Throughout elementary school, Alexis was a star of her community swim team. But after she got her period, she didn't like the way her figure started to change. She was still slim and fit, but her new curves made her uncomfortable, and she felt self-conscious in her swimsuit.

She stopped eating bread and pasta and started skipping lunch - sometimes breakfast, too. She ran two miles every morning before school. She felt tired all the time, and her grades suffered, but as long as she was losing weight, she was happy. When her pediatrician discovered Alexis had lost 12 pounds in a year, the doctor informed Alexis' parents that their daughter met the criteria for a diagnosis of anorexia nervosa, an eating disorder.

Alexis' experience is one that is common among the young people I treat in my psychiatry practice. American popular culture presents mixed messages about food and weight. Tantalizing ads for fast food and sweets are seemingly everywhere, while fashion models starve themselves, and fat shaming is common. In my practice, patients often express a fear of becoming obese. Our alarmist culture exacerbates these responses to what may be perfectly normal weight gain.

For children and adolescents already struggling with body image in puberty, this presents additional challenges and self-doubt. Am I thin enough, or am I too thin? Do I have enough muscle, and is it in the right places? In children like Alexis, worries about appearance become a major preoccupation, and their self-image becomes distorted in a quest for unattainable physical perfection.

Eating disorders like anorexia nervosa and bulimia, which at one time affected mostly teenage girls and young women, are now seen in preteens - and increasingly among boys. Male adolescents are comparing themselves to models and celebrities, becoming anorexic out of a desire for the long and lean physique they see in Abercrombie ads and in the pages of GQ.

Left untreated, eating disorders can segue to serious illness, including heart disease, and can be fatal in extreme cases, in some by leading to suicide. Girls can stop having periods because the body reacts to severe stress by diminishing key hormones in the brain, causing drops in estrogen. This leads to decreased bone density, causing early bone loss. Some of the damage from these conditions cannot be reversed. And this is on top of the tremendous emotional toll these all-consuming conditions take.

Subtle Signs

Eating disorders fall under one of two main categories: anorexia nervosa, in which a person severely restricts calorie intake to meet an internalized standard of thinness; and bulimia, in which a person experiences a burst of overeating and then tries to purge the body of the food. In both conditions, the patient feels out of control and focuses on food as a way of exercising some control.

In bulimia, the patient binge eats compulsively to assuage emotional discomfort, then feels guilty and atones by vomiting, taking laxatives or abusing diet pills. Some may react by severe restricting after binging. Other binge-eaters don't necessarily purge or restrict afterwards, and they gain weight from this out-of-control emotional eating.

Anorexia affects as many as 10 percent of young females. The signs can be subtle, and the disease may start innocently, with a child just trying to "eat healthy." It's when that good intention becomes an obsession, when the youngster weighs serving portions or refuses to eat entire food groups, that this eating behavior shows signs of being a serious problem.

I have seen young patients completely cut out carbohydrates or fats to lose weight. This is dangerous, because a young brain starved of these important nutrients will undergo organic changes, some permanent.

I am also seeing more awareness of a new diagnostic category known as "avoidant restrictive food intake disorder," or ARFID, what parents might pass off as "picky eating." What we now understand is that in some extreme cases of picky eating, these young children have too many taste buds or strong taste receptors on their tongue, which make them overly sensitive to certain textures and flavors. Picky eating is not something we normally think of as an eating disorder, but it does cause challenges at mealtime. When it affects a child's growth and development, it's important to consider ARFID, as these children may go on to develop another eating disorder, such as anorexia or bulimia.

What to Watch For

In addition to noticing sudden weight loss, parents should be alert to signs that their child's attitude toward food is changing. Children who start restricting food intake - whether by eliminating entire food groups, like carbohydrates or fats, skipping meals or becoming overly focused on portion size - may be struggling with an eating disorder.

I had a patient who weighed herself multiple times each day, congratulating herself when her weight was down, even by half a pound, and berating herself when the number went the other way. Exercising to excess, using laxatives to lose weight and vomiting after meals are all signs that your child may have an unhealthy relationship with food.

Children with eating disorders often lose interest in activities that once were important to them. They complain about feeling fat or unattractive, and may have digestive or dental issues due to their unhealthy habits. In fact, changes in the mouth - such as bleeding of the gums, mouth sores, weakening of the teeth and enlarged salivary glands - are often the first physical signs of an eating disorder.

Because some activities, such as ballet, running and gymnastics, emphasize leanness, participants might be at increased risk for developing the disorder. As a rule, athletes need to consume more calories, not fewer, to replenish the fuel they burn with exercise.

There are many factors that go into why someone develops an eating disorder, but researchers have determined that genetics play a role, especially when it comes to a tendency to have a distorted body image. Perfectionism in general - in children or in their parents - has been linked to the onset of eating disorders in young people. A perfectionist streak may also be an inherited trait, and this is something researchers are continuing to explore.

It appears that these inherited tendencies emerge during puberty and are amplified by hormonal triggers and societal pressures.

What Parents Can Do

If you suspect that your child has an eating disorder, share your concerns with your pediatrician. He or she will help you decide your best course of action. Severely underweight patients might need hospitalization to allow the child's nutrition and weight to be carefully managed by professionals.

Many adolescents also suffer from other problems, including depression, anxiety and substance abuse. It is important to recognize and get appropriate treatment for these issues as well. We still have much to learn about eating disorders, but excellent treatment is available from qualified specialists. Many treatment plans combine both inpatient and outpatient therapy and treatment.

Youngsters with anorexia often benefit from family therapy, and the most important component is expectation setting in parental education. This is key because, often, attitudes about stress management and food are shaped at home during childhood. While medication can be helpful, children with bulimia and anorexia often respond to cognitive behavioral therapy combined with group therapy. For both bulimia and anorexia, recovery can be a long road, with relapse a genuine risk.

As a parent, it's useful to examine your own parenting style. I have two children, and I know how difficult it can be to balance high expectations with unconditional love. We know that anxious parents send unintentional signals that there is a lack of safety and control. This unfortunately may bring out the worst in youngsters, often exacerbating whatever insecurities they already have.

Setting healthy expectations is an art form. Parents shouldn't enable a child to underperform just to avoid stress. However, setting standards that might be too high for your children can equally be counterproductive, and it puts them at risk for eating disorders and other health problems. Food issues are often a way of rebelling against rigid parenting and the pressure to overachieve.

Let's rid our vocabulary of words like "diet," and not categorize foods as "good" or "bad." Encourage your children to enjoy a variety of foods in moderation. Be a role model in this, and don't be too focused on your own body shape or appearance.

Adolescents are naturally narcissistic as part of their development to allow them to differentiate into their own healthy adult selves. They need encouragement and positive feedback from the adults around them, along with the freedom to try new things and make mistakes along the way.


Humaira A. Siddiqi, M.D., is Chief of Psychiatry with Mid-Atlantic Permanente Medical Group. She graduated from the Baqai Medical College in Karachi, Pakistan, and completed her residency in psychiatry at St. Elizabeth's Hospital in Washington, D.C. She sees patients at the Kaiser Permanente Burke Medical Center.