During a hectic sports season, the Lancaster County mom noticed her daughter's obsession with food.
The girl, just 13, was suddenly restricting how much and what she ate, eliminating most fat and paring her daily intake to 600 calories, far short of the 2,200 recommended for teen athletes.
Her body began withering away.
Once thought to be the province of older teens and college-age women, eating disorders now are being diagnosed in younger teens and children here.
At a time when most children are experiencing growth spurts, others are risking their lives to shed pounds. Nemours/Alfred I. duPont Hospital for Children in Delaware estimates one or two out of every 100 children struggles with an eating disorder, many hiding the fact for months or years.
"We have seen children as young as 9," says Dr. Vanessa Vigilante, a clinical child psychologist with Nemours' Eating Disorders Program.
Sometimes parents don't know the symptoms, including meal avoidance or food monitoring, or recognize that the problem can be found in children so young.
"It's hard to know when it starts," says Dr. Rollyn Ornstein, an adolescent medicine specialist and director of Hershey's partial hospitalization program, which is designed to accommodate children as young as 8. "Sometimes parents will try and wait it out. They should trust their instincts … This is not about willpower."
Fortunately, recent changes to national diagnosis and treatment guidelines have given young patients access to more experienced medical teams. In the case of the Lancaster County athlete, early recognition led to 16 weeks of daily treatment at Hershey.
"There was something that took over in her," says the mother, whose name is being withheld to protect her daughter's privacy. "She had the ideal body (before). I'm not sure she ever had the body image issue. It was about fitting in maybe, or competing."
Who is at risk
Certain characteristics, like cognitive and behavioral rigidity, are common among children and teens who have eating disorders, Vigilante says.
Many are perfect students or athletes, Ornstein says. Others have co-existing conditions like anxiety, depression or personality disorders.
Athletes — especially those who compete in judged sports — are at higher risk.
And the disorder is not limited to just girls.
The National Eating Disorders Association reports that extreme stigma makes boys with eating disorders experts at denying and covering up their illness. The association also says boys may be under-diagnosed because girls are more likely to seek help, and health practitioners are more likely to diagnose eating disorders in females.
They have a secret
Ornstein says children of both sexes are good at covering up disordered eating. Though she can often make a diagnosis in 60 minutes, children tend to lie to her because they don't want to get in trouble.
She and Vigilante say eating disorders might be trending among younger children partly because of health classes they're not intellectually prepared for. Kids who purge, for instance, wouldn't link the behavior to weight loss unless shown or told about it, Ornstein says.
It also can be difficult to make younger child understand the consequences of poor eating habits. Doctors must retrain patients on everything from eating to positive self-thinking.
Kids must learn to focus on ability and talents unrelated to their bodies.
1 step forward, 2 back
Patients with eating disorders don't always have a smooth recovery.
A third of anorexia patients recover after an initial episode. But two thirds have relapses or spiral downward.
And the cost of treatment is high.
The idea of children solidifying lifelong, unhealthy behaviors is daunting, both to doctors and families in search of treatment. Roughly 10 percent of eating disorder patients receive treatment, with outpatient costs sometimes topping $100,000.
The road to recovery
Family support and good modeling are critical to recovery.
Hershey's program includes peer support (students attend individual and group sessions during school hours), nutrition counseling and family-based strategies.
The Lancaster teen's treatment team prescribed specific goals, such as eating with friends or enjoying a doughnut, to help her regain 40 pounds.
"The idea was for her to get back to normal, to go to a sleepover and not worry about the food," her mom says.
Registered nurse Kristen Ebaugh facilitates a support group at LGH's Women's and Babies Hospital. Ebaugh was diagnosed with anorexia and bulimia at 18 and struggled with the disorders for six years. She knows the power a good support network can provide.
But she says it's essential to consider how teens might handle information shared in group, especially one mixing adults and teens.
"There is a risk to having a group setting because competition and comparisons are huge," Ebaugh says.