Eating disorders in boys and girls

“I missed all the signs,” says Elizabeth Komar. Her daughter, Monica, was always a little secretive. The 12-year-old had begun spending less and less time with her mother and younger sister, Maya, then 10. Pictures of fitness exercises lined her bedroom walls — exercises Monica would do after her mother had gone to sleep at night. Monica also started wearing baggy clothes. “But all the kids were wearing them,” says Komar.

The Kanata, Ont., mother had little reason to worry or be suspicious of her preteen. Always a good student, Monica’s grades remained high. When she started losing friends, Monica simply explained: “I just don’t like them anymore; I have nothing in common with them.” Considering her daughter had just started puberty, Komar assumed it was all part of growing up.

One evening not long after dinner, Maya told her mother that Monica was throwing up. Suddenly, Komar put the pieces together. She rushed to the bathroom to confront her daughter. “I asked her what she was doing, why she was doing it and for how long. Frankly, I think she was relieved.”

Although barely 12, Monica was struggling with two early onset eating disorders — anorexia nervosa and bulimia. Characteristically, people with anorexia are fearful of body fat, so they eat very little, diet constantly and suffer extreme weight loss. Those with bulimia secretively binge and later purge either through vomiting, using laxatives, doing excessive exercise or fasting.

For years the medical community viewed eating disorders as mostly a problem for women who are white, female and privileged, and starting around 14 or 15, or in early adulthood. Last May, Gail McVey, a research scientist at The Hospital for Sick Children in Toronto, published a study, “Dieting Among Preadolescent and Young Adolescent Females,” which is helping to shatter those perceptions. The study revealed that almost 30 percent of a sample of about 2,000 Ontario girls between the ages of 10 and 14 were dieting to lose weight, and, according to scores on the children’s version of an eating attitudes test (called ChEAT), just over 10 percent of them were in the danger area for eating disorders. These girls were also likely to be using methods other than dieting to lose weight — just over 30 percent of the 10-year-olds and almost a quarter of the 11-year-olds were trying to lose weight.

McVey’s report focused on “disordered eating,” a term referring to one specific behaviour, such as dieting. Anorexia and bulimia are full-blown syndromes. However, dieting can be a risk factor for eating disorders and Health Canada provides a startling national statistic: Since 1987, hospitalizations for these syndromes have increased by 34 percent for girls under the age of 15. Furthermore, a burgeoning amount of research shows that kids under 12 are increasingly at risk. One kink is that, although crucial, diagnosis of these disorders is difficult, something that Komar discovered first-hand.

“It’s very hard to diagnose anorexia nervosa, for instance, in a child under 12, because it doesn’t meet the adult criteria for the disorder,” says Debra Katzman, an associate professor of paediatrics and the medical director of the Eating Disorders Program at The Hospital for Sick Children. According to the diagnostic criteria, an adult with an eating disorder has to show a full range of symptoms including losing about 15 percent of her body weight, losing a menstrual period, obsessing about body fat, dieting, being preoccupied with food and exercising excessively.

The limitations of these criteria are obvious. For instance, a 12-year-old may not have had her period yet. Plus the body mass index (BMI) for children is higher than for adults and any weight loss during a time when kids should be growing is cause for concern. Still, these criteria do play an important role: Aside from ruling out other possible reasons for eating problems or weight loss, such as depression or food phobias, these criteria help to assuage parental paranoia about a child’s eating habits. “Eating disorders occur on a continuum of behaviour,” says psychotherapist Abigail Natenshon, author of When Your Child Has an Eating Disorder: A Step-by-Step Workbook for Parents and Other Caregivers. “You have to think in terms of, ‘Is it a benign quirk or pathology?’”

New perspectives on diagnosis, who can be affected and approaches to therapy are ensuring that younger children aren’t overlooked and that parents are getting the tools they need to help them cope.

Discovering the Disorder
Although parents are usually the first to suss out that their child is in trouble, symptoms can go unnoticed because once children become committed to the disorder, they hide it really well. However, recognizing earlier warning signs before weight loss — such as changing moods or attitudes, the development of certain fears and preoccupations — can go a long way to curtailing the devastating effects. “A child’s growth is impaired, there’s a delay in puberty, they can develop osteoporosis, become socially withdrawn and have mood disorders,” says Katzman. Monica, for example, went undiagnosed for about eight months and finally had to be admitted to hospital, by which point, she had a low pulse, an uneven heartbeat and could barely walk.

The effects aren’t just physical; relationships with family, friends and peers become strained. Lucyna Neville’s daughter was diagnosed with anorexia at 14, but started showing symptoms in grade three. “We had no relationship,” says the co-founder of the Hopewell Eating Disorder Support Centre of Ottawa. “I was trying to fight the monster and she was trying to hold onto it.” Neville watched her “perfect” daughter start to avoid social situations with food, become deceitful and plummet into total denial. “It’s heartbreaking. At times when she was in a hospital bed with tubes up her nose and an IV, she’d still say, ‘I’m fine.’”

Witnessing their child’s struggle, parents feel lonely, lost, helpless and can’t escape feeling partly responsible. But parents need to get beyond guilt and realize they’re not the culprit. “I don’t think anyone today knows why eating disorders occur,” says Katzman. “There is no single cause — they’re complex and multiple.”

Searching for Answers
Starting in grade one, Tiffany Dalling of Kitchener, Ont., constantly complained about being fat. But she wasn’t. Initially, her mom, Heather, thought the comments were typical for young girls and ignored other signs such as Tiffany restricting her food around age nine. “I knew we were in trouble the first time I heard her purge.” Negative comments about weight or size were never a factor in their home. So Dalling wondered if her divorce when Tiffany was five or her ex-husband’s desire for his daughters to be “perfect” could have been contributing factors. “I wanted to know what I didn’t do or say to make her love herself more.”

It’s long been established that socio-cultural factors, home environment and behaviour traits can trigger eating disorders. Recently, scientists have also been investigating the effects of serotonin, which regulates appetite and moods, and autoimmune disorders similar to those causing rheumatoid arthritis or multiple sclerosis.

Although in its infancy, genetic research into eating disorders shows promise in uncovering why some people are more predisposed or susceptible than others. Like many girls suffering from an eating disorder, Monica focused on excelling at anything she did. “Nothing was good enough,” says her mom. “If she couldn’t be the best, she wouldn’t even try.” An international group of scientists has discovered a possible chromosomal link between this sort of trait — perfectionism, along with obsessive-compulsiveness and harm avoidance — and eating disorders. Furthermore, they concluded, “…a substantial body of literature has shown that bulimia…as well as the related eating disorders...is strongly familial.” These findings also reflect what’s happening in the Dalling household. In December 2003, Tiffany’s younger sister, Mariah, then 11, started to binge and purge.

But these factors do not reveal why younger children are being affected. Mariah’s situation ties into another area of investigation that might — hormones. “Mariah went through early puberty,” says Dalling. “She started her period at nine and her breasts started to develop at 10.” Beyond the physical changes, Mariah endured harsh teasing at school, which made her bingeing worse. Significantly, puberty involves coping with the stress of growing up, issues of sexuality, fitting in with peers — and weight gain. With eating disorders, “there is some defect with the endocrine system,” says Katzman. “Studies on this are beginning to help us figure out the puzzle, but they’re not definitive.”

Undoubtedly, the media play a role. According to a 2003 article in Paediatrics & Child Health, there’s a link between exposure to beauty and fashion magazines and an increased level of weight concerns or eating disorder symptoms in girls. Researchers found that the importance of being thin and trying to look like women in the media were predictive of girls between ages nine to 14 starting to purge at least monthly.

“Kids are growing up in a culture that promotes dieting behaviour,” says Katzman. “This has a bigger impact on a person who is more vulnerable. A lot of these messages are intended for adults who we hope can look at them and weed out the garbage; a lot of young kids don’t know how to critically evaluate this information.” In this age of The Swan and increasing acceptance of plastic surgery, children are learning it’s normal to hate their bodies.

One unlikely culprit is the continental campaign against obesity. Children attending support groups at Hopewell say the messages have a huge impact. “We shouldn’t be vilifying fat,” says Neville. McVey has similar concerns. “There is so much attention on the rise in obesity, but less information on guidelines or the best strategies to use [to].”

Given the multitude of possible triggers leading to an eating disorder, treatment has to be multi-faceted to be successful — and it has to involve parents, not just the child.

Finding a Cure
Parents face several obstacles in getting children the help they need, including a lack of resources in some areas around the country and the high cost of therapy. They may also find themselves in conflict with a doctor telling them their child is just going through a stage — feedback Dalling and others have had to endure.

“An eating disorder is not a normal part of development,” stresses Katzman. “If people are getting those messages, they should see a paediatrician who specializes in eating disorders.” Treatment should begin as soon as a diagnosis is made to ensure a quicker recovery. “The average duration of an eating disorder is five to seven years; it is tenacious and long-standing, but about 80 percent will recover.”

Typically, treatment is collaborative, combining cognitive-behavioural therapy for the individual, group work, workshops and, in cases where a child is seriously malnourished, tube feeding and bedrest. In recent years, family therapy has become a standard part of treatment. It has been used to treat anorexia patients since the 1970s, and one of the most effective approaches is one developed at the Maudsley Hospital in London, England. “The Maudsley family approach has been shown to work best for kids under 18,” says Joanne Gusella, a clinical psychologist and team leader of the Eating Disorders Clinic at the IWK Health Centre in Halifax. But children will be resistant. “They will not initially thank you for getting them into treatment,” says Gusella. “They may be angry with you — don’t let their anger derail you.”

During therapy, parents discover how to support their child without making the disorder stronger. They learn to be more objective and to understand that the disorder distorts how their child sees her body and relates to food. They are also given the skills they need to resume their role of feeding their child — as family meals can be particularly trying. They learn to watch for such behaviour as cutting food into tiny pieces, hiding food away in napkins or pockets, refusing to eat or hurrying to the bathroom immediately after dinner.

Last year the BC Children’s Hospital released a manual and video, Effective Meal Support: A Guide for Family and Friends. The video begins with four scenarios — two positive and two negative — of mealtimes with friends and family. In the positive family scene, a mother gently encourages her daughter to eat, the family engages in light conversation, and when the daughter wants to go to the bathroom afterwards, the father suggests she help out with dishes instead. The scenes help to illuminate what works — patience, distraction and structure, and what exacerbates an eating disorder — discussing diets, bribing and coercion.

Pierre Leichner, psychiatric director of the Eating Disorders Program at the BC Children’s Hospital and producer of the video, says with younger children, parents can take a more directive approach. But there’s a catch. “A person needs to be confident about their own eating habits, have a reasonable self-image and enough energy to give.” Furthermore, Leichner says parents need to help children develop the motivation to change — which is no small feat.

Spreading the Word
Ultimately the goal is to create conditions to halt eating disorders in their tracks. Gail McVey, who is also the director of the Ontario Community Outreach Program for Eating Disorders, has developed school-based programs to help prevent eating disorders. During health class, for example, grade-six girls have visualization and relaxation sessions, group discussions, and do role-playing and self-critiques. The goal is to help girls be more assertive, cope with stress in their relationships and boost their self-esteem. The kids also learn healthy approaches to eating and keeping active, and are encouraged to question the unrealistic ideals of body image perpetuated by the media.

As children are becoming susceptible at younger ages, McVey would like to see the programs initiated in grades four and five — before kids face stressors that could trigger body image obsessions. McVey isn’t limiting her efforts to girls, and has developed other school-wide strategies. “Developmentally, what’s important to children is the adults in their world, so we are targeting teachers and parents, increasing their awareness that what they say or do has a huge impact on children.” Parents also need to just listen, as many girls who suffer from eating disorders have lost their voices, feeling they have to please others.

Natenshon agrees that parents shouldn’t inadvertently convey negative messages through dieting regularly, skipping meals or substituting power bars for meals. “A lot of times when I ask people what healthy eating is they say, ‘fat free’ eating. That’s not my definition. Balanced, fearless — that’s healthy eating.”

On a national level, advocacy is needed to address funding and increase awareness in many spheres, such as government. As Chantal Martineau, a nutrition advisor with the Office for Nutrition Policy and Promotion at Health Canada, puts it: “We do not hear messages as much about eating disorders.” Parents and the medical community need to speak up.

That’s what Elizabeth Komar is doing. No longer hiding her pain, she says, “Now I’m very open. If I can help one parent, I will.” Four years after her diagnosis, Monica is still battling eating disorders. And although Komar allowed her daughter to vacation in Europe last summer, she insisted Monica attend an intense eating disorders workshop at Sick Kids Hospital beforehand. Every day she prays there’ll be a turning point for her family. “I wouldn’t wish this on my worst enemy.”

What About the Boys?
Boys may be the forgotten victims of eating disorders. Although they represent a small percentage, evidence suggests the number is rising.

Between 2002 and 2003, Gail McVey, director of the Ontario Community Outreach Program for Eating Disorders, surveyed 670 Ontario boys between ages 10 and 14 to identify dieting behaviours. According to the results, of the 25 percent who were dieting to lose weight, 56 percent were exercising and about five percent were using laxatives or self-induced vomiting.

While boys are also influenced by socio-cultural factors, such as the media and teasing from peers, and warning signs are virtually the same, there are some key differences from girls with the disorders. According to a UK report, the triggers for boys are centred on the roles and behaviours considered acceptable for males. They are more likely to be losing weight for a sport, cite bullying as a part of their problem, and focus on medical, rather than aesthetic, reasons for being thin. They also express shame about having a “girl’s problem.”

A lack of funding creates additional hurdles for boys. “We can barely keep up with the demand for females, so males have to enter a peer support group with 12 females,” says McVey. Sadly, the result is that often boys drop out before receiving the support they need.

To Learn More
Effective Meal Support: A Guide for Family and Friends. Contact Margo Catamo, BC Children’s Hospital, 604.875.2260 or mcatamo@cw.bc.ca.

When Your Child Has An Eating Disorder: A Step-by-Step Workbook for Parents and Other Caregivers, By Abigail Natenshon, Jossey-Bass, 1999. Also visit Natenshon’s website at empoweredparents.com.

something-fishy.org, a pro-recovery website, offers loads of articles about eating disorders, culturally-specific information, first-person accounts and online support. The site is also available in French and Spanish.