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When a child seems to lose interest in food, it is natural to worry and assume something must be wrong. Up to a third of very young children go through what is known as the fussy eating stage and most grow out of it fairly quickly.
For some, they may be experiencing a growing sense of independence, wanting to choose for themselves what they consume, and they may be discovering that refusing food is a way of asserting themselves. As children start to get older, most begin to accept a wider range of food and fussy eating becomes a thing of the past.
Eating disorders, however, are not fussy eating; they are problems with the way a child eats and their relationship with food. Over the last 30–40 years, the prevalence of eating disorders has increased to become a widespread problem across the UK. The number of children and young people admitted to hospital with eating disorders has increased by 35% in the last year (2022), and there was a 128% increase in hospital admissions for boys and young men from 2015/16 to 2020/21. Almost 10,000 children and young people started NHS eating disorder treatment between April and December 2021.
Most eating disorders develop during adolescence, although there are cases of eating disorders developing in children as young as six years old. They affect children both physically and mentally and can create a lot of stress for families. Understanding when food has become a problem for a child can help parents and other caregivers to support the child through the condition.
What is an eating disorder?
Eating disorders are not a lifestyle choice or a “phase” that someone is going through. They are serious, complex mental illnesses that involve disordered eating behaviour and are not just about food. Eating disorders can cause serious harm physically, mentally and emotionally, and they have the highest mortality rate of any mental illness.
Disordered eating behaviours might mean avoiding certain foods, limiting the amount of food eaten, eating very large quantities of food at once, getting rid of food eaten through unhealthy means, for example purging, laxative misuse, fasting, or excessive exercise, or a combination of these behaviours.
Who do eating disorders affect?
Eating disorders can affect people of all ages, genders, ethnicities and backgrounds. Statistically, eating disorders affect more females than males and early signs can begin when a child is eight years old or younger, although many eating disorders develop during adolescence.
Approximately 1.25 million people in the UK have an eating disorder and around 25% of those affected by an eating disorder are male.
Common eating disorders that can affect children
There are many different types of eating disorders, and each person’s experience will be unique to them and their personal history.
Eating disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the authoritative guide to the diagnosis of mental disorders, are:
- Anorexia Nervosa – This is more commonly known as anorexia, and is both an eating disorder and a metabolic condition that results in excessive weight loss and extreme thinness caused by self-starvation. With anorexia, a person severely restricts food and obsessively controls their weight because they equate thinness with self-worth. Unfortunately, this distorted sense of body image is physically and mentally damaging.
- Avoidant / Restrictive Food Intake Disorder (AFRID) – This is an eating disorder similar to anorexia in the sense that food intake is restricted and there is a general resistance to eating that results in significant nutritional deficiencies and extreme weight loss. The symptoms and health concerns of ARFID and anorexia are similar. However, the motivation for avoiding food of AFRID differs from anorexia; those with ARFID avoid many foods because they fear choking or vomiting or because they are disturbed by qualities such as the textures, smells or colours of certain foods, rather than having an excessive and obsessive fear of body fat and weight gain.
- Binge-Eating Disorder – This is characterised by a person regularly and compulsively eating large amounts of food, often rapidly, and to the point of discomfort or pain from an overfilled stomach. Binge eaters are emotional over-eaters and most, but not all, who suffer from BED are overweight. People with BED feel that they have no control over their eating habits.
- Bulimia Nervosa – This is more commonly known as bulimia. It is characterised by overeating and purging or trying to compensate for consuming too many calories by vomiting, using laxatives or over-exercising. People with bulimia are caught in a chronic cycle of bingeing and purging and experience this cycle of bingeing and purging multiple times a week or, in severe cases, multiple times each day.
- Orthorexia – This refers to an unhealthy obsession with eating “pure” food. Food considered “pure” or “impure” can vary from person to person. As with other eating disorders, the eating behaviour involved – “healthy” or “clean” eating in this case – is used to cope with negative thoughts and feelings, or to feel in control. Someone using food in this way might feel extremely anxious or guilty if they eat food that they feel is unhealthy.
- Other Specified Feeding or Eating Disorder (OSFED) – Sometimes a person’s symptoms don’t exactly fit the expected symptoms for any of three specific eating disorders, that is anorexia, bulimia, and binge-eating disorder; they might be diagnosed with an “other specified feeding or eating disorder” (OSFED). Like any other eating disorder, OSFED is a very serious mental illness that is not only about the way the person treats food but also about underlying thoughts and feelings.
- Pica – This is an eating disorder in which someone eats non-food substances that have no nutritional value, such as paper, soap, paint, chalk or ice. People with pica don’t usually avoid regular food, meaning they may still be getting all the nutrients they need. However, some non-food items that they consume can be very dangerous, especially if eaten in large quantities.
- Rumination Disorder – This involves regurgitating food that isn’t caused by gastrointestinal problems. It involves a person regularly vomiting undigested food. Typically, the person may burp or belch before throwing up. Unfortunately, this pattern of vomiting often becomes a habit that can lead to malnutrition if not treated.
The most common eating disorder that affects children is Avoidant / Restrictive Food Intake Disorder (AFRID). ARFID usually starts at younger ages than other eating disorders and unlike anorexia and bulimia, which are more common in girls, boys are more likely to have ARFID.
In the UK, the prevalence rates outside of controlled studies and clinical assessments for restrictive food intake disorder are widely unknown. On average, 5% to 13% of tertiary-aged students were found to have ARFID in medical and psychiatric settings (BMJ Journals).
Anorexia is an eating disorder more common among older children. According to the National Institute for Health and Care Excellence (NICE), the overall incidence rates are around 6.0 per 100, 000 population with the highest incidence in people aged 15–19 years and it is more prevalent in girls than boys.
The prevalence of bulimia has been reported as less than 1%–2% and the peak age of onset is in later adolescence and young adulthood, age 15–25 years.
Obesity is linked to binge eating, although binge eating is not always the cause of obesity. It is, however, becoming a worrying factor in the increase of childhood obesity. 10.1% of reception age children (age 4–5) were obese in 2021/22, with a further 12.1% being overweight. At age 10–11 (year 6), 23.4% were obese and 14.3% were overweight according to the latest figures from House of Commons Library Obesity Statistics.
Signs and symptoms of an eating disorder in children
Eating disorders are not always obvious. A child can look “normal” and “healthy” on the outside but have serious physical and emotional problems on the inside. The first sign that you may notice is that your child isn’t gaining the typical amount of weight for their age or height.
Some of the early signs you may notice may include, but are not limited to, that the child is:
- Not eating what they used to eat or becoming picky.
- Not eating what the rest of the family eats.
- Taking a long time to eat and/or “playing” with their food.
- Not wanting to go to events with food, such as birthday parties.
- Secretive about food.
- Worried about their weight or size.
- Showing signs of low self-esteem.
Whilst eating disorders share many signs and symptoms, individual eating disorders have their own specific indicators:
Avoidant / Restrictive Food Intake Disorder (ARFID) – picky eating and a general lack of interest in eating are the main features of ARFID. People with ARFID may not feel hungry or are turned off by the smell, taste, texture or colour of food. Some children with ARFID are afraid of pain, choking or vomiting when they eat.
You may notice that the child:
- Avoids eating an entire category of food, such as fruits and vegetables.
- Will eat only specific brands of food or specific categories such as meat.
- Will only eat foods with certain textures.
- Prefers foods with lots of carbs such as snacks or fast foods.
- Has a history of eating struggles or fussy eating from infancy or early childhood.
- If eating out, is very specific about restaurants they are willing to eat at and what they order there.
Anorexia nervosa – children with anorexia tend to have a distorted view of their bodies. They have an intense fear of weight gain and deliberately eat very little.
The first signs might be:
- Increased rigidity around eating.
- Being much more selective about the types of foods or the times of day of eating.
- Starting to lay down rules about what they can and cannot eat.
- Missing meals (fasting).
These increased rigidity and restricted eating practices don’t start to look like weight loss until further down the line.
You may then start to notice that:
- Their food intake is limited, leading to very low body weight for their age and height.
- They develop issues with body image and/or they deny that their underweight condition is a serious problem.
- They have an extreme fear of weight gain and of being fat or take extreme measures to prevent weight gain, even though they are underweight.
- They are taking appetite suppressants, such as slimming or diet pills.
- They are wearing baggy clothing to hide their body, due to self-consciousness or to make weight loss less noticeable.
If a child or young person is developing bulimia, often changes in behaviour are noticeable before changes to physical appearance.
Look out for:
- Frequently checking body shape or weight.
- Avoiding looking at their body or checking their weight.
- Comparing their body with those of others.
- Secrecy, especially about eating.
- Eating large amounts of food (bingeing).
- Purging after bingeing by vomiting, over-exercising, using laxatives or diuretics, fasting.
- Excessive exercising.
- Worries about weight and shape.
- Feeling of loss of control overeating.
- Feelings of guilt and shame after bingeing and purging.
Children with bulimia may also experience symptoms such as tiredness, feeling bloated, constipation, abdominal pain, irregular periods, swelling of the hands and feet, and blood sugar swings, potentially leading to mood swings and fainting.
Binge eaters usually are unhappy about their weight and many feel depressed.
Children who are binge eating might also:
- Eat a lot of food quickly.
- Hide food containers or wrappers in their room.
- Have big changes in their weight (up or down).
- Skip meals, eat at unusual times such as late at night, and eat alone.
- Have a history of eating in response to emotional stress such as family conflict, peer rejection or school problems.
Binge eating is different from bulimia. Those with bulimia binge eat but try to make up for overeating by throwing up, using laxatives or over-exercising to lose weight.
How do eating disorders impact children?
Eating disorders can take over a child’s life and can have an immense impact on home, school and social life whilst also impacting the lives of the entire family. Any eating disorder can have long-term physical effects, some of which may be permanent.
Specific eating disorders may impact a child’s health and wellbeing as follows:
ARFID can lead to serious malnutrition and be associated with significant impairment to psychological wellbeing.
The possible impact of ARFID includes:
- Weight loss or, in younger children, not gaining weight as expected.
- Weight gain, particularly if their diet is restricted to foods that are high in calories.
- Developing nutritional deficiencies, such as anaemia through not having enough iron in the diet.
- Needing to take supplements to make sure nutritional and energy needs are met.
- Finding it difficult to recognise when hungry.
- Being limited in terms of what they can eat often causes children to experience significant difficulties at home, at school or college, and when with friends.
Anorexia can have long-term physical and psychological effects, some of which may be permanent, including:
- Loss of bone density (osteoporosis).
- Erosion of tooth enamel.
- Difficulty conceiving, infertility.
- Heart problems.
- Damage to other organs, such as the kidneys, bowels and liver.
- Weakened immune system.
- Delayed onset of puberty or stunted growth in children and young teenagers.
- Anxiety, particularly about eating in front of other people.
- Low confidence and self-esteem.
- Difficulty concentrating.
- Perfectionism and setting very high standards for themselves.
Bulimia can cause serious damage to the body.
Long-term health and psychological effects of bulimia include:
- Permanent damage to teeth.
- Damage to the vocal cords and the throat.
- Damage to the intestines and the stomach.
- Increased risk of heart problems.
- Kidney damage.
- Organising life around shopping, eating and purging behaviour.
- Mood swings.
- Social withdrawal.
Binge-eating disorder can cause weight gain, and in terms of physical health it is associated with:
- High blood pressure.
- High cholesterol.
- Type 2 diabetes.
- Heart disease.
Most seriously, eating disorders may be fatal if not treated in time. However, many of the effects of eating disorders are reversible or can be prevented from worsening, and eating disorders are treatable, with full recovery possible.
What are the causes and risk factors of an eating disorder in children?
There is a complex range of factors, including genetics, biology, psychology and environment, that cause eating disorders. They can be a way of coping with feelings or situations that are making the child unhappy, angry, depressed, stressed or anxious.
They may also be coupled with specific anxiety disorders such as obsessive-compulsive disorder (OCD). An eating disorder is often symptomatic and suggests there is an underlying issue that needs to be identified, understood and treated.
Food becomes a problem when it is used to help cope with painful situations or feelings, or to relieve stress, perhaps without even realising it. There are a number of factors that can make children more vulnerable to developing an eating disorder.
- Having a close family member with an eating disorder.
- Having an existing mental health issue such as depression or anxiety.
- Stressful life events such as a family break-up or the death of a family member.
- Abuse – physical, sexual and/or emotional.
- Pressures at school including exam pressures, peer pressure, needing to fit in.
- Media imagery and body image ideals to be thin.
- Having hobbies where being thin is seen as important, such as dancing or sports.
Children with ARFID are more likely to have:
- Anxiety or obsessive-compulsive disorder (OCD).
- Autism spectrum disorder or attention deficit hyperactivity disorder (ADHD).
- Problems at home and school because of their eating habits.
Children with anorexia are more likely to have other mental health problems such as poor body image or body dysmorphia, and low self-esteem.
Children with bulimia are more likely to have other mental health problems such as anxiety, obsessive-compulsive disorder (OCD), or depression. Smoking, alcohol or drug use and self-harm are also more common with bulimia.
Children with binge-eating disorder are more likely to have other mental health problems, such as depression, anxiety, post-traumatic stress disorder (PTSD) and ADHD.
Treatment and support for eating disorders in children
If you are worried about your child’s relationship with food or their body, in the first instance try talking to them about what they are experiencing. Be patient with your child. Their eating habits may be a way of controlling or coping with something. They might feel embarrassed or ashamed. If your child is OK with you speaking to their school, this could help ensure they are getting support during the day.
If you have concerns about the child’s health or feel ill-equipped to begin a conversation with your child, talk to your GP right away. Your GP will ask you questions to help figure out whether your child has an eating disorder, what type of eating disorder your child may have and how best to help.
Treatment will depend on the type of eating disorder that your child may have and their age, but it usually includes a talking therapy. Children and young people will usually be offered family therapy. Family therapy involves the child and their family talking to a therapist, exploring how the eating disorder has affected them and how their family can support them to get better.
For older children, adolescent-focused psychotherapy is available and usually involves up to 40 sessions, and normally lasts between 12 and 18 months.
During treatment, the doctor will give you and/or your child advice about the best foods to eat to stay healthy. They will probably also advise taking vitamin and mineral supplements.
Occasionally, someone with a severe eating disorder may refuse treatment even though they are seriously ill and their life is at risk. In these cases, doctors may decide, as a last resort, to admit the person to hospital for compulsory treatment under the Mental Health Act. This is sometimes known as sectioning or being sectioned. Doctors should always try to think of other ways to look after the child or young person first, such as asking them to go into hospital as an informal patient.
Family members can play a key role in helping their child recover from an eating disorder and return to a healthy weight. Recovering from an eating disorder may take time and recovery will be different for everyone.
Sources of advice and support include: