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.
