Childhood Onset Eating Disorders

The mean age of onset for anorexia nervosa is 17 and the prevalence among females in late adolescence and early adulthood is approximately 0.5 to 1.0 percent. Bulimia nervosa occurs in between 1 to 3 percent in young adolescent and adult females and typically begins in late adolescence or early adulthood. Early onset of eating disorders typically refers to children aged 8–14. Little is known about eating disorders in children; it is rare that children younger than 8 experience anorexia nervosa or bulimia nervosa because of the cognitive features associated with the disorders.

Evaluations of children should rule out other forms of disordered eating and reasons for food refusal including mood disorders, general food refusal unrelated to body concerns, and selective eating. Early onset anorexia nervosa involves weight-loss attempts or food restriction to avoid weight gain and/or purging behaviors. Dieting for weight control and binge eating and purging are indeed a source of concern given that they are associated with the development of eating disorders.

Although the clinical presentation of childhood onset eating disorders is similar to adult eating disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria were developed for use in adults. The Great Ormond Street Diagnostic Checklist was developed to diagnose AN in children and includes criteria for food avoidance, weight loss or failure to gain weight, and two of the following: preoccupation with weight, preoccupation with energy intake, distorted body image, fear of fatness, self-induced vomiting, extensive exercising, and purging.

In children, the prevalence of binge eating disorder (BED) or binge eating symptoms ranges from 0 to 37 percent (depending on the measure or interview used). Given that the DSM criteria for BED were developed for adults and considering the subjective definition of a binge episode, provisional BED criteria for children have been proposed, including binge eating (food seeking in the absence of hunger and lack of control over eating) and at least one of the following: eating in response to negative affect, eating as a reward, sneaking or hiding food).

Finally, for diagnosis, symptoms persist for at least 3 months and are not associated with compensatory behavior. We have compared these criteria via a brief checklist in children aged 5–13 versus diagnosis via the Structured Clinical Interview for the Diagnosis of DSM-IV Disorders (SCID-IV) and found that 44 percent reported wanting to eat when not hungry, 52 percent reported that they lose control over their eating, 63 percent acknowledged eating as a result of negative emotions, 48 percent reported that they use food as a reward, and 28 percent stated that they sneak or hide food. Approximately 30 percent of the children met criteria for either syndromal or subsyndromal BED.

Several risk factors are related to the development of eating disorder including genetics, biological vulnerability (e.g., appetite dysregulation), psychological factors (e.g., perfectionism, low self-esteem, obsessionality), and sociocultural factors (e.g., internalized thin ideal). Factors posited to relate to resiliency include positive self-esteem and sense of life control, positive peer and adult role models, values, and behaviors factoring abstinence from health risk behaviors. Early detection and intervention improve the odds of recovery. In terms of BED, prevention and early interventions are needed to avoid the associated consequences including adult BED, obesity, and other medical and psychiatric comorbidities.

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