Gerald Hurowitz, M.D.·Published 28 April 2011·11 min read
Key points
Adolescent girls tend to form exclusive groups called cliques, complete with leaders and specific codes of behavior regarding what is acceptable.
As we mentioned in Chapter 3, perfectionism often occurs with an eating disorder, sometimes predating the illness.
When a girl aspires to join a particular clique, her day-to-day progress (or perceived lack of progress) toward that goal are of dire importance to her; any remark, however casual, from a popular clique member can either make her day or consign her to the doldrums.
"My daughter's outgoing personality draws people to her," states Jordan, Holly's father.
Adolescent girls tend to form exclusive groups called cliques, complete with leaders and specific codes of behavior regarding what is acceptable. A given middle or high school may include many cliques, each with its own distinct subculture. For example, when members greet each other, a specific phrase (as in "Wha's up?" or "Yo"), gesture, and voice inflection may be required. Often, there are certain expectations regarding clothes and physical appearance; perhaps members all ascribe to multiple ear piercings, streak their hair, sport the same style bracelet, or worship thinness.
When a girl aspires to join a particular clique, her day-to-day progress (or perceived lack of progress) toward that goal are of dire importance to her; any remark, however casual, from a popular clique member can either make her day or consign her to the doldrums. However, life inside a clique is not as rosy as wannabe members assume; although these groups may offer a sense of belonging, they sometimes exert intense pressure to conform and become hotbeds of subtle or not-so-subtle aggression. A girl who is "in" one month can be "out" the next. Holly knows about that firsthand. A year ago, she developed anorexia shortly after a falling-out with her girlfriends. Now 13, she and her parents have kindly offered to tell their story.
"My daughter's outgoing personality draws people to her," states Jordan, Holly's father. "She's always been very popular, a leader among her classmates. Her seventh-grade teacher described her as an extraordinary girl not only because she is an enthusiastic learner and has a strong work ethic, but also because the other kids looked up to her. Never timid, she gets a great deal of satisfaction from her friendships."
Holly describes how her social life took a turn for the worse: "It started as a little fight and blew up way out of proportion.
Melanie was my best friend in seventh grade, and there were four other girls in our group. In the winter, Melanie started feeling left out. And she was right; the others weren't including her like they had in the past. She wanted to know why they were down on her, so she tried to talk about it with them, but they got mad at her for making a big deal about it. When they were mean to Melanie, I stood up for her, and then they turned against me as well. If I'd given in and taken their side in their fight with Melanie, they would have liked me again. But I never gave an inch. I'd pass them standing in their usual spot in the hallway, and they'd get closer together and sort of whisper. One of them, Christie, used to say, 'Bitch,' just loud enough for me to hear it. I tried to keep on walking, pretending that I didn't care. But one day, I must have blushed or looked upset because I paused for a second. So Christie turned to me and said, 'I was just joking around. Can't you take it?' I'd never been so embarrassed in my life.
"After a while, I stayed away from their hallway get- togethers.But sometimes we'd all be in class and one of them would look over at me and mouth, 'Bitch.' I'd feel like mouthing that same name, or a worse one, back at her. But I didn't because they just would've hated me more. It was hard to get away from their mean looks, especially when they rolled their eyes as if I was from another planet. Before all this started, I'd shared all their inside jokes. Now they had new ones. These girls had been friends with me since kindergarten. They knew which buttons to push to upset me. Mostly, they acted like I didn't exist. It went on like that for months."
Written and revised by
Gerald Hurowitz, M.D.
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The kind of bullying Holly experienced is all too common.
Mainstream American culture places girls in a bind regarding how to cope with anger and other emotions. Females tend to place special value on their friendships and go to great lengths to preserve them, sometimes at substantial personal cost. Resolving a dispute in a healthy way generally requires opposing parties to talk about their feelings. Yet many women have grown up unprepared for this. Raised to be nice at all times, girls typically avoid voicing anger face-to-face. Instead, they tend to express it quietly and indirectly. Like Christie, the girl who is annoyed at a friend may engage in name-calling, claiming to be kidding when she isn't. Maybe she passes nasty notes in class, spreads rumors about her perceived rival, or stops talking to her, encouraging others in their social circle to do the same. Perhaps she finds safety in numbers. Recruiting peers as allies often affords her the opportunity to bully under the protective blanket of a group; if she's one of many aggressors, no one is likely to blame her directly. In fact, with access to e-mail, girls can gang up on an opponent without saying a single word to her face.
"By sticking up for her best friend," says Holly's mother, Marianne," Holly did what was strong and noble. It bothered me that she had to pay such a high price for being a true friend. She took the aggression of these girls hard, and I sympathized with how she felt. For the first time in her life, kids weren't knocking the door down to be her friend. Ostracized from her group, she became withdrawn, slept much later than usual on weekends, and spent a lot of time moping. Another change was that she complained of headaches and stomachaches prior to her hip-hop ballet rehearsals. I wondered whether these were the result of social pressure.
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Or maybe she was stressed about the new dance routine she was learning; she tends to come down hard on herself when she doesn't catch on to something as quickly as she wishes or if she flubs a step that she feels she should have mastered. When I discovered how skinny she'd become and how little she was eating, I realized that her headaches and stomachaches were probably hunger signals.
"I clung to every last hope that Holly didn't have an eating disorder. She'd always been average in weight for her age and height. I reminded myself that she'd never before been obsessed with the size or shape of her body. Why now? What's more, she'd just turned 12 the previous month. Wasn't she too young to have an eating disorder? My pediatrician explained that although these illnesses commonly begin between the ages of 13 and 25, they have, over the past decade, started to afflict children at increasingly young ages. While no one knows exactly why this is happening, he said that improved awareness of parents is likely allowing more kids to receive help."
Holly remembers the turmoil that marked her descent into anorexia. "I was on a diet before the fight with my friends, but afterward, I cut way back on my eating. Lots of girls dieted, so I never thought anything was wrong with it. I just wanted to look thin. At lunchtime in school, girls always talk about what they should or shouldn't eat. Someone might say, 'I can't have that. It's too fattening,' or 'I ate too much yesterday, so today I have to be good.' When I first lost weight, everyone said how great I looked.
Then the diet kept going. My doctors said I had an eating disorder, but I didn't feel sick. At the time, I thought losing weight would help me. That's why I fought against gaining it back."
Jordan's memories of that time period are vivid. "Treatment was a team effort," he says. "Holly started out seeing the pediatrician every week to have her weight and vital signs checked and to learn why it was important for her to eat more. She also had individual therapy every week, as well as an appointment with a nutritionist. At first, she was all smoke and mirrors around food.
If Marianne or I hadn't been right there with her at every meal, she might not have eaten. She also put up a fuss about going to individual therapy. But over time, that changed. One day, I was driving her home from an appointment when she mentioned the possibility of using the same level of control to gain weight as she had to lose it. I liked that line of thinking, which, I figured, had come from therapy. Granted, she wasn't yet ready to put that theory into practice, but she was processing it, and that was a good sign."
Marianne adds, "Throughout every stage of treatment, Holly's professional caregivers have made it clear to Jordan and me that we did not cause our daughter's eating disorder. Given that I tended to blame myself for the illness, the reassurance was more than welcome. The thought that Holly was caught up in physical appearance at such a young age struck a sensitive chord in me.
When I was growing up, I too had idolized the sleek models in magazines. Even now, I have to think twice about buying in to the advertisements that connect happiness with skinniness. And my own mother had dieted. Maybe I'd absorbed some thin-is-in thinking from her.
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"I'd always made a point of serving my children balanced meals, including lean meats, salads, veggies, and starches. Sometimes, however, I'd be watching my carbs, and that might have had an effect on Holly. It's not that I broadcast my intention to lose weight to my children. On the contrary, I barely mentioned it. Still, Holly was at an age where she may have picked up on my personal weight concerns and developed similar ones about her own body."
In talking about what has helped her improve her health, Holly focuses on her friendships. "Some of the girls from that group acted so mean to me that I wasn't sure I wanted their friendship back," she admits. "But there were a couple I still liked. My therapists were on my side, and we discussed how to go about ending the fight. One day, I sort of cornered one girl, Alexa, and spoke my mind. I told her how a fight I'd never wanted in the first place had gone on far too long, how we'd both been in tough spots, and how I wanted us to like each other again. To my surprise, she felt badly about everything that had happened too. So we ended up hugging and staying friends. It was scary to approach Alexa, but it was worth it."
During treatment, Holly's parents and therapists helped her modify the extreme stand she took in response to her girlfriend crisis. They guided her as she changed approaches to the problem from those that didn't work (locking horns with the aggressors) and were actually harmful (starving herself) to those that proved productive (reevaluating the friendships, talking to Alexa). Now doing well in recovery, Holly acknowledges the pain of last year's girlfriend crisis and feels good about the steps she took to resolve it.
Of her stoicism, she says, "I wouldn't do the same thing again."
Marianne and Jordan are heartened that Holly has gained some weight and that her natural vibrancy and sociability-which waned with the illness-are starting to return. Between dance rehearsals, academic requirements, and social activities, Holly's days are busy, and, like many individuals in recovery from anorexia, she continues to demand a lot of herself. In addition, she sometimes has trouble going with the flow. Switching gears-moving from one train of thought or plan of action to another-comes more naturally to some people than to others. For many individuals with past or present anorexia, adjusting to unexpected changes-going from one mind-set to another-is not always easy. On the bright side, Holly is gradually realizing that she doesn't have to do everything to the max. In addition to learning less extreme ways to cope with problems, she is trying to be kinder to herself, a skill that will help her throughout adolescence and long after.
Is She a Perfectionist?
As we mentioned in Chapter 3, perfectionism often occurs with an eating disorder, sometimes predating the illness. Although compliance is commendable, some children take it too far. These are children who obey everything requested of them to the nth degree and make painstaking efforts to stay out of trouble. Eager for approval, they aim to be model children, sometimes at the expense of their own needs. If they mostly operate based on what others tell them to do, it may become hard for them to chart their own course. Rather than making every decision for your child or expecting her to make them in isolation, work with her, allowing her to make the final choices.
Perfectionists typically expect themselves to perform flawlessly-in school, in extracurricular activities, on the athletic field, and on the job-in order to earn and keep approval. In addition to setting high standards for everything they do, these individuals have difficulty bending their self-imposed rules to take their personal needs into account. For example, a pupil who continually overstudies in her quest for the perfect A is not necessarily doing herself a favor. Suppose she insists on doing homework until midnight Monday through Friday. Some nights she's sleepy by 10:30 or 11:00. Her drowsiness is a signal that it's time to quit working. But that's not what happens. Instead, she strains to stay awake until the stroke of midnight. As the semester progresses, sleep deprivation prevents her from performing as well as she'd like. In addition, working many hours every evening keeps her from participating in other activities. Yet she resists reevaluating and possibly modifying her study habits.
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David B. Herzog, M.D., Debra L. Franko, Ph.D., Pat Cable, RN
David B. Herzog, M.D., is the Harvard Medical School Endowed Professor of psychiatry in the field of eating disorders at Massachusetts General Hospital and the director of the Harris Center at Massachusetts General Hospital. Debra L. Franko, Ph.D., is a professor in the Department of Counseling and Applied Educational Psychology at Northeastern University and the associate director of the Harris Center at Massachusetts General Hospital Pat Cable, RN, is the director of publications at the Harris Center.
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