Eating Disorders: From the Plate to the Brain and Everything In Between
Discovering how Early Intervention and Treatment for Teenagers and Young Adults can save a life.
Parents often find it difficult to describe ‘when and where’ they first noticed signs that their child was struggling with the early signs of an eating disorder.
For many parents, periods of increasingly ‘picky eating’ and changes in style of clothes or food preferences can seem like a normal phase in the pre-teen or teenage years. Some parents move on to feelings of guilt and confusion as they realise that the ‘phase’ was in fact, the beginning of something far more serious.
Parents can often wonder when to intervene. They can feel concerned about creating a conflict at home or making a ‘fuss’. Some mums and dads tell us how they fear actually causing an eating disorder by ‘making something out of nothing’. We have never seen a parent create or encourage an eating disorder by reaching out for help.
Many parents hope that disordered eating will not progress. Others hope that maladaptive relationships with food and body issues will resolve themselves. The reality is that this very rarely happens. Instead, restricting, purging, over-exercising, and binge episodes tend to get worse over time.
Eating Disorders are Serious Psychiatric Disorders
Eating disorders are increasing in young people on a global level. Eating disorders can affect people of all ages; however, pre-teens, adolescents and young adults are particularly vulnerable. Eating disorders affect all cultures, countries and gender identities.
Whilst the average age of onset is 13–25, with girls being more at risk than boys, an awareness of the early signs and symptoms is important for parents.
The Diagnostic and Statistical Manual of Mental Disorders, also known as DSM-5, outlines the criteria for the diagnosis of eating disorders.
Young people can reach the threshold for diagnosis in the following:
- Anorexia Nervosa (AN)
- Binge Eating Disorder (BED)
- Bulimia Nervosa (BN)
- Other specified Feeding and Eating Disorders
- Avoidant / Restrictive Food Intake Disorder (ARFID)
- Unspecified Feeding and Eating Disorders
- Rumination Disorder.
Orthorexia is not formally listed in DSM-5 (instead, patterns may be grouped under ARFID or AN).
It can be frightening and frustrating to watch your child struggle with escalating symptoms of disordered eating.
It can be difficult to understand why young people with eating disorders seem to be unable to ‘stop’ or change. It can also be difficult for parents to know when to reach out for professional advice.
Early Warning Signs
Eating disorders are characterised by abnormal patterns of eating.
However, there are many factors in the development of eating disorders that are not directly related to food intake or body image.
Depression, anxiety, bullying, conflict at home, perfectionism, obsessive-compulsive disorder (OCD), and other co-occurring psychiatric illnesses can all influence the development of eating disorders in young people.
Having a parent or family member who has suffered from an eating disorder, or other mental health concern can significantly increase the likelihood of a young person being diagnosed with an eating disorder or other mental health condition.
Whilst many young people will experience some of the following signs and symptoms; it is important to reach out for advice from an eating disorder specialist if you notice any of the following*:
- Restricting food groups (meat, flour, butter, sugar, carbs, etc.)
- ‘Clean eating’, Vegan or Vegetarian (in families where not routinely practised)
- Refusing meals or skipping meals
- Lunchbox regularly left untouched or ‘forgotten.’
- Changes to eating patterns
- Skipping family mealtimes of sharing foods
- Eating alone or in secret
- Sudden interest in menu planning, food shopping, cooking or baking, but refusing to eat what they have cooked or baked
- Going to the bathroom immediately after eating
- Adding water or other liquids to foods
- Cutting foods into small pieces, eating food in a specific order, or any other rigid habits around plating or ordered eating
- Insisting on certain plates or cutlery
- Time rules around eating (e.g. no food after 6 pm, or no carbs after 2 pm)
- Hiding, smearing, throwing or chewing and spitting food
- Eating large quantities of food (with or without appearing to gain bodyweight)
- Eating regularly overnight
- Drinking excessively (particularly water before meals or when hungry)
- Changing clothes types – wearing baggy clothes
- Starting a ‘Diet’ or ‘Food Plan’
- Regular use of meal replacements
- Vomiting after meals
- New exercise goals / over exercise / high exercise
- Changes in physical appearance
- Increased concerns about appearance, shape or body size
- Expressing negative views on those in large bodies
- Feeling cold more often
- Stomach pains / constipation / loose stools (laxative use)
- Expressing guilt or anger after eating
- Irritable mood / increased feelings of stress at mealtimes
- Self-harm or thoughts of suicide / depression / insomnia
- Increased anger
* This list is for information only and by no means outlines all the signs and symptoms of eating disorders. Each young person will present with a slightly different set of symptoms and behaviours. Parents and young people should consult their GP, psychiatrist or the Admissions Team at The Wave Clinic for more detailed information and advice.
When a Parent is Worried, They’re Usually Right
Parents typically have a great internal barometer for the wellbeing of their children.
Young people can ‘play down’ the impact of their eating disorder behaviours. They may even become angry when parents attempt to talk about food and body issues.
It is important for parents to gently support and ask their teens more about the issues. Reassuring and supporting young people is the best option for parents. An angry, shouting parent at mealtimes is unlikely to encourage either eating or a willingness to talk further.
Negotiating, creating ‘deals’ or arguing at mealtimes is generally unproductive. Young people will find ways to avoid the family confrontation, hide the activity further, or pretend that all is now well by agreeing and further burying their problems.
Early Intervention and Treatment
Early intervention and treatment for young people is essential. If it looks like there is an issue, it is important to seek advice at the earliest opportunity.
Eating disorders (and associated behaviours) of up to three years’ duration have a significantly higher rate of successful treatment. (FREED, 2020. In conjunction with The Maudsley Hospital).
Treatment Tailored to the Needs of Teenagers and Young Adults
Engaging in treatment that meets the specific needs of teenagers and young adults, with recent onset of eating disorder symptoms, can significantly change the course of the eating disorder.
Research has shown that teenagers and young adults benefit from treatment programmes that are specifically designed to meet their developmental needs. Services designed for young people increase long-term engagement and have a positive effect on treatment outcomes. Evidence-based treatments include CBT-e, FREED, FBT, EMDR and DBT.
One of the most important considerations in the treatment of young people is building great therapeutic relationships. The effective partnership between the treatment team and the family is essential in the treatment of teenagers and young adults.
Family therapy helps to build treatment plans that you can feel comfortable and confident with continuing at home.
Families are encouraged to learn as much about eating disorders as they can, through:
- early psychoeducation
- nutritional involvement
- evidence-based psychotherapy
- family therapy
- education on eating disorders for families.
Understanding helps families to appreciate the complexity and severity of the diagnosis in young people.
It challenges the myths and unhelpful beliefs that young people can simply eat more, pull themselves together, or that it is ‘just a stage that all kids go through’.
It also helps families to understand that what is on the plate (or not) is really the tip of the iceberg.
Early Treatment Increases Positive Outcomes
Recovery from eating disorders is possible and encouraged at any point. In research, treatment undertaken within the first three years of the onset of the illness has been proven to be somewhat easier and to have a higher rate of long-term success.
Early intervention means that treatment takes place before any significant brain changes have occurred.
Behaviours related to eating disorders become neuro-cognitively ingrained, which means changes happen inside the structure and systems of the brain itself.
The longer these behaviours continue to become ingrained, the more challenging it can be to treat.
Young People with Eating Disorders at Risk of Interrupted Development
The longer a young person remains in an active phase, the more likely they are to suffer from adverse family, education, social, and emotional developmental issues.
Eating disorders, together with co-occurring psychiatric conditions, can interrupt the course of normal adolescent development.
78% of young adults in treatment report that their eating disorder became significantly worse whilst they waited for treatment or delayed attending a specialist facility.
Eating Disorder Onset
Your treatment team will help to explore the duration of an untreated eating disorder (DUED).
The team will also help you to understand the triggers and stages that teenagers and young adults with eating disorders may have experienced.
Eating disorders of all types are severe mental health conditions. They are progressive and, if left untreated, will become chronic and often treatment-resistant.
Brain Changes in Teenagers
Our brains are continuously adapting and changing. The human brain is not fully developed until we are well into our 20s. The brains of teenagers are rapidly changing and developing, making the adolescent and emerging adult years developmentally important.
It also makes the teenage brain vulnerable. Eating disorders, substance use, trauma and other mental health concerns may influence, change and impact the fragile system of a teenager or young adult.
Eating disorders can cause significant changes to the brain during these important developmental years.
Inadequate nutrition, changes to eating patterns, restriction, bingeing, trauma and stress have all been shown to cause changes to the brain and affect some of its important functions.
Brain Changes can Keep the Symptoms of Eating Disorders Active
The maladaptive, circular patterns of ‘Act–Change–Affect–Change–React’, can be really tricky for young people to break. Eating disorders can cause structural changes to the brain, and this becomes more significant over time.
The longer the eating disorder is active, the more difficult it is to change the way that the brain has ‘rewired’. Of course, recovery is possible at any stage, although we do know that the earlier treatment is started, the better the chances of a good long-term outcome.
The part of the brain that is responsible for habit-forming is used in relatively simple every day decisions. In young people, this is similar to exercising a muscle every day – the muscle becomes stronger and more efficient at the job it is given. This is similar to many choices made in eating-disordered behaviour.
Young people challenged by eating disorders may experience brain changes in other areas too. One area that is often a concern for families joining programmes at The Wave is the changes in relationships.
Research indicates that teenagers and young adults demonstrating behaviours related to eating disorders will have more difficulty in maintaining interpersonal relationships. Reading the situation, understanding and empathising with others, and the way young people react to certain situations, are governed by some of the changes in the brain’s development.
For example, the brain shows greater activity in the area responsible for ‘self-control’ in active phases and recovery phases of Anorexia Nervosa.
This is suggestive of a developmental character trait possibly prior to the onset of an eating disorder, which encompasses perfectionism and control.
Starvation changes the brain, and these emotional and cognitive changes can lead to:
- rapid changes in mood
- obsessive and intrusive thoughts
- fears and feelings associated to sensations in the body
- loss of interest in previously enjoyable activities
- impaired concentration
- difficulties in relationships
- poor judgment.
Genetics – Is Our Genetic Profile a Loaded Gun?
Current research indicates that genetic links could be at play in 50–70% of eating disorders (Bulik et al., 2007; Cui et al., 2013.).
However, eating disorders are still considered a bio-psychosocial condition; where genetics may remain latent during childhood and the pre-teen years, or even longer.
Adolescence comes with many challenges, including friends, school, rapidly changing bodies, sexual development and increased independence. For those who are vulnerable, this period can ignite triggers for the development of Prodromal or Early Stage Disordered Eating patterns.
Can the Brain Recover?
The brain is exceptional at making changes and adapting. The brain is described as ‘malleable’, which means change and repair are possible.
Brain scans (in those struggling with Anorexia) have been able to demonstrate that the loss of brain cells in the active phase of Anorexia leaves a pattern similar to those seen in Alzheimer’s; a form of dementia most often seen in much older adults.
Whilst this can be very upsetting for families to witness, it can also be a marker of determination. Repeat imaging can show the increase of cell volume as recovery stabilises.
We are often asked how long full recovery will take. Whilst each and every young person arrives with different symptoms, needs and goals, a study in 2005 (by Wagner and colleagues) indicated that recovery can take between 29–40 months. The brain does indeed recover in long-term recovery.
The WaveED Team – Setting Goals Together
Eating disorder programmes at The Wave are designed for young people to feel heard, understood and motivated.
We are dedicated to helping families to find solutions, to remain optimistic and change-focused.
We are exceptionally proud of our 100% completion rate.
We have created a home-from-home environment, engaging young people in programmes of recovery with full medical support. Our teenagers and young adults enjoy an experiential programme with opportunities for Volunteering and Education, Activities and Sports.
Eating disorder treatment requires a level of understanding and compassion. The journey to recovery can feel like climbing a mountain, but with the right support, the view from the top is amazing.
Fiona Yassin is The Clinical Director at The Wave Young Adults Programme, in Kuala Lumpur. Fiona has a specialist interest in Eating Disorders and Borderline Personality Disorder.
Trained in CBT-e (The Oxford Group. CREDO), FREED, EMDR (EMDRIA) and an Accredited Clinical Supervisor (UNCG). Fiona is a Fellow of ACCPH and a member of IAEDP, FDAP and ANZMH. Fiona is an accredited Child and Family Trauma Professional.
Mahisha Naidu is a registered Dance and Movement Psychotherapist. She has extensive experience in Eating Disorder Treatment in Residential Settings. She is currently studying Internal Family Systems and enjoys using expressive and creative therapies with teenagers and young adults.