When Mia Walter's 10-year-old daughter decided to quit gymnastics, the Nashville mom was almost relieved.
A talented gymnast, Sheila had been moving steadily up the ranks of competition since she was 4 years old, but the effort was grueling: By fourth grade, she was practicing 14 to 16 hours a week, she nursed frequent injuries, and her ankles and knees constantly hurt.
"It just wasn't fun for her anymore," says Walter. Tiny when she quit gymnastics, Sheila began to fill out a bit once she dropped the rigorous practice routine. Walter liked the change in her daughter: "It was just a pound or two at most—it wasn't really noticeable—but she looked healthier."
But that pound or two began to bother Sheila. "I'd been around all these older girls at the gym who were always saying things like 'Oh, I'm so fat,' and I started to worry that once I quit gymnastics, I would get fat, too," Sheila, now 13, remembers.
Over the next six months, worry gradually turned into obsession as she cut out sweets and chips, then dairy and meat and finally everything but salad.
"If I put something in front of her that she thought would make her fat, you'd see the fear in her eyes. She'd force herself to take a bite or two, and then she couldn't eat any more. I tried being nice, and I tried being firm, but there was just no way to make her eat," says Walter.
Sheila also began to exercise obsessively. After meals, she would go up to her room to do crunches and jumping jacks for two hours straight. She couldn't watch TV without doing push-ups or running on the treadmill at the same time.
In the beginning, Walter never suspected that her fourth-grader might be developing an eating disorder. "She was only 10," she says. "If she'd been 13, I would have worried, but I didn't think it could happen to a 10 year old."
In fact, the physical changes in Sheila came so gradually that neither Walter nor Sheila's pediatrician noticed them at first. At her well-child checkup in July, Sheila's weight was still within the normal range for her growth pattern, and she showed the early signs of puberty—breast buds, a slight widening of the hips—that a doctor would expect to see in a girl her age.
Walter mentioned her concern about the change in Sheila's eating habits, so the pediatrician explained the importance of eating from all the food groups, including fats, and Sheila said she understood.
By the end of August, there was no mistaking that something was terribly wrong. Normally a "happy, social, easy-going girl," according to her mom, Sheila became withdrawn, anxious and depressed. She complained of being cold all the time, despite the hot Nashville summer, and kept bundled up in sweatpants and baggy jackets.
When Sheila put on a swimsuit for the first time in weeks, Walker was shocked: "She looked like a death-camp survivor, all bones. I asked her, 'Sheila, do you realize how much weight you've lost?' But she said she still felt fat. So I took a picture of her and showed it to her and asked, 'Is this too skinny?' And she said, 'Yes.' She could tell that the girl in the picture was too skinny, but when she looked in the mirror, she felt fat."
A rush trip to the doctor revealed that Sheila had lost 17 pounds—almost a quarter of her body weight—in the six weeks since her well-child visit. Her body temperature was only 94 degrees, her heart rate was low and she was severely dehydrated.
Immediately, the pediatrician hospitalized Sheila, and Walter tried to arrange for her to see a child psychiatrist. "I pulled every string I could think of to get her in, but the only one in the area who was taking new patients had a three-month waiting list," she says. "I was hysterical. I remember calling the psychiatrist's office and saying, 'Please, we can't wait. My child will be dead in three months.'"
Unfortunately, Sheila Walker is not alone. Consider these real cases:
—A 7 year old announces that she's become a vegetarian because she loves animals. Then she starts eating less and less of her food. When her parents bring her into treatment, she is emaciated but pinches a tiny amount of flesh between her thumb and forefinger to illustrate "how fat" she really is. She is a full-blown anorexic.
—A 10-year-old girl, newly back in the U.S. after her missionary parents return from overseas, feels guilty about the abundance of food she finds here when children in other parts of the world are starving. She cuts her food into smaller and smaller bites and eats fewer and fewer of them. Her parents have no idea she's anorexic until a pediatrician notes that though the girl has grown taller, she hasn't gained weight in more than a year.
—An 8 year old whose parents are involved in a very messy divorce is frequently too upset to eat. The less she eats, the more concerned her parents become about her health. Soon the fighting virtually stops, transformed into a shared fear for their daughter. The family dynamic has shifted away from the divorce, and her parents have inadvertently reinforced the girl's eating disorder.
Stories like these alarm experts. Eating disorders are dangerous at any age, but when one isn't recognized in a child, or when treatment comes too late, the effects can be catastrophic.
Children have a lower percentage of body fat, which means they get much sicker much faster than adolescents and adults. And because their bodies and brains are still developing, the most severe cases can permanently affect their development—limiting growth potential, damaging vital organs (particularly the heart, kidneys, and brain)—even when the eating disorder is eventually successfully treated.
Once considered a risk only for wealthy, high-achieving teenage girls, eating disorders such as anorexia (and, more rarely, bulimia) are becoming increasingly common among children, even little boys.
"In the last two years, we've actually had to add a treatment track to deal with kids ages 9 to 11," says Margaret Kelley, clinical nurse manager for the eating disorders treatment program at The Children's Hospital in Denver. "And we're getting many more boys. We used to see one or two a year at most, but we've almost always got one or two boys in the program now."
The average age for the onset of anorexia used to be 13 to 17. Now it's 9 to 12, and children as young as 7 have been diagnosed, says Abigail Natenshon, a psychotherapist and author of "When Your Child Has an Eating Disorder."
No one knows how many preteens are affected today, though 5 percent of adolescents are affected. What is known is that at least 10 percent of adult anorexics first showed clear symptoms of the condition before they were 10 years old—and kids growing up today may be even more vulnerable.
More than 60% of elementary and middle school teachers reported that eating disorders are a problem in their schools, according to a study by the National Association of Anorexia Nervosa and Associated Disorders.
The vast majority of kids in this country don't have an eating disorder and will probably never develop one. But experts are concerned about the rise in nearly epidemic proportions of "disordered eating"—a pattern of dieting or calorie restriction that's unhealthy and a known trigger for eating disorders. Some troubling statistics from the National Eating Disorders Association:
—42 percent of kids in first through third grades wish they were thinner
—81 percent of 10 year olds are afraid of becoming fat
—51 percent of 9- and 10-year-old girls say they feel better about themselves when they are on a diet
Numbers like these are red flags for experts. And perhaps the most worrisome news is that it's not just overweight kids who are restricting calories.
According to the Centers for Disease Control and Prevention, significant numbers of normal-weight and underweight kids are also dieting: 16 percent of girls ages 8 to 11, and 19 percent of girls ages 12 to 15. The numbers are slightly lower for boys, though these, too, are rising.
Why kids are vulnerable
Eating disorders have been documented across cultures for hundreds of years and are linked to certain personality traits that appear to be inherited—such as high levels of anxiety, perfectionism, obsessive-compulsive tendencies, depression and addiction.
"With genetics, kids can be preloaded," says Kelley. So when a kid with a genetic predisposition for obsessive-compulsive disorder (OCD) goes on a diet, for example, the combination of calorie restriction and obsessive-compulsive behavior can quickly create an eating disorder.
It's impossible to predict exactly which of the many children who show signs of disordered eating will go on to develop an actual eating disorder, but there's no doubt that the world we live in isn't exactly helping to protect them.
For one thing, kids today hear a lot more about weight and body shape than we heard in childhood. They get anti-obesity messages at school (which can sometimes backfire, making perfectly healthy children paranoid about ice cream and other "fattening" foods), are bombarded by weight-loss ads on TV, see six-pack abs on the covers of magazines and idolize stars in teeny-tiny jeans.
Our culture serves up such a vast smorgasbord of body judgments, is it any wonder that so many kids are unhappy with the way they look?
"Children today are internalizing the idea of not being okay with who they are, and dieting is a way to change that," says Dena L. Cabrera, a psychologist at the Remuda Programs for Eating and Anxiety Disorders.
Kids also participate in sports at a much more competitive level than they did in the past. Some activities—like gymnastics, ballet, wrestling, running and diving—can make them particularly conscious of their appearance, because their bodies are under heavy audience scrutiny and weight can affect the outcome of the competition.
"One of my patients developed an eating disorder at age thirteen when her figure-skating coach told her that she would look much better in her outfit if her rear end were smaller," says Natenshon.
For girls, puberty itself can be a trigger in this era of stick-thin stars. Kids tend to grow taller in rapid growth spurts, but they gain weight a bit at a time, all along the way.
Right before a growth spurt, both girls and boys can look a little chunky because their height hasn't caught up yet with their additional weight. For girls approaching puberty, add breast buds and widening hips, and you've got a recipe for self-consciousness. They may begin to diet or exercise excessively as a way to compensate.
Nowhere near all kids who exhibit early symptoms of an eating disorder will go on to develop the full-blown disease. But parents need to recognize the warning signs because it's far easier to prevent a case of disordered eating from becoming an eating disorder than it is to treat an entrenched case.
Coming back to life
We can't protect children from unhealthy cultural messages or prevent the inevitable changes of puberty, but we can teach them how to respond in healthy ways.
For Sheila Walter, getting back on track wasn't easy. Three hospitalizations in Nashville during a single two-week period—which her mother calls "the worst two weeks of my life"—only identified how sick she really was.
During one visit, she actually lost more weight and told a doctor she wanted to die. "I felt so helpless," says Walker. "It's an awful feeling being a mother and just watching your child waste away."
Desperate, Walter finally checked Sheila out of the hospital and flew her to Remuda Ranch, a residential treatment program in Arizona. By then, Sheila was so weak that she has no memory of leaving the hospital in Nashville, no memory of the flight itself, no memory of the hour-long drive across the desert.
When she got to Remuda, she was assigned to the same cottage as an 8 year old, and roomed with a 12 and 13 year old. Just meeting the other kids was a big help to Sheila: "At home I didn't know anybody else who had the same problems, and I felt like nobody understood, but when I went there, I realized I wasn't alone," she says.
For the next 75 days, Sheila participated in intense therapy programs—both one-on-one and in groups—designed to help her challenge the voices in her head telling her she was fat, she was ugly, she would never fit in.
It's important for kids with eating disorders to learn to feel connected to their own bodies, as well as to identify their particular stressors and find ways to cope with them in ways that don't involve food. In therapy, the kids at Remuda also learned to be critical of media messages, and through art, journaling, horseback riding or yoga, they worked to break the cycle of negative thoughts and develop the kind of self-esteem and overall wellness that will be a buffer against recurrence of the disease. "It was really hard work to get better," says Sheila.
After 10 weeks, Sheila finally went home, where she was carefully monitored by a team of specialists—her pediatrician, but also a family therapist, a child psychiatrist, a psychologist and a nutritionist.
Sheila's diagnosis included underlying components of OCD and anxiety, and at Remuda she was treated with medication—Risperdal and Prozac—for those conditions, although her doctors successfully weaned her from both drugs. She also kept a detailed food log so her team could be sure she was getting enough calories.
There were a few setbacks at first—episodes of anxiety, brief periods when her calorie intake dropped off a bit—but nothing debilitating, and today she feels completely normal.
"When I was sick, I knew I wasn't eating right, and I tried real hard to fix it, but I kept hearing a voice inside telling me that I wasn't good enough," remembers Sheila. "I feel a lot better now. I'm happy with the way I am."
For her mother, it's taking a little longer to feel that life has returned to normal, but she's getting there.
"For a long time, I was braced for something to happen. But each year that goes by, I feel more and more comfortable," says Walter. "I'm so grateful for our happy ending. I'm so grateful to have my daughter back."
*Some names and locations have been changed.