Hargrave-Klein says. “Residential programs often fall short, with anorexia returning in up to 50% of child and adolescent patients. Hospitalization may be necessary for medical issues, but family-based treatment (FBT) can begin inpatient and continue at home once the child is medically stable.”

Brown adds: “Recovery at home is absolutely possible! There are many benefits of at-home recovery, including decreased life disruptions, not needing to constantly shift treatment teams and locations—leading to decreased disruptions and increased stability in overall care—as well as increased patient and family confidence in their ability to maintain recovery at home. However, when heightened medical risks are present, the child may require hospitalization to stabilize these risks; I encourage families to follow their treatment team or medical provider’s guidance when heightened medical risks are present.”

What do I do if my child denies having a problem?

“This may happen, as eating disorders are egosyntonic so parents can anticipate some—or a lot of—pushback in early recovery,” Brown says. “Recovery is still possible even when the child denies that there is a problem, and the FBT model and treatment team can help guide parents as to how to respond when there is pushback. Therapists and treatment teams who utilize FBT can help guide parents and families in how to renourish their child and manage eating disorder symptoms at home even when the child is struggling and pushing back.”

Will my child ever be "normal" around food again?

“Full recovery from anorexia is 100% possible and should be the goal of the treatment team,” Hargrave-Klein says. “If not, seek other providers. Once your child is weight and nutritionally restored, they should be able to interact with food as they did prior to the onset of the eating disorder.”

“Recovery is absolutely possible!” Brown agrees. “Early intervention and support can be key to recovery. Everyone’s recovery journey is unique and some might notice a re-emergence of old thoughts during periods of heightened stress and may benefit from continued support during stressful times, but overall it is absolutely possible for children to return to regular eating, regular life, and being able to enjoy mealtimes without being overtaken by intrusive eating disorder thoughts.”