Eating Disorders

A Parents' Guide, Second edition

Rachel Bryant-Waugh, Bryan Lask

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135067694
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Eating problems are common in children and teenagers. Yet myths about such problems abound and it can be very difficult to separate the facts from popular beliefs; unusual or disturbed eating patterns can be understandably bewildering and distressing for parents.

Whatever aspect of your child's eating behaviour is causing you concern, this book will help you understand some of the more common reasons why problems arise, and will give you advice on what you and others can do to manage the situation.

Written by two experienced clinicians, this new edition of Eating Disorders: A Parents' Guide is dedicated to clarifying the subject of eating disorders. Combining an accessible and straightforward introduction to the subject with practical advice, this book represents the first step towards recognising, understanding and dealing with the problem.

Case-studies are used to help parents understand their children's experiences of this complex and challenging subject and sensitive advice is offered on a range of issues, including:

• how to identify a complete range of eating difficulties
• how to approach specific problems
• where to seek help and treatment.

This book will be welcomed by anyone who is concerned about the eating habits of their children and will be invaluable to professionals working with those suffering from eating disorders.

Chapter 1

What are eating disorders?

There is a wide range of eating patterns in childhood and adolescence. Only a few of these are really problematic and most would not constitute an ‘eating disorder’. Many children’s eating patterns cause concern to their parents at some stage and yet these are usually just normal phases of development. For example, most toddlers go through a phase of food faddiness during which they will eat only a very narrow range of foods, possibly just three or four different foods. As long as they take in enough calories to avoid feeling hungry, and are growing normally, they are eating adequately. No harm comes to them and the vast majority will move on to normal eating in due course. A few children persist with their faddiness over the years and we will discuss these later in this chapter (see pp. 16–18).

Many children in their pre-school years go through a phase of quite restricted eating. Not only may the range of foods be narrow but also the amount eaten is small. It is surprising how such children manage to thrive because they seem to defy conventional wisdom about calorie requirements. In general, adults need to balance calorie intake with calorie expenditure to maintain a steady weight. Children need to take in more calories than they use up as they need the extra to grow. Yet some pre-school children really do seem to have an inadequate intake. Despite this they seem to have far more energy than their parents and are clearly not experiencing any harm. Again, this pattern tends to resolve with time and only a few children persist with such restricted eating (see pp. 18–20).

Another phase worthy of mention is that noted in many adolescents, during which they eat vast quantities of food. Indeed, at times they hardly seem to stop eating; having just finished one meal they launch into a large snack, which is repeated just before starting another meal, and so on. The two snacks do not interfere with the next meal. This is again usually simply a phase, presumably linked to the adolescent growth spurt when many more calories are required. This normal adolescent behaviour differs from that seen in some children who persistently overeat throughout their childhood. Almost always such children are overweight. We discuss this group below (see pp. 22–23).

The examples given above represent the varying patterns of eating seen during childhood and adolescence, none of which is in itself abnormal or harmful. It is understandable that parents often become concerned about something as fundamental as their child’s eating habits. Is she getting enough of the ‘right’ sorts of food? Is he eating too much or too little? Such concerns can be picked up by the child and may in some cases contribute to the continuation of difficult or worrying behaviour that might otherwise have been short-lived or unproblematic. As a general rule, if children are growing as expected and seem generally healthy and settled, variations in diet and eating patterns should not be a reason to worry.

What, then, constitutes a real cause for concern and, specifically, when does difficult eating become an eating disorder? In fact, the terminology is quite confusing because often eating disorders have as much to do with a negative and distorted view of oneself as with food and eating. People with eating disorders tend to be very critical of themselves, thinking that they are useless or not particularly worthwhile. This self-disparagement manifests itself through dissatisfaction with appearance, shape and size, and this dissatisfaction in turn leads to abnormal eating behaviour, which becomes problematic. This is already beginning to sound quite complicated, so let’s take a step back and consider in turn the specific eating problems of childhood and adolescence. The conditions which we will discuss are:

• anorexia nervosa

• bulimia nervosa

• selective eating

• restrictive eating

• swallowing phobia

• food avoidance emotional disorder

• compulsive overeating.

Anorexia nervosa

Anorexia nervosa is perhaps the best known of the eating disorders. The term actually means ‘nervous loss of appetite’ but this is misleading because people with anorexia nervosa do not have a true loss of appetite; indeed they may have good appetites. The disorder is characterized by a strong drive to lose weight, and children with anorexia nervosa develop an ability to override and block out their feelings of hunger. This seems quite extraordinary to most people, as satisfying hunger pangs is a basic human instinct. People with anorexia nervosa will avoid eating whenever they can, and when eating is unavoidable they will try to eat as little as possible either in real terms or in calorific value. Because hunger does not disappear, the temptation to eat can sometimes be so strong that the young person ‘gives in’. She will then feel dreadful for having done so, and there can be an overwhelming need to get rid of what has just been eaten. This can lead to the girl making herself sick, taking laxatives or exercising excessively. If a girl’s periods had started before she developed anorexia nervosa, they will stop (we return to this in Chapter 3).

Anorexia nervosa has in the past sometimes inappropriately been called the ‘slimmer’s disease’. This is also misleading because it is not simply an extreme form of slimming or dieting somehow ‘gone wrong’. Although these behaviours share the aim of losing weight, the vast majority of people who go on a diet do not develop anorexia nervosa. It is not just about ‘successfully’ restricting food intake; this is certainly a key aspect but one that overlies deeper problems and concerns such as an intense fear of gaining weight and getting fat, a very distorted view of one’s body and the general self-disparagement we have already mentioned.

Susie, aged eleven, had always been a happy, healthy girl, albeit slightly perfectionist and rigid in her approach to life, attending to the fine detail of whatever she did. She liked looking at her mother’s magazines and carefully read all the tips about health and beauty. Recently she had begun to feel unhappy with the way her own body looked compared to the pretty models she saw in the magazines and decided that she should put a bit more effort into losing some weight and staying healthy. She announced that she was too fat and was going to go on a diet. Her parents didn’t take this too seriously at first, Susie looked fine to them, and they thought she probably would not be able to stick to a diet anyway. They began to get a bit annoyed at the way Susie insisted on choosing all the food for family meals and participating in their preparation. She became so angry and upset when her mother tried to stop her, or cooked something when Susie was out, that her parents began to get quite worried. It seemed easier for everyone to let her do what she wanted as no one in the family liked the shouting and arguing that was beginning to happen every evening. Susie would enthusiastically help serve the meals but ate very little herself. She began to make negative remarks about herself as a person, and about her body in particular. She started weighing herself two or three times a day. Her parents’ attempts to reassure her and to encourage her to eat more led to tantrums and tears, with Susie screaming that she was already too fat and that she felt disgusting. She started losing weight quite rapidly. She seemed increasingly confused and was totally unaware of how unwell she had become. Nothing Susie’s parents did or said seemed to help and eventually, feeling completely helpless, they sought help from their family doctor.

It can be seen from this example that Susie had far more of a problem than just dieting or ‘slimming’. ‘Normal’ dieters stop dieting once they have lost some weight or, more usually, once they have got fed up with being on a diet; they certainly do not suffer from the very poor self-image so characteristic of people with anorexia nervosa. Susie manifested the characteristic features of an eating disorder, namely an extreme preoccupation with weight and shape, a distorted view of her body and a very poor view of herself, in addition to abnormal or inadequate eating. She genuinely believed she was fat and saw herself as overweight and disgusting, despite having lost a worrying amount of weight, and was extremely fearful of putting on more weight. In other words, abnormal eating is only one aspect of an eating disorder. People with anorexia nervosa often have perfectionist tendencies, are somewhat inflexible, and sometimes so fine-detail focused that they occasionally miss the big picture. They are inclined to set themselves high standards, which they work hard to achieve. As the illnees progresses they become increasingly irritable and confused. Susie showed many of the features of childhood-onset anorexia nervosa.

Anorexia nervosa usually develops in girls and young women between the ages of fifteen and twenty-five, at an estimated rate of around one in every 200 females in this age group. However, it can also occur in children; the youngest we have seen with true anorexia nervosa being only seven years old. Although this is rare, we are no longer surprised when we do see such young children with this worrying problem. It occurs far more often in girls, with fewer than 5 per cent being boys. These children come from all different kinds of families in terms of race, religion, wealth and parental occupation.

It will be evident from Susie’s story that anorexia nervosa is an illness that can seem to have little logic. People with anorexia nervosa think they are fat when they are thin, full when they are empty, failures when they are successful, useless when they are useful, obsessed with food but avoid it, and see many advantages to being very thin despite all the dangers. It can be helpful to be aware that this apparent lack of logic is part of the illness and cannot be easily changed by normal reasoning. The child with anorexia nervosa will truly believe she is fat, ugly and useless, however unlikely or ridiculous that may seem to everyone around her.

Bulimia nervosa

The other well-recognized eating disorder is known as bulimia nervosa. ‘Bulimia’ means ‘ox hunger’ and refers to the fact that people with bulimia nervosa appear to have ravenous appetites. This is manifested by their tendency to engage in frequent binges, feeling they have lost control and eating quantities of food at one time that a ‘normal’ eater would consider to be excessive. During such episodes they may consume three or four times as much food as most people would eat in one meal, or sometimes even more. They may eat unusual combinations of things, such as peanut butter and ice cream, or they may eat large quantities of the same thing, for example two packets of chocolate biscuits. They feel deeply guilty and disgusted with themselves and almost always try to get rid of the food by making themselves sick. Occasionally, they may also use laxatives or other pills in an attempt to control weight gain, or they might try to go for long periods of time without eating anything at all. People with bulimia nervosa have the same deep-seated dissatisfaction with themselves as those with anorexia nervosa. They share a preoccupation with their weight and shape and judge their self-worth by the way they think they look. They are usually extremely self-critical in this respect and suffer from feelings of worth-lessness. People with bulimia nervosa are often of normal weight, so their eating difficulties may be less apparent to the onlooker than is the case with the obvious weight loss accompanying anorexia nervosa, or their weight may fluctuate far more than is usual. In girls who have started menstruating, periods may become irregular or even stop completely.

Fran, fifteen, had always been an outgoing, gregarious and somewhat impulsive girl. She started going out with boys when she was thirteen and had occasionally found herself in difficult situations. She also started experimenting with drugs and frequently drank alcohol. Her parents had been unaware of any of this, despite keeping what they believed to be a close eye on her. One night her mother found her sitting on the floor in the kitchen with the light off, eating food straight out of the fridge. When her mother asked what on earth she was doing, Fran ran upstairs screaming at her mother to mind her own business. She locked herself in the bathroom, where her mother could hear her retching and vomiting. Fran’s mother felt confused and frightened; she did not understand what was happening to her daughter. Fran eventually emerged from the bathroom looking pale and unwell and they went downstairs to talk things over. She admitted that she had been doing this for several weeks, that the episodes occurred mostly when she was feeling upset, and that she absolutely hated herself.

Many young people with bulimia nervosa behave in ways similar to Fran. They worry intensely about their weight and shape, try hard to diet but binge regularly, feeling they have no control over these episodes. They then use vomiting, laxatives or exercising to control their weight, and sometimes a combination of all three. This can be very dangerous indeed (see Chapter 3). They differ from those with anorexia nervosa in that they tend to maintain their weight at a relatively normal level, or may sometimes be overweight. Young people with bulimia nervosa may not, on the surface, have the perfectionist tendencies commonly associated with anorexia nervosa and they may be more likely to engage in risk-taking behaviours such as experimenting with drugs, excessive drinking and unprotected sex. Almost always, these behaviours are related to feelings of self-dislike and feeling out of control, and are aggravated by low mood.

Bulimia nervosa is rare before puberty and we have seen very few such children. However, once into adolescence the incidence increases and it probably affects around 3–4 per cent of teenage girls; it is rarer in boys, but does occur.

Selective eating

‘Selective eater’ is a term used to describe a child who will only eat a very restricted range of foods. Such children seem not to outgrow the normal developmental phase of food faddiness seen in younger children. They persist in eating only a very narrow range of foods, often as few as five or six. These foods tend to be carbohydrate based, although there may be some variation. Such children are averse to trying new foods and cannot usually be persuaded to do so under any circumstances. They may retch or appear to be going to be sick when confronted with new foods, although they clearly have no difficulty at all swallowing and keeping down their preferred foods. Surprisingly, they tend to thrive, usually being of normal height and of a reasonable weight. However, in some cases, particularly in children with long-standing, markedly restricted diets, weight may be higher or lower than normal, depending on the constituents of the diet. In general though, selective eaters do manage to obtain adequate calories, and the fact that they are generally healthy suggests that they are obtaining all the necessary nutrients. Even though at first glance their diets may appear rather unhealthy, most selective eaters will take sufficient amounts of the major food groups. There is sometimes a history of a close relative having had similar problems in childhood.

Sometimes selective-eating problems form part of a wider pattern of behaviour. A few children are very resistant to new experiences of any kind, preferring instead to stick to what they know. Such children do not like their routine to be disrupted, find new faces and places difficult to tolerate, or may become distressed at having to wear new clothes. They also find it difficult to make friends. These behaviours form part of a spectrum of behaviours associated with autism, autistic tendencies and Asperger’s syndrome. Selective eating can sometimes be a reflection of the insistence on sameness and absence of risk-taking behaviour associated with this spectrum. If you think your child might fit into this spectrum, don’t hesitate to consult your doctor to discuss your concerns further.

Medical investigations of selective eaters rarely reveal anything unusual or any underlying problems and these children usually tend to function quite normally in other respects. They do not seem to have many more problems than other children, although they can sometimes experience difficulties with friendships. Unlike children with anorexia nervosa and bulimia nervosa, they are not preoccupied with their weight and shape, do not have distorted views about their own body size and do not suffer from particularly low self-esteem. Most commonly it is the parents who are concerned about growth and social development. We usually see such children between the ages of about seven and eleven, when they are beginning to mix more with other children and the parents are worried not only about their health but also about the social implications of such narrow eating.

Younger children can usually get away with faddy eating habits but as school and social eating become more a part of life, the selective eater may become more isolated socially.

Rosie, eight, would eat only peanut-butter sandwiches, French fries, crisps, bananas and baked beans, and she would only drink water and chocolate milkshakes. She had stuck to the same foods for a number of years and was even particular about different brands of the same food. Her mother knew what to buy and her older brother and sister were so used to her fussy eating that they no longer noticed it. Rosie’s grandmother and aunt had frequently expressed their concern in family discussions and although Rosie’s parents agreed that it wasn’t right, they really did not know what to do. Every time they tried something new, Rosie became very upset and said she was going to be sick. Despite trying every way they could think of to encourage Rosie to eat a wider range of foods, her parents had not had any success at all. Despite this she was growing normally, was not underweight and was otherwise happy and contented. She was doing well at school and had many friends. Rosie’s parents finally sought help after she had spent a tearful weekend at the prospect of going to a school friend’s house for tea and had refused an invitation to stay overnight with her best friend. Rosie’s eating habits were now clearly interfering with her social development, stopping her from participating in activities that other girls of her age would normally enjoy.

This is a fairly typical manifestation of selective eating. The main problem is often the social restriction imposed, which often leads to a request for help. Having now seen a large number of such children and followed their development, we have concluded that in the majority...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• About the authors
• List of illustrations
• Foreword
• Acknowledgements
• Introduction
• 1 What are eating disorders?
• 2 What causes eating disorders?
• 3 How do I know if my child has an eating disorder?
• 4 What can I do? General principles
• 5 What can I do? Specific problems
• 6 Who should I consult and what will they do?
• 7 What about the future?
• 8 Case vignettes
• Postscript
• Glossary
• Index