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The Child with Eating Problems - Restricted Eating

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Eating, the consumption of nutrition, is necessary for human life. Healthy infants are born with the ability to take in liquid nutrition in the form of breast milk or breast milk substitutes. Ideally, as children grow and develop, so do their eating skills. They move from liquid foods to soft foods, until they are finally able to eat a wide range of liquid and solid foods in the quantity and variety that sustain a healthy body. As with all developmental processes, there may be bumps along the road that work themselves out with time, and there may be problems that do not get resolved and develop into disorders or developmental delays. It is important to remember that one cannot tell simply by appearance how well a child is eating. Some children with above or below average weight, may be normal eaters who are naturally healthier at that weight. On the other hand, some children who fall into a normal weight range may have very disturbed or life-threatening patterns of eating.
 
This chapter focuses on disturbances in behaviour related to eating. These disturbances may affect health, growth and/or development, but not necessarily appearance. Some of the behaviours may be observed at school, while others may be more likely to occur in the home. Regardless, the goal is to understand what is happening with the child. The behaviours discussed will include: 
  • Refusal to eat
  • Not eating or eating too little
  • Restricted eating (using diet products, diuretics, over-use of diet caffeinated drinks)
  • Pursuit of thinness
  • Fear of gaining weight or becoming fat (fear of fat in specific body parts such as stomach and thighs)
  • Thin but thinks she or he is overweight
  • Vomiting after eating (other purging: using laxatives or substances to induce vomiting)
  • Excessive involvement in exercise to lose weight
  • Dieting, losing weight, thin, too thin.
 
Introduction
  • We all eat to survive. Babies are born with the ability to suck, and to sense when they are hungry and when they are full, but their ability to eat well develops over time, just like walking and talking. They learn about eating from their families, their school, and social environment. Like all other developmental processes, there are often detours along the way, but, with a stable and supportive eating environment, most children find their way.
  • Most children know when they are hungry and when they are full. They know what they like and what they do not like. Their opinions should be respected whenever possible. 
  • At different developmental stages, eating habits may change. Each child moves through the developmental stages at his or her own pace, and at every stage, genetics, biology, psychology and environment can affect food preferences, the cues about being hungry or full, and responses to food restriction and over eating. Depending on the readiness to move on to the next stage, a child may be a great eater at some stages and a difficult or picky eater at others. 
  • Readiness depends on a child’s physical ability to eat in new ways, such as the ability to chew, or the fine motor control to manipulate eating utensils. It is also affected by encouragement in the child’s environment, as well as personality and biology. Difficult or traumatic life events can stall the process or even result in going backward. 
  • Most people fall into an average range for weight, but some will naturally fall outside either end of the average range, to various degrees. For these people, being outside the average range may be perfectly healthy if they are maintaining a healthy lifestyle. Some people are genetically destined to be above average weight. 
  • In recent years there has been a growing concern about increasing numbers of children who are above average weight, and the possible health implications for these children. Research on this trend is ongoing.
  • There is no way to tell, just by looking at a child, whether that particular individual maintains a healthy lifestyle. It is important not to make assumptions about individuals by relying on studies of whole populations.
  • Research has not yet discovered why children are getting heavier or how to make a heavier child weigh less in the long term, although there are many compelling theories and interventions. What we do know is how to help all children achieve good health, independent of weight. This is accomplished the same way for all children who do not have an ongoing medical condition.
  • Health is achieved through regular, daily, moderate to strenuous activity, and moderate eating from all food groups. In order to achieve a healthy lifestyle that includes healthy eating and activity, the adults in the child’s world must build an environment that allows for a healthy lifestyle for the child. This is an adult’s responsibility and not the child’s. 
  • For children, physical activity occurs through play. This means that all children, in order to be healthy, need: 
    • Access to a safe environment that is large enough to allow for physical play
    • The opportunity to engage in organized games or sports appropriate to their developmental stage
    • The opportunity to engage in unorganized free play appropriate to their developmental stage
  • To allow play to occur, there must be:
o        Safety
o        Space
o        At times, equipment or appropriate environmental conditions such as a park, playground, gym, pond, pool, countryside, or yard. The equipment may be a ball, a doll, a rock, a swing set, or even a child’s imagination. A concrete lot where it is dangerous to be outside is not useful to a child. 
 
Food for children needs to be nourishing, varied and adequate in quantity. There is no such thing as a bad food. All foods when eaten in moderation are potentially healthy, assuming they do not contain artificial or natural substances that are harmful to humans (for example, some pesticides or possibly trans fats). This means that french fries or candy are acceptable, as long as they are not the main source of nutrition. Children need to have fruits, vegetables, grains, protein, and dairy products in their diet, but they can also enjoy and benefit from chocolate. The 2007 Canada Food Guide is a good guide for a healthy diet and includes all types of food. The Guide is available at

http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/order-commander/index-eng.php
 
There is no conclusive evidence that education programs on healthy lifestyle choices designed for children and adolescents actually work. Because it is primarily parents or guardians who make decisions about providing and preparing foods, one may educate a child about how to construct a healthy diet, but it is problematic to assume that they will follow through. In addition, a child cannot go out and play if there is nowhere safe to play; they need parents or guardians to provide the time, location and equipment for physical activity. Research suggests that changes in the child’s environment are more effective than education in shaping eating and exercise patterns, and that educational programs need to be supported by environmental changes in order to achieve long-term results. 

Under eating, over eating, disrupted eating, unusual eating patterns and unhealthy or extreme weight control methods are all related behaviours. They often have similar underlying causes and similar treatments. It is useful to see all of these behaviours as dysregulation of eating. The same trigger, such as bullying or sexual abuse, may result in under eating in one child, overeating in another, and may not affect eating at all in a third child. Many of the recommendations in this chapter are the same for the under eater, the over eater, the below average weight and the above average weight child. How a child responds to any change, whether it is biological, environmental, or part of normal development, can best be seen as a “collision of events” that make that child an individual who is special and unique.

Many of the behaviours related to eating that concern parents do not indicate a mental health problem. Most commonly, these behaviours are part of the developmental process of eating and will sort themselves out with time and clear expectations.

All of the signs of problems related to eating described in this resource can be normal and expected at certain ages and stages, or in mild degrees. However, what may be a normal and understandable problem related to eating at one stage may not be appropriate at another. The material that follows provides examples related to early and middle childhood, young adolescence, and the adolescent years.
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The child may:
  • Be a picky eater, only eating certain foods that are prepared a certain way
  • Refuse to try new foods, insisting that he or she does not like the food offered
  • Be still learning now to manage table manners and may eat things with his or her hands
  • Be still developing skills at eating and may take a long time to complete meals
  • Eat small amounts, since growth is slower than that of babies and less food may be needed
  • Show fluctuations in appetite from day to day. Some days the young child may eat a large amount while on other days the child may eat only small amounts of food
  • Be anywhere on the weight spectrum, since normal weight is variable at this age; some children may be quite thin and others quite chubby. Weight at this age does not predict adult weight and may change quite dramatically as the child grows.
  • Vomit easily when very anxious, sick, or affected by the motion of a car or bus
  • Use the word “fat” as an insult. At this stage children already know that “fat” means something bad in our culture (at times heard from family or caregivers), although they may not actually relate it to a particular size or shape
  • Occasionally put inedible objects in his or her mouth
  • Suck thumb when nervous or frightened
  • Bite or pick nails occasionally
  • Pull on own hair occasionally; may eat hair or place it in his or her mouth
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The child may:
  • Express unhappiness with appearance or weight. This may be the focus of bullying that leaves the child feeling bad about him or herself. Young children may not be able to distinguish between “teasing” and bullying. What may be intended as playful may in fact be hurtful and taken very seriously by the child. Children may also be bullied by older school children or siblings.
  • Not want to eat in front of other children. May have been bullied about eating habits.
  • Refuse to go on play dates with friends
  • Refuse to use utensils of any kind
  • Complain of abdominal pain regularly after eating
  • Regularly refuse to eat anything at some meals, but will eat some food during some of the time every day
  • Limit eating to only one or two items and will not vary
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Some kinds of behaviour strongly indicate a mental health problem when they interfere to a significant extent with a child’s functioning at home, in school, with peers, or in other normal activities.
To address these kinds of behaviours you will need to refer to a mental health specialist.
The child:
  • Is bullied about weight, shape or eating habits
  • Does not eat enough on a regular basis, and there is a noticeable weight loss
  • Either loses weight or fails to gain weight; children at this age should be gaining weight as they are growing
  • Does not grow any taller over the course of a school year. The child may start out as average in height but becomes one of the smallest as other children keep growing.
  • Stops eating or drinking
  • Loses a lot of weight and looks frail or weak

Children with these last two signs (in italics) should be seen by a pediatrician or family physician as soon as possible. The child may have to go to the local emergency department.
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The child may:
  • Still be a picky eater; this slowly improves with age
  • Prefer to have the same foods every day, sticking to what is familiar
  • Prefer to bring the same lunch foods every day, sticking with what is familiar
  • Start to talk about being worried about getting fat and even plan to go on a diet (girls in particular); however they will abandon the diet when hungry or when a favourite food, like french fries, is served.
  • Experiment with amounts of food and, when he or she has access to a particular food (like cake) that is usually only available in limited quantities, may indulge in unusually large amounts. Children are still learning that sometimes you can have too much of a good thing.
  • Be reluctant to try new foods. However, children do become more open to new foods as they grow older, often due to peer influence.
  • Still be working on perfecting his or her table manners and may still be a slow or messy eater
  • Thin out during middle childhood and then plump up at the end of childhood, just before early adolescence. Their bodies are preparing for the impending growth spurt. This is more common in boys but also happens for girls.
  • Be more easily shamed by and less confident in his or her body than in earlier childhood. There is more concern with looking and dressing like the peer group and wanting to fit in.
  • Have a clearer understanding that fat is not good in our culture; children may be worried they are fat, but it does not stop them from participating in activities and enjoying themselves
  • Be worried about physical performance in gym or sports. Children are aware of who is good at sports and who is less coordinated. This may affect how physically active they are.
  • Vomit easily when very anxious or when affected by the motion of a car or bus
  • Feel uncomfortable and try to hide an early start to puberty by doing things such as avoiding changing in front of others or wearing baggy clothing. They may become the focus of teasing. This may be more pronounced in girls.

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Within the range of behaviours parents see at home, it is sometimes not clear whether or not a behaviour needs to be considered a mental health problem. 
 
The child may:
  • Express unhappiness with appearance or weight; this may be the result of bullying or teasing that leaves the child feeling bad about him or herself
  •  Express regularly that he or she is worried about being fat or having any fat on the body
  •  State regularly that he or she needs to lose weight
  • Be over focused on eating, eating patterns, or being healthy
  •  Weigh self regularly
  • Be fascinated with television programs about modelling and weight loss
  • Be fascinated and look up internet information on weight loss 
  • Complain of abdominal pain regularly after eating
  • Like being small and not want to get any bigger in size
  • Not want to eat in front of others. May have been bullied about eating habits. Cultural or ethnic food differences may have been a focus of teasing.
  • Refuse to participate in gym class
  • Refuse to go on play dates with friends 
  • Actively maintain a diet and not eat any foods that most children would enjoy because it is a “bad” food and has too many calories, or is “unhealthy.” Some children may not like one or two things that are commonly enjoyed but usually will like some typical items that are high in sugar or fat, such as ice cream, french fries, candy, chocolate, chips. 
  • Limit eating to only one or two items and with no variations
  • Restrict eating by eating smaller amounts than is usual for this age or by skipping meals regularly
  • Cut out important food staples from the diet such as carbohydrates, all protein, all sugars or all fats 
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Some kinds of behaviour strongly indicate a mental health problem when they interfere to a significant extent with a child’s functioning at home, in school, with peers, or in other normal activities. 
 
To address these kinds of behaviours, you will need to refer to a mental health specialist.
 
The child:
  • Abuses physical exercise for weight loss at the expense of engagement in key normal activities. For example, the child is so determined to exercise to lose weight that he or she excuses him or herself to go to bedroom or bathroom in order to exercise. May take the stairs at home more often than is needed.
  • Is very critical of his or herown body weight and shape. Body dissatisfaction is central to the child’s poor self-esteem and negative mood.
  • Covers body in many layers to cover extreme weight loss, or to address extreme body dissatisfaction in a way that stands out among peers. May have trouble selecting what to wear each day; nothing looks good enough.
  • Is being bullied about weight, shape, or eating behaviours. Such bullying may also go along with harassment related to gender, sexuality, racial or ethno-cultural group membership. When the body is the target of the harassment, bullying, or abuse, children may engage in potentially dangerous behaviours, such as self-harm. 
  • Spends inordinate amount of time watching television shows about weight loss or modelling, or be on the internet looking up information on such topics 
  • Is always hungry and only stops eating when there is no food left. This happens at all eating opportunities. 
  • Does not eat enough on a regular basis (e.g. always has an excuse for missing supper), and there is noticeable weight loss relative to height
  • Either loses weight or fails to gain weight. Children at this age should be gaining weight as they are growing.
  • Shows no growth in height over the course of the school year. The child may start out as average in height, but becomes one of the smallest as other children keep growing. 
  • Displays thick but downy hair on cheeks, or hair on arms; hair is becoming noticeably thicker (this can be caused by starvation and significant weight loss)
  • Has significant hair loss; hair falling out in clumps
  • Consistently complains of being cold when the temperature is warm and no one else feels cold
  • Has low energy, or poor concentration
  • Has large fluctuations in mood, or becomes highly anxious or compulsive in behaviour
 
Behaviours of even more concern include:
  • Stops eating or drinking
  • Loses a lot of weight and looks frail or weak
  • The child faints
  • Complains about feeling light headed or dizzy
 
Children with the above behaviours in italics should be seen by a pediatrician or family physician as soon as possible. The child may have to go to the local emergency department. 
 
There are two common patterns in children with these signs:
  • One pattern involves children who is are worriers or a little sad, who also complain about mild aches and pains and who do not feel like eating and loses weight. These children do not really want to lose weight, or do not understand why they are losing weight. When asked why they are not eating, they will say they have an upset stomach or butterflies in their stomach. They do not feel fat, and they want to gain weight. They are not pursuing thinness.
  • A second pattern involves children who are focused on their weight and shape, worried about being too fat or unhealthy, and losing weight, thought they may not look underweight. They may not be able to say why being thin is important, just that they feel better when they are losing weight. These children tend to be strict dieters, but in rare cases they may also vomit as a way of getting rid of calories.  Characteristics of such children may include:
o   Declining school marks and difficulty concentrating
o   Tendency for emotional responses
o   Obsessive thinking patterns (repeatedly focusing on certain thoughts)
o   Trying to be perfect, and focus on pleasing others
o   Development of fine, downyhair on face, back and arms (known as lanugo hair)
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The young adolescent may:
  • Quite likely be dieting at this age, particularly the girls, but dieting is moderate and there is no precipitous drop in weight. The girls still enjoy eating and the diets tend to be short lived and inconsistent.
  • Feel she is not thin enough and worry about being fat. She may become focused on what size clothing she fits into. These thoughts are mild in intensity and do not interfere with daily living, activities, or mood.
  • Experience a drop in self-esteem, depending on how much he or she likes the changes in their bodies, but the change is mild and does not interfere with choices of activities
  • Feel awkward and self-conscious if developing too soon or too late. For example, a girl may feel anxious if she thinks that her breasts are too large or if she has yet to develop. Likewise, a boy may feel anxious if he has not started to grow taller or to increase his muscle mass. 
 
In general:
  • Young adolescents may begin to gain weight as part of development towards adulthood. Body composition begins to change from that found in children. Boys increase in muscle mass and girls increase in body fat, needed for menstruation and fertility in adulthood. For girls, unlike boys, this may be difficult as the increase in body fat runs counter to current ideals of beauty.
  • There is a wide range of healthy weights and heights that children move through during this developmental period on the way to adulthood. Some teens are genetically destined to grow up to be tall, others to be short; some are genetically destined to be below average weight while others will be above average weight.
  • A boy may become focused on wanting to develop muscles and get taller. He may become self-conscious if he is small or skinny or later than others in starting puberty.
  • Young people experience an increase in nutritional requirements due to growth spurts. This is most noticeable in boys, who can eat a surprising amount of food at one sitting. This is normal consumption and not binge eating.
  • They may still be picky eaters. This may be more noticeable in some boys who are also unlikely to ever be adventurous eaters. Nonetheless, they are likely to expand their eating repertoire in early adulthood. 
  • They may start to focus on healthy eating; this may be more common among girls.
  • They may become vegetarian. Some may do so for political reasons, like concern for the environment or not wanting to kill animals.   This is not worrisome,as long as the adolescent is still eating a wide variety of foods. 
  • They may start to drop out of gym class. Often their reason is that theydo not feel they are skilled, or they want to focus on other academic or personal interests. 
  • They may make poor food choices and will often eat whatever is easily accessible, fast, and socially approved by peers. They will often choose fast food or junk foods. Young adolescents tend to be fearless and not concerned about health or longevity.
  • The young adolescent may still not have hit his or her growth spurt and may still be in the plumped-out stage.
  • They may be anywhere on the weight spectrum. Adolescents come in a range of weights, shapes and sizes. Some children are genetically destined to be heavier, while others will be lean. As long as the teen is eating a normal range of food and exercising moderately, they will be whatever size they are meant to be genetically.
  • Young adolescents may feel awkward in their bodies since body size and shape is changing, and sexuality becomes more of a focus. Interacting with peers is more complicated and requires lots of experimenting.   This experimenting may be with appearance, such as hair colour and length or piercings, or it may be with music choices, urge to try alcohol, or determining attraction to others of the same or opposite gender. 
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Within the range of behaviours parents see at home, it is sometimes not clear whether or not behaviour needs to be considered a mental health problem. 
 
The young adolescent may:
  • Express unhappiness with his or herappearance or weight; this may be the focus on bullying or teasing that leaves the teen feeling bad about him or herself. Unhappiness with one’sappearance or weight has a mild effect on activities or mood.
  • Refuse to participate in gym class or other sports due to body shape concerns
  • Express regularly that he or she is worried about being fat or having any fat on the body. A boy may express desire to be all muscle or be “cut” or have a “six-pack.”
  • State regularly that he or she needs to lose weight
  • State regularly that he or she is afraid of gaining weight or getting fat 
  • Weigh self regularly
  • Be fascinated with television programs about modelling and weight loss
  • Be fascinated and look up internet information on weight loss 
  • Wear baggy clothing that is out of keeping with the fashion of the peer group
  • Be over focused on eating, eating pattern, or being healthy
  • Like being small and not want to get any bigger in size (more common in girls)
  • Not want to eat in front of others. May have been bullied about eating habits; cultural or ethnic food differences may have been the focus of teasing. 
  • Exercise frequently during the day for long periods of time and consistently look for ways to be active, such as taking the long way to burn more calories 
  • Actively maintain a diet for long periods of time and not eat any foods that most teens would enjoy because it is a “bad” food, has too many calories, or is “unhealthy” 
  • Restrict eating by eating smaller amounts than is usual for his or her age or by skipping meals regularly, especially when more than one meal a day is skipped or the adolescent goes the whole day without eating anything
  • Cuts out important food staples from the diet such as all carbohydrates, all protein, all sugars or all fats
  • Replaces eating by drinking a large number of caffeinated drinks such as diet coke or black coffee
  • Is very physically active while not eating or drinking enough to compensate for the extra activity
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Some kinds of behaviour strongly indicate a mental health problem when they interfere to a significant extent with a child’s functioning at home, school, socially or in other normal activities. 
 
To address these kinds of behaviours you will need to refer to a mental health specialist.
 
The young adolescent:
  • Abuses physical exercise for weight loss at the expense of engagement in key normal activities. For example, the teen is so determined to exercise to lose weight that he or she excuses him or herself to go to the bedroom or bathroom in order to exercise. May take the stairs at home more often than is needed.
  • Is very critical of own body weight and shape. Body dissatisfaction is central to the teen’s poor self-esteem and negative mood.
  • Is being bullied about weight, shape, or eating behaviours. Such bullying may also co-occur with harassment related to gender, sexuality, racial or ethno-cultural group membership. When the body is the target of the harassment, bullying, or abuse, children may engage in potentially dangerous behaviours. These behaviours may include self-harm, food restriction or risk-taking behaviours such as substance abuse. They may engage in these behaviours either as a response to their emotional distress or they may try to do anything to fit in. 
  • Spends inordinate amount of time watching television shows about weight loss or modelling or both, or stays on the internet looking up information on such topics 
  • Does not eat enough on a regular basis (e.g. makes up excuses for not coming to supper), with a noticeable weight loss relative to height
  • Either loses weight or fails to gain weight; youngsters at this age should be gaining weight as they are growing 
  • Shows no growth in height over the course of a year. The adolescent may start out as average in height, but becomes one of the smallest as peers keep growing.
  • Displays thick but downy hair on cheeks, or hair on arms; hair is becoming noticeably thicker (this can be caused by starvation and significant weight loss)
  • Displays significant hair loss; hair falls out in clumps
  • Consistently complains of being cold when the temperature is warm and no one else feels cold
  • Displays large fluctuations in weight
  • Has low energy, or poor concentration
  • Has large fluctuations in mood, or becomes highly anxious or compulsive in behaviour
 
Signs of even more concern include:
  • Shows evidence of blood in vomit
  • Faints
  • Complains about feeling light headed or dizzy
  • Complains of chest pain or heart palpitations
Young teens with the above behaviours in italics should be seen by a pediatrician or family physician as soon as possible. The teen may have to go to the local emergency department. 
 
There are two common patterns in these young teens with problems related to eating.
  • One pattern involves young people who are focused on their weight and shape, and worried about being fat. While weight loss is present, these teens may not look underweight. They are often strict dieters, but may also vomit as a way of getting rid of calories. Characteristics of these teens include:
o   Low self-esteem
o   Socially isolated
o   Difficulty concentrating and declining school grades
o   Tendency for emotional responses
o   Obsessive thinking patterns
o   Development of fine, downy hair on face, back and arms known as lanugo hair.
o   Trying to be perfect and focused on pleasing others. 
  • A second pattern involves young people who are impulsive and risk-taking, may be dependent on alcohol or other substances, and may engage in self-harm behaviour. These teens are not socially isolated. They engage in a binge-purge cycle, and may be underweight, normal weight, or above average weight. Purging may be in the form of vomiting, using laxatives, or through over exercising and dieting.
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The adolescent may:
  • Quite likely be dieting at this age, especially the girls, but dieting may be moderate and there is no precipitous drop in weight. The girls still enjoy eating and the diets tend to be short lived and inconsistent.
  • Feel they are not thin enough and worry about being fat. They may become focused on what size clothing is fitting and what brands are most popular. These thoughts are mild in intensity and do not interfere with daily living, activities, or mood.
  • Experience a drop in self-esteem, depending on how much they like the changes in their bodies, but the change is mild and does not interfere with choices of activities.
  • Feel awkward and self-conscious if she thinks her breasts are too large. 
  • Feel awkward and self-conscious if he has not started to grow taller or to start to increase his muscle mass. 
 
In general...
  • Adolescents continue to gain weight as part of development towards adulthood. Body composition continues to change. Boys increase in muscle mass and girls increase in body fat, needed for menstruation and fertility in adulthood. For girls, unlike boys, this may be difficult as the increase in body fat runs counter to current cultural ideals of beauty.
  • There is a wide range of healthy weights and heights that children move through during this developmental trajectory towards adulthood. Some teens are genetically destined to grow up to be tall, others short, some below average weight, others above average weight.
  • A boy may become focused on wanting to develop muscles and get taller. He may become self-conscious if he is smaller or less muscular than his peers, depending on when puberty starts.
  • Young people experience an increase in nutritional requirements due to ongoing growth spurts. This is most noticeable in boys, who can eat a surprising amount of food at one sitting. This is not unusual. This is not considered binge eating, since the adolescent is choosing to eat this amount of food and could stop when he wants to stop. 
  • Adolescents may still be picky eaters. This may be more noticeable in some boys who are also unlikely to ever be adventurous eaters. Nonetheless, they are likely to expand their eating repertoire in this stage of adolescence.   
  • They may start to focus on healthy eating; this may be more common among girls.
  • They may become vegetarian. Some may do so for political reasons, like concern for the environment or not wanting to kill animals.   This is not worrisome, as long as the adolescent is still eating a wide variety of foods. 
  • They may no longer want to take physical education at high schoolOften their reason is that they do not feel they are skilled, or they want to focus on other academic or personal interests. 
  • They may make poor food choices and will often eat whatever is easily accessible, fast, and socially approved by peers. They will often choose “fast” or “junk” foods. Adolescents tend to be fearless and not concerned about health or longevity.
  • The adolescent may be anywhere on the weight spectrum. Adolescents come in a range of weights, shapes and sizes. Some individuals are genetically destined to be heavier, while others will be lean. As long as the teen is eating a normal range of food and engaging in moderate activity, they will be whatever size they are destined to be genetically.
  • Sexuality becomes more of a focus as bodies are changing. Interacting with peers is more complicated and requires lots of experimenting. This experimenting may be with appearance, such as body piercings, tattoos, hair length and colour, or it may be with music choices, use of alcohol and substances, or determining attraction to others of the same or opposite gender. 
  • Young people are becoming more independent in later adolescence. They start to have part-time jobs; they may or may not be at home for meal times; they are gaining more control over their eating and taking more responsibility for it themselves, such as when they go out to eat. 
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Within the general range of behaviours parents may see, it is sometimes not clear whether or not the behaviour needs to be considered as a mental health problem. 
 
The adolescent may:
 
  • Express unhappiness with his or her appearance or weight; this may be the focus of bullying or teasing that leaves the teen feeling bad about him or herself. Unhappiness with one’sappearance or weight has a mild effect on activities or mood.
  • Refuse to participate in gym class due to body shape concerns. You may hear about initial testing of individual students that is done in front of the rest of the class and how stressful this was for them. You may hear that sharing a gymnasium space or mixed gender classes was stressful. 
  • Regularly express worries about being fat or having any fat on the body. A boy may express desire to be all muscle or be “cut.” Boys and girls talk about having a “six pack” and start to do more comparing with others. 
  • State regularly that he or she needs to lose weight
  • Spend a lot of time looking in mirrors or avoid looking in mirrors for fear of what they may see in terms of real or perceived weight gain
  • Spend a lot of time gauging body size and changes in weight
  • State regularly that he or she is afraid of becoming fat
  • Wear baggy clothing that is out of keeping with the fashion of the peer group
  • Wear inadequate amount of clothing in order to be cold so that shivering is induced; this is thought to result in burning calories and weight loss 
  • Be over focused on eating, eating pattern, or being healthy
  • Like being small and does not want to get any bigger in size; this is more common in girls
  • May not want to eat in front of other children; may have been bullied about eating habits or teased about cultural or ethnic food differences
  • Exercise frequently during the day for long periods of time and consistently look for ways to be active, such as take the long way to burn more calories, or walk the dog more often than is needed 
  • Actively maintain a diet for long periods of time and will not eat any foods that most teens would enjoy because it is perceived as a “bad” food,” has too many calories or is “unhealthy”
  • Restrict eating by eating smaller amounts of food than usual for this age or by skipping meals regularly, especially when more than one meal a day is skipped or the adolescent goes a whole day without eating anything
  • Cut out important food staples from the diet such as all carbohydrates, all protein, all sugars or all fats
  • Replace eating by drinking a large number of caffeinated drinks such as diet coke or black coffee
  • Be very physically active while not eating or drinking enough to make up for the extra activity

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Some kinds of behaviour strongly indicate a mental health problem when they interfere to a significant extent with a child’s functioning in school, socially, or in other normal pursuits.
To address these kinds of behaviours you will need to refer to a mental health specialist. 
 
The adolescent:
  • Abuses physical exercise for weight loss at the expense of engaging in key normal activities. For example, the adolescent may be so determined to exercise to lose weight that he or she excuses him or herself to go to the bedroom or bathroom in order to exercise. May take the stairs at home more often than is needed. 
  • Is very critical of own body weight and shape. Body dissatisfaction is central to the teen’s poor self-esteem and negative mood.
  • Covers body in many layers to cover extreme weight loss, or to address extreme body dissatisfaction, in a way that stands out among peers. 
  • Is being bullied about weight, shape, or eating behaviours. Such bullying may also co-occur with gender and sexual harassment, or harassment related to racial or ethno-cultural group membership. When the body is the target of harassment, bullying, or abuse, young people may engage in potentially dangerous behaviours. These behaviours may include self-harm, food restriction or risk taking behaviours such as substance abuse. They may engage in these behaviours either as a response to their emotional distress or they may try to do anything to fit in.
  • Does not eat enough on a regular basis (e.g. does not eat during an entire school day), with a noticeable weight loss relative to height
  • Either loses weight or fails to gain weight. Adolescents in this age group should still be gaining weight even though they have reached their maximum height, as indicated on growth charts. 
  • Displays thick but downy hair on cheeks, or hair on arms; hair is becoming noticeably thicker (this can be caused by starvation and significant weight loss)
  • Displays significant hair loss; hair falls out in clumps.
  • Consistently complains of being cold when the temperature is warm and no other family members feel cold
  • Displays large fluctuations in weight
  • Has low energy or poor concentration
  • Has large fluctuations in mood, or becomes highly anxious or compulsive in behaviour
  • Starts missing menstrual periods
 
Behaviours of even more concern include:
  • Shows evidence of blood in vomit
  • Complains of feeling light headed or dizzy
  • Faints
  • Complains of chest pain or heart palpitations
Adolescents with the above behaviours in italics should be seen by a pediatrician or family physician as soon as possible. They may need to go to the local emergency department.
 
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There are two common patterns in these adolescents with problems related to eating.
One involves adolescents who are focused on their weight and shape, and worried about being fat. While weight loss is present, these teens may not look underweight. They are often strict dieters, but may also vomit as a way of getting rid of calories. Characteristics of these adolescents may include:
  • Low self-esteem
  • Social isolation
  • Difficulty concentrating, and declining school marks
  • Tendency for emotional responding
  • Obsessive thinking patterns (repeatedly focusing on certain thoughts)
  • Development of fine, downy hair on face, back and arms known as lanugo hair
  • Perfectionistic thinking
  • Focus on pleasing others
A second common pattern involves those adolescents who are impulsive and risk-taking, may be dependent on alcohol or other substances, and may engage in self-harm behaviour. These teens are not socially isolated. They engage in a binge-purge cycle, and may be underweight, average weight, or above average weight. Purging may be in the form of vomiting, using laxatives, or through over-exercising and dieting.
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What may be behind the behaviours that represent problems with eating? The following discussion applies to all age groups.
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  1. Girls are much more likely to struggle with eating disorders than boys. In children under the age of twelve the ratio of girls to boys is about 7: 1. By late adolescence the increases to about 10:1.
  2. Girls are also more likely to have a poor body image.
  3. Boys and girls are equally likely to binge eat or to be above average weight.
  4. Height and weight are strongly genetic (related to heredity). On average, children look like their biological parents; tall kids usually have a tall parent and above average weight kids often have an above average weight parent. When heavier children are exposed to teasing or critical comments about their weight, they are more likely to have a negative body image and disordered eating patterns.
  5. The time when puberty begins is strongly influenced by genetic factors. When girls mature early, they are more likely to weigh more than their peers, to be exposed to teasing, and to have a negative body image and disordered eating patterns.
  6. Temperament and certain personality traits are also genetic. Temperament is a way to describe a child’s disposition or personality. It is also thought of as a way of responding to the world. Children who have certain personality traits such as trying to be perfect, avoid harm, and obsessive tendencies (focusing on something over and over) can be prone to developing clinical eating disorders. There is some research that suggests that a generally depressed mood may be related to the development of clinically significant bingeing and purging.

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Children may be more prone to develop eating disorders if they live in an environment where:
  1. There is an over focus on weight and shape
  2. Someone is always on a diet and talks about not living up to set goals
  3. The adults criticize themselves or others as being too fat
  4. It is okay to be teased (bullied) about your appearance or weight
  5. Foods are characterized as “good” or “bad” or “junk”
  6. Fathers criticize their wives or daughters about their weight or appearance
  7. A parent has an eating disorder
  8. Meal time becomes a source of stress or put downs
 
Children may be more prone to gain weight and to be heavier than otherwise expected if they live in an environment where:
  • There is no or little opportunity to be physically active
  • There is unlimited access to screen time (television, computer, video games, gaming devices etc.) and the child spends most of their time in front of the screen
  • Children are expected to ignore their internal cues of hunger and feeling full, eat past their point of fullness and finish what is on their plate
  • There is little access to fruits and vegetables
  • Adults model likes and dislikes of foods, with a focus on few choices and little variety
  • Adults prepare foods that are limited in choice and tend to be predominantly high in fat, high in sugar, and high in starches or simple carbohydrates, or both
  • Adults give food to children as a reward for good behaviour
  • Adults take away foods or favoured foods as a punishment for bad behaviour, e.g. sending a misbehaving child to bed without dinner
  • Adults model eating food as the only way to fulfill emotional needs, such as loneliness or anxiety
  • Parents give the message to their children that eating the foods in the amount given to them will please the parents
  • Adults give the message that children should eat, regardless of when they are actually hungry
  • Adults engage in bingeing or dieting behaviour or both
  • Adults often or always allow children to eat meals or snack in front of the television or computer
  • Family issues and changes are occurring, such as a new sibling, divorce, death or illness
 
Any major stress can trigger or influence the development of an eating disorder or a change in weight (either gain or loss) in children. These stresses can include:
  • Divorce, particularly if it is very conflictual
  • The illness or death of a parent, grandparent or sibling
  • Parental job loss, or a major financial stress in the family
  • High levels of parental conflict or the presence of spousal abuse
  • Child abuse, either physical, emotional or sexual
  • Moving to a new neighbourhood or new school, or frequent moves and many transitions
  • A parent with a substance use or abuse problem
  • The arrival of a new sibling or other family member such as a grandparent moving in
  • Being bullied or teased by a sibling or parent about weight or appearance
  • Being bullied or teased by a peer about weight or appearance 
  • Being teased or bullied in general, or isolated at school or in their peer group
It is important to remember that there may not be familial cause or trigger for an eating or weight problem. Most children with eating problems come from average families, and, in general, families DO NOT cause eating disorders. However, they are often the most important players in helping their children recover from an eating disorder.
 

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  • Children with visible disabilities may already feel uncomfortable in their bodies. As a result, they may try to at least meet cultural expectations for weight and shape. They may try to lose weight or be thin as a way of fitting in.
  • Some children may be worried about their health and misunderstand the messages about weight and health that abound in Western culture. Taken to an extreme, worries of gaining weight or eating food that is unhealthy can lead to a restricted eating pattern, resulting in significant weight loss and serious health consequences. Once an eating disorder has developed, the treatment is the same as with all children and requires a trained team of health care professionals. 
  • Children with some chronic illnesses are more at risk for suffering from an eating disorder. These illnesses tend to be ones where the illness or the treatment affects either eating or body weight. These illnesses include diabetes, cystic fibrosis, and inflammatory bowel disease.
  • Certain illnesses increase appetite or weight such as diseases of the thyroid. As well, certain medications that are used for a variety of illnesses can cause weight gain or appetite changes as side effects of the medication. A common example of this would be steroids such as prednisone used forasthma, inflammatory and autoimmune diseases.
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Sometimes feeling different from others can spark a desire to be thin as a way to fit in. These differences may be related to a variety of things such as culture, race, religion, height, sexuality, physical deformities, hair, eye colour, illnesses, family structure, level of wealth, personality differences, etc. Efforts to be thin in order to fit in with others can lead to extreme methods of weight control, significant weight loss, and possible health consequences. Once an eating disorder has developed, the treatment is the same as with all children and requires a trained team of health care professionals.

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  • Sometimes holiday feasts can trigger a worsening of eating disorder symptoms. Some children may binge on feast foods if they are plentiful, accessible, and favoured. This may then trigger a need to purge. Some children will avoid feast foods that are not what they would usually eat, and may be afraid that the food will make them fat.
  • Eating on holidays often means eating in a larger group with extended family. For children with eating or weight problems this can be anxiety provoking, particularly if they think that they are going to be noticed or watched. Depending on the child, this may trigger overeating, under eating or complete meal refusal. 
  • Fasts related to cultural or religious traditions or beliefs can also lead to either restriction or bingeing and purging. If a child who is prone to an eating disorder successfully completes a fast, he or she may well decide not to stop the fast, but to keep on going. On the other hand, a fasting child may become so hungry that he or she loses control of eating, and binges. In some cases, feelings of guilt or upset over the amount eating may then lead to a purge.
  • The Western culture is focused on thinness as an ideal of beauty. In some other cultures, being plump is more of an ideal. 
  • Children are strongly influenced by their peers. If their peer group is focused on shape and weight, this will affect how children view themselves, and may affect a child’s eating. For some, purging through vomiting can be a social behaviour done in groups.
  • Sometimes a child may not eat lunch because they do not have one. Children who come from poor families sometimes go hungry if there is not enough money to buy food. To avoid embarrassment, a child may pretend that they have a lunch but are not eating it because they do not want to.
  • Eating or not eating at the wrong times can be a way of sending a message to adults. Eating during a religious fast period or not eating at a holiday or festival where eating is part of the tradition can mean many things. It can be an expression of anger, rebellion, or sadness. It can also be a conscious rejection of the family’s religious practices. Each child will have a unique reason for eating or not eating at religiously inappropriate times. This should be explored on an individual basis.
  • Communication and a sense of love are sometimes seen to be related to eating patterns. Children can please adults by eating, and may be viewed as well behaved when doing so. Some cultures relate children’s size to health and/or wealth and ability of the family to provide for its members.
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  • Experience or witness of a traumatic or very stressful event such as abuse, war, serious accident, or hurricane can trigger an eating problem.
  • More commonly, having a parent who has been in a traumatic situation, particularly one where there was a lack of food or a risk of starvation, may lead to an eating problem in the child, even if the parent does not have an eating problem.
  • Children who have a history of abuse or an unstable environment are more likely to develop eating problems than those who do not. However, having an eating problem does not mean that a child has a history of abuse. 
  • Some children, whose family struggles with food or income security, may restrict their eating in an attempt to help their parents spend less money on food.
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How to create a home environment that minimizes children’s and adolescents’ problems with eating?
  • Have regular meals and snacks and do this as a family whenever possible. Be a good role model in eating a variety of foods. Encourage eating in moderation and that all foods are good. 
  • Enjoy eating and see it as nutrition and energy. Appreciate that eating also plays a role in socialization and in our ethno-cultural identity. 
  • Be a good role model for accepting all body sizes.
  • Send out the positive message “Healthy bodies come in a range of weights, shapes, and sizes.” There is not one “ideal” body size, shape or weight. 
  • Every body is a good body. We need to respect the bodies of others even when they are quite different from our own. 
  • Be aware of the messages you send about your body and the comments you make about other people’s bodies, both through your words and behaviours. Children and adolescents pick up on negative attitudes very quickly. 
  • Help your children focus on their abilities rather than their appearance. Remind your children and adolescents of all the things they are besides a body (e.g. good musician, friendly, caring, funny etc.).
  • Discourage children and adolescents from weighing themselves; the scale focuses on numbers and not on a range of healthy weights.
  • Throw out the scale at your home.
  • Assure your children that they are loved and respected as they are. They should be encouraged to develop personal attributes and skills that make them feel good about themselves.
  • Eating is a shared responsibility between parents and adolescents. Adolescents should be allowed to enjoy the pleasures of eating foods of all kinds and to trust their own bodies in making choices. 
  • Physical activity should be encouraged by participating in activities with adolescents, making sure it is enjoyable and accessible, and by providing the opportunities to learn the needed skills.
  • Watch television with your child or adolescent so that you can model critical thinking. Promote critical thinking about the media, by raising questions, such as:
    •  What did you feel about a television show, a movie, advertisement? (encourage critical thinking)
    • What were the messages in that media clip?   About males and females? Beauty?   Health? Food?
    • Who do you think creates these messages? Would you tell the same story if you created the media clip?
    • How technology can change images.
  • Reduce media exposure. Keep the television out of your children’s/adolescents’ rooms. Keep the television off at meal times. Monitor your children’s or adolescents’ use of computer and internet sites. 
  • Do not draw attention to your own diet habits. If you are on a diet for any reason, keep that private. Be a positive role model through your own comfort with a range of weights (beyond the cultural ideal of “thinness”) and with eating from a broad range of foods. Do not put yourself or others down in regard to weight or appearance. Even complaining to a friend or family member about gaining weight over a holiday break, or commenting that someone “looks better” because he or she lost weight, can be overheard and can affect how your children or adolescents view their own weight gain.
  • Sexual harassment has been linked to negative body image, low self-esteem and other negative consequences. Be on the lookout for harassment related to weight, gender and race. Have a zero-tolerance policy at home for any teasing about weight or shape. 
  • Harassment and teasing related to weight, shape, appearance, gender, race, social class, health and disability, or other characteristics, should be addressed immediately. Regarding gender, common labels that make girls uncomfortable in their bodies include “slut” (re: sexuality), “bitch” (re: assertiveness), or a combination of gender and weight harassment in labels such as “fat cow.”
  • Timing of puberty can become a focus of teasing as well.   Educate your children about changes in their bodies and be respectful at all times.  
  • Bullying of any kind should be stopped and dealt with immediately.
  • Be aware of your own biases, inevitably learned from the wider culture, about weight, shape, eating and appearance, and aim to work through these biases, similar to biases about race or gender. This can prevent communicating negative messages to your family, such as “fat is bad.” 
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  • It is important to develop a predictable, orderly and non-coercive environment for eating.
  • Meals and snacks should be scheduled at regular times and should be long enough to all the child to finish eating.
  • Children should not be involved in any other activity while eating, apart from talking with family members at the table.
  • Children should be sitting comfortably when they eat.
  • Children should be offered a wide variety of food and allowed to eat how much they want. Children who appear to be overeating may do this a few times but will listen to their own hunger and fullness cues if supported in doing so. 
  • Young children may refuse a new food when it is first presented to them. It is important to keep offering them this food in a non-critical or non-coercive way. Children may need to be offered a new food ten to fifteen times before they may accept it.
  • Do not assume that a child does not like a food if he or she refused it once or twice.
  • It is important to keep meal times non stressful and fun.
  • Children should not be coerced or shamed into eating or stopping eating. 
  • Allow for time to eat and remember that it may take a long time for young children to complete their meals. If they have stopped eating and are just playing with their food, it is reasonable to remove the food and move on to the next activity.
  • Children at this age can tolerate waiting until the next meal or snack time, even if they are hungry. If they did not eat lunch, they will likely be hungry for afternoon snack or dinner. Just let nature take its course.
  • Be clear that using the word fat as a derogatory term is not acceptable anywhere. Explain to children that people come in all shapes and sizes and everyone should be treated well and with respect. Bullying of any kind should be dealt with immediately.
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  • If a child refuses to use utensils of any kind, work with him or her on how to hold the utensils. Consider setting up a behavioural chart where the child would get a star or checkmark for every use of utensils, with a modest reward at the end of the day or week.
  • If there are complaints of abdominal pain regularly after eating, go see your pediatrician or family physician.
  • If a child expresses unhappiness with appearance of weight, or does not want to eat with the family or other children, think about bullying. Discourage bullying of any kind in your home or among playmates. 
  • If a child regularly refuses to eat anything at some meals, but will eat some food some of the time every day, keep offering them food. If this is a new behaviour or any reasoning for it is unclear, see your family physician.
  • If a child limits eating to the same one or two items, keep offering new foods. Remain optimistic and non-coercive. Allow the child to refuse.
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Some kinds of behaviour strongly indicate a mental health problem when they interfere to a significant extent with a child’s functioning at home, school, socially or in other normal activities. To address these kinds of behaviours you will need to refer to a mental health specialist. 
 
The child:
  • If there are complaints of abdominal pain regularly after eating, go see your pediatrician or family physician.
  • If a child is refusing to eat; choosing to eat only one or two items of food, and is noticeably losing weight or failing to gain weight at this time in their life, go see your physician.
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  • It is important to provide an appropriate space and regular time for eating at home. Eat with your child whenever possible. 
  • Diets should be discouraged in a non-judgmental way and healthy moderate eating of a wide variety of foods should be encouraged and modelled
  • It is very important for parents to model normal eating. Children should not be told that their parent is on a diet or skipping meals to lose weight.
  • Parents should not put down their own bodies or other people’s bodies in front of children. Even speaking about weight gain in oneself or others can have a negative impact.
  • Allow experimentation with amounts of food. Remember that children are still learning that sometimes you can have too much of a good thing. They will also learn that missing a meal can leave you quite hungry.
  • Support children who are still working on perfecting their table manners and discourage any shaming comments from others.
  • Be very careful with wording related to shape or weight. Remember to model acceptance of all body shapes. Similarly, model acceptance of changing bodies.
  • Remind children in a non-shaming way that their bodies are changing and that this is a normal part of growth.
  • On family trips, be prepared with plastic bags for the child who may vomit easily in response to the motion of the vehicle.
  • Remember that children who are the first among their peers to start puberty may feel uncomfortable and try to hide it, by doing such things as avoiding changing in front of friends or wearing baggy clothing. Allow them their dignity. 
  • Discourage teasing of any kind, as this can turn into harassment and bullying.
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Within the range of behaviours you see, it is sometimes not clear whether or not the behaviour needs to be considered a mental health problem.
 
The child may:
  • Express unhappiness with appearance or weight, or not want to eat with others. If this is happening, ask your child about bullying.
  • Refuse to participate in gym class or other sports. Speak to your child about why, and then try to help him or her problem-solve a way to rejoin. Remember to do this privately and supportively. 
  • Complain of abdominal pain regularly after eating. Please take your child to the pediatrician or family physician. 
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  • If the child is skipping meals regularly, has cut out important food staples from the diet, limits eating to only one or two items and will not vary, it is important to speak to the child in a supportive and non-judgmental way about what is going on. Let him or her know what you have observed and that you are worried about the behaviour you see. These behaviours can lead to serious consequences and need to be stopped. Try doing some problem-solving together, but take your child to see the family physician.
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  • It is important to provide an appropriate space and regular time to eat at home. Try to eat with your children whenever possible. 
  • Diets should be discouraged in a non-judgmental way and healthy moderate eating from a wide variety of foods should be encouraged and modelled.
  • It is very important for parents to model normal eating. Teens should not be told that their parent is on a diet or is skipping meals to lose weight. Ideally, parents are discouraged from these behaviours.
  • Parents should not put down their bodies or other people’s bodies in front of their children. Even speaking about weight gain in oneself or others can have a negative impact. 
  • Talk about the media and use critical thinking when watching television together. 
  • Tolerate food choices that adolescents make, but try to have an eating environment where healthy options are more common than unhealthy food options. Consider having a limit on amount of pop per week, if any. 
  • If your teen is placing inedible objects in his or her mouth, ask them to remove the object. 
  • Try to help your teen come up with a plan to avoid placing things in the mouth. Use distraction; keep their hands and mouths busy with alternative activities.
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Within the general range of behaviours you may see, it is sometimes not clear whether or not the behaviour needs to be considered a mental health problem.
 
The young adolescent may:
  • Complain of abdominal pain regularly after eating. 
    • Try resting or relaxing breathing. Take your teen to the pediatrician or family physician. 
  • Express unhappiness with appearance or weight, or not want to eat with others.
    • Ask them about bullying.
  • Refuse to participate in gym class or join other sports teams.
    • Speak to your teen to see what is going on and try to help problem solve a way to get back into these activities. Remember to do so privately and in a supportive manner.
  • Skip meals regularly, cut out important food staples from the diet, limit eating to only one or two items and will not vary, use laxatives for weight loss, or use diet pills or diuretics.
    •  It is important to speak with him or her in a supportive and non-judgmental way. Let your teen know what you have observed and that you are worried about these behaviours. Do some problem solving together to make sure that they get back on track with eating regular meals and snacks. 
  • Be very physically active while not eating or drinking enough to compensate for the extra activity.
    • Develop a plan with the teen that prevents participation in physical activity until there is adequate intake and hydration. Use incentives to work back to including physical activity in the teen’s day.
    • Explain the reasons for this plan and help problem solve ways to balance intake with energy output.

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  • If the teen is struggling with regular and adequate intake, along with extra activity
o        See a mental health provider and physician in order to monitor physical health as well as to develop a treatment plan
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  • It is important to provide an appropriate space and regular time for eating at home. Try to eat with your family as often as possible
  • Diets should be discouraged in a non-judgmental way and healthy moderate eating from a wide variety of foods should be encouraged and modelled.
  • It is very important for parents to model normal eating. Adolescents should not be told that their parent is on a diet or skipping meals in order to lose weight.
  • Parents should not put down their own bodies or other people’s bodies in front of their children. Even speaking about their own weight gain or that of a friend can have a negative impact.
  • Encourage adolescents to stay in Physical Education and Fitness class. Talk about imagining a gym class where all sizes and skill levels are not just accepted, but welcomed. 
  • Tolerate food choices that adolescents make, but try to have an eating environment where healthy options are more common than unhealthy food options. Consider limiting pop drinks in your home. Do not have “diet” soft drinks available either. Parents should “walk the talk” by keeping in mind their own behaviours at all times.
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Within the general range of behaviours parents may see, it is sometimes not clear whether or not behaviour needs to be considered as a mental health problem. 
 
The adolescent may:
  • Complain of abdominal pain regularly after eating.
    • Please take your child to the paediatrician or family physician.
  • Express unhappiness with appearance or weight, or not want to eat in front of other children.
    • Ask about bullying.
  • Refuse to participate in gym class.
    • Speak to your son or daughter to find out why and then try to help problem solve in a way to rejoin the class. Remember to do so privately and in a supportive manner. 
  • Refuse to change with the other students.
    • Speak to your son or daughter to find out why and then try to help problem solve in a way that enables them to maintain their privacy but to also feel accepting of his or her body. Remember to do so privately and in a supportive manner. 
  • Skip meals regularly, cut out important food staples from the diet, limit eating to only one or two items and will not vary, use laxatives for weight loss, or use diet pills or diuretics.
    • It will be important to speak with him or her in a supportive and nonjudgmental way.
    • Let the adolescent know what you have observed and that you are worried about these behaviours.
    • Do some problem solving together to make sure that they get back on track with eating regular meals and snacks. 
  • Be very physically active while not eating or drinking enough to compensate for the extra activity.
    • Develop a plan with the teen that prevents participation in physical activity until there is adequate intake and hydration. Use incentives to work back to including physical activity in the teen’s day.
    • Explain the reasons for this plan and help problem solve ways to balance intake with energy output. These behaviours could lead to serious consequences, and need to be stopped.
 

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If the teen is struggling with regular and adequate intake, along with extra activity, see a mental health provider and physician in order to monitor physical health as well as to develop a treatment plan.

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