Research

JAMA Psychiatry | Original Investigation

Association of Emotion Regulation Trajectories in Childhood With

Anorexia Nervosa and Atypical Anorexia Nervosa in Early Adolescence
Mariella Henderson, MSc; Helen Bould, PhD; Eirini Flouri, PhD; Amy Harrison, PhD; Gemma Lewis, PhD;
Glyn Lewis, PhD; Ramya Srinivasan, BMBCh; Jean Stafford, PhD; Naomi Warne, PhD; Francesca Solmi, PhD

Supplemental content
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). Author Affiliations: Division of
Psychiatry, University College
CONCLUSIONS AND RELEVANCE These findings suggest that difficulties in developing London, London, United Kingdom
age-appropriate emotion regulation skills in childhood are associated with experiencing (Henderson, Gemma Lewis,
broad anorexia nervosa in adolescence. Interventions to support the development of Glyn Lewis, Srinivasan, Stafford,
Solmi); Centre for Academic Mental
emotion regulation skills across childhood may help reduce the incidence of anorexia Health, Population Health Sciences,
nervosa. Bristol Medical School, University of
Bristol, Bristol, United Kingdom
(Bould, Warne); Gloucestershire
Health and Care NHS (National
Health Service) Foundation Trust,
Gloucester, United Kingdom (Bould);
Institute of Education, University
College London, London, United
Kingdom (Flouri, Harrison).
Corresponding Author: Francesca
Solmi, PhD, Division of Psychiatry,
University College London, 148
Tottenham Court Rd, Maple House,
6th Floor, Wing A, W1T 7NF London,
JAMA Psychiatry. 2021;78(11):1249-1257. doi:10.1001/jamapsychiatry.2021.1599 United Kingdom (francesca.solmi@
Published online July 7, 2021. ucl.ac.uk).

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 Research Original Investigation
A
norexia nervosa is a psychiatric disorder typically be-
ginning in adolescence and characterized by restric-
tion of food intake and severe anxiety regarding eat-
ing, body shape, and weight gain.1 Anorexia nervosa, including
its subthreshold presentations, affects approximately 1% of
young people and is associated with mental and physical health
comorbidities and high mortality.2 Childhood interventions
could help to prevent a number of anorexia nervosa cases, yet
longitudinal etiological research remains scant, and targets for
such interventions are elusive.
Emotion regulation, defined as the ability to both intrin-
sically and extrinsically monitor, appraise, and modify one’s
emotional state,3 has been increasingly proposed as a poten-
tial target.4 In clinical samples, people with anorexia nervosa
often show suboptimal emotion regulation and awareness com-
pared with healthy controls, as well as greater difficulties tol-
erating distress and other maladaptive emotion regulation
strategies such as rumination and suppression.5-7 Poor emo-
tion regulation can lead to emotional overcontrol, which is as-
sociated with cognitive rigidity, reward insensitivity, and per-
fectionism, all commonly observed in patients with anorexia
nervosa.8,9 It has been hypothesized that emotional avoid-
ance might increase negative affect and the use of maladap-
tive coping strategies, such as disordered eating behaviors.10-12
Although such maladaptive behaviors typically begin during
adolescence, emotion regulation difficulties emerge through-
out childhood13 and are associated with later psychopathol-
ogy, including obsessive-compulsive disorder, depression, and
anxiety,14,15 common comorbidities16,17 of and proposed risk
factors for anorexia nervosa.18,19
Existing studies of emotion regulation and anorexia ner-
vosa have predominantly used case-control designs within
clinical populations.7 These studies have limitations. They are
prone to reverse causality and cannot exclude the possibility
that emotion regulation difficulties are a consequence rather
than a cause of anorexia nervosa. For instance, some studies
of people with anorexia nervosa have found that body mass
index (BMI) or weight restoration did not affect emotion regu-
lation skills,20,21 whereas others have found that the latter im-
proved with weight restoration.22 Clinical studies are also sus-
ceptible to selection bias because cases are commonly drawn
from secondary care and controls from the general popula-
tion samples; in addition, they can be an unrepresentative se-
lection of all people with eating disorders, because the latter
group often does not seek help.23 Residual confounding and
small sample sizes are also a concern regarding the existing
literature.
Longitudinal general population studies can address many
of these limitations. They can also detail how emotion regu-
lation difficulties develop across childhood and how these
changes might be implicated in the etiology of anorexia ner-
vosa. This process allows identification of key developmen-
tal stages when preventative interventions could be more ef-
fective. To this end, we used data from the Millennium Cohort
Study (MCS), a large UK longitudinal general population birth
cohort, to investigate the association between trajectories of
emotion dysregulation across childhood and broadly defined
anorexia nervosa at 14 years of age.
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Emotion Regulation Trajectories in Childhood and Anorexia Nervosa in Early Adolescence
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.
Methods
Sample
The MCS is a longitudinal population-based birth cohort study
of children born from September 1, 2000, to January 11, 2002,
who were living in the UK at 9 months of age and their fami-
lies (eMethods 1 in the Supplement).24 The Multi-Centre Re-
search Ethics Committee gave ethics approval for the MCS.
Participants gave written consent. The study followed the
Strengthening the Reporting of Observational Studies in Epi-
demiology (STROBE) reporting guideline for cohort studies.
In this study, we included children with complete data on
exposure, imputing missing confounder and outcome data. In
cases of twins or triplets, we selected 1 child at random to avoid
overestimation or underestimation of effects resulting from
shared genetic and environmental factors.
Outcome
We used a set of questions broadly covering DSM-5 criteria for
anorexia nervosa or atypical anorexia nervosa to identify par-
ticipants who at 14 years of age had behaviors and cognitions
consistent with these 2 diagnoses (hereinafter referred to as
broad anorexia nervosa) (Table 1 and Table 2) These DSM-5
criteria include deliberate restriction of energy intake, fear of
gaining weight, behaviors preventing weight gain or maintain-
ing low weight, and disturbed body weight perception.1 Low
weight is a diagnostic criterion for anorexia nervosa, but not
atypical anorexia nervosa. We defined adolescents as having
broad anorexia nervosa if they met all the following criteria:
report of lifetime dieting and exercising for weight loss, cur-
rently trying to lose weight, skipping breakfast every day, de-
scribing themselves as overweight despite a BMI in the under-
weight or normal weight range, and scoring below the median
sample score on a question on body image. We calculated BMI
from objective measures of weight in kilograms divided by
height in meters squared taken by trained researchers when
participants were 14 years old. We used the Stata egen func-
tion zbmicat()25 to generate age- and sex-appropriate BMI cat-
egories, based on International Obesity Task Force growth
charts.26,27
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 Emotion Regulation Trajectories in Childhood and Anorexia Nervosa in Early Adolescence Original Investigation Research

Table 1. Criteria Used to Define Anorexia Nervosa

Answer or category used
to define broad anorexia
Question No. Questionnaire item Answer or category choices nervosa
MCS questions at age 14 y
1 Which of the following are you 1. Lose weight Lose weight
trying to do about your weight? 2. Gain weight
3. Stay the same weight
4. I am not trying to do anything
about my weight
2 Have you ever exercised to lose 1. Yes Yes
weight or to avoid gaining 2. No
weight?
3 Have you ever eaten less food, 1. Yes Yes
fewer calories, or foods low in fat 2. No
to lose weight or to avoid gaining
weight?
4 How often do you eat breakfast 1. Never Never
over a week? 2. Some days, but not all days
3. Every day
5 Which of these do you think 1. Underweight Slightly or very
you are? 2. About the right weight overweight
3. Slightly overweight
4. Very overweight
6 How do you feel about the way On a scale of 1 to 7, where 1 means >4a
you look? completely happy and 7 means
not at all happy
MCS physical health at age 14 y
7 Age- and sex-standardized BMI 1. Underweight Underweight or normal
at age 14 y 2. Normal weight BMI Abbreviations: BMI, body mass index;
3. Overweight MCS, Millennium Cohort Study.
4. Obese a
Indicates median value.

We used a broad anorexia nervosa definition for 2 rea- Table 2. Criteria Used to Define Anorexia Nervosa
sons. First, individuals who do not meet the low BMI crite- in the MCS vs DSM-5 Criteria
rion are less likely to be referred to specialist services and are
DSM-5 anorexia nervosa criteria Question No. useda
thus often excluded from clinical studies. Including adoles-
Restriction of food intake leading to weight loss or a 1, 2, 3, 4
cents with symptoms typical of clinical diagnoses can help elu- failure to gain weight, resulting in a “significantly
cidate risk factors that operate across the spectrum of disor- low body weight” of what would be expected for
someone’s age, sex, and height
der severity. Second, low BMI results from protracted restrictive Fear of becoming fat or gaining weight 1, 5
eating behaviors and weight and shape concerns. Some people, Have a distorted view of themselves and of their 5, 6, 7
despite experiencing all other behavioral and cognitive symp- condition
toms of the disorder, might never reach an underweight BMI. All criteria for atypical anorexia nervosa are met 7
except, despite significant weight loss, the
Furthermore, at the early stages of anorexia nervosa (which individual’s weight is within or above the normal
we are likely to observe at this age), people with the condi- range
tion may still be in the normal BMI range. For descriptive pur- Abbreviation: MCS, Millennium Cohort Study.
poses, we also restricted our definition to underweight par- a
Indicates questions from Table 1.
ticipants.

Exposure
At the sweeps of data collection at 3, 5, and 7 years of age, moth-
ers reported on their children’s emotion regulation abilities over
the previous 6 months using 5 questions from the Child So-
cial Behaviour Questionnaire (a modified version of the Adap-
tive Social Behavior Inventory).28,29 These questions are scored
on a 3-point Likert scale (eTable 1 in the Supplement) giving a
total score ranging from 0 to 10, with higher scores indicating
greater difficulties regulating emotions. Published studies30,31
using MCS and other data sets have used this measure previ-
ously. Our main exposures were children’s predicted emo-
tion regulation scores at 3 years of age (ie, intercept) and their
within-person linear change in score from 3 to 7 years of age
(ie, slope), derived using multilevel models. More details on
how this variable was created are found in the Statistical Analy-
sis section. Data were acquired from June 2001 to March 2016.
Confounders
We used direct acyclic graphs (eFigures 1 and 2 in the Supple-
ment) to guide our choice of confounders, based on assump-
tions informed by previous literature and clinical observa-
tions. According to these assumptions, to estimate the total
effect of both exposures on broad anorexia nervosa at 14 years
of age, it was necessary to adjust analyses for each child’s birth-
weight, gestational age, sex, ethnicity, breastfeeding status,
cognitive self-regulation, and cognitive development (in-
dexed in our sample by language development and school
readiness) at 3 years of age and underlying genetic risk. It was
also necessary to adjust for family socioeconomic status, ma-
ternal and paternal depression, maternal and paternal emo-
tion regulation, maternal prepregnancy BMI, smoking habits
in pregnancy, and maternal attachment to the child. We had
data on all these hypothesized confounders except genetic risk

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 Research Original Investigation
and parental emotion regulation. Additional details are pro-
vided in eMethods 2 in the Supplement.
We also adjusted analyses of the association between emo-
tion regulation slope and broad anorexia nervosa for child BMI
and mental health difficulties at 3 years of age. We did not in-
clude these 2 measures in the intercept analyses because we
hypothesized that they could be mediators of its association
with the outcome. Longitudinal evidence suggests that more
emotionally dysregulated children have higher BMI30 and
greater internalizing and externalizing symptoms.32,33 Be-
cause measures of emotion regulation, mental health difficul-
ties, and BMI were collected at the same time, it was difficult
to disentangle temporality. However, emotion regulation dif-
ficulties can also occur as a result of neurodevelopmental
disorders,34 and some evidence suggests that emotion regu-
lation improves with weight restoration.22 Hence, in sensitiv-
ity analyses, we also included mental health difficulties and
BMI as potential confounders.
Statistical Analysis
Data were analyzed from June to November 2020. To create
the exposure variables, we used multilevel models to model
within-child repeated emotion regulation scores from 3 to 7
years of age. We used linear and quadratic indicators of
child’s age at assessment (3, 5, and 7 years) and included a
random intercept for child and a random slope for linear
time. For each child, we predicted an intercept and a linear
slope value representing their predicted emotion regulation
scores at 3 years of age and the within-child score changes
from 3 to 7 years, respectively. To derive the child’s inter-
cept, we centered the age variable at 3 years. To derive the
slope, we centered the age variable at 5 years. In regression
models, we standardized these values to have a mean of 0
and an SD of 1.
To investigate the association between emotion regula-
tion exposures and broad anorexia nervosa, we used univari-
able and multivariable logistic regression models. First, we ran
univariable models for each exposure. Subsequently, we ran
a series of multivariable models progressively adjusting each
exposure for child- and family-level confounders. Models test-
ing the association between emotion regulation slope and
broad anorexia nervosa were also further adjusted for emo-
tion regulation intercept to test whether changes in emotion
regulation are associated with broad anorexia nervosa regard-
less of baseline levels. We imputed missing confounder and
outcome data using multiple imputation with chained equa-
tions (eMethods 3 in the Supplement).35 In all analyses, we used
survey and nonresponse weights and accounted for sampling
strata.
As sensitivity analyses, we reran all models restricting the
sample to participants with complete exposure and outcome
data and imputed confounders and complete data on all vari-
ables. We then ran univariable and multivariable models using
emotion regulation scales 3, 5, and 7 years of age separately
as exposures. These analyses were based on participants with
complete exposure and imputed confounders and outcome at
each time point. Finally, we used linear mixed models to model
trajectories of emotion regulation scores for adolescents with
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Emotion Regulation Trajectories in Childhood and Anorexia Nervosa in Early Adolescence
and without broad anorexia nervosa. Our models included a
random intercept for child and a random slope for linear time.
We ran univariable and multivariable models, adjusting for all
previously identified confounders, and included interactions
with age and age squared to test for differences in trajecto-
ries’ slopes centering age at 5 years. Analyses were run in Stata,
version 16 (StataCorp LLC). P < .05 indicated statistical signifi-
cance.
Results
Sample and Missing Data
Of the 18 552 children included in the first wave of the MCS,
15 896 (85.7%) provided data for at least 1 emotion regulation
assessment and were included in the analyses. Of these, 9255
(58.2%) had data on all 3 assessments, 4103 (25.8%) had data
on 2 assessments, and 2538 (16.0%) had data on 1. Among chil-
dren with complete exposure data, 5984 (37.6%) did not have
outcome data. In eTable 2 in the Supplement, we present fac-
tors associated with missing outcome data. A total of 8110 par-
ticipants (51.0%) were male and 7786 (49.0%) were female.
Most participants were White (13 432 [84.5%]), had at least 1
parent in a nonmanual occupation (9572 [63.7%] among those
with data available), and had a mother who only completed
compulsory education (10 218 [64.5%] among those with data
available). A complete overview of sample characteristics is
provided in Table 3.
Emotion Regulation
Mean (SD) emotion regulation scores were 4.39 (2.25) at 3 years
of age, 3.61 (2.30) at 5 years of age, and 3.59 (2.37) at 7 years of
age. Multilevel models also showed a decrease in scores from
3 to 5 years of age and a subsequent stabilization (eTable 3 and
eFigure 3 in the Supplement). Overall, boys, children from more
deprived backgrounds, and children whose parents had greater
depressive symptoms had more difficulty regulating emo-
tions. Children with mental health difficulties, lower cogni-
tive development, and greater prenatal and perinatal adver-
sities (eg, those born prematurely or at lower weight or exposed
to maternal smoking in utero) also were more emotionally
dysregulated (Table 3).
Broad Anorexia Nervosa
Among the 9912 participants with complete exposure and out-
come data, 97 (1.0%; 86 girls [88.7%] girls, and 85 [87.6%] White
individuals) had symptoms consistent with a broad diagnosis
of anorexia nervosa in adolescence. Prevalence was lower in
boys (11 of 4967 [0.2%]) than in girls (86 of 4936 [1.7%]) and
was similar in White (85 of 8354 [1.0%]) and ethnic minority
group (14 of 1558 [0.9%]) participants (eTable 4 in the Supple-
ment). Seven of the 9912 participants (0.07%) met strict
criteria for anorexia nervosa.
Emotion Regulation and Anorexia Nervosa
There was no evidence that children with higher intercept
scores had increased odds of broad anorexia nervosa at age 14
years in the univariable model (odds ratio [OR], 1.19; 95% CI,
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 Emotion Regulation Trajectories in Childhood and Anorexia Nervosa in Early Adolescence Original Investigation Research

Table 3. Sample Characteristics

No./total No. (%) Emotion regulation Emotion regulation slope,
Characteristic of participantsa intercept, mean (SD) P valueb mean (SD) P valueb
Child’s sex
Male 8110/15 896 (51.0) 4.57 (1.52) −0.19 (0.16)
<.001 <.001
Female 7786/15 896 (49.0) 4.30 (1.47) −0.21 (0.16)
Child’s race/ethnicity
White 13 432/15 896 (84.5) 4.41 (1.52) −0.20 (0.16)
Black 516/15 896 (3.2) 4.34 (1.35) −0.19 (0.15)
South Asian 1303/15 896 (8.2) 4.76 (1.30) <.001 −0.19 (0.15) .02
Mixed 460/15 896 (2.9) 4.53 (1.50) −0.19 (0.16)
Otherc 185/15 896 (1.2) 4.56 (1.31) −0.18 (0.14)
Thirds of child’s mental health
difficulties scores at age 3 y
First (lowest symptoms) 5358/13 620 (39.3) 3.39 (1.17) −0.20 (0.15)
Second 3944/13 620 (29.0) 4.45 (1.21) <.001 −0.21 (0.17) .047
Third (highest symptoms) 4318/13 620 (31.7) 5.57 (1.27) −0.20 (0.17)
Parents’ highest social class
Manual 5459/15 031 (36.3) 4.13 (1.47) −0.21 (0.16)
<.001 <.001
Nonmanual 9572/15 031 (63.7) 4.89 (1.44) −0.19 (0.15)
Fifths of family weekly income
First (lowest income) 3724/15 853 (23.5) 4.99 (1.44) −0.18 (0.16)
Second 3464/15 853 (21.9) 4.67 (1.46) −0.20 (0.16)
Third 3053/15 853 (19.3) 4.34 (1.45) <.001 −0.21 (0.16) <.001
Fourth 2925/15 853 (18.5) 4.08 (1.43) −0.21 (0.16)
Fifth (highest income) 2687/15 853 (16.9) 3.88 (1.44) −0.22 (0.16)
Child’s BMI at age 3 y
Normal weight (including 10 138/13 317 (76.1) 4.38 (1.52) −0.20 (0.16)
underweight)
Overweight 2423/13 317 (18.2) 4.42 (1.48) .03 −0.21 (0.17) .053

Obese 756/13 317 (5.7) 4.52 (1.50) −0.19 (0.16)

Thirds of maternal Kessler-6
depression score
First (lowest symptoms) 5175/12 853 (40.3) 3.99 (1.44) −0.21 (0.16)
Second 4449 (34.6) 4.37 (1.47) <.001 −0.21 (0.16) <.001
Third (highest symptoms) 3229 (25.1) 5.00 (1.50) −0.20 (0.17)
Thirds of paternal Kessler-6
depression score
First (lowest symptoms) 3684/8903 (41.4) 4.14 (1.46) −0.22 (0.16)
Second 2537/8903 (28.5) 4.23 (1.50) <.001 −0.21 (0.17) <.001
Third (highest symptoms) 2682/8903 (30.1) 4.48 (1.54) −0.20 (0.17)
Child’s birthweight
Low 1093/15 853 (6.9) 4.43 (1.50) −0.20 (0.16)
<.001 .005
Normal 14 760/15 853 (93.1) 4.68 (1.46) −0.19 (0.16)
Gestational age
Preterm 1161/15 708 (7.4) 4.42 (1.50) −0.20 (0.16)
.002 .04
At term 14 547/15 708 (92.6) 4.57 (1.49) −0.19 (0.16)
Maternal prepregnancy BMI
Underweight 814/14 596 (5.6) 4.76 (1.52) −0.20 (0.15)
Normal weight 9539/14 596 (65.4) 4.34 (1.51) −0.21 (0.16)
<.001 .008
Overweight 2952/14 596 (20.2) 4.50 (1.51) −0.20 (0.17)
Obese 1291/14 596 (8.8) 4.60 (1.52) −0.19 (0.17)
Maternal highest academic
qualification
Compulsory 10 218/15 834 (64.5) 4.71 (1.47) −0.20 (0.16)
<.001 <.001
Noncompulsory 5616/15 834 (35.5) 3.95 (1.44) −0.21 (0.16)

(continued)

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 Research Original Investigation Emotion Regulation Trajectories in Childhood and Anorexia Nervosa in Early Adolescence

Table 3. Sample Characteristics (continued)

No./total No. (%) Emotion regulation Emotion regulation slope,
Characteristic of participantsa intercept, mean (SD) P valueb mean (SD) P valueb
Maternal age at child’s birth, y
14-20 1389/15 859 (8.7) 5.13 (1.38) −0.18 (0.15)
21-30 7368/15 859 (46.5) 4.66 (1.47) −0.20 (0.16)
<.001 <.001
31-40 6793/15 859 (42.8) 4.08 (1.47) −0.21 (0.16)
>40 309/15 859 (1.9) 3.88 (1.48) −0.22 (0.17)
Housing tenure
Own 9852/16 136 (61.1) 4.15 (1.45) −0.21 (0.16)
Rent 5327/16 136 (33.0) 4.91 (1.48) <.001 −0.19 (0.16) <.001
Live rent free/other 957/16 136 (5.9) 4.81 (1.39) −0.20 (0.16)
Maternal smoking in pregnancy
Never smoked 10 231/15 875 (64.4) 4.23 (1.47) −0.21 (0.16)
Smoked but stopped 2026/15 875 (12.8) 4.60 (1.45) <.001 −0.20 (0.16) <.001
Smoked throughout 3618 (22.8) 4.94 (1.48) −0.19 (0.16)
Child was ever breastfed
No 5025/15 863 (31.7) 4.73 (1.49) −0.20 (0.16)
<.001 .02
Yes 10 838/15 863 (68.3) 4.31 (1.48) −0.20 (0.16)
Thirds of British Ability Scales
language score
First (lowest scores) 4769/13 597 (35.1) 4.76 (1.50) −0.20 (0.16)
Second 5663/13 597 (41.6) 4.31 (1.49) <.001 −0.21 (0.16) <.001
Third (highest scores) 3165/13 597 (23.3) 3.99 (1.46) −0.21 (0.16)
Thirds of Bracken School Readiness
score
First (lowest scores) 4369/12 935 (31.4) 4.83 (1.50) −0.20 (0.16)
Second 4371/12 935 (33.8) 4.32 (1.49) <.001 −0.21 (0.16) <.001
Third (highest scores) 4195/12 935 (32.4) 3.99 (1.45) −0.21 (0.16)
Thirds of maternal attachment score
First (lowest scores) 6077/13 347 (45.5) 4.53 (1.49) −0.20 (0.16)
Second 4055/13 347 (30.4) 4.38 (1.51) <.001 −0.21 (0.16) .01
Third (highest scores) 3215/13 347 (24.1) 4.30 (1.50) −0.21 (0.16)
b
Abbreviation: BMI, body mass index. Calculated using the χ2 test; values are 2-sided.
a c
Percentages have been rounded and may not total 100. Details on all scales Other included other Asian, Chinese, and any other background.
used to measure these variables are provided in eMethods 2 in the
Supplement.

0.94-1.48). The association remained largely unchanged when
including all hypothesized confounders (OR, 1.21; 95% CI, 0.91-
1.63) (Table 4). Including child BMI and mental health diffi-
culties in the sensitivity analyses did not alter these findings
(OR, 1.15; 95% CI, 0.82-1.62).
Increases in emotion regulation slope were associated with
greater odds of broad anorexia nervosa at 14 years of age in the
univariable model (OR, 1.40; 95% CI, 1.13-1.74). This associa-
tion persisted in models adjusted for all hypothesized con-
founders (OR, 1.45; 95% CI, 1.16-1.83) (Table 4).
Sensitivity Analyses
When running models for participants with complete expo-
sure and outcome variables and imputed confounders
(n = 9912) (eTable 5 in the Supplement) and those based on
complete cases (4004 for intercept and 3768 for slope) (eTable 6
in the Supplement), the results showed a reduced strength of
association, although the 95% CIs overlapped with those of the
main analyses. When we used individual measurements of
emotion regulation, we found no evidence of an association
between poorer emotion regulation at 3 years of age (fully ad-
justed OR, 0.99; 95% CI, 0.89-1.11) and 5 years of age (fully ad-
justed OR, 1.11; 95% CI, 0.95-1.31) and broad anorexia nervosa
at 14 years of age. However, we found strong evidence of an
association between poorer emotion regulation at 7 years of
age and increased odds of broad anorexia nervosa at 14 years
of age (OR, 1.19; 95% CI, 1.05-1.36) (eTable 7 in the Supple-
ment). These findings were also mirrored by mixed model
analyses. Here, we found no evidence of differences in score
at 5 years of age between those with and without anorexia ner-
vosa (mean difference, 0.25; 95% CI, −0.09 to 0.60). How-
ever, there was an interaction between broad anorexia ner-
vosa and time (interaction coefficient, 0.20; 95% CI, 0.08-
0.32; P = .001) indicating that, although emotion regulation
scores were similar between groups at 3 years of age, trajec-
tories began to diverge at 5 years of age, resulting in differ-
ences in scores by 7 years of age (eTable 8 in the Supplement
and the Figure).

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 Emotion Regulation Trajectories in Childhood and Anorexia Nervosa in Early Adolescence Original Investigation Research

Table 4. Results of Univariable and Multivariable Logistic Regression Figure. Trajectories of Emotion Regulation Derived From Multilevel
Models Testing the Association Between Increases in Emotion Growth Curves Models Conducted as Sensitivity Analyses
Regulation Intercept and Slope and Anorexia Nervosa
at 14 Years of Agea 5.0

Anorexia nervosa at age 14 y

4.6
P

Emotion regulation score

Model OR (95% CI) valueb Broad anorexia nervosa
present
Emotion regulation intercept 4.2
Univariable model 1.19 (0.94-1.48) .14
Adjusted model 1: child’s sex and 1.27 (1.00-1.62) .04
3.8
ethnicity
Adjusted model 2: model 1 plus birth 1.29 (1.00-1.67) .045
weight, gestational age, breastfeeding Broad anorexia nervosa
3.4
status, self-regulation, language score, absent
and school readiness at 3 years of age
Adjusted model 3: model 2 plus family 1.23 (0.93-1.64) .16 3.0
socioeconomic statusc 3 5 7
Adjusted model 4: model 3 plus 1.21 (0.91-1.63) .18 Age at emotion regulation measurement, y
maternal prepregnancy BMI, smoking in
pregnancy, maternal and paternal
depression, and maternal attachment Trajectories are estimated from model 3 presented in eTable 8 in the Supplement
(n = 15 896). Error bars represent 95% CIs; higher scores on the emotion
Emotion regulation slope
regulation scale indicate greater difficulties regulating emotions. The dotted line
Univariable model 1.40 (1.13-1.74) .002 represents adolescents with broad anorexia nervosa at 14 years of age; the solid
Adjusted model 1: child’s sex and 1.48 (1.19-1.85) .001 line, adolescents without broad anorexia nervosa at 14 years of age.
ethnicity
Adjusted model 2: model 1 plus 1.48 (1.18-1.85) .001
self-regulation and mental health
scores, language score, school Interpretation of Findings
readiness, BMI at 3 years of age,
gestational age, birthweight, and Clinical case-control studies7 have found that people with an-
breastfeeding status orexia nervosa have emotion regulation difficulties. A previ-
Adjusted model 3: model 2 plus family 1.47 (1.17-1.84) .001 ous longitudinal study36 also found that adolescents with emo-
socioeconomic statusc
tion regulation difficulties had greater disordered eating
Adjusted model 4: model 3 plus 1.47 (1.17-1.84) .001
maternal prepregnancy BMI, maternal behaviors at a 7-month follow-up. Our study improves on these
smoking in pregnancy, maternal and
paternal depression, and maternal
previous investigations by showing that emotion regulation
attachment difficulties not only precede the onset of anorexia nervosa, they
Adjusted model 5: model 4 plus 1.45 (1.16-1.83) .001 also likely emerge during the course of early to middle child-
emotion regulation intercept
hood. We observed that although most children experienced
Abbreviations: BMI, body mass index; OR, odds ratio. improvement in their ability to regulate their emotions be-
a
Based on participants with complete exposure and imputed confounder and tween 3 and 7 years of age, this was not the case for those who
outcome data (n = 15 896). Details on all scales used to measure confounder
variables are provided in eMethods 2 in the Supplement.
later developed symptoms consistent with a diagnosis of an-
b
Values are 2-sided.
orexia nervosa or atypical anorexia nervosa (Figure). This sug-
c
Includes maternal educational attainment and age, highest parental social
gests that failure to meet key emotional developmental mile-
class, weekly family Organisation for Economic Co-operation and stones, as opposed to having greater emotion dysregulation
Development equivalized income, and housing tenure. since early childhood, could confer an increased risk for an-
orexia nervosa. Emotion regulation difficulties might also be
independent from low BMI and increase the risk of restrictive
eating behaviors across a range of eating disorders. This
Discussion hypothesis needs to be investigated further.
Several mechanisms could explain the association we ob-
In this cohort study, we found that children whose emotion served. Emotion dysregulation might represent an early mani-
regulation skills improved less during the course of child- festation of genetic and neurobiological risk. Cognitive rigid-
hood and who had greater problems regulating emotions by ity, reward insensitivity, and perfectionism typical of anorexia
7 years of age had increased odds of broadly defined nervosa8,9 could emerge in response to or accompany diffi-
anorexia nervosa at 14 years of age. This association was culties regulating negative emotions. Emotion dysregulation
independent of baseline levels of internalizing and external- could also trigger environmental risk factors. For instance, chil-
izing symptoms, emotion, cognitive self-regulation skills, dren learn from a young age to avoid peers who display ex-
cognitive development, maternal attachment, BMI, and treme emotions, and consequently children who are unable
family characteristics and was consistent across main and to regulate emotions often struggle to develop peer relations.37
sensitivity analyses. We did not find consistent evidence of Poor social competence and emotional control can lead to being
an association across main and sensitivity analyses when bullied,38 a risk factor for eating disorders in young people.39
investigating emotion regulation difficulties at 3 years of The ability to regulate emotions also helps individuals cope
age as the exposure. with negative experiences and fosters resilience in stressful

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 Research Original Investigation Emotion Regulation Trajectories in Childhood and Anorexia Nervosa in Early Adolescence

situations.40-42 In adolescence, when peer relationships be-
gin to play a key role in an individual’s life, the lack of such skills
could lead to feelings of anxiety and consequently to devel-
oping coping strategies such as emotional avoidance, which
are common clinical observations in this population.43
Limitations
This study has some limitations. The MCS did not collect in-
formation on binge eating and purging behaviors. Hence, we
cannot exclude that some participants whom we classified as
having symptoms of broad anorexia nervosa could have had
bulimia nervosa or binge eating disorder, although at this age,
this is likely to be a minority of adolescents.44 Also, some ado-
lescents with broad anorexia nervosa at 14 years could have
later transitioned to a different eating disorder, as this is of-
ten observed in clinical samples. Future studies should aim at
capturing whether emotion dysregulation is a shared or spe-
cific risk factor across diagnoses.
The question on weight perception does not include a
qualitative element (ie, whether the adolescent is happy or not
with their perceived weight) and that on body image is not
weight or shape specific. To capture adolescents who were dis-
satisfied with their weight, we included only those who over-
estimated their weight and also scored higher than the me-
dian sample value on the body image question. This choice
should have restricted our definition to adolescents with more
severe weight and shape concerns.
We made our causal assumptions around confounder ad-
justment explicit by using direct acyclic graphs, and we were
able to adjust for most variables that we had identified. How-
ever, we did not have data available on possible confounders
such as parental emotion regulation and genetic factors.
Residual confounding may explain our results. Although this
can never be excluded entirely as a possibility, we observed
minimal change in the magnitude and strength of the asso-
ciation between the univariable and the multivariable mod-
els, thus providing some reassurance around the robustness
of the results.
As is common in longitudinal cohort studies, this study was
affected by some degree of attrition. Nevertheless, our main
analyses—based on participants with complete exposure—
included most of the sample (85.7%). Furthermore, when we
compared the results from these models with those of com-
plete case analyses and analyses imputing only confounders,
our results remained largely consistent.
Conclusions
This cohort study found that difficulties in developing age-
appropriate emotion regulation skills in childhood were asso-
ciated with experiencing broad anorexia nervosa in adoles-
cence. If the associations we observed were causal, universal
interventions fostering skills for emotion regulation in this age
group, such as building tolerance for uncomfortable feelings
and learning how to overcome frustration, could have a pre-
ventative role in the emergence of eating disorders and other
mental health problems with an onset in adolescence.

ARTICLE INFORMATION
Accepted for Publication: May 6, 2021.
Published Online: July 7, 2021.
doi:10.1001/jamapsychiatry.2021.1599
Author Contributions: Dr Solmi had full access to
all the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Concept and design: Henderson, Flouri, Srinivasan,
Solmi.
Acquisition, analysis, or interpretation of data:
All authors.
Drafting of the manuscript: Henderson, Flouri,
Harrison, Gemma Lewis, Stafford, Solmi.
Critical revision of the manuscript for important
intellectual content: Henderson, Bould, Flouri,
Gemma Lewis, Glyn Lewis, Srinivasan, Warne,
Solmi.
Statistical analysis: Henderson, Flouri, Gemma
Lewis, Glyn Lewis, Solmi.
Obtained funding: Solmi.
Administrative, technical, or material support:
Henderson.
Supervision: Harrison, Glyn Lewis, Stafford, Solmi.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported
by Sir Henry Wellcome fellowship 209196/Z/17/Z
(Dr Solmi) and grant 211163/Z/18/Z (Dr Srinivasan)
from the Wellcome Trust; grants MR/S019707
(Dr Harrison) and MR/S020292/1 (Drs Warne and
Bould) from the Medical Research Council/Medical
Research Foundation; and the University College of
London Hospital National Institute for Health
Research Biomedical Research Centre. The
Millennium Cohort Study is funded primarily by the
UK Economic and Social Research Council with
cofunding by a consortium of UK government
departments.
Role of the Funder/Sponsor: The sponsors had
no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Data Sharing Statement: The Millennium Cohort
Study data are available free of cost to researchers
from the UK Data Service website (https://www.
ukdataservice.ac.uk/).
Additional Contributions: We thank the
Millennium Cohort Study families who voluntarily
participate in the study and a large number of
stakeholders from academic, policy-maker, and
funder communities and colleagues at the Centre
for Longitudinal Studies involved in data collection
and management of these cohort studies.
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