Reflect

It is estimated that approximately 22.36% of children and adolescents worldwide exhibit disordered eating behaviours. Adolescent girls typically tend to be disproportionately impacted, but eating disorders (EDs) in boys are on the increase.

How do EDs begin? And are they easy to spot? The answer to this is that they start slowly, often imperceptibly, and no, they aren’t easy to spot. As Dr Sophie Nesbitt, an Eating Psychologist explains, “They involve so many different symptoms”, and are accompanied by a combination of physical, emotional and behavioural changes. The challenge is that such changes can also look like other things related to adolescent development, and so, “It’s a really difficult maze to navigate with twists and turns and very frequent dead ends”. However, Dr Nesbitt suggests that there are certain things that parents can watch for, based on her experience of supporting patients in a clinical setting.

Firstly, changes in eating, which can happen gradually. Yes, they can be tricky to spot as our teens often eat independently, so who knows what they are eating, right? Dr Nesbitt asks us to pay attention to the types of food being eaten or avoided. Is there a new degree of resistance that just wasn’t there before? Are you starting to dread raising the issue of food or what to serve for dinner? Is this consistent over time?

She also asks us to notice ‘changes in body image’. These are tricky to unpick from the typical self-consciousness of adolescence, but she suggests that it is a constant preoccupation with looks and frequent checking that may be a red flag. Again, she suggests the intensity of the preoccupation matters most. Does it feel new to you? Is it accompanied by excessive weight checking or measuring? Is your teen being self-critical in a way that concerns you? This in turn might exacerbate low mood and make you worry. Perhaps it is becoming harder for you to shift your teen’s mood or thinking pattern?

Your teen might slowly withdraw from things that once mattered to them. Anxiety around food can make social events hard and so it becomes easier not to engage with social experiences as not doing so feels safer and more predictable. In turn, this can lower mood, increase anxiety and impact their confidence. Dr Nesbitt suggests that even if your teen is struggling, try to keep social opportunities in the family diary as, “If everything falls away, there is nothing to recover for, and motivation can then become a real challenge”.

Not every ED is accompanied by physical changes that are perceptible, such as weight loss, gain or unexplained changes in weight. Other physical changes such as dizziness, fatigue or continually feeling cold may be more noticeable symptoms. Disrupted menstrual cycles, or delayed puberty in boys, can also be indicators of an ED. Both changes may suggest hormone production that has altered from the typical course of development, which may be due to poor nutritional intake.

School staff might raise concerns and can shed helpful light on some behaviours. Prolonged poor nutrition can cause concentration difficulties which impact on academic performance. Perhaps at first your teen seems overwhelmed with school and takes more time to do things. Perhaps they never seem happy with their performance and are very self-critical even when they do well. As Dr Nesbitt notes, “This suggests a degree of perfectionism and obsessiveness which can also be symptoms of an eating disorder”.

It goes without saying that the first port of call should be your family doctor. Remember that early detection can be important when it comes to recovery outcomes, so there is never any harm in reaching out for early medical advice.

Motivate

We all know that food is essential to survival. So, we must understand that, on some level, an eating disorder is about questioning the need to survive, not necessarily because a person wants to die, but because they are in a psychological process that is questioning their life. Perhaps the need to assert independence from the body is a way of taking ownership again if we feel lost, confused or are struggling to work out who we are.

Food also provides a means of being with others. As parents, we have been focused on ensuring our children eat well and have enough to eat everyday of their lives since birth. An eating disorder challenges family bonds and severs a cord that is focused on nurture and nutrition. Parents describe feeling powerless as a child slowly relinquishes the desire to eat. At that moment, the clock almost stops. Whether it is food restriction, binge-purge behaviours or compulsive overeating, eating is relational; it is a behaviour that can connect us to others, but just as easily disconnect us from others if we need or want it to.

Food is also intricately linked to how we feel. Most families value cultural traditions and share preferences for specific foods and how to prepare them. Over time, this creates a strong family narrative that can elicit positive and negative memories. Which dishes bring you back to memories that are associated with the person serving the meal or who you shared dinner with?

Other emotions can also impact on our appetites, like anxiety. Anxiety can cause some people to binge eat, purge food or simply restrict intake. Certain emotions may create urges to engage in eating disorder behaviours as a way of coping with feelings that are very overwhelming or leave us feeling completely full.

It is important to understand the warning signs and the changes that are commonly observed in young people with eating disorders. However, it is also just as important to try to understand why it is an eating disorder and what it represents for the young person. It is never simply whether a person can eat or not. It is about a young person being unable to identify and understand their emotions and the eating behaviour is replacing the emotion expression. It feels important to understand the eating disorder to ask ourselves what the emotions might be behind the eating.

What is the message that they are trying to communicate?

Our motivation to understand the psychological motivation behind disordered eating behaviours is important, as is our care and curiosity. Where might a parent start? We recommend leaning into the supportive world of Eva Musby and use resources supplied by national charity Beat or global charity F.E.A.S.T. Certain charities focus on support for boys and men, such as The Laurence Trust.

Support

To answer this question, last year Tooled Up delivered two conferences for our members exploring body image dissatisfaction. We called them “Reaching Children Early” events and hosted 16 academics. What did we learn that we can pass on as useful tips?

One of the stand-out talks for me was by Dr Kat Schneider, a Research Fellow at the Centre for Appearance Research at the University of the West of England, whose main message was that we should try to stop using ‘body talk’. This refers to comments about one’s own or someone else’s appearance that suggest that there is an ideal way to look. These kinds of comments are not only limited to our own or others’ height and weight, but can include references to less obvious appearance characteristics, such as skin shade, hair texture or individual body parts. Dr Schneider gave examples such as, “I look so fat today” or, “I hate my legs. They are covered in stretch marks”. Body talk, she explained, is not limited to overtly negative comments, or even neutral ones. We can also slip into body talk when giving someone else a compliment; “Your legs look amazing!”. Either way, body talk fuels appearance scrutiny, which is unhelpful and often anxiety-inducing, and isn’t good for anyone’s mental health.

One action we can all take to stem the tide of body dissatisfaction is to stop caring about and commenting on our own or others’ shape and size quite so much. Imagine someone looking at you and saying, “Your smile is just infectious!”, instead of, “You look amazing. Have you lost weight?”. We can also refuse to respond to body talk with reassurance and actively avoid our instinctive response, which is often to reciprocate. Dr Schneider’s talk reminds us about the power of our words and of the need to choose them wisely.

So if we aren’t commenting on appearance, what should we focus on? Research shows that concentrating on functionality (the amazing things our bodies can do, not just whether they conform to a particular image) is associated with better body image. Body functionality can be a great way to challenge body talk and shift the focus away from appearance. This might be sport-related skills such as hand-eye coordination, speed or strength. It could also relate to general physical activities such as playing with friends, or bodily functions such as healing from injury. Find opportunities in physical activity, movement, play, dance and creative endeavours to comment on what our bodies are capable of. For example, if a young person says, “My thighs are so big. I wish I had your legs”, you might respond, “Your legs are super strong and help you run really fast”. It can improve body confidence to reflect on what our bodies can do and why this is important to us. If you’d like to find out more, the free Body Confident Sport programme is a fabulous resource.

With boys in particular, focus on strength and endurance, rather than muscularity, which could fuel existing preoccupations with getting bigger. Muscularity is a distinguisher in the body type desired by most males compared to most females, and a talk by Professor Scott Griffiths explored how 85% - 90% of people with muscle dysmorphia are male. The condition involves an excessive focus on developing muscles and a corresponding self-belief that the sufferer is too scrawny, puny or out of shape. Similarly to anorexia, if muscle dysmorphia is not interrogated, it becomes central to self-identity. It can be extremely difficult for sufferers to change, recover and walk away, and they need help. Australian organisation, the Butterfly Foundation provides information and support around the condition.

Ensure that conversations around positive body image are backed up by strict rules and consequences around teasing or shaming, especially in regard to weight and body shape. Bullying is shown to have long-term impacts including heightened risk for disordered eating.

We can also strive to improve our children’s critical thinking when it comes to making comparisons with things that they see online. Discuss image manipulation, re-shaping or stretching, the power of good lighting and professional make up, and the composition and arrangement that goes into even supposedly candid shots. As another of our presenters, Dr Chris Stiff, notes, a healthy level of cynicism is a good thing! A social media audit, removing content that causes distress, and increasing realistic influencers, can help to reset algorithms and promote a healthier feed. Influencers such as @BenCarpenter, @drjoshuawolrich, @kelvindavis and @kennyethanjones provide positive messages about body image in a way that will resonate with men and boys interested in fitness. Establish the concept of digital discernment at an early age. Talk about it as a family and consider your own family digital values.

It’s also vital to consider how we talk to children about food in general. How do we help children develop and nurture a healthy relationship with food? Think back. Were you ever told, “You can't have dessert until you eat all your vegetables?” Or to, “Be grateful for your meal?” Perhaps you yourself have said, “I’m on a diet so I can't eat that”. We may not realise, but we are constantly communicating our thoughts on food to our children. Want to learn more? In a brand new book, clinical psychologist Dr Anna Colton explores how we’ve formed our own relationships with food and gives us practical, evidence-based tools to instil in children a positive relationship with eating. We highly recommend it!

One final point. Eating disorders are common. Your child may have a friend who is suffering, and this too can be challenging. In a podcast interview, Dr Amy Harrison, told us that people with eating disorders tend to be very sensitive to any perceived criticism or social threats. It's likely that friends will accidentally offend or upset them at times. If this happens, remind your child that it’s normal and that they are doing their best to support them. It’s advisable that they avoid conversations about food which could make their friend feel under the spotlight and the best thing they can do is sustain normal interactions. Your child might be able to keep their friend involved in social scenarios by exploring how certain situations could be made easier for them. Perhaps you could nudge them to find out what strategies might help. Remind them that if they are worried about a friend, it's ok to tell someone.

Let’s do all we can to ensure that our children can name their sources of support and are comfortable seeking help when they need it (this doesn’t have to be from us). Asking curious questions in caring ways can be a really good starting point for parents and for school staff. Never be afraid to seek external help. All we can do is our best, and sometimes that looks like seeking support and advice from those around us as to how to proceed.