Pediatric Eating Disorders: A Guide for Parents

Eating disorders (EDs) are really stress and anxiety disorders in which the individual chooses to manipulate food as a means of feeling more in control.

I’m Dr. Scott Moseman, medical director of Laureate Psychiatric Clinic and Hospital Eating Disorders Program, and in this post we’ll explore eating disorders in children—common misconceptions, differentiating a disorder from normal picky eating [CS1] , signs for parents to watch for and treatments for children and teens.

Defining Disordered Eating

Anorexia Nervosa is defined by the American Academy of Pediatrics (AAP) as restricted caloric intake relative to energy requirements, leading to significantly low body weight for age, sex, projected growth and physical health.

Bulimia Nervosa is repeated episodes of binge eating with repeated use of inappropriate compensatory behaviors to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise.

Binge Eating Disorder is recurrent episodes of binge eating, with “binge eating” characterized by eating an amount of food that is clearly larger than what most individuals would eat during a distinct period of time under similar circumstances (e.g. 2 hours).

Avoidant/Restrictive Food Intake Disorder (AFRID) is a disrupted eating pattern characterized by seeming lack of interest in eating/food, avoidance based on sensory qualities of food, or concern about unpleasant consequences of eating that result in persistent failure to meet appropriate nutritional/energy needs and expected growth (for children)

See this table for the AAP complete list and diagnostic features.

Disordered vs. Picky Eating in Children

When a kid comes into my office, no matter what they’re presenting with, I think a kid should be able to eat, sleep, go to school, have some friends, and do the normal developmental kid stuff.

If your child says, “I don’t want to eat, so I don’t go to lunch, and I don’t hang out with friends,” or if they have some nutritional deficiencies (i.e. not meeting their normal growth curve) or have anxiety around eating and can’t go to school or even leave home, then I would say, “OK, now this is getting in the way of normal function.”

Some picky eating can be due to other sensitivities that kids tend to outgrow. In that scenario, as a parent, you’re just saying, “Can we meet needs, and can everybody pick the same restaurant?”

Signs of Disordered Eating for Parents

Being a parent myself, I think just taking an active part in your kids’ lives and what’s happening with them is crucial. As they become teenagers, our kids don’t always want us to be around and be available, but it’s important to try anyway.

If you’re able to sit down to dinner as a family regularly, you can notice if your kids are eating, if they’re doing OK. Do they seem very anxious about eating? Is it occasionally or at every meal?

Another good place to start for parents to start is with your pediatrician—if they notice changes in your child that could be attributed to malnutrition, they can offer solutions and refer you to a specialist or program like ours.

I would watch for:

Changes in functioning, especially how they eat and what they’re willing to eat
Changes in grades, what your child wants to participate in at school
Lots of talk about their body/appearance, anxious fixation on calories or dieting
Falling off the growth curve they’ve maintained through childhood

A lot of patients I see are much more aware of mental health than my generation growing up. For example, I get a lot of cases where friends are noticing that a peer is not eating at school, and they’re the ones informing parents.

If your child’s friends say something like, “Hey, Jane has stopped eating with us”, or “they’re on some calorie-counting app on their phone, and I have concerns about them.” Take them seriously enough to investigate.

Causes and Commonality of ED in Children

What causes disordered eating is a question that is on the mind of science a lot. Frequently in mental health, we describe things phenomenologically. You’re sad, get depressed, you’re anxious—we recognize that there’s a spectrum of illnesses and different ways our brain responds to those.

Global data indicates that ED is highly prevalent worldwide despite its complexity, and is a major health concern for lots of countries, not just the U.S.

I like to look at patients in a broader way—neurologically how my patients present. Do they have brain-stress resiliency issues? In other words, how does their brain and body respond to a situation where things don’t go how they wanted or expected?

We all probably know one or two (or more) people in our lives who are more anxious and would tend to respond by either shutting down or panicking, or by trying to manipulate and fix things. On the other hand, some people are very laid back and easy-going—they take things as they come.

I do think some of these reactions are hard-wired into us, and that they can manifest when we’re young. I think eating disorders do affect people that have brain-stress resiliency issues.

I work with Dr. Sahib Khalsa at Laureate Institute for Brain Research, and right now we are actually doing research to look at both GI systems and brain systems, especially the insula. How do the brain and body interact differently in someone who gets an eating disorder and someone who doesn’t—we’re working to identify consistent risk factors.

What we do know is that kids who grow up with self-esteem issues, anxiety—especially if they’re avoidant in their anxiety—as well as kids that grow up with somatic illness, headaches, stomachaches and GI-oriented anxiety issues are more likely to develop something like anorexia. I think those are the questions that science is still trying to get answers to.

Age and Sex Factors

We know that disordered eating is more common in females than males, but data indicates an increase of disordered eating in males—teen boys, in particular tend to hide disordered eating behind a strict diet for sports or weightlifting.

Many girls have been on some kind of diet by the time they enter high school. Many high school girls in the last 30 days have tried to restrict their eating. Rates of anorexia are still about 1 percent in females.

Eating disorders in general affect 3-5 percent of people, so there’s probably some underlying issue that is relieved when they manipulate their eating. Unfortunately, that relief over time can become a problem.

Treatment for ED

At Laureate, we’re very lucky to have one of the longest-running treatment programs in the country and it’s a not-for-profit treatment program. We’ve been running since the ‘80s and have inpatient and outpatient services available.

Like any other illness, our goal is to treat an eating disorder with the least amount of intervention that we can. Generally, ED treatment looks like:

Intensive therapy (inpatient or outpatient)
Working with an outpatient dietician
Engaging parental/familial/friend support
In extreme cases:
- Admission to a hospital or rehabilitation facility with 24-hour care
- Feeding tube to treat severe malnutrition
- Six moderate meals daily (once feeding tube is removed)
- Group and/or one-on-one therapy sessions daily

I’m going to be a little bit artificial in dividing them up, but if I look at anorexia or a restricting illness, you first make sure the patient’s brain and body are nourished. When their brain and body aren’t nourished, therapies don’t work as well; once brain and body are in a good place, you treat the underlying anxiety, so that the patient is not choosing to manipulate their food intake when they get anxious.

Bulimia and/or binge-eating tends to be more of an impulse than anorexia. The person feels anxious as well, but their goal in either binge-eating or purging tends to be making their brain feel better as soon as possible. We address the impulse, then treat the aggravating anxiety and help them avoid impulsive behaviors.

Long-term Treatment Results

Because there are different severities, people have different results from treatment. In anorexia nervosa, for instance, over the longitude of the illness, between 8-10 percent of people that develop it die from it—it can be a very serious illness over time. That being said, about 90 percent of people will find some sort of recovery. I’ve seen that take as little as several months and as much as several years.

To give an example from medicine, I would compare it to having asthma. If you’re having attacks, you might be younger, your body adapts and grows. And as you get older, you may hardly ever have an attack again and don’t even have asthma anymore. Others might find that they need chronic therapy over time.

Key Takeaways

See this table for the AAP complete list and diagnostic features
Most children grow out of moderate to severe picky eating
Anxiety and missed developmental milestones are key signs of ED in children
Teens’ friends are often the first to notice and speak up about a potential problem
ED is more prevalent in females than males, but cases of ED are increasing in male patients
ED generally affects 3-5 percent of people and is a major public health concern in most developed countries, not just the U.S.
Treatment relies on therapy, anxiety management and parental support; it can take several months to several years depending on each individual
About 90 percent of people with ED are able to recover over time