Eat

Children’s eating disorders

Eating difficulties and disorders can start from any age. Dasha Nicholls explains the differences between anorexia, bulimia, binge eating and more. Dasha also explains how to treat eating disorders and reinforce healthy eating habits at home.

Transcript

Who are you?

Hi, my name's Dasha Nicholls.

I'm a child and adolescent psychiatrist.

Ask me about children and young people's eating disorders.

What is an eating disorder?

So eating disorders are a group of mental disorders

in which anxieties, thoughts, feelings,

and behaviours that are associated with eating

become problematic.

So an example might be when somebody is eating so little

that it makes them unwell

or stops them being able to function in some way

or eating so much without being able to stop.

Those are sorts of examples of disordered eating behaviours,

but also like all mental disorders, it's really the thoughts

and feelings that are central to them.

And that depends which eating disorder you're talking about.

Can children get eating disorders?

Some kind of feeding

and eating disorders are more common in children such as,

for example, ARFID, avoidant, restrictive food intake disorder.

We think that's probably more common in children

and young adolescents.

But the eating disorders like anorexia nervosa,

bulimia nervosa, binge eating disorder, they tend

to onset slightly later.

However, anorexia nervosa can occur in children

probably from about seven upwards as soon

as children are able to really articulate the thoughts

and fears that are driving their eating behaviour,

and those examples

of children having anorexia nervosa date

back to Victorian times.

So that's not a new phenomenon.

Are eating disorders more common in girls than boys?

The ratio of girls to boys

who have any particular eating disorder does depend on which

eating disorder, anorexia nervosa, which is the one

that often worries parents the most is more common in girls

by some margin, but that may be partially

because we're not as good at recognising it in boys.

However, some of the other eating disorders,

perhaps the ones that are less obvious, like bulimia nervosa

and binge eating disorder, can affect boys in

comparable ratios sometimes to girls

and avoidant restrictive food intake disorder - ARFID -

in younger children is actually more common in boys than

girls.

What are the most common eating disorders in children?

So the Commonest eating disorders in children does depend

on what age you are looking at. Children presenting

to clinical services tend

to have restrictive eating disorders

because that's what worries people is when a child is not

eating enough and it's starting to impact their health,

which means that in clinics we tend to see a lot of children

with anorexia nervosa

and increasingly with ARFID.

With younger patients under say the age of eight,

ARFID is probably the most common diagnosis.

From about 11-12 upwards,

anorexia nervosa would probably be the commonest diagnosis,

but in the population as a whole, bulimia nervosa

and binge eating disorder are probably as common,

if not more common than anorexia nervosa,

but they often take much longer to get to clinical care

for somebody to notice that anything's wrong

because it isn't associated with

dramatic changes in health in such an obvious way as

when a young person's not eating enough.

So there's a difference between what's common in clinic

and what's common in their population.

Are eating disorders associated with any other conditions?

Because eating disorders are mental disorders,

they are associated with lots of other disorders that affect

emotions, thoughts, and feelings

and things that make it difficult to process emotions.

So some examples might be anxiety, depression,

obsessive compulsive disorder,

but also people who have autism spectrum disorder

and attention deficit hyperactivity disorder are also more

prone to have eating difficulties as well,

because these all affect a young person's ability

to manage their feelings, to manage their behaviour,

and to be able to self-control essentially.

And in some of these disorders, there's a tendency

to have too much control or to need quite a lot of control.

And then in some of the eating disorders,

there are difficulties with self-control.

So it does depend on the type of eating disorder,

what sort of other mental health problems are likely

to go alongside.

What is the difference between 'normal' behaviours like picky eating and an eating disorder?

Telling the difference between an eating disorder

and normal eating behaviour

or the way that eating behaviour changes

as a child is growing up can be really tricky.

A really easy example is picky eating.

It's very normal for children to go through a phase

of picky eating when they're about two or three, maybe four.

And then again, actually often there's a phase

of being more restrictive in the types

of foods you'll accept at times of big change.

So an example is when a child is coming up to changing

to secondary school, for example,

and the world gets a bigger

and more scary place, they're more likely

to revert to safe foods.

So I think it's important to kind

of think about is this normal

for the developmental phase that somebody's in?

But, and I don't know if this analogy works for you,

but it's one I often use a bit like wetting.

The bed is normal when you're a small child,

there comes a point where it's no longer normal.

So if you're still wetting the bed

as a child when you are 9

or 10, that's starting to look outside the normal range.

So with all these things, it's about normal variation,

developmental variation.

And then at what point do you start to think, okay,

this has been going on a little bit too long,

or this has become a persistent pattern of behaviour

that is starting to look abnormal.

So that's one way of telling is when a behaviour becomes

persistent in some way.

Now some of their behaviours, depending on how

worrying they are, that behaviour can only last

for a short period of time before you get into trouble,

before you're likely to start to experience some kind

of compromise as a result of it.

But with other behaviours, it's not until you start to

really have some impact from that behaviour that you are

likely to be thinking "hm, maybe this is tipping

outside the normal range".

So an example might be with picky eating,

if somebody has a very restricted range of foods

and that's absolutely manageable until they're 8

or 9, but there comes a point

where they're no longer able to go out with friends

or go for sleepovers or go on school trips

because their range of foods is so restricted,

that's when you might start to think this is beginning

to cause a problem, what we would call

in the technical term, some functional impairment

as a result of the eating difficulty.

So that's one way of knowing when something's

outside the normal range, is it's beginning to impair

function in some way, what somebody can do.

The other way of knowing when something's falling

outside the normal range is when it starts

to cause a lot of distress.

If it's causing anxiety, if it's causing somebody

to get very upset when they're faced with foods

or leading somebody to avoid doing things

because it's so challenging.

That's another way of knowing when something's

outside the normal range.

But it can be very hard to know at what point to worry.

And I think if you're not sure, that's the time to check in

with a health professional.

My child's eating habits have changed, could it just be a phase?

Learning to move from being fed

to feeding yourself -

eating - what we would call eating, is a really tricky process.

There's a real back and forth about who's in charge,

who's in control, who's making the choices and so on.

And it's very common for children

and young people to use food as a way

of regulating both their own behaviour

but also their relationships.

So you'll probably know that when a child's upset

or cross, they may refuse to eat.

That would be a very common way of a child saying,

this is something I've got a bit of control over

and I'm going to do things differently.

And knowing when

that's a short term thing,

and of course, understanding that for what it is, which is

a momentary emotional thing,

is very different from seeing a persistent

change in behaviour.

The other time that young people tend to want

to distinguish themselves

through their eating behaviour is adolescents.

So it's very common for adolescents, young people to

try experimenting with different ways of eating.

And a very, for example, common one in recent years is

for people to become vegan.

That used to be quite a rare thing to do.

Now it's relatively common,

but it's not unusual for an adolescent to say,

to express their identity through a set of different set

of values or beliefs from their parents.

It's part of developing your identity as a young person.

And again, that's where it's really important

to make a judgement about whether this is something that

is okay and a part of young person's growing up experience

and wanting to define themselves.

Or whether it's the beginning of a young person beginning

to show some anxiety about something.

So, my overall response would be,

yes, it is common for young people to go through phases

of experimenting with different ways of eating,

but it's okay as a parent to be curious about that.

I've noticed your change.

I've noticed you've changed how you're eating at the moment.

Just wondered why. And to try and understand it.

Because what you're really trying to work out is,

is it driven by anxiety of some kind,

or is it just sort of some way of beginning to think,

who am I and who do I want to be?

And that's the tricky thing.

But if you can open up some conversation about it rather

than allow it to be secretive

or develop a life of its own, I think

that's the most likely way of preventing

what might be a phase turning into a problem.

How can I encourage my children to have a healthy attitude towards food, emotions and body image?

The best way to encourage your child to have

a healthy relationship with food

and their body is through your own behaviour.

I know it's an obvious thing to say

and puts a lot of responsibility on parents,

but actually it matters quite a lot.

So if you are constantly commenting on their weight in their

shape, they're going to become self-conscious about it.

If you're constantly commenting on your own weight and your

shape, they're going to become self-conscious about theirs.

So the language that you use around weight, shape, eating,

really does matter, and also showing that you can eat

and be healthy in a normal way is really important.

That can be challenging if you yourself have got struggles

with eating, of course, in which case it's probably

important to be quite transparent.

You've had your own difficulties, and

therefore you are really concerned about making sure that

your child doesn't have the same sorts of difficulties.

It doesn't necessarily mean

that you will be handing on any worries

that you have about eating,

but what it will mean is that you are in a better position

to recognise it if your child is struggling

and that you might be able to head it off

or even help them through your own experience

or make sure that they get to help if they're struggling.

How important is language in relation to eating disorders with children?

Eating disorders are all about thoughts and feelings,

and so how a young person defines themselves,

what they value and how they think are all shaped

by language and what's central to

the most,

but not all, eating disorders are concerns about body weight

and shape, and that can be really challenging in society,

particularly right now I think,

where everybody's very concerned about

how many people are overweight in the population

and also with the challenges

that young people face on social media

with people telling them the right way to look,

the right way to eat the right way, to be

the right way to exercise.

These are all things that can make young people feel

that they're not good enough

or they're inadequate in some way.

So it's really important that you acknowledge

that young people are surrounded by all these pressures

and these messages from society

about weight, shape and eating behaviour.

And I think

just talking about eating disorders straight up isn't really

what we would think is the most helpful thing to do in terms

of preventing somebody to be anxious.

But encouraging positive body image,

helping somebody not deal

with negative feelings about themselves through their eating

and through taking it out on their body, is really the best

way to think about preventing a young person

having an eating disorder.

It's also quite common for young people

to be worried about their body, particularly

as their body shape changes quite

dramatically during puberty.

And so that's a time when girls, particularly, often become

very anxious about how their body is going to be

until it sort of settles down into its adult shape.

So anticipating those normal changes in body shape as well

and helping your child adjust to those normal body changes

is probably more important than talking to them about

anxieties that they may develop an eating disorder.

My child is at a higher weight, should I be concerned?

You don't need me to tell you

that being at a higher weight has long-term health risks.

Those messages are everywhere

and everybody knows them and children know them.

And it's manifest in everyday life with calories on menus

and posters on walls and healthy eating lessons in schools

and being weighed and so on.

So there's a lot of messages out there about the

concerns about higher weight.

What I don't think is talked about enough is

what the psychological impact of that can look like

and whether it poses a risk for eating disorders.

And people at higher weight, regardless of their age,

are much more likely to have a negative body image

to dislike their body,

and they're much more likely, importantly, to try dieting.

And dieting is one of the biggest risk factors

for the development of eating disorders,

particularly in children and young people

because they often don't know how to do it in a healthy way.

They don't know how to lose weight effectively.

And so they experiment,

they try things and they get it wrong.

They misjudge how to do it

and so they repeat it.

So that's one of the ways that we often see young people

presenting is that they've started out

what looks like a really sensible way of trying to

manage their own weight,

but it's got out of control in some kind of way,

or they've got themselves fixed into a set of beliefs

or rules about ways of eating

that are actually not based in reality

or health or sensible advice.

So there are ways I think that you

as parents can help both

encourage a young person to have a

positive body image is really, really important

for preventing that risk of feeling that going on a diet

and losing weight is the only way to be happy.

Encouraging activity and moving bodies in a healthy way

and encouraging healthy eating behaviours is much,

much more important and valuable

and hopefully would prevent both escalating weight gain,

but also prevent the development of eating disorders than,

for example, labelling somebody as obese

or overweight, encouraging them to diet in ways

that are not proven to be helpful.

And some of the things that young people might think are a

solution to managing what

for them has become a source of distress.

And I guess related to that is the important part

of acknowledging if there is distress.

If your young person's upset by their weight,

how can you help them with that?

So those are all important ways

of both preventing escalating weight gain,

but also preventing the onset

of eating disorders if your child is at a higher weight.

My child has an eating disorder - how should I approach mealtimes?

Meal times when your child has an eating disorder are the

most tricky moment,

and it happens three, four times a day,

sometimes five or six, depending on where your child is at

with their eating disorder and how much they need

to be re-fed.

The most important thing is planning. That everything is...

there's no surprises for anyone.

Everyone knows what's going to happen.

Everyone knows what's expected,

that there's some agreement about how long the meal is going

to take, what's expected to be eaten and so on.

And that enables everyone to feel a little bit calmer

because I think the other key issue is about remaining calm,

about being able to manage emotions

because for your child, this is the biggest,

most anxiety provoking moment. An analogy I often use

and it's not a perfect one is if you've got a fear

of flying, the moment of getting on the plane is the bit

that is the hardest.

And you need people around you to really stay calm

and reassuring

and just keep nudging you in the right direction,

helping you overcome that anxiety.

There's a lovely video by somebody called Eva Musby

about bungee jumping,

and she uses the analogy that eating a meal

you are trying to help your child overcome the sort

of anxiety that would be associated with bungee jumping.

And no amount of logic about the strength of the rope

and calculation of risks and so on

and so forth is going to help somebody

actually take that leap.

They just need a moment of courage and calm reassurance.

So that's a video

that's well worth watching if you're trying to think

what sort of language do I use to help my child do the thing

that I know for them is the hardest?

That's particularly the case for anorexia nervosa.

But I think it's also important to recognise that people

with other types of eating disorders arfid, bulimia,

nervosa, binge eating disorder.

You may be trying to help them do something different.

You might help them manage, be able to control

how much they're eating for example,

and then really importantly,

after they've eaten, you need to anticipate

that there will be heightened emotion afterwards.

So if you've done what is so hard

and all of the fears of doing it have risen up,

I've eaten the wrong thing, I shouldn't have done that.

Planning what the post meal time will look

like is really, really crucial.

There are all sorts of techniques

and there's a lot of good advice

now out there that parents can actually use

during the mealtime.

But I think this is a conversation.

It's a conversation within a family.

It's what would happen during the treatment.

You would talk and you would practice thinking,

how's this meal going to work best for us?

Who needs to be at the table?

Where do I sit in relation to my child?

Do I sit opposite them? Do I sit next to them?

What's the best way of reassuring my child?

How do I plate up the food?

Who's doing the plating at what stage in treatment?

So all of this is very much part

and parcel of what treatment is about

because we know that successfully managing treatment,

managing mealtimes is the key thing,

certainly in the first stages of treatment

and through successfully managing the eating

and the mealtime behaviour, then you're more likely to get

to the emotions behind it, the thoughts and feelings

and anxieties that arise out of it.

And that's where the talking therapies

and the talking elements of therapies come in.

Do I need to tell my child's school if I am worried about their eating?

Given that young people spend quite a significant amount

of time at school, it may be important

to have a conversation with school depending on

where they're at in their illness, in their treatment,

or whether you are just in the early stages

of having some concerns.

If you're worried about a child's eating, then talking

to school is probably not a bad way

of finding out whether what's happening is just happening at

home or whether they've also had concerns.

But it's important to remember that you need to make sure

that you are not breaking trust as you do that,

that you are not going behind your child's back

and talking to their teachers about them.

Particularly with older adolescents,

that breakdown in trust probably wouldn't be a good starting

point. If they are quite unwell,

if they're needing help to eat at most meal times,

then talking to school is going to be necessary, isn't it?

Because they're not going to be able to be in school

unless they can manage to eat lunch

and probably some snacks as well.

And then you may need to enlist the help

of somebody at school either to see if they can help

and schools do vary in how much they're able

to support young people in schools or

because you'll need to make special arrangements in order

to help your child eat

what they need to have to be in school.

So at that point, regular dialogue

with school will be necessary,

and your clinician can help with that if you're in treatment

by that point, to work out

how school can best support somebody.

So yes, it's very much a team effort.

All the adults that are around a child usually need

to be involved in thinking about how to help them

and support them, and school's a central part of that.

My child's weight is healthy, but could they still have an eating disorder?

It is a common myth that eating disorders

are defined by weight.

They're really not. Anorexia

Nervosa can result in very low weight.

Uncontrolled binge eating can result in higher weight,

but most people who have an eating disorder,

you wouldn't know by looking at them.

That's the nature of mental disorder.

It's in the head, and sometimes the behaviours are obvious,

and sometimes they're not obvious.

But eating disorders are not defined by weight.

So it's abnormal eating behaviours, anxieties about eating

that you're looking for rather than judging by weight.

However, if somebody's weight is changing rapidly,

that's another sign that something's happening.

Something's going on,

that somebody's changed their eating behaviour in some way,

or that they're doing other things

to influence their weight and their shape.

So a sudden change in weight, either

loss or gain, might tell you that somebody is

struggling with their eating behaviour,

even if they're in the healthy weight range.

My child cannot eat certain foods due to an allergy - could this trigger an eating disorder?

Medical and physical illnesses

that affect eating behaviour are very common,

and some of them require you

to be more attentive to your eating.

So examples would be food allergies, type one diabetes

where you're having to count carbohydrates.

These things all require children

and young people to focus on food in ways

that they wouldn't normally have to.

They can't be spontaneous about food in quite the same way.

And that increased focus and care and attention to food

and having to count things

and having to measure things does put some people

at higher risk depending on whether they

have other risk factors.

So if your child is somebody who has a tendency

to get very caught up in the details of counting

and measuring and following rules, they're much more likely

to get: A, they're much more likely

to control their eating well rather than being impulsive

and chaotic about it.

But also there is a slight tendency to be at greater risks

to become a bit obsessed by it.

And that's what you need to be mindful

of is has this tipped over from good control

of whatever the physical condition is,

whether it's an allergy or diabetes, into something

that's bordering on anxiety driven

or becoming obsessional about food

and eating to the point

that it is causing your child either impairment,

so they're not able to do normal activities,

they're not able to eat with friends or go out

or participate in sport

because they're so worried about whether they're going

to get their eating right or it's causing them distress.

They're spending hours thinking about

or worrying about whether they're getting it right or not.

So that's, I think something to be mindful of is that

because they've got to pay this extra attention to

how they eat, there is an associated risk

that they will become anxious about it.

And if your child is prone to anxiety, not everybody is,

then that's something to be aware of

and to make sure that you are in conversation

with them about that, whether they're worrying about it

and that you can share their worries with them

and even help them with it.

What role does anxiety play in eating disorders?

Specific anxieties in eating disorders is

what distinguishes one eating disorder from

another eating disorder.

And I'll go into more detail about this in some other

responses when I describe each

of the individual eating disorders.

But as an example,

the central anxiety in anorexia nervosa is a

fear of becoming fat.

And that anxiety organises the behaviour, the thoughts,

feelings, fears of that person who's got anorexia nervosa.

And that's different from, for example, in bulimia nervosa

and binge eating disorder, where that fear

of becoming fat may also be associated

with an anxiety about losing control

over their eating behaviour.

Again, all of these behaviours can occur across eating

disorders, but it's what's the central anxiety

that's driving somebody's eating behaviours.

What you need to try and understand,

sometimes you can infer it from their behaviour,

but sometimes they're able

to actually directly articulate it

and share what it is. In ARFID - avoidant restrictive food intake

disorder - the anxieties are not about weight and shape.

They're not about fear of fear of weight gain,

they're not about appearance,

but they might be, for example, about a fear of choking

or a fear

of eating foods, of particular textures with smells,

other types of anxieties that might manifest

and lead a child to avoid eating is what's central

to ARFID.

And that's what distinguishes ARFID from anorexia nervosa,

bulimia nervosa, binge eating disorder, purging disorder,

and the other eating disorders.

So trying to understand what the concern is

and what the anxiety is

behind somebody's eating disorder is really helpful in terms

of helping understand what's driving their behaviour,

but also how to help them.

It's worth saying that most mental disorders are associated

with some sort of change in eating behaviour.

So for example, in depression, people lose their appetite.

Often it's one of the core symptoms.

Anxiety can make you lose your appetite,

but there isn't an anxiety about eating in those other

mental disorders, and that's what distinguishes this group

of eating disorders from the other types of mental disorders

that can affect eating behaviour.

What could the impacts of an eating disorder have on my child's growth and development?

A child's growth and development is only going

to be impacted by an eating disorder if there's some sort

of malnutrition and depending on what stage

of development they're at.

So if your child develops an eating disorder

after they've completed puberty,

and this is a rough rule of thumb, but for girls, that means

after their periods have started and for boys

after they've had their growth spurt,

then the impact on their growth

and development will be minimal.

There are other risks at that point,

but not really on growth and development.

So the risks for growth

and development perspective really all come pre-puberty

and only if malnutrition is prolonged.

So that's why it's another reason to make sure

to get somebody to treatment if they have got signs

of significant malnutrition.

And obviously that's one of the criteria for saying

that something's reached clinical significance that you need

to go and get help from a healthcare practitioner.

So malnutrition can be either in terms

of quantity or in terms of range.

So when somebody's malnourished in terms of quantity of food

that they're having, then that will be evident

because they'll become thinner.

And as you lose weight,

your body goes into conservation mode.

And one of the things that it conserves is growth.

So for example, children

who are bought up in famine conditions have relatively

stunted growth and delayed puberty in order

to conserve energy

and growth is considered expendable at the expense

of keeping the rest of your body organs alive and kicking.

So if somebody stops growing as a result of

malnutrition, as a result of being at a low weight,

that will also delay the age at which they go into puberty

and is a sign that some intervention probably is needed

for their nutritional status.

In terms of range, that's a bit more complicated.

If your child is only eating in a very narrow range of foods

that might be associated with

what we call micronutrient deficiencies.

So specific types of vitamins

or particular food groups are excluded from their diet,

resulting in malnutrition that may not have a direct result

impact on their growth as such,

but it may impact other aspects of their health.

So for example, their bone strength

or the development of their muscles and so on.

So malnutrition is something

that needs medical intervention.

It's part of the diagnostic criteria

for avoidant restrictive food intake disorder, for example,

is malnutrition and would be a reason

to go and see a clinician.

The good news is that young people's bodies are incredibly

resilient and flexible, and if you correct malnutrition,

Your body tends to catch up.

So if you have got growth impairment as a result

of an eating disorder or feeding disorder and it's corrected

and it doesn't last too long, then the chances are

that you'll get back onto your original growth trajectory

and be able to, as it were, bounce back.

And we see this all the time with physical illnesses

that impact children, that growth stops while they're ill

and then it restarts

and with extra speed

to catch up back to where they should have been.

And it takes really chronic illness

to deviate your growth trajectory permanently.

So you can be ill for four or five years

and still catch up on growth and development.

So it's not all bad news,

but it is a reason to get medical help.

Can an eating disorder cause other health problems in the future?

There are long-term risks associated

with an eating disorder, but it does depend on whether the

eating disorder persists or not.

So living with a chronic eating disorder

that's not responded to treatment

can have significant impacts on health

and as I'm sure you know, can result in death -

can result in premature death.

And anorexia nervosa is one

of the deadliest illnesses that we have

among the psychiatric disorders,

you're six times more likely on average to die

as a result of anorexia nervosa than by not having it.

But the other eating disorders also carry long-term risks.

So bulimia nervosa, purging disorder, misuse of

laxatives, repeated vomiting,

they can all have impacts on health in the longer term.

If successfully treated, the long-term

risks can be minimal.

Almost all risks can be reduced almost entirely.

The exception might be concerns about anorexia,

prolonged low weight, whether it's as a result

of anorexia nervosa or as a result of ARFID.

Sometimes of ARFID are associated with low weight.

Prolonged low weight can have a longer term

impact on bone density.

So it's worth being aware of that.

And there are treatments available for adults who have got

thin bones, osteopenia

or osteoporosis, if that has been a consequence

of having been ill in the longer term.

And it's one of the reasons that we measure young people's

bone density after they've been ill

for more than six months or a year.

Other complications in the longer term,

prolonged vomiting can damage the lining of your stomach

and the lining of your gullet, the oesophagus,

and can also damage teeth

because the acid can wear away the dental enamel.

So that's one of the risks that we look out for

and dentists are very much aware of

that potential impact is also sometimes a way

that people detect that somebody's got eating disorder is

from the impact on their teeth.

Other long-term complications are relatively minimal.

As I say, the key thing is to do

with whether somebody's recovered or not.

If somebody's recovered, the long-term damage is likely

to be relatively minimal,

but there are obviously long-term complications associated

both with low weight and with high weight.

I think my child has an eating disorder - how do I get professional help?

So eating disorders are best treated by

what we call a multidisciplinary team.

That's a team of clinicians where there are different people

with different professional backgrounds.

That might include psychiatrists, psychologists, nurses,

dietitians, various types of therapists depending on

what sort of intervention is needed.

So you really need to get

to a specialist team if at all possible,

because the evidence suggests that if you go direct

to a specialist team that the likelihood

of getting in early, getting the right treatment early,

not needing hospitalisation and so on,

and the outcome generally tend to be better.

That can depend

how easily you can get to a specialist team.

May depend a bit on where you are living.

Although in England there's now a specialist team in every

part of the country that has been trained to the same sort

of standard. Getting to these teams,

usually people go through their GP

and of course if you're not sure whether you need it,

your GP is a reasonable starting point.

A lot of teams do accept self-referrals,

so it's worth checking that out whether you can

refer yourself directly.

Schools can refer to eating disorders teams as well.

That's another way into services, particularly

through school nurses, for example, or pastoral care.

So there are a number of routes to access

a specialist team if it does look

as if your child might have an eating disorder.

And the important thing is to act soon and act quickly

because the earlier we can intervene, the better.

If you do go and see your GP

and your GP says nothing to worry about, it's just a phase

and that's not uncommon.

It's worth looking at the BEAT website.

BEAT is the UK's eating disorder charity

and they have some leaflets that they provide for parents

with guidance on the sorts of questions

and the sort of information to ask your GP

and that you need to be armed with in order to access care.

But it's also, of course a useful checklist for you

to know whether your right to be worried.

So that's a tool that's designed for parents to try

and help them them get the right sorts of decisions out

of clinicians about accessing care should they need it.

My child tells me I have nothing to worry about, should I trust them?

If you are worried about

your child's eating behaviour

and think that they might have eating disorder thoughts

or worries in their head

and you are telling that from their behaviour

and they say nothing to worry about, mom, I'm fine.

Or Dad, I'm fine. Back off.

I think my response would be, trust your instincts.

You know your child, you know when something's not right.

If there are other signs that something's wrong,

they're moody, they're irritable,

they're changing their behaviour in other ways.

These are all can all be early signs of an eating disorder

and it is the nature of eating disorders,

some types of eating disorders, particularly

to be secretive, to not want other people involved

eating disorders, cut young people off from their support

and from the real world by telling them

that if they do certain things in certain ways

and stick to certain rules, then everything will be okay.

And breaking down that wall of isolation

that can surround somebody with an needing disorder

is a really important part of treatment.

So I'm not sure I would necessarily accept

if somebody said "No, I'm fine" if you can see

that they're not, so trusting

somebody when they're in the grip of an eating disorder

probably isn't the wisest thing to do.

And the important thing at that point is a parent is to

trust your instincts.

Be confident that you are going to help,

even if they're in the grips of something so

that they can see that they can trust you

more than they can trust that inner voice that's talking

to them.

I'm struggling as a parent, is that okay?

I don't think I've ever met a parent who hasn't struggled

with having a child with an eating disorder.

It's incredibly challenging.

Not only do you have the distress that goes

with having a child that's upset

and struggling with something,

but also sometimes you can see the

physical consequences of that.

And there's something particularly emotive, I think,

about a child not being able to eat,

not being able to eat well.

That kind of gets to the heart of what parenting

and being a parent seems to be about.

So struggling is normal,

and that's why there's so much support

and resource aimed at parents of people

with eating disorders almost more,

or at least as much as there is aimed at the young people.

And that's why we involve parents in treatment.

This is not a situation where we take your child away

and say, we'll fix your child for you.

We would expect parents to be involved in treatment

because we know that how you are

and how you are with your child is absolutely crucial,

but we also need to look after -

you need to look after yourself.

So the kind of commonest ways

that parents might struggle are

with their own mental health, getting anxious, depressed,

staying awake at night, for example.

And if you are finding that that's starting to affect

how you function, then I would encourage you

to access help in your own right.

It might re-trigger your own thoughts

and feelings about food and eating and body shape.

And again, if that starts to become problematic,

that's something to think about.

Do I need to get help about that

in my own right? It might be more everyday

struggles with how do I balance work

against my child's needs?

How do I balance the needs

of my other children against my child?

We would always encourage parents

to use the support of each other if there were two of you,

any partners, any friends, to make sure

that you are well surrounded by people who've got your back

and who are going to look out for you

and who are supportive, and who understand the severity

and the impact of what it is that you are dealing with.

The analogy of if your child was ill with a physical,

a very serious physical illness,

people would absolutely understand how challenging that is.

For some reason, mental health is still stigmatised

and people don't quite understand what the impact can be

and how severe it can be.

The final comment I'd say about looking

after yourself is about pace yourself.

In the early phases,

it can feel like it's going to go on forever.

Recovery takes at best six months, more commonly a year,

even if things go really well in treatment.

And of course there are some people

for whom treatment doesn't work first time.

So it's really important that you think long-term about

how can I make what I've got to deal with here sustainable

for me and to work for me and my family.

How can I start a conversation with my child about their eating habits?

Talking to your child about their eating

is potentially a motive,

and you will know better than anyone,

whether it's a touchy subject for them.

It's harder to talk to your child if it is a touchy subject,

but probably even more important.

If you notice that they've changed their eating habit.

That's a way in, and at

that point you can just make a comment about it.

Maybe not ask a question,

because sometimes that can feel intrusive,

but I've noticed X, I've noticed Y about your eating,

and I've been wondering whether sharing your thoughts

about what might be happening and what might be going on.

Sometimes people make those sorts

of changes when they're worried about this or that.

So making comments

and observations if your child is the sort of child

who will react defensively

or get upset if you ask them questions as such.

So that's one way of getting into it.

Weight is another issue that can be quite touchy.

For some people, it's very personal.

It's experienced personally differently by different people.

But that's another area where you might want

to explore gently,

whether they've been worried about their weight,

so you're not interested in what their weight is per se,

but whether it has become a source of anxiety for them.

Because with all these conversations, what you're trying

to get at is whether their weight, their shape,

or their eating has become a source of anxiety to them.

What role has social media played on eating disorders within children?

Social media is a mixed blessing, isn't it?

On the one hand, it's a lifeline for some people.

It's the way they stay connected

to their social world, to their friends.

People would really have struggled

during the pandemic without social media

because it's such an inherent part of

how young people relate to each other

and how they explore things like their identities,

who they want to be, who their role models

are, and so on and so forth.

But like anything that's very immediate and engaging,

and importantly available 24/7, it can have its downsides

and the amount of time somebody spends on social media

is correlated with the likelihood

of them having mental health problems, particularly

if it's displacing sleep or if it's a source of bullying,

or if they're looking at inappropriate content

or content that's feeding

existing anxieties that they might have.

There are examples of very dangerous content

with respect to eating disorders on social media.

There are websites

that promote eating disorder behaviour quite actively in a

destructive way, but those are the

exceptions rather than the rules.

But people who are very severely in the grips

of an eating disorder may be looking at some really harmful

and inappropriate content,

and that's something to discuss with a clinician about how

to help manage that.

The bigger issue, I think, is the more everyday content.

The content that is encouraging a focus on body image

in ways that are unachievable for many people,

or ways that are prescribing ways of eating

that may not be based in health and reality,

and leading to aspirations and gaps,

and making people self-conscious about themselves

and their body image

and their eating behaviour in ways

that are actively unhelpful, particularly

for growing children and young people.

And that's where I think the content can be really harmful,

particularly if your child is prone to perfectionism,

a tendency to negatively compare themselves to others.

So I think knowing some of the content of

what young people are looking at

and the sorts of material they're looking at is helpful.

And it may come up through conversations.

So for example, if you notice

that a child's eating differently,

as well as asking them whether they've got some anxieties

about it, where they've got their ideas from about what

they're trying to eat and how they're trying

to eat differently, you'll find some people are kind

of imitating particular influencers

in terms of what they eat.

But we all know that social media isn't a reality,

and you are there as a parent to provide a reality check

And to encourage them to recognise that

what they're seeing on some

of those artificial screens is not where reality is.

And a lot of eating disorders prevention work

is about media literacy.

It's helping people understand that

what they see in the media and social media is not reality,

and that it doesn't reflect reality.

How can I protect my child from the potential impact of social media?

The potential of impact

of social media is a really tricky thing to know how to deal

with because there isn't really a one size fits

all answer to that.

It's about recognising when the balance has

gone wrong in some way,

when the online world has become more

important than the real world.

And there isn't that ability to provide balance

and checks against what they might be seeing online,

which may or may not represent some version of reality

or maybe giving them some unhelpful or harmful messages.

And an example of that might be

if they're getting messages about perfect body image,

that you can provide some kind of reality check in terms of

body positivity or being able to reassure them that

how you look is not the be all and end all.

And those messages can be quite different for girls

from boys in terms of what

social media is telling them that they should be doing.

If you are aware that your child is looking at problematic

material, that's

where the first starting point is communication,

talking about it so

that you can understand whether it's feeding into

anxiety in some kind of way.

And again, you might pick up clues about that

by their behaviour about the way they're behaving,

whether they become overly obsessed

with their appearance in some way,

where they've changed their eating as if they're kind

of imitating or following some sort of new set of rules

about how to eat.

Those would be an opportunity

to open a conversation up about it.

And then at the more extreme end, if you become aware

that they accessing actively harmful material, you may need

to feel that you need to step in more, that you need

to take some sort of control.

And there are increasingly ways of parents being able

to exert control over the content of

what young people are accessing online.

Social media companies are thinking about this quite a lot

as well, and starting to put alerts and warnings.

Did you really mean to look at this?

And so on in a way of trying to help people to

steer away from the more harmful content.

But it's tricky to get that right

because I think you might think, oh, I want

to take my child's phone away,

but you need to balance that against,

am I cutting them off from their only source

of social support by doing that, and/or

am I going to break down my relationship with them

by taking away something that's so important

and meaningful to them?

Because phones have unfortunately become

essential to all of our lives.

So I think that's where,

and having a conversation with a clinician about

that might be a helpful way of thinking about it.

Is there a sensible way of dealing with this?

Because you don't want somebody to be able

to access actively harmful content.

But on the other hand, if you can see

that somebody's online world has become actively toxic

and is feeding their eating disorder, that may be something

that you need to take action about.

Has social media led to an increase in children with eating disorders?

Social media is blamed for a lot of things.

There isn't direct evidence

that social media is causing an increase

in eating disorders.

The overall incidents

and prevalence of eating disorders hasn't actually changed

very dramatically since the 1970s.

Younger age groups are more vulnerable

now than they used to be.

So the only groups that we're seeing rises in prevalence

of eating disorders among are younger

children and among boys.

And it may be that social media has some role in that

and the access that young people have

to content now that is focused on body weight and shape

and the sorts of values

and what we call the thin ideal that is thought

to contribute to the development of eating disorders.

But it's by no means the only culprit.

There are plenty of other explanations

for why there may be increases

among children in society as a whole.

We've become much more nutrition conscious.

Food is covered with information about nutrition,

calorie labelling, calories on menus, posters about weight

and shape, and the pandemic raised everybody's

concerns about weight because it was recognised

as a risk factor in the older population.

So there's been quite a bit of concern about their potential

negative impact of those anxieties in the population

as a whole about food, eating on weight,

and whether that might have impacted children.

So social media is part of a complex picture.

It's certainly not a direct cause and effect,

but it's important to be aware of the sorts of influences

that your child is subject to.

And that's why you as a parent are so important

because you are providing the immediate environment

that can help balance

and mitigate those wider societal concerns

and anxieties that your child might have.

How can I better understand my child's eating behaviours?

Everybody's different when it comes to eating behaviour.

There are lots of factors that influence it,

and not all of them are environmental.

They're not all things that are in our control.

For example, genetics vary enormously in terms of

your appetite and well,

there's quite a famous experiment called the marshmallow

test where children are put into a room,

I think they were about four

or five with a marshmallow in front of them.

And the experimenter leaves the room

and says, if you don't touch that marshmallow,

then you can have two when I come back.

And some children can not touch it

and some children can't not touch it.

There's a huge, and they time how long it takes

before they eat the marshmallow.

So huge variation in terms of appetite.

And that particular test is testing something

called food responsiveness.

So that's how, if an example of that would be buffets.

Some people when they're faced with a buffet

or there's food in front of them,

they just can't not eat it.

The other component of appetite is what's known

as food satiety.

So how good you are at recognising when

you're full and stopping eating.

And again, it's quite strongly genetically driven,

but it's also something you can learn.

It's something you can learn to self-regulate,

to recognise your appetite responses,

to recognise when you are feeling full.

And it's an inherent part of what we call intuitive eating

and to learn to recognise your own satiety cues.

And it's really important

that children are given an opportunity to learn those things

for themselves, that they're given an opportunity to learn

to self-regulate, to know when to stop.

And if you as a parent are too overly focused on their,

or you are controlling their intake,

that doesn't give them the space to do

that learning in the same way.

So whilst it's helpful to obviously know

how your child is doing nutritionally,

you are obviously going to be involved,

particularly when they're younger in deciding

what they're eating and roughly what sorts of quantities

and your best place to do that.

It's also important to give them a little bit of space

to learn to self-regulate, to learn to

recognise their own satiety cues and so on.

So that's one component

of eating behaviour is are they getting

their self-regulation right?

Are they learning self regulation

in the right sort of way?

And can I help with that? Can I nudge, can I remind them?

Have you had enough of you?

Are you sure you can't manage a bit more?

Depending on which end of the spectrum they are from a

satiety perspective, then eating behaviour can

become a way of expressing

and learning about self-control in a broader sense.

So it can become a way of saying this is, I want

to do things in a particular way

and I want to do it in my way.

And of course, depending again on how worrying that is,

that can become a battleground.

And it's important for you as parents to

not let it become a battleground, not get into battle

with your child if you can, around food,

because that's when it starts to become an emotive problem.

So typically toddlers, for example,

will have fights over whether they will

or won't eat specific types of foods.

But it also, again, that can become manifest

during adolescence when young people are wanting

to control their own eating behaviour

and not be controlled by you as an adult.

If it does start to become an emotive issue, if it starts

to become a source of anxiety, then

that's a different issue again.

And you can tell from somebody's eating behaviour

what the nature of that anxiety is.

So if somebody, for example, has anorexia nervosa

and their core anxiety is about fear of weight gain,

they're likely to be avoiding the sorts of foods

that are fattening in inverted commas.

So typically that would look like cutting out foods,

cutting out sugars, cutting out carbohydrates, more extreme.

And so they would avoid certain types of foods.

If they have ARFID

and the anxiety is a fear of choking

or a fear, a difficulty with managing foods

of a particular texture or colour

or some other sensory aspect of food,

then they're eating behaviour will look entirely different.

And so you can pick up clues to what the anxieties

and the thoughts are or the rules indeed in their head

that might be driving their eating

behaviour from what they're eating.

But it's important not to be too intrusive

and too overly focused on their eating themselves,

giving a bit of space

and recognising that food is a very common source

of experimentation for children

and a way of finding out who they are, how they want

to feed themselves, and they need

to learn in the longer term how to feed themselves.

And food varies enormously by family, by culture.

So there isn't a right way to eat.

And that's why your task as a parent is

to help a child find a way to eat that they are happy with

and that works for them and for their identity

and who they want to become in the longer term.

And that may include becoming a master chef,

or it may be some people have got no interest in food

whatsoever and they just need to be reminded

that eating food is a habit.

It's just got to happen in a regular way,

like filling your car with petrol,

otherwise it'll stop working.

My child has an eating disorder - is there anything I should avoid saying or doing?

It is difficult to give one size fits all answers

to what's upsetting

for a child when they've got an eating disorder.

But if they've got anorexia nervosa or bulimia nervosa

or binge eating disorder, it's likely

that they're upset about their body weight

and their shape in some kind of way.

So commenting on weight and commenting on shape,

and sometimes even commenting on food is probably unhelpful.

And what we usually advise parents is to steer away

from food related conversations at the meal table

in particular, and to save those for the meetings

with your clinicians or your therapists.

So that one of the purposes of treatment is to say, well,

once a week or however often you meet your clinician,

that's when we'll talk about food.

We'll plan for what the food is going to look like.

Everybody knows what to expect for the coming week,

and then we don't have

to talk about it the rest of the time.

We can find other ways of

distracting, having more normal conversations

and building life as being one in which food, weight

and shape are really not the most important things

because ultimately that's

what helps support recovery from an eating disorder is the

rest of life becomes more important than

what you you're eating or what you look like.

My child's eating disorder is affecting the rest of my family, what can I do?

For most children and young people, we try

and involve the whole family in treatment, and that's

because we know that eating disorders do impact family life.

We don't bring everybody along

because we think that the problem is the family.

We bring everybody along

because everybody might have a role in helping

the young person in their family

recover from an eating disorder.

Everybody in the family is likely

to be worried about the person who's got an eating disorder

in the family, and it's important that we hear about that

and there's a space where they can talk about it

and different people may be impacted in different ways,

and it's important that clinicians can pick up on that

and address it if necessary.

If it does look as if your other children are

really struggling, then it's important

that they get help in their own right.

But a way of preventing that is

to bring it a bit more out in the open

during family meetings, if at all possible.

If your child's treatment is not involving the whole family,

so for example, if they're an older adolescent

and so on, usually clinicians would find a way

to talk to you as parents about how you can support

your child with what they're working on,

but also how you can think about other

family members as well.

So I would suggest that you try

and talk to the clinician who's involved in your treatment

if you are worried about other members of the family.

What is 'anorexia'?

Anorexia actually isn't the full term for the illness.

That's an eating disorder.

Anorexia Nervosa is the full term,

and that's without going off into too much detail

because anorexia on its own means loss of appetite.

And in anorexia nervosa, which is the illness,

that's an eating disorder,

people haven't lost their appetite.

They've just determined

or decided sometimes

to override their body's natural wish to eat.

So it's a very different kind of illness.

And it is an illness that is driven by

determined weight loss

and a drive for thinness is the central psychopathology driven

by a fear of obesity, a fear of weight gain.

And the diagnosis of anorexia nervosa is

we're not just talking about normal anxieties

that anyone might have about wanting to be healthy

and wanting to not be overweight,

that we get regular messages about how dangerous that is.

We are talking about an overriding belief that being

a healthy weight is the worst thing in the world,

that almost that you'd rather die than be a healthy

weight or overweight.

So it's become so powerful as a thought

that it can get to the point of bleeding

to illness in its own right.

So behaviourally, this manifests as significant weight loss

and avoidance of foods that are perceived as fattening,

and it's driven by a distorted, a body image, a belief

that you are fat

or overweight, even though everybody else can

see that that's not the case.

You don't have to be thin to have anorexia nervosa.

You can have that determined to drive for thinness

and avoidance of foods and catastrophic

and dangerous weight loss at any weight.

So it's not determined by weight, it's determined

by thoughts, feelings, and behaviours.

What is the difference between restrictive anorexia and binging and purging anorexia?

In restrictive anorexia nervosa,

a person controls their weight

and indeed their weight loss

through restricting their food intake.

Hence the name. Sometimes that's also accompanied

by excessive exercise as another way

of burning off calories.

But that picture overall is

what restrictive eating anorexia nervosa looks

like. In some people,

anorexia nervosa is also accompanied by bingeing

and purging, and bingeing

and purging is when a person

with anorexia nervosa feels like they've lost control over

their appetite and they've eaten more than they want to.

And sometimes that might be objectively more than they want

to, and sometimes it's just subjectively like they feel

they've eaten much more than they were,

but the idea is that they've lost control.

And then they would take some action in order to compensate

what we call compensatory behaviours for having over eaten.

And that combination of bingeing

and purging in the context

of somebody who's got this overriding drive for thinness is

what we would call binge purge anorexia nervosa.

And there's a lot of similarities between that presentation

and bulimia nervosa.

The reason for making this distinction between restrictive

and binge purge anorexia is that we think there are likely

to be different risk factors, different genetic profiles

for people and psychological profiles who might be at risk.

There's a potentially different course of illness

and they might respond to slightly different treatments.

So that's the reason for making that distinction.

What are the signs and symptoms of anorexia in children?

So anorexia nervosa is characterised by a drive

for thinness, a determination to lose weight, and

therefore the signs

and symptoms of that are

that somebody is doing weight loss behaviours

that looks like avoiding foods that they perceived

to be high in calories.

It might look like monitoring calories on food,

sometimes even weighing out or measuring foods,

and it would look like trying to find ways

of reducing food intake in whatever sort of way.

So that might look like disguising food or hiding food

or being secretive, throwing food away, for example.

Anything to avoid eating food

and then in more extreme ways, going

for long periods without eating anything at all.

So just cutting back and back more

and more with the amount of food that's being taken in

as a way of trying to drive weight loss.

Depending on whether it's restrictive

or binge purging type of anorexia in nervosa,

it may be accompanied by other food

avoiding type behaviours, so

that might look like exercising to burn off calories.

It might look like finding other ways

to eliminate calories from their body, whether that's by

vomiting food after eating it, whether it's

by taking substances such as laxatives in order

to induce elimination

of food from the body.

And then there were some more ominous

variants of eating disorders where people might manipulate,

for example, their medicines in order to

facilitate weight loss.

But the driving psychopathology behind all

of it is a determination to be as thin as possible,

and that's the core psychopathology of anorexia nervosa.

What causes anorexia?

The causes of mental illnesses of any kind are complex.

There isn't a single answer.

There's a combination of factors.

We often think about the bio-psycho-social

causation of eating disorders.

So there are biological factors

that might look like genetic factors.

It might look like individual

predispositions of various kinds.

The psychological being different personality traits,

different risk factors from that perspective.

So an example of that might be perfectionist traits,

for example, or a tendency to, we call

what we call cognitive rigidity.

The idea that you have very black

and white thinking about things

and that rules are absolute rather than being able

to see things in shades of grey.

And then there are social risk factors.

So that might be specific triggers, some sort

of event might've happened that is distressing

or traumatising, or it may be more

a developmental exposure to things

that somebody is finding psychologically challenging, such

as friendship groups, for example, being quite difficult.

Being rejected by your friends

is quite a commonly cited figure,

a commonly cited risk factor.

Or there's a lot of talk isn't there about social media

and how that can drive a focus on body shape and appearance

or picking up unhelpful ideas.

So we tend to talk about a jigsaw

and everybody's jigsaw of risk factors looks different.

There's quite a lot in that jigsaw

that you won't be able to change.

So for example, if you know you carry genetic risk

for something, it's really important to understand

that those genetic risk factors are there.

And genetic factors probably account for,

depending on which eating disorder, somewhere

between about 40 and 70% heritability.

There are things you can't do anything about like that

about, but it's important to know you carry that risk.

So in the same way that if you know you're at higher risk

of say, cancer

or heart disease, you also know there are things you can do

to mitigate that risk.

And that's the bit that we can intervene with.

So within any individual child, what we try to do is come up

with a formulation about what are the things

that are contributing that may be contributing

to this person's eating disorder,

and which of those things are keeping the problem going,

which were things that happened in the past

and there's nothing we can do about,

and what are the things that might be keeping it going?

And they're the things that we often can intervene with.

So we don't talk about cause

and effect in a direct linear sense.

We think about the whole picture

from individual up to society, biological,

psychological, and social.

And everybody's individual story is different.

How common is anorexia in children?

So the peak age of onset for anorexia nervosa is

between the ages 15 and 25 roughly.

Although it can occur in younger people

and it can obviously occur in older people as well.

Even at that highest risk peak age, the prevalence of,

or the kind of number of people in the population

with anorexia nervosa is probably around

roughly half to 1% of the population.

And that's because once it's established,

it doesn't go away quickly.

Not like a cold. But the number of new people

with anorexia nervosa

who present every year is still relatively low.

That's what we call the incidence of anorexia nervosa.

And so it's not what we would call one

of the common mental illnesses.

How can I tell the difference between a small appetite and anorexia?

So in medicine, anorexia means small appetite,

and that's different from anorexia nervosa,

which is the mental illness.

That's one of the types of eating disorder.

Anorexia nervosa is not driven by a small appetite,

although some people can learn

to override their own appetite drive, and

after a while, particularly if you're in ketosis, your

body's recognition of appetite does get diminished.

But anorexia nervosa doesn't start off as a loss

of appetite or even as a small appetite.

People do vary in terms of

what their appetite's like

and whether they've got a strong appetite.

And a poor appetite can lead

to problems

from a nutrition perspective, that is one of the subtypes

of arfid is driven by a lack of appetite.

So a variant of arfid is defined

by having a poor or low appetite

and being unable to recognise your satiety cues.

Anorexia nervosa is different.

Anorexia nervosa onsets with people who've had

a relatively normal relationship with food or appetite

and whose eating behaviour has changed

because a thought has come into their head

that losing weight is desirable,

and that's very different from a constitutionally poor

appetite.

How is anorexia diagnosed?

Diagnosis of anorexia nervosa is made

through talking to people.

It's gathering a history usually from parents

in terms of what they've noticed.

When did they notice a change of eating behaviour?

Is it a change from usual, importantly

because this is about the onset of an illness

and there are characteristic behaviours

that parents will describe.

So for example, I noticed last Easter

that she didn't eat her Easter eggs,

and then I noticed that she wanted to go

to the gym on a more regular basis and so on.

So there's a very consistent narrative about

that we hear from people,

and it sounds very similar from one person to another,

and often at the point

before they get to clinical care,

it has resulted in weight loss

because that's one of the cardinal features

of anorexia nervosa is determined drive for weight loss.

But there are often signs

and symptoms when you ask that go back several months

or even longer. Parents aren't always aware of how

their child is feeling about their body

and their body image, although they may have picked up clues

by watching a young person's relationship

with themselves in the mirror, whether they're willing

to change in changing rooms, those sorts of things.

But to get to those thoughts

and feelings side of things, you really need

to talk directly to the young person.

So as part of an assessment,

you would always have a conversation with a young person

about their thoughts

and feelings about themselves, about their body

specifically, and the extent to which concerns about weight

and shape have become primary in their mind,

the most important thing to them.

How important relatively is your weight

and shape in terms of how you see yourself as an individual.

And those are the core characteristics of anorexia nervosa.

To say that it's become an illness,

usually we would want some evidence

that it's clinically significant in terms

of the impact on their physical health as well.

So you would get a history that somebody,

parents don't always know what their child's weight is,

but they would usually notice if they'd gone down a dress

size or a T-shirt size or trouser size.

Sometimes we'll have old weights

and you'll be able to say, lost

however many kilogrammes in however many months.

But that documentation that those thoughts

and feelings have actually resulted in behaviour change

and change that is visible

and starting to have an impact on health is the other thing

that you would do.

And of course, for children, that weight can only be

interpreted in light of their height.

So we would then do a bit of maths

to work out whether somebody is underweight

or still in the healthy weight range.

Although the diagnosis

of anorexia nervosa is not made on the basis of weight.

What are the treatments for anorexia in children?

The treatment for anorexia nervosa.

The best evidence-based treatment

for anorexia nervosa is a family approach, a family therapy

approach that is focused on the eating disorder.

So not a general family therapy approach,

what we call a systemic family therapy approach, where we're

encouraging communication between family members,

but one where there are specific

strategies that are used to help parents

support a young person become nutritionally rehabilitated,

but also then begin to renegotiate responsibility

around their own eating behaviour

again. Of course

that requires a conversation about communication.

It requires family members to work together

to understand each other's points of view about things,

to listen to each other, but it's all with the purpose

of helping a young person address the thoughts

and feelings that are driving their eating disorder.

So that's the first line intervention for most people.

And even if you are a single parent,

that would usually be the first starting point for treatment

and likely what you'll be offered.

Occasionally, there's a very good reason why a family-based

treatment approach is not going to work for whatever reason.

And of course, the older adolescents get,

the more they have choice about what they're willing

to accept in terms of treatment,

and then you might move to a more

individual treatment approach.

The reason we start

with a family approach rather than an individual approach is

that when a family treatment approach works,

it works quicker and it's therefore more effective

because we know that the earlier somebody responds

to treatment, that determines their outcome

and their treatment prognosis.

So individual approaches are available.

The two commonest ones

that are used are something called adolescent focused

psychotherapy and cognitive behaviour therapy.

And those are working with a young person

to think about the way that their thoughts and feelings

and in adolescent focused thoughts, some

of the developmental challenges

that they're facing

have become entangled with their eating behaviour.

If a young person is having an individual approach,

it would be quite usual for their parents also

to have some sessions to think about

how they can support their young person.

If those first line interventions, the family approach,

number one, or the individual approach number two,

isn't enough, then there are all sorts of ways

that we can intensify treatment.

But usually we would start with one of those

and then say, well,

is somebody responding in the way that we would hope?

And if not, why not?

And depending on how we've understood the problem with

that young person or what they're struggling with,

what the clinician who's working with them and the family

and young person think is getting in the way of treatment,

then we may be able to

suggest additional

interventions that might help with that.

So for example, sometimes we might suggest a medication

that would help, sometimes we might suggest some separate

sessions for parents to help them think about how they can

approach the situation differently.

Sometimes we might suggest some specific work

for the young person on a particular problem, say anxiety

or obsessionality and so on.

And then sometimes if things they're really struggling,

we might think, oh, actually you need a more intensive

treatment, and that could look like a day treatment

programme, or it might look like a hospitalisation.

What support can parents offer to children who are experiencing anorexia?

Parents are absolutely vital to children

who are experiencing anorexia nervosa.

The first thing is about helping them get to treatment

because often somebody

with anorexia nervosa isn't particularly looking for help.

Anorexia for them sometimes is the answer,

and they don't want people to interfere or intervene.

So recognising when a young person does need help is the

first thing a parent can do to support their child

and involve the right people in

that, work out who needs to be involved,

and importantly, who doesn't.

If you have got your child to help

and a diagnosis of anorexia nervosa has been made,

the likelihood is that you've been involved directly -

you are going to be involved directly in treatment,

particularly if they're under the age of 16.

Children have more choices when they get to 16 and above,

but assuming that you've been involved in treatment,

your clinician will guide you in terms of

how you can be most helpful to your child.

But in the early phases of the illness, generally speaking,

parents are encouraged to take responsibility from the child

who is recognised as essentially being out of control,

having lost control over their own

anxieties about eating.

And so we support

and scaffold parents

to become more effective against the incredibly

powerful driver that anorexia nervosa can be

once it's taken hold.

And so that parents stepping into that role

and very early and very effectively is absolutely key

to turning things around that early treatment response.

And being able to put a stop to some

of those more harmful eating behaviours is really the first

stage of treatment and where parents are so important.

So just essentially taking over, recognising

that your child is no longer able to control

what they're doing. As time goes on,

parents will be encouraged to hand responsibility back.

And there, the important thing is to find ways

of talking about that

and communicating about it so

that the eating disorder doesn't kind of trick you into

reassurance or assuming

that things are okay when actually your instincts are

telling you're not.

Your child isn't ready yet.

So being open-minded

and listening to your young person about what they want to,

what's important to them, but also balancing

that against your parental instincts

to protect them from this awful illness.

How do I get that right?

The balance of how much responsibility

to give my child or not?

And that whilst your child might be telling you

that they hate you and that they are absolutely

furious with you, is actually the best way you can support

them because you are staying calm

and effective as a parent in the face of

a potentially dangerous illness.

And then as time goes on, your task really is to

support them to discover

who they are in themselves without their illness

and rediscovering a kind of sense about who they are,

who they want to be, and an identity

out the other side of their illness.

Because anorexia can take over

to the extent it convinces you

that it's the most important thing about who you are

and your weight and your shape is the most

important thing of who you are.

And that journey of rediscovery

and identity afterwards can take many forms.

And as parents supporting your child with allowing them

to explore who they are and who they want to be,

and their identity is

what those final phases of treatment look like.

So you are absolutely key to, it's the sort

of accelerated version of development, if you like,

condensed into a short period of time.

And actually now, I know it sounds bizarrely paradoxical.

Many people find that journey, parents

and young people going on that journey together can be

extremely powerful.

And many people say that they're glad that they've been

through it in terms of what they've learned about themselves

and how they've learned to think differently about

what matters and what's important to them.

So parents, supporting young people on that journey

of discovery is an absolutely vital part of treatment.

What is bulimia?

Bulimia or bulimia nervosa, as its full name should be, is

an eating disorder in which there's a

similar kind of focus on wanting to be thin

and being unhappy with your body.

But the difference from anorexia nervosa is

that the core feature of bulimia nervosa is the fact

that despite wanting to be thin

and to eat very little, people

with bulimia nervosa can't control their appetite.

And so what happens is that they have binge eating episodes.

Binge eating episodes are characterised

by a loss of control.

Overeating. I'm not just talking about overeating,

like I've eaten too much, and I feel bad about that.

I'm talking about not being able to stop.

And for some people it's almost, it can kind of go into

almost a dissociative state we would call it,

or into a frame of mind where

you just keep going until only being sick

or something else will stop you eating.

So it's a real loss of control.

And because the psychopathology of bulimia nervosa

is involved with thinking about

being unhappy about your body weight

and wanting to be thinner

because the person with bulimia nervosa perceives themselves

to have eaten too much, they then feel driven

to do something to compensate for that.

So often people think bulimia nervosa is characterised

by self-induced vomiting,

and of course that can be one of the symptoms.

That's one of the ways in which people

with bulimia nervosa can eliminate the food

that they feel bad about having eaten.

But it's the binge eating

and then followed by compensatory behaviours of some kind,

which characterises bulimia nervosa.

And that compensatory behaviour might be self-induced

vomiting, but it might be the need

to compulsively exercise afterwards,

or not allowing yourself to eat afterwards.

So fasting to compensate for the fact that you feel

that you've eaten too much or taking some other kind

of medication to eliminate the food that you feel

that you've overeaten.

And I think hopefully inherent in that, you can understand

that one of the things that often happens in bulimia nervosa is

an intense feeling of shame

and guilt about these loss of control eating episodes,

because it's the very opposite of what the person

with bulimia wants to be doing.

So that's the core of bulimia nervosa is,

and it's extremely distressing, but often very secretive

because it's so bound up with feelings of shame and guilt.

What are the signs and symptoms of bulimia in children?

So the characteristic of bulimia nervosa is

binge eating, which is a loss

of control over your eating behaviour.

And for it to be considered pathological, that has

to happen fairly regularly.

So more than once a week for a significant period

of time, more than two months.

So it's a consistent behaviour. It's not just a one-off.

And then because it's associated with strong feelings

of guilt and shame about having over eaten, the person

with bulimia nervosa will then compensate for that

by feeling the need to eliminate that

food from their body in some way.

And they might do that by what we call purging.

Purging is any form of eliminating food from your body.

So it might be by inducing vomiting.

It might be taking a medicine such

as a laxative, for example.

But you can also compensate for excessive energy intake

by fasting or not eating for long periods of time,

or by excessively exercising,

and that can in itself become compulsive.

So the core features of the signs

and symptoms of bulimia nervosa are binge eating, followed

by compensatory behaviours for a consistent period of time,

and on a regular basis.

These behaviours are often hidden,

so they can be very hard to spot.

By definition, a person

with bulimia nervosa isn't severely underweight,

so you can't tell by looking at somebody whether

they've got bulimia nervosa.

If they were severely underweight,

they would have a diagnosis of anorexia nervosa.

But the fear of weight gain

and the dissatisfaction with the body weight

and shape can be as intense as it is for somebody

with anorexia nervosa.

What causes bulimia?

The causes of any eating disorder are complex

and there's no direct cause and effect,

and there certainly isn't a single cause.

We tend to think about a jigsaw of factors

that come together for any one individual,

and those factors can look different from

one individual to the other.

But there are some things

that we can say about the risk factors for bulimia nervosa

that are different for example, from the risk factors

for anorexia nervosa.

So although there are genetic factors that will contribute

to bulimia nervosa, they're different from the genetic

factors that will contribute to

anorexia nervosa in some respects.

So people with bulimia nervosa are more likely

to have a high appetitic drive, whereas some people

with anorexia nervosa have a very low appetitic drive.

In other words, they have a tendency

to overeat rather than to undereat.

And it's that overeating that can feel like

and can become out of control.

But some of the psychological characteristics are very

similar to anorexia nervosa.

So they're often driven by feelings of low self-esteem,

of having negative mood,

feeling very negative about yourself,

poor self-esteem. Depression is very strongly associated

with bulimia nervosa.

And then there are other sort of characteristics that

can occur in somebody with bulimia nervosa, such

as high levels of impulsivity.

And so there are a different set of other type

of mental disorders that can be associated

with bulimia nervosa.

That again, looks slightly different from what you might see

with somebody with anorexia nervosa.

So there's more likely to be an association with depression,

more likely to be association with addictions

of various kinds,

and more likely to be associated

with other disorders related to impulsivity such

as attention deficit hyperactivity disorder and so on.

So it's a different set of factors. Central

to bulimia nervosa,

as for anorexia nervosa is this overvalued idea about weight

and shape because the guilt and the shame about,

and self disgust, I think is probably a discussed

as a very strong emotion in people with bulimia nervosa.

Some of that comes from values to do

with the importance of weight and shape.

So all of the factors in society

and elsewhere that drive people to feel ashamed

of themselves are also relevant for people

with bulimia nervosa.

How common is bulimia in children?

So bulimia nervosa doesn't really happen in younger

children, and there are biological reasons for that.

Some of the what we would call social emotions rather

than basic emotions.

So a basic emotion would be something like anxiety, fear,

or experience of threat.

Whereas a social emotion is to do with relationships.

So guilt and shame where you need to see yourself

through somebody else's eyes.

They don't come on stream

until you've got the hormones working in your body

to enable you to see things from

other people's perspectives.

And because of that, you don't start

to see bulimia nervosa emerging

until those hormones are active.

In other words, well into puberty.

So people with bulimia nervosa don't tend to present

to, don't tend to develop bulimia nervosa.

There's obviously always going to be a few exceptions,

but generally speaking, bulimia nervosa is something

that develops during or after puberty.

But then because it's a hidden illness,

it often takes a long time for anybody to notice it.

So again, unlike anorexia nervosa

where it's pretty obvious if somebody is starving

themselves, bulimia nervosa can be hidden for a long time.

So there's a very long gap sometimes

between somebody's bulimia nervosa starting

and them presenting for clinical care.

Because of that, we don't actually know how common it is

in the general population.

We know roughly that lots of people

do disordered eating behaviours of one kind

or another, whether that's binge eating, fasting,

purging, and so on.

We know that up to 60% of girls have done one

or other of these behaviours at any point in time.

And as a whole, about 11% have done those to the extent

that it would be considered clinically significant.

But how many of those have the full syndrome

of bulimia nervosa?

It's probably near a 1 to 2%, depending on

what age you look at, whether you look at females

or both genders and so on.

So the prevalence

and the incidence of the disorder does depend on age,

but it really tends to emerge in the teenage years,

but can be rather late to clinical presentation.

My child has a big appetite or tends to overindulge, could they have bulimia?

So a tendency to have a big appetite

and to overindulge isn't in itself bulimia nervosa,

but it might be a risk factor

because somebody who is overeating

by their own perception,

or even by yours, is potentially more likely

to be unhappy about how much they're eating,

and that is more likely to trigger them to feel guilty

or bad or shamed in some way about their eating behaviour.

The thing that's most likely to precipitate somebody who's

overeating into bulimia is attempting to restrict,

because if you've got a high appetite and you are hungry

and you try and restrict your eating behaviour in order

to lose weight, your appetite, your body will give you very,

very powerful messages about how hungry it is.

And if you are at the more impulsive end of the spectrum,

if you appetite drive's too too much,

or if it's making you feel bad in some way, the tendency

to eat is going to be higher.

And the issue then is about if you do eat, can you stop?

And that's when it starts to

move from overeating into bulimia nervosa.

So the biggest risk factor for the onset

of bulimia nervosa is dieting,

by which I mean dieting to the point of fasting

for prolonged period so

that your body gets into a starved state,

and it's that starved state that's thought

to precipitate binge eating behaviour in those

who are vulnerable for the reasons

of having either a high appetite or being impulsive

or being unable to regulate their own behaviour in some way.

How is bulimia diagnosed?

So bulimia nervosa isn't diagnosed by looking at somebody.

You can't tell from their weight whether somebody has got

bulimia nervosa. Weight may change if they're binge eating on a

regular basis, or they're compensating

more than they're bingeing.

So if you notice fluctuations in weight,

that might be important.

Somebody's periods may get less regular if their weight is

changing on a regular basis as well.

In terms of what you might observe as parents with a person

with bulimia nervosa, you might notice

that they're losing control over their eating,

that they can't control their appetite,

and you might notice that your child is upset by that.

But the other way that you might pick up bulimia nervosa is

because of your child's need to eliminate the food, either

because they're inducing vomiting, or

because they feel the compulsion to go out

and exercise after they've eaten.

And it's doing that on a regular basis over a period

of time, and more than once a week that would be necessary

to make a diagnosis of bulimia nervosa.

But anything you observed would need to be corroborated

by talking to the young person themselves.

They'd need to be able to describe their valuation of weight

and shape, how important that is to them,

how it's driving their eating behaviour.

They'd need to be able to describe the feelings of guilt

that drive the compensatory behaviours,

and they'd need to be able to tell you about the binge

eating episodes for you to be able

to make the diagnosis fully.

What are the treatments for bulimia in children?

The treatment for bulimia nervosa is similar

to the treatment for anorexia nervosa.

It's a whole family-based approach, and that's

because, again, eating disorders affect the whole family,

but also the whole family can be helpful in terms

of helping a young person get the balance right,

again, in terms of what matters in life

and challenge the primacy, the strength

of the eating disorder and the effect

that it's having on their life.

So a whole family-based treatment approach,

family therapy for bulimia nervosa focused on

challenging the eating disorder is the first line

intervention that's recommended.

If for any reason, that's not possible,

and you don't need to have two parents

to have family therapy, you can have

family therapy with two people.

You don't need a big family.

But usually if a family is involved,

it would be the whole family, at least for some of the time.

If for whatever reason, family therapy isn't going to work,

then the other option is an individual therapy,

and there's a cognitive behaviour therapy that is effective

for adolescent onset

bulimia nervosa, we tend to start with a family-based approach

because when it does work, it works quicker

and can be more effective.

But an individual approach is possible if the young person

is distressed by their behaviour

and is motivated to work on it.

What do you do if the first treatment you have tried doesn't work?

The first psychological intervention

that's been tried for bulimia nervosa

hasn't been effective,

whether that's a family

or an individual approach, you could try swapping,

you could go to the other alternative.

But usually what we would do

before doing that is kind of pause

and think, why is this not working?

What's going on? Is there something maybe in the

relationships that aren't working?

Is there another disorder that's getting in the way, such

as anxiety or low mood?

Has something been missed that we aren't aware of?

Whether it's a trauma

or whether it's an undiagnosed developmental disorder.

So we'd stop and have a think about why is it not working.

The other one of the options at that point would be

to add in a medication.

That's what we would call a stepped care.

So you'd start with a psychological intervention.

You start adding others in

as you see the treatment response.

So sometimes some types

of antidepressants can be very helpful in bulimia nervosa.

And then as with any disorder, if it has really become out

of control, we can think about higher levels

or more intensive levels of care.

And rarely that could involve inpatient treatment.

But there are other day treatment options.

Some people are particularly struggling with difficulties

with managing emotions

and regulations, emotional regulation,

and that would make us think about other types of treatments

that have been helpful in other disorders

that are associated with an emotional

and behavioural dysregulation pattern.

What support can parents offer to children who are experiencing bulimia?

As a parent, you are often the first person

who will notice that something's wrong with your child.

And because bulimia nervosa is associated with secretiveness

and shame and guilt, a young person may be unwilling

to talk to you about it.

So the first step that a parent can take in terms

of supporting a young person is enabling them to get

to help, enabling them to talk about what's wrong

and acknowledge that something's wrong

and that they might need help with it.

So helping a person with bulimia access care is the first step.

Once they're in treatment, the treatment is likely

to involve you as parents

because it is parents that can help put things in place,

structures in place, scaffolding, emotional support

that might be absolutely key to that young person

managing their eating behaviour in a different kind of way.

So an example would be

because binge eating disorder is often associated with

feeling guilty after eating

or is associated with feeling guilty after eating.

The tendency is for people to then go

for a long time without eating afterwards in order

to compensate for that.

But that, of course, will then make them hungry,

which increases the likelihood of them binge eating again.

And so one of the things that parents can do is ensure

that somebody's eating on a regular basis,

even though they'll be anxious about the fact that

that will make them put weight on, actually,

it might help reduce the frequency of bingeing and purging.

And ultimately, over time, that's likely to mean

that their weight is more stable,

which is what they would want.

So that's an example of the sort of structure

that a parent might put in place that would be helpful.

So things that are challenging the eating disorder

and some of the behaviours.

So supporting a person

after a mealtime so that they can't go

and vomit would be another example.

So that they are not able to follow through

that binge episode or as they perceive it to binge episodes.

Sometimes it may be subjective rather than objective,

or for example, trying

to help them limit their exercise behaviour and so on.

So there's all sorts of ways

that parents can directly intervene with the symptoms

of bulimia nervosa and this is what the family therapy

would be focusing on.

And then later on, as a young person is recovering,

then it's more about providing the sort of holistic support

that you would for an adolescent who's trying to re-identify

with themselves and to think about themselves

free from bulimia nervosa

and in a more comfortable place with their body.

And that's where things like the sort of language

around body image, supporting self-esteem, making sure

that they can find other ways of dealing with anxiety

and negative mood, if that's what's driving bulimia.

Keeping the conversation open about more supportive ways

that a young person can help

themselves with their mental health.

Other ways that parents can be supportive.

What is binge eating disorder?

Binge Eating disorder is an eating disorder in which the

person experiences a loss of control over their eating

to the extent that they binge, that means

that they can't stop eating, and

because they feel out of control about their eating,

they often feel really bad about it.

Unlike bulimia nervosa, people with binge eating disorder,

however don't do anything to compensate for it,

and that's what differentiates binge eating disorder

from bulimia nervosa.

People with binge eating disorder if they binge sufficiently

frequently, often gain weight as well, so it can be one

of the things that can drive continued weight gain,

and that might further contribute to

feeling bad about yourself

or feeling distressed by your binge eating behaviour.

But binge eating disorder is not defined by weight,

and as with other eating disorders,

you can't tell whether somebody has binge eating disorder.

By looking at them, you would need to talk to them

and find out how they were experiencing their eating

behaviour.

What are the signs and symptoms of binge eating disorder in children?

Binge eating is when a child has lost control

over their eating behaviour.

That means when they start eating, they can't stop

and they need something else

or somebody else to stop them eating.

Otherwise, it will just carry on.

And for somebody to have binge eating disorder, they need

to be doing this on a regular basis

for a significant period of time.

So over several months,

and at least once a week.

We're not just talking about overeating, overindulgent,

normal, greedy behaviour.

We are really talking about can't stop eating,

uncontrolled eating,

and it can be quite distressing for the young person.

What's the difference between binge eating disorder and bulimia?

So in binge eating disorder, the primary behaviour

of concern is binge eating behaviour

and on a regular basis, on a habitual basis.

And because somebody is overeating on a regular basis,

sometimes that can be associated with weight gain as well

and with distress.

However, unlike people with bulimia nervosa, people

with binge eating disorder don't compensate

for their binge eating behaviour by making themselves sick

or fasting or purging in some other way, or exercising.

In other words, they sit with the unhappy feeling

of feeling they're doing something which feels out

of their control and are often very distressed by that.

But it doesn't result in compensatory behaviours such

as you see in bulimia nervosa because the drive for thinness

and the wish to be losing weight isn't

as strong generally in people with binge eating disorder

as it is in people with bulimia nervosa.

What causes binge eating disorder?

With any eating disorder, there isn't a single cause.

It's a complex jigsaw of biological,

psychological, and social factors.

In people with binge eating disorder,

they often have strong genetic tendencies towards having a

high appetite and may also have tendencies

to have carry genetic risk for other disorders associated

with what we would call disinhibited behaviours.

So addictions, impulsivity, things that lead people to

be unable to stop doing something even

though it's potentially harmful.

So there's that background, biological risk

that people carry.

But then of course, usually there are individual

psychological and social factors

that will come on top of that.

And these are the things that we can intervene with.

So they're very important, but no one

of them is the same from one person to another.

So anything that is leading somebody to have

negative emotions, such as unhappiness or anxiety

or trauma, is more likely

to precipitate binge eating behaviour.

So these are often emotionally driven binge eating episodes.

And similarly, there may be factors

that are making it difficult for the young person to

feel emotionally in control

and to learn to regulate their own behaviour.

So they may not have learned the capacity to

talk about their feelings

and to self-regulate when it comes to knowing when to stop.

And that's of course where parents can come in is helping a

child recognise what's going on for themselves

and learn to find some language about how they're feeling

to help to know when to stop doing something

that's potentially harmful.

How common is binge eating disorder?

We actually don't know how common binge eating disorder in

children is because there haven't been very many good

studies looking at this,

particularly in the UK. Binge eating

behaviour is probably more common in children

who are at a higher weight.

So if you go to weight management clinics, roughly

25 to 30% of children there will be feeling

as if they've lost control over their eating

at some point or another.

But not all of those will meet full criteria

for binge eating disorder.

In terms of who comes to eating disorder services,

it's relatively rare for children

and young people to be bought for treatment

for binge eating disorder, in my experience.

And that's probably because it's under recognised

as a treatable cause of mental distress

and indeed of a driving weight gain.

So it's something that in my view, we need

to be get better at recognising in children and young people

and making sure that they do get help early.

Because we know that in adults, it can be a real driver

for distress and weight gain and ill health in later life.

And often people have been ill for a very long time

before they've got to help.

So in short, we don't really know

how common it is in the general population for children

and young people, but probably more common than we think.

How can I tell the difference between a big appetite and binge eating disorder?

So the thing that distinguishes a big appetite from binge

eating disorder, well, there's two things.

One is the loss of control over eating.

The feeling that you can't stop,

and it really is qualitatively different from

just overindulging.

People often describe going into almost a trance-like state

as they just keep eating until they can't stop.

And then the other is how upset people are.

People are overeating and overindulging often enjoy that.

It's a hedonistic thing,

whereas binge eating is really not pleasurable.

It is something that is associated with feeling disgusted

with yourself and ashamed.

It's a negative experience driven by negative emotions.

Not the same thing at all.

How is binge eating disorder diagnosed in children?

To make any diagnosis In children,

we usually get the parents' reports as well

as talk to the young person.

Eating disorders aren't defined by weight,

but sometimes people

who are binge eating on a regular basis have gained weight.

So changing weight

or are being at a higher weight might make you suspect

that somebody has got binge eating disorder.

And certainly one of the things that we are encouraging is

that everybody who is at higher weight

and who's seeking help is asked about whether

they're binge eating or not.

Parents might notice that a child can't stop their eating,

or may have tried to encourage a child not to eat so much

and being met with distress or anger or resistance,

and that would be a sign that there's something

that's not okay for the child, that they're not able to take

that without it getting very emotionally charged.

But as with any eating disorder, ultimately it comes down

to a conversation with the young person about their

experience of their eating behaviour,

how they feel about food, whether they're able

to resist the urges to binge eat

and how they feel about it when they have binge eaten.

And that's what makes the diagnosis

and identifies binge eating behaviour.

And then to meet the diagnostic criteria that needs

to be happening on a regular basis,

by which we mean more than once a week

for a significant period of time.

So not just a transient time associated with some distress,

but over a period of two months

or more that somebody's been showing this binge eating

habit.

What are the treatments for binge eating disorder in children?

Because we don't see very many people, young people

with binge eating disorder in clinical services,

there also haven't been very many clinical trials

for binge eating disorder in children

and young people, so we don't actually know

whether there are treatments that might work better

for children and young people than for adults.

So, we tend to use principles of eating disorders treatment

that seem relevant to binge eating disorder,

and that means usually taking a family-based approach,

working with parents to help a child learn

to regulate their own behaviour,

and focusing the treatment

on the eating behaviour itself

and helping a person eat regular small amounts

and learn to recognise their own appetite

and to express their emotions.

These are both core parts of eating disorders

treatment that would apply regardless

of which eating disorder diagnosis is.

If a family-based treatment approach isn't working,

then we would normally offer an individual approach,

or sometimes in an older adolescent, they may prefer to go

for an individual treatment approach right from the word go,

in which case the cognitive behaviour therapy approach would

be the first line treatment,

and that cognitive behaviour therapy involves recognising

the link between your thoughts and your behaviours

and then challenging them often through experiments

or seeing whether what happens when you try

to do something different.

First line usually

with young people is family-based treatment,

and if not, an individual treatment therapy approach.

If those approaches aren't working

and we think that there's something else may be driving

their binge eating disorder, such as low mood for example,

or anxiety, or ADHD,

attention deficit hyperactivity disorders,

very strongly associated with impulsivity

and high appetitic drive,

then we might consider whether a treatment for one of those,

what we call comorbid,

or disorders

that's going alongside binge eating disorder might be

helpful as well.

What support can parents offer to children who are experiencing binge eating disorder?

Parents support children

with mental health problems in all sorts of ways.

And the first is getting them to recognise

that there is a problem and

that they might need help with it.

And so that's the first thing to do, is to have

that conversation with your child to say,

is this something that's a problem for you?

Is this something you'd like me to try and get help with?

So getting your child to treatment is step one.

Then I think in terms of supporting during treatment

or once you have recognised the problem,

there are really two things, main things to think about.

One is how do you support with the behaviours?

How do you help your child learn

to regulate their behaviour?

And that's best done through conversation.

What can I do that would help? Would it help if I did this?

Would it help if I did that?

That's what you would be doing in therapy.

If you were in therapy for binge eating disorder,

is you'd be having a conversation with your therapist

and with your child and with other family members to think

of all the things that we can do

and all the things we've noticed about

the times when you are most likely to binge.

We've got this idea, shall we try this?

So there's isn't a one size fits all for exactly how

to do it, but helping the child regulate their eating

behaviour is one part.

And then the other part is the broader

part about the emotions.

How do you help your child deal with their distress

and their negative emotions in different kinds of ways?

And so as with any kind of therapy, that's a combination

of recognising what those emotions are, what drives them,

but also what can be done to help them talk about it

and to help deal with those negative emotions in different

ways other than through eating behaviour.

So it's that combination

of thinking about the eating specific side of things

and then the emotional support that you can offer

as parents.

What is OSFED?

OSFED stands

for other specified feeding or eating disorder.

The key word in that sentence is specified.

So OSFED isn't a single diagnosis, it's a group

of disorders that are specified

and that don't meet the main criteria for anorexia nervosa,

bulimia nervosa, or binge eating disorder.

So there are four specific OSFED diagnoses.

One is atypical anorexia nervosa.

That's anorexia nervosa

in every way except there's one feature missing.

And typically, depending on which classification system you

use, that thing that's missing may be

that the person is not at a very low weight.

Or it may be that they don't articulate the fear of fatness

and the drive for thinness that we would expect to find

in anorexia nervosa.

So there's something, in other words, it's anorexia nervosa,

but with one of the criteria missing.

Atypical bulimia nervosa

or subthreshold bulimia nervosa is exactly the same as bulimia nervosa,

the second type of OSFED,

but it is less frequent than

the behaviour is happening less frequently than is required

to meet the full diagnostic criteria.

So if somebody's bingeing

and purging once every two weeks rather than once every

week, but it's been over a significant period of time,

you would still think it was a clinically significant eating

disorder, but it doesn't quite meet the full threshold.

So that's the second OSFED subtype.

And the same is true for binge eating disorders.

So binge eating, but not at the frequency

of once a week for more than two months.

The third type of OSFED

is actually quite a clinically significant problem.

We see a lot of this, and this is something

called purging disorder.

So purging disorder is what it sounds like.

It's purging, but without the bingeing.

In other words, the person doesn't meet criteria

for bulimia nervosa because there's no bingeing.

And they don't meet criteria for anorexia nervosa

because they're not underweight and it's not driven

by extreme fear of weight gain,

but, and they're not just binge eating,

they're just purging.

The reason that purging disorder was pulled out

as a separate diagnosis was

because the cognitive behavioural theories of

bulimia nervosa said

that the purging behaviour was a

compensation for the binges.

But the person who first described it, Pam Keel, said, well,

actually I'm seeing a lot of women

who are purging without the binges.

So how does that fit into this cognitive behavioural theory?

So it was identified as a separate disorder so

that people could study it.

And that's one of the reasons for naming diagnoses.

So purging disorder is where children

and young people engage in purging behaviours -

Behaviours designed to eliminate calories and control weight

and shape, but they don't binge eat

and they don't lose significant amounts of weight.

And those purging behaviours can look like making yourself

sick, compulsively, exercising, laxative misuse,

all the things that you get in the other eating disorders.

And then the final type of

OSFED is something called night eating syndrome.

Now, I have to tell you that I have never seen night

eating syndrome in a child.

It's most commonly described in middle age

and in men as commonly as women.

So it's really not a disorder of childhood

and adolescence to my knowledge.

But of course I live and learn every day

and new things emerge all the time.

But night eating syndrome is the other subtype of OSFED.

So when you're making a diagnosis of OSFED, it's important

to say, or somebody gives you a diagnosis of OSFED, you say,

which type of OSFED. The OSFED has to be specified

so that you know how to approach it and to treat it.

What is ARFID?

Avoidant restrictive Food Intake Disorder

or ARFID for short, is a collection of presentations

that have previously been given all sorts of names,

but never was there a formal way of making their diagnoses.

So the purpose of making diagnoses is to enable people

to study a disorder.

And because the presentations that fall under the umbrella

of ARFID hadn't been described or characterised

or included in the classifications,

there was almost no research to help us understand

what happened in people who had ARFID presentations.

And there were a number of them, and I'll

explain what they are in a minute.

But since ARFID has been named as a collection of

presentations or collection of clinical characteristics,

if you like, there, research in ARFID has exploded.

And so now we know much,

much more about ARFID than we did 10, 20, 30 years ago

as a result of naming it as a new diagnosis.

But actually it's not new.

So what falls under the umbrella of ARFID are a range

of presentations, all of which include avoidance

and restriction of food that hence the name.

But the key characteristic of ARFID

that distinguishes it from anorexia nervosa,

which is the other restrictive eating disorder, is that

in ARFID, the restriction of food in the avoidance

of food is not driven by weight and shape concerns

or by anxiety about weight gain.

So if anybody is restricting their food intake

for any reason other than a fear of weight gain,

that would fall under the umbrella of ARFID.

And as you can imagine, there are quite a range

of reasons why somebody might restrict their food.

So they might have a fear of contamination of food.

They might have a fear that food might choke them.

They might have a fear that food will make them feel sick.

They might have a fear of food because it's the wrong colour

or the wrong shape, or the wrong texture,

or some other sensory feature about it.

Or they may avoid food just

because it doesn't like they don't like food.

I had a patient with ARFID the other day, said,

I find eating a chore.

It doesn't interest me. I don't want to do it.

But there was no fear associated with it specifically,

they just had no interest in food

and no drive, internal drive to eat.

So all

of those presentations fall under the umbrella of ARFID.

Now, the proposal was

that there were three subtypes of ARFID.

The first subtype is the lack of appetitic drive, a lack

of interest in food, if you like, but resulting in,

and this is key to have a diagnosis of ARFID, it needs

to be having a significant impact on your health,

whether it's physical or psychological.

So if your lack of interest in food is beginning

to impair your nutritional status,

You are losing weight or you are not growing adequately,

or you're not able to function in social terms

or psychological terms for your age

because of your lack of interest in food,

that's when it tips over into being ARFID.

The second type of ARFID is the avoidance

of food for sensory reasons.

And I've given some examples of that,

but it might be smell, texture, appearance,

the wrong packaging,

and these sorts of presentations, while strongly associated

with autism spectrum disorder can also,

people can be very sensitive to the sensory aspects of food

and avoid food for that reason.

And then the third type of ARFID that was proposed is

what I would call a more phobic type, a fear-driven type of

ARFID where there's a specific anxiety.

And this group of patients often have eaten normally,

not always, but sometimes have eaten normally.

And then something happens, they have a choking incident,

or sometimes something's happened to someone else

and they become fearful about eating food.

So for example, if

they observe somebody else being sick,

then they become fearful

that they might be sick if they eat.

So that's a more anxiety driven type of ARFID.

So these three subtypes

of ARFID were proposed when the diagnosis was first put

forward in 2013.

In fact, we see quite a lot of young people

who have a mixture of all three.

So you can have one of those subtypes

or you can have something that looks like a bit like a

blend of them.

But with all of them, the key issue is

that it's become clinically significant

that the malnutrition associated with ARFID is significant

or that the ARFID is getting in the way

of them functioning in some way psychologically or socially.

What are the signs and symptoms of ARFID in children?

So the core feature of ARFID is that it's associated

with malnutrition,

and that malnutrition can be manifest in a number of ways.

It might be that somebody is failing to grow,

a child is failing to grow and develop it normally

because they're malnourished, typically underweight.

They may have signs of micronutrient deficiency,

so vitamin deficiency, for example.

Or they may be unable to eat enough food generally

to be able to survive without having

nutritional supplements.

So if a child is dependent on nutritional supplements,

that would be one of the diagnostic criteria for ARFID,

or that they are unable to eat in a way

that other young people like them are able to eat.

And I use the word like them advisedly,

because if you've got, say for example, a food allergy

or type one diabetes or autism spectrum disorder

or other disorders that affect how you can eat

and what you might expect to eat,

or you've got a gastric disorder of some kind

that makes it impossible for you to eat

as other children would eat, then

that wouldn't mean you necessarily have ARFID.

ARFID would only be diagnosed if the difficulty

with eating is over

and above what you would expect for that disorder.

In other words, it's become a problem in its own right

rather than simply secondary

to whatever the primary problem is.

So that's the key to a diagnosis of a ARFID, is

that you've got some evidence of malnutrition

and that it's impairing function in some way.

And importantly that any avoidance

and restriction of food is not driven by weight

and shape concerns, because then

that would be another eating disorder diagnosis.

Specific types of ARFID present in slightly different ways.

So for child's not interested in food, it's much more likely

to present as weight loss or failure to grow.

If somebody's got a phobia of eating, they're more likely

to have gone into acute food refusal

or only be able to eat liquid foods, for example.

And if somebody's got a sensory avoidance of food,

then they're more likely to be highly

selective about the types of foods that they will eat.

And so what you'll see is a very narrow range of foods,

but not necessarily a small quantity of food.

And what that means is

that you can have ARFID at any weight,

so the weight isn't one of the criteria

for the diagnosis of ARFID.

You can be underweight or you can be eating plenty of food

or sometimes more than you need and be overweight,

but you are only able to eat, say, French bread

or Yorkshire puddings or something like that,

and you're not able to eat any other food.

So it's not a weight-based diagnosis.

How can I tell the difference between picky eating and ARFID?

So picky eating isn't a diagnosis, it's a description

of children's eating behaviour,

and it's a very common behaviour in children.

It's very common for children to go through phases

of picky eating as they transition from

toddlerhood into school, times when they're feeling more

challenged psychologically, such as transitions from school.

People often go back to

being very picky about their eating behaviour.

So food is very sensitive to children's emotional states,

but when it becomes clinically significant is when

that picky eating has become associated with malnutrition.

In other words, that the selectiveness of the foods

that that picky eater is able

to eat has become stuck in such a way that you are unable

to help them broaden their range of foods,

that they're unable to adapt developmentally to eating foods

that other children of a comparable age may be able to eat,

and that it's starting to impair their physical

and their psychological and social wellbeing.

Where can I go to get treatment for ARFID in children?

Treatment services for children

and young people with ARFID are still in development.

And that's because ARFID is a complex diagnosis

with multiple presentations.

And you can find out more by watching my section on

"What is ARFID?".

Because it's associated with malnutrition,

the first step is going to be correcting that malnutrition

and depending on how it's impacting the child,

that may mean you need to see a paediatrician,

it may mean that you need to see a dietitian,

or it may be that you are able

to access a specialist multidisciplinary

ARFID treatment team, which will incorporate paediatric

and dietetic input

because correcting malnutrition is the first step

with treatment with any eating disorder.

The question then becomes about access

to psychological interventions.

And there are psychological interventions for ARFID,

both family-based and individual cognitive behavioural

therapy interventions, and getting to that sort of treatment

or being assessed for whether

that treatment is likely to be effective,

that will require you being able to get to a specialist

of some kind, but which specialist

that is may depend on the type of presentation.

So if your child has ARFID on top

of autism spectrum disorder, you'll need to see somebody

who knows quite a bit about autism in order for them

to be able to understand how to adapt their treatment

to work for your child.

Similarly, if you've got the type of autism

that's associated with anxiety

and fear, it may be that that is available

through your child

and adolescent mental health services where they treat a lot

of treatments, anxiety based disorders.

And then if there's association

with significant malnutrition

or emotional difficulties more broadly

and that you need their full multidisciplinary team for,

then it may be that your eating disorder service can help.

So the answer does depend a little bit on the type

of presentation where the areas of difficulty are,

how old your child is.

So if your child is very young, it may be

that a feeding clinic is the most appropriate

place for you to get care.

If your child is older

and a teenager, then they may be more able

to participate in an individual psychological therapy,

and that's likely to be available

through a mental health service, all

through a specialist eating disorder service.

What's the difference between ARFID and anorexia or bulimia?

ARFID is distinguished from anorexia nervosa,

bulimia nervosa, and binge eating disorder by the extent

to which the centrality of weight, shape,

and appearance are what's driving

the distress or the behaviour.

So in ARFID, people

with ARFID don't care about their weight.

They don't care. They often want

to be heavier if they're thin

or it really won't be a factor.

They don't get upset about their weight.

And similarly, the fears that are driving their avoidance

of food are not driven

by concerns about their weight or their shape.

And that's what distinguishes ARFID from anorexia nervosa

and bulimia nervosa.

Sometimes it can be hard

to tell whether somebody's got ARFID or anorexia nervosa.

Sometimes you can only tell

by watching their eating behaviour.

And in anorexia nervosa, people tend to avoid specific foods

because what's at the back of their mind is "is this fattening?".

Whereas in ARFID, they may be more than happy to eat chocolate

and cake, but they won't touch vegetables.

Very, very different type of eating pattern.

And so getting to the core of what the anxiety is

that's driving the avoidance of food

and the restriction

of eating behaviour is really the key way

to tell the difference between whether somebody's got ARFID

or whether they've got anorexia nervosa

or another eating disorder.

How can I tell if my child has an eating difficulty?

Harriet Finlayson and Danielle Panton

Specialist Nurse Advisers – Mental Health, Bupa

23 April 2024

Next review due April 2027

Most children have likes and dislikes when it comes to food. But when does picky eating become something more? Here, we’ll tell you what you need to know about eating difficulties and eating disorders in children. We’ll also outline the signs that your child might have an eating difficulty.

What’s an eating difficulty?

An eating difficulty is when someone has a difficult relationship with food. For example, your child may not like certain foods or have unusual eating patterns. Not all eating difficulties are diagnosed as disorders.

Eating difficulties, whether diagnosed or not, may affect a child’s mental and physical wellbeing.

What’s an eating disorder?

Eating disorders are eating difficulties that have been formally diagnosed. They’re mental health conditions related to unhealthy thoughts and behaviours around food and eating.

Someone with an eating disorder may use food to feel more in control or cope with feelings. Some may also have unhealthy obsessions with weight, body image, and exercise.

There isn’t one single reason your child might develop an eating disorder. The reasons are complex and unique to each child.

What are the signs of an eating difficulty?

Some possible signs of an eating difficulty include:

not having much of an appetite
exercising more than usual
a significant change in weight
leaving the dinner table quickly
avoiding eating in front of others
constantly thinking about food, weight, or body shape
only eating certain foods
not feeling able to eat even though you want to
limiting how much you eat
becoming distressed at mealtimes
drinking excessive amounts of fluids
using the bathroom directly after meals

The signs of an eating difficulty may not always be obvious. And there may also be other signs not included in this list.

It’s best to seek help if you notice anything worrying about your child. A medical professional will be able to give your child any support they need.

What are the types of eating disorder?

There are several different types of eating disorder, which we describe below.

Avoidant restrictive food intake disorder (ARFID)

People with ARFID restrict how much food they eat or avoid certain types of food. This might be due to smell, texture or taste, or past negative experiences around food, such as choking or vomiting. ARFID isn’t usually linked to worries about weight and body image.

People with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) and intellectual disabilities are more likely to develop ARFID.

Bulimia (also known as bulimia nervosa)

People with bulimia will eat lots at once (binge-eat) and then get rid of the food from their body (purge). They may purge by vomiting or laxative use, for example. Bulimia is linked to worries about weight and body image.

Anorexia (also known as anorexia nervosa)

Anorexia is when someone restricts the amount they eat or drink for fear of gaining weight. They may create rules around food, such as what, where, or when they can eat. People with anorexia may have a low body weight.

Binge eating disorder

People with binge eating disorder will eat lots at once (binge-eat). They may feel unable to stop themselves from eating.

As well as becoming uncomfortably full, they may experience feelings such as guilt and disgust. They may also have rules around food and restrict what they eat, which can lead to more binging.

Other specified feeding or eating disorder (OSFED)

If your child’s symptoms don’t match a specific disorder, they may be diagnosed with other specified feeding or eating disorder (OSFED). For example, they may have anorexia but remain at a healthy weight. This is called atypical anorexia. Or they may eat lots of food at night or after dinner if they have night eating syndrome.

Like all other eating disorders, these behaviours might result from a child wanting to feel more in control, or to cope with difficult thoughts and feelings.

How are eating disorders treated?

The first step towards treatment is talking to a GP. Your child’s physical health will be monitored, and the GP may refer them to a specialist for further assessment and treatment. Your child may be offered specialist services such as:

online self-help programmes
talking therapies, like cognitive behavioural therapy (CBT) or family therapy

You could also try finding a private therapist through the British Association for Counselling and Psychotherapy (BACP). Or use free services from charities such as Beat.

If your child is very unwell, they might need to be monitored in a hospital, as an outpatient or inpatient. The treatment could include:

talking therapies
medication
refeeding (gradually reintroducing food)
group work
managing physical health

Where can I get support?

There are lots of helpful organisations that provide support for children and young people with eating difficulties. For example, Beat, stem4, Young Minds, and Mind. Beat has an online Helpfinder where you can find support services near you. They also run a helpline and offer online support groups.

You can also contact your child’s school to see if they can get help from the school nurse or counsellor. They may be able to put adjustments in place at school to make your child more comfortable.

So, if you think your child may have an eating difficulty, don’t be afraid to ask for support. It’s available if you need it.

Looking for more support? Our Family Mental HealthLine connects you with mental health nurses for advice and guidance about your child's mental wellbeing.

Harriet Finlayson and Danielle Panton

Specialist Nurse Advisers – Mental Health, Bupa

More by this author

Co-author

Atiya Henry, Health Content Editor at Bupa UK

Sources Sources
- What is an eating problem? Mind. mind.org.uk, published January 2021
- Types of eating disorders. Mind. mind.org.uk, published January 2021
- Types of eating disorder. Beat. beateatingdisorders.org.uk, accessed April 2024
- A guide for young people – eating problems. Signs and symptoms of eating problems. Young Minds. youngminds.org.uk, accessed April 2024
- Parent Toolkit. National Eating Disorders Association (NEDA). nationaleatingdisorders.org, accessed April 2024
- Avoidant/restrictive food intake disorder (ARFID). Royal College of Psychiatrists. rcpsych.ac.uk, published December 2022
- What is ARFID? ARFID Awareness UK. arfidawarenessuk.org, accessed April 2024
- Bulimia nervosa. Summary. BMJ best practice. bestpractice.bmj.com, last reviewed March 2024
- Anorexia nervosa. Summary. BMJ best practice. bestpractice.bmj.com, last reviewed March 2024
- Anorexia nervosa. Beat. beateatingdisorders.org.uk, accessed April 2024
- Binge eating disorder. Beat. beateatingdisorders.org.uk, accessed April 2024
- OSFED. Beat. beateatingdisorders.org.uk, accessed April 2024
- Eating disorders: recognition and treatment. NICE guideline [NG69]. nice.org.uk, last updated December 2020
- Treatment and support for eating disorders. Mind. mind.org.uk, published January 2021

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Children’s eating disorders

Transcript

Who are you?

What is an eating disorder?

Can children get eating disorders?

Are eating disorders more common in girls than boys?

What are the most common eating disorders in children?

Are eating disorders associated with any other conditions?

What is the difference between 'normal' behaviours like picky eating and an eating disorder?

My child's eating habits have changed, could it just be a phase?

How can I encourage my children to have a healthy attitude towards food, emotions and body image?

How important is language in relation to eating disorders with children?

My child is at a higher weight, should I be concerned?

My child has an eating disorder - how should I approach mealtimes?

Do I need to tell my child's school if I am worried about their eating?

My child's weight is healthy, but could they still have an eating disorder?

My child cannot eat certain foods due to an allergy - could this trigger an eating disorder?

What role does anxiety play in eating disorders?

What could the impacts of an eating disorder have on my child's growth and development?

Can an eating disorder cause other health problems in the future?

I think my child has an eating disorder - how do I get professional help?

My child tells me I have nothing to worry about, should I trust them?

I'm struggling as a parent, is that okay?

How can I start a conversation with my child about their eating habits?

What role has social media played on eating disorders within children?

How can I protect my child from the potential impact of social media?

Has social media led to an increase in children with eating disorders?

How can I better understand my child's eating behaviours?

My child has an eating disorder - is there anything I should avoid saying or doing?

My child's eating disorder is affecting the rest of my family, what can I do?

What is 'anorexia'?

What is the difference between restrictive anorexia and binging and purging anorexia?

What are the signs and symptoms of anorexia in children?

What causes anorexia?

How common is anorexia in children?

How can I tell the difference between a small appetite and anorexia?

How is anorexia diagnosed?

What are the treatments for anorexia in children?

What support can parents offer to children who are experiencing anorexia?

What is bulimia?

What are the signs and symptoms of bulimia in children?

What causes bulimia?

How common is bulimia in children?

My child has a big appetite or tends to overindulge, could they have bulimia?

How is bulimia diagnosed?

What are the treatments for bulimia in children?

What do you do if the first treatment you have tried doesn't work?

What support can parents offer to children who are experiencing bulimia?

What is binge eating disorder?

What are the signs and symptoms of binge eating disorder in children?

What's the difference between binge eating disorder and bulimia?

What causes binge eating disorder?

How common is binge eating disorder?

How can I tell the difference between a big appetite and binge eating disorder?

How is binge eating disorder diagnosed in children?

What are the treatments for binge eating disorder in children?

What support can parents offer to children who are experiencing binge eating disorder?

What is OSFED?

What is ARFID?

What are the signs and symptoms of ARFID in children?

How can I tell the difference between picky eating and ARFID?

Where can I go to get treatment for ARFID in children?

What's the difference between ARFID and anorexia or bulimia?

How can I tell if my child has an eating difficulty?

What’s an eating difficulty?

What’s an eating disorder?

What are the signs of an eating difficulty?

What are the types of eating disorder?

Avoidant restrictive food intake disorder (ARFID)

Bulimia (also known as bulimia nervosa)

Anorexia (also known as anorexia nervosa)

Binge eating disorder

Other specified feeding or eating disorder (OSFED)

How are eating disorders treated?

Where can I get support?

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