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Chapter One



Is Twenty-five the New Fifteen?


As fifteen-year-old Perry shuffled into my office, with his parents trailing tentatively behind, he glanced at me with a strained neutral expression that I'd found usually masked either great anger or great distress; in Perry's case it was both. Although anorexia is a disorder most often associated with girls, Perry was the third in a line of anorexic boys I had recently seen. When he came to see me, Perry's weight had dropped to within ten pounds of the threshold requiring forced hospitalization, yet he denied there was any problem.

"He just won't eat," his mother began. Then, turning to Perry as if to show me the routine they'd been enacting, she asked with tears in her eyes, "Perry, why can't you at least have a simple dinner with us?" Perry refused to eat with his family, always claiming he wasn't hungry at the time and that he preferred to eat later in his room. Except that that rarely happened. New menus, gentle encouragement, veiled threats, nagging, and outright bribes had all been tried, to no avail. Why would an otherwise healthy fifteen-year-old boy be starving himself? The question hung urgently in the air as we all talked.

Let's be clear from the outset: Perry was a smart, good kid: shy, unassuming, and generally unlikely to cause trouble. He was getting straight A's in a challenging and competitive public school honors curriculum that spring. And he later told me that he hadn't gotten a B on his report card since fourth grade. In some ways he was every parent's dream child.

But beneath his academic success, Perry faced a world of troubles, and while he took awhile to get to know, eventually the problems came pouring out. The problems weren't what I'd expected, though. Perry wasn't abused, he didn't do drugs, and his family wasn't riven by conflict. Rather, at first glance, his problems would seem more like typical adolescent complaints. And they were, in a way. But it was only as I got to understand him that I realized the adolescent problems Perry experienced weren't just occasional irritations, as they'd been for me and my cohort as teens, but rather, had grown to the point where they cast a large shadow over much of his day-to-day world. I'd later come to realize that Perry wasn't alone in that regard.

One big problem was that while Perry was a strong achiever, he was not at all a happy one. "I hate waking up in the morning because there's all this stuff I have to do," he said. "I just keep making lists of things to do and checking them off each day. Not just schoolwork, but extracurricular activities, so I can get into a good college."

Once he got started, Perry's discontent spilled out in a frustrated monologue.

"There's so much to do, and I have to really work to get myself motivated because I feel like none of it really matters... but it's really important I do it anyway. At the end of it all, I stay up late, I get all my homework done, and I study really hard for all my tests, and what do I get to show for it all? A single sheet of paper with five or six letters on it. It's just stupid!"

Perry was gifted enough to jump through the academic hoops that had been set for him, but it felt like little more than hoop-jumping, and this ate at him. But that wasn't his only problem.

Perry was well-loved by his parents, as are most of the young people we see. But in their efforts to nurture and support him, his parents inadvertently increased his mental strain. Over time, they had taken on all his household chores, in order to leave him more time for schoolwork and activities. "That's his top priority," they said almost in unison when I asked about this. Although removing the chores from Perry's plate gave him a bit more time, it ultimately left him feeling even more useless and tense. He never really did anything for anyone except suck up their time and money, and he knew it. And if he thought about backing off on his schoolwork...well, look how much his parents were pouring into making it go well. Sandwiched between fury and guilt, Perry had literally begun to wither.

The upcoming summer break initially seemed to offer some potential relief for this anxious and distraught young man. I saw the first brightening of Perry's countenance as I suggested that this might be a time when he could explore something other than school. But it was not so simple. Financial constraints, and more important, his parents' fears, quickly brought the dark clouds back to his face. Perry had been mind-numbingly bored alone at home in previous summers, especially during those times when other kids were off on vacation or at camps. I asked him about activities he might do on his own.

Tennis, it turned out, was a sport he was trying to learn, and he even liked just practicing by hitting a ball against a wall. Okay, I thought, that's something we could build on. Yet when I suggested he could ride his bike to nearby tennis courts to practice, his parents cut me off.

"That road's too busy to bike on," his mom interjected.

"And the courts by the high school are awfully isolated. It just doesn't seem safe," Dad added, even though the high school was in a tame residential neighborhood, and six-foot-tall Perry did not look like an easy mark.

"They won't even let me have my best friend over to hang out unless they're home," Perry complained. In the name of safety, his parents had indeed ruled out such activities. "Trouble" could be the result, although Perry, save for his weight loss, was not a troublemaker.

Perry's parents were just trying to do what all parents do: keep their child safe. But they were keeping him "safe" at home, while exacerbating a condition that eventually kills one in ten young people. As other options for the summer fizzled one after another, Perry just stared silently out at me, looking away only to discreetly wipe the tears that kept welling up in his eyes. He'd spent a good part of the prior summer reading books on a sofa in his dad's office and didn't want to do that again.

With an illness as life-threatening and dramatic as anorexia, I was expecting, and even wanted, to find some equally dramatic set of causes. But the more I learned about Perry, the more surprised I was to discover that what was pushing him to the breaking point could best be described as an extreme form of modern adolescent life. Though he had his own unique vulnerabilities, most of what burdened him was just a more intense version of what many teens face: endless hoops to jump through, high pressure, lack of the chance to do anything meaningful for anyone, and numerous constraints designed to keep floundering teens "safe." We might wonder if we'd missed something with Perry, except that addressing these problems, as we'll describe later, was indeed enough to turn his life around--these "typical" adolescent experiences had in fact been precisely his problem.

In one sense Perry was not unusual in that adolescent problem behaviors are often bizarre and exasperating. But what was ultimately most disconcerting about his story was just how mundane and prosaic his motives were. We've often found that identifying the underlying intent behind teens' behaviors--finding out what they are really trying to get at, however ineptly--is a critical first step toward identifying ways to help them. And so it was with Perry.

"BUFF"

As I got to know Perry, it became clear that the only thing "real" that he could easily feel any mastery over was his weight. He had stumbled into his eating disorder almost by accident. It started with a growing adolescent awareness of his body and his wish to be fit and in shape. He began working out and reading fitness magazines, and soon took to watching what he was eating. He liked the initial results as some visible muscle replaced what had been baby fat. He found the idea of having a body that was "buff" quite appealing, and even more than that, he liked being able to make a difference in something real and immediate in his life that he actually cared about.

No one else needed to help him, and this wasn't part of someone's agenda about maximizing his potential. In some ways Perry was doing what adolescents have no doubt been primed by thousands of years of evolution to do: see a challenge and take steps, however dramatic, to master it. And the results, unlike in school, weren't years in the future. If he worked hard at school, Perry got abstract feedback that he wasn't sure he cared about weeks or months down the road in his report card. In contrast, if he watched what he ate and worked out, he could see the results on the scale and in the mirror within a few days. The irony, of course, is that the best way Perry could find to nurture his cravings for control and autonomy was to starve himself.

If he had been "working his tail off" to buy himself a car or to master a first job--as his dad had once done--his sense of accomplishment might have served as a counterweight to the intense pressure, grinding drudgery, and boredom he felt. He could have been throwing his efforts into these tasks (or even overdoing it, as adolescents have often been wont to do) in productive ways that might have provided immediate satisfaction. But like most of his peers, Perry was on a high-achieving track where the real payoff for his work wouldn't come until after his graduate or professional training was complete. That was so far in the future that he couldn't even accurately estimate the years involved. Perry didn't feel he was so much on a path as on a treadmill. And though he could scarcely allow himself to verbalize it, he wanted desperately to get off.

PERRYS OF THE PAST

On the one hand, the pressures Perry faced were remarkably mundane and typical. But one of the more intriguing aspects of his situation was that just a few generations ago--for example, in his grandfather's generation, or perhaps his great-grandfather's--most of Perry's problems simply wouldn't have existed. Yes, school has always mattered a great deal for some, but it was only the rarest of teens who could expect to spend a decade or more in school after ninth grade. And even for those teens, parents wouldn't have had the time to remove all other meaningful work from their lives. On the contrary, if we go back a little further, say a hundred years or so, typical teenagers in a family were not only essential to making a household run each day, but contributed almost a third of the family's total household income.

In many ways, teenagers were already functioning as adults then. Yes, working extremely hard, but also experiencing the gratification of seeing the tangible results of their efforts in a way that mattered not just to them, but to their entire family. Today's parents can wistfully imagine how this might have been good for the family. What they might not realize was just how good, indeed critical, it was for the teens as well. And while parents have always sought to keep their offspring safe, earlier generations simply lacked the resources to hypermonitor their teens' activities. No one had the luxury to be a "helicopter parent," and teens had plenty of room to exert control over their lives in ways other than by starving themselves.

Perry's problems, unfortunately, represent just the visible and dramatic tip of a very large iceberg. Even as our teens have become better nourished, and the stresses of untreated illness and material deprivation have become rare, rates of eating disorders and adolescent depression and anxiety have skyrocketed. Some of the changes have been building for a while, but some have occurred across just a single generation. For example, the average college student now reports as much anxiety as did the average psychiatric patient forty years ago. While some of this is undoubtedly due to a greater willingness to acknowledge mental problems, much appears to be a truly new phenomenon. At the other end of the socioeconomic spectrum, we find that more than one in every four teenagers in America is still failing to complete high school after twelve years.

We start with Perry's story because much of what he experienced--from his anxiety and misguided efforts to gain a sense of control to the seemingly supportive but ultimately suffocating environment in which he lived--is reflective of what many of our teens are going through. Perry's weight loss made the problems all too visible, but the strains can appear in many guises. Often the problems grow quietly over years, with only the occasional disturbing behavior to indicate that something may be seriously wrong just beneath the surface. Such was the case with Ellen.

WHAT WAS THERE TO LOSE?

Ellen was a gifted eighth-grade lacrosse player, with visions of college scholarships dancing in her parents' heads. She was also a fine student in school, though not hitting her full potential, but then how many students do? And while there were the usual adolescent ups and downs at home, life generally proceeded smoothly. So Ellen's mom was shaken to her core one cold Tuesday night a few Februarys back when a friend and fellow "lacrosse mom" informed her of the rumors that Ellen had been having oral sex, not only with her boyfriend, but with several boys in her class. A long night of harsh questions and tears all around revealed the truth to these rumors, but no hint of their root cause.

Ellen's parents were devastated. "How could this be happening with our little girl?" her dad asked. Ellen herself was sheepish and a bit frightened. She hadn't expected things to turn out this way. In some ways, her behavior was a mystery to her as well. Was she "seriously disturbed," as her dad angrily suggested? If only that were the case, we could at least write off Ellen's behavior as something that needn't concern most parents.

But as Ellen thought later that night about what had happened, and talked with friends the next day about it, she felt less sheepish and more frustrated. What else was there really to do? She did okay in school, but it was boring, and seemed fairly pointless as well. This was an area of consensus among Ellen's friends, even those who got good grades. Yes, lacrosse was great. The competitions and practices were crazy and tense, but overall it was fun. If only it lasted more than an hour or two a few times a week. And beyond that... well, as far as she could see, nothing else was all that interesting.