289: Signs Your Teen is Heading Towards an Eating Disorder | Dr. Kelly Bhatnagar

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1:03you know that thing that happens when we're raising our tweens and teens where there's something we want to bring up maybe because we're worried about it but we also have the worry that bringing it up is going to make it worse right that it's something sensitive for our kid or uncomfortable or that they're going to shut it down or even be hurt or angry that we brought it up so it might be something like they used to hang out with a friend that you're not seeing around so much anymore, or they're just not seeming like themselves. At these times, here's a metaphor I have found to be really helpful.

1:34We need to give kids warning, and we need to give kids a chance to invite us into that conversation. So rather than just like the equivalent of like walking through a door to try to have the conversation, I like to think of ways to try to knock on the door to get them to open the door to the conversation. Giving them warning, making space, not having it come up out of nowhere really, really ups the odds of a more successful conversation. Okay, but what if it's something really dicey, like how a young person is eating? We have a letter from a parent who is really worried, and I think has reason to be worried, about the fact that her daughter is eating less and losing weight.

2:15So to tackle this letter, and to tackle the question of how we even have this conversation at home, I have called on my colleague, Dr. Kelly Botnager. Dr. Botnager has cared for adolescents for more than 20 years, specializing in eating disorders. She is the recent past president of the Academy of Eating Disorders, and she's been honored by the Academy of Eating Disorders for her distinguished contributions to that field. Let's get into it. Kelly, thank you so much for being here. Thank you so much for having me. It's such a pleasure. Let me give you this letter. So, dear Dr. Damore, my 14-year-old daughter has anxiety.

2:55And because of her anxiety, and particularly her fear of getting sick, she can be quite sensitive about what she eats. For example, she is picky about textures and avoids things like the veins sometimes found in chicken breasts. Lately, I noticed that she has lost some weight, and I'm increasingly concerned, but I'm also very worried about saying the wrong thing and making the situation worse. This is the first year she has consistently eaten breakfast. In the past, she's often skipped it due to stomach aches from anxiety. And while I'm glad she's now eating breakfast, her lunches are very limited, usually just carrots and hummus and rice cakes.

3:33She eats a good dinner, but is concerned about how healthy the food is. And she recently decided to stop eating sugar. So no more cookies, no more cakes, desserts, anything like that. She has mentioned that she's worried about getting fat because she ate so much last week. To that, I've responded, no, your body needs fuel, your brain needs fuel, you are still growing. We've always been careful not to comment on weight or appearance, instead focusing on her strengths. I don't know how to approach this more directly without increasing anxiety or resistance. I would really appreciate your guidance on how to raise concerns about eating and health in a way that is supportive, effective, and protective of the parent-child relationship, especially when anxiety is already part of the picture.

4:18So we'll get into the details of what's going on with this kid. But I want to start, you have cared for so many families. I want to start with where a parent is in this moment, what they are feeling, what they are thinking, when their child is, I'll just say it like messing with eating in a way that's starting to be concerned. Like what's the parent's feeling at that time. Sure. You know, with the families that I work with, I think I hear parents most say that they are terrified when they see that for the first, really strong, big words. You see your child struggling with something, a basic developmental task that you think that they would have mastered by age three.

4:57Eating, right. And then you see that basic developmental task start to shift and start to change. And we get so many messages from social media, from all over, you know, about what we should and should not say, particularly to kids and teens about eating weight and all of that. So when we start to see things that as parents we get nervous about, but yet we're grappling with these messages, do I say something? Do I not say something? We're kind of left out feeling helpless in what to do. And helplessness leads to feelings of fear and being terrified. So parents feel that, you know, there's just so many complex emotions going on that they And at times it feels debilitated and as if they don't know what to do in that situation.

5:39Okay. So terrified, helpless. And also like as a parent, like if your kid's not like to get your kid to eat, right? I mean, it's such a fundamental part of our relationship, right? Okay. So holding that space for the parents, just sheer fear. Absolutely. And I would say along with fear, disempowered, you know, because they may have heard along the way. You get advice from friends, from family members, from teachers, from school administrators about this is what you should do. And sometimes those messages match up, sometimes they don't. So that leads to a lot of confusion as well. Okay. So lost.

6:16Just scared and lost. Scared and lost. Okay. Horrible. All right. Let's get this. Let's start to sort through this so that this parent, other parents don't have to feel scared and lost. Okay. So in reading you that letter. You've cared for so many kids. Are you worried about this kid? Are you concerned about eating and possibly an eating disorder? So what I would say is, yes, anytime a parent's spidey sense gets set off, I'm going to join them in being a little bit worried at first, right? You know, granted, we'll have to do a further evaluation to know how worried we should be. But trust your gut, you know, and yes, I would be a little bit worried at first.

6:55That being said, what's then going to decrease my worry is how on it this parent is. This parent seems to be asking the right question. They're observing the right things, you know, and they're expressing concern about what they're seeing. So that is going to be a protective factor. If this early on, a parent is able to identify that this doesn't feel right to me, and I'm going to seek out the advice from the experts on how to manage it, that's going to help a lot. So that's something that's going to decrease my worry and think we can do this. Okay. And this is something we do as clinicians. We're like, what's in the worry column?

7:31What's in the reassurance column? So there's, I think also having cared for kids in similar states, there's stuff that's got me in the worried column too. But I really hear what you're saying, that in the reassurance column is you have a parent who is paying attention, who is asking, who is curious, who's not just saying, oh, she's eating healthy. Yay. Who's doing that. But on the worry front, I think this is something I learned from you. Teenagers should not usually be losing weight. And this kid's losing weight. Talk to me about that. I think that's right. You know, what we would typically expect is for teenagers to follow their historic growth trajectory, right?

8:13So that's why our pediatrician, from the time we bring the babies in from the beginning, why they're plotting their data points along that graph, you know, so we can ensure that But they're growing at the pace that that particular child was intended to grow. And it's like an arc, and they should sort of stay on that arc. So if they're falling off the arc, whatever their arc was, we don't expect to see that. That's exactly right. And for some kids, it may mean something. And for some kids, it may not. But it's certainly worth more evaluation at that point, because a fall off of one's growth curve is a telltale sign that something might not be right.

8:46Okay. So then to press this point, when is it okay for teenagers to be losing weight? Mm-hmm. That is a good question. And I don't know if I have a perfect answer for that, you know. So what I would say is, you know, it's not common for teenagers to need to lose weight, you know. I certainly think that there are behavioral interventions that if one is concerned about behaviors, you know, so if my child is overeating, if my child is endorsing binge eating, if my child is gaining weight at a faster trajectory than what we would expect, in those situations, I still don't know if a prescribed diet per se is what should be recommended.

9:30But instead, how about we focus on the behaviors that have changed and then that's what we would attend to. So I like to shift conversations, and the American Academy of Pediatrics put out a statement a few years back saying the same. I like to shift conversations about weight in and of itself and then instead focus on the behaviors that could or could not be dangerous. Okay. That's really helpful. Because it's always been so helpful to me from our conversations and work together that, like, by the time a kid's losing weight, usually something's up. that that is a pretty reliable indicator that something's not right.

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12:18So the thing in this letter that really got me and that I think so many parents will feel is I can feel there's something not right. I know I want to say something or try to intervene. How do I do it without making it worse, right? That that's for me, probably why this parent wrote in. It's not that they don't know there's an issue. I think they do know there's an issue because they're writing. It's the how do I even bring it up without exacerbating her anxiety or the behavior? How do you guide parents? I think I'd first want to have a conversation with the parent about, define for me what it means to get worse.

12:59So if we're trying to avoid dysregulation and we're trying to avoid a child becoming upset or angry, tearful, that's probably not going to happen because this is very difficult to do. And often kind of a hallmark sign of eating disorders and disordered eating is a lack of insight into the behavior. So whereas we as the providers or as parents can clearly see that there's something wrong, the child may not have that same insight and genuinely be thinking that we're all nuts and we're crazy. No, I've had those conversations with kids. I can't tell you the majority of my initial assessments, kids coming in and looking at me and saying, Dr.

13:35B, I think you're nuts. You know, there's absolutely nothing wrong with me. You know, I've had those conversations with a kid whose leggings were hanging off of her. You know, so I know what you mean, where there can be such a disconnect between what we can see or what this parent might know and where the kid's at. So what I hear you saying is. Don't be frightened of a kid getting upset. One, there's no reason for us to be frightened of kids getting upset. usually. Emotions are part of the deal. But I also think I hear you saying it's also maybe less likely than a parent might imagine in this situation.

14:14Is that it? Yes. And I also think, you know, eating disorders thrive off of secrecy. That's how they're able to, you know, continue to destroy the lives of adolescents, kids and adolescents, you know. So we want to break that secrecy. Breaking that silence is one of the first steps of intervening and letting the child know that we are here to support and help you out of this and you don't have to navigate it alone. And oftentimes we'll get a very angry, strong reaction. But oftentimes what we also see is later on a kid being relieved that someone said, we're just taking this out of your hands right now because they've been grappling with their own voice and the eating disorder voice for a lengthy period of time.

14:56And sometimes to be able to hear that's a way, we don't have to worry about that anymore. We are going to make that decision for you. So you don't have to brings about a lot of relief for the child. So I always say, you know, to parents, first and foremost, we don't walk on eggshells. If you see something, say something because the shorter duration of illness and the faster that we can intervene, early intervention is critical. So the faster we can intervene, the best chance we have of making a full-blown recovery. So we always want to say something. Okay. This is so, so valuable because I think we love our kids.

15:30We don't want to upset them. The kid's not saying anything. You're watching something unfold or something may be unfolding. So I totally understand the letter writer wanting to like, I don't want to rock the boat too much. And what I hear you saying is go ahead and rock the boat. Better to stand for reality. Your child may get upset. That's okay. Your child may not get upset. That's okay. But this needs to drive toward an honest conversation about health. Yes, and how we rock the boat is incredibly important too, right? So what I like to share with families I work with is NAA, notice, ask, and then act.

16:08So notice, we want to observe that there's something, if you observe that there's something going on, look for changes in not just weight or physical appearance, but also look for changes in mood, how much socialization your teenager wants now, how are they doing in school, any sort of change might be an indicator that there is something going along paired with other behavioral symptoms with an eating disorder, you know. And then with ask, you know, when I would ask, this is probably the important one. So we want to approach our adolescent with curiosity and with empathy. And we want to be very careful to not make accusations, you know, because that is a surefire way to put up that defensive wall and basically get nothing at that point, you know?

16:51Okay. So like this parent in this situation might say, I notice that you're losing weight. And then what would they ask me? What would they ask? Their asking could be, tell me, or how have you been doing with eating? Is there anything, how has your relationship with food been? Or even if you want to start off more generally, you know, has everything been okay lately? And just sharing your observations. I've noticed, you know, we as parents have noticed X, Y, and Z. And we're curious, is everything okay? And we want to let you know that we are here for you in any situation. Okay. So then I'm going to play the 14-year-old.

17:31I'm fine. I'm fine. Now what happens? So that brings us to act. Okay. We don't have to wait for our kids' permission in order to act. or we don't have to wait for them to agree with us that there is a problem in order to act. These illnesses, unfortunately, can just be too dangerous to just sit and to wait. So whereas, of course, we want to take in their perspective, that'll be helpful data for their clinician as well. If we're still concerned and we have those clear examples of behaviors that are a change, then we still act by setting up an evaluation with an expert or a trained professional in the field just so that we can get that extra reassurance that things are okay.

18:08Okay. So the parent might say, we hear you're fine. We're not entirely comfortable. We're setting up an appointment to get this evaluated by somebody who really knows what they're doing. And one thing I've learned along the way, and I think that this is what you're gesturing at, not all pediatricians are going to evaluate these things in the way that eating disorder experts would want them to. I've had the experience clinically of sending a kid who I was very worried about to their pediatrician who's like, nope, they're doing fine. And I'm thinking, I really don't think so. But that can derail, you know, the process.

18:47So am I right in hearing you say, like, you want to find somebody who does this in a more specialized way to do the evaluation? Absolutely. And I think a person, too, that is not just doing it because this is their passion or because this is their interest, but genuinely has specialized training in this area, too, because it does cross physical, emotional, psychological. It crosses so many different domains. And we do have evidence-based treatment protocols for eating disorders. So finding a trained professional is critical to outcome. Well, and that's such an interesting, I think, story in our field that we used to be really kind of bad at treating eating disorders that we would put severely underweight people in psychotherapy and just try to get talking about feelings.

19:33And the field has come so far in how we care for people with eating disorders. Efficacy has improved so much. But you do need to find people with the right training. So how do people find people with the right training? Good question. So there are several professional organizations that are helpful for this for the start. Now, if we're talking about kids and adolescents here, you know, more often than not, you know, the search will begin with something called Maudsley family based treatment. Right now for adolescent anorexia nervosa, it is a first line treatment for adolescent. Standard of care.

20:08Standard of care. What we expect. It's what we would expect. And there is some evidence for FBT, what it's referred to as well, for bulimia nervosa, binge eating disorder, and ARFIT as well. So usually a search for monthly family-based treatment is going to be the first way to lead you somewhere. So I would say the first place that I would start would be with your child's pediatrician. I think now we are learning more and more about eating disorders. And there's been a lot of work done to disseminate more information about evidence-based treatment protocols for eating disorders. So pediatricians, I always call them the quarterback of a child's care.

20:45So they're typically the place to start. And if your pediatrician is affiliated with a larger hospital system, then they should be able to supply resources. But if for some reason you're not able to, there are professional associations such as the Academy for Eating Disorders, the Training Institute for Child and Adolescent Eating Disorders, FEAST, which is a family-based professional organization that has a ton of resources for family. They're a great place to get started because they have provider directories across internationally and nationally to be able to get started. Great. Okay, I want to walk this back a little bit.

21:20I know there's plenty in this letter that has us concerned, right? Cutting out food categories, losing weight. you know, that there's enough here that you and I as clinicians know, like, it's time to call in a pro. What about the situation where a teenager resolves to just start eating healthy, right? That they're going to start eating healthy, that they're going to up their protein, up their fruits and vegetables, cut their sugar out or way back. What should be this stance of the loving adult in that moment? That's such a great question. And I'm kind of giggling to myself because I would say 90 % of the kiddos that come to see me, the problem started there.

22:02You know, I hear that very frequently that it was not this intention to dabble in an eating disorder, but it started off with genuine efforts. I learned something in health class about how to care for my body. So I'm making these changes. And for some kids, that's perfectly fine. And they can make those changes and there's no issue, but not all kids, you know. So if your kid says, I'm going to start being healthy, I think we can join with them on it. Again, that's when we want to be curious, right? And ask, okay, tell me about what that means for you. We want to just check to make sure that our kids aren't thinking in extremes.

22:37The behaviors and the things that they want to do in order to get healthy actually are in line with health guidelines. Because sometimes what they're learning on TikTok is not always healthy. Is not actually a measure of health. That's right. So I would just want information on what that means to them and why, you know. And then what I would say is if those efforts to get healthy really aren't looking healthy, I would still say we move to act. And trying to get an evaluation just to see, because on my end as an eating disorder clinician, you know, working with a child who is just starting off, maybe not meeting criteria for a full-blown eating disorder, but is definitely engaging in disordered eating, much easier intervention.

23:20and much shorter intervention. So that's kind of where I like to see them so we can get things back on track sooner. I've always thought about eating disorders and drug treatment a little bit the same. Like if a kid is messing around with weed for a few weeks, that's not that hard to turn around. If a kid has been doing it for three years, you're in a different situation. And I've always felt that way about eating, that if a kid is starting to dabble in dieting that doesn't really make sense at all, you can make a big difference fast. If things go very far down that road, it's a lot harder. Absolutely.

23:55That's such a great analogy for it, you know, because we want to intervene before the illness becomes fully entrenched in the brain, because that is when it becomes very difficult to treat. Unpack that. Fully entrenched in the brain. When you say that, what do you mean? So when I say that, I mean the child is no longer able to disengage themselves from the eating disorder. So they feel like one in the same. So you may have had this previously compliant, high performing, high achieving child that suddenly things are looking different, you know, and all of you, but their brain is not functioning in the same way anymore.

24:28They're just not able to rationalize things in the same way. And they could be getting straight A's in school, but just can't understand why not eating adequately isn't okay. Why passing out is not okay. There's a concreteness and a rigidness. A concreteness and a rigidness is a great way to put it. That can kind of come over kids in these situations. Okay. As I've gotten older, I have felt like my sleep is more fragile, and I know I'm not alone in this. Orion is a smart sleep system that fits right over the mattress you already have, and it adjusts your temperature to help you sleep. Now, what's cool about this is that it's totally personalized to you.

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26:59So it's okay for kids to want to eat healthy, but if they come home and declare they're eating healthy, start watching. And I think it's important to remember, too, what does healthy mean? Healthy really is a subjective relative term. What's healthy for one child may not be healthy for another child. So, again, we want to make sure that they have realistic expectations for themselves. Okay, so that it's within the range of what really is healthy for them. But to watch. And if it starts to get weird, not wait. That's when we move to say something. Okay, excellent. What else am I not asking about, either from this letter or just in general, that you think is really important?

27:34I think, you know, a question that I often get to is, well, should I be concerned? My child doesn't look any different, you know? And I'm not seeing that weight loss is either not noticeable or maybe the child hasn't lost a significant amount of weight. Maybe they haven't grown in the way that their pediatrician would have expected them to grow, you know? But I think an important message, too, is that you can't tell an eating disorder just by physical observations alone, just by what someone looks like, you know? So, again, this is why it's important to pay attention to those behaviors and not their physical appearance alone when making these decisions about whether or not to act.

28:11Okay, so like what they're doing. What they're doing. More than how it looks. Yes. Okay. So, true confessions here, but I know I'm not alone. I live in this world. I'm a woman in this world. there are times when I have discontents about my own body. And I'm very aware of this in light of having two daughters myself. When parents have their own unhappiness with their size or shape, what do you want them to do? What do you not want them to do for themselves, but also for their kids? Got it. I think, you know, first and foremost is we want to practice what we preach, And we're all kind of coached as parents to really do what we can to boost our kids' self-esteem and to make them feel good.

28:57And there's a strong body of research that suggests parents making negative comments about their own bodies can significantly negatively impact their adolescence, particularly in relationships between mothers and daughters. So one of the things to not do is if we are feeling insecure or we aren't feeling great about our bodies, we've got to try not to say that in front of our kids. and seek out our own help, our own professional to be able to work with to kind of grapple with that. That said, I do think that there's something to be said for honest conversations with your teen girls, you know, to be able to validate that experience that, yes, at times I'm a woman living in this culture too, and there are times that I don't always feel great about my body too, but here's what I do to not let it ruin my day.

29:43And there's been a big shift in the body image feel, in the body image area, kind of away from only pushing body positivity. And in a sense, I'm kind of glad because when I would work with a lot of my teens on body image, you try to talk about positive body image and they look at you like you're creepy. They roll their eyes. They're rolling. It's so spooky. No, I'm so glad you said this because I think for years I've thought like, you know, and for 20 years I consulted to a girls' school and I would sometimes be the person saying that stuff, sometimes watch an adult saying this stuff. And I'm watching these 14-year-old girls who so had the drop on the adult.

30:15Like, who are you kidding? You lose them right there. You are up there saying that you are all for body positivity. I know full well that you may worry about your body as much as the rest of us do. Okay, so tell me where we've come from there because I'm so glad to hear it. Sure, sure. So now I think we try to focus more so on body neutrality and body appreciation. So even if it feels like too big of a goal to truly feel positive about your body in this moment, what would it take to feel just neutral about your body? Like this thing gets me around. It gets me around. I'm not letting it influence my day, influence how I feel.

30:51I'm able to move past it even if I don't love how I look in these jeans today. And then I think a way, a strategy to do that is to start to focus less on what your body looks like and more so on what your body does. What can you appreciate your body for? So I may not love my stomach, but it helps me digest food. I may not appreciate my thighs, but guess what? I can run track because of my thighs. I love it. Let's end on that. I may not love my thighs, but I can run track with them. I love that. Let's do the headlines. What, from this conversation, would you want families to take away? Okay. So I think the big takeaways would be, one, don't fear what you see.

31:40Instead, be an observer, be curious about it, and approach your adolescent with concerns in the kindest, most empathic way possible, but make sure that you're saying something. Engage others around you, you know, the pediatrician, if there are partners, if there are, you know, other people that are important to your child's life, you know, while still protecting their privacy and being thoughtful and mindful of, you know, of their privacy. but engage others in your life to help too if you need that extra support. But also too, I think we have to be careful to kind of stay away from the global messages about eating disorders that may or may not be accurate and really make sure that we're doing our due diligence to get good information about what truly is an eating disorder.

32:26How is that different from disordered eating? And what do I do for either one of those? Well, how are those different? So the two are kind of like what we were talking about earlier. You know, disordered eating is certainly the precursor to an eating disorder. So with disordered eating, they may start to engage in some of the behaviors, but maybe the frequency, the intensity, or how long they've been having the symptoms just doesn't match up with what a clinician would diagnose with an eating disorder. But that said, it's still concerning. So it's a precursor that may or may not turn into an eating disorder.

32:57That may or may not, yes. So one other thing that I would add in as a takeaway, too, would be it's so important for me that people understand that parents and families do not cause eating disorders. And in fact, parents and families can be the best possible resource. They are the best possible resource and agent for change and for recovery. So it should truly feel like a partnership. if you are seeking help for eating issues with a child, it should be a big red flag if there is no parent involvement and if parents aren't involved in any way possible. Right. That's the old school model. That's the old school model.

33:33Right. Gotten rid of. Dr. Botnager, Kelly Demay, thank you so much for joining me. It is always such a pleasure to be here. And thank you so much for having me and for this podcast. You bet. It's my favorite too.

33:50So for parenting to go, I want to pick up on something I noticed and I think you noticed in that conversation, which is Dr. Botnaggard never said, yes, this child has an eating disorder or no, she doesn't. And I know why. It's because any ethical clinician is going to really want to evaluate a young person themselves before making that kind of call. But here's what she did say. If you are concerned, seek help. Talk to somebody. Your scooby sense is what really matters here. we know our kids. And if we're worried, we should explore that. In fact, one of my favorite sayings that other experts have said before me is never worry alone.

34:30And Dr. Botnager was saying that too. Talk to some other folks, check in with your family physician, don't sit on this. The hazard of worrying alone is either it becomes way too big, or it becomes too small. We push it to the side. When we talk with others about our concerns while respecting our teenagers' privacy, we can help figure out how worried we should be and also what we can do to try to address that concern and get things back on track. Be sure to be back here next week because I will be joined by another wonderful colleague of mine, Dr. Mark McConville, author of the book Failure to Launch.

35:09And we're going to tackle a letter about a parent who's worried that her kids, they're just not launching the way she was thinking they might. I'll see you next week. Thanks for joining us. Be sure to subscribe to the Ask Lisa podcast so you get episodes just as soon as they drop. And send us your questions to asklisa at drlisademore.com. And now, a word from our lawyers. The information provided on this podcast is for educational purposes only and does not constitute or substitute for professional psychological treatment, therapy, medical advice, or other professional intervention. Views expressed by guests are their own and do not necessarily reflect the views of Dr.

35:52Lisa DeMoor or Ask Lisa. If you have concerns about your child's well-being or your own, please consult a physician or mental health professional. If you or someone you know is in crisis, contact the 988 Suicide and Crisis Lifeline by calling or texting 988. For additional resources, visit drlisademore.com.