At Risk: Recognizing an Eating Disorder and Spotting Early Warning Signs Ruth, age thirteen, is well adjusted, at the top of her class academically, and loves to play soccer. Her mother, Susan, has been somewhat worried about Ruth's recent weight loss, but reassures herself that Ruth looks noth- ing like the images of girls suffering from eating disorders that she has seen on television talk shows and in magazines. Instead of ghoulishly skeletal, Ruth really looks cute, athletic, slim, and energetic. One day, however, while straightening up Ruth's room, Susan comes across a diary in an open drawer. She can't resist taking a peek, thinking that it might shed light on Ruth's recent weight loss. Susan learns that Ruth has thrown up for the first time the night before. Although she has been trying to self-induce vomiting for a number of weeks up until now, this is her first success. Ruth writes that she is relieved that vomiting is not very hard to do once you figure it out, and that she is confident she can continue doing it. Susan replays recent changes in Ruth'; behavior-occasional dizziness, the significant reduction in her food intake, the way she was eager to bake a birthday cake for her brother but refused to eat any of it herself. She realizes that she has been oblivious to the early signs of an eating disorder in her daughter, a disorder which, left untreated, could become life threatening. Most people know what the extreme emaciation of full-blown anorexia looks like, and some of us might even be able to recognize some of the tell- tale signs of chronic bulimia, the swollen cheeks, or trips to the bathroom after every meal. But recognizing an eating disorder before it reaches these stages is trickier. In this chapter, we will describe the different types of eat- ing disorders and provide checklists of early warning signals.4 . The Parent's Guide to Childhood Eating Disorders As we note throughout this book, although we separate anorexia, bulimia, and binge-eating disorder into neat categories, often people will go from being an anorexic to a bulimic, or the reverse, or even exhibit all the hallmarks of both disorders at the same time. I advise parents not to get distracted trying to figure out which diagnosis is correct, but simply to take action as early as possible if they suspect their child has an eating disorder. Anorexia Nervosa The anorexic child refuses to maintain even a minimally normal body weight. (See the growth chart, Appendix B, for guidance on how to assess your child's body build and weight history.) She is intensely afraid of gain- ing weight, a fear that is fueled by a distorted perception of her body's shape and size. No matter how thin she gets, she sees herself as fat and unat- tractive, and this distortion in perception usually becomes more severe the more weight she loses. Some anorexics who have not yet reached adult- hood will not necessarily lose weight. Instead, they may fall short of expected weight gains while still increasing in height. Others will not grow at all and may be permanently stunted in height unless they begin to eat better. Anorexic girls who have already begun menstruating stop getting their periods due to their starving bodies' abnormally low levels of estrogen. Among girls who have not yet reached puberty, menstruation may be delayed or completely inhibited by anorexia. In all of these cases, lack of estrogen poses serious risks to bone health of girls. Boys' bones can also be affected by starvation-induced hormonal changes. In anorexic boys, low- ered levels of testosterone can lead to reduced bone density. The History of Anorexia and Anorexia-like Behaviors Self-imposed starvation is an ancient disorder that dates back to medieval times. In the Europe of the thirteenth century, historical records tell of women saints who fasted and refused food as part of their religious prac- tice. In 1689, one of the earliest 'cases of what is now known as anorexia involved a sixteen-year-old English boy. By the 18'70s the term anorexia neruosa, meaning loss of appetite due to emotional reasons, had been coined to describe the self-starvation found primarily among upper-middle-class western European and American girls. The historian Joan Jacobs Brumberg, author of the book Fasting Girls, argues that modem anorexia is distinct from early cases because of its body- image concerns triggered by "mass cultural preoccupation with dieting and a slim female body."Identifying an Eating Disorder 5 Anorexia Subtypes There are two subtypes of anorexics. The first is the restricting type. The anorexic of this subtype loses weight simply by reducing her food intake, fasting, or engaging in excessive and lengthy periods of exercise as a means of working off calories. The second subtype is the binge-eating/purging type. She restricts her intake as well, but alternates this behavior with bouts of binge eating and often purging. The purging can take the form of self- induced vomiting or the abuse of laxatives, diuretics, or enemas. Some anorexics of this type don't binge, but still purge after consuming even small amounts of food. Common Triggers Often anorexia nervosa is triggered by a stressful life event-leaving home for the first time to enter boarding school, summer camp, or college, being teased about one's weight, breaking up with a boyfriend, not getting chc~ sen for a sports team, or problems within the family, such as divorce. Other risk factors include affluent and welleducated parents, early feeding prob lems, low selfesteem, high neuroticism (overly moody, sensitive, or fear- ful), an overprotective mother, having a relative with anorexia or bulimia, especially a parent or sibling (identical twins are particularly at risk in that if one develops an eating disorder, the other is at high risk), and childhood sexual abuse. (For more information on eating disorders and sexual abuse, see p. 248.) Anorexia among Children Although it was at one time thought that anorexia rarely develops before puberty, this appears to be changing, despite the lack of firm data to sup port what therapists, nutritionists, and other professionals have observed in their own practices. While researchers have not yet documented a rise in childhood anorexia, they have shown that girls as young as six years old equate thinness with "goodness," worry about being too fat, and initiate dieting for