Anorexia Nervosa is an eating disorder that can cause children and adolescents to starve themselves. Children and teenagers with anorexia believe they are too fat, even though everyone else sees them as way too thin. To maintain a very low weight, they eat very little and engage in behaviors such as vomiting on purpose or exercising intensely. They do not understand that their body image is not accurate and that their choices are not healthy/ dangerous.

Anorexia typically begins during the adolescent years. Because children with anorexia often do well in school and are usually within desired body ideals, it can be hard for caregivers and other adults to notice there’s a problem. Females are diagnosed much more often than males, but that could be partly because anorexia is harder to spot in males.

Anorexia is extremely serious. The earlier it is treated, the better. If it is not treated, it can lead to fatal medical problems or even suicide.

Bulimia Nervosa is an eating disorder in which a child or teen has episodes of out-of-control eating called “binging.” After eating way too much, the child tries to reverse their binging behavior by “purging,” or vomiting on purpose, using laxatives, not eating, or exercising too much. Unlike kids with Anorexia Nervosa who are usually extremely thin, kids with only Bulimia Nervosa are usually normal weight or somewhat overweight, maintaining their weight is very unhealthy.

Binge Eating Disorder, like Bulimia Nervosa, is characterized by episodes of binging, during which a child or teen feels that they have lost control and cannot stop eating. This is not always a conscious loss of control. Many kids report that they were not planning to binge eat; rather, they report eating large quantities when an opportunity arises, such as when they are home alone, and “zoning out” while they eat. Because of this behavior, kids tend to gain weight. If they realize they are binge eating, they may experience distress due to their loss of control when eating and the resultant weight gain. But Binge Eating Disorder is sometimes diagnosed in teens seeking weight loss support who do not even realize they are struggling with an eating disorder.​​​​​

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​​Avoidant-Restrictive Food Intake Disorder (ARFID) is a newly defined type of eating disorder in which a child restricts or avoids certain foods to the point where it interferes with their life and health. Some children may show an “aversive” behavior pattern characterized by an aversion to a specific quality of the food, such as its texture or taste, while other children may exhibit an “avoidant” behavior pattern, which stems from fear of choking, vomiting, or getting ill. Additionally, some children show a “restrictive” behavior pattern, which involves little to no interest in food or eating, often forgetting to eat or eating exceptionally slowly. In contrast to other eating disorders, ARFID is not motivated by a desire to lose weight. However, it often leads to unhealthy weight loss, compromised growth, and extreme malnourishment. ARFID tends to affect a similar number of males and females and appears at a much younger age in comparison to other eating disorders.​

What are the symptoms of Eating Disorders?

The key indication that a child or teen has Anorexia Nervosa is that they look in the mirror and see themselves as too fat when everyone else sees them as way too thin.

Core Symptoms of Anorexia Nervosa

Associated Symptoms of Anorexia Nervosa

  • Restricted food intake leading to significantly or dangerously low body weight
  • Notable fear about gaining weight or becoming fat
  • A disturbance in the way the individual evaluates their body weight or shape,
  • Body weight or shape have disproportionate influence during self-evaluation
  • Consistent lack of recognition of the severity of low body weight

  • Extreme dieting or exercising
  • Making themselves vomit or using laxatives (this is called purging)
  • Weak nails or hair loss
  • Constipation
  • Low self-esteem or negative views about self
  • Fatigue
  • Mood swings
  • Disturbed menstrual cycle (for girls)

The key indicators for Bulimia Nervosa are the presence of binging and purging behaviors, which children and teens often hide well, making them difficult to spot.

Core Symptoms of Bulimia Nervosa

Associated Symptoms of Bulimia Nervosa

  • Repeated binge-eating episodes*
  • Repeated inappropriate compensatory behaviors to avoid or prevent weight gain, including self-induced vomiting, fasting, or excessive exercise, or using medications (e.g., laxatives, diuretics)
  • Body weight or shape have disproportionate influence during self-evaluation

  • Having a self-image that is mostly focused on body weight
  • Missing a lot of meals
  • Rushing to the bathroom right after eating
  • Long periods of not eating
  • Being secretive about eating
  • Physical effects of vomiting, including sore throat, swollen glands, acid reflux, and teeth damaged by stomach acid
  • Low self-esteem or negative views about self
  • Mood swings

*Binge eating involves consuming large quantities of food very quickly in a discrete period of time, even when not hungry, and to the point of being uncomfortable. During the episode of binge eating there is a sense of lack of control over eating.

Binge Eating Disorder is distinguished from Bulimia Nervosa because the child or teen does not attempt to counter their binge eating with purging behaviors. The Binge eating behavior must be present at least once per week during a three month period and results in marked distress.

Core Symptoms of Binge Eating Disorder

Associated Symptoms of Binge Eating Disorder

  • Recurrent binge-eating episodes* associated with three (or more) of the following:
  • Eating much more quickly than normal
  • Eating until uncomfortably full
  • Eating large amounts when not physically hungry
  • Feeling embarrassed about eating, or eating alone
  • Feeling guilty, depressed, or disgusted with oneself after eating
  • Finding certain foods particularly rewarding
  • Hiding food wrappers and containers in bedroom or other places at home
  • Noticeable weight changes
  • Eating alone
  • Eating at unusual times (often at night)
  • Skipping meals
  • Having a history of eating in response to stress

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​​​ARFID differs from other eating disorders as it is not motivated by a desire to lose weight. However, it can sometimes present similarly to anorexia or can be mistaken for picky eating, making it difficult to distinguish. ​​

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​​​Core Symptoms of ARFID​​

​​​Associated Symptoms of ARFID​​

  • ​​​Food avoidance or restriction that leads to the following: ​​
  • ​​​Not consuming enough food, leading to extreme weight loss, significant nutritional deficiencies, dependence on supplements or tube feeding, or other negative impact on the child’s health ​​
  • ​​​Disturbance to personal, family, social, or educational function caused by distress related to eating ​​
  • ​​​Behavior is not motivated by concerns about weight or appearance ​​
  • ​​​Impact on physical and/or mental health is not caused by something else, such as a different medical condition​​
  • ​​​Refusing food, gagging, or vomiting ​​
  • ​​​Not engaging with caregivers during meals ​​
  • ​​​Not communicating hunger and engaging in other activities instead. ​​
  • ​​​General emotional difficulties ​​
  • ​​​History of an aversive experience with food ​​
  • ​​​Willing to eat a limited range of foods, sufficient to maintain appropriate weight but with poor nutrition ​​
  • ​​​Disruption to typical family functioning due to distress at mealtime​​

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How are Eating Disorders diagnosed?

​​Both Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder are diagnosed by a medical professional. They look at the child’s or teen’s weight and compare it to what is average for their age and gender. They also examine the child’s or teen’s behaviors to determine if symptoms, including restricted food intake, binging, and/or purging behaviors are taking place.​​​

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​​ARFID is also diagnosed by a medical professional who examines whether the child is exhibiting aversive, avoidant, or restrictive behavior towards food. In order for a child to be diagnosed with ARFID, their avoidance or restriction of food must be having a significant negative impact on their health, such as causing extreme weight loss or inhibiting growth.​

The medical professional may also interview and/or assess both the child or teen and a caregiver in order to determine the specific nature of the current eating behaviors. The practitioner will also seek to determine that the child’s or teen’s symptoms are not related to something unforeseen.

Eating Disorder Facts

Worldwide frequency of the condition

Eating Disorders, altogether, are estimated to be present in between 0.72% and 1.69% of the world's population, although the estimations per disorder vary to a degree: Anorexia Nervosa ranging from 0.6% to 0.8%, Bulimia Nervosa ranging from 0.28% to 1%,​ and​ Binge Eating Disorder ​ranging ​from 0.85% to 2.8%​, and ARFID around 1.98%​​.​ There is no recent, specific epidemiological data for Greece.

Burden of the condition in Greece

Eating Disorders account for 0.6% for all disability adjusted life years (DALYs) lost to health conditions in Greece for 5- to 14-year-old children and adolescents. It is the 7th most prominent mental health condition adding to the health burden of the Greek child and adolescent population.

Gender ratio

Gender comparative data for Eating Disorders varies based on the type of disorder. Generally, females are more likely to be diagnosed than males, at a ratio of about 8:1 for Anorexia Nervosa, 3:1 for Bulimia Nervosa,​ and​ 2:1 for Binge Eating Disorder​,and 1.7:1 for ARFID. ​​.​

Peak age of onset

The peak age of onset for Eating Disorders, in general, is estimated to be 15.5 years, while the estimates for Anorexia Nervosa, Bulimia Nervosa, ​and ​Binge Eating Disorder​, and ARFID​ are 15.5, 15.5, ​and ​19.5​, and from 9 to 12 ​​ ​years, respectively.

Proportion of the condition that emerges before age 18

According to recent data, 48.1% of individuals with an Eating Disorder will have been diagnosed by the time they are 18 years old. Specifically, 55.2% with Anorexia Nervosa, 45.3% with Bulimia Nervosa, and 34.5% with Binge Eating Disorder will have been diagnosed by the time they are 18 years old.​ Data for ARFID is not yet available.​

What are the associated factors for Eating Disorders?

Some common factors associated with Anorexia Nervosa are:

  • Genetic and Familial factors. Having a parent or sibling with the disorder.
  • Emotional factors. These include anxiety, depression, and low self-esteem.
  • Environmental factors. These include doing activities that focus on being thin, such as modeling and sports; excessive use of social media; and high parental demands.
  • Other factors. These include perfectionism, obsessive thinking, and excessive focus on physical appearance.

Some common factors associated with Bulimia Nervosa are:

  • Genetic and Familial factors. Having a parent or sibling with the disorder.
  • Emotional factors. These include anxiety, depression, and low self-esteem.
  • Environmental factors. These include childhood physical or sexual abuse, and excessive use of social media.
  • Other factors. These include internalization of a thin body ideal, weight concerns, and excessive focus on physical appearance.

Some common factors associated with Binge Eating Disorder are:

  • Emotional factors. Experiencing depression, anxiety, stress, or interpersonal difficulties.
  • Responsiveness to food. Being particularly responsive to certain foods as rewards.
  • ​​Executive functioning difficulties. These include poor impulse control and self-regulation skills.​​​

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​​​Some common factors associated with ARFID are: ​​

  • ​​​Genetic and Familial factors. Having a parent with an eating disorder .​​
  • ​​​Emotional factors. These include anxiety, sensory sensitivity, ASD, OCD, and ADHD.​​
  • ​​​Environmental factors. These include high levels of familial anxiety, misinformation towards specific foods, and traumatic experiences.​​
  • ​​​Other factors. Having a history of gastrointestinal conditions, reflux, or vomiting.​​​​

What other disorders co-occur with Eating Disorders?

Even though each child and adolescent are different, multiple mental health disorders, including bipolar, depressive, and anxiety disorders, might commonly co-occur with either Anorexia Nervosa, Bulimia Nervosa, or Binge Eating Disorder​. ​​,​​ARFID most commonly co-occurs with anxiety disorders and neurodevelopmental disorders. ​​ ​​and ​OCD sometimes co-occurs with individuals with Anorexia Nervosa.

How are Eating Disorders treated?

The first goal for the treatment of Anorexia Nervosa is to get the child or teen to a healthy weight. This may require hospitalization or a residential program if his or her health is in danger. Treatment works best when the disorder is caught early.

The most successful therapy for children and teenagers with anorexia is family-based therapy (FBT). When the whole family participates in therapy, they learn how to support in developing healthier eating habits at home. The longer a child or teen stays at a healthy weight, the less likely it is that they will experience Anorexia Nervosa again. Some studies indicate that individual cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), or group therapy may be effective, but the evidence for kids is limited.

There are no medications for Anorexia Nervosa. However, a child may be prescribed antidepressants if they also have another disorder like OCD, anxiety, or depression. Treating these disorders with medication can make the therapy for anorexia more successful.

For Bulimia Nervosa, psychotherapy is the first line of treatment. CBT is often used to help reduce the child’s or teen’s concerns about body image, help understand what triggers binge eating, and change unhealthy eating habits. IPT, which focuses on how the child’s or teen’s relationship with others affects feelings and actions, is also beneficial. Lastly, there is some evidence that group psychotherapy may be beneficial for children and adolescents, but the evidence is limited.

Some antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can be beneficial in treatment of Bulimia Nervosa. Medications can have side effects, but they are safe for children to use with proper care from their doctor. A child or teen who is taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

There is evidence that CBT, IPT, and dialectical behavior therapy (DBT) are effective for treating Binge Eating Disorder, although these treatments have been studied in adults more than children and adolescents. In general, these treatments focus on a child’s or teen’s self-regulation around eating and strengthening self-regulation in general.

​​Some stimulant medications may reduce impulsive behaviors associated with binge eating in Binge Eating Disorder, and some antidepressant SSRIs may reduce binge eating by improving mood.​​​

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​​ARFID is a newly defined eating disorder and there is not yet enough evidence to support a specific treatment model. Each behavior pattern of ARFID may benefit from various approaches. While both FBT and CBT have shown to be effective in treating ARFID, it has been suggested that FBT is most beneficial for children with restrictive behaviors, but that CBT may be more effective for children with aversive tendencies. Pharmacological treatments can also be used to treat comorbidities that may improve presentations of ARFID.​

Where to find more information

If you need more information on eating behavior and reasons for concerns, you can also go to "Eating concerns" [website link].

To learn more about the technical work conducted to develop this guide, please consult our reference list:

References

Clinical description, symptoms, and diagnostic information

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Bourne, L., Bryant-Waugh, R., Cook, J., & Mandy, W. (2020). Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature. Psychiatry Research, 288, 112961. https://doi.org/10.1016/j.psychres.2020.112961
  • Sheldon-Dean, H. (2023, May 10). What Is ARFID? How to recognize (and treat) avoidant restrictive food intake disorder. https://childmind.org/article/what-is-arfid/

Facts

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Bourne L, Bryant-Waugh R, Cook J, Mandy W (2020) Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature. Psychiatry Research 288:112961.
  • Di Cara, M., Rizzo, C., Corallo, F., Cardile, D., Calabrò, R. S., Quartarone, A., Buda, M., & Cucinotta, F. (2023). Avoidant Restrictive Food Intake Disorder: A Narrative Review of Types and Characteristics of Therapeutic Interventions. Children, 10(8), 1297. https://doi.org/10.3390/children10081297
  • Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, Available from https://vizhub.healthdata.org/gbd-compare. (Accessed 11/15/2022)
  • Qian, J., Wu, Y., Liu, F., Zhu, Y., Jin, H., Zhang, H., Wan, Y., Li, C., & Yu, D. (2022). An update on the prevalence of eating disorders in the general population: A systematic review and meta-analysis. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 27(2), 415–428. https://doi.org/10.1007/s40519-021-01162-z
  • Sanchez‐Cerezo, J., Nagularaj, L., Gledhill, J., & Nicholls, D. (2023). What do we know about the epidemiology of avoidant/restrictive food intake disorder in children and adolescents? A systematic review of the literature. European Eating Disorders Review, 31(2), 226–246. https://doi.org/10.1002/erv.2964
  • Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. https://doi.org/10.1038/s41380-021-01161-7
  • Van Buuren, L., Fleming, C. A. K., Hay, P., Bussey, K., Trompeter, N., Lonergan, A., & Mitchison, D. (2023). The prevalence and burden of avoidant/restrictive food intake disorder (ARFID) in a general adolescent population. Journal of Eating Disorders, 11(1), 104. https://doi.org/10.1186/s40337-023-00831-x
  • Tanofsky-Kraff, M., Schvey, N. A., & Grilo, C. M. (2020). A developmental framework of binge-eating disorder based on pediatric loss of control eating. American Psychologist, 75(2), 189–203. https://doi.org/10.1037/amp0000592

Associated factors

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Arango, C., Dragioti, E., Solmi, M., Cortese, S., Domschke, K., Murray, R. M., Jones, P. B., Uher, R., Carvalho, A. F., Reichenberg, A., Shin, J. I., Andreassen, O. A., Correll, C. U., & Fusar‐Poli, P. (2021). Risk and protective factors for mental disorders beyond genetics: An evidence‐based atlas. World Psychiatry, 20(3), 417–436. https://doi.org/10.1002/wps.20894
  • Caslini, M., Bartoli, F., Crocamo, C., Dakanalis, A., Clerici, M., & Carrà, G. (2016). Disentangling the Association Between Child Abuse and Eating Disorders: A Systematic Review and Meta-Analysis. Psychosomatic Medicine, 78(1), 79–90. https://doi.org/10.1097/PSY.0000000000000233
  • Grogan, K., MacGarry, D., Bramham, J., Scriven, M., Maher, C., & Fitzgerald, A. (2020). Family-related non-abuse adverse life experiences occurring for adults diagnosed with eating disorders: A systematic review. Journal of Eating Disorders, 8(1), 36. https://doi.org/10.1186/s40337-020-00311-6
  • Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. https://doi.org/10.1038/mp.2013.50
  • Padín, P. F., González-Rodríguez, R., Verde-Diego, C., & Vázquez-Pérez, R. (2021). Social media and eating disorder psychopathology: A systematic review. Cyberpsychology: Journal of Psychosocial Research on Cyberspace, 15(3). https://doi.org/10.5817/CP2021-3-6
  • Tanofsky-Kraff, M., Schvey, N. A., & Grilo, C. M. (2020). A developmental framework of binge-eating disorder based on pediatric loss of control eating. American Psychologist, 75(2), 189–203. https://doi.org/10.1037/amp0000592

Co-occurring disorders

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Aouad, P., Barakat, S., Boakes, R., Brennan, L., Bryant, E., Byrne, S., Caldwell, B., Calvert, S., Carroll, B., Castle, D., Caterson, I., Chelius, B., Chiem, L., Clarke, S., … Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: Findings from a rapid review of the literature. Journal of Eating Disorders, 10(1), 132. https://doi.org/10.1186/s40337-022-00654-2
  • Mandelli, L., Draghetti, S., Albert, U., De Ronchi, D., & Atti, A.-R. (2020). Rates of comorbid obsessive-compulsive disorder in eating disorders: A meta-analysis of the literature. Journal of Affective Disorders, 277, 927–939. https://doi.org/10.1016/j.jad.2020.09.003
  • Filipponi, C., Visentini, C., Filippini, T., Cutino, A., Ferri, P., Rovesti, S., Latella, E., & Di Lorenzo, R. (2022). The Follow-Up of Eating Disorders from Adolescence to Early Adulthood: A Systematic Review. International Journal of Environmental Research and Public Health, 19(23), 16237. https://doi.org/10.3390/ijerph192316237

Interventions

  • Berg, E., Houtzager, L., Vos, J., Daemen, I., Katsaragaki, G., Karyotaki, E., Cuijpers, P., & Dekker, J. (2019). Meta‐analysis on the efficacy of psychological treatments for anorexia nervosa. European Eating Disorders Review, 27(4), 331–351. https://doi.org/10.1002/erv.2683
  • Bourne L, Bryant-Waugh R, Cook J, Mandy W (2020) Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature. Psychiatry Research 288:112961.
  • Buerger, A., Vloet, T. D., Haber, L., & Geissler, J. M. (2021). Third-wave interventions for eating disorders in adolescence: Systematic review with meta-analysis. Borderline Personality Disorder and Emotion Dysregulation, 8(1), 20. https://doi.org/10.1186/s40479-021-00158-6
  • Chang, P. G. R. Y., Delgadillo, J., & Waller, G. (2021). Early response to psychological treatment for eating disorders: A systematic review and meta-analysis. Clinical Psychology Review, 86, 102032. https://doi.org/10.1016/j.cpr.2021.102032
  • Correll, C. U., Cortese, S., Croatto, G., Monaco, F., Krinitski, D., Arrondo, G., Ostinelli, E. G., Zangani, C., Fornaro, M., Estradé, A., Fusar‐Poli, P., Carvalho, A. F., & Solmi, M. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. https://doi.org/10.1002/wps.20881
  • Di Cara, M., Rizzo, C., Corallo, F., Cardile, D., Calabrò, R. S., Quartarone, A., Buda, M., & Cucinotta, F. (2023). Avoidant Restrictive Food Intake Disorder: A Narrative Review of Types and Characteristics of Therapeutic Interventions. Children, 10(8), 1297. https://doi.org/10.3390/children10081297
  • Linardon, J., Kothe, E. J., & Fuller-Tyszkiewicz, M. (2019). Efficacy of psychotherapy for bulimia nervosa and binge-eating disorder on self-esteem improvement: Meta-analysis. European Eating Disorders Review, 27(2), 109–123. https://doi.org/10.1002/erv.2662
  • Murray, S. B., Quintana, D. S., Loeb, K. L., Griffiths, S., & Le Grange, D. (2019). Treatment outcomes for anorexia nervosa: A systematic review and meta-analysis of randomized controlled trials. Psychological Medicine, 49(4), 535–544. https://doi.org/10.1017/S0033291718002088
  • Slade, E., Keeney, E., Mavranezouli, I., Dias, S., Fou, L., Stockton, S., Saxon, L., Waller, G., Turner, H., Serpell, L., Fairburn, C. G., & Kendall, T. (2018). Treatments for bulimia nervosa: A network meta-analysis. Psychological Medicine, 48(16), 2629–2636. https://doi.org/10.1017/S0033291718001071

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