Running head: FORESEEING THE SILENT KILLER
Foreseeing the Silent Killer:
Development of Eating Disorders Throughout Childhood
Cassie Johnson
Submitted for First Year Research Writing Award
Author Note
This paper was prepared for HONS 112, taught by Professor Cochran.
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Abstract
Many signs of potential eating disorders (EDs), including biological influences, co-morbid
diseases, personality types, and psychological stressors can be identified from an early age. Until
this point, multiple studies have confirmed these individual risk factors for developing
disordered eating, but none have studied the conglomerate effect of multiple risk factors.
Determining degree of risk may be simplified constructing a list of potential predictors for
disordered eating using a model of the typical ED patient. If this type of list were to be available
for guardians to aid earlier recognition of the onset of eating disorders, it could lead to less
people plagued by this disease.
FORESEEING THE SILENT KILLER
Foreseeing the Silent Killer:
Development of Eating Disorders Throughout Childhood
Her hands are red and raw from washing. They tap the door six times as she enters the
doctor's office. Five year-old Sarah's mind is too full of obsession to jump rope, too busy
counting steps to laugh. The doctor diagnoses her with Obsessive Compulsive Disorder, hands
her mother the appropriate prescriptions, and sends them on their way. The problem seems
solved and Sarah's sleepless nights are forgotten. Ten years later, those same hands open the door
to the doctor's office, and a waif of a girl enters. Sunken eyes and a protruding collar bone lead to
an immediate classification. Anorexia Nervosa. The scale says 86, and the mother says, "I
thought she was okay." What if this second visit to the physician’s office could have been
prevented? Could the warning signs from ten years previous have led to preventative measures to
stop the eating disorder before it started? In this paper, I discuss the risk factors of Anorexia
Nervosa (AN) from birth until average age of onset. Using these warning signs to predict the
degree of risk in young children could lead to earlier recognition and ultimately fewer people
afflicted by this disease.
The earliest risk factors for eating disorders (EDs) are entirely unpreventable by the child
him- or herself. For example, research indicates that complications during pregnancy could
correlate with development of an eating disorder in the child later in life (Moorhead et. al, 2003).
Two of the largest predictors of Anorexia Nervosa are present at birth: female sex and Caucasian
ethnicity. Ninety-five percent of all people with EDs are female and Caucasian. Children born
into a family of middle-high socioeconomic status are also at an increased risk of inhibited eating
(Salbach-Andrae et. al, 2007). This increased risk may be due to elevated pressure to maintain
perfect image among wealthier families, coupled with the tendency to hide and ignore problems.
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Evidence additionally suggests that high maternal body mass index (BMI) at the time of giving
birth and as the child grows up predicts inhibited eating in children (Stice, Agras, & Hammer,
1998). Children may see their overweight mother and worry about being overweight themselves,
leading to restriction of food intake.
Other commonalities seen among those treated for AN exist even in infants. Nicholls and
Viner (2009) note that many ED sufferers experienced feeding problems as babies: either
overeating or under-eating tendencies, tantrums and difficulties during feeding times, or
indifference towards nutrients. This exhibits the biological influence of eating disorders, meaning
some children may be predisposed to complex food concerns. Interestingly, infant sleep pattern
difficulties correlate strongly with the development of AN (Jacobi, Hayward, de Zwaan,
Kraemer, & Agras, 2004). This is an example of the anxious personality type that is commonly
demonstrated in those with eating disorders. Many also exhibited abnormal amounts of bodyfocused behaviors, such as thumb or pacifier sucking (“Childhood Risk,” 2007). This could
indicate early onset of oral fixation, a focus on the mouth that can lead to abnormal relationships
with eating.
The toddler-preschool age could be a critical period for the future development of an
eating disorder. At this age, onset of many co-morbid syndromes and disorders may become
apparent. Gastrointestinal issues plague countless young children, and their relationship to eating
disorders is studied at length by Boyd, Abraham, and Kellow (2005). According to their study,
ninety-eight percent of all adults with eating disorders also have some type of Functional
Gastrointestinal Disorder (FGID). FGIDs seem to go hand-in-hand with those predisposed to
anxiety and obsessive tendencies, two significant causes of AN. Children suffering from
heartburn, constipation, or even abdominal pain may be at risk for an eating disorder, as these
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could be early signs of anxiety in the child's temperament.
Another co-morbid disorder to AN is Obsessive Compulsive Disorder (OCD). JimenezMurcia et al. (2007) found that 16.7% of all children with OCD will develop an eating disorder.
While this is a rather alarming statistic, it is logical that these diseases would go hand in hand.
Obsession lies at the heart of both disorders. A young child who is haunted at night by worries of
tasks not being completed to perfection will grow up to be a girl who is worried that if she chews
a stick of sugarless gum she’ll gain weight. The drive for perfection does not just spring up in
teenage years; it is spurred along from a young age, never ending. Another connection between
OCD and AN lies in the human anatomy. OCD has been associated with a deficiency of
serotonin in the brain, a neurotransmitter that controls sleep, memory, and depression. This same
deficiency is also present in AN patients (Jordan et. al, 2008). With signs of OCD appearing as
early as age five, these obsessive inclinations should be recognized and dealt with completely to
avoid related diseases, such as Anorexia Nervosa, down the road.
Another potential childhood predictor of inhibited eating that is more recently being
researched is picky eating. Some children refuse to eat foods with certain textures, appearances
or smells. Fussy eating predicts a fixation on food that can lead to unhealthy eating patterns in
the future. Studies by Jocobi, Schimtz, and Agras (2008) prove that picky children are also more
likely to worry about being fat, try to lose weight or even diet. Other causes for concern among
young children are adjustment problems, such as while switching schools or moving. This
resistance to change indicates the inflexibility that characterizes many patients with eating
disorders. They may also exhibit a high amount of compliance with rules set by authority figures,
becoming distraught when punished (Anderluh, Tchanturia, Rabe-Hesketh, & Treasure, 2003).
Some could claim this is simply timidity, but I believe this is internal control issues exemplified.
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Those with Anorexia Nervosa desire a sort of internal utopia. Eating only seven carrots for lunch
every day, or running on the treadmill faithfully for 57 minutes demonstrates the use of routine
and rigidity to maintain control of their eating, their weight and, ultimately, their life. When their
life is altered, be it by punishments, divorce of parents, or moving, their utopia is shattered. This
inflexibility can be evidenced early on, even before the onset of eating disorders.
Moving into the late adolescence/ preteen stage, many factors may lead directly to the
onset of AN. In this stage, adolescents start to identify who they are and recognize differences
between themselves and others. Body image begins to play a larger role in the mind of preteens,
and they may consider calories and food decisions for the first time. In a study by Moorhead et
al. (2002), mothers of 27-year-old patients suffering from Anorexia Nervosa claimed their
children experienced anxiety-depression problems around the age of nine. This could be due to
the social comparison that begins between children and their peers and the pressures that come
from these comparisons.
Major thinking strategies are also developed in this time period. Global processing of
those with AN has proven similar across the board. Most excel at tasks involving analytical skills
and details, while having poor organization skills. Also, most have weak central coherence, a
term used to describe brain function which focuses on details over the large picture. For example,
in a test in which an individual must locate a certain shape within a jumble of lines and other
shapes, those with weak central coherence are able to locate the shape almost immediately. On
the contrary, those who focus on the “big picture” have difficulty locating the shape. Weak
central coherence is a trait also exhibited by individuals with autism or Asperger syndrome, and
has been proven present even in their relatives (Treasure, 2007). Thus, this is a genetic influence
that could possibly be used to predict eating disorders. Another common characteristic of those
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with eating disorders is that they learn intentionally, but not incidentally. In other words, they
may be book smart without maturing using social cues and situations. These similar learning
patterns portray a very narrow type of thinking among those who develop eating disorders.
Most will agree that puberty is a critical time period for development, but I believe the
extent of its affect on Anorexia Nervosa is extremely underestimated. Studies by Attie and
Brooks-Guun suggest that girls who enter puberty at a young age and mature earlier than their
peers are more likely to develop problems with eating (as cited in Moorhead et. al, 2003). While
puberty is already an awkward and emotional time, these feelings can be magnified infinitely if
the girl feels larger or more developed than her friends. Body insecurities can give way to a very
complex, unhealthy relationship with food if guidance and careful explanation is not offered by a
trusted adult.
Directly following the delicate time of puberty is the usual time of the beginning of an
eating disorder. The average age of onset is found to be during the sixteenth year (Jordan et. al,
2008). Up until this point, several variables could impact the development of eating disorders at
any period of the child's life. Any event that causes extreme stress on the body, mind, or
character of the child could lead to extreme psychological disorders, such as AN. These include
sexual abuse, parental depression or drug use, parental alcoholism, repeat negative commentary
on weight, physical neglect, divorce of parents, or even social concerns. Although the study by
Jacobi, Hayward, De Zwaan, Kraemer, and Agras (2004) confirmed these events' correlation
with eating disorders, few studies have followed up to find the extent of stressful childhood
effects. I believe this should become a main concern in identifying potential eating disorders
because any of these events has the power to alter a young child's entire outlook on life. A
joyous, exuberant seven-year-old could turn into a depressed, anxious preteen after experiencing
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sexual abuse. Any sort of abuse causes these tendencies for depression, which, as previously
discussed, is a strong link to the onset of eating disorders.
As I have demonstrated up to this point, eating disorders are not afflicting a random
pattern of people. If one hundred people were gathered in a room, it would not be accurate to
simply say that ten of the people would be affected by an eating disorder. If the room were filled
with women, that number would be much higher; if it were mostly men, it would be lower. In a
room containing wealthy Caucasian women, the percentage would skyrocket. As exemplified, a
certain type can be classified as "high risk" for developing some type of eating disorder. While
all the studies I've cited contain risk factors and predictors for EDs, each examines only a few
risk factors and their effects. None inspect the conglomerate effect multiple risk factors could
have. What if determining a young girls likelihood of developing an ED was as simple as adding
up the extent of the risk factors she exhibits or experiences? I propose a checklist of sorts, which
lists the main predictors of eating disorders and could be totaled to determine the degree of risk.
(See Appendix) This checklist could then be distributed at doctors’ or psychiatrists’ offices.
The obvious question I must address is, "Who should watch and recognize these signs?" I
believe the logical person is the child's mother. Evidence suggests that a mother's attitudes
towards food and eating habits carry great weight in the mind of her daughter. (Littleton &
Ollendick, 2003). Linked with this is that fact that she spends a lot of time with her daughter and
can recognize the signs before others. Likewise, any authority figure in a child's life, such as the
father, teacher, grandparents, or a family doctor, can recognize and prevent eating disorders. I
must anticipate argument against the simplistic approach of having a mother or other adult
recognize eating disorders. Of course, it is not realistic to assume every child has a caring,
attentive mother present to identify potential disordered eating. Furthermore, doctors and
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physiatrists cannot be expected to educate themselves on every minute cause of EDs among the
copious amount of other diseases and symptoms they must be aware of. However, when a child
is brought into the doctor’s office with co-morbid traits to disordered eating, the physician could
easily provide a pamphlet with a checklist of predictors of EDs such as the one I created. The
child (or guardian) could then sum up the predictors in order to determine the degree of risk.
Such a checklist would not necessarily be used to diagnosis an ED, but instead to signal a
guardians' radar to high alert. It is not the small issues alone that predict eating disorders, but the
cumulative signs that could equal disaster. An eating disorder predictor is an easy way to see all
the signs in one place and determine the degree of risk.
Suppose a parent ascertains that their child has a high chance for developing an eating
disorder. What's next? The answer, of course, varies from child to child, depending on age
amount of predictors in effect. If the child is twelve and obsesses over his or her weight, it may
be long overdue to seek treatment from a psychologist or medical personnel. On the contrary, if a
seven year old is diagnosed with depression, jumping to the conclusion that they will have an
eating disorder is probably not necessary. In this case, preventative action on the part of family
members may be enough to avert the development of an eating disorder. Pritts and Susman
(2003) state, “Early diagnosis with intervention and earlier age at diagnosis are correlated with
improved outcomes in patients who have eating disorders.” Earlier age of recognition could lead
to less afflicted by this horrible disease.
Although I am not a doctor, the issue of eating disorders is very pertinent to my life. I was
a girl just like Sarah, a classic case study of the typical eating disorder patient. Born a white
female into a family of marathon runners and health nuts, I already had three strikes against me.
After complications at birth, I grew into a child riddled with insomnia, picky eating habits, and
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OCD. When my parents found me outside in a thunderstorm at midnight, obsessively coiling a
garden hose, they decided it was time to take me to a doctor. Since I was only six, my doctor and
psychiatrist assured my parents I’d grow out of these tendencies. Eventually, I did, but these
were only traded for a new set of problems triggered by my perfectionistic temperament. This
disposition was only reinforced by my parents’ perfectionism; hard work, exercise, and strict diet
were implemented from a young age. After entering puberty in third grade, years before my
peers, I was teased for a prematurely developed figure and an awkward growth spurt. When I
was diagnosed with Irritable Bowel Syndrome at 17, I used it to excuse the 35 pounds I’d lost
from my subsequent eating disorder. If an eating disorders checklist had been offered at any
point in my life, almost every predictor would have been present. Had my doctor or psychiatrist
been able to tip off my mother by giving her a checklist, my entire life may have been very
different.
As suggested, the most important protective factor against developing an eating disorder
seems to be a strong family unit. A set of principles for families has been cultivated to aid in the
nurturing of well-adjusted children with healthy eating habits. Among these include limiting
discussion of weight, modeling healthy eating and physical activity, helping the child develop
self-esteem in areas besides external appearance, and teaching proper coping mechanisms in
times of distress. Furthermore, if the parents themselves have psychological or emotional issues,
they should be dealt with in a mature manner to provide an example for the child (Loth, 2009).
Although providing a supportive home environment and disordered eating may seem unrelated, I
believe a balanced, nurturing background can make all the difference. A supportive family can
help a child overcome biological influences, such as tendencies towards perfection and
obsession, to develop into a healthy, well-adjusted adult. Similarly, health problems, such as
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gastrointestinal disorders or depression, can be managed in the least stressful manner for the
child. Although social pressures from peers simply cannot be avoided, parents can promote a
lifestyle with a balanced perspective towards body image from an early age, so the child will
have confidence when faced with these pressures. This self-worth could also be established by
participating in sports, music programs, or other creative endeavors. The self-esteem a child will
develop with the knowledge that their family supports them 100 percent is invaluable.
Some may argue that family support is not enough; preventative measures must be more
drastic. However, I assert that changes in the family are enough to reverse biological tendencies
towards eating disorders or other diseases. Alternatively, preventative measures that originate
outside of the home seem to have little positive affect. For instance, studies have shown that
preventative programs in high school which seek to educate children on nutrition, healthy eating,
and exercise had little or no effect. Furthermore, curriculums that endeavor to reverse the
glorification of being skinny, or to encourage making low-fat, low-calorie choices, result in
increased body dissatisfaction and elevated risk for eating disorders (Littleton & Ollendick,
2003).
Throughout my research, a typical ED patient emerged. Caucasian, female,
perfectionistic, most likely with family issues, this girl will turn her ambition towards one of the
only areas she truly has control over: food. However, this inclination does not have to win out.
Yes, a common trend can be constructed using studies of the typical girl to become afflicted with
eating disorders, but these commonalities can be used in a beneficial manner to prevent future
casualties of this disease. If predictors are recognized from early on, guardians and the child himor herself can work to prevent the onset of eating disorders. Many girls would need only one
person to acknowledge their struggle and care enough to get them help. Somewhere out there is a
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girl just beginning her spiral downward. She hands in her cupcake for a rice cake; her beautiful
figure for a lie. Maybe all it would take is one person to recognize her struggle, one voice to
drown out Anorexia’s deceptive whisper.
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Appendix
Predictors of Eating Disorders
Birth
☐ Complications in Pregnancy
☐ Caucasian
☐ Female sex
☐ Middle-high Socioeconomic Status
☐ High maternal BMI
Infancy
☐ Feeding problems
☐ Sleep difficulties
☐ Body-focused behaviors
Toddler/Preschool
☐ Functional Gastrointestinal Disorders (FGIDs)
☐ Obsessive Compulsive Disorder (OCD)
☐ Perfectionistic tendencies
☐ Picky eating
☐ Adjustment problems/ inflexibility
Late adolescence/ Preteen
☐ Anxiety
☐ Depression
☐ Weak central coherence
☐ Early pubertal timing
Throughout Life
☐ Sexual Abuse
☐ Parental alcoholism/ drug abuse
☐ Parents divorce
☐ Familial neglect
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