National surveys estimate that nearly 20 million females and 10 million males will have an eating disorder at some point in their lives, according to the National Eating Disorders Association. And when most eating disorders get diagnosed? “Between the ages of fourteen and eighteen,” says Joanna Steinglass, M.D., associate professor of clinical psychiatry and director of translational research in eating disorders at the Columbia Center for Eating Disorders. “There are some reports that people are noticing and diagnosing and getting kids to treatment even earlier, which may be a sign that parents are getting more informed.” In fact, NEDA cites an increase in the diagnosis of children, some as young as 5 or 6.
Eating disorders are mental illnesses that are serious and can be treated, though it’s unclear for certain why they occur. Some factors include body image issues, self-esteem issues, being bullied about looks, the need to control something in his life, and societal pressures for looking like the actresses and models she sees on TV, in magazines, and in the movies. There is also a possibility that eating disorders could be genetic. Studies have found that having a parent or sibling with an eating disorder increases a child’s risk of developing one, according to NEDA.
And while the Internet and social media may have a negative role in eating disorders, a lot of celebrities and “regular people” have used various platforms to talk about their experiences with eating disorders, including Sadie Robertson of Duck Dynasty and Dancing with the Stars, who wrote about her eating disorder on her blog Live Original; actress Troian Bellisario, known as Spencer Hastings on FreeForm’s Pretty Little Liars, who wrote about her eating disorder for Lena Dunham’s Lenny Letter; and pop star Kesha, who wrote some of the songs on her new album during a three-month stay at an impatient facility for women with eating disorders, addictions, mood disorders, and trauma while getting treatment for “an eating disorder that nearly killed her,” according to her recent Rolling Stone profile.
With eating disorders being talked about more and more often, parents may be left wondering whether their child has one, what the signs are, and how they can support him.
Eating Disorders Explained
“I think it’s probably most helpful for parents to know that there are a lot of different ways that eating disorders can present themselves,” Dr. Steinglass says. “It may be more important to have a sense of whether something feels like it’s not quite right and let the doctors figure out what the right name for it is.”
While a medical professional should do specific diagnosing, it may be helpful for parents to know about the various eating disorders and how they typically present.
A person with anorexia generally restricts the number of calories and the types of foods she eats, according to NEDA. Typically someone with anorexia is of low weight and is restricting his eating to the point where if he is growing, he’s not gaining weight, so he becomes thinner and more out of his range for expected weight and height, says Michelle Miller, Psy.D., a psychologist at the Child Study Center at NYU Langone Health. Alternatively, if she’s stopped growing and stays at the same height, her weight is going down.
“That is all due to restriction of eating that’s related to control, which may be a concern about weight or body image. Some individuals may be over concerned about a health focus as well. They feel that every food has to be ‘healthy,’ and so they’ll only eat certain types of food to maintain that,” Dr. Miller says, adding that an individual with anorexia may engage in compensatory behavior such as self-induced vomiting, using laxatives, or excessive exercising to address their concerns about body image and compensate for what he has eaten.
An individual with bulimia will go through periods of two hours or less during which she eats an amount of food that is larger than what one would expect to eat in that period—and feels she has no control over the behavior. After that period of time, she engages in a compensatory behavior to “undo” the effects of binge eating, according to Dr. Miller.
Binge Eating Disorder
Like with bulimia, an individual with binge eating disorder consumes a large amount of food in a short period of time. However, unlike with bulimia, compensatory behaviors are not present, and patients will typically present very overweight, according to Michele Calderoni, D.O., who specializes in adolescent medicine at Crystal Run Healthcare.
While we all have occasional periods of time when we might eat more, such as a dinner out with friends or at Thanksgiving, “when they do it, they feel a lack of control in the episode, like they can’t stop eating,” Dr. Miller says. “They’ll eat until they feel extremely, uncomfortably full, and they keep eating even when they’re not physically hungry. They also may eat alone.”
Avoidant / Restrictive Food Intake Disorder
Previously referred to as Selective Eating Disorder, ARFID is similar to anorexia in that it involves limitations to the amounts or types of foods consumed, but it does not involve concerns about body shape or size, according to NEDA.
A person with ARFID is “avoiding whole food groups not because of fear of weight gain or body image concerns or a need for control, but because of a lot of sensory difficulties, because they have low interest in food, and/or because they’re concerned with having negative consequences from eating, such as feeling so uncomfortably full that they’re nauseous or they’re afraid of throwing up,” Dr. Miller says. “The condition usually starts early on, so it’s not something that we would typically see as developing later. You see it usually starting in childhood and they become pickier and pickier as they get older and start getting more and more anxious around food.”
Those with rumination disorder regurgitate or vomit food, chew it, and swallow it, and there is no known gastrointestinal etiology, Dr. Calderoni says. “I actually have a patient right now who has this. She has had a full GI workup, and we can’t find any reason for her vomiting. It can happen any time on any day. There are no real triggers or explanation…and there are no electrolyte abnormalities that correspond and no physiological abnormalities that correlate,” she says. “[Rumination disorder] is very rare, but we do see it from time to time.”
Although it’s not formally recognized in the DSM, awareness of orthorexia—a fixation on so-called “healthy eating” that a person damages his or her own well-being—is on the rise, according to NEDA.
Other Specified Feeding and Eating Disorder
Previously known as Eating Disorder Not Otherwise Specified, OSFED is considered a “catch-all” to classify eating disorders that do not meet the criteria for anorexia or bulimia, according to NEDA. “It’s a huge category, which we all hate to use, but sometimes it really is the only diagnosis that encapsulates what’s going on at the time,” Dr. Calderoni says. “But we try very hard not to put our patients in that category.”
Signs of an Eating Disorder
The main signals for parents that their child may have an eating disorder are changes in behavior of eating, changes in behavior of physical activities, or changes in weight, Dr. Steinglass says. As an eating disorder progresses, you may start to see your child isolate himself, and see mood changes.
Typically with anorexia, a child will become preoccupied with what foods she is eating, a decrease in the amount of food she is eating, she may push food around the plate, or make excuses as to why she can’t eat.
“Bulimia and binge eating disorder are a little trickier to recognize because they’re often done in secret,” Dr. Miller says. Another possible sign of binge eating disorder or bulimia is if quantities of food disappear over an evening or a short period of time, Dr. Calderoni adds. Other possible signs of bulimia include frequent use of the bathroom immediately after meals, signs of vomiting or laxative use, and tooth decay from vomiting frequently.
“And I think with all of these conditions, except with ARFID, you’re hearing concerns about how they look and what they’re eating and complaints about their weight,” Dr. Miller says.
Talking to Your Child About Eating Disorders
If you suspect your child may have an eating disorder, it’s best to approach him in a nonjudgmental way. “I think it’s really wise to sit down with your child and ask your child very nonjudgmental questions about their health and how they’ve been feeling. I think you need to make it nonjudgmental because you want your child to trust you and to feel that they can tell you what’s going on because many kids will try to hide this,” Dr. Calderoni says.
“You can comment that you may have noticed changes or things they’re saying about themselves or things about their eating that made you concerned,” Dr. Miller says, adding to be cautious if your child is showing signs of bulimia or binge eating as those conditions are associated with a lot of guilt. “So going about it like, I’ve noticed you’ve been stressed around your eating, and I want to see if there’s a way we can help you feel better,” she says.
As with any medical diagnosis, it’s important to see a doctor to get your child evaluated. “It’s good to go to a doctor to get a health workup to see if there’s anything going on with [your child’s] health, and rule out any cause that is unrelated to eating. I’d also recommend getting an evaluation through a psychologist or psychiatrist who specializes in eating disorders to help identify if it is an eating disorder before jumping to any conclusions,” Dr. Miller says. “If it is identified as an eating disorder, either through a physician or a therapist, then the next step would be to make sure the child is enrolled in treatment. Eating disorders can be very complex and is not something you should try and fix outside of therapy.”
Treatments for Eating Disorders
Across the board, “parents play a huge role in helping kids get out of an eating disorder and they may need to take a big role in figuring out how to get their kids back on track with normal and healthy eating,” Dr. Steinglass says. “The kinds of treatments that tend to be helpful are things that have a real emphasis on seeing change in behavior and paying attention to what’s actually happening with eating and normalizing eating. That can occur in all kinds of settings and all kinds of different ways,”
While specific treatment plans will vary depending on the child and the eating disorder, there are a few techniques medical professionals employ when treating a child or teen with anorexia, bulimia, binge eating disorder, or ARFID.
With this approach, your child will have a three-person treatment team: a medical provider, a nutritionist, and therapist. “Eating disorders are multi-factorial and the treatment has to be tailored to each of these components,” Dr. Calderoni says. The medical provider identifies the medical consequences of an eating disorder and ensures the patient is physically and medically safe. The nutritionist ensures adequate nutrition is part of the treatment plan. “It’s important to have somebody who understands nutrition from a macro- and a microelement perspective, and who also understands eating disorders,” Dr. Calderoni advises. The therapist addresses the mental health piece of the eating disorder. “Again, it should be a certified eating disorder therapist. That’s very important as well because there are triggers and other behaviors that are just really not understood by all therapists,” she adds. This approach is very individualized, meaning the child is the one who works with the medical provider, nutritionist, and therapist.
Unlike with the multi-disciplinary approach, parents are heavily involved in FBT, which can be used to treat adolescents with anorexia or bulimia. Families work with an FBT therapist through three phases of treatment. During phase one, the parents have complete control over what the child eats—the parents plan, serve, and supervise all meals. In phase two, the patient gradually gains control over mealtimes—deciding what, when, and how much to eat. In phase three, the FBT therapist works with the family in addressing other issues in adolescent development as needed, according to Dr. Calderoni.
Off the C.U.F.F.
Developed for treating ARFID by Nancy Zucker, Ph.D., a child and family psychologist, eating disorder specialist, and director of the Duke Eating Disorder Center, C.U.F.F. stands for clear, undisturbed, firm, and friendly. This program provides practical strategies to help parents deal with their child’s eating behaviors.
When treating a child with ARFID, “it’s important that parents use different terms that are very clear and specific around what they want their child to eat and how much of it while remaining as calm and undisturbed around their child as possible,” Dr. Miller says. “That they’re being very firm in what they want their child to do, but they also have moments where they’re doing positive things with their child unrelated to food because often times when a child has an eating disorder, it can become the sole focus for the family. So we want them to do things with each other outside of the eating disorder.”
Physical and Mental Health Risks of Eating Disorders
Eating disorders have a number of associated physical and mental health risks.
Eating disorders can: cause abnormalities in electrolytes; cause changes in potassium, phosphate, and magnesium; affect bone marrow and white blood cell count; put a young adult at risk for a heart attack; and affect growth. They can also compromise fertility and reproductive systems. “In young girls, they either won’t get their period, or if they were getting a period, their periods will go away, and when we look at the hormones that correlate with cycling normally—LH, FSH, and estrogen—those hormones are decreased. In young boys or young men, testosterone will also become decreased,” Dr. Calderoni says. The decrease in estrogen and testosterone affects bone density.
Bulimia affects tooth health, while those with binge eating disorder are at risk for obesity. And “the starvation that comes with anorexia nervosa has one of the highest mortality rates of any psychiatric illness,” Dr. Steinglass says.
As a result of a malnourished brain, individuals with eating disorders may also experience depression, anxiety, irritability, inability to sleep, cognitive impairment, and decrease in memory and attention, Dr. Calderoni says. And social anxiety and obsessive-compulsive disorder are common in those with anorexia, according to Dr. Miller.
Reducing the Risk of Eating Disorders
While there are no sure-fire ways to prevent children from developing eating disorders, there are things parents can do at home to reduce the risk of their child developing one.
The experts we spoke with agree that families should not talk about food in terms of good and bad or healthy and unhealthy, and instead focus on having a balanced diet and moderation in meals. “Teach your child that having fruit one night and having ice cream one night for dessert is okay,” Dr. Calderoni says. “What I find is if you tend to have a very restrictive food environment at home, many times these kids become binge eaters or they learn that being restrictive is the way to eat.”
Other things that can help reduce the risk are: have family meals together as often as possible, keep conversations during family meals positive, and make sure meals include a variety of foods, Dr. Miller says.
Dr. Steinglass advises parents also keep the focus on body wellness—how your body can be healthy for you—rather than body image or size.
“I also think families should try to not use negative terms like ‘chubby,’ or ‘you have thick legs,’ or ‘you’re built like Grandma, who is three-hundred pounds.’ I think staying away from comments about their bodies and body types is really important,” Dr. Calderoni adds. “We’re all born differently. Sometimes you do get one kid in the family that’s a little heavier than everyone else. It’s just best to not really talk about it. When you go shopping for clothing, try to stay away from sizes and comparison between children and not be so concentrated on what size your children are. Just love your child for who they are.”