"I always wanted to be the good girl. Good girls are skinny and happy. The bad girls are the fat ones."
That was the justification a recent visitor to the Alliance for Eating Disorders Awareness in West Palm Beach, Fla. gave when asked why she starved herself to the point of hospitalization. She is eleven years old.
Anorexia and its sister-disorder, bulimia, have historically been thought of as striking white, middle to upper class teenage girls. But a recent report from the American Academy of Pediatrics warns doctors that eating disorders are happening to younger girls -- and boys -- at an alarming rate.
"People tend to have this idea of who gets eating disorders, but an eating disorder doesn't discriminate between age, gender, race, or class," says Johanna Kandel, founder and director of the alliance.
"Some research says that as much as ten percent of those with eating disorders are under the age of ten. What I'm finding at the alliance is that the number of parents seeking help for their 7-, 8-, 9-year-olds is escalating rapidly," she says.
A 2009 analysis found that in the last decade, hospitalizations for eating disorders more than doubled among children under twelve and now account for four percent of all such hospitalizations.
"Pediatricians need to be aware of the early symptoms of eating disorders because they are the medical professional that a child is mostly likely to see in any given year," says Dr. Jim Lock, director of the Eating Disorder Program at Packard Children's Hospital. "They are the gatekeepers."
It used to be that the onset of an eating disorder tended to be around mid-adolescence, around age fifteen or around the time of first menses (about age thirteen). So why are there a growing number of girls who are showing signs of bingeing and purging as young as eight?
It could be hormonal, he says, as the onset of puberty has been occurring earlier over time, but a big trigger might be the dropping psychological onset of puberty as opposed to the physiological one. In terms of interest in appearance, clothing, social behavior and sexualization, girls at twelve are experiencing what girls at fourteen were experiencing just a decade ago, Lock says. Culturally, the cues to be concerned with appearance are being delivered to girls at younger and younger ages.
Another part of the growth of anorexia may have to do with the growing focus on educating kids about obesity, Kandel says.
"There's been so much emphasis on childhood obesity, all these programs to ameliorate the situation and in a way we're actually potentiating eating disorders. That's a very thin line we need to walk and make sure the dialogue is one of a healthy attitude towards food," she says.
In many ways, an anorexic ten-year-old may not behave very differently from a fourteen-year-old one, experts say, but because of their age, parents and doctors may be less likely to recognize the signs of an eating disorder.
"What you look for is the same -- they stop eating, they start to restrict food intake or binge," says Dr. Carol Bernstein, associate professor of psychiatry at NYU School of Medicine. Unreasonable amounts of exercise and an obsession with food or weight are also signs that would be similar across the age group. The personality traits that tend to accompany eating disorders in older patients are also seen in children: anxiety, perfectionism and obsessive tendencies.