Eating Disorders in Children and Adolescents
Anorexia nervosa, bulimia nervosa, and binge eating disorder are serious, often life threatening mental illnesses. Anorexia nervosa is diagnosed when an individual restricts food intake, does not maintain a normal body weight, and has an intense fear of gaining weight. Bulimia nervosa is characterized by recurrent episodes of binge eating that are accompanied by a loss of control, followed by efforts to purge calories through means such as vomiting, excessive exercise, or laxatives. Binge eating disorder also involves episodes of binge eating, but sufferers do not engage in purging behaviors. The causes of eating disorders are numerous and complex, with genetic, biological, environmental, and social factors contributing to their development.
Eating disorders are particularly relevant to kids and adolescents because most eating disorders develop during this period of development. About 0.3% of adolescents will develop anorexia nervosa, 0.9% will develop bulimia nervosa, and 1.9% will develop binge eating disorder in their lifetime (1). Many more children and adolescents are dissatisfied with their bodies and engage in dangerous dieting behavior, with up to 27% of adolescent girls between the ages of 12-18 engaging in disordered eating attitudes and behaviors (2). Even body dissatisfaction, dieting, and disordered eating habits that do not meet criteria for an eating disorder can be highly distressing and can negatively affect mental health, physical health, school performance, and overall quality of life.
Due to the seriousness of eating disorders, early identification and intervention are important, and treatment outcomes are better with earlier intervention. (See the Symptoms of Eating Disorders page for more information on recognizing the signs and symptoms of eating disorders).
Can Eating Disorders be Prevented?
Given the complexity of factors that place an individual at risk for developing an eating disorder, and the complex nature of eating disorders themselves, not all eating disorders can be prevented (3). Because researchers don’t yet know exactly how to prevent eating disorders, the targets for prevention efforts are usually risk factors, such as body dissatisfaction.
Eating disorder prevention programs have been shown to effectively increase knowledge of eating disorders and reduce some factors that place students at risk for developing eating disorders (4). Some programs have been shown to reduce disordered eating, and a select few evidenced-based prevention programs have resulted in fewer cases of eating disorders following participation (4). Research does not show that eating disorder education or prevention interventions are harmful to students (5). Furthermore, most students will receive some benefit from interventions targeted at risk factors, because improving body image is a positive outcome in and of itself even if it doesn’t prevent an eating disorder.
Which Prevention Programs are Effective?
While many educational and prevention efforts are available, only a few have demonstrated effectiveness at reducing risk factors, disordered eating, or eating disorders themselves (6, 7). Qualified professionals with knowledge of eating disorders should provide prevention programs, or school personnel should obtain training in how to deliver interventions in a sensitive and appropriate manner. Prevention programs that have been demonstrated to be effective are included below:
- The Body Project (8) – A program for high school and college women that teaches participants to argue against the thin ideal standard of female beauty.
- The Healthy Weight Intervention (8) – A program promoting energy balance to impact lasting improvements in dietary intake and physical activity.
- Healthy Body Image: Teaching Kids to Eat and Love Their Bodies Too – A program focusing on body image, eating, fitness, and weight concern in children and adolescents.
The field of eating disorder prevention has a long way to go. Unfortunately, many of the evidence-based interventions have not been tested on boys or younger children. And while the current prevention strategies are promising and may reduce risk factors and prevent some cases of eating disorders, they cannot completely prevent eating disorders in all kids and adolescents. For these reasons, early identification and intervention remains key to the health of children.
Should Schools Play a Role in the Early Identification of Eating Disorders?
Intervention should take place as soon as possible to increase the odds of a fast and full recovery. Schools and educators should share responsibility for the early identification of eating disorders in children and adolescents as signs and symptoms may be especially apparent in the school environment. School educators, coaches, and staff should be familiar with the signs and symptoms of eating disorders, treatment options, and available resources in order to facilitate early identification and initiation of treatment when needed.
In 2013, Virginia passed a law requiring provision of eating disorder education and a voluntary eating disorder screening program for students. This is a promising development that acknowledges the importance and seriousness of this issue for children and adolescents. Educators can find specific recommendations for addressing concerning signs or symptoms of eating disorders with students and family members via the National Eating Disorders Association (NEDA) Educator Toolkit.
Should Schools Promote Healthy Eating and Lifestyle?
Related to eating disorder prevention efforts are school-based programs designed to address healthy eating and/or weight among children and adolescents. These efforts are often targeted toward reducing overweight and obesity among children and adolescents. While well intended, these anti-obesity messages can be harmful to students. Weighing students in school, calculating and reporting body mass index (BMI), and encouraging students to focus on weight loss may contribute to shame, distress, or elevated risk for eating disordered behavior. Research shows that these methods do not result in better health or weight loss, and these practices can actually result in future weight gain. In fact, the Centers for Disease Control and Prevention (CDC) have recently made a statement noting the lack of evidence to support school-based BMI screening as a prevention method, and acknowledging the potential for these programs to cause harm via increased stigma or pressure to engage in risky diet behaviors. The CDC also outlines safeguards that should be in place for schools that implement BMI screening (9).
Rather than focusing on weight loss, schools should take a proactive stance at teaching and encouraging behaviors that have been shown to improve health and well being among students including healthful eating and regular physical activity. Some helpful strategies are summarized here from the National Association of Anorexia and Associated Disorders (ANAD) school recommendations, and the Academy for Eating Disorders (AED) guidelines for childhood obesity prevention programs:
- Focus on health as an outcome, not weight
- Focus on improving the environment to support healthful eating and physical activity
- Implement a no-teasing/bullying policy and response protocol
- Weighing should occur only when there is a clear and compelling need
- Height and weight should be communicated to children and families in a straightforward, non-judgmental manner with acknowledgement that BMI is only one part of overall health
- Encourage students to reduce intake of sugary drinks such as soda
- Encourage students to reduce daily “screen time,” in front of computers and devices
- Encourage students to eat foods from all food groups in moderation
- Discourage dieting and encourage eating in response to hunger and fullness cues
- Encourage students to engage in regular vigorous physical activity
Written by Dr. Elisha Carcieri – 2015
ANAD School Guidelines for Educators (available by request via email)
Healthy Bodies: Teaching Kids What They Need to Know (By Kathy Kater, LICSW)
“Prevention of Eating Disorders: Optimism and Caution” by Carolyn Black Becker, PhD, FAED. Video recorded at F.E.A.S.T.’s 2014 Dallas Conference, January 31, 2014
1. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.
2. Jones, J. M., Bennett, S., Olmsted, M. P., Lawson, M. L., & Rodin, G. (2001). Disordered eating attitudes and behaviours in teenaged girls: a school-based study. Canadian Medical Association Journal, 165(5), 547-552.Kalarchian et al., 2007).
3. “Prevention of Eating Disorders: Optimism and Caution” by Carolyn Black Becker, PhD, FAED. Recorded at F.E.A.S.T.’s 2014 Dallas Conference, January 31, 2014. Accessed March 2015.
4. Stice, E., & Shaw, H. (2004). Eating disorder prevention programs: a meta-analytic review. Psychological bulletin, 130(2), 206.
5. Cororve Fingeret, M., Warren, C. S., Cepeda-Benito, A., & Gleaves, D. H. (2006). Eating disorder prevention research: a meta-analysis. Eating Disorders, 14(3), 191-213.
6. Ciao, A. C., Loth, K., & Neumark-Sztainer, D. (2014). Preventing Eating Disorder Pathology: Common and Unique Features of Successful Eating Disorders Prevention Programs. Current psychiatry reports, 16(7), 1-13.
7. Stice, E., Becker, C. B., & Yokum, S. (2013). Eating disorder prevention: Current evidence‐base and future directions. International Journal of Eating Disorders, 46(5), 478-485.
8. Stice, E., Marti, C. N., Spoor, S., Presnell, K., & Shaw, H. (2008). Dissonance and healthy weight eating disorder prevention programs: long-term effects from a randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76(2), 329.
9. CDC Body Mass Index (BMI) Measurement in Schools. Accessed February 2015.