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Addressing concerns about body image

If a school or youth group is concerned that a student may have body image issues or an eating disorder, staff should follow the same procedures as they would for any student who may be at risk. This will involve treating the issue carefully and sensitively, not making any judgement or diagnosis, keeping a record of any causes for concern, and talking to the student and his/her parents/guardians.

Signs and symptoms of negative body image or an eating disorder

⚠️ They make negative comments about their body

⚠️ They seem unhappy in general

⚠️ They start to spend more time on their own

⚠️ They make frequent comments about how other people look

⚠️ They compare themselves e.g. wishing they looked like other people

⚠️ They refuse favourite foods or mention calories or fat content of foods

⚠️ They spend more time at the mirror and seem unhappy with what they see

⚠️ They get upset when trying on clothes or buying new clothes

⚠️ They talk about dieting

⚠️ They start exercising obsessively or change to ‘appearance focused’ exercise to change their body such as weight lifting or going to the gym

⚠️ They start eating less at meals

⚠️ They link guilt to food and may talk about good or bad foods

⚠️They may choose to follow a special diet to have more control over what they eat – e.g. decide to become vegan, follow a sugar-free or gluten-free diet

Body Image

Parents can be given appropriate information on promoting positive body image and directed to the section of this Bodywhys website designed for parents. You can also contact Bodywhys and request our parents booklet and other relevant leaflets to provide to parents if you are concerned the child may have an eating disorder.

Eating Disorders

For the most part, students with eating disorders remain at school. Only those who are seriously at risk medically and/or psychologically are hospitalised. The challenge for those working with the young person is to provide a safe, supportive environment that does not contribute to their obsessive attention to food, weight or body image. All teachers or youth workers will need to have the appropriate information on eating disorders and be familiar with the range of approaches to effectively respond to and support the student. If in addition there are any child protection concerns, adhere to the procedures outlined in your school policy.

It is recommended that the young person is involved in any decision-making so they can be given as much ownership as possible over the choices being made. It is also important to evaluate with them their strengths and limitations, help them to accept these and set realistic goals that will guide them away from perfectionist thinking and behaviour.

Exercise and sport, for example, may require careful observation as over-exercising frequently occurs as part of obsessive preoccupation with weight and shape. Returning to school after hospitalisation can be a particularly difficult time as the expectation is that the young person will now be “better”. It is crucial to remember that recovery is a gradual and often very slow process. Change needs to take place at many levels – physical, psychological and behavioural. The restoration of a healthy weight, for example, will not automatically translate into emotional balance and the discontinuation of disordered behaviour. Acceptance by parents and teachers that recovery can be a very slow process, together with recognition that relapses can and do occur, will help to avoid placing undue stress on the young person.

In cases where teachers/youth workers have concerns that a student may have an eating disorder but the family or student have not come forward, it is important to note that it is not the role of the teacher/youth worker to diagnose whether or not a student has an eating disorder. However, if concerns have been raised with regards to the well-being of a particular student and the school feels that intervention is necessary, the information contained in this resource may serve as a guide in relation to how to take the appropriate steps.

The school can play a very important role in terms of supporting a student who has a problem. Social, Personal and Health Education (SPHE) plays a lead role in prevention as it addresses issues such as self-esteem, body image, influences, peer pressure, coping strategies and decision-making. The SPHE programme not only provides students with relevant information but also challenges their attitudes and values and helps them to develop the skills necessary which empower them to make healthy lifestyle choices. Many other aspects of school life will also provide a positive and supportive environment for students at risk such as the pastoral care provision and extra-curricular activities.

Q. How can I prepare myself to talk to a student I suspect may have an eating disorder?

There is a possibility that the young person and maybe even their parents will react negatively to any suggestion of an eating disorder. Denial of a problem is often the first response. The following are some guidelines to consider if you are hoping to approach a student and/or parents:

✅ Concerned teachers are advised to keep clear, concise accounts of the incidents and behaviours that have led them to believe that there is a problem. This will give you concrete information to help you present your concerns clearly.

✅ Avoid diagnosing, but your careful observations may assist in any assessment and diagnostic process further down the road.

✅ Share your concerns, in confidence, with the school counsellor or the person concerned with pastoral care in the school. Decide together who is the most appropriate person to approach the young person and his/her family.

✅ Check the school policy on making contact with parents and refer to any existing policies around duty of care for young people.

✅ Friends may be the first to bring concerns about a fellow student to the attention of the school. Ask them to describe what they have observed or heard their friend say. Reassure them that they did the right thing by talking to you. Tell them what you intend to do with the information you have been entrusted with. If appropriate, let them know that you will talk to their friend. Signpost them to information that may be of help to them.

Q. What is the best way to approach and talk to a student about eating disorder concerns?

Approaching a student about an eating disorder with the intention of providing help and support is first and foremost about accepting the person as they are now, showing your willingness to support them, and listening without judgement. If you are feeling very apprehensive and anxious about approaching someone, you may find it helpful to seek support for yourself first. Approaching a student from a position of fear or anxiety is unlikely to be constructive and may add to their distress. You may wish to use the services of Bodywhys, talk to a healthcare professional who has experience in the area of eating disorders, or talk to others who are supporting a person towards recovery.

Guidelines for dealing with eating disorders

The following are guidelines for talking to a student who may have an eating disorder:

⭕ Before talking to a young person, familiarise yourself with the information on eating disorders in this resource pack. This will increase your capacity for understanding and empathy.

⭕ Arrange to talk to the young person in private and with plenty of time to avoid feeling rushed.

⭕ Gently let the person know that you are concerned about him/her. Be sure to communicate care and concern, using phrases like: “I am concerned about you because lately you seem unhappy/sad/ preoccupied/anxious/tired…”

⭕ Communicate in a direct and non-judgemental way the specific incidents or behaviours that have given rise to your concern, i.e. “I have noticed you often throw out your lunch/often visit the bathroom after meals.” Talking abstractly or in general terms is more likely to lead to a denial of behaviours.

⭕ Communicate an understanding that food, weight and body image issues are only part of the picture and focus more on how the person is feeling.

⭕ Gently invite the young person to respond in terms of how they feel about what you had to say. It is also important to explain the limits of confidentiality and the reporting procedures arising from your school or organisation’s Child Protection Policy.

⭕ Encourage them to speak as openly as possible and listen without interrupting. Accept all their feelings as real and valid. Avoid judging, blaming, criticising, or trying to persuade the person to see things your way.

⭕They may deny that there is a problem or become upset. Listen to what they say without interruption and without making any judgements.

⭕ Remain calm and reflect back to them what they have said to make sure that they feel that their thoughts and feelings have been heard accurately.

⭕ Do not use scare tactics, become involved in a power struggle or prolong a conversation that is not going well.

⭕ Communicate a belief that recovery is possible and your belief in their ability to recover. Communicate an appreciation of the energy it takes to struggle with an eating disorder. That same energy is the person’s most valuable resource for recovery.

⭕ Try to negotiate a way forward together. Ask the person what they need from you to help reduce the stress they are experiencing. If they find it hard to identify their needs, suggest to them what you feel might be helpful but be sure to check with them whether they feel what you are suggesting will make things easier or more difficult for them. Be honest with them about your own limits.

⭕ If appropriate, state that the student should seek help and outline what help is available to them both within and outside the school context. Make it clear the role you will play in accessing this support.

⭕ Provide them with helpful information about eating disorders and support services but do not force it on them.

⭕ Do not be discouraged if your approach is met by resistance and/or rejection. It may take some time before the person feels ready to be more open to your approach.

⭕ Decide with them what will happen next. It may be that other school personnel and their parents need to be informed. Consider action in relation to duty of care if a student requests that parent(s)/guardians not be informed.

Stigma

Important: If it is an adolescent male that you are concerned about, the following should be considered: Unfortunately there is still a lot of stigma surrounding mental health issues which can prevent individuals from seeking support. As eating disorders are often viewed as a predominantly female concern, it can increase the sense of stigma, shame and embarrassment experienced by males who have an eating disorder. It may be even more important to refrain from mentioning the term “eating disorder” in the discussion, but rather focus on the specific behaviours of concern that you have noticed.

Keep the conversation brief and tell him what you’ve observed directly and why it worries you. Eating disorder behaviour can sometimes present differently in males. Although the emotional and physical consequences of eating disorders are similar for both sexes, males may be more likely to focus on muscle gain, while females may be more likely to focus on weight loss. However, this is not to say that males cannot also develop eating disorders which focus on weight loss, such as anorexia or bulimia.

Q. What guidelines do I need to consider if I have to inform a parent or guardian that the school/youth group has concerns about their child?

Consider the family dynamics and any cultural or social issues that may make it difficult for the parents/guardians to discuss issues relating to body image and eating disorders.

Begin by telling the parents/guardians that you are concerned about the student and offer specific, factual observations about the student’s behaviour to illustrate your concerns. It is not your role to make a diagnosis. Do not interpret what the behaviour could mean – just state the facts of the observed behaviours.

Here are some examples which can be adapted depending on whether the contact is verbal or written:

• ‘We are concerned about (student’s name) because of some behaviours we’ve noticed recently. Specifically, he/she has been keeping to himself/herself a lot and has been [distracted, fidgety, agitated, unfocused, etc.] in class. I was wondering if you had any concerns or noticed anything recently.’

• ‘We are concerned about (student’s name) because of some comments we’ve heard him/her make about himself/herself recently. We’ve heard (student’s name) make a lot of comments about feeling unhappy about his/her appearance, weight. I was wondering if you had any concerns or noticed anything recently.’

• ‘We are concerned about (student’s name) because of some behaviours we’ve noticed recently. We’ve noticed (student’s name) does [not eat lunch; eats very little; throws lunch away; always requests permission to use the toilet immediately after eating and becomes very agitated or upset if not allowed to leave at that moment, etc.]. I was wondering if you had any concerns or noticed anything recently.’

• Show empathy and support as the parent responds to what you have said. Give ample time to listen to what they say without interruption or judgement.

• Aim to establish and maintain a positive, open, and supportive relationship with parents/guardians. Be mindful that parents/guardians may feel guilty, blamed, or responsible for the eating issue or disorder in some way.

• Be clear about the support the school can offer and the services available through the school.

• Ask the parents/guardians what kind of support would be helpful. This may provide useful information about how to proceed, and it may also facilitate a sense of trust and safety with the family.

• Encourage the family to access support, information and have resources available to refer them to.

• If appropriate, involve the student in conversations with his/her parents/guardians.

• If possible, negotiate an agreement with the student to enable open communication with parents/guardians.

• Consider what action you are permitted to take if parents/guardians deny that there is a problem and you believe the student is in crisis.

• Encourage them to speak to their family doctor.

• Specify who at the school will be a family liaison so that the family has the opportunity to develop a supportive relationship with a school staff member.

• Follow up with a written summary of the conversation and action steps agreed upon, and send the summary to the parents/guardians to check mutual understanding of what was discussed. If you feel it is appropriate, the following information may be helpful to pass on to the parents of a student you suspect may have an eating disorder.

• Talk about confidentiality and its value. For example, promoting the idea that medical information is private and therefore nobody else’s business.

• Do not persist with a conversation that isn’t going well. This may damage future communication. To end a conversation that isn’t going well:

• Acknowledge that you sense it must be difficult to talk about it;

• Affirm that the choice to not talk about it is OK;

• Reiterate the school’s concern for their son/daughter;

• Leave the door open by reassuring them of the support available through the school;

• Let them know that the school will contact them again soon to check in.

Frequently asked questions by teachers and youth workers

When someone we care for is in distress, it can have an impact on us too. It is natural to want to help and make them feel better. It is not always easy to know what to do.

Q. I’m noticing some changes in weight, eating habits, exercise etc. with a student, but I’m not sure if it’s an eating disorder. How can I tell?

Unless you are a healthcare professional, you can’t make a diagnosis, but you can refer the student to appropriate resources that might help. Keep in mind, however, that denial is typically a big part of eating disorder behaviour and a student may not be receptive to the suggestion that anything is wrong.

Q. What if I say the wrong thing and make it worse?

Family, friends, and school staff often express concern about saying the wrong thing and making the eating disorder worse. The causal and maintaining factors of eating disorders are complicated. Just as it is unlikely that a person can say something to make the eating disorder significantly better, it is also unlikely that someone can say something to make the disorder worse. The best thing to do is to make sure you are as well informed as possible about eating disorders so that you are equipped with accurate information and can confidently engage in conversations around the topic.

Q. A number of students are dieting together. What should we do?

Seeing a friend, family member, or fellow student develop an eating disorder can sometimes lead other students to feel confused, afraid, or full of self-doubt. Other students may begin to question their own values about thinness, healthy eating, weight loss, dieting, and body image. At times students may imitate the behaviour of their friends. Imitating the behaviour may be one way of dealing with fear, trying to relate to the friend with the eating disorder, or trying to understand the illness. In other cases, a group of students dieting together can create competition around weight loss and unhealthy habits. If dieting is part of the accepted norm of the peer group, it can be difficult for any young person seeking peer acceptance to resist joining the behaviour. Approaching a student who is imitating the behaviour of a friend with an eating disorder should be similar to approaching a student with a suspected eating problem.

Q. What should be done when rumours are circulating about a student with an eating disorder?

If a student has an eating disorder and other students are talking about it to the point where the student with the eating disorder is uncomfortable coming to school, it is important to employ a strategy to deal with this. When a student is suspected of having or is diagnosed with, an eating disorder, fellow students may have different reactions. Rumours often develop that further isolate the student experiencing the eating disorder. Rumours can also be a form of bullying. Here are some suggested strategies:

• Refer to relevant school policy and procedure.

• Assess the role of the rumours. Sometimes rumours indicate students’ feelings of discomfort or fear.

• Demystify the illness. Eating disorders can sometimes become glamourised or mysterious. Provide age appropriate information that focuses on several aspects of the illness such as the causes as well as the social and psychological consequences (not only the extreme physical consequences).

• Work privately with students who are instigating and/or perpetuating rumours:

• Talk about confidentiality and its value. For example, promoting the idea that medical information is private and therefore nobody else’s business.

Without identifying the students as instigators of the rumours, encourage them to come up with ways of dealing with the rumours by establishing a sense of shared concern and responsibility. For example, “Can you help me work out a way of stopping rumours about (student’s name), as he/she is finding them very upsetting?”

The issue could be addressed through the SPHE programme where appropriate.

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