The majority of those with eating disorders develop them during their teen years or earlier. The most common age for onset of eating disorders among teens is roughly twelve years old. To meet the high need for eating disorder treatment among tweens and teens, visionary scientists and clinicians have pursued innovative and brave new directions to improve treatment and prevention program outcomes, e.g. Family-Based Treatment for anorexia nervosa and The Body Project for prevention.
Despite better treatments and prevention programs based on scientific research, rates of eating disorders among teens have remained roughly the same. There are an astoundingly low number of teens that receive eating disorder treatment despite increasingly sophisticated treatment methods, more effective treatments and improved training for treatment professionals. Data from a recent, large cross-sectional sample of American teens (10,123 teens between 13 and 18) showed that of those with eating disorders, only 20% actually sought specific care for an eating disorder. How can this occur when there is an increasing availability of evidence-based treatments provided by specialty-trained professionals?
Not Enough Treatment Available For Teens
Unfortunately, the availability of eating disorder treatment by trained professionals may be limited. In 1999, researchers reported that access to specialty trained eating disorder care was in short supply. Twenty years ago there was a paucity of eating disorder treatment centers and a lack of well-trained healthcare professionals. Although there are undeniably more and better quality treatments available now than in 1999, the larger treatment picture reveals an even bigger problem with the limited availability of mental health services in general – not just for eating disorders. Not so long ago research estimated there were 700,000 professional mental health providers in the US – far too few to service the nation’s population of over 3 million. This is especially startling when considering that 25% of the population struggles with some psychiatric disorder in any given year.
Current models of mental health treatment are usually delivered in a clinic or office setting on a one-to-one basis. This limits accessibility and availability. Mental health services tend to be concentrated in affluent urban areas and urban college communities. They tend to be expensive to deliver and often have limited insurance coverage. Most importantly they are less available to vulnerable populations like children (among whom eating disorders are concentrated) and ethnic and cultural minorities. Drawing on a nationally representative survey of over 10,000 adolescents between the ages of 13 and 17, researchers found that over half of teens in need of treatment for any psychiatric condition did not receive treatment and when they did, it was often provided by service providers not trained to treat mental health conditions, e.g., pediatricians. When considered in this context, it is less surprising to find that only 20% of those with eating disorders receive specialty-trained care.
There are an estimated 30 million people in the US who will suffer from an eating disorder in their lifetime. Treatment services for those with eating disorders are even scarcer and less available than general mental health services. Not only are eating disorder services difficult and expensive to deliver but also they require additional specialty training, beyond that which is provided to health care practitioners in their general graduate training. In addition, the dissemination and implementation of research-based treatments for eating disorders, while critically important, are often slow to reach a significant population of treatment professionals. Clinicians who do receive specialty training at workshops, conferences, or concentrated advanced training programs often feel that the new manualized, evidence-based treatments are too rigid or a poor fit for their patients. Consequently, specialty treatments tend to be modified from their original form in clinical practice. In the end, only a small minority of those with eating disorders receives good quality, evidence-based care.
Barriers To Teens Getting Treatment
Another barrier to teen eating disorder treatment is the mismatch of psychotherapists to psychologically different ethnic and cultural minorities. Lack of cultural sensitivity and cultural competence on the part of practitioners prevents eating disorder treatment among adolescents in these groups. For example, healthcare practitioners, especially psychotherapists, need to acknowledge racial and ethnic differences during treatment with their patients. But they may not know how. Seeking treatment for eating disorders among ethnic minorities in the US has long been low compared to the relative need for treatment. This may be because ethnic minorities often perceive mainstream healthcare treatments as unrelated to their own cultural group experiences.
To complicate matters, teens with eating disorders frequently have other psychiatric problems (known as comorbidities), especially mood disorders like depression and anxiety disorders. Accompanying anxiety disorders include generalized anxiety, obsessive-compulsive disorder, separation anxiety disorder, social phobia, and panic disorder. Comorbidities may also include substance abuse disorders, behavioral disorders, and suicidal thoughts. While most mental health professionals assess and treat comorbid psychiatric conditions, a top priority in eating disorder treatment, after ensuring a patient’s safety, is the reduction of eating disorder behaviors. This is because a nutrition-restored brain is often necessary to effectively address psychiatric comorbidities. As noted earlier, this type of clinical intervention requires specialized, eating disorder treatment skills in addition to a practitioner’s general abilities to treat psychiatric conditions.
There are ways in which comorbidities might lead to greater treatment seeking. Those with recognizable, serious eating disorder impairment may seek treatment for other mental health problems and, as a result, be treated for eating disorders discovered along the way. Sometimes patients with comorbidities have used mental health or medical services for psychiatric conditions in the past and are therefore more likely to be at ease with using services for eating disorder treatment. In fact, researchers recently found that any past utilization of mental health services or medical services for an emotional or behavioral problem was associated with adolescents seeking eating disorder treatment.
It goes without saying that eating disorder symptoms associated with more obvious signs such as self-induced vomiting and physical indicators such as weight loss are more likely to result in treatment-seeking since friends, family, teachers, and healthcare providers often identify these as serious or dangerous. As a result, more severe levels of eating disorder impairment are associated with seeking eating disorder treatment.
Some alarming and hidden barriers to treatment are pro-eating disorder web and digital communications, e.g., blogs and YouTube videos. Researchers found lower treatment seeking among those with severe eating disorder pathology when combined with high levels of online pro-eating disorder activity. Given the modern adolescent’s penchant for consuming electronic and internet-based information, it stands to reason that interacting with or viewing pro-eating disorder communications would result in avoidance of treatment seeking. Those suffering from serious symptoms would likely ask for validation, help and support from pro-eating disorder contacts rather than seeking treatment intended to reduce eating disorder behaviors. On the positive side, however, it is possible those who seek online support and validation from pro-eating disorder websites may also be more likely, if they decide to pursue recovery, to turn to Internet-delivered treatments. New and innovative treatments delivered online might appeal to those who are already comfortable with digital communications.
Some young people avoid eating disorder treatment because they have internalized a common social stigma against those with mental health concerns and eating disorders, in particular. Research long ago confirmed that those with eating disorders are thought of negatively. Fear of being labeled “crazy’ or “weak” because of mental health problems can result in self-stigmatization and resistance to seeking treatment.
In addition to self and societal stigma, those with anorexia nervosa often resist treatment because they characteristically do not believe they are ill. Likewise, those with other eating disorders typically experience shame and secrecy. They loathe revealing their eating disorder behaviors and attitudes to everyone, including treatment professionals.
Young age is often a barrier to treatment. As with many mental health concerns, young people with eating disorders under 18 years old rarely seek treatment independently – that is, without encouragement and/or direction from friends, trusted adults and family. Teens understandably lack the maturity, knowledge and consent status to pursue professional services. They hold more negative attitudes toward treatment. Among teens, older adolescents have been found to be more likely to seek eating disorder treatment than their younger counterparts. Even so, in most areas of the US, older adolescents still under 18 years old require consent from a parent or legal caretaker to receive eating disorder treatment. This puts the burden of treatment seeking on parents and caretakers.
Gender and sex affect whether teens will seek treatment for eating disorders. Among those with eating disorders, researchers in 2017 found that fewer than 10% of adolescent boys sought treatment compared with 20% of adolescent girls. Unfortunately, previous diagnostic criteria set by the American Psychiatric Association for eating disorders added to public misimpressions about which gender has eating disorders. In the past, only females with a loss of menstruation (amenorrhea) were identified as meeting criteria for anorexia nervosa. This helped construct a misinformed, publically accepted stereotype that only girls develop anorexia nervosa. Boys were not included in the old diagnostic criteria. As a result, eating disorders in boys were more likely to be missed by under-informed treatment providers who didn’t recognize the signs and symptoms in their male patients. Boys with eating disorders not only experience different hormonal changes than girls. They present differently than girls in other ways. For example, boys are prone to focus on leanness and muscularity whereas girls with eating disorders are more often focused on thinness. Treatment providers assessing eating disorders need to be aware of gender and sex differences in eating disorder presentation.
Compared with other eating disorders, teens with binge eating disorder are least likely to seek treatment. This may be because binge eating is often associated with embarrassing and stigmatizing weight gain. Further, behaviors not often associated with binge eating like vomiting, laxative abuse, and restricting food intake (associated with anorexia nervosa and bulimia nervosa) can result in serious health impairments like electrolyte imbalance, heart arrhythmia or hypotension. Compared to binge eating disorder, immediate and serious medical complications are more likely to draw attention from friends, family and treatment providers and are therefore more likely to result in eating disorder treatment.
How To Get Teens The Help They Need
Here are some suggestions to improve and facilitate treatment seeking among adolescents with eating disorders:
- Make more specialty treatments and treatment delivery methods available. For example, we can change the mode of delivery of therapist-led interventions in order to reach under-served populations and teens that would not (ethnic minorities) or could not (rural or economically underprivileged populations) access or attend typical face-to-face treatment. For example, Cognitive Behavior Therapy can be provided via telemedicine for the treatment of bulimia nervosa.
- Continue to increase the availability of specialty training for eating disorder health care providers through multiple modalities, i.e., eating disorder training conferences or Webinar-based programs such as Project ECHO Eating Disorders clinic for community providers offered by The University of Rochester Medical Center.
- Increase outreach and public education to reduce self and societal stigmas associated with mental health issues and, in particular, eating disorders.
- Increase the acceptability and importance of treatment to parents and caretakers. Since young people usually do not seek eating disorder treatment independently, informed parents and caretakers are key to young people receiving treatment. Caretakers need to know signs and symptoms of eating disorders and how to access helpful resources. And they need to be encouraged to seek treatment for their teens even when their teens are resistant. Opposition to receiving help, in the case of eating disorders, is common.
- Better prepare treatment providers to correctly diagnose eating disorders. When parents or caretakers approach treatment providers with concern about disordered eating, their concerns need to be taken seriously.
- Increase public education about how eating disorders affect a heterogeneous group of teens well beyond stereotypic presentations of anorexia or bulimia. For example, boys and those with binge eating disorder may be under-recognized and therefore under-treated.
- Improve practitioners’ ability to detect eating disorders beyond vague definitions of “weight problems” or “eating issues”. Those in a position to assess might use brief assessment tools like Morgan’s SCOFF Questionnaire to make more precise diagnoses and, as a result, to make better referrals.
- Increase cultural and ethnic diversity competence among practitioners.
- Along with increasing parent and caretaker literacy about eating disorders, help parents and caretakers to be more effective in getting their teens to treatment. Teach parents and caretakers how to effectively approach their teen about treatment participation.
Here are some tips for parents:
- Pick a time where you can talk to your teen alone. Group interventions may cause a teen to feel “cornered” and embarrassed.
- Make sure that your teen knows the discussion is not optional.
- Expect teens may resist talking because they don’t necessarily want to give up eating disorder behavior or receive treatment.
- Address denial or minimization of illness by saying you want to be heard. Start again with kind, supportive talk if your teen resists.
- Use “I” statements rather than accusatory “you” statements, e.g., “I found vomit in the shower” versus “You have been vomiting in the shower.”
- Let your teen know you are there to help and be prepared to listen.
- Explain that you have decided there will be an evaluation by a professional and you are prepared to do what it takes to help your teen be well.
- Friends are often the first to know about a teen’s eating disorder behavior. As with any unsafe behavior, teach teens to report harmful behavior in a friend to a respected adult who can intervene to facilitate an evaluation and treatment.
- Once treatment is recommended, seek specialty-trained professionals for the best results.
Evidence from recent studies showed that while adolescents with eating disorders may receive some kind of treatment, e.g., medical attention, only a minority received services specifically for eating disorders. Given the large number of youth who experience clinical (about 3%) and subclinical eating disorder behaviors (roughly 20% or more), this has broad public health implications. It is imperative treatment seeking and access to specialty trained professionals among adolescents with eating disorders improve despite multiple barriers to treatment.
Return To Eating Disorders In Teenagers
About The Author:
Cris E. Haltom, PhD, is a Certified Eating Disorders Specialist who has treated eating disorders in her private practice in Ithaca, NY, for over 30 years. She has presented eating disorder training workshops at national and local conferences. She is past Education and Prevention Liaison of the Western New York Comprehensive Care Centers for Eating Disorders and she authored A Stranger at the Table: Dealing with Your Child’s Eating Disorder (2004, Ronjon Publishing) and, most recently, Understanding Teen Eating Disorders: Warning Signs, Treatment Options, and Stories of Courage by Cris Haltom, Cathie Simpson and Mary Tantillo (2018, Routledge press). She published research on her co-authored eating disorder education program, the Parent Partner Program TM. In addition to her clinical psychology practice, she is part-time faculty at Ithaca College in the Department of Psychology.
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Written – 2018