Anorexia Nervosa Eating Disorder

Anorexia nervosa is an eating disorder, characterized by the refusal of an emaciated individual to maintain a normal body weight (CITATION ENCYCLOPEDIA). More specifically, its diagnosis is based on three distinct criteria presented by the American Psychiatric Association (APA) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): First, consistent restriction of energy consumption resulting in a relatively low body weight must occur. Second, there is an irrational fear of weight gain. Finally, there is a disturbance in the way one's body or shape is experienced or a lack of recognition for the seriousness of their low body weight (American Psychiatric Association [APA], 2013).

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Eating disorder diagnoses are typically made during ages 12-19 with the peak onset age of anorexia being 12-14 years old (Diamond-Raab & Orrell-Valente, 2002). These diagnoses are unfortunately common, and according to Romero (1984), anorexia affects as many as 1 in every 250 girls between the ages of 12 and 18. While the onset age of anorexia focuses on upper middle school and high school, the development of anorexia is during middle school (Romero, 1984). Additionally, there have been cases of children as young as six with disordered eating (Tanofsky-Kraff et. al., 2004), suggesting that the development of anorexia can start even earlier. Often, by the time a diagnosis is made in older adolescents, there are deeply ingrained psychological effects, long-term health complications, and a low recovery rate (Romero, 1984, p.17). These complications make it imperative to educate on the disease during middle school and early adolescence for prevention and early intervention.

While it is acknowledged that there isn't a single origin for anorexia nervosa, there are a multitude of impacting factors that can be broken down into psychological, biological, and environmental categories (CITATION Mayo Clinic). These impacting factors are important to understand in order to recognize at-risk children. General summary of external factors.

Psychologically, there are high rates of affective disorders, depression, anxiety disorders, obsessive-compulsive disorders, personality disorders, and substance use in adolescent girls with eating disorders (Emans, date). More specifically, middle school girls who are psychologically vulnerable to anorexia development (Romero, 1984) are perfectionists, praise-seeking, and overachievers. This type of girl often seeks praise due to an underlying lack of self-esteem (Romero, 1984). These traits coincide with anorexia development because, generally, individuals who have low self-esteem or view their bodies in a negative light are more likely to develop an eating disorder (citation Creative Wellness).

Insecurity and low self-esteem can result in eagerness to receive praise from outward sources and can also result in control-oriented and perfectionist tendencies (Emans, date). These tendencies can be observed in anorexia patients, as many view anorexia as a form of control in their lives. People with anorexia often have obsessive personality traits (Mayo Clinic). This trait is recognized in a patient's intense, all-consuming focus on food and strict control over their energy consumption. In fact, a study conducted by Thornton and Russell (date) discovered additional OCD diagnoses for 37% of patients with anorexia nervosa. This high comorbidity rate raised awareness for the role of control in anorexia nervosa development and the significant impact of psychological factors.

Beyond perfectionism and controlling tendencies, anxiety is also linked to anorexia nervosa. Often, girls with anorexia nervosa are anxious and use food restriction as a means to cope with their anxiety. The element of control that comes with food restriction is an attempt to combat anxiety (Mayo Clinic citation).

Many of these psychological risk traits can be traced back to the biology of patients. Biologically, while there is no definite distinction of which genes cause a heightened risk for anorexia development, it is known that a person's genetic makeup can influence the development of controlling, perfectionist, and anxious tendencies (Mayo Clinic). There is supporting evidence for the genetic component of anorexia, although further research needs to be conducted. A study on twins conducted between St George's and the Maudsley Hospitals found 56.25% of the monozygotic (MZ) pairs and 7% of the dizygotic (DZ) pairs concordant for anorexia nervosa, providing further evidence for the genetic and familial component of anorexia nervosa. (Holland, et.al). Additionally, the risk of developing anorexia increases 11-fold in people with anorexic family members (sciencemag), and having a first-degree relative with anorexia also increases one's likelihood of developing anorexia (Mayo). While it can be argued that this increased likelihood is due to environmental influences, researchers at the University of Pittsburgh believe otherwise (sciencemag). Psychiatrist Walter Kay found a link between defective proteins in appetite systems and a varied region of chromosome 1 in anorexia patients (sciencemag). More research needs to be conducted on this link, but its discovery has inspired further curiosity about the genetic component of anorexia nervosa and an excitement for future genetically focused treatments (science mag).

While part of the familial component of anorexia can be attributed to genetics, there are many familial and environmental influences on the development of anorexia. In adolescents, parents have a significant influence on their children's behavior. Since children learn from direct observation, parental habits, and thoughts surrounding food can be adopted (citation). Additionally, parental opinions and comments on appearance can influence children's self-perception. Further exploration is necessary on how parental attitudes and opinions influence their children's behavior. Parental attitude and opinion hold great weight in shaping children's attitudes towards foods (White 2000).

Focusing broadly on eating disorders, Emans (date) reported a high frequency of eating disorders among children with family histories of "eating disorders, depression, alcoholism, substance abuse, and other mental illnesses". For example, daughters of mothers with eating disorders have a higher risk of developing an eating disorder than children without an immediate connection to the disease (book). Emans (date) also claims that these families often have high expectations, unstable marriages, and a lack of communication skills. Also, irrespective of individual factors, students have a higher chance of developing an eating disorder if their parents are highly educated (Bould). More specifically, these trends have been identified in patients with anorexia nervosa.

Romero (1984) depicts the families of anorexia patients as those with managerial or professional positions and high expectations. These parents emphasize physical appearances and academic achievement (Romero, 1984). Transition sentence.

Family culture may be associated with anorexia development. It was once argued that anorexia was most common in upper-middle-class white girls due to Western culture's emphasis on thinness (Romero, 1984). However, this belief has been challenged, on the grounds that those suffering in a White upper-middle-class culture have the financial ability to receive treatment and report their eating disorder cases, whereas other minority anorexia patients may not be as fortunate and thus are underrepresented (GET CITATION). There have been numerous studies revealing the prevalence of eating disorders in minority populations. In a study of 545 Hispanic, Native American, and White high school students, it was discovered that both Native Americans and Hispanics had higher percentages of disturbed eating than non-Hispanic Whites (Smith & Krejci, 1991). The outcomes of this study contradict the belief that anorexia is primarily experienced by white communities. Moreover, a study conducted by Shaw, Ramirez, Trost, Randall, & Stice (2004), investigated the perceived differences in eating disorders between minority groups and Whites. Their findings showed "little support for the hypothesized ethnic differences in eating disturbances and suggested "that ethnic minority groups have achieved parity with Whites in this domain" (Shaw et. al, 2004). These studies raise awareness of the prevalence of eating disorders in groups once presumed to be less affected.

While these studies were not anorexia-specific and focused more generally on all eating disorders, they provide evidence that eating disorders do not discriminate their victims. Educators should bear this in mind and eliminate cultural biases when identifying eating disorder cases in their classrooms. Further research on anorexia-specific cultural trends should be conducted to identify correlations between culture and anorexia nervosa. However, from an educational and professional perspective, it is better to remove assumptions and consider that all students could be at risk to avoid overlooking cases (book).

Anorexia nervosa should be examined in an educational context because adolescent development places middle school students at risk for anorexia nervosa development. The onset age of anorexia corresponds to when students are in middle school (Romero, 1984). Many of the physical and social developments taking place during middle school can become risk factors for anorexia or cause side-effects that are risk factors for anorexia nervosa development (citation).

To start, there are heightened environmental transitions entering and exiting middle school. Many students transition into a new school for middle school and will transition into a new school for high school. These transitions come with new friends, classes, and unfamiliar environments. According to the Mayo Clinic (date), transitions are risk factors in the development of anorexia because of the emotional stress they cause. Those who experience emotional turmoil from transitions may use anorexia nervosa as a coping mechanism (Mayo Clinic, date). The physical environment transitions that often occur at the beginning and end of middle school, therefore, place students at risk for anorexia development.

Beyond the environmental transition to a new school, there are additional physical developmental changes that place middle schoolers at risk for anorexia nervosa. Puberty occurs during early adolescence and causes weight gain and increased fat distributions. These bodily changes can make middle school girls more conscious and insecure about their bodies (Romero, 1984). These insecurities can develop into body dysmorphia, delusional thoughts, and anorexia nervosa. If not treated, the lack of energy consumption from anorexia nervosa can stunt physical maturation, force amenorrhea, cause patients to lose up to 50% of their original body weight, and eventually die of starvation (Romero, 1984). Adolescents with anorexia nervosa have a 12 times higher mortality rate than those who do not have the disease (NEDA), making the intervention and prevention of anorexia nervosa imperative in middle schools.

During this time, adolescents are also emotionally developing an identity and cognitively developing their values. Physical development affects identity development since physical appearance is the number one factor that influences global self-esteem (book).

The recent development of identity and cognitive development among adolescents has made them more prone to fall under the weight of peer pressure. Social acceptance is prioritized over healthy choices (book). Peer influence is accentuated because during early adolescence, preoccupation with how their peers see them can become all-consuming (book).

INTERVENTION:

Its prevalence and 20% mortality rate (Romero, 1984, p.16) make it an important illness to examine in schools nationwide.

No programs were effective in improving body image in boys and girls with 12-18 year olds BUT effective programs were conducted with 1213 year olds. https://www.sciencedirect.com/science/article/abs/pii/S1740144513000405

What are current or possible responses at the classroom level? At the school or system level?

"The development of values, beliefs, and assumptions is transmitted through the school's curriculum, the teachers' attitudes, and peer interactions." (Ricciardelli & McCabe, 2001).

"Wellness groups in schools, along with the education of parents and teachers, are crucial in identifying and preventing eating disorders in children and adolescents." (Smolak, Harris, Levine, & Shisslak 2001; Russell-Mayhew, et al., 2008).

Classroom intervention

I. Counselor

II. Peer education on a topic

III. In health class

IV. Regular teachers

V. The effectiveness of these methods

VI. Dependence on School Environment:

Rates of eating disorders (ED) vary between schools, and this is not explained by individual characteristics. (Bould)

"Girls at schools with a high proportion of female students, and students with highly educated parents, have higher odds of ED regardless of individual risk factors." On average, a young woman, regardless of her own background, is more likely to develop an ED if she attends a school with a higher proportion of girls or a higher proportion of children of highly educated parents. (Bould)

Schools are not entirely to blame for this, but this issue is crucial to examine from an educational perspective because of its prevalence and high mortality rate. School teachers see kids more often and during meals, and can pick up on abnormal behaviors.

Interventions that have statistically worked:

Intervention:

To date, it appears that the important elements of school-based programs include media skills, appreciation of body shapes and sizes, healthy eating at home and school, physical activity and exercise, outreach to parents and communities, and referrals for services. (Emans)

Conclusion: Going forward, more research is needed and there are flaws with the information we currently have.

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