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Adolescent Girls at Risk for Eating Disorders: How Educators Can Help
Esther Altmann      Email This Article

Esther Altmann, Ph.D. is a psychologist in private practice in Manhattan specializing in work with adolescents and families.  She is an eating disorders consultant and on the teaching faculty at YCT Rabbinical School and the Drisha Institute.

 

Read the accompanying sidebars here and here.

 

Research indicates that girls in kindergarten are already expressing worries about being fat.

Rebecca, a pale 8th grade student in a baggy sweatshirt, appeared to be assiduously taking notes. Her long thin face and tired eyes rarely glanced up at the teacher or looked around to check in with her friends.  It was only by chance that Mrs. Kramer caught a glimpse of Rebecca’s notebook as she strode down the aisle of the classroom.  She was startled to observe that instead of lecture notes, Rebecca had been recording a list of foods with corresponding numbers.  Some of the items on the list were crossed out, others underlined.  One side of the paper had a large DO NOT EAT heading.  Sensing Mrs. Kramer’s gaze, Rebecca quickly turned the page of her notebook.  

 

After class, Mrs. Kramer gently approached Rebecca and tried to talk with her about what she had observed.  With a shrug, Rebecca dismissed Mrs. Kramer’s concern and said that she had been momentarily distracted by thinking about what she would eat for dinner. 

 

A few days later Rebecca’s two best friends, Shira and Danielle, knocked on the door of Dr. Stern, the school psychologist.  Barely seated, they revealed how worried they were about Rebecca because she was constantly talking about feeling fat and her latest diet. She never ate lunch with them anymore and they missed her company. Shira commented that on at least two occasions, she had seen Rebecca throw out her lunch.

 

Dr. Stern recalled her conversation with Rebecca’s teacher about the food lists and called Rebecca to her office.  She was quite startled to find that Rebecca, typically an amiable, highly respected student, responded to questions about her eating habits in a cursory, sullen manner.  When Dr. Stern stated that she was worried enough that a meeting with her parents was in order, Rebecca stomped out of the office. Dr. Stern was surprised when Rebecca’s parents minimized the school’s concerns about Rebecca’s weight and food preoccupations. With some urging on Dr. Stern’s part, Rebecca’s mother agreed to have Rebecca checked by her pediatrician who diagnosed Rebecca with Anorexia Nervosa.

 

A leading cause of death in adolescent girls in the United States, Anorexia Nervosa, is a diagnosis that in its incipient stage is frequently missed by parents and teachers.  Bulimia Nervosa, also common amongst adolescent girls, can be even harder to detect as it is not always associated with extreme weight loss and girls often hide shameful behaviors such as vomiting, laxative abuse and binge eating.

 

Eating disorders are most prevalent within upwardly mobile demographic groups, and are amongst the most emotionally and physically devastating problems affecting young Jewish women. Since thinness has become synonymous with both beauty and success, the imperative to perfect the female body through dieting, exercise, and plastic surgery has become as obsessively preoccupying for teenage girls as for older women. Although there has been growing concern about eating disorders in boys as well, it remains a predominantly female problem. In a recent review of prevalence studies by Dr. Caroline Peyser, the data regarding eating disorder rates amongst American Jews was inconclusive as to whether eating disorders are more frequent in the Jewish community in comparison to the general population.  However, anecdotal observations reveal that most Jewish women have had a friend or family member who has struggled with some sort of eating disorder. 

 

There is little doubt that a main cause of the problem is the emaciated female body prototype glorified in popular culture. This unobtainable thinness ideal is an unrealistic, harsh lens through which girls see their own bodies as well as the bodies of their friends. The toxicity of this culture of body hatred and objectification is absorbed by girls at increasingly younger ages.  Research reports indicate that girls in Kindergarten are already expressing worries about being fat.

 

I feel so fat today” is a familiar refrain when teenage girls greet each other before class in the morning. In a recent session, a lovely, intelligent high school sophomore explained how her group of friends had rated each other’s body parts in order to determine who had the very best of each feature – eyes, nose, hair, mouth, breasts, shoulders, legs, arms, stomach, behind, fingers, nails, feet, toes, skin – no feature escaped scrutiny. Just as mothers may both consciously and unconsciously communicate the way they feel about their own bodies to their daughters - in a parallel process, girls communicate their negative body image to their close friends. Girls' critical and insecure feelings about their own bodies oscillate within themselves and between one another in complex and destructive ways.   

 

Like parents, it is also possible that teachers may inadvertently model anxieties and preoccupations about thinness to their students when they innocently talk about their own diets, weight goals, or exercise regimes. This is particularly worrisome at the high school level where the boundaries between teachers and students are often less rigid. Teachers’ well intended compliments to students about a new outfit or about how wonderful they look upon return to school after a summer of dieting may reinforce the cultural message that appearance matters and that thinness counts.

 

Periods of transition are also times of vulnerability when eating disorder symptoms are more likely to emerge. Students who feel ill-equipped to negotiate the transition into adolescence may turn towards their bodies as a sphere that they can control. The transitions from lower to middle school, middle to high school and high school to college are all common years in which problematic dieting and distorted body images develop.

 

Each community imposes its own unique demands on adolescent girls. For example, in large Orthodox families, girls may be expected to achieve academically and at the same time assume significant child care responsibilities for younger siblings. They may also feel pressure to marry before they are developmentally ready. In other school environments, the pressure may be admittance to a prestigious college or to be the star on a sports team. Girls who go to Israel for a year after high school and are sent home because of an eating disorder have frequently stated that their weight preoccupations were not taken seriously enough when they initially emerged in high school.

 

The bar and bat-mitzvah year is another time of vulnerability. In communities where elaborate evening parties are the norm, many girls believe that they need to diet in order to fit into tight, revealing dresses that are often designed for much older girls.  From a biological perspective, this is precisely the time of puberty and accelerated, but completely normal, weight. Thus, the social pressure to be a beautiful Bat-mitzvah comes at a particularly unfortunate moment when girls struggle with the awkwardness of a body in transition.

 

One central underlying theme that fuels body dissatisfaction and eating pathology is the ever elusive wish for perfection.  During adolescence there is a deeply embedded fantasy that deprivation and drive can buffer feelings of vulnerability and fears of rejection.  In her book Perfect Girls, Starving Daughters, Courtney Martin writes, “This age is the beginning of the giant, deadly delusion that perfection is just out of reach for you and effortlessly possessed by the next girl…Despite a teenage girl’s best intentions, perfection is impossible, and even self-confidence will not be accomplished by buying one more pair of shoes, spending one more hour at the gym, eating one fewer meal.”  According to eating disorder specialist Dr. Judy Rabinor, dieting girls learn to disconnect not only from their bodies but from their minds as well; they learn to restrain rather than express their inner needs, appetites, and hungers. Emotional problems are ignored and the hurt from being teased, scapegoated, or rejected by friends or family gets transformed into body hatred.  

 

How can schools help break the cycle of eating pathology and the seduction of the thinness ideal? Increasingly, educators and guidance counselors are playing a central role in the identification and prevention of eating disorders.  Awareness of the early warning signs of an eating disorder is a critical first step (see sidebar).

 

Eating pathology caught at an early stage is much more amenable to intervention than a full blown syndrome that may become a chronic lifelong illness even with intensive treatment.  Many girls flirt with diets and eating disordered behaviors as a call for help.  When ignored, these maladaptive coping mechanisms are at risk of becoming ingrained, rigid patterns that grip like a vise and can be nearly impossible to shake off.  For schools and parents, the crucial message is that the earlier one seeks treatment, the more successful and complete recovery will be.

 

Teachers are the first line of defense in this endeavor and may be less reluctant than parents to see a developing problem.  Peers are also very sensitive barometers to a friend’s distress and their concerns should be respected.  The dilemma for teachers is what to do when they suspect a problem as they may fear losing a special connection with a student.  Dr. Marian Getzler-Kramer, a high school psychologist, aptly describes the teacher’s quandary, “With adolescents it is so hard to gain their trust and also so easy to lose it!”  However, Dr. Getzler-Kramer believes that students want their distress to be noticed by adults even when their initial reaction may be anger and denial.   In most schools, teachers are advised to first consult with guidance rather than talking directly to a student about their concerns.  Dr. Jill Schehr, a school psychologist, cautioned that it is important to preserve the teacher’s relationship to the student around the task of teaching.  She noted that in Jewish day schools the boundaries between students and teachers may be more blurred.  Teachers may also be mothers with children in the school, and live and go to synagogue in the same community.

 

In addition to emphasizing early detection, some schools are incorporating prevention programs into their curricula. The current thinking in eating disorder prevention is to help girls experience their bodies as a source of strength, pleasure, health, wisdom, and creativity. These programs typically include the following elements:

  • Support the development of a positive self-image that is independent of         physical appearance
  • Encourage a healthy approach to eating and exercise
  • Deconstruct the cultural and media images which influence the way girls think and feel about food and their bodies
  • Explore how familial attitudes towards food, exercise, body image, achievement and femininity interact with self-image and identity
  • Teach about the dangers of eating disorders, dieting, excessive exercise, and other risky behaviors

 

Most importantly, prevention programs attempt to open a dialogue with students about their worries and send the message that obsessional dieting and exercise can be dangerous before they reach levels of clinical pathology.  An essential component of any successful prevention program must include parallel meetings with parents.  What girls may learn in a prevention program is of little value if they return home to a refrigerator full of fat free products, parents who are perpetually dieting and family meals that are rare events.     

 

When an eating disorder emerges, a school can be a crucial source of support for students and their families.  Several specific ways schools can respond to the crisis that will assist in a student’s recovery include:

 

Health Comes First: The most helpful message a school can give a student with an eating disorder and her family is simply that health comes first. The approach should be similar to that of a child with a significant medical illness. Families who perceive the school as bending over backwards to accommodate to their child’s medical and emotional needs are forever appreciative of the educational staff.

 

Modification of Academic Requirements:  Consideration should be given to modifying a student’s academic responsibilities while she is ill.  Treatment for an eating disorder, whether outpatient or inpatient, is a time consuming and intense psychological experience. Inpatient treatment removes the child from school and often results in significant academic set backs.  Outpatient treatment typically involves two to five appointments a week with a treatment team – physician, psychotherapist and nutritionist.

 

Many students who suffer from eating disorders are high achievers and will continue to excel despite their illness.  However, they may still require accommodations such as early dismissals for appointments, extended deadlines for assignments and exemptions from classes that require physical exertion such as gym.  Exemption from gym class and other strenuous activity is usually recommended for anorectics by their physicians in order to maximize the potential for weight gain by minimizing the amount of calories burned.

 

Reevaluation of School Placement:  Since an eating disorder is often a signal that something is awry, one possible factor could be a mismatch between the child’s educational needs and the school. This may be particularly true in schools with high academic standards and a competitive environment. Parental expectations of the student’s academic performance are also important to explore.

 

For some girls, eating problems may serve as an opportunity to reassess whether they are in a school best suited for them.  A change to a less stressful school setting can be very helpful.  This is sometimes true even for intellectually gifted students who may be achieving at high levels of academic excellence.  Given that one of the central dynamics of an eating disorder is a striving for perfection, letting girls know that they do not necessarily need to be the star pupil at the most competitive school can be a powerful and healing message.

 

Increasingly, clinicians who treat eating disorders have noted that learning problems may be a risk factor for eating disorders. Children who struggle with learning disabilities may experience diffuse feelings of being damaged that they cannot articulate. The drive to perfect the body may reflect a buried wish to repair a brain that learns differently from others.           

 

Many schools are flexible and respond to the crisis by reducing academic requirements for a particular student.  However, not all schools are willing to make accommodations. The decision whether or not to change schools can be complicated and requires a team effort.  Consultation between school staff, parents, psychotherapist, physician and the student herself is usually the best way to proceed with this decision.           

 

Accommodations for Eating Meals in School:  For recovering anorectics, eating lunch in school is often the most difficult meal.  It is also the meal that they can most easily skip without anyone noticing.  For some students, eating in a more private setting, such as in a guidance counselor’s office, may facilitate their ability to eat lunch. While this is not ideal, it can be a helpful interim step while eating behavior is normalizing. Similarly, for girls recovering from bulimia in which vomiting after meals is a problematic behavior, eating under the supervision of a nurse or in the guidance office may thwart their urge to run to the bathroom.   

 

Support for Siblings: Eating disorders can be devastating for parents and cause significant disruption of family life.  Family meals may become battlegrounds and turn into unpleasant experiences for siblings. Parents may be preoccupied with worries about their starving child and may temporarily neglect the other children in the family. In contrast to a more straightforward medical crisis, families with an eating disorder do not always get support from relatives and friends. Siblings within a school may therefore need some additional attention from teachers as they try to cope with this stressful family experience.

 

So many girls live precariously on the edge of an eating disorder. At this juncture, early detection of eating disordered behaviors and prevention programs are the fundamental tools at our disposal to combat the problem.  Although most girls do not cross the line to a full blown syndrome, a preoccupying angst about food and body drains precious emotional and intellectual resources that could be directed towards more productive endeavors.

 

Eating disorders also pose a unique opportunity for Jewish educators to feed their students’ spiritual hunger. The challenge is to harness the transformative power of Judaism to nurture and develop positive and strong Jewish identities that can transcend external accomplishments.  It is hoped that a meaningful Jewish education can redirect the destructive rituals of eating disorders towards the constructive rituals embedded in Jewish life.  This monumental task – to nourish body and soul, mind and heart – will enable students to emerge from our educational institutions possessing the essential tools that they will need to lead sanctified lives.

 

References

 

Diagnostic and Statistical Manuel of Mental Disorders - DSM IV (1994).  American Psychiatric Association.

 

Martin, C.E. (2007). Perfect Girls, Starving Daughters: The Frightening New Normalcy of Hating Your Body.  Free Press.

 

Peyser, C. (2005). Body and Soul:  A Guide for Addressing Eating Disorders in a Jewish Educational Setting.  Atid.

 

 

 


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