Eating Disorders in School Children

Eating disorders are observed with increasing frequency in children and adolescents. Although food restriction is the most commonly reported symptom, children with eating disorders may have varying presentations and may meet only partial criteria for anorexia nervosa or bulimia nervosa.

General Diagnostic Criteria

The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), published by the American Psychiatric Association, establishes criteria used in diagnosing and distinguishing eating disorders.

Anorexia nervosa is diagnosed according to three diagnostic criteria: a refusal to maintain body weight within a normal range for the person's age and height, an intense fear of gaining weight, and a severe disturbance of body image in which body image becomes responsible for self-worth accompanied by a denial of the gravity of the illness. The illness may take the form of one of two subtypes: restricting (ANR), or bingeing/purging (ANBP). Individuals with ANR use constraint in their eating to reduce their weight and are, in general, more perfectionistic in personality and [Page 214]restrictive in their eating behaviors. In contrast, individuals with ANBP may binge and use purging methods (i.e., vomiting, laxatives) to control their weight.

Formerly seen only in young and older adults, eating disorders are becoming far more prevalent in younger children.

The DSM-IV criteria for bulimia nervosa include recurrent episodes of binge eating accompanied by a feeling of a loss of control (binge eating constitutes a consumption of larger-than-normal quantities of food in a discrete period); recurrent compensatory measures to avoid gaining weight postbinge that either involve purging (e.g., self-induced vomiting) or nonpurging activities (e.g., excessive exercise or fasting); the bingeing and purging behaviors occur a minimum of two times a week for a duration of 3 months; self-evaluation is disproportionately influenced by body shape and weight. Also, these disturbances do not occur during episodes of anorexia nervosa.

Also included in the DSM-IV is the category Eating Disorder Not Otherwise Specified (EDNOS), which includes all clinically significant eating behaviors that do not fit into the other categories.

Eating Disorders in Children and Adolescents: Unique Features

Diagnosing eating disorders in children and adolescents poses a difficult challenge as children and adolescents tend to present atypically and carry unusual features with their illness. Consequently, children with eating disorders may pass undetected by medical providers, as they may not meet the full criteria for anorexia nervosa or bulimia nervosa. For example, a child who has not yet reached menarche may “miss” the anorexia nervosa criterion of absent periods.

Research on eating disorders in children and young adolescents suggests that they are most likely to be given a diagnosis of EDNOS as these younger patients are less likely to engage in typical binge/purge behavior and are likely to meet only partial criteria for anorexia nervosa or bulimia nervosa. Restriction of food is identified as a common presenting feature in children and adolescents. Furthermore, younger patients with eating disorders are more likely to be male and to have a high rate of comorbid psychiatric illness such as obsessive-compulsive disorder. Additionally, younger patients are less likely to admit to the use of diet pills or laxatives as methods of weight control. Of particular concern is the finding that younger patients experience a more rapid rate of weight loss than older patients, thereby increasing the risk of bone loss and abnormal growth and development. Other possible medical complications in younger patients include damage to reproductive organs and decreased brain cortical mass.

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