How Do I Know If My Child Has an Eating Disorder?

Ask Lisa Podcast, Ep. 37: How Do I Know If My Child Has an Eating Disorder?

The Ask Lisa Podcast does not constitute medical advice and is not a substitute for professional

mental health advice, diagnosis or treatment. If you have concerns about your child’s well-being,

consult a physician or mental health professional.

REENA: Okay, so you know I’ve been talking about the struggle to go back to my pre-COVID weight, drinking lots of water, but it’s interesting, we have been getting some letters about children and their relationship with food, and we got this fascinating letter from this mom who says: ‘I have three teenage daughters. Obviously in the house with four females the topic of weight and physical appearance definitely gets brought up. I grew up with a mother who was on a new diet every Monday and constantly discussed her weight and dissatisfaction with her body. I spent the past 18 years with my girls focusing on healthy eating, never using the D, diet or F, fat words, staying physically active, and trying to avoid making negative comments about my body. We mostly keep healthy foods in the house but I also believe in not depriving ourselves of treats. This has generally worked really well for us until recently. For the past six months or so my middle daughter, age sixteen, has been really trashing her body. She complains constantly about it and goes back and forth one week eating almost nothing and constantly working out to the next week of eating everything in sight and spending all day on the couch. Three of her closest friends have developed eating disorders this year and are receiving a lot of praise from their group for how great and skinny they look. I’ve broached the topic with her numerous times without pestering too much, but I’m not sure exactly how and what I should be doing. Any advice? Many thanks to both of you. I’m hearing there’s so much more from parents.

LISA: I am too, Reena, I am too. Clinically I am hearing it. I actually wrote a column for The New York Times about this. I  interviewed experts around the country. What one expert said to me in that interview was that eating disorders among teenagers are exploding in the country.

REENA: Why do you think that is? Why now?

LISA: Well I think it’s been going on to be honest. I think that it has had rumblings from early in the pandemic, and I saw early surveys where kids were talking, and by kids I mean both boys and, girls talking about worries about their body, worries about how they look, I certainly people who treat eating disorders have been really aware of this for a long time. I think it may be rising to the level of a broader consciousness just because the eating disorders, I hate to say this, are getting bad enough that they are visible or that people are finally talking about them. I think there’s often some shame around eating disordered behavior, and so parents may not actually be sharing or talking about it until it is no longer deniable.

REENA: Wow.

LISA: Yeah, so it’s been there, but it’s I think becoming more visible in a way and the whys, oh, Reena the whys, I mean there’s so many whys, and and so many that actually anybody in the pandemic can resonate to. So, there’s things like you know our patterns got all messed up. Our relationship with food, when we ate, where we ate, access to food. You know we have access to food all day. You know that is different.

REENA: Yes. That’s huge.

LISA: Our activity levels got all messed up, we’re not moving in the ways we were, and so then we don’t always fit into our clothes the way we did.

REENA: So, I want to ask you, how can you tell if your child has an eating disorder?

LISA: I think there’s very discreet and obvious things to point to and there’s also like the gut feeling, I mean there’s like a gut feeling. So, in the experts interviewed they’re like if your gut is telling you to be worried, you should be worried, like pay attention to that and get your kid checked out by a physician, but then there are other things you can say, so this this mother describes really beautifully of like this you know eating very little and then exercising very intensively in one week, and what you hear in that is actually a joylessness to it. Right? That food has become an enemy, it is something to be avoided and minimized and controlled and contained, and exercise has become like a punishment. You do it in this really kind of you know obsessive and intensive way. If you’re seeing that like you should be worried. And then this mother also describes eating everything in sight and you know being very you know, flopping on the couch I think that’s what she said. So if you are seeing your kid hoard food or consume huge volumes of food or food’s disappearing or you’re discovering wrappers you know things like that could either be binge eating, which is a disorder in its own right, or bulimia, which is in a binge eating and then what we call compensatory behaviors like vomiting or intensive exercise or use of laxatives diuretics. If you have a sense that any of that is going on go to your physician,  and one of the things that we know to be true about eating disorders is they are sneaky, they sneak up on people quickly, they can take hold very quickly, and kids can become medically unstable very quickly. If you’re worried don’t wait and watch. Get a physician involved.

REENA: Wow. What would you say to this mom because she’s talking about how her daughter’s friends have already developed eating disorders, and she says here her words: ‘I’m trying not to pester her too much’ but she doesn’t know how to approach this. What would you tell her she should be doing now?

LISA: In terms of how to approach, right? How to even do the approach, my guidance on this is that the frame the parents should have in their mind, and the frame that they should bring into these conversations is that we want our kids to be taking really good care of themselves, and that’s a good kind of north star for having these. So, she might sit or daughter, honey when you’re not eating as much as your body requires you are not taking good care of yourself. When you are exercising in that intensive obsessive way you’re not being good to yourself. Exercise should be fun. We should be doing fun activities. When you’re eating everything in sight, what it tells us is that your body has become very out of tune, that your hunger is so huge, maybe because you haven’t been eating enough. That’s not taking good care of yourself, and so our goal as parents as we don’t want to know how but we do want to get at the reality that what they’re doing is potentially  a very dangerous we want to always push the idea of taking good care of yourself, eating when you’re hungry, eating a wide variety of balanced and enjoyable foods, exercising in a way that’s physically enjoyable, it’s all about the self care and putting it there really helps.

REENA: You mention it’s all about the self care, and you also mention about the loss of joy. There’s not many ways to find joy, and I think for so many of us food has been that comfort and that joy.

LISA: That’s right. Right? I mean we are stressed, we are anxious, we are near the refrigerator right? And so are our kids, and of course then we know that what we call emotional eating can rise in the context of feeling stressed or feeling bored. You know one of the experts I interviewed for the column said like, when kids are in school physically the fact of being in school becomes a barrier to emotional eating. They’re not around a refrigerator. And then you’ve got a poor kiddo who may be home all year, or much of the year, and who of course is unhappy and bored and, you know, anxious and stressed, and of course food helps us feel better, but it what it does is it then just starts to really change in very powerful ways how we relate to food.

REENA: Yeah. What about boys because they’re also concerned about body image? Is this an issue that affects boys as well?

LISA: It does. It does, and they go on to be unrecognized. It goes under-diagnosed because we really have this idea of like it’s a girl’s challenge or it’s white girl’s challenge, like there’s also that belief, and what we know is in boys and kids of color you definitely see eating disorder behavior. In boys it’s more likely to take the form of talking about being really fit or getting really lean or getting really muscular, so that’s sometimes how it gets missed, and we talk about it. The terms we use, not that this is really all that essential, but we call it body dysmorphic disorder, like a real preoccupation with not seeing themselves as fit enough, and so they may not talk about thin-ness in the same way but they are definitely coming to the conclusion their body doesn’t look right and needs to be fixed.

REENA: You mentioned this as sort of being what you call a white girl problem. What about people of color? Kids of color? Does this affect them? What are you seeing in the research?

LISA: We do see this and we consistently see this, and again just like with boys it gets missed because of this view that it’s a girl thing. It gets missed and kids of color because of this view that it is only for white kids, but we do see it, and we also see there’s some breakdowns that are fascinating, that I learned about while researching this article where Latina girls are very high in the rates at which they’re using like laxatives and diuretics as weight control behavior, so you see these pockets where there’s I guess, I hate to say, like surprising but like real evidence that different cultural groups may engage in different kinds of weight control behaviors, and that there’s just tremendous variety out there in terms of who eating disorders affect, and then also you know we see some very specific things in in particular populations about eating disordered behavior. The bottom line, bottom line, you see eating disorders everywhere. At every level socioeconomically, across all genders, across all races, and you also see elevated levels in kids who are gay, lesbian, bi, trans, or you know in a gender fluid place, and so we do huge harm if we assume it’s only going to show up in white heterosexual girls.

REENA: Yeah, and for so long I feel like that’s the image that eating disorders have had, and you’re telling me that’s so wrong. It affects boys, it affects people of color, it affects so many other communities. We’re not talking about this.

LISA: We’re not, and we need to. The other thing, you know, Reena, like I say it all the time, like you know I’m not against social media. The other thing we’ve got to talk about is where social media comes into this because it does, and it does in worrisome, worrisome ways. So, kids are home. They have tons of time on their hands, they, of course we know from data, they’ve spent a lot more time on social media, which is largely a good thing, right? Largely they’ve been able to connect and get support and stay connected to their peers safely, but social media is tricky in this. The first part is it’s visual. They’re looking at their peers, and what’s important, especially I think in the pandemic, they’re not checking the image of the kid they see online against how that kid looks in real life. You know how you can always get a photo where you like how you look, and then you’re like, oh I don’t like that photo. Like no kid is putting up a photo where they don’t like how they look, so you can get the angle, you can get the the shot that is the most flattering, which may not actually match with what that kid looks like walking around in real life, but kids can’t see that now.

REENA: Right. Right. You know what’s interesting, what’s sticking out in my mind? You keep saying that this is a sneaky thing, that just really speaks up on parents. What do you mean by that? Like why should parents be so concerned? Because I feel like you’re hitting the alarm bell on this, that people are not taking this as seriously as they should.

LISA: Yes. That’s right. In terms of why to be so scared, eating disorders are really dangerous. Anorexia is highly lethal.

REENA: What do you mean? Like why is it so dangerous? What does it do?

LISA: Anorexia is not unlikely to lead to death. That there is a significant, I think it’s around 10 percent of people who become fully anorexic, can die from anorexia. It’s a very alarming number, and the sneakiness, there’s a lot of levels of sneakiness. One is often it looks like, I’m using finger quotes “healthy behavior” at the start. Parents are like, oh that’s fantastic you’re cutting out dessert or that’s fantastic you’re working out more, and so there’s a sneaking, where a kid gets on a road that turns out to be a very frightening road, but at the start of the road everybody is cheering, and then, I mean this letter had some of the sneakiness, then sometimes they start to drop weight and people are like, you look fabulous, right? So continuing to reinforce it, and then what happens is their thinking really becomes compromised by hunger, and so they lose the ability to maintain perspective on what they’re doing or to question what they’re doing. So that’s a sneaky aspect. The other sneaky aspect, actually, is the social media piece, and this I learned about while researching this piece for The Times and it really made me uncomfortable and kind of blew me away, and I don’t think I should have been the surprised, but when kids are looking at social media, and especially things like TikTok that have advertising algorithms built in what TikTok does is it notices what you search for and then it feeds you more of that.

REENA: Oh wow right. The algorithms.

LISA: Yup. So when kids start searching for fitness or weight, and there’s this whole like fitspiration universe on social media of images of these very slim or ultrafit, but when they start searching for it, well then TikTok starts serving more up to them, and these before and after pictures, and then advertisements for diet supplements, things like that. So, part of where it gets really frightening to me is that kids can sort of fall down a social media rabbit hole or they can get pulled down a social media rabbit hole, and then, you know, absent the broader world this becomes their input. Their input becomes a, as kids say, a side of TikTok, which they’re describing the algorithms, like you’d end up on different sides of TikTok. They’re describing a side of TikTok where they are swimming in content that normalizes pathological weight control.

REENA: But what do you do? How do you redirect because the truth is they’re not getting off TikTok. This is, as you’ve mentioned before, their town hall. This is how they’re communicating. So okay you can have a conversation about algorithms, but what else can you do? You can’t get them off social media, and it’s feeding into the problem.

LISA: Totally, totally. I mean you can’t get them off and it’s a problem. I would say you start talking about it, talking about it, talking about it, right? That what you are putting into TikTok is actually then crafting what you can get out of TikTok. I would be curious about what side of TikTok your kid is on, and I’ve said this before, I love the way teenagers talk about this, like you know the various sides, and if your kid has found themselves on a side of TikTok where there is an abundance of imagery around weight loss and fitness, I would take that very seriously. I wouldn’t be like, oh well, we can’t control social media, I would say to them, I think the side of TikTok you’ve found yourself on is very dangerous. How do we reset this? How do you take a break from it? How do you change the algorithms that are driving what you’re seeing? I would not mess around with that, and that’s actually the prevailing wisdom on eating disordered stuff, like you don’t mess around with this. This is dangerous and gets out of control quickly and can become a long battle. So you know I often argue for a fair bit of like being relaxed about social media, and there’s places where I don’t feel relaxed is the right approach, and if you worry that your kid is flirting with an eating disorder and social media is part of the problem, I would make a big deal of that. I would maybe limit their access. I would maybe contain what they’re looking at. I would take that very seriously.

REENA: You’ve also said, I’ve heard you say today, don’t watch and wait. Listen to your gut. What are the resources for parents at this point if you don’t know how to proceed? What’s step one?

LISA: Step one is I would call your pediatrician and have your kid evaluated. You know, get a weight, get some blood tests, make sure that they are stable, physically. You need to know that. You absolutely need to know that as a parent. If your pediatrician is worried at all, hopefully they can direct you to some resources. That said, and oh, Reena, I hate this, the mental health world is swamped. We are swamped. It is so hard to get in with anybody, and this is what I found when I was researching my piece for The Times. Everyone I talked to said our resources are out-stretched. Like we we can’t take more people, and so one thing that the experts I talked to that I found really helpful is they directed me to, there’s some good online resources, which one expert said it’s not ideal but it’s where we’re at, and so there’s the National Eating Disorders Association has an excellent website. There’s several other excellent websites, and we will put them in the show notes, and these are vetted. These are high quality. These are reliable resources about how parents can help their kids if they’re worried at all, how parents can help their kids if they’re on a wait list for treatment, which I hate saying, but that’s where we are. That’s where we are.

REENA: That’s so troubling to hear it’s taking months for parents to get kids help. You know that they’re just overloaded at this point. If you are in that situation and you can’t go in to see somebody immediately, what do you suggest? I mean how can you go in to see your pediatrician, great. You’ll get some great advice, but how do you approach this? One I want to start first to ask you how do you start having these talks with kids so you don’t get down that route, and if you do get down that route what’s the best reaction?

LISA: If you’re worried about your kid’s eating I would just say it. Our kids know, you know, they know when we’re being cagey. I would just come right out and say it. I would say, kiddo I love you, and I have to tell you that I am worried that your relationship with food or exercise or weight, whatever it is, I would worry that it is not where it belongs. I’m worried about you and I don’t want you to have to deal with this now or down the line. I would be really had on, and either look at websites with them, actually National Eating Disorders Association has a screening tool that you can actually fill out yourself, so that you can involve a neutral third party on a website that they can highlight whether there’s grounds for concern. The rule, though, the rule in eating disorder treatment is early intervention matters. A way to think about, and there’s some problems with the substance abuse and eating disorder analogy, so don’t take this too far, don’t you know hang your hat on it forever, but you know you think about like say a kid’s been smoking weed for three weeks, and you’re like dude you’ve got to stop, right? That’s one thing, versus say a kid’s been abusing weed  for a year and you’re like, dude you’ve got to stop. You know intuitively or having two different conversations, and for me that idea also applies for eating concerns. If your kid’s been suddenly counting calories, or restricting food categories for three weeks, your chance of being able to turn that around is a lot better than if they are a year into a highly restrictive or binging and purging pattern. So, early is better. Early is definitely better.

REENA: You know on top of this I talk a lot, honestly, about how you know I want to lose my COVID weight, but I also know I haven’ tbeen walking and taking the steps that I normally do. I’m working out with my group in the neighborhood. I feel great. I love the way I feel after exercise. We talk about healthy dinner options and everybody weighs in. You know, while I’ve gained weight, I feel really good also about where I am. You know I’m not down on myself about it. What do you say to parents who might also be struggling with their weight? What should they be doing? They want to get back on track but they don’t want to set a bad example about dieting.

LISA: Exactly, and we see the data. I mean the data on weight gain in adults is amazing. I mean adults have gained a lot of weight in the pandemic and kids have gained weight in the pandemic too. And in the letter, you know, this mom had it just right like you don’t want to talk about diet, you don’t want to talk about fat, and yet people are also like, I’d like to also where my old pants, you know, so trying to reconcile that as a family is not easy. The experts I talked to for the piece I worked on for The Times they said, and I thought this was so smart, they said, talk about going back to old patterns. Talk about returning to the patterns that we had before the pandemic. How we moved, how we ate, when we had access to food when we were not near food, as opposed to talking about it in terms of dieting or shame around our bodies or restricting foods. It’s really important that we model for kids a balanced approach to eating, that we enjoy all foods, that we eat in ways that are enjoyable and also nutritious, and that involve treats, as this terrific letter writer included. Anything we can do to steer clear of what we call diet culture, you know, this view of human value being tied to a number on a scale. Anything we can do to steer clear of that we have to do all the time, and then in this horrible perfect storm of kids with too much time on their hands, kids who are able to become preoccupied with their weight because they’re looking at people and looking at themselves way more than they usually do, and then of course the weight gain yeah some people are struggling with.

REENA: I’m so grateful to this mom who sent in this letter because it opened up so many things to talk about, particularly that it affects more people than you think, and that to hear you say in this pandemic using the numbers skyrocket and it’s hard getting into treatment because the places are so overwhelmed. It’s really remarkable.

LISA: It’s breaking my heart, Reena, I have to tell you, and I didn’t see this one coming. I was really worried about substance use in the pandemic, and depression.

REENA: That’s surprising. Because you focus on eating disorders, that’s like one of your specialties, and to hear you say that you’re surprised to see just how much this has exploded. That’s remarkable.

LISA: Yeah I mean I’m not a specialist like the real specialists, but I know enough and I didn’t see it coming and I worry it’ll actually be one of the lasting legacies of the pandemic.

REENA: Wow.

LISA: So it’s how all the more important that we as adults keep a close eye on it and model the right behaviors, get our kids help if we think they may be moving in that direction, but it’s tough and I know it’s tough for families, and I’m so grateful to this mom for writing in as she did.

REENA: Yeah. Boy, I tell you you find these topics for this podcast, like that the porn one, I encourage if you guys have not listened to the porn episode, I was blown away and one of our top performing podcasts, and this one I think, great advice for people who really might not have known about this. So thank you, and you have a fantastic For Children Everywhere today.

LISA: I do. So, one thing that I did not know until recently is that food insecurity is also associated with eating disordered behavior. That when people don’t have enough food eating disorders rise, and in teenagers it can involve things like fasting, skipping meals, using laxatives, using diuretics as a way to control weight, and that was surprising to me to learn and yet at the same time you think, oh food insecurity has so many anxieties around eating and food that of course eating disorders are going to be one of the one of the ramifications. So, for For Children Everywhere today I want people to know where their local food banks are. If they want to donate to their local food banks, and so we’ll put in the show notes the link and it comes from the website Feeding America, which deals with food and security questions, and we’ll put the link to the page on the website where you can locate your local food bank and make a donation to help address food insecurity in your community.

REENA: And we’re also going to have your fabulous article in eating disorders from The New York Times just as soon as it’s out. You can check out our show notes, and would you have pressed for parenting to go?

LISA: For parenting to go I want adults to be mindful about how we talk about food, both for ourselves and then in front of kids, and we want to try to steer clear of value judgments about food. Calling foods good or bad, or healthy food or junk food, because when we see kids going down the eating disorder road, often it’s because they decided to cut out so-called bad foods or so-called junk foods, and that’s where they can really start to get themselves in trouble. One of the phrases that I came across while researching my column for The Times was the idea that all foods fit, and I think that that’s how we want to approach eating and food, we talk about it with our kids and also think about it for ourselves.

REENA: That’s really great. I learned so much this podcast. Thank you, Lisa. I’ll see you next week?

LISA: I’ll see you next week.