Defeating the Monster: Helping Little Girls Overcome Anorexia Nervosa

Over the past two years, I have had an influx of very young girls with Anorexia Nervosa (AN) come to me for treatment. This trend mirrors recent media coverage of the rise in AN among pre-teens. When I tell friends and acquaintances about my work, they are shocked and horrified to learn that many of my AN patients are between 9-12 years old. The typical response is first incredulity, then a remark about how “sad” it is that little girls are under such pressure to be thin and perfect. I am not sad about this at all – in fact, a very young child presenting for AN treatment represents an ideal scenario.

Let me explain. First, there are no good data to support the popular notion that the prevalence of AN has increased over the past few decades (in contrast, the prevalence of bulimia nervosa and binge eating disorder has skyrocketed in recent decades, but that is beyond the scope of this post). Most data in fact suggest that the incidence of AN has remained constant throughout recorded history. Second, we do not yet know how to prevent AN, nor do we know whether AN is possible to prevent.

We do know that children are being diagnosed with and treated for AN at much younger ages now compared to a generation ago. Research has also shown that the prognosis for AN is inversely correlated with age and duration of illness prior to the start of effective treatment. In other words, the younger the patient, the better her chance for full recovery.

The 5th and 6th grade girls who are diagnosed with AN today would most likely have developed AN anyway, but in previous generations the illness would not have been triggered, diagnosed, or treated until later in adolescence, when it is more difficult to treat. Therefore, I view younger age of onset as a positive thing.

AN is triggered by an energy imbalance – that is, a period of time in which a person’s caloric intake is lower than her body’s energy needs. My theory is that kids are developing AN at younger ages because there are more opportunities for energy imbalance to occur in younger children now compared to generations past.

Several factors contribute to this trend of children developing AN at younger ages:

1.) National hysteria about the “obesity epidemic” and well-intentioned but misguided government programs aimed at children.

Children who are predisposed to AN tend to be anxious, sensitive, perfectionistic, rigid, and overly compliant with rules. These are the kids who actually take the “obesity prevention” messages to heart and follow them to the letter. They avoid “unhealthy foods” (e.g., those high in calories) in favor of “healthy foods” (e.g., those low in calories and fat), thus creating a negative energy balance and triggering AN. The irony here is that it is very unhealthy for a growing child to eat a low-fat or restricted-calorie diet.

2.) Earlier puberty.

This generation of children tends to enter puberty earlier than their parents or grandparents. The hormonal changes of puberty, combined with the increased energy needs of the pubertal growth spurt, provide a perfect opportunity for a negative energy balance. Add to that the tendency of girls to begin dieting to counteract their body’s pubertal changes to conform to the thin ideal, and you have a perfect storm.

3.) Participation in intense athletics at younger ages.

It used to be that athletically-inclined kids did not begin intense athletic training until high school. These days, 6-year-old kids begin practicing for their sport multiple nights per week and traveling to games on the weekends. These kids have extremely high energy needs, as they must consume enough food to fuel their sports in addition to keeping up with normal growth and development. Kids who are predisposed to AN are not able to eat enough to fuel their body’s needs. Further, thinness is considered an advantage in many sports such as gymnastics, track and field, cross country, dance, cheerleading, and diving.

4.) Increased stress.

The modern lifestyle is fast-paced, rushed, overscheduled, and pressured for all of us, even children. Every time I listen to an elderly person talk about their childhood, I am struck by how different life was in the 1940’s and ‘50’s and how much more laid back things were for children then. Stress can trigger loss of appetite, which creates a negative energy balance, which can be the beginning of AN in a vulnerable child.

5.) Decrease in family meals.

For a number of reasons, including busy schedules, families are eating together less often now. If a young child is responsible for fixing her own breakfast, packing her own lunch, or microwaving her own dinner, it is much easier for her to skip meals or restrict her food intake without her parents knowing.

6.) Ignorant pediatricians.

In most cases, pediatricians are the first healthcare professionals to spot (or miss) early signs of an eating disorder. I cannot count the number of patients I have seen whose pediatrician was completely unconcerned by a child or adolescent’s weight loss or failure to gain weight. They will often say things such as “Don’t worry, she’s still in the normal weight range for her age” or “she could lose 10 more pounds and still be fine.” Even worse, many pediatricians will congratulate a child for losing weight. It is as if pediatricians have become so consumed with “fighting childhood obesity” that they have forgotten that kids are supposed to grow and gain weight from birth until age 20. Weight loss is not normal or healthy for any child or adolescent. Generations ago, people understood this, and any weight loss in a child was cause for alarm. You know how grandparents always want to feed you a lot, and say “you’re looking thin” as if it were a bad thing?

Like many diseases, AN in children presents differently than in teens or adults. Here are some key differences I have observed in the young children I treat:

1.) Young children are much less likely than teenagers to fall into AN through dieting. In little girls, the negative energy balance is more likely to result from unintentional weight loss through illness, athletic training, or “healthy eating.”

2.) Fear of fat, drive for thinness, and body dysmorphia – which are considered the hallmark cognitive symptoms of AN – are often absent in young children. Eating provokes extreme fear and resistance, but they often cannot articulate why.

3.) Young children are more likely to present with dehydration as well as malnourishment. Whereas teenage anorexics drink large quantities of water, diet soda, and black coffee, little kids sometimes cannot grasp the concept of calories. Many little kids with AN will fear and avoid anything that enters the mouth- including water, gum, vitamins, and medicine.

4.) Teens and adults with AN usually have a list of “safe foods” which are low calorie and low fat – such as salads, fruit, rice cakes, and nonfat yogurt – and they tend to fear high calorie foods such as ice cream and pizza. However, sometimes young children’s food rules and food fears make no caloric sense. For example, I have worked with children who will willingly consume any beverage, including milkshakes, but who refuse to take a bite of solid food, even a carrot stick. Other kids will have a narrow list of safe foods which are familiar but not low-calorie (e.g., chicken nuggets, pop tarts, and grilled cheese sandwiches).

5.) Young children become medically and mentally unstable much more quickly than teenagers. Post-pubescent teen girls and women, even slender ones, start out at a higher body mass and have reserves of fat. Prepubescent children are already light and very lean. A loss of even a few pounds is enough to cause severe medical problems and extreme cognitive distortions in a child. It is not uncommon for a child to go away to summer camp completely healthy and return three weeks later in grave danger.

6.) It is easier for young children to externalize their illness. They often describe feeling “taken over” by a voice or by some evil force beyond their control. They love to name their illness and refer to it in the third person, unlike teenagers who tend to balk at this exercise, or who experience their illness as more ego-syntonic. My young patients have come up with various names for their illness – the monster, the beast, the devil, Scary Larry, and Voldemort are a few that come to mind.

In my experience, young children tend to make a full recovery more quickly and more easily than teens or young adults. Because they fall into AN so quickly and because they are still so dependent on their parents, they are brought into treatment very early in the course of the illness. Their AN thoughts and behaviors are not as engrained as, say, a 16-year-old who has suffered from AN for two years.

Young children are more dependent on their parents than teens. Thus, it is far easier for both parent and child to adjust to the “magic plate” technique of parents preparing and supervising all meals and snacks – this is not so different from what most parents do for their healthy 10-year-olds anyway. It is extremely difficult for teens and especially young adults to accept the amount of parental support and supervision required for successful re-feeding.

I love treating little girls with AN. Each time I get a call from a terrified parent whose little girl who is showing signs of AN, I breathe a sigh of relief, grateful that they have come to my attention so early in the course of the illness. Although these children and their families are in for a harrowing journey, I have complete confidence that they will defeat the monster. These kids can enter their teen years fully recovered and able to enjoy high school and college unencumbered by this horrible illness.

8 Replies to “Defeating the Monster: Helping Little Girls Overcome Anorexia Nervosa”

  1. Bravo and thank you Dr. Ravin for illuminating the treatment of the young sufferer. As a mother of a 10 yr old (DX at age 9.5) there is a dearth of clinical support. She did have a rapid medical decline and was hospitalized. However…..since discharge, she has done extremely well using Maudsley FBT, completely WR to her historic growth curve, (30 pounds in 8 weeks – this was hard slogging work), systematically confronted all fear foods with clinician support and sees a CBT pediatric psychologist. In my case it was clearly genetically predisposed ( I had a brother with AN). Her progress gives me great hope in the neuroplasticity of the brain and the efficacy of expsoure therapy in treatment of AN. Bottom line though is with Maudsley I was empowered to know I saved my child’s life…….and hopefully will continue to work toward a lifetime of health mindful and vigilant. Kudos.

  2. Thank you for this information. Unfortunately my daughter started at 14 and received great medical care but the doc did not have anyone to offer for psych care. As this care was not covered by insurance, it was delayed and then the cost was so monunmental that we had to emmancipate her in order to get her care. The care has repeatedly been less than optimal. I will continue to read your blog and offer this info to my daughter. FEAST is a great organization which is where I saw your blog. Always hopeful.

  3. I can see how treating someone at a younger age is very successful, but isn’t their chance of relapse much greater? I would think that many of them would relapse during their adolescent years since they are already proned to the illness.

    1. PTC – I understand why it may seem that many kids who are treated early would relapse in adolescence. I am not aware of any research on this issue, so this response is purely my professional opinion based on my experience and knowledge of this disease. Kids who are diagnosed and treated early with effective, family-based treatment are much less likely to relapse in adolescence because their families, having already been through treatment, know exactly how to respond at the first sign of ED symptoms. However, I would imagine that kids who suffer from AN but do not receive effective treatment are probably much more likely to relapse in their teen years. Kids who are sent away to residential treatment centers with little family involvement (other than the token “family weekend” or weekly family phone therapy sessions) are probably more likely to relapse in adolescence because their family has not been taught the skills they need to intervene early when their child begins to struggle. In these cases, the family has actually been taught to back off, which is precisely the opposite of an effective intervention. Similarly, I imagine that kids who are treated as outpatients in an individual therapy approach would also be more prone to relapse in adolesence for the same reasons.

  4. No I don’t think the rate of relapse is greater with younger ones at all. But I will let the Dr. speak to that. The biggest prognostic indicator is weight restoration to historic growth curve and maintaining this over time (and growth). By the time a child reaches adolescence, they will have had years of full nutritional ordered eating supported and created neuropathways that protect against relapse. If it does happen, parents step in with magic plate and maudsely as they had initially to catch things early.

  5. Dr. R’s post supports our experience. My d was dx with restrictive anorexia at 10 and we have been treating with FBT. It may seem an odd thing to say but I feel lucky her eating disorder presented as early as it did. We have years to treat and manage this as a family before having to worry about her managing it independently. The evidence based treatment model that has proven to be successful works especially well with the little one. “Parenting” through an eating disorder is extremely intense but it is a difference in degree not in kind from the parenting a non-ed 11 year old. With an early diagnosis and proper treatment the outcome feels truly hopeful. The key is proper dx/treatment and sadly this is often lacking for parents and children. We need more (many more) Dr. Ravins!!!

  6. Our daughter was diagnosed with RAN at age 9. She was very mentally ill for about 15 months. At 10, we started Maudsley/FBT and within 3 months, she was weight restored to her original growth curve. It took about 18 months post weight restoration for her brain to heal so that she could have a normal life. This was over 3.5 years ago. She is now 15 and has a normal and very happy life. She is now much happier than she was as a younger child. There is no shadow of the ED so I completely disagree with the poster who said that their chance for relapse in adolescence is greater. Not only is she aware that diets and restrictions are a slippery and dangerous road for her, but we her parents are totally tuned in to her nutrition and mental health state. IF she were to start restricting, which she hasn’t done during the previously stated time, we would step in to help her get back on track. This doesn’t mean that we are hovering over her. We monitor her from a distance and she has a healthier relationship with food and with her body than most of her 15 year old peers.

  7. My D was diagnosed at age 10, started with the whole “obesity epidemic” thing at age 9. She wanted to be the next “Julian Michaels” from TV. She is now 11 and it has been nearly a year/ She was refed relatively quickly. She spent 1 month in a hospital and it was a nightmare. We came home and began magic plate. As the weight went on the OCD, depression etc. all evaporated. It was like watching my child be re-born again.Now here we are with a girl who is happy, healthy, social, loving life. She has become very hypermetabolic- needing 6000 calories a day to maintain and grow through puberty. She has grown over 2 inches now since April. We still have many battles to win of this war, but I am thankful every day that my daughter was so young. It gives us the time to get her healthy and well for many years. We will know any signs of EDs return- if he dares to enter my house again. Thank you for this blog! Mamabear

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