They came to their visit together. Jessica (not her real name) did not want t be there. I let her stay in the waiting area fixated on her cell phone (she made up her mind she hated me, at least that is what her facial expression conveyed). Instead, I took her mother into my individual counseling room to get the story before I met with Jessica. It was one I have heard before. In fact, the entire scenario became predictable. Mom was all over the place, at first angry that her teenager was being so rebellious, she was driving them all crazy. She refused to go anywhere with the family, she hid out in her room, refusing to sit at the family dinner table. Vacations were a night mare. “She used to be such a sweet girl, so happy and care free, she LOVED helping me in the kitchen and really enjoyed going out for pizza with the family, but now she is like someone else. We don’t know what to do”. Next, after the anger, comes the crying. “She looks horrible. She passed out the other day and it was so scary. Yet, she won’t stop this. It does not make sense!”Jessica took to wearing very loose and baggy clothes, and it wasn’t until her mother walked in on her changing that she noticed her protruding ribs and the obvious weight loss. After lots of threatening, Jessica agreed to go to her pediatrician’s and was then referred to us. How did it get to this point, and how did this family miss it?

Eating disorders can happen at anytime, but transitions are especially tough. Back to school, back to college, back to normal life. Simple, predictable, or is it? Not for everyone. Times of transition and change, such as starting a new school, going away to college, new teachers, different friends, all of it can be a challenge for some kids. Times like these can be risky when it comes to falling into the grip of an eating disorder. Couple that with society’s obsession with losing weight and it is pretty easy to understand why lots of eating disorders often go unnoticed until it is almost too late. As a parent, what signs or symptoms should you look for? Some things that you should not ignore:

• Weight loss. Sounds obvious, but actually, especially in teenagers who are larger or fatter, parents mistakenly tend too think the weight loss is a “good” thing. Even doctors make the mistake of automatically praising weight loss, especially if it brings a child closer to a “healthy” BMI (gag).  That meaningless number does it again…….clouds the judgement of otherwise smart and well-meaning people (parents and professionals alike). The great news is the American Academy of Pediatrics came out with a new report in August highlighting the risk of treating obesity in adolescents with disordered eating as well as the importance of focusing on health verses weight. See this article in American Academy of Pediatrics for the specifics. The bottom line is that we need to get off the losing weight bandwagon, fight the cultural message that everyone needs to be thin, or a certain BMI, and NEVER EVER praise weight loss in a teenager. Yes, there are times when a kid may lose weight. A teenager who is very sedentary who goes away to college and finds themselves having to walk 9 miles a day just to get to all their classes may indeed lose some weight. This is not what I am talking about. But even then, making a big deal about weight loss is never good. Even this kid, if they get lots of attention for losing weight may decide they like the attention, and start doing things to purposefully lose weight (I have seen this happen many times). Don’t do it. Don’t compliment weight loss in a kid. Instead, compliment growing up and being successful.
• Food refusal. When your teenager has always loved your home-made macaroni and cheese, and even begged you to make it, but now refuses to eat it, NOT GOOD. Unless there is a really good reason for refusing a favorite (recent stomach bug, stomach ache, cramps, etc) don’t ignore this red flag. Should you try to force your kid to eat it, or pressure them to answer you as to why they don’t want it? Like I said, one refusal because they don’t feel good is normal, but a few times in a row is just not normal, however responding with anger is not helpful. Instead, I have found those parents who are able to open up a caring dialogue with their teen have a better chance at getting to the bottom of it. It is important to pay attention to all signs and symptoms so you can then make a plan to address it. Forcing food or anger does not help.
• Decreased socialization. For a teenager with an eating disorder, any situation that involves food and eating is threatening. You will start to notice they don’t want to go to their friends houses, or to birthday parties, and they especially will try to get out of family functions (those typically aren’t a teen favorite anyway, but they are doubly horrifying because of the food involved). They may lose interest in going to what once was a favorite restaurant and a big treat. They will refuse to eat the family’s favorite pizza on “pizza night”. Red Flag.
• Loss of menstrual period. Not that you need to keep track of your teenage daughter’s cycle, but if you notice she does not ask you to buy feminine hygiene products the way she usually does, ask. Don’t ignore it as this can be a sign of weight loss and inadequate calorie intake.
• Obsession with exercise. If you notice your teen going out for long runs, or running both morning and night, or if you notice the bedroom door is always closed and when you walk in she just so happens to be exercising, this could be a sign that something is not right. Yes, being active is good for all of us, but if doing calisthenics is something new and different, and especially if your teenager seems to be hiding it, then this is also a red flag.
• Going to use the bathroom after every meal. If this has always been normal for your child that is one thing, but if it is a new behavior, it could mean they are purging or throwing up their food. You can check the bathroom for evidenced or you may hear it, but don’t ignore this. Vomiting on a regular basis is an eating disorder behavior and could leads to electrolyte imbalances that can be deadly.
• Body checking. Do you notice your teenager looking at her body, especially her stomach obsessively? Does she tend to squeeze her arms as if to check for fat? This is a common behavior for people with body image issues and should not be ignored, especially if other signs are present.
• Obsession with food labels, writing food in a journal, or counting calories. I can’t tell you how many food journals complete with calorie counts I have seen in my life. It is NOT normal. It is NOT a good thing. Yes, there are apps and websites and even the My Plate site has trackers for this. I hate them.This is as far away as normal, intuitive eating as you can get.

So what should you do if you notice any of these symptoms? Remember, your teenager is not doing this on purpose. They can’t stop. It is a very complicated disease and the triggers and causes are different for each person. It is important to be empathetic, kind and loving and to avoid blaming as this will not help. The first step might be to call your pediatrician and share your concerns. They will probably want to see and evaluate your child and may recommend therapy and a visit to a dietitian. Be sure that both specialize in treating eating disorders. Your teenager probably won’t be happy, but you can also get support from the therapist as far as how to handle resistance. The sooner you address the issue, the better chances for recovery. Remember, it does not matter what size your kid is, if they are fat or thin. It is very easy to ignore some of these red flags, like I said, some are so socially acceptable and desirable that it is sometimes hard to see what is going on. Don’t ignore these signs. They won’t go away on their own, and the longer you put off getting help the harder it will be.

There is hope. You can get your old teenager back.But you gotta move fast.

For more information and for great resources, check out the website: Eating Disorders Awareness and Prevention.