The cheerful drawings depicted carrots, broccoli, and other vegetables, and the childish scrawl over them read, "Good Foods!" When 9-year-old Lily showed them to her mother, Maria Adams, one spring afternoon, Adams did what any health-conscious mom might: She grinned with pride. "Lily and her friend had started 'The Healthy Eating Club,' and this was their information packet," says Adams, of Columbia, South Carolina. "I was big on natural foods, smart fats, that sort of thing. I thought, 'How cute that she's taking after me.'"
Even more impressive was Lily's follow-through. Later that day, Adams served the girls a snack of ice cream. As her playmate gobbled it up, Lily primly pushed the bowl away. "It's a bad food, Mom," she said. Over the next few weeks, Lily started refusing all treats, and at mealtime, she moved more food around her plate than she put in her mouth. "I'm not hungry" or "I just want to eat healthy," she'd say, when her parents pressed her. After a few months passed and her pickiness persisted, Adams talked to Lily's pediatrician, who connected the family with a psychologist and a dietitian. The dietitian calculated that Lily was eating only 700 calories a day -- less than a third of what she needed. Adams supervised mealtime more closely, but when she managed to force her daughter to eat more than a few bites of vegetables or bread, Lily would ramp up her activity, racing her bike up and down their street, or sneaking in extra laps after swim practice. "It was like Lily suddenly had an uncontrollable urge to move," says Adams, who requested that we not use her or her daughter's real name for this story.
Within a year, Lily had grown 3 inches, but had not gained a single pound. She dropped from the 80th percentile to the 40th percentile on the growth chart. Previously a muscular little girl, she now had a jutting collarbone, prominent ribs, and a new layer of fine hair on her arms -- lanugo, which the body grows as a way to help regulate its temperature. Barely out of third grade, she was diagnosed as having anorexia.
An Alarming Trend
Lily's story is becoming increasingly familiar, as more and more young kids are developing anorexia, government statistics reveal. They're limiting their food intake so dramatically that they drop to a weight that's 85 percent or less of what it should be for their height, according to American Academy of Pediatrics' diagnostic criteria. Or, as they get older and more independent, they become bulimic, vomiting or using laxatives after eating an unusually large quantity of food in one sitting. Left unchecked, bulimia may cause serious digestive and dental problems, while anorexia can lead to brittle bones, an abnormally slow heart rate, and, in 10 percent of cases, death. In fact, the National Eating Disorders Association (NEDA) says that eating disorders have the highest fatality rate of any mental illness, including depression.
It's estimated that up to 10 million Americans have an eating disorder, according to the National Association of Anorexia Nervosa and Associated Disorders, but hard data on the prevalence of these conditions in children are scarce. The number of children under 12 who were hospitalized with eating disorders more than doubled between 1999 and 2006, the biggest increase for any age group, according to the Agency for Healthcare Research and Quality. "The typical onset of anorexia used to be 13 to 17 -- but now it's dropped to 9 to 13," says psychotherapist Abigail Natenshon, author of When Your Child Has an Eating Disorder, and director of Eating Disorders Specialists of Illinois, a clinic in Highland Park. And the very youngest patients are getting younger: "We're treating 6- and 7-year-olds with anorexia, and 11- and 12-year-olds with bulimia -- a problem that used to be almost nonexistent in children," says Ovidio Bermudez, M.D., medical director of child and adolescent services at the Eating Recovery Center, in Denver. "It baffles the mind." The pressure is also growing for boys, who make up 5 to 15 percent of anorexia and bulimia cases.
Unfortunately, these cases may be the tip of the iceberg. The number of children dieting or complaining about their body -- considered "gateway" behaviors to anorexia and bulimia -- is rising too, says Lynn Grefe, CEO of NEDA. "We're hearing about first- and second-graders who ask, 'Mommy, do I look fat in this?'" she says. "More children are displaying an unhealthy concern about food and body image. And parents are at a crossroads: They don't want their children to have eating disorders, but they don't want them to be overweight either."
With obesity rates climbing, health experts have been pushing for the past decade for more nutrition education in schools and less fat and sugar in kids' foods. "The problem is, some kids are interpreting the message to be 'food is fattening' or 'food is the enemy,'" says Natenshon. "They'll say they don't need to eat breakfast, or think they can't eat a big meal unless they'll be burning those calories later." She describes an 11-year-old patient whose friends eat a smaller lunch on days when they don't have soccer practice. "These children are mimicking what they're seeing adults do," says Natenshon. "But kids' nutritional needs are different from those of adults. They need enough calories and fats to fuel their body, grow their bones, enter puberty, and create neuronal pathways in their developing brain."
It's hard to know how big a role the anti-obesity movement has played in the rise of eating disorders in younger kids. "The teasing that goes along with early-childhood obesity can become a trigger for food restriction and eating disorders as well," explains Natenshon. "In fact, a child's actual body weight has little or no bearing on the development of an eating disorder. The child's distorted self-perception leads to the sensation of feeling fat, even though she might be painfully thin." But obesity-prevention efforts are almost certainly contributing to delayed diagnoses, says Julie O'Toole, M.D., medical director of Portland, Oregon's Kartini Clinic for pediatric eating disorders. "Many pediatricians are so focused on curbing obesity that they'll miss an eating disorder that's right in front of them. If a child is declining rapidly on the growth chart, even if he was in a too-high percentile before, that's a red flag." Overweight kids are at special risk, because they may -- out of pressure from parents or concerns about teasing -- go on a diet severe enough to cause their heart to fall into a dangerously slow rhythm (a response to extreme caloric restriction, common in anorexia) before they drop enough weight to get the attention of parents and doctors, says Dr. O'Toole.
It doesn't help that celebrities aren't just thinner than ever, but younger too. "When I was a child, most of the big stars were in their late teens or older, so my friends and I didn't really compare ourselves to them," says Susan Deemer, 37, a teacher at an all-girls primary school in San Francisco and mother of a 7-year-old girl. "Now, kids have idols closer to their own age. This makes them concerned about their body at a much younger age."
The Eating-Disordered Brain
Though cultural forces may contribute to eating issues, experts now think that these disorders stem from abnormalities in the brain -- and genes may be responsible. A study of twins conducted at Michigan State University found that eating disorders are 59 to 82 percent heritable. A child who has a close relative with anorexia is up to ten times more likely to get it herself.
More research is needed to find out which genes put a child at high risk. Until then, parents can recognize personality traits in their children that tend to go hand in hand with eating disorders -- most often, anxiety, obsessive-compulsive disorder, and perfectionism -- and then watch for signs of eating-disorder behaviors, such as restricting certain food groups or obsessing over body size. "A child who tends to put a lot of pressure on herself might find that restricting what she eats helps her gain a sense of control over something in a satisfying way," says Dr. Bermudez.
An Intense Treatment
Today, Maria Adams credits a lot of home cooking and focused family meals for helping her anorexic daughter learn to enjoy food again. From the psychologist recommended by Lily's pediatrician, she learned about the Maudsley Method, a treatment approach that top specialists and advocacy organizations (including NEDA) consider to be especially successful in helping children, particularly those who have at least one parent who's able to be with them all day long. It required Adams, who also has a younger son, to prepare and oversee all of Lily's meals and forbid her daughter to leave the table unless she consumed a set number of calories that had been determined by her pediatrician, who weighed Lily weekly to track her progress. The theory behind Maudsley: Malnourishment triggers illogical thinking, leading to more starvation and frenzied exercise; it's only when a child returns to a normal weight that she'll be able to respond to her natural hunger cues and reflect on her quest for thinness. Says Adams, "My mantra became, 'Food is your medicine.'"
When Lily's psychologist helped Adams realize that her own determination to eat only healthy foods might have been counterproductive in her daughter's recovery, she began to relax her rules and serve a greater variety of foods to the entire family. The early weeks were excruciating: Lily cried constantly and would often scream, "You're making me fat!" Her mom had to lock the door during meals to prevent her from running out of the house. "One day, I put a bowl of ice cream in front of her for dessert," she recalls. Six hours later, Lily downed the last soupy drop.
Within three months, Lily gained 25 pounds, returning to the 70th percentile for her age. "As soon as she hit the point where her body was naturally supposed to be, it was as if all those crazy behaviors started melting away," says Adams. During that school year, Lily got permission to eat all her meals at home -- including lunch -- but gradually, she needed less and less coaxing to eat.
Now a healthy eighth-grader, Lily plays soccer, swims competitively, and talks openly with her mother about body-image hang-ups when they arise. While Adams knows that anorexia is a chronic illness, she's grateful that she -- and Lily -- can now deal with a potential relapse and fight it. "Am I sad that my child had to deal with such a grown-up problem at such a young age? Yes," she says. "But I'm glad we caught it when we did."
Six Signs of Trouble
1. She's constantly looking in the mirror or running her hands over her body. Sometimes referred to as "body checking," it's a way for children to monitor their weight-loss progress without stepping on the scale.
2. He is frequently constipated. Gut function slows down with your metabolism when you starve your body, says Dr. Ovidio Bermudez.
3. She won't stop moving. This can range from compulsive exercise to simply fidgeting in a chair. The child's goal is to burn calories at all times.
4. She suddenly becomes a vegetarian. Many anorexic children will use this as an excuse to restrict themselves from cerrtain food groups.
5. She doesn't get her period. You may chalk this up to your child being an athlete. But if your daughter enters her teen years without a period or has an irregular cycle, be sure to monitor her growth on the weight chart closely with your pediatrician. Most girls start to menstruate between ages 10 and 15, with 12 being the average age.
6. She checks out "thinspiration" or "pro-ana" websites. The sites continue to crop up, despite advocates' efforts to ban them, and have tips for starvation plus photos of scary-thin celebs.
Nurturing a Healthy Eater
While parents don't cause eating disorders, moms and dads can push a vulnerable kid into the danger zone -- or out of it, says Dr. Ovidio Bermudez. Many of the strategies for discouraging anorexia and bulimia are actually the same as those that curb overeating, he adds.
Model moderation. You can help prevent hang-ups about "good" and "bad" foods by serving well-rounded meals -- fruits, veggies, whole grains, lean meats -- and treats. "There is nothing wrong with sweets in moderation," says eating-disorders expert Lynn Grefe. "Don't use a 'treat' as a reward or take it away as a punishment. It's just a food to be enjoyed."
Avoid the "D" word. Talk of diets can lead to trouble. "When a mother says something as seemingly innocuous as, 'I'm skipping lunch today -- my clothes are too tight,' it can have a powerful effect on her daughter's own body image," says Andrea Vazzana, Ph.D., a clinical psychologist at New York University's Child Study Center. Likewise, talk about how the right foods give you energy and keep you healthy, says Dr. Vazzana.
Cook for your kids and with your kids. Keep a variety of healthy foods readily available at home, serve nutritious and well-balanced meals, and eat those meals together as often as possible, advises author Abigail Natenshon. Research shows that kids who regularly dine with their family are less likely to develop an eating disorder. Involving children in meal prep -- measuring flour, pounding dough, topping a pizza -- can help them learn to respect and appreciate what they're eating.
Early Eating Disorders
Talk to a doctor if your young child is showing signs of the following food issues.
Problem: Feeding disorder of infancy
Age of Onset: Birth to 12 months
What It Is: An infant refuses to eat or is unable to eat, leading to poor weight gain or significant weight loss over at least a one-month period. The cause is often an undeveloped sphincter muscle between the stomach and esophagus, or developmental delays, sensory processing disorders, or celiac disease (an autoimmune disorder that leads to an intolerance to the gluten in wheat and other grains).
Get Help: Schedule regular doctors' visits to track your child's growth. A pediatric gastroenterologist can diagnose acid reflux and prescribe medication until your baby outgrows it. Occupational and speech therapists can work with children for whom eating is unpleasant or difficult.
Age of Onset: 2 to 3 years
What It Is: As many as 30 percent of children at some point have pica, a compulsive tendency to eat nonfood items (such as dirt, paint chips, or laundry detergent) for one month or longer, beyond the baby years. Pica usually passes with age but can persist in developmentally delayed kids, who are also at higher risk for it.
Get Help: Pica can cause lead poisoning, so keep nonfood items out of reach with high shelves and childproof locks. You may want to talk to your pediatrician or a child psychologist who specializes in eating disorders.
Problem: Selective eating disorder
Age of Onset: 3 to 10 years
What It Is: A selective eater will progressively limit his diet to only a few foods. Most common in boys for reasons that remain unclear, selective eating doesn't lead to growth or health problems in most cases. There's no strong research showing that selective eaters are at risk for other eating disorders later.
Get Help: Some experts say that if your child is growing normally, it's best not to make an issue of it -- but find out whether your child should take a multivitamin and calcium supplement. A child psychologist can teach him how to try new things.
Originally published in the January 2011 issue of Parents magazine.