Even so, it is essential that these girls get the treatment they need. Anorexia is a very serious disorder. If these girls don’t get better, they may die. Recent studies say that anywhere from 5 to 7 percent of all children with anorexia will die within 10 years. With treatment, about 70 percent will eventually have full medical, social, and psychiatric recovery. The sooner the disorder is treated, the more favorable the prognosis will be.
The best treatment for anorexia is cognitive behavioral therapy, often in combination with medication and family counseling. After an initial examination, including a thorough physical, children with anorexia will need at least weekly sessions with a psychiatrist; many will need to come in twice a week. They also need weekly weigh-ins and other medical follow-ups. In the past, when dysfunctional families were thought to be the cause of eating disorders, family therapy alone often was the treatment of choice. Today we rely largely on cognitive behavioral therapy, which concentrates on changing the girl’s distorted perceptions about food and decreasing the significance of thinness in determining her self-worth. Family counseling can be very useful in helping parents and other close family members cope with a sick child.
Not all child and adolescent psychiatrists have experience with anorexia, and others aren’t really comfortable treating these kids. Parents shouldn’t be shy about getting answers to some important questions here, since finding the right physician is critical. “Do you treat kids with anorexia?” is the best place to start. “Do you believe in outpatient management?” “Do you use medication?” and “May I talk to you and be involved in the treatment?” are other questions to which a parent should receive an unqualified yes.
It’s not necessary to find an eating disorders specialist for the child with anorexia or to check her into an eating disorders clinic, although there are many good ones out there. It is necessary to find a good psychiatrist who is interested in the disorder and can do the therapy, prescribe medication, and follow the child for at least a year and a half. That’s about how long the outpatient therapy for anorexia will take, though severe cases will take longer, sometimes much longer. The worst case I’ve encountered took six years of treatment before the girl was completely well.
Many children being treated for anorexia will take some sort of medication, but the role of medicine is limited with this disorder. Antidepressants, specifically the SSRIs (selective serotonin reuptake inhibitors), such as Prozac, Zoloft, and Paxil, may help with the obsessive-compulsive symptoms and the depression that often accompany anorexia. Prozac has been effective in helping these girls maintain their weight gain and normalize their eating habits. The medicine needs to be taken for at least a year. Appetite stimulants are sometimes recommended; the one most often prescribed is Periactin, an antihistamine that has been helpful in increasing weight and maintaining weight gain. The MAOIs (monamine oxidase inhibitors), especially Nardil, have also helped girls put on weight.
Many of these girls hate taking pills, and not for the usual reason. They panic because they think the coating has too many calories. Others are terrified that the pills will make them eat, so I tell them—quite truthfully—that there is no pill that makes a person eat. “I wish there were a medicine that would make you eat, but there isn’t,” I say. “All this pill will do is help you not to worry so much about what you do eat.
When the medication and therapy described above don’t work, when there is no increase in weight and no improvement in the child’s overall health, hospitalization may be necessary. Hospital care offers a multidisciplinary approach to the disorder, involving dietitians, nurses, and psychologists as well as psychiatrists. Inpatient treatment can be done in any adolescent psychiatric unit or in special eating disorder units that combine both pediatric care and child and adolescent psychiatry.
BULIMIA
The young women who have bulimia (again, some 90 percent of the patients are female) don’t starve themselves; they binge, they purge, they try to fast, and they have strange attitudes about food. Like girls with anorexia, they’re afraid of getting fat, but they don’t have a distorted body image. They don’t see themselves as fatter than they are. They’re afraid of food, but they can’t help taking in a huge amount of it—anywhere from 3,000 to 20,000 calories per binge. I’ve talked to girls who would eat several loaves of bread and boxes of cereal at home and then go from one fast food restaurant to another, consuming an enormous amount of food in a few hours. The frequency of the binges of someone with bulimia will vary greatly, from twice a week to several times a day. A binge may last from several minutes to several hours. Young women with bulimia describe having a lack of control during the binges; some describe it as an altered state of consciousness. Unlike girls with anorexia—who are preoccupied with their success at restricting their calorie intake—young people with bulimia are not very good at dieting. They often diet, but restricting calories makes them uncomfortable and usually leads to bingeing.
After bingeing usually comes purging (some people with bulimia binge but don’t purge), by vomiting or using laxatives—as many as 20 a day —or both. Many use diuretics or diet pills. Some exercise for hours at a time. Not surprisingly, there are medical complications associated with bingeing and purging, among them low blood pressure, dehydration, low potassium and other metabolic problems, cavities, constipation, swollen cheek glands, and hormonal changes. The physical signs of bulimia are frequently pointed out by other health care professionals, especially dentists, who notice the enamel wear on a young woman’s teeth as a result of the acid in the vomitus.
It’s not difficult to spot a girl who has anorexia, no matter how baggy her clothes are, but people with bulimia can look completely normal. In fact, most are of normal weight or even a little heavier. Young people with bulimia are generally older than girls with anorexia too; the peak age of onset of bulimia is 19 years. The incidence of bulimia is estimated at 2 percent of the population, but some studies show that 3 to 5 percent of all college-age girls have this disorder.
Many people with bulimia have a history of anorexia or obesity. There is also a high co-occurrence with major depressive disorder, generalized anxiety disorder, social phobia, and panic disorder. Alcohol and substance abuse are also common.
THE BRAIN CHEMISTRY There is almost certainly a genetic component attached to this disorder. Twin studies of bulimia show a higher rate in identical twins than in fraternal twins, and family studies tell us that the relatives of people with bulimia have a higher incidence of the disorder than the relatives of people who don’t have it. Other evidence suggests that there is a neurochemical component to bulimia, specifically a decrease in the manufacture of serotonin and a hypersensitivity to changes in serotonin levels.
THE TREATMENT Unlike kids with anorexia, young women who have bulimia will ask for treatment. The distress and dysfunction associated with this disorder are such that these girls with bulimia want to get better. Untreated, people with bulimia will continue to get worse over time. Their binges begin to get more and more extreme, and their distress grows. A small but significant percentage of all young people whose bulimia is left untreated will die within five years; many of them will commit suicide. With treatment about 70 percent will have a full recovery.
Again, the treatment is cognitive behavioral therapy combined with medicine. We usually recommend individual therapy with a cognitive behavioral approach. This treatment, which requires a minimum of six months, has four phases. In the first phase, we examine the problem with the girl’s active participation, asking her to monitor her food intake and record her eating habits, especially binges and purging. Next we focus on changing her eating behavior, limiting food intake to three meals a day and two snacks. In the next phase we work on correcting her distorted thoughts and attitudes about calories, weight, and body image. And finally we move to relapse-prevention, in which we simulate high-risk situations and encourage the girl to practice her new behavior. Interpersonal psychotherapy (IPT), discussed in Chapter 14, has al
so been useful in the treatment of young women with bulimia. Group therapy can also be very helpful for these girls; discussing their eating behaviors openly tends to make them feel less isolated. College students often do well in group cognitive behavioral therapy.
Meanwhile, antidepressant medication, such as Tofranil, Desyrel, and Prozac, will help to cut down the frequency of the bingeing and vomiting cycles and alleviate the underlying depression. Tofranil may cause dry mouth and sedation, and it has effects on the heart that make cardiac monitoring necessary. The most common side effect of Desyrel is sedation, and because it may also cause nausea and vomiting, the medicine should be taken with meals. Prozac and the other SSRIs have minimal side effects. For best results, medication for bulimia should be taken for six months to a year.
PARENTING AND EATING DISORDERS
Family dinners are often the setting for conflict and disagreement in any household. It is a rare family indeed that doesn’t feature a tantrum, a blowup, or some other scene at the dinner table once in a while. When there is a child in the house who has an eating disorder, every meal is a potential nightmare.
“We just sit there, day after day, watching her starve herself to death, and it’s killing all of us,” one desperate mother told me. “I know that the minute we go upstairs she’s going to run into the downstairs bathroom and start vomiting, and there’s nothing we can do about it,” said another. “My husband and I are desperate.”
Parents faced with their child’s eating disorders do become desperate. They also become depressed, angry, and worried. Having a child with anorexia or bulimia has a tremendous impact on the entire family. Parents feel frustrated and helpless because they can’t control their children and make them well. After all, giving a child nourishment is one of a parent’s fundamental responsibilities. Normal siblings may become jealous and angry because, the way they see it, their parents are being tricked and manipulated. “I think you should just make her eat,” they might say. “She always gets her way. She’s just doing this so you’ll pay attention to her.”
The parents of Susannah, a 17-year-old girl who was successfully treated for an eating disorder, say now that in some ways the hardest thing about the disorder was admitting that they couldn’t fix what was wrong with their daughter. For nearly a year they did everything they could to persuade Susannah to eat, but she was obviously getting worse. They finally took her to a child and adolescent psychiatrist who specializes in treating anorexia and bulimia.
“The hardest thing for us was accepting the fact that we couldn’t do it alone, that we needed someone to help us. We really thought we could handle Susannah’s problem ourselves. Once we did put her and ourselves into the hands of a professional, things really did get better, not just for her but for the rest of the family too. It was such a relief to talk to someone who didn’t blame us for what our child was going through and who didn’t hold it against us when we lost our tempers with her. And because he kind of ‘took charge’ of Susannah, he freed us up to spend more time thinking about our other kids. In that year before we took Susannah to see the psychiatrist, there were times we almost forgot we had other children. But the best thing about it is that Susannah got better. He gave us our daughter back.”
CHAPTER 18
Conduct Disorder
Douglas, 12 years old, was brought into the hospital by his parents after he tried to choke his five-year-old brother. It wasn’t the first time Douglas had done something terrible at home. Over the three or four years before we saw him for the first time, Douglas had set several fires. Quite recently he had soaked a whole package of firecrackers in gasoline and had lit them, basically destroying half of his family’s backyard. Douglas was odd and socially awkward, and his classmates never let him forget it. They teased him mercilessly and refused to include him in their activities. In the last year Douglas had been going through some tremendous mood swings, including lengthy periods of depression. I don’t think I’ve ever met anyone of Douglas’s age who was so socially inept.
Jared was 10 years old and in fifth grade when he first came to see me, but he had been having behavior problems ever since nursery school. At three years old he was already a “handful,” his parents said, and as the years went by, Jared’s behavior got worse. At school he routinely stole from his classmates. In third grade he beat up a child because the boy had “squealed” on Jared, telling the teacher that Jared cheated on his math test. He took the pet turtle from science class, threw it into boiling water, and watched as the turtle died. Jared was an unusually attractive boy, with blonde hair, blue eyes, and a dimple. He was even a little charming, despite his grisly exploits. As he told me about the things he had done, he showed no remorse whatsoever.
THE “BAD SEED”
It’s the stuff of fiction: children who set fire to the living room curtains, boil their turtles, throw their baby brothers down the stairs. But it can also be fact, if a child has conduct disorder. Children with conduct disorder—CD—are physically and verbally aggressive. They routinely lie, steal, set fires, and torture animals. When they reach adolescence, they may rape and otherwise physically abuse people and terrorize the community. It’s no wonder that kids with CD are featured so prominently and so often in fiction. They seem too bad to be true.
THE SYMPTOMS
All children misbehave some of the time. Children and adolescents with CD misbehave a lot of the time, in fairly serious ways. They have temper tantrums and use bad language. They do things that violate the rights of others, such as stealing or defacing property or creating a nuisance. They’re physically aggressive and may even be sex offenders. They have symptoms that fall into four categories: aggression toward people and animals; destruction of property; deceitfulness and theft; and serious violation of society’s rules. It is estimated that 6 percent of all children have CD, with a male-female ratio of about 4 to 1.
There are two types of CD: early-onset CD, which occurs before the age of 10 and is the most common type; and late-onset CD, which comes after age 10. The age of onset for CD is significant; there’s a tremendous difference between someone who first shows the symptoms of CD at age six and someone who does so at age 15. The earlier the onset of CD is, the worse the prognosis is.
CD may show up in the very young. Children as young as three may behave aggressively, fighting with their siblings and their peers. I’ve seen five-year-olds who become sexually aggressive. They’re too young for rape, of course. Small children are more inclined to take off all their clothes and play with their genitals or to try to touch their peers. The more violent behavior associated with CD, such as animal torture and attacks on people, occurs during the elementary school years. Rape and the other serious assaults come later, in the teenage years.
Another significant factor associated with CD is the IQ of the child. A child with CD whose IQ is 70 presents a very different picture from one with an IQ of 125. On the one hand, the child with the higher IQ will be easier to work with when it comes to treatment; on the other, he’s probably more imaginative and creative in acting out his antisocial behavior to begin with. He may also be more wily in evading detection.
Many children with CD have learning disabilities and lower-than-average verbal skills. Although children with CD often seem tough and fearless, the very embodiment of the word bravado, they usually have very poor self-esteem. The younger children are impatient and easily frustrated, given to frequent outbursts of temper. Teenagers with CD tend to be more reckless and accident-prone.
A few years ago there was a story in the New York newspapers about a gang of girls in their early teens who were roaming the streets of Manhattan’s Upper West Side, sticking unsuspecting passersby in their backsides with pins. It didn’t take long for the girls to be apprehended, and when police questioned them, their ringleader explained their behavior in a way that has stayed with me ever since: “We thought it would be fun, and it was.”
The leader of that girls’ gang vividly illustrates one of CD
’s most dramatic symptoms. Children with conduct disorder do not seem to experience remorse. Quite the contrary: they enjoy their antisocial behavior and often welcome the opportunity to tell people what they’ve been up to. Listening to some of their stories can be positively bloodcurdling. I’ll never forget the time a cherubic six-year-old told me in gruesome detail what he did to the gerbil the teacher brought to his classroom. Just about the only time these children are in any real distress is when they’ve been caught and are about to be punished; they show remorse to lessen the punishment. Then they become angry and upset at the system for not letting them do exactly what they want.
THE DIAGNOSIS
In making the diagnosis of CD we talk to the child, of course, but we also interview parents and teachers and look closely at school records. We take a comprehensive history, paying special attention to the youngster’s development and his aggressive behavior, and examine the family history for conduct problems and criminal infractions. Before an official diagnosis of CD can be made, the symptoms of CD must be persistent—children have to have several symptoms for a period of at least one year and at least one symptom for the past six months—and the symptoms must exist in more than one setting. (We have to satisfy ourselves that the symptoms are not just reactions to a bad situation.) Finally, we look for other disorders, especially attention deficit hyperactivity disorder, separation anxiety disorder, and major depressive disorder, all of which are likely to co-exist with CD. At least 50 percent of all kids with CD also have ADHD.
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