“I got a text from Sophie’s best friend telling me that Sophie is throwing away her lunch at school. Should I confront her?”
“The toilet smelled like vomit after Andy took his shower last night. He ate so much food at dinnertime. I think he might be purging. Should I confront him?”
“I thought I saw some cuts on Bianca’s wrist this morning, but she pulled her sleeves down before I could get a better look. Should I confront her?”
Parents of my adolescent patients frequently ask me if they should confront their child when they receive concerning information about their child from a third party, or when they have a worrisome suspicion about their child but no actual proof.
Let’s take a closer look. The word “confront” typically connotes facing someone with hostile or argumentative intent. Confrontation often conveys anger, suggests an accusation of wrongdoing, and brings up defensiveness in the child. Confrontations can lead to explosive arguments, lashing out, or shutting down. These reactions create or exacerbate the rift between parent and child, thus making it much harder for the parent to provide – and harder for the child to receive – the support and assistance that they need. For these reasons, I don’t recommend confrontation.
On the other hand, failing to act on information or suspicions about a child’s concerning behavior does not help the child either. Keeping quiet may keep the peace, but it deprives the child of an opportunity to discuss what is troubling them, receive much-needed help, and overcome the problem.
Instead of confronting their teenager, I recommend that parents take the following steps when they have concerning information or suspicions:
Shift your perspective. Rather than viewing your child as doing something wrong or deceptive, recognize their behaviors as signs of suffering, symptoms of an illness, or cries for help. Think about how you would view your child if they had a more tangible ailment, such as a seizure, or a broken ankle, or an asthma attack. Most parents would view these symptoms not with blame, shame, or anger, but with concern and compassion. This is the same concern and compassion with which you should view a child who is secretly disposing of food, throwing up after meals, or harming themselves.
Approach your child privately, in a calm moment, with compassion and curiosity. Share the information or suspicions that you have in a nonjudgmental, non-accusatory way.
“Sophie, someone at school saw you throw away your lunch in the cafeteria. I’m curious about what is happening at lunchtime.”
“Andy, I thought I smelled some vomit in your bathroom last night. I promise I’m not mad. But I am worried about you. Can you help me understand what’s going on?”
“Bianca, I could be mistaken, but thought I saw some cuts on your wrist yesterday. I wanted to check in with you. I know you’ve been feeling really depressed lately. I wonder if you have been hurting yourself?”
Support your child. Express your love and concern for your child and ask how you can help them. This may involve having an in-depth conversation with your child in that moment, if they are willing, and letting them know that you are always willing to talk with them about the issue in the future. Ideally, you and your child can collaborate to help create a safer environment and work through the problem together.
“I love you very much, and I want to help you stop purging. How can we work together to make this happen? Would you like to walk the dog with me tonight after dinner?”
“I understand that this is difficult to talk about, so I won’t push you. But please know that you can always come to me in the future whenever you are ready to talk.”
If your child shuts down or refuses your help, you may need to step in and provide support anyway. Even without your child’s permission or buy-in, you can create a safer environment at home or at school by removing sharp objects, providing post-meal support, or arranging supported lunches. In most cases, it will be helpful – or even necessary – for you to inform your child’s other caregivers and healthcare team about the symptoms, or arrange for your child to see a mental health professional if they are not currently working with someone.
“I am going to hide the sharp objects for a period of time to keep you safe, until you can get a handle on this symptom. Also, Dr. Ravin needs to know about the self-harm so that she can help you. Would you like to tell her yourself in your next session? Would you like me to come to the session with you so we can tell her together? Or would you rather I call and tell her about the cutting before you meet with her?”
The SHIFT, APPROACH, SUPPORT strategy helps to disarm anxious or angry teens, nurture connectedness and trust, and empower parents to help their children.
“Everybody lies.” This was the credo of the titular character in one of my all-time favorite shows: House, MD. And of course, it is true. From the saints to the malignant narcissist politicians and everyone in between, no one is completely honest all the time.
When it comes to eating disorder treatment, there is an unsettling phenomenon that is not discussed as much as it should be: the majority of eating disorder patients are dishonest about their symptoms. The dishonesty can range from occasionally telling their parents that they ate lunch while out with friends when they did not, to a minimization of symptoms, such as reporting to their therapist that they binged and purged twice in the past week when really it was six times, to a long-term deception, such as throwing away snacks for weeks or months on end while claiming to have eaten them, or performing hours of secret calisthenics in a locked bathroom or closet. With restrictive eating disorders such as Anorexia Nervosa (AN) or Avoidant-Restrictive Food Intake Disorder (ARFID), the deception often takes the form of manipulating the number on the scale by water loading right before weigh-ins or hiding heavy objects in their undergarments.
Dishonesty about symptoms is absolutely the rule, not the exception, for all eating patients ranging from innocent elementary school children who know nothing about eating disorders to the most seasoned treatment veterans who have been ill for decades and have experienced multiple stints in hospitals and treatment centers. Individuals with AN, in particular, are often very well-behaved, perfectionistic, rule-abiding individuals who have never misbehaved, and never been in trouble. Many of these kids are extremely honest with a strong moral compass; that is, until AN swept into their lives and took over their psyche.
Why is this deception so pervasive in eating disorder treatment, and what can we do about it?
First, it is important to understand why the patient is being dishonest. Eating disorder patients may be deceptive for any number of reasons. The most common reasons include:
Extreme fear of eating and/or weight gain.
Desire to please or appease their parents or treatment providers.
Fear of the negative consequences of telling the truth about symptoms or revealing their true weight, which may include losing independence, being hospitalized, entering a higher level of care, having to withdraw from sports or take a leave of absence from college.
Extreme shame or embarrassment about engaging in the symptoms (this is especially true for people who struggle with binge eating and / or purging symptoms).
Desire to appear “better” so that they can end treatment before they are truly ready.
Distorted perception of their eating or exercise behaviors (people with AN and ARFID tend to overestimate the amount of food that they eat and the caloric content of their food, so they may report that they are eating enough to maintain weight when in reality they are not).
Distorted perception of what is “normal” or “healthy,” either due to the eating disorder or due to environment (for example, a 14-year-old soccer player rising at 5:00 AM to run 5 miles each morning and failing to mention this habit to the treatment team because his parents and older siblings do the same).
I recommend that treatment providers, parents, and loved ones of eating disorder patients take the following steps to address dishonesty:
Recognize the deception for what it is: a symptom of the eating disorder.
The patient is not lying because they are manipulative or immoral; they are lying because they have a severe mental illness that makes them absolutely terrified to do exactly what it is that they need to do to recover.
Deception in an eating disorder is no different than a seizure in epilepsy or low blood sugar in diabetes. It is par for the course of the illness and it is not the patient’s fault. I do not mean this in a fatalistic way. Eating disorder patients can develop the skills to be honest in recovery just as diabetics can utilize medications and dietary changes to control blood sugar.
Meet the patient with nonjudgment, empathy, and compassion.
When deception is discovered, remain calm and gentle. If the patient “came clean” and admitted to having lied in the past, commend him for his honesty now. Make it abundantly clear that you are not angry or disappointed (even if you secretly feel angry or disappointed inside). Rather, you are grateful that he has revealed this information because now you have important data to help support him more fully in his recovery. Let the patient know that you understand the deception as part of his eating disorder, not a reflection on his true character.
Explore the emotions that have arisen for the patient surrounding the deception and surrounding the disclosure of deception.
Did he feel guilty for lying over a period of time? Was she experiencing extreme inner conflict between the compulsion to engage in an eating disorder behavior vs. a drive to follow the treatment recommendations? Is he feeling ashamed, or relieved, now that the secret is out in the open? Helping the patient explore these thoughts and feelings around the deception helps him feel heard and validated and also opens the door for a deeper connection.
Initiate a dialogue with the patient to help discover what is motivating the eating disorder behaviors.
Why is the patient throwing away her lunches? Does she dislike the food? Are her friends all dieting? Is she studying during lunchtime instead of eating? Is she too full after a large breakfast and morning snack? Is she afraid of gaining weight? Is she embarrassed to eat “so much” in front of her peers? There may be multiple motivations behind the behavior. Some of the motivations may be disordered (e.g., a strong desire to lose weight) and some may be perfectly normal (e.g., not liking the taste of the food or not being hungry). Regardless of the motivation(s) behind the eating disordered behaviors, the behaviors must stop. To someone with an eating disorder, skipping lunch because “school food sucks” is just as dangerous as skipping lunch due to drive for thinness.
Ascertain the reason(s) for the deception.
Many eating disorder patients have very good reason for being deceptive, and their reasons should be understood and respected (though not necessarily condoned). This is analogous, in a sense, to the reality that most LGBTQIA individuals were “in the closet” until this century, and many are still in the closet today. Being honest about their sexuality or gender identity would have led to discrimination, ridicule, oppression, disownment, or worse. Pretending to be straight or cisgender was an act of self-protection, born of realistic fear.
Whether you are the parent, the therapist, the dietitian, or the boyfriend, ask the patient whether there is something about you, or something about your relationship with them, that drives them to be dishonest. For example, many patients are very attuned to their parents’ anxiety, and the parents’ anxiety feeds into the child’s anxiety. Patients may hide or minimize their symptoms to control their parents’ anxiety as a roundabout way to manage their own anxiety. Some treatment providers or parents may outwardly express disappointment in the patient or anger towards him when he has lost weight or struggled with eating disorder symptoms. Whether you are a parent or a treatment provider, it is natural to feel angry, disappointed, or terrified when your child or patient is struggling with symptoms. However, expressing these emotions directly to the patient is rarely helpful and may even make the situation worse.
Use this conversation to help build trust and resilience and to create an environment more conducive to recovery and honesty.
If the patient is minimizing symptoms due to shame or embarrassment, talk about it! The best way to unpack and dismantle shame is to bring it out into the open. Try to understand why the patient is feeling ashamed (perhaps because the eating disorder is compelling him to act in ways that are incongruent with his personal values and goals), and help him begin to let go of the shame. Let him know that there is no shame in being authentic about struggles and seeking help.
If the patient is dishonest about symptoms due to fear of making their parents anxious, angry, or disappointed, then part of the parents’ work is to learn to manage their own emotions around their child’s symptoms. Therapists are trained to do this. Parents are not, and it is much harder for parents to be neutral or objective about their own children, especially when their children are unwell. This is one of many reasons why therapists are not supposed to treat their own children! Parents can have conversations with their children about how they can best respond to their child’s symptoms in a way that promotes honesty.
Change the environment to make it very difficult, if not impossible, for the dishonesty to persist.
Leaving a patient to struggle with the eating disorder without adequate support is cruel and sets everyone up for failure and disappointment. If the patient has been skipping lunches or snacks, it is best to arrange support and supervision around lunch and snacks for a sustained period of time – usually weeks or months – until the patient is well enough to eat on her own. If the patient has been secretly binge eating in the evenings, arrange some support around that vulnerable time period, such as watching a family movie together or going for a walk. If the patient has been hiding heavy objects in his clothing for weigh-ins, consider doing future weigh-ins with minimal clothing, or on random days, to make it harder for the patient to prepare.
Frame the dishonesty, the disclosure, and the subsequent collaborative problem-solving as a stepping stone towards a stronger recovery and a more trusting relationship.
Everyone makes mistakes and experiences setbacks. This is a natural and inevitable part of recovery. These experiences, if handled skillfully, can help the patient build a stronger foundation for full and lasting recovery and help build a deeper trust in their support system to keep them safe and healthy.
AFRID is a relatively new diagnostic category which was first added to the Diagnostic and Statistical Manual of Mental Disorders – Volume 5 (DSM-5) in 2013. ARFID is characterized by a pattern of avoidant or restrictive eating behaviors which led to significant nutritional, medical, developmental, and/or social-emotional consequences. Individuals with ARFID may restrict their food intake for a variety of reasons. Some individuals are hypersensitive to textures, tastes, and smells and feel comfortable with only a narrow variety of foods. Others don’t experience hunger cues, derive little pleasure or enjoyment from eating, and seem to have little interest in food. Still others begin restricting their food intake abruptly after a food-related trauma, such as choking, vomiting, or having an allergic reaction. Unlike those with Anorexia Nervosa or Bulimia Nervosa, patients with ARFID do not experience drive for thinness, fear of weight gain, or distorted body image.
One of the most rewarding aspects of my job is the opportunity to engage with patients in long-term therapy. In my practice today, I have a number of patients who began treatment with me years ago, in adolescence, and are now in their 20’s. These patients first presented in my office with their parents during middle school or high school, suffering from severe eating disorders or depression or debilitating anxiety or, in some cases, all of the above. Some entered treatment kicking and screaming; others reluctant but resigned; still others wanting help and suffering desperately but requiring immense parental support to stay afloat.
In many cases, these adolescent patients received intensive Family-Based Treatment for six months or a year or more. In other cases, the teenage patients received individual Cognitive-Behavioral Therapy with active parental involvement. All of them made substantial progress in treatment. The majority recovered fully from their initial presenting diagnosis. Those who have not recovered fully are doing significantly better, living independent, fulfilling lives, but still experiencing symptoms and receiving ongoing care to keep their illness at bay. Now, years later, some of them continue with weekly therapy sessions. Others come in once or twice a month, or perhaps biannually like dental cleanings (we call this “mental hygiene”). Still others elect come in on an “as needed” basis, scheduling a few sessions here and there to help them cope with life events, navigate relationships, manage stress, or deal skillfully with bouts of depression or anxiety.
What unites these incredible young men and women is the fact
that they have taken full responsibility for their well-being. They have chosen to engage in long-term
individual therapy as an act of self-care.
Through their adolescent suffering, they have become acutely aware of
their susceptibility to mental illness.
They are choosing to receive therapy not only to prevent relapse of
illness but also to pursue optimal health.
Many of these young adults have
chosen to abstain from drugs and alcohol, even as their peers regularly smoke
pot and drink to excess. Many of them
have adopted consistent home practices of meditation or yoga. They make conscious, health-promoting choices
when it comes to sleep, nutrition, stress management, and physical activity. When faced with an important decision about
which graduate program to pursue, which job offer to take, which city to live
in, or even which person to date, they carefully consider the impact of these
choices on their quality of life.
Engaging in long-term therapy with patients like these
involves a number of gradual but significant transitions for all members of the
therapeutic relationship: the patient, the parents, and me. For
the parents and for me, there is the progression from the crisis management of
an acutely ill adolescent to the joy of stepping back into a supportive role
for young adult in his own quest for greater levels of well-being. The parents and I often begin our
relationship communicating multiple times per week to put out fires and to
ensure that we are in lock-step as we form a circle of safety around a suicidal
or eating disordered patient. As the
patient gradually assumes responsibility for her own well-being (which often
takes several years for those with adolescent-onset mental illness),
communication between parents and me subsides into an occasional email or phone
call. The patient is now a much
healthier, more mature young adult, and is trusted to schedule, attend, participate
meaningfully in her own therapy sessions.
In many cases, she pays for her own treatment as well.
The therapy itself goes through a significant evolution as I
shift from being directive and prescriptive, setting firm limits around
dangerous or debilitating symptoms, to engaging with the patient in deep
psychological work and collaborative goal setting. For the patient, there is the very welcome
shift from being told what she must do, in therapy and at home, to deciding
what issues are important to her and taking the initiative to seek support,
both therapeutic and familial, in achieving personally relevant goals. For the patient, this shift brings with it
a transformation from a defensive posture (as evidenced by panicking, shutting
down, or lashing out in therapy and at home) to a stance of openness and
receptivity (as evidenced by increased self-disclosure and self-awareness along
with the display of more vulnerable emotions).
I cannot begin to describe how rewarding it feels to support
a frightened, malnourished, deeply depressed teenager as she blossoms into a
healthy, confident, independent young woman who is attending college or
graduate school in another state, working at an exciting full-time job, getting
married, or giving birth to her first child.
It is fulfilling beyond words to join with young adult patients in the
journey of long-term wellness as they clarify their personal values, decide who
they want to be in this world, and take concrete steps towards achieving their
dreams.
Those of you who have engaged in long-term therapy, either as a therapist, as a patient, know well how deeply personal and meaningful these relationships can be. There is a level of emotional intimacy that surpasses even that between spouses, between parent and child, or between the best of friends. In many ways, engaging in long-term therapy with self-motivated young adults is the polar opposite of Family-Based Treatment (FBT) for Adolescent Anorexia Nervosa. For most patients in my practice, the former would not have been possible without the latter.
WW International, the company formerly known as Weight Watchers, recently launched an app calledKurbo which is designed to help children ages 8-18 to diet and lose weight. The app is marketed as a “health coaching” tool, but a closer look at the company’s website reveals testimonials of children losing weight and dropping BMI points, complete with “before” and “after” photos. In recent years, the words “diet” and “dieting” have been replaced with words like “wellness” and “healthy eating” in popular nomenclature. But more often than not, when people refer to “eating healthy,” they are talking about restricting calories, reducing carbohydrates, and decreasing portion sizes. In other words, dieting in pursuit of weight loss. The brilliant marketing team at Weight Watchers, aware of this cultural shift in nomenclature, re-branded themselves as WW (Wellness that Works) to stay in vogue with their client base: people living in larger bodies.
But make no mistake: Kurbo is a diet app designed to help children lose weight. Although the app is touted as being based on years of scientific research, the very existence of this app defies the best available scientific evidence, which strongly suggests that CHILDREN AND ADOLESCENTS SHOULD NOT DIET.
Why? Let me count the reasons.
Bodies are meant to be diverse in size and shape. The very notion that a child or adolescent should lose weight in order to have an acceptable body flies in the face of genetics and natural size diversity.
Weight loss disrupts crucial physiological processes in the growing bodies of children and adolescents. Puberty requires significant weight gain to ensure proper development of the brain, bones, reproductive organs, and other vital body systems. Losing weight during adolescence can halt puberty, stunt vertical growth, and alter hormone levels.
Dieting is not effective at producing long-term weight loss, but it reliably predicts weight gain and depression. More often than not, dieting leads to weight cycling: losing weight in the short-term but regaining weight and ending up at the same weight, or a higher weight, in the longer-term. Our bodies have evolved to protect us against famine by slowing down metabolic processes when food is scarce (such as, when we are dieting and losing weight) and ramping up hunger signals and cravings, which often leads to overindulgence or binge eating. Weight cycling is associated with negative health outcomes, including increased risk of depression. Individuals who diet frequently experience cycles of shame, guilt, and feelings of failure each time they regain lost weight.
The normalization and glorification of diet culture is harmful and toxic to all children. When a person in a position of authority (e.g., doctor, parent, teacher, coach) tells a child or adolescent to lose weight, or places that child or adolescent on a diet, the message being sent (either subtly or overtly) is: “Your body is not acceptable as it is, and you must work very hard change your body in order to be attractive, healthy, happy, or socially accepted.” This message is damaging to a young person’s self-esteem, confidence, and body image.
Diet culture disproportionately targets and stigmatizes individuals in larger bodies, thus perpetuating weight stigma.
Although dieting itself does not cause eating disorders, dieting (or food restriction of any kind) can trigger the onset of an eating disorder in a child who is genetically vulnerable. Further, diet culture creates a toxic environment for individuals who are recovering from eating disorders. Eating disorders are dangerous, debilitating, difficult to treat illnesses that have the highest mortality rate of any psychiatric disorder.
Thankfully, there are many other individuals and organizations who share my sentiments on this matter and are publicly condemning this app.
Healthcare Providers Against Kurbo. A group of physicians, psychologists, therapists, and dietitians who specialize in treating eating disorders has formed a petition protesting the Kurbo app. You can read and sign the petition here.
Registered Dietitian Christy Harrison published an article in the New York Times explaining why the Kurbo app is harmful to children.
So, you might ask, if dieting is not the answer, then what should we do about childhood obesity? The answer, based on the best available scientific research, is that obesity per se is not the problem, and thus the pursuit of weight loss per se is not the solution. Instead, adults who are charged with the task of caring for our youth (e.g., parents, teachers, coaches, and doctors) should encourage health-promoting behaviors in children across the weight spectrum. Children of all weights will benefit from eating balanced family meals containing a wide variety of foods from all food groups. Children of all weights benefit from adequate sleep, daily physical activity, and limited screen time. Children of all weights should be taught body acceptance and should be educated about size diversity. This is true health promotion. In some cases, these health-promoting behaviors will result in weight loss for higher-weight children, and in some cases, they will not. But regardless of what happens to the child’s weight, these health-promoting behaviors bring about genuine improvements in the child’s physical and mental well-being. And – this is important – NO HARM IS DONE.
