When an eating disorder develops in a child or teenager, parents and family members are shocked and mystified about what is really going on. The binging and purging behaviors of an anorexic or bulimic teen can seem bizarre and frightening to those who have not seen it before. What seems most shocking perhaps is that otherwise "normally-functioning teens" can be hiding such powerful and destructive impulses that control their lives from the inside out. The universal element in an eating disorder is not just a problem with food or with weight. It is the use of food intake and weight control to solve unseen emotional conflicts that is the defining principal of an eating disorder. As noted by several experts in the field, eating disorders represent an attempt by individuals to use an external solution to solve an internal problem.

Sara is a 15 year-old sophomore distance runner, who recently earned first place at the regional track event. Her daily running regimen serves to counteract unrealistic fears about becoming fat. Having felt insecure and marginalized in her peer group since her parents divorced and she moved to a new school in the third grade, Sara has been prone to anxiety and self-doubts that undermine her sense of worth. Her daily workouts involve two hours of intense aerobic exercise, and she knows she must perform these repeatedly until she feels exhausted and barely enough energy left to do her chores or interact with family before going to bed at night. Her workouts have become the single most important aspect of her daily routine. Without them, she fears she would gain weight or become visibly unattractive. Throughout her day, she is plagued by thoughts about her body appearance. In class, her thoughts drift to how her clothes feel too tight, maybe pinching her at the waistline. "Ten extra laps," she tells herself, reassuring herself that she can make up for her breakfast calories by the end of this afternoon's practice. By the end of her workout, she'll feel some relief. However, exhausted and depleted of her body's needs for sufficient rest and calories, she may be setting herself up for strain injuries or even malnutrition.

Lying just beneath the surface, many teens suffer from painful thoughts about their physical appearance and body image. When the thoughts become so prominent and destructive that they dominate the teen's entire daily schedule, an eating disorder may be on the rise. An anorexic teen may begin to restrict calories as a response to panic feelings that develop during the onset of normal weight gain associated with the hormonal changes of adolescence. She might initially feel relief or a sense of control over her body after skipping a meal, so she starts to experiment with skipping more meals and restricting more calories. Soon, her whole daily regimen starts to revolve around this drive to feel a sense of mastery over her outer appearance, through carefully constructed plans to minimize her intake of food. Food becomes the enemy, and she finds herself planning her day around how to avoid eating. The starvation she feels as her malnourished body craves needed calories is ignored. She continues a deadly cycle of skipping meals or eating maybe an apple or a few leaves of lettuce with carrots at lunch. Her ability to concentrate and learn is impeded, and she has dizzy spells and faintness at times. Friends' and parents' comments that she looks "too thin" are discounted or seen as potential threats to her goal of weight loss. No matter what he appearance, she feels constantly aware of extra weight or loose skin on her arms. This young woman may be dehydrated or possibly close to a chemical imbalance that could be deadly. On the surface, her moodiness and irritability are signs that her body's health is out of balance and needs desperately to be fed. Any efforts others' make at changing her behaviors however, will be seen as threats and quickly thwarted.

Teens fall into many different forms of eating disorders. They may restrict food intake throughout the day, until overtaken by hunger and binging on large amounts of food (often junk food or "empty calories") at night. They then feel panicked and driven to rid themselves of the calories through either exercise or purging and restricting again the next day. This cycle seems endless and exhausting. They may feel intensely shameful about their behaviors and a sense of lost control. Restrictors may briefly achieve a sense of mastery or control when their empty stomach signals thinness has been achieved. However, this is only short-lived and must be followed by compulsive restricting in order to be maintained. Bulimic teens purge after eating, through either excessive exercise or through vomiting or use of laxatives or diuretics. Yellowing teeth are a sign of eroded enamel that occurs when repeated vomiting damages the teeth's outer coating. Bulimic teens may maintain a normal weight despite their efforts, while anorexic teens continue to be underweight, missing their normal menstrual cycles, struggling to concentrate and developing heart irregularities and possibly kidney failure. Their behaviors bring them dangerously close to death, and many will eventually die from the disease. More recent attention has been given to a destructive cycle of binge eating, where the individual gains excessive weight due to recurrent binge eating episodes that are not followed by attempts to purge or restrict calories. These individuals feel a similar loss of control and shameful sense of isolation in their daily battle with food.

What can parents do when their teens develop these dangerous behaviors? The first step is to call a spade a spade. Kids in these destructive patterns will inevitably deny that there is a problem. But parents know this is not true. There must be intervention to stop the destructive cycle and restore needed balance and nutrition before it's too late. The cycle of denial can permeate family systems and keep problems from being addressed (the proverbial "Elephant in the Living Room" effect). This only serves to further the isolation and despair that a teen experiences. Do not be timid and do not be dissuaded. The disease of Anorexia kills many teens, and their bodies will begin to quickly shut down once they reach an irreversible state in the disease. Become educated by a local specialist in eating disorders, such as a local psychologist (American Psychological Association, apa.org, click on "find a psychologist"), or an eating disorders program at a Children's Hospital. Reliable information can be obtained through websites such as nimh.gov and medline.gov. Organizations like the National Eating Disorders Organization (NEDO) and the American Anorexia/Bulimia Association Inc (AABA) can be helpful resources. Dr. Christopher Fairburn is the leading expert on a type of treatment that has proven success in treating eating disorders. His Cognitive Behavior Therapy for Bulimia, Anorexia or Binge Eating Disorder is practiced by many psychologists and psychotherapists who specialize in eating disorders in their private practices or clinics around the country. Teens can attend individual therapy to reverse their behavior patterns, but family therapy is often most helpful to reverse harmful communication patterns that cause problems to develop. Parents need help responding to their teen's destructive patterns, and teens need education about the consequences of their behaviors and learning to control destructive patterns. Some teens may be willing but many need help developing motivation to change their ways. Specific residential and in-patient programs are designed to help teens and adults struggling with more severe forms of eating disorders. Many other programs exist and can be helpful. Consulting with a therapist or psychologist locally may help parents to find appropriate resources and become educated about the next step.

In summary, eating disorders represent the individual's attempt to solve an internal conflict or problem by controlling their external bodily appearance. An obsession with their body and weight may lead to destructive cycles of restricting food intake, then either binging and/or purging afterwards. Problems with self-worth and self-acceptance are central to eating disorders. The binges and purging are a source of shame and isolation for the individual, and there may be a strong tendency to deny or hide their problem. Parents can interrupt the cycle by refusing to go along with the denial and by accessing help and education through therapy and specialized resources.

About the Author: Nicole Pray, PhD, is a licensed clinical psychologist who works with individuals with eating disorders in her private practice in Glenwood Springs, Colorado. She began seeing teens with eating disorders during her work in wilderness and residential treatment of adolescents in the early 1990's. She led eating disorder groups at The University of Montana Counseling Center and at The Seattle VA Medical Center. She has lectured on eating disorders at local schools and has helped mentor teens in developing prevention efforts targeting their peers with eating and body image issues.