Mirror mirror: Facing up to body dysmorphic disorder in children

Body dysmorphic disorder is on the rise among children, many of whom are influenced by the edited pictures they see on social media, writes Helen O’Callaghan.

THEY hate the shape of their face. They’re ashamed and embarrassed about being ‘ugly’. They hate their stomach or their legs. These are the kinds of concerns increasingly being shared by teens in Ireland with counselling psychologists. More worrying again are reports that this preoccupation with perceived flaws didn’t just kick in as they hit their teens. Fears that their physical selves didn’t measure up had been there since they were nine, 10 or 11 years old.

The sobering reality was thrown into sharp focus just before Christmas when the inquest into Millie Tuomey’s death by suicide heard the 11-year-old Dubliner had been unhappy with her physical appearance for a number of years.

Yet, it’s very common to have a degree of body concern or body alienation, says Professor Jim Lucey, clinical director of St Patrick’s Mental Health Services (its children’s unit is Willow Grove). “A degree of body disgust is almost universal to a degree. And the narcissism of youth is also a feature.”

Much further along the spectrum from the wish common to most of us — to change/improve some aspect of our physical appearance — is body dysmorphic disorder (BDD). This is an obsessive and widely misunderstood psychiatric illness. What starts as dissatisfaction with an aspect of one’s body — ranging from concerns about thinning hair, skin texture, and perceived blemishes, asymmetry of face or nose, size of ears, nose, and lips — can escalate into an obsessive preoccupation with that aspect of appearance.

This appearance component of BDD can distract people from the serious psychiatric nature of the condition, says clinical psychologist Dr Annemarie O’Connor. A co-author of Body Image Problems & Body Dysmorphic Disorder: The Definitive Treatment and Recovery Approach, O’Connor emphasises that BDD is not excessive vanity. Vanity is based on enjoyment of your appearance, whereas with BDD, people reject their appearance. With vanity, says O’Connor, someone looks in the mirror and thinks ‘how good do I look?’ With BDD, they’re checking to see how awful they look — or whether they’re just barely acceptable to other people.

The obsession with the perceived flaw can be extraordinarily intense.

The Broken Mirror author Katherine Philips cites research showing one third of sufferers think about the perceived defect/defects between one and three hours daily, while 40% are preoccupied for three to eight hours a day.

According to OCD Ireland (psychologists link BDD with OCD because of its obsessive compulsive aspects), when there’s no mirror, any shiny object or surface is used to focus on the flaw — shop windows, cutlery. “These substitutes typically distort one’s reflection, [which] might even exacerbate the negative feelings experienced by the person.”

Estimated BDD incidence in Ireland is one in 100, though some experts put it at 2%. A recent trend is its emergence in pre-teens. Consultant child and adolescent psychiatrist Dr Sarah Buckley says her clinic — Dean Clinic, Cork, part of St Patrick’s Mental Health Services — used to only see 13-17-year-olds. But then GPs began requesting 12-year-olds be seen too.

“It could be for depression, anxiety, eating disorders, or BDD,” confirms Buckley.

“It’s commonly known that BDD begins in adolescence — but when people look back, they describe not being happy with their body at nine, 10, or 11 years of age. There’s now a trend, over the past five years, where we’re seeing it emerge younger. I’ve had 13- and 14-year-olds tell me they’ve been concerned since fourth class.”

And it’s not just that these kids were conscious of their perceived deficits at a young age. “They were very distressed and preoccupied,” says Buckley.

Counselling psychologist with Spectrum Therapy Tracey O’Neill works with teens. Serious body image concerns come up a lot. “It rarely presents as BDD but when you work with them a while, it’s there — a general ‘I don’t like myself’.”

A disorder affecting equal numbers of boys and girls, O’Neill finds boys often fixate on height — believing they’re not tall enough — whereas for girls, it’s they’re not skinny enough. What surprised her was the frequency with which girls fixate on hair. “I’d have thought it’d be boobs or bums, but hair stood out — it’s not long enough, not thick enough. There’s this desire for a fabulous mass of blonde hair.”

In O’Neill’s experience, BDD is “never just a stand-alone”. It usually runs parallel with anxiety or other mental health issues.

A British statistic tracking anxiety in young people found 19% suffering in 1993 compared with 25% in 2014. “It’s gone from one fifth to one-quarter,” says Prof Lucey. “Everybody’s pondering why there’s been this dramatic increase in anxiety and in body dysmorphic concerns. Does it correlate with the emergence of social media? People are telling us they feel challenged and put under pressure on these systems. They describe being distressed and bullied on social media.”

Fiona Flynn, youth development officer with Bodywhys, says young people she meets in schools, focus groups, and at youth events often refer to pressure from the media to look a certain way. “They refer to the slim flawless look we see for girls and the muscular ideal we see for guys.”

She says research indicates increased time on social media can adversely affect body image in teen boys and girls. “Young people who spent more time online were more likely to link their self-worth to their looks.”

No matter why she’s seeing them, O’Neill says all her teen clients are spending huge amounts of time online. “When they’re not at school, they’re spending eight hours a day online. They’re constantly being fed ideas of perfection.

“Take a boy, following Conor McGregor or some football star on Instagram — he’s constantly seeing this person turned out very well with a fantastic lifestyle. It’s the same for the girls. Children are all the time being assaulted with images of what they’re not.”

The Western World’s ever-present pursuit of a particular ideal male or female image is likely confusing young people. Buckley says: “They’re distressed they don’t ‘look right’ and make the negative assumption that they won’t be successful. The subliminal message is if you’re pretty and have nice teeth you’ll enjoy life more.”

BDD is thought to be caused by a complex interplay of biological, psychological, and environmental factors. Unkind comments don’t cause it but they can trigger it. Buckley says some of her young clients recall being slagged at the age of nine or 10, girls telling each other ‘if you stand with your feet together and your thighs touch, you’re overweight’. “They talk about it in the yard, they check and they slag a girl who’d never noticed this before and she starts getting preoccupied.”

Lucey says males and females differ in how they photograph themselves on social media. “Boys tend to photograph themselves on Instagram in groups — girls tend to photograph themselves as individuals. So there’s more focus on the individual body of the female — the male is still herding and can get lost in a photo, whereas the female is much more objectified for her individual appearance.”

Transitioning from childhood to puberty — and adapting to the emerging new body — can be dramatic for children, says Lucey, adding that kids now have a tremendous screen — in the form of social media — amplifying this. Put this amplified exposure to a body you’re struggling to get used to alongside the diminished regard people often show each other online and it’s easy to see why distress about one’s body can arise.

So what are the red flags that something may be amiss with your child? Chartered counselling psychologist Leslie Shoemaker lists the following warning signs: Child seems blue/down in the dumps most of the time; they’re having problems with day-to-day functioning, struggling to do the basics like getting dressed or having a shower; they’re becoming preoccupied with appearance and weight; their grades are dropping, they’re opting out of sports or avoiding things in general.

BDD has higher rates of suicide ideation than most other disorders, warns Shoemaker. “Pay great attention if they start talking about suicide — ‘I want to die’, ‘I wonder what it would be like to die’, ‘Would people miss me?’”

How can parents protect children? Shoemaker warns against putting out a negative message about appearance or one that values appearance above all. “Ask yourself, what’s the message I’m putting out? Do I comment all the time on people’s appearance — ‘She’s put on a few pounds, what’s going on with her?’ Am I always on a diet? Is our family very focused on appearance versus achievements or skills?”

Pointing out that human beings don’t do well with uncertainty, Shoemaker urges parents to be upfront with children approaching puberty. “Tell them ‘your body’s going to change, you’re going to be uncomfortable in it for a while and then you’ll get used to it’. Parents also need to show children how media doesn’t portray things accurately — explain how images are airbrushed and Photoshopped.

“Parents need to help kids learn how to critically evaluate media messages and how they’re being sucker-punched.”

A firm believer in parents being part of their child’s Facebook and Instagram lives, Shoemaker says parents have to have access so they can see what sites their kids are on. “Look at their emails. People get angry and say that’s very Big Brother but the role of the parent is to care for the kid.”

Lucey agrees parents should introduce some digital controls, but without strife. “These are new parenting skills — but for generations parents have had to make sure their kids are safe in other spaces. I’d recommend postponing full iPhone access until the child’s in their mid-teens and you can teach them how to use it [appropriately].

“It’s like teaching them how to manage cycling a bike on a busy road — it’s the normal risk management of growing up.”

How to help your child develop positive body image

Be a positive role model

How do you speak about your own body? Avoid making negative comments about other people’s bodies or your own — even as a joke. Be aware too of positive comments you make about bodies to ensure you don’t inadvertently endorse media ideals. Watch how you talk about food. Do you express guilt when you eat certain foods?

Shift focus away from body image

Focus less on child’s appearance and more on their skills/abilities — being kind, good at sharing, great at helping, good fun, good dancer. When talking about others, steer clear of comments about what they look like. Instead, remark on qualities they have, eg, being a good listener, good fun, lively.

Encourage children to find what they enjoy

Promote activities that make you feel good, which don’t focus on appearance. Let children try different things and find what they enjoy. Doing things we enjoy helps us feel self-confident and positive about ourselves.

Media literacy

Encourage child to think critically about messages in the media and to notice that body shapes we see in media are not like bodies we see in real life. Promote acceptance of different body shapes — focus on what the body can do rather than how it looks.

Talk to child about social media

Be aware of your own online behaviour. How often does your child look to you and finds you looking down at your screen? Lead by positive example.

Set clear parental boundaries around screen time

It may make you unpopular but it will encourage children to develop other interests. Limit time they spend online. Allow time for offline activities and family time to communicate.

- Visit ocdireland.org/the-three-disorders/body-dysmorphic-disorder/; also bddfoundation.org


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