Eating Disorders in Young Children: Types, Warning Signs, & What to Do

Types of Eating Disorders in Children

Unfortunately, there is limited research on the prevalence and unfolding of eating disorders in young children. However, the literature is growing, particularly with the DSM introducing avoidant restrictive food intake disorder (ARFID) and binge eating disorder in its 2013 edition. It’s estimated that upwards of 3% of children experience ARFID and that the rates of ARFID range from 5-14% in pediatric inpatient eating disorder programs.²

Compared to anorexia and bulimia, ARFID patients tend to be younger. They’re also more likely to be male and diagnosed with other comorbid psychiatric conditions or medical issues.² It’s also estimated that up to 3.5% of preschoolers meet the criteria for pica, an eating disorder associated with having urges to eat non-nutritious, non-food materials.³

Anorexia Nervosa in Children

Anorexia is an eating disorder characterized by an intense fear of gaining weight, distorted body image, and restrictive eating. Children with anorexia may lose weight rapidly, and they can also fail to gain the appropriate developmental weight needed to help them grow.

A child might develop anorexic behaviors for several reasons, including stress, trauma, bullying, abuse, or low self-esteem. Eating disorders have a genetic component, and anorexia can run in families. Young children often pick up on their family’s dietary habits both consciously and subconsciously. Anorexia may also coexist with other underlying mental health conditions, including depression and anxiety disorders.

Symptoms of anorexia in children may include:

• Weight loss
• Brittle hair/nails
• Unable to tolerate cold temperatures
• Gastrointestinal distress
• Losing weight quickly or being very thin
• Consistent fatigue

Bulimia Nervosa in Children

Bulimia nervosa is an eating disorder characterized by a repetitive cycle of binging and compensatory behaviors like vomiting or over-exercising. In the United States, studies report the average age of onset for bulimia is around 12 years old.⁴ Unfortunately, over half of children with bulimia also report suicidal ideation at a concerning rate of 53%.⁴

Children may become bulimic due to their self-evaluation of body weight or shape, family relational issues, or cultural pressures.⁵ Bulimia can negatively impact a child’s physical health, relationships, and self-image. They can develop tooth decay, dehydration, or throat and stomach damage. Additionally, children may develop obsessions with food and weight that make them distractible and unable to participate in school and social activities.

Symptoms of bulimia nervosa in children may include:⁵

• Normal or low body weight
• Appearing anxious
• Depressed or isolating
• Overly concerned about shape or weight
• Disappearing after meals
• Eating habits or rituals outside the norm
• Perfectionistic or over-achieving tendencies
• Eating in secret or not participating in family meals
• Feelings of shame around food
• Lack of period for menstruating children
• Calluses on hands from self-induced vomiting
• Repeatedly talking about food or weight
• Excessively exercising
• Binge eating (often in secret)
• Vomiting (often in secret)

Binge Eating Disorder in Children

Binge eating disorder (BED) is an eating disorder defined by patterns of binge eating, which refers to consuming large amounts of food in a short amount of time. People who binge often do so secretly, and they may experience great shame and discomfort surrounding the behavior. Unlike bulimia, people with BED do not engage in compensatory behaviors to offset their binges.

Children may start binge eating as a way to soothe difficult emotions. They may pair food with pleasure and take to eating as an unhealthy coping mechanism for feelings of anxiety, depression, guilt, or loneliness. If a child grows up with other family members who binge, the behavior may seem normalized, which can exacerbate the risk of them engaging in it as well.

Symptoms of binge eating disorder in children may include:

• Weight gain
• High blood pressure
• Food frequently goes missing
• Hiding wrappers or other evidence of food
• Gastrointestinal problems
• Eating alone or secretly

Pica in Children

Pica is an eating disorder where people experience urges to eat non-food items. It’s estimated that 25-30% of all children have some pica cravings.⁶ Like all eating disorders, the exact reasons why people develop pica are unknown, although some people with pica have nutritional deficiencies. Although symptoms can occur at any age, it’s more common among young children.

Research shows that children who are easily overstimulated by sounds, skin contact, and visual stimuli may be more prone to pica.³ Pica is also more prevalent in autistic children and those with developmental disabilities.⁷ Eating non-food items may provide sensory feedback (i.e., pleasure), and some children also struggle to discern food from non-food items.

Symptoms of pica in children may include:

• Anemia
• Non-food items found in bowel movements
• Eating from the trash can, floor, or outside ground
• GI problems
• Teeth injuries
• Infections

Avoidant/Restrictive Food Intake Disorder in Children

ARFID is an eating disorder characterized by limiting food without an attempt to lose or control weight. Children with ARFID can look “extremely picky,” and they do not receive adequate nutrition from the amount or types of food they eat. Many people with ARFID have little to no interest in the actual act of eating.

Children with ARFID have significant aversions to food. Mealtimes often feel anxious, as these individuals don’t want to eat with others and feel stressed about having to eat. They often fear vomiting, choking, or having allergic reactions. These children may also refuse to eat entire food groups and tend to avoid eating whenever possible. ARFID may coincide with ADHD, autism, and other eating disorders.

Symptoms of ARFID in children may include:

• Seemingly having little to no appetite
• Weight loss or failure to gain weight
• Extreme anxiety around food
• Little to no interest in eating
• Refusal to try new foods
• Stated fears of gagging, choking, vomiting, or getting sick

Eating Disorders in Boys Vs. Girls

Cisgender boys tend to present for treatment earlier than cisgender girls and usually for eating disorders that are not anorexia or bulimia.⁸ Cisgender girls, however, report more eating disorder behaviors such as restriction, weight concerns, shape concerns, and eating obsessions.⁸ Both cisgender boys and girls tend to have similarities in how long their symptoms last, their self-esteem, and the number of binge and purge episodes.⁸

It is important to acknowledge that not all children fall into the categories of boys vs. girls, and researchers are beginning to conduct studies to help these children, too. One study found that trans youth reported higher levels of eating disorder symptoms before treatment than their cisgender counterparts.⁹

Early Warning Signs of Eating Disorders in Children

Eating disorders can be insidious, but parents of young children may notice obvious changes when it comes to how their child eats or acts around food. Because they live with their child, they can also see the emotional and visible changes happening in real-time. It’s important to remember that eating disorders can start slowly, and children may not talk about their emotions candidly.

Early warning signs of an eating disorder in a child include:

• Stunted growth: Weight loss or the failure to gain weight can result in a child’s stunted growth. This can lead to several negative, long-term impacts on physical and emotional well-being.¹⁰
• Mood swings: Children with eating disorders may experience mood swings just before, during, or after meals.
• Increased talk about dieting: While diet culture is undoubtedly mainstream, a child discussing how they want to “eat better” may indicate a preoccupation with their weight, body shape, or food.
• Body dissatisfaction: Young children with eating disorders may make complaints about their bodies. They might also express fears associated with gaining weight.
• Eating in secret: Children may sneak or steal food to eat alone. This does not always indicate an eating disorder, but it’s a common symptom of eating disorders.
• Constant arguments during meals: Parents may get this sense that eating is always a “battle” with their child. If that’s the case, it may not just be stubbornness- it may speak to the presence of a child’s distress and a potential eating disorder.
• Weight fluctuations: Children with eating disorders come in all shapes and sizes. However, they may gain or lose weight rapidly, depending on their condition.
• Increased somatic distress: Eating disorders can coincide with constipation, nausea, diarrhea, headaches, achiness, and other forms of physical discomfort.
• Excessive exercise: Some children with eating disorders may start exercising more frequently or compulsively to the extent of developing an exercise addiction. This may have to do with wanting to be “healthier” or wanting to lose weight.
• Drop in self-esteem: Eating disorders can be distressing and shameful. If a child who once presented as more confident or secure now seems more insecure or fragile, it could indicate they’re struggling with their mental health.

Health Consequences of Eating Disorders in Children

Short-term health consequences of eating disorders in children include slow heart rate and metabolism, stomach pains, hair loss, electrolyte imbalances, nutritional deficiencies, mood changes, and feelings of coldness.¹¹ Long-term health impacts of pediatric eating disorders include delays in growth and puberty, infertility, higher risk of chronic eating disorder development, and loss of bone mass.¹¹

Psychological Impact of Eating Disorders in Children

Short-term psychological consequences of disordered eating in children include feelings of anxiety, shame, or loneliness, poor self-image, mood changes, irritability, social withdrawal, and disrupted food beliefs. Long-term psychological impacts might include a risk for additional mood disorders or lasting disturbances in self-image. The most dangerous psychological impact of eating disorders in children is the risk of suicidal ideation.

Causes & Risk Factors

The exact causes of eating disorders in children are unknown. However, researchers have identified several risk factors that may increase the likelihood of a child developing an eating disorder. Specific genetic sequences, traumatic experiences, personality traits, body image, social influence, co-occurring mental health conditions, and cultural ideals have all been identified as risk factors.¹²

A child may be more at risk of developing an eating disorder if:

• Someone in the family has an eating disorder: Eating disorders can run in families. Research shows that heritability may range anywhere from 59-82%.¹³
• There was a lack of access to adequate food: Not having enough food can create a scarcity mindset. This can lead to disordered habits around eating, which may coincide with developing an eating disorder.
• The child experienced trauma: Trauma is a significant risk factor for eating disorders. When a child has PTSD, their eating disorder behaviors may act as a way to provide relief or regain a sense of control.
• They are in an elite sport: Eating disorders, particularly anorexia athletica, are rampant in certain appearance-focused sports like dancing, gymnastics, and wrestling. Coaches and parents alike may pressure their children to lose weight to perform better.
• They have a co-occurring mental health condition: Eating disorders often coincide with other mental health issues, such as OCD, depression, anxiety, and PTSD. The eating disorder may exacerbate the other condition’s symptoms.

Potential causes of an eating disorder include:

• Environmental factors: Where a child is raised, how they were raised, and the overall temperament of their environment may contribute to an eating disorder. Children growing up in family dynamics that prioritize dieting or losing weight may be more susceptible to developing eating disorders.
• Trauma: There is a link between eating disorders and trauma. While trauma itself probably doesn’t cause an eating disorder, it may be a catalyst.
• Traits of neuroticism: Neuroticism refers to the disposition of experiencing negative emotions, such as irritability, self-consciousness, and anxiety. There’s some research showing a relationship between high rates of neuroticism and eating disorders.¹⁴
• Biology: Biological variables, including variations in brain chemicals, may contribute to eating disorders.
• Dieting: Frequent dieting can cause disordered eating, which may lead to an eating disorder. If children start dieting young, they may grow up with a distorted relationship with food.
• Chronic stress: Children who frequently experience high-stress situations may be more vulnerable to developing eating disorders.

Diagnosis of Eating Disorders in Children

Diagnosing eating disorders in children usually takes a team approach of specialists. Once you notice symptoms in your child, you can take them to their pediatrician for further evaluation and diagnosis. Your pediatrician may want to rule out other medical conditions that can present with symptoms similar to disordered eating.

If symptoms are caught early, your pediatrician may recommend a therapist, psychiatrist, and registered dietician. If symptoms persist and medical monitoring is needed, you may be referred to a higher level of treatment, such as intensive outpatient programs or hospitalization.

Levels of Care for Eating Disorders in Children

Different levels of treatment exist for pediatric eating disorders to address varying levels of symptoms. Based on symptom frequency and severity, providers can recommend different treatment standards. Some levels are outpatient and minimally disruptive to a child’s routine, whereas others will require the child to spend the majority of their time in treatment. It is important to follow your provider’s recommended level of treatment.

Levels of care for eating disorders in children include:

• Outpatient treatment: Outpatient treatment is recommended for children whose symptoms are not severe enough to warrant hospitalization and may be resolved by weekly therapy with an outpatient provider. It is also recommended for someone who has stepped down from other treatments and is ready to mostly manage recovery on their own (with parents’ help). Sometimes, additional specialists, such as a psychiatrist, pediatrician, or registered dietician, are still recommended with outpatient treatment.
• Intensive outpatient treatment (IOP): IOP is recommended for children who need extra support outside of a weekly therapy appointment but are ready to attend school for most of the day. IOP offers some structure to the child but mostly depends on the child and parent to practice recovery skills outside of treatment. IOP is generally only offered when a child is medically stable and weight is restored.
• Partial hospitalization program (PHP): PHP is recommended for children who have gained some recovery skills but still need a lot of structure and routine to prevent relapse. PHP might look like spending most of the day in treatment, but having evenings free to practice recovery skills in the family environment. PHP offers the opportunity for parents to practice helping their child maintain recovery outside of treatment.
• Residential treatment: Residential treatment is recommended for children who need 24/7 support and supervision to learn recovery skills. They may still require some medical monitoring, meet for individual and group therapy, and have visits with parents to ensure the best support for the child following their release.
• Inpatient hospitalization: Inpatient hospitalization is recommended for children who are experiencing acute medical and mood issues because of their eating disorder. Through inpatient hospitalization, children will receive medical monitoring, assessments, and therapy while they live 24/7 at a treatment facility. Once medically stable and weight is restored, they will be released for residential treatment.

Types of Eating Disorder Treatment for Children

Treatment options for eating disorders in children may be multifaceted. The type of treatment largely depends on the type of eating disorder and its predominant symptoms. A treatment team may include a therapist, pediatrician, dietitian, and other healthcare professionals. It’s often recommended that parents participate in their therapy and family therapy with their child present.

Feeding therapies can be common when treating young children, particularly if they have symptoms of ARFID or pica. It’s important to address nutritional deficiencies and help children return to healthy weights for their age and body type. Although it’s less common, severe cases of eating disorders in children may require hospitalization or inpatient treatment.

Types of treatment for eating disorders in children include:

Individual Therapy

Sometimes, a child’s eating disorder symptoms may be resolved with individual therapy approaches for eating disorders. The most common individual therapy is cognitive behavioral therapy (CBT) for children. Through CBT, the child will learn how to challenge food beliefs that are keeping them feeling anxious enough to engage in disordered eating. CBT sessions may involve workbooks, tracking behaviors, activities, and food exposures.

Parents will generally be involved in treatment to help understand how the child’s thoughts and emotions are connected to their eating-disordered behaviors so that they can also help challenge negative patterns at home. Some challenging behaviors at home might include food exposures, which are developed and coached through the provider’s assessments.

Nutrition Counseling

Eating disorders in young children can cause nutritional deficiencies, which may negatively impact growth and development. Nutrition counseling is necessary to provide the child and parents with guidance on how to encourage healthy eating patterns, avoid nutritional deficiencies, and develop a well-balanced relationship with food.

Nutrition counseling might involve learning to structure family meals, how to talk to the child about food preferences, and how to encourage checking in on hunger and fullness cues at an age-appropriate level. It may be encouraged to involve the child in meal preparation to model healthy behaviors.

Family Therapy

Eating disorders in children sometimes develop because of familial influences of food and weight beliefs. Family therapy is often recommended for treating pediatric eating disorders to address how the family environment can better support recovery. The Maudsley approach is a particularly popular type of family therapy that is used when weight gain recovery is required.

Parents may be asked to examine their own food and weight beliefs and increase positive modeling of a healthy relationship with food. Family therapy may sometimes involve siblings if they can play a supportive role in the child’s recovery.

Group Therapy

Group therapy for eating disorders may be recommended for children if they are at an age-appropriate level for this type of treatment. Group therapy for children with eating disorders can offer the potential for practicing important social skills, learning from peers who are further along in recovery, and, if parents are involved, strengthening support systems and social validation necessary to prevent relapse.

Parent Education

Parent education is an important piece of children’s recovery from eating disorders, as children are highly influenced by the beliefs and environment supplied at home by parents. Parents may be unaware of how their own food beliefs and behaviors can maintain their child’s symptoms. Educating parents on risk factors for relapse can prepare the family for noticing if a child begins to worsen outside of treatment support. Through parent education, parents can feel better armored to recognize their child’s warning signs and prepare the home environment to support recovery.

Medication

Medication may be recommended for children with eating disorders who have a co-occurring psychiatric diagnosis, such as anxiety, depression, or other mood disorders. It is important to adhere to a routine with medication and follow-up visits with the prescribing provider. Keeping track of medication, locking it in a cabinet when not providing it to your child, and reporting any side effects are recommended protocols to follow when medication is prescribed.

What to Do If You Think Your Child Has an Eating Disorder

If you suspect your child may be struggling with their relationship to food, speak to their pediatrician right away. Make sure to follow through on treatment recommendations and find nutrition counseling so that your child’s development is not adversely affected. Examining your own relationship to food and strengthening the relationship with your child can also help provide an environment for recovery.

Here are five things to do if you think your child has an eating disorder:

1. Speak to the Child’s Pediatrician

If you have any concerns about your child’s relationship to food or body image, you should speak to their pediatrician for recommendations. If you let your child’s symptoms worsen, they become more at risk for developing eating disorders or related psychological issues, like mood disorders. Asking questions at the first sign of concern can help you avoid worsening your child’s physical or emotional symptoms.

Possible questions to ask your pediatrician:

• Is my child within the normal growth and development range?
• Should my child have any labs to check for medical concerns related to eating?
• If you are not concerned about my child’s symptoms, are there warning signs I should continue to monitor?
• What are your treatment recommendations based on my child’s symptoms?
• Is there anything I can do to help support my child in their recovery?

2. Follow Through with Your Pediatrician’s Recommendations

Your pediatrician is likely trained to recommend certain treatment standards based on your child’s presenting symptoms. It can be difficult to hear recommendations for hospitalization or higher levels of treatment. However, not following through with your pediatrician’s recommendations may mean that your child’s symptoms quickly worsen. Make sure to follow through with recommendations, such as referrals for treatment programs, psychiatry, nutrition counseling, or therapy.

3. Find a Registered Dietitian

If your child is not recommended for hospitalization or treatment, it may still be important to seek treatment from a registered dietician to support your child’s nutrition. A registered dietician can help you with ways to plan, prepare, and administer food to your child that is necessary for maintaining their growth and development. Make sure to ask if they specialize in your child’s age bracket or can recommend someone who does.

4. Strengthen the Relationship Outside Food

Once treatment starts, many conversations with your child may be structured around the topic of food. It is equally important to develop a relationship with your child outside of focusing on food and body image. Especially in recovery, your child will need to develop an identity outside of food beliefs. Helping them to explore hobbies and interests and encouraging or participating with them in these activities can help them develop important coping skills for their eating disorder and healthy self-esteem.

5. Examine Your Own Relationship to Food

Eating disorders in children unfortunately sometimes happen because of influence from the family environment around food beliefs. It may be an important step to examine your own relationship with food and body image. Seeking your own professional support may be needed if you discover you feel anxious or distressed when exploring your personal food and body image perceptions.

How to Find Professional Support for Eating Disorders in Children

The best way to find professional support for eating disorders is to begin with your child’s pediatrician. Even though they may not have much experience with eating disorders, they can provide referrals to the appropriate healthcare professionals. Recommended services might include psychiatry, nutrition counseling, or outpatient therapy. You can also find a therapist specializing in child and adolescent eating disorders via word-of-mouth or using an online therapist directory.

It is especially important to see if insurance coverage is available if your pediatrician is recommending inpatient treatment. Insurance may cover all or parts of your child’s treatment, usually based on their symptom severity and diagnosis. Even if you are referred for services and the provider says you are covered, make sure to call your insurance to confirm coverage and what your financial responsibility might be following treatment.

If you have suspicions or evidence that your child may be struggling with an eating disorder, it is imperative to seek medical support. Delayed growth in children can have serious consequences, both in the short and long term. In addition, untreated eating disorders often worsen progressively over time. Symptoms that might seem mild now could become severe in a few months or years.

Role of the Family in Eating Disorder Recovery for a Child

Loved ones can play a vital role in helping young children with eating disorders. It is important to be patient, compassionate, and empathic with the child’s emotions. Even if you feel frustrated or concerned, try to regulate those emotions instead of taking them out on the child. Remember that the child is not intentionally trying to give you a hard time.

Here are some practices that can help your child who is living with an eating disorder:

• Model a healthy relationship with food and body image: Be aware of your biases/struggles with food and body. Aim to be a positive role model for your child.
• Have meals together: Make meals as pleasant and inviting as possible. Do not force your child to eat, but create a friendly environment that limits anxiety.
• Take an active role in their treatment plan: Eating disorders are often conceptualized as family illnesses. Commit to being active in their recovery and adhering to guidelines recommended by therapists, doctors, and dietitians.
• Do not shame their behavior: Avoid criticizing their habits or asking why they’re doing it. Strive to be understanding and remember that no child intentionally chooses to struggle with their mental health.
• Strive to be patient: Recovery can be a long process full of ups and downs. Try to be optimistic and celebrate small successes along the way.
• Advocate for your child’s well-being: Speak up if you have concerns about their treatment or symptoms. Remember that children may not know how to verbalize their feelings, especially when young.

Resources & Support for Families With a Child Who Has an Eating Disorder

As your family moves through the recovery process, it is important to ensure different types of support. Resources such as support groups and online forums can help provide validation and build a recovery community. Resources for cultivating a healthy relationship with food and a positive body image may also help prevent relapse for your child.

Here are some resources and forms of support for families who have a child with an eating disorder:

• Support groups: Support groups are generally available to patients and families. F.E.A.S.T. offers both sibling and caregiver support groups to provide resources for loved ones affected by disordered eating.
• Online resources: Online resources can help provide education and therapy services to patients and loved ones affected by disordered eating. Resources like The National Alliance for Eating Disorders provide verified information about disordered eating as well as resources for virtual support groups.
• Resources for healthy food relationships: Modeling a healthy relationship with food is an important piece of helping your child recover from their eating disorder. The Houston Food Bank provides direct advice on how to help your child cultivate a healthy relationship with food.
• Resources for self-esteem: Your child’s sense of self-esteem has likely been damaged by disordered eating behaviors. You can help them cultivate self-respect by using resources such as Nemour’s Kids Health.
• Apps for self-esteem and body image: As your child grows, they may still sometimes struggle with eating and body image. Apps like Worth Warrior can support your child in building positive self-esteem through activities like challenging negative thoughts, increasing self-soothing behaviors, and journaling.