ndersen er an - Gundersen Health System

Authors:
Alissa R. Reierson
Daniel D. Houlihan, PhD
Minnesota State University –Mankato
Mankato, Minnesota
Address for correspondence:
Daniel D. Houlihan, PhD
Psychology Department
Office WH 261
23 Armstrong Hall
Minnesota State University–Mankato
Mankato, MN 56001
Telephone: (507) 389-6308
email: daniel.houlihan@mnsu.edu
Childhood Onset of Anorexia Nervosa
ABSTRACT
Extensive research concerning the presentation and treatment of adolescents and adults
diagnosed with anorexia nervosa can be found within the literature. Conversely, the research
regarding early-onset anorexia is limited. Children presenting with anorexia nervosa may
display qualities and experience challenges disparate from those of their older counterparts.
This review of the literature examines these differences and their significance regarding the
diagnosis, treatment, and outcome of early-onset anorexia nervosa.
T
he rates of individuals seeking treatment for anorexia
nervosa (AN) have risen in recent years. 1,2 This increase
may be attributable more to the attention AN has received, rather
than to a genuine rise in the incidence of the disorder. However,
in conjunction with this increase in individuals seeking treatment
comes an increase in prepubertal individuals experiencing AN-type
symptoms.
It is estimated that early-onset AN accounts for nearly 5% of
all AN cases. 3 Within the literature, AN is considered early-onset
if individuals are 13 to 14 years old or are prepubertal. 4-6 Only a
small proportion of the eating disorders literature has addressed
this younger population. 7,8 Many studies fail to differentiate
between early-onset and late-onset AN, which may be problematic
because of the differences between early-onset and late-onset AN.
For example, compared with individuals with late-onset AN, those
with early-onset AN are more likely to be male and more likely
to belong to families with high socioeconomic status. Individuals
with early-onset AN also are usually physically and psychologically
less mature than their peers. 4,9 These differences are significant
and can affect the diagnosis, course, and treatment outcome. The
following review will focus on differences between early-onset and
late-onset AN with regard to diagnosis, characteristics, physical
risks, treatment, and outcome.
Discrepancies in Diagnosis
Anorexia nervosa is the willful refusal to maintain a body
weight that is within 85% of a healthy weight for an individual’s
height and age. Along with this refusal, people with AN display
a fear of becoming overweight. 10 They make extreme attempts at
avoiding weight gain, which may include an extremely restricted
diet and/or excessive exercising. Accompanying this fear of weight
gain, individuals with AN don’t recognize that they are dangerously
thin. Their perception of their body weight or shape is distorted.
Consequently, they may be 15% or more under their ideal weight,
but still believe that they need to lose weight. 10
The criteria for AN have been subject to much debate,
especially for prepubertal children and those under 13 years of
age. 5 Conflicting reports on children’s presentation of AN are
found within the literature. Some researchers have found that
children who are referred for AN-type symptoms often do not
have a distorted body image. 11,12 Most of these children have not
yet reached puberty and may simply fear that they will gain weight
as their bodies change. Therefore, they do not necessarily believe
they are currently overweight, yet they have gone to great lengths
to not gain weight. 12 Consequently, the characteristic distortion in
body image, weight, and shape may develop later, as children go
through puberty and their bodies change and the social appeal of
their appearance becomes a factor.
Other differences between early-onset and late-onset AN have
been noted, as well. 6 For example, Matsumoto and colleagues
found that fewer early-onset than late-onset AN patients had
extremely low weight. 6 Similarly, others have found that the
average weight of children with early-onset AN was only 5% below
their ideal weight. 11 This less severe weight loss may be because
younger individuals are still in the early stages of AN. 11 Still other
researchers have found that children often lose weight more rapidly
than adolescents and adults do. 7 Perhaps because their weight loss
occurs in a shorter period of time, and because they are usually more
supervised than adolescents and adults, younger children present
to a physician or psychologist earlier than other AN patients do.
However, it should be noted that some researchers have reported
no differences between early-onset and late-onset AN. 13
The question remains whether the weight criterion and
a distorted body image are essential for the diagnosis of AN in
preadolescence. Imposing the weight and distortion criteria on
children who present for assessment may underestimate the
number of children who are experiencing severely disordered
eating patterns. In younger children, it is easier to attribute
symptoms to something less serious, such as being a picky eater.
This misattribution is especially true when children have not
met the weight loss criterion and do not have a distorted body
image. 14 Yet many of these children will eventually be diagnosed
with AN. In their study, Lask and colleagues found that girls with
early-onset AN had a higher rate of physician visits within the 5
years preceding diagnosis than did girls with no history of mental
health problems. 14 Indeed, just 1 visit to the physician for eating,
weight, or shape concerns was a strong predictor of a subsequent
diagnosis of AN. 14 Early diagnosis is important because the longer
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