2-Omar & Shahtahmasebi: Making it to adulthood (2)

Making it to adulthood (2): why do we miss the warning signs?

Hatim Omar1 and Said Shahtahmasebi2

1Department of Pediatrics, Division of Adolescent Medicine and Young Parents Program, University of Kentucky, Lexington, KY. 2Good Life Research Centre Trust, Christchurch, New Zealand.

Correspondence: Hatim Omar: haomar2@uky.edu

Keywords: eating disorders, anorexia, bulimia, youth violence prevention, bullying, suicide prevention

Received: 3/7/2018; Revised: 24/8/2018; Accepted: 7/9/2018

Abstract

An earlier paper presented three selected letters from a collection of letters received by the first author. The letters provided insight into the risks and dangers that young people face during the transition into adolescence. In this paper, the contents of 15 randomly selected letters from the collection are explored. The results suggest that the letter writers’ solution to life-changing events or perceived problems was taking risk with their health which in turn resulted in a bigger problem to deal with such as eating disorder and/or suicidality. Although the majority in our sample claimed that they hid their new life style from those around them, there is sufficient evidence to deduce that the changed life-style was meant to be noticed. Because the changes were often extreme and out of character thus they were intended to be noticed. But in the majority of our sample changes were picked up too late by which time the life style had developed into an eating disorder, anorexia, or suicidality. While the life change issues may not be directly the result of an incident, it is safe to conclude that the event contributed as precipitating factor. The letters also indicate that a lack of quality information and knowledge of adolescent behaviour development, and disconnectedness from (parents, friends, medical professionals) were some of the reasons for the warning signs to be missed. However, for the young people in our sample, having access to a trusted and caring professional was the difference between life and death.

Introduction

In an earlier paper (Omar & Shahtahmasebi, 2018) we discussed some of the issues facing young people when transitioning into adolescence. The main issues relate to a lack of quality information about adolescent development, a lack of appropriate and relevant support, and most importantly, a lack of trust in others, a confidant, or someone who ‘cares’.

These issues were raised based on the accounts given in three letters selected from those who had received treatment at the adolescent health clinic run by the first author, henceforth will be referred to as the Clinic. The first author receives many emails and letters from adolescents who have been through the Clinic and have subsequently recovered and/or are on the way to recovery.

In this paper we explore a sample of letters in order to seek further evidence to support the issues raised earlier.

Methods

One of the main aims of the Clinic is to create a trusting relationship with the adolescent in order to increase patient compliance. As part of maintaining this relationship post treatment, the first author offers continuous access and availability via email and internet. Emails are often sent as a call for help or seeking advice on how to deal with a negative event that could push the adolescent to the edge. On the other hand, the letters written by a number of adolescents voluntarily often tell the real story behind the development of their illness.

For this paper, the contents of fifteen letters are explored to gain additional insight into the process of adolescent transition.

All letters and emails were anonymised before analysis.

Results

The sample consisted of 8 cases of suicidality/suicide attempts, and 9 cases that had eating disorders. Three writers had expressed their experiences in a poem, ten described their experiences, three were a summary of what happened to the individuals in the third person, and one was a dialogue between two adolescents where one admitting having difficulty coping and needing company.

The letters do not provide an explicit reason as the cause of the adolescents’ problems. Apart from the fact that for most of the sample suicidality or eating disorders had started during early adolescence, other reasons mentioned in the letters included starting high school, domestic violence and sexual abuse, bullying, being a perfectionist or pressure to do well at school/sport, busy parents, moving house/state, and the pressure of perceived social expectations (e.g. body shape, look and size) as portrayed by the media and entertainment industry.

Because the letters are structured by the writer they only tell the sequence of events from the writers’ perspectives. In other words they were not designed to conform to an academic or scientific structure in order to generate data. They do, however, contain information that can be extracted to gain insight about the adolescents’ problem solving.

Therefore, in this second round of exploration we searched the letters for any signs that may point to what caused a young person to be so dis-satisfied with themselves to engage in severe self-harm such as an eating disorder and suicide attempt both of which lead to hospitalisation and/or death. So, for each case an attempt was made to follow the simple rule of problem solving. In other words, from the information provided in the letters we sought to answer the following questions, e.g.:-

  • What was the problem?
  • What resources, help and support were available?
  • What were the adolescents’ solutions to their problem?
  • What were the outcomes?

Problem: The majority of the letters recounted a long battle with eating disorders ( anorexia), and suicide, which nearly ended in death. Suicidality was a reaction to adverse events such as abuse or bullying. Similarly, eating disorders were a reaction to events, change in environment (e.g. starting high school) or, perceptions of having problems. It seems that the adolescents’ solution to these problems was self-harm, e.g. reducing food intake, or suicidality. Presumably, diet and food intake are targeted by the adolescents because it is the one thing that they can exercise control over.

“Anorexia happened to be my way out of all the craziness.  It is as if I am trying to get the attention and approval of my parents or husband and still remain immature so I would not have to grow up and learn to cope with the world around me.  I want that sense of security back in life, but aren’t sure how to reach that point again.”

“Without my anorexia, I didn’t know how to deal with stress or how to communicate that I wasn’t okay. Not eating was a profound way for me to express myself and my feelings without having to use my voice. It removed any shame I felt about being inadequate and burdening other people with my problems.”

“Two years ago, life was more than I could handle. Anything and everything overwhelmed me and life didn’t make sense. I didn’t have a good coping mechanism and I started to play around with my food.”

“Until the eighth grade, I never really paid attention to the “diet” commercials and the obsession of America to lose weight.”

“I entered high school. I was no longer a big fish in a small pond. Instead, I began to see myself as a “fat” fish in a big pond.”

Clearly, this type of problem solving does not help the adolescent solve the original crisis yet the solution becomes a much more complex problem with severe adverse outcomes especially when the adolescent is prone to such problems. The reason for this is the lack of access to quality and appropriate information about adolescent development. In other words, our process of decision making is only informed by assumptions and perceived values rather than facts. For example, parents believe that working hard to provide for their family will support their children’s development and decision making. Whilst in some cases, working long hours is interpreted as parental absence in a growing child’s life, i.e. lack of parental care and support – it is not that children do not understand ‘to provide means working hard’. Another example, included adolescents who attempted to deal with their feelings about fitting in to a new school by changing their diet and reducing their food intake. Another example is the case of an adolescent who wanted to teach his/her parents a lesson by attempting suicide.

Quite often the circumstances/reasons leading to the disorder/suicidality were absent from the letters. A common reason that appears in both suicidality and eating disorders is having busy parents or disconnectedness from parents due to the parents’ lifestyle, in other words, perceived lack of love and support. The letters expressed non-specific problems and how the adolescent felt at the time prior to the development of their disorder. For example, the letters contained statements such as, “I didn’t have a good coping mechanism”, or “was overwhelmed”, or “everything was fine until age12”, and so on, which can be interpreted as issues of growing up that face all pre-teens transitioning into adolescence. There were several cases with specific issues: 2 cases of domestic/sexual abuse, one case of bullying, and three cases that linked their problems to starting high school.

However, a family environment where parents are busy working long hours, where there is a pressure to be perfect and do well academically and in sport, and parents with problems is conducive to miss the warning signs leading to behavioural issues during transition into adolescence.

Support and help: was absent from the letters and was only forthcoming by parents, friends and teachers when a dramatic change in the case was noticeable such as massive weight loss.

Whether it was a suicide attempt or an eating disorder, help, in the form of a medical intervention, was organised only after the case sought help, i.e. a wish to live a ‘normal’ life again. This places those adolescents who do not ask for help at a very high risk. For example, one suicidal young adolescent played a game of Russian roulette but fortunately stopped after three attempts and decided they wanted to live.

In most cases with non-specific problems, cases hid their course of action (e.g. reducing food intake, weight loss, feeling suicidal) from their family, close friends, and teachers, e.g.:-

“It became an obsession and an addiction.”

“That was when the excuses started.  I probably compiled enough excuses to create a newer version of Webster’s Dictionary. I’d tell them I just wasn’t feeling well, that the school stress was “getting to me.”  For all they knew, I was still eating three meals a day.”

“About six months ago, X[name replaced] started missing school. X began a pattern of attending school in the morning but skipping in the afternoon.  X finally admitted to feeling very depressed and threatened suicide.”

Those with an eating disorder acknowledged that losing weight had given them a sense of control and every time they lost a target weight (e.g. another 1 or 3 or 5 pounds) this gave them a sense of achievement.

“My anorexia had brought with it a sense of accomplishment, safety and security,”

In order to maintain their addiction the letter writers adopted a path of deception, e.g.:-

“It came down to throwing away my lunch, feeding it to my dog after school, or even giving it away.”

Parental support following intervention became a must, but due to a lack of information about suicidality, eating disorders, and generally about adolescent development, parental support became more of a barrier than support, e.g.:-

“My parents, especially my mom, became Public Enemy Number One. Everyone wanted to make me fat. People started to enquire about my weight loss.”

In most cases there was intervention in the form of counselling and visits to doctors and psychiatrists. But the writers were highly critical of the medical profession because they perceived them as someone who does not care and did not ask the right questions and who prescribed medication. This belief reinforced their resolve to be non-compliant and continue with a life of deception and denial that they had an eating disorder.

The question is how long could they get away with it? When rapid weight loss is observed, alarm bells should be ringing very loudly. Were the doctors really fooled by their deception and lies? Whatever the reality, the cases’ health problems worsened after visits to their doctor until such time that hospitalisation were necessary or recommended.

Solution: In terms of solutions medical professionals had failed these young people firstly and most importantly by not establishing a trusting relationship, e.g.:-

“I went to 3 or 4 psychiatrists to try and get better but all they did was prescribe me different kinds of medications and talk to me for about 5 minutes.  Not a real big help.  I also went to my doctor to try and get help.  They didn’t ask me questions they just automatically stuck me on anxiety and depression pills.  I don’t even think they cared, they just wanted the money.”

An additional problem facing the writers was the public perception of anorexia and other eating disorders. Their criticism is the lack of understanding of the disease and a lack of sensitivity, e.g.:-

“In a word, anorexia can best be described as an obsession. The obsession of control, the amount of calories consumed and burned, clothing size, the number on the scale (at every hour of the day), and that tiny flab around the stomach that’s really just skin.”

“The constant fight against the mirror is a battle never won through the eyes of an anorexic; you’re never good enough.”

“And my dad is another story…he will never let me forget the fact that I’ve ‘ruined the family for 3 years.’”

“My dad told me yesterday that he expected me to gain 20 pounds. That scared me…”

“I am “normal.” but it just seems only worse.  I don’t know what to do, and it’s honestly making me hate food again.”

“I’m having an awful day today…my parents are acting just like before.  I told my mom (like you said) that I was feeling fat today and was getting those bad thoughts.  At first she was sincere and nice about it…and then she sort of blew up and told me to get a grip.”

The solution to the problem is not as simple as eating food; the whole problem with anorexia is that ‘food’ or eating is enemy number one along with those who attempt to enforce an eating regime.

“My parents, especially my mom, became Public Enemy Number One. Everyone wanted to make me fat. People started to enquire about my weight loss.”

As is reflected in the comments without the will to live and return to some form of ‘normality’ it is so easy for the illness to return and take control of the patient despite intervention.

The tragedy is that most of the writers had battled with anorexia and suicidality in silence potentially because of a lack of connectedness with helpers (parents and the medical profession). So the adolescents maintained control through deception even after medical intervention. For these cases the solution was a combination of wanting to get better and the intervention of someone they could trust – which made the difference between living and dying, e.g.:-

“The next week Dr. Omar came and saw me at school.  At first I didn’t want to see him because I thought he would be another doctor who didn’t care.  I was really shocked when we had our meeting though.  He asked questions and actually tried to help.”

“This trip is literally what saved my life, when I visited Dr. Omar he told me how bad in shape my body really was, my heart was so weak I was prone to having a heart attack.  A heart attack?! At 15?!”

Outcome: clearly these cases survived their years of ordeal to be able to tell their stories. However all of them have suffered the consequences of their actions in terms of the short-term as well as long-term damage to their bodies. Most of them acknowledged that the road to recovery is long and uneven and full of difficulties but they have expressed the will and desire to work hard to return to some sort of normality, e.g.:-

“For three years, I wasted my life, simply threw it away.  And for what? Absolutely nothing.”

“I won’t let this cause any setbacks, I will keep gaining weight, don’t worry.  I just hate the entire process, it’s so emotionally draining and it makes you feel like you don’t deserve anything in this world. I wish I were just normal.”

“I don’t want to lose and I don’t want to gain. I would like to maintain. But now, it’s just back to the whole “tension” between me and my parents, especially my dad.”

“And I’ve been able to eat normal portions at normal time frames with a snack or two every once and a while without depriving myself and without stressing so much about my diet.”

“I’m still a patient of his and I feel much better.  I’m sober and I’m gaining weight back.”

“Have health problems as a result of the medicine I used to attempt suicide. This medicine caused severe liver damage that requires frequent monitoring and treatment.  This condition has also many restrictions on life activities that I didn’t have before.”

Perhaps an additional positive outcome is the motivation in this group, and others in similar situations to proactively work towards preventing other teenagers fall into the trap of silent self-harm, and learn to talk about their issues, if not with their parents with someone they feel comfortable with such as best friend, a teacher, school counsellor.

Discussion

The first set of problems are often pre-teen or early teen which require attention but are left without addressing – possibly due to the common misconception that ‘it is a phase’ and that children will ‘grow out of it’. There is not much in the letters highlighting what these issues may have been. But, the majority of the letters remember at what age or the circumstances where they felt that their life was problematic leading to their disorders. For example, some use the word ‘suddenly’, e.g.:-

“Suddenly at age 14 found life overwhelming,”

“Anything and everything was a problem,”

“Life was more than I could handle,”

“You could say I was a normal kid until high school…”

It appears that all the adolescents’ decision making processes may have involved drawing attention to themselves without directly engaging with their family/friends, e.g.:-

“Not eating was a profound way for me to express myself and my feelings without having to use my voice. It removed any shame I felt about being inadequate and burdening other people with my problems.”

“I decided to run away from my problems…”

However, this is a high risk strategy, and as evident from the letters, by the time the problem was noticed the playing with food had become a serious eating disorder. It seems that in our sample the solution to perceived ‘non-specific’ growing-up problems is to exacerbate them, e.g.:-

“Overnight, it was as if I decided life wasn’t “complicated enough.”  I guess I just wanted to make it harder.”

There is very little information in the public domain about suicidality and eating disorders. Young people and their parents are ignorant about what it means to feel suicidal or have an eating disorder. Therefore, for the adolescents in our sample messing with their diet seemed a reasonable choice at first, but for the parents the warning signs such as changes in behaviour were easily missed.

The first clue is having busy parents who work hard to meet the financial needs of the family. Under these circumstances the child transitioning into adolescence was unnoticed, ignored, unsupported, alone and lonely, e.g.:-

“This is a story about me [name replaced] who represents yet another teenager with professional parents that are disconnected from their daughter.”

“My [name replaced] parents work long hours and they are very busy with their own lives. An important connection between Jane and her parents is missing.”

“One of the causes of anorexia is insecurity due to lack of knowledge.”

The second clue is the young person’s age at the time of a life changing event, for example, ‘entry to high school’, or moving house or city/state at the ‘onset of early adolescence’, e.g.:-

“But things began to change as I entered high school. I was no longer a big fish in a small pond. Instead, I began to see myself as a “fat” fish in a big pond.”

“We moved to a different county, which means a new school, new friends, new teachers, new church, and a new lifestyle.”

Of course issues such as domestic violence/abuse and self-blaming for parental problems are more difficult to detect, e.g.:-

“It all started by the age of 12.  My parents were having problems and I felt like I had something to do with it.”

“… and every night that I went without sufficient food I felt like I was actually doing something right, that I was making up for my burden on the world.”

 

Other clues related to social perceptions, views (ideal shape, size and look) and knowledge of anorexia e.g. the presumption that the solution to eating disorders is to eat. As reflected in the comments above, parental expectations increase when accompanying their child to a doctor but without modifying their own behaviour which in turn leads to resistance by the case to comply and frustrations on both sides.

 

The fact that adverse outcomes such as eating disorders and suicidality appear to occur following a change suggests that the writers’ protective parameters were not well established during childhood, e.g.:-

 

“I didn’t have a good coping mechanism and I started to play around with my food.”

“I always was, and still am, the “people pleaser”.  That was my goal in life; to be the perfect daughter, the perfect sister, the perfect student, the perfect softball and piano player, the perfect friend, the perfect…”

“Growing up is tough.  The world tells you one thing, but “mommy” tells you another. I look back now and wonder why teenagers have it the hardest.”

 

The main reason is that in almost all cases the individuals broke from their usual habit and behaved out of ‘character’. When this important warning sign, i.e. change in behaviour, is missed by the individual’s parents and caregivers then health complications and adverse outcomes, such as eating disorders and suicide attempts, may occur, e.g.:-

“Here is the girl who used to eat half the ice cream carton box after school for snack, now almost too skinny to set your eyes on.”

While we cannot anticipate protection for every possible combination of scenarios for each child, nor can we all be expected to know everything there is to know about every illness. But, we can use our knowledge of adolescent development to inform and modify our own behaviour in order to prevent young people feeling the need for extreme reactions to life events in order to attract attention. In this way society would be better prepared in acting swiftly in cases where intervention may be necessary thus preventing severe adverse outcomes.

Conclusions

All the letters in the sample suggest that at some stage adolescents may fall through the safety nets. Although we cannot observe all teenagers all of the time but we can modify our own behaviour and adopt policies and strategies that are more inclusive and are protective of young adults entering high school, or moving to a new county and school.

In cases of eating disorders, the letters provide vital information that there was a period of between three to six months when the adolescents first started messing around with their diet and weight loss became an obsession resulting in an eating disorder. Given that in most cases the initial weight loss coincided with other life changes such as coming of age, entry to high school or a house move,  communities must be more vigilant and discard the assumption ‘it won’t happen to us’. As reflected in the letters, when there is disconnectedness in the family and community environment, vulnerable people will fall through the safety net with severe adverse consequences. What saved these letter writers was a trusting health professional who was willing to listen, provide advice and patient centred care.

Young people’s solution to a problem they cannot handle is to ask for help but different people follow different paths in order to seek help. In the case of our sample they tried to attract attention by changing their routine, e.g.:-

“Here is the girl who used to eat half the ice cream carton box after school for snack, now almost too skinny to set your eyes on.”

“I spent countless hours on the treadmill, and began cutting out the snacks and desserts until I soon started to skip my breakfast, throw out my lunch at school, and leave half of my dinner untouched.”

References

Omar, H., & Shahtahmasebi, S. (2018). Making it to adulthood: Why do we miss the warning signs? Dynamics of Human Behaviour (DHH), 5(1), https://journalofhealth.co.nz/?page_id=1510.