Bulimia: Parent and Teacher Perceptions in Childhood Eating Disorders
Disagreement between what constitutes abnormal and normal behaviour in childhood disorders is a recurrent issue in the field of child psychopathology. For parents, identifying problematic behaviours within their child is not an easy or obvious task. Many parents lack knowledge of childhood disorders and may not be able to recognize the signs and symptoms that accompany a disorder, especially when it comes to childhood and adolescent eating disorders. The distinction between abnormal and normal eating behaviours in children and adolescence is very obscure and may present a problem for parents and teachers when it comes to identifying this behaviour. In almost all cases, parents and teachers play a critical role in assessing childhood and adolescent eating behaviours. There are many limitations to parental and teacher perceptions of childhood and adolescent eating disorders that affect their assessment and diagnosis.
This paper will serve to discuss the barriers of parental and teacher perception in the assessment of childhood and adolescent eating disorders, particularly focusing on childhood and adolescent obesity, anorexia nervosa, and bulimia nervosa. The paper will begin with a discussion about parental involvement in the childhood home environment, eating pathology, and the parent-child relationship surrounding the consumption of food and body image. Subsequently, discussion around the active role of teacher recognition, help-seeking, and teacher-parent communications will also be reviewed. This paper will conclude with a discussion of maternal psychopathology pertaining to eating disorders and how this may influence the assessment and diagnosis of eating disorders in their children.
Researchers have argued that the dynamics surrounding the family and home environment may play a causal role in the development of eating disorders among some children and adolescents. Reports of child and adolescent eating behaviours are typically based on parent interviews or questionnaires, which makes them the proximal agents when it comes to recognizing the signs of an eating disorder (Harvey et al., 2015). These measurements are highly variably and may be biased based on parental perceptions of eating pathology and the dynamics within the home and between themselves and their child. Substantial evidence indicates that parents have a powerful impact on child body weight, food choices, and physical activity (Braden et al., 2014). Researchers have hypothesized some risk factors to maladaptive eating behaviours, such as poor general family functioning, lower socioeconomic status, inappropriate parenting style, and the experience of traumatic life events (Gibson et al., 2007).
One maladaptive eating behaviour observed in children and adolescents with eating disorders is emotional eating. Emotional eating, or eating in response to negative emotional states, has been identified as a trait that contributes to the development of bulimia nervosa, binge-eating disorder, and obesity in children and adolescents (Braden et al., 2014). A central element of the etiology of emotional eating appears to be the family’s contribution to the child’s development of negative emotional states (Haslam et al., 2008). The onset of negative emotional states is related to both general parenting style and specific feeding practices within the home (Braden et al., 2014; Haslam et al., 2008).
General parenting style describes how parents interact with their children, such as the level of warmth, control, and acceptance directed towards the child (Braden et al., 2014). Parents who tend to minimize their children’s negative emotions, provide little support, are controlling, over-involved, or overprotective may contribute to the child’s development of negative emotional states (Braden et al., 2014; Haslam et al., 2008; Scheel, 2012). In these circumstances, the child has learned that is it not acceptable or safe to experience such states, such as depression, anxiety, sadness, or dejection. Many of these emotional states are associated with body dissatisfaction and the drive for thinness, which many adolescents experience and contribute to the onset of certain eating disorders. Maladaptive perceptions made by parents surrounding emotional dysregulation create an invalidating environment for the child’s emotional experiences (Braden et al., 2014; Haslam et al., 2008). The child may begin to use blocking mechanisms, such as those involving impulsivity (such as binge-eating and purging) and/or compulsivity (such as dietary restriction and compulsive exercise) to reduce the awareness of the emotions that are regarded as unacceptable (Field et al., 2001; Haslam et al., 2008; Mash & Wolfe, 2019).
Subsequently, many parents perceive maladaptive eating behaviours as unmanageable in their children and use certain feeding strategies such as offering food to regulate these negative emotional states (Braden et al., 2014; Estrem et al., 2016; Thomson et al., 2012;). Parents may learn that food has a calming effect on their child, resulting in increased reliance on encouraging food when the child is distressed (Braden et al., 2014; Scheel, 2012). This “quick-fix” approach often leads the child to rely on food as a security vessel to downregulate their negative emotions in future circumstances. These commonalities are observed in patients suffering from bulimia nervosa, binge-eating disorder, and obesity.
In studies that use parental report measures, many have reported that their experience with a child who displayed problematic feeding and eating behaviours created a burden that impacted their day-to-day lives (Estrem et al., 2016). Parents report struggling with children who refuse to eat or have restrictive eating and often blame themselves or feel guilty that they could not recognize the signs sooner (Estrem et al., 2016; Gibson et al., 2007). Parents often report feeling powerless with respect to managing their child’s eating difficulties, and also report difficulty with comprehending the idea that their child’s pattern around food and body image may not be normal (Thomson et al., 2012). Parents from a study conducted by Thomson et al. (2012) found it hard to conceptualize their child’s difficulties as an illness and many reported feelings of denial as a consequence of using the words “anorexia” or “obese” to label their children. These ideas may prevent parents from seeking help for their children because they fear the reality of their child’s difficulties and fear the parental stigma that is associated with such disorders.
Feeding practices in the home are also reliant on the parent’s lifestyle. Many parents that are single-parents may find it difficult to afford nutrient-dense food options for their children (Gibson et al., 2007). With restricted access to less energy-dense foods and adequate facilities for recreational exercise, many children who are predisposed to a history of family obesity, may struggle to maintain a healthy weight (Gibson et al., 2007). Studies have shown that having overweight parents and family members increases the likelihood of a child being overweight or obese (Gibson et al., 2007). Similarly, parents (particularly mothers) that struggle with anorexia or bulimia nervosa can influence the onset of eating disorder symptoms in their children (Lydecker & Grilo, 2017). Parents attitudes regarding the eating environment can have an impact on their child’s eating behaviour, especially if the attitudes around food and body image are detrimental to the child’s mental health. Parent’s who do not have a willingness to change their lifestyle or seek help for their own disorder may not see the need to seek help for their child.
Recognition of eating disorders is a very real issue for teachers working in secondary schools. With the peak age of onset of eating disorders being between the ages of 10 and 19, most school staff members are likely to encounter students suffering with eating disorders several times throughout their school career (Knightsmith et al., 2013). The consequences for a student suffering from an eating disorder during their time at school can lead to impacts on both their academic and social development, which makes teachers a crucial asset in the recognition, diagnosis, and assessment of childhood and adolescent eating disorders (Knightsmith et al., 2013). Many researchers have studied teacher recognition of eating disorders among students in secondary schools and have similarly concluded that school staff are ill-equipped when it comes to the matter of eating disorders.
One of the most widely cited studies by Knightsmith, Treasure and Schmidt (2013) investigated teachers’ perceptions on eating disorders in students. The study consisted of school staff members from a secondary school in England who were asked to discuss topics in relation to eating disorders, such as school culture, knowledge and understanding, communication with students, support strategies, and working with parents and external agencies. Derived from participant discussions, the researchers recognized four key themes in their experiences with eating disorders. The first two being that many staff do not have a basic understanding of eating disorders which makes them uncomfortable when talking to students about these disorders. The third theme was that eating disorders and other mental health issues were seldom discussed in the staffroom and among staff members. The final theme was the lack of relationships and communication with parents regarding food and their child’s eating behaviours.
This study, and many similar studies, reveal the barriers in teacher perceptions and assessment of eating disorders in students and how many teachers may not be equipped to spot the warning signs or offer support (Knightsmith et al., 2013). Many staff members would not know how to respond if a student had a suspected eating disorder which highlights the need for training for school staff to improve their basic understanding and recognition of eating disorders (Knightsmith et al., 2013). For children and adolescents to get the support they need, teachers need guidance on how best to talk to students about their eating disorder and prepare staff so that they feel comfortable in this area. Based on findings from this study, it is also suggested that teachers and parents work together with the child so students have support in multiple domains in terms of recovery (Knightsmith et al., 2013). Guidance about how to work with parents and how to approach parents regarding eating disorders in their children would be beneficial training for school staff so that the collaboration between teacher-parent is proactive (Knightsmith et al., 2013). Extensive training and guidance for teachers will allow them to feel comfortable discussing eating disorders with their students and ensure that the information expelled is educating students on the dangers of maladaptive eating behaviours.
A subsequent barrier to the recognition and assessment of childhood and adolescent eating disorders is maternal psychopathology. Maternal psychopathology significantly impacts child development, including child behavioural and emotional functioning, and child eating behaviours (Braden et al., 2014; Gibson et al., 2007). Specific disorders, including eating disorders, depression, and anxiety have all been linked to the development of childhood feeding and eating disorders in as young as children 4 years old (Braden et al., 2014). Children who are exposed to psychopathology in their parents, particularly their mothers, may observe them eating in response to their own negative emotions, which may contribute to child emotional eating and eventual weight gain and body dissatisfaction (Braden et al., 2014). Similarly, overeating behaviours in mothers, such as binge-eating, or night eating have also been correlated to unhealthy eating patterns in children (Braden et al., 2014; Lydecker & Grilo, 2017).
A study conducted by Lydecker and Grilo (2017) examined the differences in child eating-disorder behaviours and parental feeding practices between a sample of parents exhibiting core features of anorexia nervosa, bulimia nervosa, binge-eating disorder, or purging disorder compared to parents with no eating-disorder characteristics. Mothers with eating disorder psychopathology reported greater perceived feeding responsibility, greater concern about their child’s weight, and more monitoring of their child’s eating (Lydecker & Grilo, 2017). These mothers also report concern about transmitting eating disorder psychopathology to their children by modelling, and report difficulty managing their own psychopathology during food preparation and feeding (Lydecker & Grilo, 2017). These concerns are communicated with their child (particularly their daughters) in the form of encouragement to lose weight or encouragement of behaviours such as restricted eating (Lydecker & Grilo, 2017).
It is evident that in conjunction with maternal eating disorders, maternal anxiety and depression are factors that may influence whether or not parents seek treatment for their overweight or underweight child (Braden et al., 2014; Gibson et al., 2007; Harvey et al., 2015; Lydecker & Grilo, 2017). A parent may be emotionally unavailable for the child because they are consumed by their own interests or has an untreated disorder (Scheel, 2012).
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