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Original Investigation
July 7, 2021

Association of Emotion Regulation Trajectories in Childhood With Anorexia Nervosa and Atypical Anorexia Nervosa in Early Adolescence

Author Affiliations
  • 1Division of Psychiatry, University College London, London, United Kingdom
  • 2Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
  • 3Gloucestershire Health and Care NHS (National Health Service) Foundation Trust, Gloucester, United Kingdom
  • 4Institute of Education, University College London, London, United Kingdom
JAMA Psychiatry. Published online July 7, 2021. doi:10.1001/jamapsychiatry.2021.1599
Key Points

Question  Is emotion dysregulation in childhood associated with an increased risk of broad anorexia nervosa in adolescents?

Findings  In this cohort study of 15 896 participants from the Millennium Cohort Study, poor emotion regulation skills at 3 years of age were not associated with an increased risk of broad anorexia nervosa. However, lack of improvement in emotion regulation skills across childhood was associated with increased risk in this disorder.

Meaning  These findings suggest that failure to meet key emotional developmental milestones from 3 to 7 years of age could confer an increased risk for broad anorexia nervosa, and support with developing emotion regulation skills across childhood could be beneficial in preventing anorexia nervosa.


Importance  People with anorexia nervosa often experience difficulties regulating their emotions. There is no longitudinal evidence as to whether these differences are already present in childhood or when they begin to emerge.

Objective  To investigate the association between emotion regulation trajectories from 3 to 7 years of age and symptoms of anorexia nervosa and atypical anorexia nervosa in adolescence.

Design, Setting, and Participants  This cohort study included all children with complete exposure data in the Millennium Cohort Study, a UK general population birth cohort. Data were acquired from June 2001 to March 2016 and analyzed from June to November 2020.

Exposures  Mothers reported on their children’s emotion regulation skills at 3, 5, and 7 years of age using the Children’s Social Behavior Questionnaire. Multilevel models were used to derive early childhood emotion regulation scores (ie, predicted intercept) and within-child changes in emotion regulation scores from 3 to 7 years of age (ie, predicted slope).

Main Outcome and Measures  Symptoms consistent with a DSM-5 diagnosis of anorexia nervosa or atypical anorexia nervosa at 14 years of age, defined using a range of questions relative to body image, weight perception, and dieting behaviors (hereinafter referred to as broad anorexia nervosa). Univariable and multivariable logistic regression models tested the association between exposures and outcome. Regression models were adjusted for child and family sociodemographic and socioeconomic characteristics and mental health difficulties, prenatal and perinatal factors, child’s cognitive development, and maternal attachment.

Results  A total of 15 896 participants (85.7% of total sample; 51.0% boys; 84.5% White individuals) had complete data on the exposure and were included in the main analyses. Among those with complete exposure and outcome data (9912 of the analytical sample [62.4%]), 97 participants (1.0%; 86 [88.7%] girls and 85 [87.6%] White individuals) had symptoms consistent with a diagnosis of broad anorexia nervosa at 14 years of age. No evidence suggested that children with lower emotion regulation ability at 3 years of age had greater odds of later reporting symptoms of broad anorexia nervosa (odds ratio [OR], 1.21; 95% CI, 0.91-1.63). However, children whose emotion regulation skills did not improve over childhood and who had greater problems regulating emotions at 7 years of age had higher odds of having broad anorexia nervosa at 14 years of age (OR, 1.45; 95% CI, 1.16-1.83).

Conclusions and Relevance  These findings suggest that difficulties in developing age-appropriate emotion regulation skills in childhood are associated with experiencing broad anorexia nervosa in adolescence. Interventions to support the development of emotion regulation skills across childhood may help reduce the incidence of anorexia nervosa.

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