Eating disorders (EDs) are complex medical and psychiatric illnesses that are generally characterized by an unhealthy relationship with food and/or body image. The root causes might be several though. Firstly, it is important to understand that it is not a choice. Secondly, understand that it is not caused by parents. Having said that, there is a lot that parents can do to help faster recovery of a child having an eating disorder. So, let us dive in deeper and understand how.

Normal eating is controlled by hunger, appetite and satisfaction. A normal person feels hungry when in need of energy or nutrition and stops when satisfied. Also, they eat at mealtimes, generally three times a day with small snacks in between. Meanwhile, for individuals suffering from an eating disorder, their eating is not controlled by hunger, appetite or satisfaction. It is controlled by their will, calories, feelings, emotions, planned diet, self-image, etc. They either eat too much or too little to satisfy their mental perceptions.

As per a 2007 study published in Biological Psychiatry, of the 9,282 English-speaking Americans who were studied, 0.9% women and 0.3% men had anorexia, 1.5% women and 0.5% men had bulimia, and 3.5% women and 2.0% men had binge eating disorder at some or the other point in their lives. Eating disorders commonly occur with other mental health conditions like depression, anxiety, obsessive compulsive disorder (OCD) and social phobia. The consequences of ED can be life threatening and the stigma associated with mental illnesses can further delay timely diagnosis and recovery.

Read on to Know More About Eating Disorders

• Risk Factors and Causes
• Seriousness
• Major Myths and Facts
• Types of EDs
  • Anorexia Nervosa (AN)
  • Bulimia Nervosa (BN)
  • Binge-eating disorder (BED)
  • Avoidant Restrictive Food Intake Disorder (ARFID)
  • Other Specified Feeding or Eating Disorder (OSFED)
  • Orthorexia
• Signs and Symptoms
  • Behavioral and Emotional
  • Physical Signs
• How to Get a Child to Take Help?
  • For Younger Children
  • For Adolescents/ Teens
• Get Professional Help
• How to Support your Child?
• Types of Therapies that might be used by a Specialist
• Issues to be Addressed for Children/ Teens having ED
• How to Train your Young Child and Possibly Prevent an ED?
• Most Important – Teach your Child to Love Themselves Just the Way they are!

Risk Factors and Causes of Eating Disorders

As per researchers and clinical experts eating disorders can be caused by both genetic and environmental factors. Hence, they fall under the gamut of bio-sociocultural diseases. Listing some of these factors below:

• Thin body ideal driven by media, peer and sometimes even parental pressure – These are societal factors which act as environmental triggers. Such triggers have been shown to increase the risk of developing eating disorders. Thinspiration was a hashtag often used by individuals in the social media to promote weight loss and thinning. Make sure you guide your children right about such misleading posts, guidelines or videos. Read on to understand why and how.
• Other environmental factors include physical, sexual and/or mental abuse; physical or mental illnesses; and childhood bullying or teasing.
• Psychological risk factors like perfectionism, anxiety, depression, difficulty with regulation of emotions, obsessive compulsive disorder, rigid thinking styles, etc.
• Life changing events like loss of a dear one, ending a relationship, personal disappointments, etc.
• Need for control – Some children or teens use their body and eating habits to reclaim control over their lives.
• Meanwhile some of the earliest cases of eating disorders were associated with religious beliefs, fasting and quest for salvation, etc.
• Biological risk factors could be family history of mental health illnesses or eating disorders; personal history of conditions like depression, anxiety, and/or addiction; food allergies that lead to picky or restrictive eating; type 1 diabetes, etc.
• Strict diets, chronic dieting, etc., could also be starting points for eating disorders. So, addressing such issues before it gets too late could help prevent a full-blown eating disorder.

No Exact Guidelines to Prevent EDs – but parental support is important

There is no single set of rules that can be followed by parents to prevent these conditions. This is because the causes are varied, and mostly tend to have a strong biological root. Nevertheless, psychologists and researchers have observed that children tend to recover faster when parents are included in the treatment process. Parents and everyone in the family system can do a lot to create a recovery-promoting environment for children. Meanwhile, something that all parents can do is to help children love themselves just the way they are, whether thin or fat, dark or fair, just the way they are. This could go a long way in improving their self-esteem and well-being in the long run.

Seriousness of Eating Disorders

This psychiatric illness has the highest mortality rate compared to any other. Up to 20% of individuals with anorexia nervosa tend to die due to their illness. All other eating disorders also have similar mortality rates, as per community studies. Apart from medical complications like anemia, cardiac issues, electrolyte abnormalities, deteriorated bone health, stunted growth, infertility, etc., suicide is also a common source of concern in such individuals. They also tend to have a bad quality of life.

Individuals who indulge in abusive use of laxatives, diuretics or get themselves to vomit too often tend to have a higher risk of sudden death. Major cause of sudden deaths in such individuals was found to be heart attacks caused by electrolyte imbalances. Increased exercise could also increase the risk of death because of excessive stress on the body.

Major Myths and Facts about Eating Disorders

• Unless someone looks emaciated, they are not sick – Although eating disorders, especially anorexia nervosa is characterized by weight loss, many people with such eating disorders do not necessarily lose weight. Some may even gain weight due to their eating disorder.
• Eating disorders are only related to food and weight – The impact can be larger. It might even be linked to perfectionism, obsessions, or need for control, which can further lead to fixation on grades, performance in sports or arts, etc.
• Eating disorders help manage depression and anxiety – Though it might be true for initial cases, as the disorder progresses, mental health will further deteriorate and affect all aspects of life.
• Only body image can cause eating disorders – Clinical reports indicate that young children, teens and many adults who have had eating disorders did not have any body image issues.
• Since eating disorders have a biological root, there is not much hope for recovery – Though biological factors play a huge role, there will be other contributing factors too. For instance, stress could be a major contributor. There are several techniques to help manage emotions and avoid relapse while under stress. There is always hope for recovery.
• Boys do not have eating disorders – Understand that eating disorders can happen in any gender.
• Young children cannot develop eating disorders – EDs can develop or re-emerge at any age. As per the National Eating Disorders Association (NEDA), children as young as 5 or 6 have been diagnosed with eating disorders. Also, note that picky eating is not an eating disorder.
• Teens are at higher risk of developing eating disorders – Again, as discussed already, it can happen at any age. Children who have had EDs at younger age tend to struggle with relapses until they get the right treatment.

A Few More…. 

• You cannot have more than one eating disorder at a time – Roughly, half of the people with anorexia will develop bulimia at some stage, as per studies. Some move from one diagnosis to another, which is known as diagnostic cross-over. All of these have life threatening consequences though.
• Purging only involves forced vomiting – It could cover any method of removing food from the body before it gets digested. This is done to compensate for perceived overeating. Purging methods also include use of laxatives and enemas. Non-purging compensatory methods include abusive use of insulin, fasting and excessive exercising. Some individuals might use multiple methods. All pose risks, but the major risk is the chance of developing life-threating electrolyte imbalances.
• Weight recovery indicates complete recovery – Weight and nutritional recovery are only the first steps to recovery. Once this is done, they can gain more benefits from psychotherapy or any other kind of therapy. Psychological recovery is important to ensure that the child or individual does not have a relapse and can manage difficult emotions appropriately later on in life.
• Eating disorders are not that dangerous – Such disorders can lead to irreversible and life-threatening health issues like cardiac problems, bone loss, stunted growth, infertility and kidney damage. Among all psychiatric illnesses, these ones rank highest when it comes to mortality rate. So they are indeed dangerous.

Types of Eating Disorders

The American Psychiatric Association lists five types of eating disorders in the Diagnostic and Statistical Manual, 5^th Edition (DSM-5):

• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Binge Eating Disorder (BED)
•  Avoidant Restrictive Food Intake Disorder (ARFID)
• Other Specified Feeding or Eating Disorder (OSFED)

Anorexia Nervosa (AN)

This is characterized by partial or complete refusal of food. It is mostly driven by the belief that food can cause weight gain. Though they might be in the normal weight range, they believe that they are fat or overweight. They have an intense fear of gaining weight, and tend to have an unhealthy preoccupation with food and exercise. Forcefully vomiting, usage of laxatives or similar substances are purging techniques used by such individuals.

Anorexia can cause permanent damage to several organs due to starvation. It can cause dehydration and kidney failure. Hormone changes can cause issues like osteoporosis. Over-exercise can cause muscle, bone, and cartilage damage. Other medical complications seen are irregular and/or low heart rate, low blood pressure, risk of heart failure due to electrolyte imbalance and damage to heart muscle.

Bulimia Nervosa (BN)

In this case the individual engages in a cycle of binge eating and purging or other compensatory behavior. Binging is characterized by consumption of abnormally large amounts of food in a short period of time (around 2 hours) and then purging by forcefully vomiting, using laxatives, exercising excessively or by fasting extremely. If you see this happening at least 1 time per week for 3 months, please get immediate professional support.

If prolonged it can lead to damages in digestive system and cause issues like ulcer. It can even damage the food pipe due to frequent vomiting. Stomach acids will wear out the enamel of the teeth and they tend to look yellowish. The salivary glands might get swollen. Dehydration is another major issue. There might be stomach cramps and difficulty in swallowing. Other gastrointestinal issues that can be caused are constipation, bloating, water retention, swelling of the stomach due to use of laxatives, etc.

Binge-eating disorder (BED)

These individual eats until they are uncomfortably full and do not indulge in purging or compensatory behavior. This generally happens when the individual is unable to regulate emotions and turn to food for comfort. They tend to do it while alone because of embarrassment and might hoard food. Such individuals tend to eat faster than normal so they can eat more than what they need and continue eating even when there is no real physical need. Such episodes might be followed by feeling of guilt, disgust, or depression later.

They tend to eat this large amount of food over a small period of time (within 2 hours) and they feel a lack of control while binging. Significant weight gain over a short period of time might also be a sign. If this happens at least 1 time a week for three months, please get immediate professional support. Binge eating can result in long term damage to major organs, obesity, diabetes and/or hypertension.

Avoidant Restrictive Food Intake Disorder (ARFID)

Like anorexia, this also involves limitations in amount or type of food consumed. However, ARFID does not have anything to do with body shape, weight, or size. A child with ARFID might not consume enough calories for proper growth and development. This could result in stalled weight gain and height. It could also result in problems at school because they might be too slow at eating and could have difficult eating with other children. Children in the autism spectrum, those who never outgrow picky eating, and those having anxiety disorders are at high risk of having ARFID. The signs are like what you observe in anorexic patients.

Other Specified Feeding or Eating Disorders (OSFED)

These are characterized by eating behaviors that causes significant clinical distress and impairment, but does not fall und

• Atypical Anorexia Nervosa – Almost fully like anorexia nervosa, but the individual’s weight will be within the normal weight range
• Bulimia Nervosa (of low frequency and/or limited duration) – Meets all criteria for bulimia nervosa, except for lower frequency and duration (less than 3 months).
• Purging Disorder – They might not binge but indulge in purging to maintain weight or shape.
• Night Eating Syndrome – Characterized by eating in the middle of the night after waking up from sleep, or by excessive consumption of food after dinner. This behavior also causes severe distress and impairment.

Orthorexia

This is not formally recognized in the DSM manual yet, but could have lasting impacts on health and well-being. It is characterized by an obsession for healthy eating. It is alright to be concerned about the nutritional quality of food being consumed, but such people tend to be fixated on it and narrow their choice of foods. They tend to cut out entire food groups like sugars, carbs, fats, etc. They show intense distress when healthy options are not available. Since the amount and variety of food being consumed by such people is not varied enough, it could lead to malnutrition. Other physical consequences are like what you see in anorexia. It is also a type of obsessive-compulsive disorder.

Signs and Symptoms of Eating Disorders

Children with eating disorders may show some, but not all the below behavioral, emotional and/or physical signs and symptoms. Please get professional help if you observe that they are struggling with any of these.

Behavioral and Emotional Signs

• Preoccupation with food.
• Negative self-image.
• Intense fear about weight gain.
• Eating too small portions or refusing food completely.
• Checking mirror too often for perceived flaws.
• Unconcerned about extreme weight loss.
• Hiding weight-loss by wearing concealing clothes.
• Self-worth and esteem getting impacted by body shape and weight.
• Intense fear of eating in public or of eating with family.
• Indulge in hoarding and hiding food.
• Eat in secret.
• Quickly disappear after eating, normally to the bathroom.
• Unusual food rituals like eating extra slowly and cutting food into extra-small pieces.
• Adopting new practices like cutting out entire food groups such as sugars, carbs, dairy, fats, etc., or eating strange combinations of foods. Trying new food fads and diets constantly.
• Obsessed about cooking shows and collecting recipes.
• Only consume safe, organic or healthy foods.
• Cook for others but refuse to eat it themselves.
• Unable to regulate emotions or lack of emotions.
• Irritability and mood swings.
• Hyperactivity and restlessness.
• Excessive exercising and working out even when ill or sick, for burning calories.
• Intense anxiety when rigid routines are interrupted.
• Also note that children with eating disorders might be at risk of developing anxiety issues, substance abuse, self-harm, suicidal thoughts and behaviors.

Physical Signs

• Noticeable weight changes, up or down.
• Gastrointestinal complaints like stomach cramps, constipation, acid reflux, etc.
• Menstrual issues like delay in menarche or missing periods.
• Abnormal lab test results like anemia, low pressure, low heart rate, low thyroid/ potassium/ hormone levels, low blood cell counts, etc.
• Difficulty concentrating, dizziness, fainting.
• Sleep issues.
• Feeling cold due to lack of body fat.
• Thinning of hair on head.
• Dry and fuzzy hair in other parts of the body. Signs that body is trying to protect from cold through other mechanisms when there is low fat.
• Cuts and calluses on top of finger joints caused while indulging in forced vomiting.
• Dental and bone issues like enamel erosion, cavities, sensitive tooth, brittle bones.
• Dry skin and brittle nails.
• Swelling around salivary glands.
• Discoloration of teeth from frequent vomiting. Stomach acids make the teeth look yellow.
• Yellow skin that might caused by eating too many carrots.
• Weakness in muscles.
• Cold extremities (hand and feet), swelling of feet, etc.
• Slow healing of wounds and impaired immune function.

How to Get a Child to Take Help for Eating Disorders?

Most sufferers will not admit that they have any such issues. Young children might not even be fully aware of what they are going through. On the other hand, some of them might feel embarrassed about their condition, especially older children. Older children might refrain from taking help since they will have to give up on their eating behaviors. Despite all these challenges, survivors always say that they were glad someone stepped in to help them at the right time. So do not hesitate.

If you feel that your child has an eating disorder, get professional support for them as soon as you can. The longer you let it be, the worse the medical complications can get. Please bear that in mind always. Eating disorders could be life-threatening for anyone.

A few pointers on how you can get them to take help

• Sit down with your child in a quiet place and tell them that you are concerned about a recent eating behavior you noticed in them. Also tell them about the steps you will be taking, like going to a doctor, or getting them evaluated by a specialist. Be calm, caring and most importantly, be non-judgmental. Try using “I” statements like, “I feel concerned when I see you heading to the bathroom soon after dinner.” You may also share your other related concerns about weight-loss, isolation, anxiety, etc.
• Your child might react in anger and denial. There is a very good chance that they will feel threatened when confronted about something like this. Do not take it personally. They must be feeling scared and uncertain about the situation. Stay calm and let them vent or talk their heart out.
• Some children might know that something is wrong with them. It might be easier to get their buy-in in such cases. If not, it might take some effort on your side. Do not expect them to understand the situation until they start feeling better. Sometimes this happens only once they are long into recovery.

And a few more..

• Always stay focused on your child’s long term needs and health. If you doubt that your child might be having an eating disorder, get them checked up by a specialist. You might not find the right therapist right way. Talk to physicians and therapist you know, take second opinions and keep trying until your child feels comfortable with their therapist and starts showing improvement.
• Some children who need intensive support might have to take time off schooling and it can leave them really shattered. Assure them that everything will be intact, and they will be able to easily pick up from where they left. Let them know that you have their back. Talk to their teachers for additional support if required.

A Few Specific Pointers for Talking to Younger Children

• While talking to younger children you might want to use “I” statements like, “I think I am having trouble with eating. We all need food to grow, stay healthy and for our bodies to function. Would you also work with me so we can learn to eat better and stay healthy together?” or say something like, “I am having trouble eating. It is not my fault. There is this doctor who is helping me get better now and I am feeling a lot happier and healthier since I started taking help. Do you also want to know anything about eating problems? Maybe we can all help each other.”
• You could tell young children about eating disorders in simple terms – “We eat a little less or more on some days, but people having eating disorders eat really less or more every day. It might be making them sick, but they cannot stop. That is why mom or dad is getting help from a doctor. Doctors can help us recover, they can help us learn to eat properly again, and stay healthy.”

A Few Specific Pointers for Talking to Adolescents/ Teens above 18 years of age

• When it comes to teenagers, in several countries they start looking after themselves once they are 18. Get them to a specialist for evaluation. If they want to do it alone, make sure that it happens. Prioritize their health and well-being above anything else. Remember that a teenager having this condition might also experience regression in maturity. So, try to accompany them to their checkups. You may sometimes be able to provide valuable insights to the specialist that your child might otherwise miss.
• If your teenager over 18 does not take help, keep talking to them about it. Tell them how taking help can help. Read more about the condition. You could simply go through this post once again maybe. Then talk to them about the seriousness of this condition, how it can impact them in short and long term, how dangerous it could get and so on. Also tell them how taking help can help them recover successfully and help them lead a normal life again. Your perseverance should pay off if you try communicating openly with them. This last one is something that you can start off with while they are very young – open communication. A lot of issues can be easily managed and tackled if you practice open communication with your child starting from a very young age itself.

Get Professional Help for Eating Disorders

• For stable cases – Get the child to a general physician or eating disorder specialist for checkup and evaluation. They will do a thorough assessment to understand patient history, family history, attitude towards food and exercise, etc. This might be followed by relevant medical examination and lab tests.
• For unstable cases or children/ teenagers who are at risk of suicide, get immediate medical/ psychiatric support or call emergency. Depending on the health status, lab test results and level of support needed, patients might be allowed to stay at home and take treatment or advised to take inpatient treatment. Patients who do not have parental support, show intention to suicide, are non-cooperative, need help with feeding, or need supervision to watch purging might also have to take inpatient treatment.

How to Support your Child who is having an Eating Disorder? 

• Learn more about eating disorders, the different types, myths, truths, signs, symptoms, seriousness, medical and psychological implications, etc. You could also refer to this guide by SingHealth.
• Talk to your child openly. Do not judge, be patient, calm and kind. Ask how you can help and how they are feeling. This way you are not just focusing on the physical aspects, but the emotional aspects of the disorder. Acknowledge and validate their feelings when they confide in you or share their feeling with you. Being open also means that you express your own concerns. Do not take their actions personally.
• Offer to help teenagers with their tasks like doctor appointments, transportation, cleaning up, laundry, etc.
• Try not to talk about food, weight, shape and eating. Avoid talking about your own food habits or that of others.
• Model a healthy and balanced relationship with food, weight, and exercise. Avoid giving sermons though, just do it yourself hoping that they will observe and learn.
• Encourage your child to follow through with the specialist’s recommendations.
• Try distracting your child during and after meals to manage anxiety. Try not telling them what to do.
• Your child might avoid socializing and even push you away. Still try to reach out.
• During family time, try introducing activities that do not involve food or eating, so your child can participate as well.
• Try not to encourage or make compliments which have to do with anyone’s appearance. Focus on other personality traits while making compliments.
• Lastly, but most importantly take care of your own emotional well-being throughout the process.

Types of Therapies that might be used by a Specialist for Eating Disorders

Please note that this is only for your information. Please take your child to a good specialist for the right help and treatment.

• Family Based Therapy (FBT) – It is a home-based approach that has been seen to be effective for children having anorexia or bulimia. All family members are involved in the treatment. The focus is on full weight restoration, healthy eating, interrupting compensatory behavior and returning control of eating back to the child or teen to promote recovery.
• Cognitive Behavioral Therapy (CBT) – This is symptom oriented and focuses on replacing the negative beliefs that the patient has about food, eating, weight, shape, exercise, etc.
• Interpersonal Psychotherapy (IPT) – Based on the premise that eating disorders are caused by interpersonal difficulties. The focus is to resolve these difficulties and hence promote recovery.

Other Therapies

• Behavioral Systems Family Therapy, Family Systems Therapy and Conjoint Family Therapy are used in cases where family structure, communication styles or family dynamics might be in some way responsible for maintaining the eating disorder. These therapies require involvement of the families in the treatment process.
• As opposed to this, there is Separated Family Therapy where patient and family are seen separately, in cases where parental criticism or hostility between parents and patient is high.
• Acceptance and Commitment Therapy is another one where patients are taught to identify values and change their actions to commit to those goals that fulfill their values.
• Dialectical Behavior Therapy is yet another technique which focuses on changing behaviors. It helps develop skills to replace maladaptive eating disorder behaviors. These might include mindfulness skills, interpersonal skills, emotional regulation, etc.

Some of the other alternative therapies that have been found useful are art therapy, coaching, support groups, appropriate exercise, hypnotherapy, journaling, massage, meditation, relaxation training, yoga, etc.

In some severe and particular cases, antidepressants or similar medication might be used to address the psychiatric issues.

Issues to be Addressed for Children/ Teens having Eating Disorders

• Firstly, the medical and psychiatric complications must be resolved. Nutritional counselling might be provided to help with meal plans, diet goals, achievement of healthy weight, etc. This will also involve basic education about nutrition and health impacts of eating disorders.
• Interruption of the behaviors like excessive or little food intake, purging, other compensatory behaviors like excessive exercise, etc.
• Establishment of normal eating and nutrition rehabilitation.
• Challenging and replacement of unhelpful thoughts and behaviors with healthy and helpful ones.
• Addressing ongoing mental and physical health issues.
• Coming up with a plan to prevent relapse.

How to Train your Young Child and Possibly Prevent Eating Disorders?

To be frank, there are no set rules or preventive measures to avoid eating disorders. As parents we can still do what we possibly can to ensure that our children have a healthy relationship with their food, exercise, eating habits, body image and self. Listing down a few general guidelines that could be used by most families. Following these guidelines are not going to guarantee prevention of eating disorders, but you are at least doing the best you can as a parent.

House Rules for Eating, Food, Exercise

• Make your house rules very clear to your child at a very early age. Create rules so they know that they must eat with the family when they are at home. For teenagers you could even create rules which will make them eat with the family at least once every day. This way you can note any abnormal behavior if it happens.
• Let your child know that they must eat food belonging to all the food groups and eat wholesome meals. Though they must have learnt this at school, repeat so they do not forget. Ensure that they have a good relationship with food, weight, shape, and exercise. If they do not like some food, introduce it in a different form later. They might like it. Keep trying. Tell them that they must try all foods and can leave it if they don’t like the taste at all. That will make them at least try it. Who knows if they might like it this time around?
• Take your child out to play, swim, walk, cycle or do some physical activity every day if possible, for at least 1.5 hours.
• Let your child know that they can talk to you or any other adult they trust if they have any problem with food, eating, weight, etc.

Watch What You or Others Say

• There will be several relatives and friends out there who will body shame your child or anyone else. If this happens while you are around, stand up for them. Tell the culprit very clearly that making such comments is not acceptable. Emphasize that you or your child is happy in their own body and no one else must really be bothered. This will give the child a sense of confidence about liking themselves just the way they are.
• Also discourage and avoid making compliments that have to do with someone’s appearance, weight, or shape.

Screen Time and Media Impact

Watch what your child is watching on television or any other media. If they are spending too much time watching cooking shows, fitness shows, fashion shows, etc., guide them right. Educate them about how the media uses digital enhancements to portray the ideal male of female body. Show them the realistic videos where actors or models are without makeup and creating awareness about how they look without these enhancements and makeup. Many such videos are available today. Read our article on screen time to understand how you can control the kind of content that your child indulges in.

Most Important – Teach your Child to Love Themselves Just the Way they are!

Remember that you can be their first role model. If you do your things right, there is a very good chance that your child will follow. Do not create unhealthy or unrealistic goals for your little one. If your child is dark, let them be. Love them just the way they are. Do not force them to use cosmetics or make them visit the beauty salons. You made your child; they must have taken after you or your husband.

Understand that some things like shape, skin color, height and weight cannot be altered, unless unnatural methods are used. Such methods will have long or short-term medical complications. Do not be that parent who teaches a child self-loathing. Be that parent who teaches a child to love themselves just the way they are.

Happy parenting!

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