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Eating Disorders in Kids and Tweens

In the spring of 2008, Caroline Meeker was your average third grader in Allen. She played basketball and softball, and loved learning to play the piano. She hung with friends and never once said anything negative about her body. Her favorite foods were spaghetti, pizza, chips and chocolate.

Not to say she was an easy child. Caroline was always a little high maintenance—moody, anxious, too much of a pleaser, worried about what others thought of her. Her mom, Janice Meeker, started to notice she looked a little on the thin side but brushed it off. Then Caroline started asking questions about food, calories, fat grams, reading labels. She wasn’t eating her lunch at school (and was too young to think to hide that fact).

Caroline started running track. On the softball field, Meeker noticed her daughter’s body language would change as she wrapped her arms around herself, trying to hide her body, she now realizes. She wore jackets during hot weather, wouldn’t hydrate on the track because she saw everything that went into her mouth as something that would put fat on her body. She weighed herself several times a day.

One day, Caroline asked her mom if her saliva had calories in it. The 9-year-old didn’t swallow her saliva again until a year later and months of hospitalization.

When she was admitted to Children’s Medical Center of Dallas that May, she’d gone from almost 70 pounds to a mere 55 pounds. Her heart rate was low and she had a collapsed lung. They tried outpatient care but Caroline was finally admitted to the hospital’s Center for Pediatric Eating Disorders—the only such facility in the state— mid-June at 48 pounds. She was put on a feeding tube and immediately confined to a wheelchair because she couldn’t afford to burn any more calories.

Meeker didn’t know until later that all of this started when a girl at school called Caroline “fat” at the lunch table. Experts say any such event—a comment from a coach, a peer or a parent—can trigger an eating disorder in a child already prone to one.

“She was a very anxious child to begin with,” Meeker says. “Her health team would always say the genetics loads the gun but society pulls the trigger. I put a lot of blame on myself and it took a lot of time for me to get past that. I’m constantly on a diet. We watch Biggest Loser. She’s so young. It was like she was too young to have an eating disorder.”
According to statistics from the National Eating Disorders Association, forty-two percent of first- through third-grade girls want to be thinner; eighty-one percent of 10-year-olds are afraid of being fat and have restricted their food intake in an attempt to be thinner. Additionally, forty-six percent of 9- to 11-year-olds report they are sometimes or very often on diets (eighty-two percent of their families are).        
Why so young?
When Dr. Ovidio Bermudez, a nationally known eating disorder expert and past chairman of the board of directors of the National Eating Disorders Association, finished medical school in 1985 and started his residency, anorexia and bulimia were issues of older teenagers and young adults. He remembers an academic conversation centered on the idea that because eating disorders are an ailment of the self, younger children—who hadn’t yet developed a sense of self—simply weren’t developmentally able to have an eating disorder.

Not so in 2011. And really, for about the last decade. Proof of that is in the American Psychiatric Association’s latest Diagnostic and Statistical Manual of Mental Disorders (known in the business as the DSM), the standard classified of mental disorders used by mental health professionals in our country. The fifth edition of the DSM is due out next year; early versions of it include a new category of eating disorders related to young children.

For what reason? The answer involves a brief history lesson in eating disorders, which Bermudez, currently medical director of the Eating Recover Center in Denver, is happy to give. Historically, anorexia wasn’t about being thin; it was about being obsessive and anxious. The first mention of a woman becoming ill because she was trying to be thin isn’t recorded until the mid-1800s. This was during Industrial Revolution, which included the birth of magazines and fashion.

In 1979, the medical community first defined bulimia, which was added to anorexia as a second eating disorder in the third edition of the DSM in 1982. That same decade, we saw new eating disorder behaviors, like laxative abuse and cutting. We now have four categories of eating disorders (anorexia, bulimia, binge eating disorder, and eating disorder not otherwise specified) and are about to have five (eating-related pathology of childhood). Medical professionals are also seeing new behaviors, which include people misusing their diabetes or thyroid medication to lose weight, more males with eating disorders, more different ethnicities with eating disorders, as well as more women between the ages of 40 and 60.

But according to Bermudez, the new category change being made specifically for children is due to two main reasons. The first culprit being culture: Six-year-olds were not on the Internet a decade ago. The second reason is stress: Kids (now more than ever) know what’s going on in the world—from tsunamis to recessions—are more stressed at school, more stressed with schedules and feel the ripple-down stress from their parents.
Another factor is our nation’s obsession with childhood obesity. Where do we, as parents, find the line between a kid who plays on the Wii to much and one who is doing hundreds of pushups before going to bed? Do we question or praise the kid who wants to eat an apple instead of a cookie or drink water instead of Dr Pepper? For 80 percent of kids, healthy choices are nothing but that. But the kids for whom it might indicate something else don’t come with a neon sign identifying them as Bermudez points out.
“Eating disorders are a casualty of our war on obesity,” he says. “Not that the war on obesity isn’t valid. It is valid. The answer is knowing your kids. You’ve got to be really careful, really self-aware. You can’t say, ‘I love you any way you are’ and then half an hour later say you feel disgusted and won’t eat for three days. That doesn’t add up.”

Dr. Stephanie Setliff, medical director of the Center for Pediatric Eating Disorders at Children’s, agrees. “People approach me all the time and say things like, ‘I think my 7-year-old needs to lose five pounds,” she says. “Those ideas, while well-intended, can be very destructive. Parents positively reward children with words, prizes or attention if she chooses an apple over an Oreo. Linking food to worth is not particularly useful.” Setliff also points out that children don’t buy food at the grocery store, bring Oreos into the house or determine the family’s level of physical activity.
Modeling healthy eating
Young children, experts point out, are very concrete, which is why parents have to be careful about what they say and model. “Children are listening to our official messaging,” Setliff says. “So the official message needs to be fit, healthy, strong, biking on weekends, eating a variety of fruits and vegetables, whole grains, protein. No food is bad food. If we as adults within earshot of children talk about how we’re so bad we can’t fit into our jeans, then we’re really sending a double message. Children will listen to that and conclude that thin is in, thin is cool and the size of their thighs as they currently are aren’t acceptable.”

Eating together as a family is huge in the battle against eating disorders, says Ramona Weatherford, the clinical manager at Children’s eating disorder unit. “You get to see what your kid is eating, see what’s going on,” she says. “As a staff, we eat with our kids [in the unit] all the time so we can model normal eating behaviors. We don’t count calories. We don’t even allow fat-free food, diet this and diet that. We really try to normalize it, talk about portion control.”

Dr. Susan Sugerman, co-founder of Girls to Women Health and Wellness in Dallas, typically starts seeing girls— healthy and not—at around age 10. Generally, eating disorders peak just before puberty (in girls, ages 11 through 13) and when young adults are transitioning to college. Most of the girls Sugerman sees are in the 14- to 16-year-old range, although she sees a lot of body image anxiety and what she calls “disordered eating behaviors” in younger girls.

“What I see more than anything is a large number of young girls who do not believe they are overweight but are terribly afraid that they will become overweight,” she says. “We live in a society where being comfortable with your body shape and size is frowned upon.”

Sugerman worries about what she calls the accidental eating disorder—kids who start out with healthy intentions and end up in her office or in the hospital. Say you have a 12-year-old girl who is an ice skater. She works out 20 hours a day on the ice or in a gym, eats properly and is the appropriate weight for her height and genetic makeup. Say she goes on vacation with her family for 10 days and can’t exercise. To compensate, she cuts down her food intake. And maybe she continues that behavior when she gets back to the ice and gym.

“In an effort to make sure she doesn’t become overweight or to maintain her athletic performance, she’s stuck in a situation where she’s afraid to eat a cookie or afraid to have one day off from the gym,” Sugerman says. “She’s afraid that if she uses salad dressing, she’ll get fat. Someone in her family is on a diet and that’s what they’re doing. All she’s trying to do is eat healthy. She didn’t want to have an eating disorder. Very few 12-year-olds wake up and say, ‘I’m going to starve myself.’”
Treating younger children
Generally, about one-third of people with eating disorders are completely successful in their recovery, about one-third struggle with it for the rest of their lives, and one-third don’t survive it. Treating younger children is often easier than treating adolescents or young adults, simply because of the state of their development. Family-based treatment works quite well with most of these kids, who still look to their families for guidance more than they look to their peers.

Caroline finished treatment at the end of September 2008, more than three months after she was hospitalized (eventually she’d gone to partial in-patient care, staying at the hospital from 7am to 7pm, seven days a week). She started swallowing her saliva again the following spring. She’s on medication to keep her brain working as it should and her moods in check, medicine Meeker hopes her daughter can be weaned off of eventually. “I still consider her in recovery,” Meeker says.

Meredith Moore, 19, generally has her eating disorder under control but remembers very well her fourth-grade year, leaving a store crying after trying on leotards in the dressing room. She was returning to ballet after a brief absence and thought she had a potbelly. That’s also the year she started throwing up her food and took her first laxative. “I went through phases when I wouldn’t eat, then I would be back to normal,” Moore remembers. “I was more dramatic about it was I was younger because I wanted to draw more attention to it. I went through another really bad cycle in the sixth grade when I started a new school. Then I really started having major problems when I was in the eighth grade.”

Like many children with eating disorders, Meredith’s peaked as she started to go through puberty. She didn’t like that she was getting curvy or developing breasts and thought she could control it by controlling her food. It wasn’t that she didn’t eat anything; she ate bananas, coffee with cream, would eat dinner but didn’t finish everything, ordered veggies with a broth when they went out to eat. In her mind, she played a game around the dinner table, trying to eat less than everybody else. She used laxatives after binging and exercised on the treadmill late at night.

The summer before she started high school, she blacked out at camp and almost went into a diabetic coma. She was 5-feet-3-inches tall and weighed 90 pounds. That was the low point, but not the end, of her eating disorder. She had a minor relapse her junior year.

“Even now, when I get really stressed, I start to think about my food more and exercise. I really have to watch that and not to overboard. I don’t think I’m ever going to get to the point when I was, though. I realize that if you don’t nourish yourself, you’re not able to enjoy anything or do anything.”
Moore is now studying art history and Middle Eastern studies at Columbia University’s Barnard College in New York City: “I’ve never been this happy before. I eat and I don’t even think about it. I’m healthy and I’m doing really well.”

Setliff’s advice to parents to help them avoid the roads Moore and Meeker found themselves on? “Do not abdicate your power as a parent to a magazine or a television show or a Facebook page, computer or billboard. Talk about how obsessed we are with the thin idea. You are not your jean size and they are not either. Our children have never seen a professional photograph in a magazine that has not been manipulated. They really think everybody walks around looking like that. Talk back to those images. Talk back to anything you see or that implies body size or weight is relevant to their worth as a person.”