"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.
But because children do not have the mental or emotional maturity of their teen counterparts, Lock warns that they might not even be able to articulate that they are doing these things to lose weight. "Older girls might be able to say, I feel like I'm losing control or I feel scared that I'll gain weight, but like with any child psychiatric issue, you have to look at their behavior," he says, because kids may not be cognizant of why they are feeling or acting this way.
A depressed child will often not recognize that they are sad but will have an unexplained stomach ache or be unable to sleep, for example, so you have to watch the behavior. Thus, parents should watch to see if their child may be displaying behaviors of an eating disorder even if they don't seem weight-obsessed.
Weight loss doesn't necessarily have to be a symptom either, experts warn, because children under twelve are supposed to be putting on weight continually so even a child that is purposefully not gaining weight could be doing his or herself harm.
The American Academy of Pediatrics report, published Monday, suggests that pediatricians screen for eating disorders as part of annual checkups or during pre-participation sports exams. If an eating disorder is suspected, a more thorough history and physical exam should be ordered and possibly assessment for psychological problems.
It's essential to catch these behaviors at an early stage, Kandel says, "because you don't want this behavior to become any more entrenched than it already is."
For parents who are worried that their child might be at risk for developing an eating disorder, experts recommend teaching by doing.
Encourage healthy eating in the home and stay away from using food as a punishment or reward, Kandel says, because this sets up an unhealthy relationship with food. Also stay away from talking about certain foods as categorically "good" or "bad" because this might lead to bingeing, she says.
"They observe and follow us," Bernstein says, so parents should set a good example and be careful not to obsess over food or their own weight in front of their children.