When you’re seeing a very young patient, eating disorders probably aren’t front of mind. This makes sense, given that eating disorders are often seen as affecting teens and young adults. For the most part, that’s true: the median age of onset for both anorexia and bulimia is 18, while for binge eating disorder, it’s 21. But the truth is that these diseases affect people of all ages, and eating disorders in children are more common than you might think.

Very young children—think kindergarten-age—can be diagnosed with anorexia, bulimia, or binge eating disorder, and research shows that eating disorders are skewing younger. This becomes less shocking when you learn that 40-60% of elementary school girls are concerned about their weight or becoming too fat (body image concerns are increasingly common among boys as well). And with Avoidant-Restrictive Food Intake Disorder (ARFID), it’s actually more common than not for the eating disorder to show up in childhood: ARFID generally sets in between age 6 and 13, and accounts for between 14-25% of eating disorders in pediatric treatment settings.

Eating disorders are serious and life-threatening, and early intervention is important, especially during the vital developmental years of childhood. As a pediatrician or healthcare provider for kids, it’s important that you have a working knowledge of eating disorders in children. Dr. Amy Rapaport, Medical Director at Equip, answered some of the most common questions on this complex topic.

How young can someone be diagnosed with an eating disorder? Does it vary from eating disorder to eating disorder?

A child can be diagnosed with an eating disorder at any age, although the most common time is during adolescence. As early as infancy, a patient can develop food restriction due to an aversion or a traumatic event and be diagnosed with Avoidant/Restrictive Food Intake Disorder (ARFID). Binge eating disorder, anorexia, bulimia, and OSFED (Other Specified Feeding or Eating Disorder) can all occur in young children as well. Studies have shown that attitudes around body shape and size may occur as young as the toddler years.

Research has shown that attitudes toward body shape and size can begin to develop as early as the toddler years, with children as young as three preferring a thin body shape, and a significant proportion of preschool-age kids expressing anxiety about their weight or body size. These concerns can be particularly pronounced for girls, with 40-60% of elementary school girls saying they are worried about their weight or becoming fat.

Which eating disorders are most common in children?

All types of eating disorders can occur in children, but the most common eating disorder in young children is ARFID. Unlike patients with anorexia and bulimia, patients with ARFID usually have no body image disturbance. Instead, patients with ARFID have picky eating habits or a general lack of interest in eating. These symptoms may be associated with a child’s aversion to texture, taste, smell, or color of food or it may be associated with a fear of pain, vomiting, or choking. Many young kids with ARFID may have experienced a traumatic triggering event, such as a choking incident, feeding issues as an infant, or an illness like the flu or strep throat.

Anorexia and bulimia are more commonly seen after the age of puberty, but disordered eating and body dysmorphia can occur as early as three to four years old. Binge eating disorder, which is defined as recurrent episodes of consuming large amounts of food coupled with a sense of loss of control around eating, can also be diagnosed in childhood.

Do eating disorders show up differently in children than they do in teens or young adults?

Young children with eating disorders are less likely to have body image disturbances and a fear of being fat than their older counterparts. Children are more likely to present with stomach aches or a lack of interest in eating. Very young children might present with more irritability or tantrums due to inadequate food intake.

Instead of rapid weight loss, young children may present with lack of expected height growth and weight gain. One important thing to be aware of is that eating disorders often go undetected if a child is in a larger body. It’s very important to closely monitor a child’s individual growth charts and investigate any change in their height or weight trajectories, rather than just looking at averages.

What are some of the specific health risks associated with eating disorders in young children?

Given that young children's bodies are growing and developing, when eating disorders occur at this time in their life, nearly every organ system can be impacted. Here are some of the most common health risks specific to young children with eating disorders:

• Lack of expected growth and delayed puberty
• Low bone density. Children with eating disorders may not reach their peak bone density, potentially putting them at a higher risk for osteoporosis later in life.
• Digestive problems. Young children with eating disorders often complain of stomach pains and have constipation and slowed gut motility.
• Cardiovascular issues. The heart can become smaller and weaker without adequate nutrition, which can make it more difficult to circulate blood at a healthy rate. Children can develop bradycardia (low heart rate), low blood pressure, and abnormal heart rhythms.
• Malnutrition. In young children, malnutrition can also present with emotional, cognitive, and social symptoms. They can become more irritable and may have increased tantrums, or present with a depressed or anxious mood. Children with eating disorders often have school difficulties, since they’re unable to concentrate and have slowed processing skills due to lack of adequate nutrition. Social interactions with peers can also be affected, as children with eating disorders often become withdrawn.

What are the treatment options for young kids with eating disorders? Does treatment itself look different than it would for older patients?

All treatment options for eating disorders in young children require active involvement of the child’s parents or caregivers. At the outset, it’s important for every caregiver to know that they did not cause their child’s eating disorder, but they are at the center of their child’s recovery.

Family-Based Treatment (FBT) is the evidenced-based model that empowers family members to help their loved ones achieve lasting recovery. Initially, family members focus on renourishing their child and helping the child eat throughout the day. They work closely with a treatment team, focusing on nutritional rehabilitation and skill development for the cessation of eating disorder behaviors.

Research has shown FBT to be the most successful treatment approach for eating disorders in young people. Unlike older populations, in which patients have more independence and may opt for individual treatment, the young pediatric population requires active family involvement for treatment and recovery. Learn more about FBT and how Equip adapted it to better serve patients virtually.

Citations:

1. Chatoor, Irene et al. “Anorexia nervosa and depression in a 5-year-old girl: Treatment with focused family play therapy and medication.” The International journal of eating disorders vol. 52,9 (2019): 1065-1069. doi:10.1002/eat.23129
2. Shapiro, J.R., et al. (2007), Evaluating binge eating disorder in children: Development of the children's binge eating disorder scale (C-BEDS). Int. J. Eat. Disord., 40: 82-89. https://doi.org/10.1002/eat.20318
3. Cohane, G.H. et al., Body image in boys: A review of the literature. Int. J. Eat. Disord., 29 (2001): 373-379. https://doi.org/10.1002/eat.1033
4. Białek-Dratwa, Agnieszka et al. “ARFID-Strategies for Dietary Management in Children.” Nutrients vol. 14,9 1739. 22 Apr. 2022, doi:10.3390/nu14091739
5. Kościcka, Katarzyna et al. (2016). Body size attitudes and body image perception among preschool children and their parents: A preliminary study. Archives of Psychiatry and Psychotherapy. 18. 28-34. 10.12740/APP/65192.
6. Cash, T. F., & Smolak, L. et al. Body image: A handbook of science, practice, and prevention (2nd ed.) (2011).. The Guilford Press.