Eating disorders in children and adolescents

Eating disorders are mental disorders that affect your relationship with food and your body weight and body image. An eating disorder also affects you psychologically and socially. It will often make you feel tired and sad, and affect your ability to concentrate. Many stop seeing their friends and family — both to avoid eating situations, but also because they simply cannot cope with being with others.

An eating disorder can manifest in many different ways. If you have an eating disorder, your goal may be to:

• Focus so much on food that you don’t have to think about negative things in your life.
• Be thin or to reach a specific weight.
• Eat extremely healthily or in a specific way.

You may not yourself think that anything is the matter. Therefore, you don’t feel that you need help.

Many girls and boys at some point in their lives feel that they look all wrong and perhaps that they are too fat. Even if they are not. Many also go through periods of trying to lose weight by dieting, eating less or exercising more.

Some have episodes of overeating and being unable to control the amount of food they eat. It may be that they eat without really being hungry, or to the point of feeling uncomfortably full.

It only becomes an eating disorder when the person finds it difficult to think about anything other than food and their body, when their behaviour changes, and when it starts affecting their life as a young person. With most eating disorders, the person’s weight will also be significantly affected.

There are a number of different eating disorders. These include:

• Anorexia
• Bulimia
• Binge-eating disorder (BED).

You can read more about the symptoms of the various types of eating disorders under ‘Symptoms’.

There is no single reason why some people develop an eating disorder. Below you can read about possible risk factors.

Vulnerability

You may be vulnerable to developing an eating disorder. Risk factors can be biological, social or psychological. Possible factors include:

• Your parents, siblings or relatives have had an eating disorder or other psychiatric disorder.
• You have experienced stresses earlier in life, such as divorce or death in your family.
• You have low self-esteem.

Triggering factors

Triggering factors are events in your life that cause your eating disorder to manifest. Possible factors include:

• Long-term stresses and strains.
• Breakup of important relationships (family, friends, boyfriend/girlfriend etc.).

Maintaining factors

Once you have developed an eating disorder, it may be sustained by a number of perpetuating factors. Possible factors include:

• Bodily changes

  If you eat very little, your stomach may shrink, causing you to very quickly feel full and therefore eat less. Conversely, prolonged overeating will expand your stomach, and you will therefore need to eat more to not feel hungry.
  A malnourished body and brain will reinforce and perpetuate the difficult and rigid thoughts about food and your body.

• Rituals and rules

  Food habits can become very ingrained. Perhaps you need to eat certain types of food – and to overeat them to feel comfortable. Perhaps you have a rule like: “I’m going to eat less today than I did yesterday!”.

• Avoidance behaviour

  It may be that you have started to avoid certain foods. By avoiding these foods, you are telling your brain that these foods are dangerous, and your avoidance behaviour therefore ends up reinforcing your thoughts about food and your body.

• Changes in body image

  A person with an eating disorder typically sees themselves as fat, even if they are actually of normal weight or even underweight. Most people with an eating disorder have a perpetual desire to lose weight.
  In those suffering from BED, overeating may lead to overweight. This may reinforce the sense of shame that perhaps triggered their binge-eating in the first place. The result is a vicious spiral.

Societal and cultural factors

Societal and cultural factors also play a role when it comes to developing an eating disorder. In our culture, there is a strong focus on the body, on the ‘ideal’ look and on how you appear to others. The media, ads and magazines are packed with exercise and fitness programmes and rules about what to eat to get a little bit thinner.

Over the past 50 years, the bodies presented in the media as being ‘ideal and beautiful’ have become thinner, while our physical bodies have become larger. Through the media, we are left with the impression that there is something wrong with us: We’re too fat.

Depending on our life situation, background, our physical and psychological structure and networks, we may be at greater or lesser risk of developing an eating disorder. Girls and young women aged 12 to 24 are at particular risk of developing eating disorders.

Boys can also develop eating disorders, but for every 10-12 girls with an eating disorder, there is only about 1 boy.

Psychological symptoms

Eating disorders are associated with several psychological symptoms. Perhaps you can recognise one or more of them:

• A sense of shame as a result of a changed relationship with food and body. Resistance to accepting being ill and needing treatment.
• Difficulty concentrating, learning difficulties, irritability and sadness.
• Preoccupation with food, eating, weight and body shape to the extent that everything else becomes unimportant. Social isolation due to difficulties eating together with others or low energy levels.
• Low self-esteem and negative self-image.
• Increased need for control. The controlling behaviour can be directed at anything from calorific intake, schoolwork, exercise, to parents or other family members.

Symptoms of anorexia

Signs of anorexia may be:

• Weight loss leading to you being underweight because you eat too little.
• Excessive exercise and physical activity, which you find difficult to cut down on. You vomit, use slimming agents or laxatives.
• You feel that you are too fat.
• You are very preoccupied with your weight and/or body shape. Hormonal disturbances, including absence of menstruation.
• Lack of or reduced physical development in the form of lack of growth or insufficient weight gain.

Symptoms of bulimia

Signs of bulimia include:

• Recurring episodes of overeating. Overeating is when:
  • You eat large amounts of food within a short time. Larger amounts than it is normal to eat.
  • You have a feeling of being unable to control your eating. You cannot stop eating, or you cannot prevent yourself from eating.
  • You are very preoccupied with your weight and/or body shape.
• You try to avoid putting on weight by:
  • Restricting how much you eat.
  • Vomiting.
  • Exercising a lot.
  • Using slimming pills, laxatives or similar products.

If you are developing bulimia, you will often feel great shame. Even though you want to get better, telling others about your symptoms might feel so embarrassing that it is easier not to seek help.

Symptoms of BED – compulsive overeating

Signs of BED include:

• Recurring episodes of overeating. Overeating is when:
  • You eat large amounts of food within a short time. Larger amounts than it is normal to eat.
  • You have a feeling of losing control of what you eat. You cannot stop eating, or you cannot prevent yourself from eating.
• You have negative thoughts and low self-esteem
• You feel shame after overeating.
• You don’t typically vomit after overeating.

Physical consequences of being underweight

The physical consequences of being underweight may include:

• Delayed puberty and absence of menstruation in girls/women.
• Low body temperature, slow pulse and constipation.
• General weakening of muscles.
• Fluid accumulations and swellings.
• Hormonal disturbances.
• Increased body and facial hair growth.

The physical consequences will subside or disappear altogether if you start gaining weight. Being severely underweight can lead to osteoporosis, cardiac arrhythmia, degradation of the heart muscle, leakage of heart valves and brain shrinkage.

Physical consequences of being overweight

The physical consequences of being overweight include:

• Type 2 diabetes.
• Elevated blood pressure.
• Osteoarthritis of hips and knees.
• Reduced fertility.
• Risk of blood clots.

In most cases, these effects may be improved or completely disappear if you lose weight.

Physical effects of compensatory behaviours

Compensatory behaviours are actions performed to lose weight. Such behaviours include provoked vomiting or excessive exercising. They may lead to:

• Dental damage and ulcers in the corners of the mouth due to corrosions from gastric juices as a result of vomiting.
• Substantial weight fluctuations of 5 to 20 kg within short periods of time.
• Poor intestinal function with sluggish and bloated stomach as a result of long-term use of laxatives or slimming agents.
• Damage to muscles, bones, joints and tendons.
• Menstrual disturbances and possibly absence of menstruation in women/girls. Delayed or absent puberty.
• Disturbed salt balance, leading to muscle cramps, cardiac arrhythmia and heart failure.

If the behaviour stops, many of these problems may be diminished or completely disappear again.

If you or your parents think you may be suffering from an eating disorder, you need to consult your own doctor. Your doctor can assess any signs that you may have an eating disorder and recommend help. Your own doctor will be able to help you or refer you to the municipal services or perhaps from a private psychologist or psychiatrist.

If you are in the early stages of developing anorexia, you will often find it difficult to admit that you have a disorder. Therefore, you will often insist that your life is under control and oppose the idea of needing treatment.

If you are developing bulimia or BED, you will often feel great shame. Even though you want to get better, telling others about your symptoms may feel so shameful that it may seem easier not to seek help.

It is important that your parents or other relatives know that a person suffering from an eating disorder may be ill for many years without seeking help. It is therefore of great importance that relatives, for example your parents, insist that you need treatment.

If your doctor has referred you for an eating disorder examination, you must:

• Wait for an invitation in your e-Boks.
• Participate in an initial consultation together with your parents.
• Be prepared to undergo a number of different examinations before it can be finally confirmed whether you have an eating disorder.

You will be called in for an examination at the Psychiatric Clinic for Eating Disorders. The examination can take place in Herning (Gødstrup) or in Aarhus (Skejby).

• Read more about the Psychiatric Clinic for Eating Disorders

You and your parents will participate in a number of examinations and consultations, where the focus is on:

• The development of the eating disorder
• Restrictions and rules in relation to your diet and eating habits.
• Overeating.
• Psychological symptoms in the form of:
  • Weight anxiety.
  • Feeling obese.
  • Difficulties concentrating due to thinking about food and eating.

You will also undergo a physical examination by a doctor, who will do:

• A blood test to assess the extent to which your organs are affected by your eating disorder
• An ECG (electrocardiogram) to assess whether your heart is affected.

Hard to put into words

Many people who suffer from an eating disorder find it difficult to describe their symptoms. This may be because you don’t understand that you’re actually ill. It may also be because it is difficult for you to sense and put into words what you are feeling and your behaviour. You may also feel reluctant to get help and treatment.

Many people may tend to:

• Understate symptoms

  Perhaps they say that they exercise like everybody else, whereas in fact they overexercise, for example by doing 500 sit-ups a day.

• Say that they’re not skipping meals

  They say that they eat normally, but they forget to mention that they avoid all foods containing fat or carbohydrates.

• Be ashamed of not being able to control their eating

  Therefore, they fail to mention that they regularly overeat and vomit.

Your parents can help describe your symptoms

It is good that your parents participate in the examination with you. They can help put into words some of the things that may be difficult for you to describe. In this way, the therapist gets a fuller picture of how affected you – and perhaps the whole family – are in your everyday life.

After your examination, you will be given an appointment to discuss the test results. You and your parents will be told about:

• Your diagnosis.
• Which treatment option may be right for you.

The treatment of eating disorders in children and adolescents is family-based, as the eating disorder affects and concerns the whole family.

Your parents are the most important resource in helping you. Therefore, your treatment primarily consists of family counselling sessions for both you and your parents. To begin with, you and your family will attend weekly counselling sessions.

During these sessions, the therapist will – together with you – establish what behaviours and signs are down to the eating disorder and what are not. You need to get to know the eating disorder so as to be able to distinguish between it and your true self. Together, you must find out how you can best be helped.

The treatment should be seen as a learning process where you, your parents and therapists work together to make you better.

The focus of the family counselling will be on supporting you as parents. It is important that you feel cared for and that you have the necessary skills to be able to ensure that your child gets enough to eat and that their other symptoms are reduced.

As parents of a child with a serious eating disorder, you should know that for a while your role as parents and carers will be different.

Often, you will need, for a period of time, to:

• Take full responsibility for all meals.
• Support your child before, during and after meals.
• Support your child in avoiding excessive and obsessive exercise, vomiting, overeating or other behaviours.

You will also need to help and support your child when it comes to their difficult thoughts and feelings. Both the thoughts and feelings that are linked to the eating disorder itself, and any thoughts and feelings that may arise as their life as a child/adolescent normalises.

As part of the family counselling sessions, it will also be possible to work with any family structures and dynamics that may be helping to sustain the eating disorder.

Usually, it will also be necessary to collaborate with others in your network such as a municipal social worker and the municipal family services department, the Pedagogical Psychological Counselling Service (PPR), your child’s school etc. It may be necessary to establish cross-sectoral collaboration with and around your family in order to support your child’s recovery from their eating disorder.

The course of treatment will be tailored to your child’s symptoms and diagnosis. Treatments will be different, depending on whether your child is suffering from anorexia, bulimia or compulsive overeating.

The specific treatment that you are being offered will be explained to you during the test results consultation.

Most people are treated without being hospitalised. However, you may have to be hospitalised if your symptoms are not improving, or if your physical health is in danger.

If your eating disorder is so severe that you need to be hospitalised, it is generally necessary to involve a municipal social worker and the social services. The social services will assess what support you and your family need outside the hospital.

If you are hospitalised, you will naturally have less contact with your parents, any siblings, your school and your friends for a period of time. However, it is important that you keep in touch with your family, your home environment and your school. Your ties to your family and the rest of your network play an important role in your recovery.

Your parents in particular will be involved in your hospitalisation. Your parents will be involved in your treatment, and you will eat together on the ward during your hospitalisation.

While you are hospitalised, you will at times be allowed to go home. This is to allow you and your family to get used to making sure that you eat regularly and enough in your home setting.

Three treatment tracks

While you are hospitalised, your treatment will follow three important tracks, which you, your parents and your therapists will be focusing on:

1.  Support for normalising eating patterns and weight

You will be supported in eating five meals a day based on a normal, varied diet with the aim of gaining 1-1.5 kg per week.

2.  Support for you, your parents and professional networks

You will be supported in working with the thoughts, feelings and behaviours that may be triggering and sustaining the eating disorder.

3.  Support for you, your parents and professional networks in revisiting resources and life content that are important to you.

The treatment on the ward is centred around you, as part of your family, and as part of the community on the ward.

Daily life on the ward

Daily life on the ward is structured around a weekly programme covering a number of group activities. Examples of group activities are:

• Five daily meals and socialising after meals.
• Conversation group.
• Image therapy group.
• Mastery group.
• Body and physical activity.
• Before-the-weekend group.

In the group, you can work on regaining skills that you have lost because of the eating disorder. You can also work with themes that are important to you and the way you are going to be living your life without the eating disorder in the future.  

Talk to your parents – or perhaps another adult you trust

• Tell them what you are finding difficult. Maybe you’re not entirely sure yourself yet – but try to talk to someone about what you’ve noticed.
• Reach out to others even if they may not know much about or understand what it means to have an eating disorder.
• Be open about your condition, when appropriate. Being open does not mean you have to tell everybody about everything.
• Try to be investigative and honest about how the eating disorder affects you. Maybe you don’t spend much time with your friends anymore, maybe you’re finding it difficult to concentrate at school, maybe you’ve stopped doing extracurricular activities?

Work on your relationship with food

• Try to eat regularly, that is 5-6 meals a day. Be sure to eat a varied diet and to eat appropriate quantities.
• Accept that for a while you will need support to make sure that you eat enough – even if you don’t want to.
• Avoid websites and social media profiles or groups that make it harder for you to eat enough and to stop excessive and obsessive exercising, or that make you focus too much on your body and appearance. You may need help to avoid this for a while.

Set small and realistic goals.

• Try to define small and realistic goals for yourself. The goals must steer you in the direction of eating normally and restricting your eating disorder behaviours.

Accept that getting better will take time

• Accept that getting better can be very challenging – but that it is possible.
• Accept that for a while you may not have the energy for as many activities as you used to. Acknowledge that changes may cause agitation, discomfort and difficult feelings. You may feel scared and sad.
• Trust that you can get better.

As a parent, don’t be afraid to express your concern and talk to your child about what you notice. Talk about symptoms, feelings, thoughts and about life with and without an eating disorder. Acknowledge how difficult it is to be suffering from an eating disorder. And keep insisting that seeking help is a parental decision.

Extended parenting role

As the parent of a child with an eating disorder, your parenting role will change for a while, as your child will not recover without your support. It can be a tough and demanding task, and you must accept that everyday life (as you know it) will change significantly.

The eating disorder affects every aspect of your life as a family. Eating disorders can affect children in different ways – some children become anxious, some feel sad and are overcome by feelings of guilt, some feel frustrated and some exhibit aggressive behaviour. Some eat without any problems, while others follow ritualised eating patterns that sustain the eating disorder.

Moreover, there can be a difference in how affected your child is before, during and after the meal. It is therefore important to find out how exactly to help and support your child.

The four Cs sum up the most important behaviours for parents:

The four Cs:

• Calm

  It’s important to try to stay calm and neutral during meal times. Shouting, criticisms and obvious frustrations should be avoided as much as possible, as such emotions are likely to rub off on your child, who will end up feeling even more anxious.

• Confident

  The more confident you appear about the meal and the food, the easier it is to calm your child. Eating disorders can seem contagious. Try to hold on to your common sense.

• Consistent

  Stick to what you have agreed and do not start negotiating. By being consistent, you can present a united front against the eating disorder, which will soon take up less time and energy. Clear rules and clear structures create a sense of security and increase the likelihood that your meals are successful.

• Compassionate

  Be compassionate and try to understand why eating is difficult for your child. This can make it easier for your child to endure difficult emotions.

In other words: You help your child by calmly standing firm, holding on to your own common sense, while at the same time showing compassion for your child and the battle your child is fighting. It is important to avoid criticising your child.

As a parent, you often need support in dealing with your own emotions.

Text on this page updated in July 2024.

Last revised by Lene Hjort, Consultant at the Ward for Eating Disorders, Department of Child and Adolescent Psychiatry, and Anette Hollesen, Specialist Psychologist at the Psychiatric Clinic for Eating Disorders, Department of Child and Adolescent Psychiatry.

Direct link: www.en.eat.bua.ps.rm.dk