Kyle: So Dr. Ho, with a child or a teen, how would they act if they were hiding an eating disorder?
Dr. Judy: Depending on the exact presentation, you might start to find that there’s food missing in the home. You might find that the child or the teenager is actively avoiding family meals at all costs.
They have a stomach ache. Oh, they have plans with their friends. They’re going to the library to study. Just anything that would avoid public eating in any way. You might find that they’re becoming more secretive. They come home and they just go right to their room and they don’t come out until they’re forced to. You might also find that there are more emphasis on appearances.
They’re looking at other people and commenting on their appearances, or talking about themselves and talking about some dissatisfaction with their own appearance. You might also find that they are more sensitive in general. You find that emotionally, they’re becoming more sensitive. Sometimes they’re even behaviorally regressing, acting like younger children.
Again, having severe tantrums. Some of these associated behaviors are all things that parents and other adults should watch for.
Kyle: That sounds just a lot like every 13-year-old girl I went to high school with. So how do you differentiate between a girl who’s just being 13, or a guy, and oh my gosh, we really need to take them to therapy because then we’re pretty sure they have an eating disorder?
Dr. Judy: As mentioned, eating disorders can be very hard to detect from family members and from friends and loved ones because the symptoms overlap seemingly with so many other things. At least what they’re showing you. So much of what’s happening is behind closed doors.
And I think that’s why it’s hard. I think you have to start by saying, “Something is different about my child” and opening the dialogue even if you don’t know exactly what that is yet.
Kyle: Yes.
Dr. Judy: And sometimes you do have more obvious signs, but not always. Sometimes they look like they’re losing an extreme amount of weight or they gained an extreme amount of weight, so that could clue you in also.
If that accompanies some of the symptoms we talked about before, but I think that’s what makes eating disorder so hard sometimes to catch, is that there is all this overlap and they sometimes just look like it’s a developmental thing. They’re teenagers and they just don’t wanna hang out with me.
Kyle: Would a teenager who has anorexia behave differently than a teenager who has bulimia?
Dr. Judy: I think with anorexia, you’re certainly gonna find that there’s a lot of avoidance of meals in general. Avoidance of family meals, avoidance of eating in public. Maybe you haven’t even seen them eat in a very long time. Perhaps you give them money for lunch and you find that the money’s just accumulated in their bag and they haven’t utilized it.
But with bulimia it’s a little bit different. You might find that food is missing in the house. You might actually witness some of the binge eating episodes in your child where they seem like they’re eating really fast, like they’re out of control with it, and then all of a sudden they’ll just disappear.
That’s a hallmark sign of bulimia – in that the minute that they’ve finished a meal, especially one that they’ve eaten more than you would think a person would eat in a regular meal, they disappear right away. “I gotta go, I gotta go to my room.” They go into the bathroom, they’re there for 20 minutes. It’s because they’re trying to engage in some kind of compensatory behavior, trying to make themselves throw up to get rid of the food that they just ate.
Kyle: What is the eating disorder or the classification for when people are only consuming foods with literally no nutrition or nutritional value?
Dr. Judy: That is a type of eating disorder called pica and it means that they are eating non-nutritive substances. Oftentimes they’re eating paint chips or just things that they find around the house, and we find that there actually is a correlation with malnutrition.
Kyle: Wait, so they’re not even eating food?
Dr. Judy: They’re not eating food.
Kyle: So it’s not like they’re eating chips?
Dr. Judy: No.
Dr. Judy: And they’re just eating non-nutritive substances.
They might eat like the piece of a rug, just different household objects. And there’s a correlation with not getting enough nutrition. So we find that in some children, especially younger children, and it’s not even an attempt to lose weight or to modify weight, it’s more just almost like a compulsive behavior because they’re not getting what their body needs.
And so that’s usually more easily fixed because then you can just start to give them more nutritive foods. But there have been some why?
Kyle: I’ve heard of kids eating Play-Doh. But why would a kid eat the rug?
Dr. Judy: Because they’re not getting the nutrition that they need, so they’re just picking up random things around the house and trying to chew on it and eat it.
So there’s some really severe cases where we’ve found in a stomach of these kids just like spools from the rug and just all kinds of terrible objects that you have to remove with surgery.
Kyle: And for me, I’m blaming the parents for not giving their kids food.
Dr. Judy: Exactly. And I think sometimes they think that they’re giving their kids food, but they’re not nutritive. Like they’re food, but they’re not getting nutrition. And kids and nutrition…it’s such a sensitive thing, like you need to be giving them foods that have very high nutrition value.
And so sometimes you can see that if they’re malnourished, not necessarily that they’re not eating any food, but it’s just that the food that they’re being given is not nourishing.
Kyle: And this is for really young children with the pica?
Dr. Judy: Mostly it’s very young children, yes.
Okay. So there
Kyle: Okay. So there are very few 25 year olds who are eating…doing this?
Dr. Judy: Yes, exactly. You don’t find that too much. Another syndrome that you sometimes see with younger children too is an avoidance, restrictive type of eating issue where there’s an avoidance of food, almost like a fear, like a phobia, but there’s also a correlation with sensory issues.
“I don’t like the way that the food feels. I don’t like the way that the food feels in my mouth or on my tongue.” And sometimes you find that there is a correlation with developmental disorders, like different spectrums of autism that can co-occur. And oftentimes with that type of issue, it’s a lot of psychoeducation and also doing sort of behavioral trials of let’s try this food, let’s try this food, let’s make it fun.
And with children, you can use rewards and consequences much more readily. So you can say if you try this food today, then we’re gonna get some video game time after. You try to make it equated to something that is positive so that they start to see food not as something to be feared or avoided, but something that could be associated with pleasant things.
Kyle: What is the youngest patient you’ve treated with an eating disorder?
Dr. Judy: A 6-year-old with anorexia.
Kyle: And because she wanted to look…skinny?
Dr. Judy: No. This particular child was very obsessed with keeping her weight at a certain level, but it was associated with this magical thinking that if she kept her weight under a certain number of pounds, that her parents wouldn’t get a divorce.
It was very sad.
Kyle: What do you think is the average age of a patient who comes in with an eating disorder?
Dr. Judy: Oftentimes the person has struggled with an eating disorder for so long, and by the time that they get treatment for it, they’re in their late twenties or even thirties, yet they’ve suffered with this since their teenage years.
And so oftentimes what we find is that people delay treatment seeking for eating disorders by 10 to 20 years very easily. And even when they do treatment seek, it’s often at the insistence of a family member, a friend, or even a coworker who says, “Hey, your performance is slipping and you might lose your job.”
As opposed to they themselves saying, “I need to do this for me.”
Kyle: If you do see somebody or a child or a teen, who do you go to address those eating disorder concerns?
Dr. Judy: I think if you are a caring adult that’s not part of the family and you witness this in another child or teenager, you start with going to the parents and you inform the parents of course that…here are some of the signs that I’m concerned with and I think you need to take your child in for an evaluation or at least talk to the child about it.
In a portion of those individuals, unfortunately, the parents are also struggling with their own eating issues, whether it’s a full fledged eating disorder or they have extreme dieting tendencies. And in those cases it’s tough because the parents may not even see it as big of a problem as you might.
And so if the child is old enough in their early teens to mid-teens or late teen years, it may be worth a shot to talk to the child directly and say, “This is what I’m noticing. I’m worried about you. What do you think?”
It’s very tricky because obviously under the age of 18, they have to have their parents’ consent to even go to treatment. And so if you feel like your concerns are falling on deaf ears with the parents, it’s worth a shot to try to address it with a child.
But ultimately, the child will then have to go to the parents and advocate for themselves and say, “I think I need to go see a therapist.” And that’s hard to do.
And so I think this is part of the trickiness of what we know about eating disorders because there is that familial link and we find that a high proportion of individuals with eating disorders, there’s some kind of weight preoccupation in the home, or there’s some kind of extreme dieting in the home.
Kyle: If you had to guess the percentage of that, what would it be?
Dr. Judy: 30 to 40%. Very easily. That’s been replicated in a number of studies where maybe the parent or one parent or both parents don’t say, “Hey, I’ve been diagnosed with an eating disorder,” but they admit to, “Oh yes, we diet all the time. We talk about dieting a lot. We talk about weight a lot. It’s a part of our daily conversation.”
I’ve seen patients who have taken their child to eating programs like Jenny Craig or something like that, and they’ll do it together. So it’s almost again, associated with a positive outcome of, hey, it’s parent bonding time.
We’re doing this together. This is fun. And I’ve also had many patients who have told me that as they were growing up, they would have binge and purge days with their mom. And they would go and buy all the food that they wanted to eat that day. They would binge it all, and then they would both purge together.
Kyle: So this is a mother and a child?
Dr. Judy: Yes. Yes. And there’s been more cases than one, so it’s tough.
Kyle: Does the mother not understand that she has a disorder?
Dr. Judy: Sometimes there’s no insight. And sometimes, again, the ego syntonic aspect of the disorder, that gives you the positive consequences of people saying that you look good…it’ll sustain that disorder for that person for a very long time, to the point where they’ve justified to themselves that it’s okay…that it’s not that big of a problem.
Kyle: So why not teach my kid?
Dr. Judy: Right.
Kyle: Because then they can have all these compliments too when they get older?
Dr. Judy: Right. And then we can have this close relationship.
We have a shared secret. There’s something that we get to do just us. And that’s another ego syntonic part of the mother, daughter or parent child dynamic of…this is associated with positive time. This is when I get my mom’s full attention and we have these Saturdays that we just get to have fun while my dad’s at work.
Kyle: but to me that is no different than a mother sitting their kid down and saying, “All right, we’re gonna cut ourselves on the arm today.”
Dr. Judy: Right.
Kyle: Because they’re both self-harm.
Dr. Judy: Right. Absolutely. But one aspect of self-harm is arguably clearly negative. You cut yourself, you could get an infection, you could have a medical emergency.
Obviously it looks terrible. But with eating disorders, that ego syntonic aspect is something that you don’t really see in any other disorders that we talk about.
There’s something positive, somebody saying, “You look great” or if you have that bonding time, then it’s time that you get with somebody that you love.
It’s really sad and it can be very sickening. I find those stories to be much more common than uncommon. I’ll find that sometimes it’s not mother and daughter, sometimes it’s sister and sister, but either way, it’s associated with some positivity somewhere. Or they watch their mom getting compliments and they see that their mom is dieting and they make that association.
“My mom’s getting compliments on her weight and on her size and on how she looks in her clothes. And maybe if I do the same thing, I’ll get those compliments and I’ll get people to be interested in me.”
Kyle: Whew.
Dr. Judy: Yes, it’s really tough.
Kyle: That’s hard for me to hear.
Dr. Judy: Yeah. It’s hard for me to hear about it too, when my patients tell me about it.
And it’s hard not to just have this extreme reaction and say, “I’m sorry, what is that?” And then you see the parents, and then you’re trying to work with the parents and the teenager and the parents are completely aloof and totally not insightful about the things that they have done to create the problems in their children.
And somebody will even say, “Yeah, my child needs treatment, but they still don’t recognize their role in advocating for the symptoms in the first place.”
Kyle: Wow.
Dr. Judy: Yes. It’s really tough. It’s very tough to do family therapy with individuals who have eating disorders.
Kyle: Do most eating disorders start in those early child teen years?
Dr. Judy: Many do. Anorexia usually has a little bit of an earlier onset and bulimia as well. So bulimia tends to start in the mid to late teens. Anorexia can start in the early teens. That’s an average timeframe that they start.
Kyle: So we’re not seeing a lot of 35 year olds developing eating disorders?
Dr. Judy: It doesn’t end up happening for the first time as much in their thirties. Maybe in their teens, they went through a phase of extreme dieting that almost looked like anorexia. Didn’t quite meet the criteria, but then they didn’t actually fully meet the criteria until their twenties or thirties. You can see that.
But very rarely do we see that. It’s a new thing that just popped up with no previous symptoms whatsoever for the first time in middle adulthood.
Kyle: At what point does somebody require immediate action?
Dr. Judy: I think when their weight is so significantly low that they clearly look frail and fragile, and they look like they’re having difficulty getting around.
At that point, they’re probably already experiencing all kinds of internal problems that we can’t see just to the naked eye. I have seen individuals at gyms who clearly have a very thin frame to the point where it’s not just a normal variant of somebody who’s just, on the thin side. And I’ll see that they have been on the treadmill for maybe two hours.
Like when I first get to the gym, they’re on the treadmill, they were already there. And then as I’m leaving, they’re still there.
And oftentimes responsible gym staff will tell them that they have to leave, but, I also wonder if at that point a responsible gym staff should be giving them like a card with resources. You look like you have a problem, excuse my imposition, but I just want you to have this. It’s really scary when you see that and you don’t know what’s gonna happen.
They could just fall down and they could have a heart attack.
Kyle: We’re dealing with such a politically correct topic. People’s weight. We just don’t talk about that, right? We don’t ask how much people weigh. Even insinuating that someone might be overweight or underweight is just a no.
So how do you begin to tell your coworker, look, Jennifer…you’re way too skinny. And I know you say you eat, but we’re not seeing it. And you need help, right? Like I don’t know how you do that.
Dr. Judy: I know when we are fighting the culture of America, which is a very independent culture, it’s individualistic.
And you’re supposed to just be left to your own devices. It’s my business, not your business. I think in maybe collectivistic cultures that might be a little bit of an easier conversation because they oftentimes live with multiple people and there’s that community sense and people are in each other’s business a lot more, and it feels okay to do that.
So I think it’s hard. It is counter-cultural, but if you are not that person who says something, I always say if you see something, you gotta say something. And obviously you are risking them getting upset with you. You might be risking a friendship or a good collegial relationship, but at least then you’ve put it out there and then it’s up to them.
Kyle: Yeah. You wouldn’t say that to a stranger though.
Dr. Judy: I think it’s hard to say that to a stranger. But sometimes you still feel so responsible, like you should.
Kyle: Did you go up to the girl on the treadmill?
Dr. Judy: I have in the past where I’ve been at a gym and I’ve seen this person, they look sick to me and I just let them know, you know what, from what I see, I feel like you might need some help.
You just look very thin and frail and I wonder if you should go for a medical checkup. I don’t insinuate that they have an eating disorder, but I do just let them know what my observations are and I don’t share that I’m a psychologist. I just say, “Hey, you just look really frail. I just wonder if you had gone to a medical check up.”
Kyle: And what’s the reaction to that?
Dr. Judy: Oh, usually they’re like, of course I do. I’m so healthy. I think they’re prepared. That’s the thing. Sometimes when you go and talk to them, it’s not a surprise.
Kyle: This isn’t the first time someone’s talked to…
Dr. Judy: Yes. So they’re usually prepared. They’re actually very pleasant.
They’ll say, “Oh, thank you for your concern. That’s so nice of you. I have been to my doctor. Everything’s fine. I’m just this way.” I’m like, okay, but at least I’ve said something and I’m glad.
Kyle: Does that person exist where they are that thin and they’re just that way?
Dr. Judy: No. I think you can see the difference when somebody has true anorexia versus you just have a thin frame and just a thin person and maybe you don’t eat that much, but you eat enough.
Kyle: Yeah.
Dr. Judy: It’s very different. You can see the difference. Like the collarbone protruding and like the fact that your legs are…your thighs look like the same width as your ankles. That is anorexia.
That is a problem, as opposed to…Okay, this person’s like a live ballerina and they just always look like this.
And probably there is part of them that says, “Hey, I’m gonna watch what I eat.” But it’s not to the point where they’re malnourished and that they’re so obsessed with it that they can’t go on with their activities of daily living without thinking about it.
Kyle: What should parents know who have children that may be susceptible to an eating disorder?
Dr. Judy: I think parents need to educate themselves as much as possible.
Kyle: You’re doing it right now, guys. Good job.
Dr. Judy: So good job. Step one. I think step two is not to be afraid to have those conversations.
Even if the child is a teenager now and they’re like, get outta my face.
You gotta get in their face. We know that parental monitoring and being on top of your kids and asking them where they are and what they’re doing is the single most protective factor towards all kinds of things like problems in school, substance abuse, unprotected sex, mental health functioning.
So you need to stay on top of them and you need to have those difficult conversations. And I would say third, for parents, recognize if there’s anything that you’re doing to maybe not consciously, but unconsciously, give your children a message that they need to care about this kind of thing.
That they need to be a certain size to be accepted, to look good, for that to be ideal. Oftentimes parents don’t realize that they’ve complimented their children on their weight. I know it’s hard because it’s cultural to say, wow…especially if you had a kid who was a little overweight and they lose some weight…you look really nice. Looks like you lost some weight.
But it’s very difficult for people to look back and say, wow, there’s some things that I’ve done. Because they’re so cultural, they’re kind of cultural norms.
I always encourage parents to not use size as a compliment, but just to say things like, “You look really healthy” because if somebody loses weight and they were overweight before, a viable compliment is that you look healthy.
You look like you’re taking care of yourself.
Kyle: And we want to encourage healthiness. We don’t want to say at least they’re overweight. Overweight also has health consequences.
Dr. Judy: And it could be an aspect of binge eating disorder or bulimia. So it doesn’t mean necessarily that they’re actually not suffering.
But I think it’s important to reframe what we compliment our children on, and also think about what you’re saying in front of your children. Are you saying things like – I can’t eat anymore and tomorrow I’m gonna have to not eat breakfast or lunch because I ate such a big dinner?
Once you’re a parent, you have such a big responsibility. You can’t say certain things. You have to really think about the impact it has on your kids because they soak up everything.
And they realize that if you’re saying that, and maybe they look up to you, you’re their hero and they say, wow. If my parents are thinking that, then what chance do I have to escape that type of thought or anxiety or nervousness about my weight?
Kyle: This is so good. This is so good for people to hear. That one little bit of awareness can change the trajectory of your entire life. Yeah. And change your entire kid’s life. Dr. Judy: Yes. It’s huge. Absolutely. That’s huge.
