Back To School And The Risk Of Relapse


When you practice as long as I have in the field of childhood eating disorders, one thing becomes abundantly clear: there are cycles to the frequency with which patients appear on our doorstep for treatment — and on the doorsteps of all the other treatment centers as well. The trouble is, it has proven difficult to understand the peaks and troughs of these cycles and correlate them to much of anything. But there do seem to be a few tentatively recognizable patterns. And these peaks and troughs of admissions/referrals to our clinic encompass newly diagnosed patients as well as relapses of patients formerly in remission. In other words, when  newly diagnosed patients increase in number, our own (existing) patients begin to do worse. No idea why this seems to happen.

An example of one of the patterns we see and believe to understand, however, involves the college-aged patient and Thanksgiving. Often, the Thanksgiving break is the first time parents see their young adult child after they sent them off to school in late August or early September. Hence, it is the first time they are aware of how much weight their child may have lost. For this reason we experience a spate of college-aged referrals around Thanksgiving — but more about that in another blog sometime.*

The other pattern involves the first few weeks after the start of school in younger patients: just about the time results of the great viral mixing of school attendance begins to hit the pediatricians’ offices, we seem to see relapses in some existing patients, in addition to those newly diagnosed. Within the first month of a new school year kids begin to present to us with weight loss and food refusal.

Of course, from the family’s point of view, this is just about the world’s worst time to get the news that school attendance will need to be put on hold for treatment, but there you have it: the child has lost weight, is often medically unstable and finding it difficult/impossible to eat at school or even at home without intense supervision.

I have often suspected that this apparent worsening of symptoms around the first month of school attendance is actually not caused by the stress of school (although I imagine it could be) but, rather, had its origins in mid to late summer, when wishful thinking took over.  

What do I mean? Summer is a two-edged sword: the academic performance stress is reduced when school gets out, of course, but summer also represents a significant reduction in the day-to-day structure of a child’s life. There is more free time, there is more down time. Free time/down time is not our friend. The experienced parents of children and youth with eating disorders can tell you that lack of structure is hard for them. The structure of a school day is actually a boon and the “freedom” of summer a challenge.  

So I think that kids often begin to struggle with their meals and even lose weight in the summer months and that is where the “wishful thinking” comes in. Rather than yank on the alarm bell, parents hope that school will normalize everything and treatment will not be necessary. The problem is, when you have anorexia nervosa, “lose weight, get happy.”  And this apparent improvement in mood fools us into complacency.  “It’s only a few pounds” lulls us into thinking the eating disorder will be satisfied with this. The kids enter school already on the (invisible) downward path, which within a few weeks becomes manifest as food refusal, hiding school lunches, social withdrawal, an increase in arguments at home about eating, etc. A few weeks later, when the degree of struggle can no longer be ignored, the family is in our office (or someone else’s) and we think “school caused this problem.”

All I can offer in the way of experienced wisdom is this: in a child with an eating disorder, all weight loss is bad. All food refusal must be taken seriously and treated immediately. Do not wait. The chances of spontaneous reversal are low, the chances of worsening high, with the nearly inevitable disruption of school attendance to follow.

Act early, act swiftly, act decisively. And salvage that school year.

Original publication date: 9/18/13
*Please note: Kartini Clinic no longer treats college-aged patients.