Campers with eating disorders.

Dear Bob,

We are an all-girls camp in the South with adolescent campers who, in recent years, have been struggling more and more with eating disorders. One case last summer was particularly disturbing to us.

A 14-year-old camper I shall call "Alice" came to camp without any warning from her parents that she might be having a problem with her weight or with eating. Alice had been with us the previous year, so we were stunned to see how thin she had become. When we expressed our alarm to her parents, her mother at first flatly denied there was any problem. However, as conversations continued, she finally admitted that she "didn't want to make a 'big deal' about it," and didn't want us to get into a struggle with Alice by talking about it with her directly. Our concern was Alice's ability to maintain her health in our rigorous, active camp program, especially in the summer heat. Against the protests of the parents, we put the girl on close monitoring and found she was eating very little. She did manage to eat "just enough," thereby assuring that she could remain at camp for the summer. However, she did go home from camp weighing 5 pounds less. The parents' response? They were angry with us that we didn't let them know she was losing weight!

Bob, what can we do to protect ourselves and the campers, get through to the parents, and understand this problem better?

Worried, But Still Eating

Dear Eating,

When it comes to camp directors' concerns about campers, your letter speaks to one of four major issues most often mentioned in an informal survey I conducted last summer in the more than 36 camps I visited. (The other three are attention deficit disorder, or ADHD; increased aggressiveness and conflict among campers; and a surge in "rudeness" toward adults by all campers and by girls in particular.)

Your letter is also timely. In October, 1995, the Carnegie Foundation published a study that voiced concern about the rise of serious signs of stress among girls in the United States, eating disorders being one of the leading symptoms. Though this is a topic far more complicated than can be thoroughly addressed here, let me cover some main points.

Anorexia nervosa, bulimia, and Binge Eating Disorder (BED) are the three eating disorders most familiar to the general public. Anorexia is characterized by weight loss ranging from minor to life-threatening as the result of abstinence or minimal eating. Anorexia is the most serious of the three eating disorders in that it can result in death or long-term damage as a result of malnutrition. Children who suffer from anorexia tend to have a highly distorted image of their own body, can be perfectionistic, and are often involved in strenuous activities like gymnastics, ballet, intensive aerobics, running, or wrestling. Demands of the activity often reinforce the belief of anorexics that they are "fat" or in need of further weight reduction. The female camper "Alice" in your letter sounds like she suffered from anorexia.

Bulimia is a condition whereby the person overeats, then induces vomiting or uses laxatives to "purge" herself of the excess calories. Bulimics cycle through periods where they engage in bingeing and purging from rarely to several times in one day. The most immediate concern from a physiological point of view is loss of energy and electrolytes, though bulimics also experience damage to their teeth, epiglottis, larynx, and so on from repeated vomiting.

Individuals with Binge Eating Disorder cycle between futile dieting attempts and uncontrolled eating binges similar to those of bulimia. Unlike bulimics, however, those with BED do not purge themselves.

The underlying causes of eating disorders are varied and complicated. Suffice it to say that they include issues of control; a desire to separate and have greater autonomy, countered by a desire to remain connected; an attempt to adapt to past trauma; and a barometer of family stress. Girls are afflicted with eating disorders far more often than boys, although boys have recently been reported suffering from anorexia (especially runners and wrestlers) in greater numbers. It is only a matter of time until more camps begin seeing anorexic boys and male staff.

Some girls have described losing weight as the only thing they felt they had control over. Others have talked about feeling like they had to "mold myself to my mom and dad," ...by taking in their parents' beliefs, only to spit them out, literally, in an attempt to regain autonomy. Still others have talked about weight loss as a way of countering feelings of inadequacy and rejection, their body being the one thing they can do something about, thus recouping control and gaining a sense of mastery in a world in which they feel helpless.

The most important thing for camp directors to remember, however, is that it is not your job to analyze the cause of a camper's eating disorder. An eating disorder is a psychological problem that can have serious medical complications. Your job has three parts:

1. to enlist qualified medical help in assessing whether the child can remain safely at camp;

2. to create a monitoring system, with the proper personnel involved, to assure the continued health of the child who does remain at camp; and

3. to create an alliance with the parents and the proper medical personnel aimed at insuring the child's continued well-being (and reducing your exposure to risk in having this child at camp).

Most children with an eating disorder arrive at camp without directors' prior knowledge. Of all behavioral difficulties a child might have, this is one where the denial of the parents is often extremely high. Even when confronted by the facts, parents will continue to deny that there is a problem and in some cases unwittingly contribute to it. In the case you describe, it sounds like Alice's parents did have some prior knowledge of her condition, but were hiding it from the camp, probably out of fear that you would not accept her or by thinking the problem would "just disappear."

Your strategy is to ask to speak to the child's pediatrician or the family doctor. If you make speaking to the family doctor a qualification for keeping the child at camp, you will get greater cooperation. Stick to your guns.

The doctor may tell you something quite different from what a parent claims the doctor has said, as was the case at one camp in New York this summer. Furthermore, if you have concerns about continued weight loss, have the doctor and the camp medical personnel work out arrangements for monitoring the child's health and weight that keep you and the child's counselors out of the struggle. Remember that this behavior is often a manifestation of some struggle between parent(s) and child for power, control, autonomy, etc. - one struggle you want to stay out of!

You will have greater success establishing an alliance with a child if you let the medical folks do the job of weigh-ins. Hovering over a child at meals or counting calories only gets you or your staff entangled in the problem.

In other issues I often recommend that directors and staff take a direct, strong stand. With eating disorders, you must be shrewd or campers will only escalate their behavior (often putting stones in their pockets at weigh-ins or getting into other deceptive behavior at meal time).

If a camp doctor or nurse, working with the family doctor, decides a child has fallen below the weight level established as the one they must maintain to stay at camp, then it frees you up to remain supportive, concerned, and not a policing force.

Letting your medical staff take charge also minimizes your struggle with parents and gives you better coverage with regard to risk. Some children with eating disorders find camp to be a refuge, helping them refrain from their symptomatic behavior while at camp.

Bob Ditter is a licensed clinical social worker specializing in child and adolescent treatment. Camp directors are invited to write to Bob at: Bob Ditter, "In the Trenches," 93 Union St., Ste. 307, Newton, MA 02159 or e-mail: [e-mail], or fax [phone]. Letters should be signed, although requests for confidentiality will be honored. "In the Trenches" is sponsored by American Income Life Insurance.