But eating disorders are not just a creation of modern life. If our culture causes anorexia, how could there have been documented cases of anorexia as long ago as the 1890s? In 1895, a doctor at an English children’s hospital described “A Fatal Case of Anorexia Nervosa” in an eleven-year-old girl. “She had a wild, hysterical appearance, was very restless, and refused all food,” recorded the doctor. He tried to feed her beef tea, brandy, and milk, but after fifteen days in the hospital, she came down with a fever and died.
One hundred years later, in the mid-1990s, a seven-year-old girl, “VE,” was admitted to Massachusetts General Hospital. She weighed just 57 pounds (26 kilograms), but stated to doctors that other children would “like her more” if only she could get down to 50 pounds. She no longer ate regular meals, and she drank nothing but water. She was fearful of eating, or even of chewing her own fingernails, for fear of gaining weight. She spoke in an “infantile manner,” yet would also make comments about her thighs and stomach being too fat. She was under the impression that folds of fat hung down over her pajamas, when in fact her tiny body was “engulfed” by her clothes. Before her hospitalization, VE was involved in competitive dancing, figure skating, and gymnastics. Her mother had wanted to be a dancer herself, and said she could imagine VE dancing on Broadway. There were conflicts in her parents’ marriage. VE’s mother had a tendency to become enraged, whereas her father would withdraw and leave the room rather than argue.
At first glance, this sad case looks like strong confirmation of the view that parents and culture cause anorexia. It’s a lot of pressure for a seven-year-old to be engaged in not one but three highly competitive individual activities—skating, dancing, and gymnastics—all of which place a premium on being thin. Four months before VE was hospitalized, her mother had discouraged her request to give up dance lessons.
But the assumption that ballet and elite sports “cause” anorexia has been questioned. Prima facie, children who do physical activity for several hours every day already look pretty similar to sufferers of
anorexia
athletica
, who engage in compulsive exercise. Disciplines that emphasize leanness have a higher prevalence of eating disorders than endurance or ball sports. In one study, more than 80 percent of female ballet dancers were estimated to have an eating disorder over a lifetime, yet other studies suggest that the prevalence is lower than 10 percent. Recently, experts have been rethinking the role of physical activity in eating disorders. In old-style treatment, anorexics were discouraged from exercising, in case it aggravated their illness. A major review of medical databases in 2013, however, found that supervised exercise could actually aid the recovery of anorexics, by building strength and cardiovascular fitness and alleviating the symptoms of depression.
In the hospital it became clear that VE’s perfectionist tendencies predated and went beyond her recent involvement in dance, skating, and gymnastics. From her earliest years, her parents had found her to be “difficult” and highly competitive with her peers. She seemed to greatly fear any sign of weakness in herself, and she was distraught about some recent poor scores in math at school. In the hospital, she worked hard to show that she was a good patient, and she was needy for praise from staff. Anorexia sufferers often say that, long before they started attempting to lose weight, they remember feeling anxious, fearful, socially vulnerable, and obsessive in various ways. Around two-thirds of people with anorexia also suffer from an anxiety disorder. While neither of VE’s parents had an eating disorder, both suffered from bouts of depression. Her mother had twice been hospitalized with postnatal depression and had been treated for OCD.
Without all the pressure surrounding skating and gymnastic competitions, VE’s anorexia might have taken longer to manifest itself. In addition to refeeding her, VE’s cure involved switching her hobbies to team sports and other group activities, such as soccer and Girl Scouts. But her anorexia was not “about” the sports or the skating or dancing. Plenty of people do manage to become elite athletes or top dancers without developing eating disorders. With the family history of depression and OCD, VE had a biological makeup that would have made her vulnerable to eating disorders even without those activities.
Anorexia tends to occur when someone who is genetically predisposed to the illness suffers some kind of stress or trauma. But often the trauma is
nothing more or less than puberty. The natural weight gain that occurs as children’s bodies change into adult ones can prompt body dissatisfaction: Are these strange, swelling limbs really mine? Anorexia may be a way for girls to desexualize themselves and return to the safety of prepubescence: as the weight falls, breasts and hips melt away and periods stop. The hormones of puberty also seem to play a role in triggering anorexia in some people. New data from twin studies indicate that estradiol, the female sex hormone, can “switch on” the genes that predispose some individuals to anorexia.
With the falling age of puberty, it follows that the age at which children develop eating disorders is also dropping. Susan Ringwood, the director of Beat, the leading eating disorders charity in Britain, confirms that rising numbers of younger children are calling the Beat helpline. “We’re not quite sure what is doing it,” she says. One possibility, however, is the younger onset of puberty. “The average age of puberty has dropped by about five years in the last fifty years,” notes Ringwood. Given that we know that the onset of puberty increases the risk of developing anorexia, it would be surprising if there were not some link between this much earlier puberty and the early anorexia.
If there is a link, then some of the current childhood anorexia, paradoxically, has its roots in the obesity crisis. The causes of early puberty are not easy to unravel, but there does seem to be a correlation in girls between higher BMI and earlier onset of periods and breasts. “It’s primarily driven by weight,” says Ringwood. “Forty-two kilos [about 92 pounds] and you are in.” In 2000, it was found that 1 in 6 girls in Britain were showing signs of puberty as early as eight. One in 14 boys had pubic hair by the age of eight, compared to 1 in 150 for their father’s generation. “We know that the biological mind of puberty starts to develop around two years before the physical effects,” says Ringwood. There is a domino effect: from child obesity to premature puberty, from premature puberty to eight-year-old anorexics. “It’s the double whammy,” she adds. “You are starting to develop an adult body when you have even less of an adult mind.” When young children become gripped by anorexia, the illness seems to escalate faster than it does with teenagers. A comparison of child and adolescent anorexics found that the children lost weight faster and were likely to
have a lower percentage of their ideal bodyweight at the time they—or their parents—sought medical help. This was all the more worrying, given that they were still of an age when they needed the best possible nutrition to help them grow and develop long-term bone density.
The only good thing about anorexia hitting the very young—and admittedly it’s not much of a silver lining—is that they tend to have better rates of recovery and a shorter duration of illness than older sufferers. In some ways, being a child helps the situation. “If they are to recover,” says Ringwood, “children with anorexia do need to be made to eat.” The advantage of being a child is that you are already in the habit of having other people feeding you. You are also in the habit of listening to adults telling you what to do, so it’s not so strange when they tell you there is simply no option but to eat. In recovery, this childish obedience can be very helpful, for as long as it lasts.
When a child has an eating disorder, family meals can be
miserable, soul-sapping occasions where children lie and parents wheedle and very little is eaten by anybody. Or they can be exercises in make-believe, where everyone politely pretends not to notice that one person has eaten no more than a couple of pieces of cucumber and half a yogurt.
But family dinner is also a child’s best hope of getting better. Viewed through the prism of anorexia, you see just what a powerful and therapeutic thing a meal can be. When it goes right, a child is, all at once, being given nutrition and love and a way to escape a prison of misery. It isn’t easy to reach this point, for any of the parties concerned. A mother of a daughter who was severely anorexic for nine years described her frustration at reading overly optimistic accounts of “parents who just insisted that the child ate, the child did, and roses grew around the door and life was lovely again.”
With anorexia and related eating disorders, the stakes are even higher than with selective eating. Restrictive eaters are not actively trying to starve themselves; anorexics are. One of the horrible truths about anorexia is that not to recover so often means death. A systematic review of the literature in 2002 looked at studies involving more than 5,000
anorexics. It found that while there was a “good outcome” for around half of anorexia sufferers (meaning that all symptoms had disappeared), and a “fair outcome” for around 30 percent (meaning improvement, but with some residual symptoms), there was a “poor outcome” for over 20 percent, meaning that the disorder was chronic. With anorexia, a poor outcome means death in some cases.
At the Maudsley Hospital in South London in the 1980s, some therapists discovered that they could achieve much more hopeful outcomes with anorexic patients than the statistical norm would predict. They did this by focusing more intensively on the symptoms of the disorder: the eating itself. Therapists noticed that when nurses sat with the patients as they ate, talking to them and sometimes rubbing their backs, they could create an atmosphere of such kind persistence that it was “impossible . . . not to eat.” These Maudsley doctors had the shrewd thought that perhaps parents could be taught to perform the same role at home. This was the kernel of the current movement of “family-based treatment” (FBT), sometimes called “the Maudsley approach,” although most of the research on which it is based was done in America at Stanford and the University of Chicago in the 1990s. FBT works on the basis that a child with anorexia needs to be systematically “refed” by her parents, until she is well enough to take responsibility for her own eating again. Research by Daniel Le Grange and James Lock, two of the leading lights of FBT, suggests that for anorexic patients who are younger than eighteen who have had the illness for a relatively short amount of time, recovery rates can be as good as 90 percent, with full remission after a year and even after five years. FBT—when followed very systematically—achieves these remarkable recovery rates by doing exactly what most eating disorder therapists had been trained not to do: allowing the parent to take control of the child’s eating.
Traditional eating disorder treatment was based on the idea that parents were to blame.
The Golden Cage,
by Hilde Bruch (1978), a German psychoanalyst working in America, was an influential book that described the parents—especially the mothers—of anorexic girls as monsters who stifled their children with impossibly high expectations and an atmosphere of neurosis. Bruch felt that in order to recover, a patient needed to
separate from the family. Individual therapy would encourage a patient “towards independence.” There was no question of family meals being used as part of the treatment, because family meals were seen as the thing that had caused the anorexia in the first place. On Bruch’s model, parents were often warned that they must not sit and eat with their children, lest their presence be oppressive. They should offer no judgment on what their children ate, but must allow them to make their own eating decisions. In some cases, therapists felt that a “parentectomy” was advisable: a total separation of parent and child. The thinking was that since anorexia was not really “about” the food, the child would choose to eat once she had worked through her other issues. But the point about having an eating disorder is that the child is
not
in control of her own eating. Left to her own devices, she will, likely as not, revert to the disordered behavior, whether it is bingeing or starving. With the traditional treatment, anorexia clinics found that their patients might recover in the hospital, where they were being actively fed—either by tube or with real food—and then relapse very quickly when they got home. Which was hardly surprising given that the parents were being told not to interfere in their child’s eating.
FBT turns this dynamic around. It is predicated on a nonjudgmental attitude toward parents. This is not to say that a family dynamic never contributes to an eating disorder, but that what very sick children need is urgent treatment rather than endless discussions of what made them ill. Guilt is a crippling emotion that makes parents feel hopeless and unable to act. The idea of FBT is that parents must feel in charge of getting their child to eat again and must therefore stop blaming themselves. Once they forgive themselves, they are in a position—with the help of a therapist—to start the hard task of “refeeding,” which is a little bit like teaching an infant how to eat solid food again. Again, the needs of the eating disorder sufferer are like a warped version of the travails we all face when learning to eat.
As with weaning, refeeding is a slow process, requiring stamina. To start with, a parent may be happy if the child manages a meal of mashed pumpkin with a teaspoon (many anorexics revert to using baby cutlery). As time goes on, you expect more of her, upping the calories in stages.
She needs to add new foods to her repertoire, like a selective eater. You refuse to give her low-fat options. No meals are to be skipped, and the child is encouraged to take one more bite beyond what she wanted to eat. The food is never forced, but nor is the child allowed to say that she doesn’t feel like eating. James Lock argues that it is a mistake to respect the voice of the child when she says she does not want to eat, because that is the illness talking.
At the start of the FBT process, the family will have one or more “coached meals” at which a therapist counsels parents in how to manage family food, such that a child will eat. By the time they arrive at an eating disorders clinic, families often say they have “tried everything” at mealtimes; but the odds are that—as with parents of selective eaters—they haven’t felt able to pursue any of the techniques consistently. Many of the families seen by James Lock do not have regular mealtimes, instead just grazing on food at ad hoc moments. The whole family, not just the patient, needs to relearn how to eat breakfast, lunch, and dinner, with structured snacks in between. Siblings, too, must be included, though parents are trained not to fall into the trap of comparing what different people around the table are eating. The “coached meal” teaches parents how to stop treading on eggshells around their child’s eating: to sit close and repeat calmly and assertively that she must eat the meal in front of her, even if she refuses or cries or says she hates you. The parents need to agree among themselves before the meal starts about how much they expect the child to eat and what the consequences will be if she doesn’t (no computer games for a day, for example). With divorced parents, Lock goes so far as to say that the child should live for the time being with the parent who is better able to manage the meals.