Creative Modalities for Children and Adolescents with
Body Image Disturbance and Eating Disorders

Kacey D. Greening
Capital University

Keywords: Body Image, Eating Disorders, Adolescents, Children, Art Therapy, Creative modalities


Body image disturbance and eating disorders are not restricted to an adult population. Recently, these disorders have been studied in children and adolescents. Although traditional modalities such as family therapy, cognitive-emotional-behavioral therapy, and interpersonal therapy are successful, the conjunctive use of creative modalities such as art therapy, myth, and metaphor appear to be promising tools in the treatment of body image disturbances and eating disorders (Makin, 2000; Clausen & Kielbasa, 2001; Johnston, 1996).



Body Image

Thompson, Heinberg, Altabe, and Tantleff-Dunn (1999) defined body image as the internal representation of the external self. When body image goes awry, the frequent result is body image disturbance. Thompson et al. (1999) described body image in terms of a continuum. One end of the continuum represents the absence of or minimal disturbance, and the other end represents severe disturbance. Most people experience body image concerns at least once in their life. However, a small amount of these people experience extreme and persistent body image distress. These persons are at risk for developing eating disorders, body dysmorphic disorder, social anxiety, and depression. Thompson et al. (1999) suggested that body image disturbances manifest in four distinct forms: cognitive (e.g., unrealistic expectations for a certain appearance feature), affective (e.g., anxiety or distress about one’s appearance), perceptual (e.g., overestimation of actual body size), and behavioral (e.g., avoidance of certain social situations where the body may be scrutinized such as swimming or working out).

The endeavor to measure body image-related phenomena is fairly new. Fortunately, a growing body of research has provided hope for understanding the prevalence and nature of body image disturbance. Serdula, Collins, Williamson, Anda, Pamuk, and Byers (1993) conducted a study with 5,582 girls in high school. The researchers found that 47.4% Caucasian, 39.1% Hispanic, and 30.1% African-American participants were trying to lose weight. Field, Camargo, Taylor, Berkey, Frazier, Gillman, and Colditz (1999) surveyed a sample of 16,000 boys and girls aged 9-14. They found that 20% of the 9-year-old girls and 44% of the 14-year-old girls were trying to lose weight. Furthermore, Wood, Becker, and Thompson (1996) found that 55% of females aged 8-10 were dissatisfied with their body size.

Undoubtedly, compelling evidence suggests that both children and adolescents experience body dissatisfaction and desire to lose weight. Some of these individuals will go on to engage in extreme behaviors, such as bingeing, purging, excessive exercise, and excessive food restriction. Some will develop eating disorders, such as anorexia nervosa or bulimia nervosa and/or depression. Interestingly, even those individuals who do not meet the criteria for eating disorders or major depression still experience enough psychological and interpersonal distress to be labeled “at risk” or “partial syndrome” adolescents (Thompson & Smolak, 2002).

Eating Disorders

The causes of eating disorders are complex. However, many researchers and practitioners agree that the motives of eating-disordered persons stem from psychological disturbance. Furthermore, children who come from eating-disordered families (eating patterns that are irregular, eating much more or much less than normal serving sizes, eating or abstaining because of guilt, fear, shame, or eating to gain control) are at a greater risk of developing an eating disorder, which demonstrates the significance of familial influences on eating disorders (Makin, 2000). In 1998, Marsha Marcus, the President of the Academy for Eating Disorders, declared that food and food-related behaviors have become moral markers of superiority and inferiority in our culture.

There are two types of eating disorders: anorexia nervosa and bulimia nervosa. Persons with anorexia nervosa are often obsessed with food, but they cannot bring themselves to eat it. Persons with anorexia are characterized by an intense fear of gaining weight or becoming fat and a refusal to maintain a normal weight for their height and age. Oftentimes, persons with anorexia, in an effort to conform to the thin ideal, starve themselves while insisting that they are overweight. When persons with anorexia limit their food intake they gain a sense of control over their bodies and their lives. Unfortunately, the control is illusive and the underlying problems remain unsolved (Makin, 2000).

Like anorexia nervosa, bulimia nervosa is characterized by the intense fear of becoming fat, but persons with bulimia are not always as visible as anorexia. There are two types of bulimia: purging and non-purging. Persons with bulimia can binge (as many as 6,000 calories at once) and purge (by self-induced vomiting, laxatives, and diuretics) several times a day. Bulimic binges and purges are often done in secret. Sadly, both anorexia nervosa and bulimia nervosa often result in severe bodily damage. The repercussions of eating disorders include endocrine, central nervous system, gastrointestinal, and cardiovascular malfunction (Makin, 2000).

Mehler, Gray, and Schulte (1997) found that anorexia nervosa affects 1% of the population. The development of anorexia nervosa starts in early adolescence and peaks at ages 14-18. Batal, Johnson, Lehman, Steele, and Mehler (1998) found that bulimia nervosa affects 1-2% of the population. The Eating Disorders Association (1997) estimated that 10-15% of persons with eating disorders would die from their illness. Moreover, anorexia nervosa is the third most chronic illness in adolescent girls. Without the proper treatment, persons with eating disorders experience significantly impaired interpersonal and intimate relationships, psychological distress, and bodily discomfort and damage (Makin, 2000).


Familial Influences on Body Image Disturbance and Eating Disorders

Why do some children develop body image disturbances and eating disorders, while other children do not? Several researchers have attempted to answer this question. Benedikt, Wertheim, and Love (1998) hypothesized that parental influence may play a significant role in the development and maintenance of body image disturbance and eating disorders. It is possible that parents knowingly and unknowingly transmit sociocultural messages about beauty to their children. Thompson and Smolak (2002) highlighted two methods by which sociocultural messages can be transmitted: (a) parents may model behavior that reveals their own concerns about body image and eating and, in turn, children may adopt those same beliefs and attitudes or similar beliefs and attitudes and (b) parents may stress their own concern or dissatisfaction with their child’s weight, body, and/or eating habits.

Thus, several researchers have sought to elucidate the relationship between parents and children who develop body image disturbance and eating disorders. The largest limitation is the correlational nature of these studies. The most difficult piece of the puzzle is deciphering whether or not parental influences cause body image disturbance and eating disorders. For example, Moreno and Thelen (1993) found that mothers with daughters who have bulimia were more likely to have persuaded their daughter to diet. Furthermore, Blitzer, Rollins, and Blackwell (1961) found that mothers of eating-disordered children were more likely to have poor relationships with their children and were more likely to be overly concerned with their own body and weight. In addition to the environmental component of body image disturbances and eating disorders, Stein and Woolley (1996) suggested that there may be a genetic component as well. Presently, exploring the genetic contributors to eating disorders is a popular research endeavor.

Connors (1996) identified four patterns in the family dynamics of body image disturbance and eating-disordered clients:

  • Parents of children with eating disorders were viewed by their children as less empathic, less affectionate and warm, and less emotionally supportive (Steiger, Liquornik, Chapman, & Hussain, 1991).
  • Humphrey’s (1989) research discovered that parents of children with eating disorders tended to ignore and negate their child’s self expression. Familial enmeshment, over control, and lack of support for independence characterize the family dynamics in homes where children have eating disorders.
  • Findings from numerous studies have found that there is a lack of communication and open expression in eating-disordered families.
  • Eating-disordered clients tended to rate their families as more achievement-oriented than did control subjects (Stern, Dixon, Jones, Lake, Nemzer, and Sansone 1989).

Future research should further explore the role of family dynamics and parental influences on the development and maintenance of body image disturbance and eating disorders.

Sociocultural Influences on Body Image Disturbance and Eating Disorders

A large body of research has been dedicated to the exploration of societal influences on body image and eating disorders. Interestingly, researchers have found some discrepancies in our culture’s ideal feminine image. The most popular example is the paper-thin model that is supposed to have a muscular physique and large breasts. How can one be super thin and muscular or super thin with large breasts? Women are constantly pressured to achieve inconsistent appearance goals (Thompson & Tantleff, 1992). Although the ideal woman has become thinner and the average woman larger, present research demonstrates that girls as young as six are accepting the thin ideal as their goal (Collins, 1991).

Fallon (1990) suggested that cultural influences play a more significant role than biological influences. He pointed to an important historical fact: many culturally-sanctioned beauty ideals have been contrary to biological determinism. If one considers the possible beauty augmentations available in our society today, one will find that many of those beauty rituals are contrary to optimum health (e.g., crash dieting and breast implants). Freedman (1986) attacked the media for playing a dangerously influential role in young girls’ lives. Freedman believed the media was largely responsible for communicating “thinness” propaganda. Furthermore, she suggested that the media blurred the line between fact and fiction. Barbie doll women are glorified, but what we forget is that Barbie is an object not a living being. It is dangerous to do such a thing. Many young girls do not realize that models are airbrushed, edited, and manipulated. Lakoff and Scherr (1984) found that young girls believed the images of women were not only the norm but were also attainable. Only a small number of girls can meet the cultural norms for beauty. What happens to the majority of girls who cannot?

The unattainable and unrealistic norms for beauty have long been implicated in the development of body image disturbance and eating disorders. Heinberg & Thompson (1995) hypothesized that there was a link between media exposure, internalization, and eating disorders. Their hypothesis received support. The researchers found that internalization of cultural beauty ideals was the most significant correlate of body image disturbance. Presently, researchers are exploring which persons may be more vulnerable to internalization of cultural beauty ideals. When this question is answered, prevention and treatment will become much more successful.

Creative Modalities: The Use of Myth and Metaphor

Although traditional modalities (e.g., family therapy, cognitive-emotional-behavioral therapy, interpersonal therapy) can be very effective with persons who have body image disturbances and eating disorders, Makin (2000), an expressive arts therapist, suggested that non-traditional treatments could be beneficial and cathartic for clients too. Makin’s use of art therapy with persons who have body image disturbances and eating disorders has been a great success. Similarly, Dr. Anita Johnston has spent much of her clinical career providing her clients with creative alternatives for treatment. Johnston (1996) found an emerging pattern in the lives of her eating-disordered clients. This pattern was a loss or rejection of the feminine quality or spirit. Johnston suggested that our society is dominated by the masculine. Masculine qualities such as logic, practicality, rationality, and realism are labeled “superior” qualities, whereas feminine qualities such as emotionality, idealism, and intuition are labeled “inferior” qualities. Consequently, many women have learned to reject their feminine nature. Johnston’s work uses the vehicle of myth to reconnect women to the lost feminine spirit. Johnston found that many of her eating-disordered clients had a dominant masculine force that drove their personality. This masculine force was frequently critical and even hostile toward its feminine counterpart. Moreover, because women have silenced their feminine voice, they live in a state of spiritual hunger. The epidemic in our society is that women long for the feminine face of God, but this is not available to them. Thus, many women go on strike. They stop eating, or eat too much, or restrict their eating, or impose upon themselves rigorous diets and exercise plans in an attempt to silence the feminine voice that whispers in their ears. Johnston (1996) explained that food is the red herring. In other words, food is not the real issue. Persons with eating disorders experience hunger and starvation not just physically, but mentally, spiritually, and emotionally. Physical hunger becomes a concrete symbol for their intangible hunger. Perhaps one woman’s hunger is for approval and acceptance, and another’s may be for comfort and nurturance. Yet, another may yearn for creative expression or spiritual fulfillment. Johnston suggested that an important part of the recovery process requires women to identify and name their intangible hunger. Until women can name their non-physical hunger, they will continue to use food to satisfy it.

The use of myth is only one of many creative modalities. Another modality is the use of metaphor. Leadbeater & Wilson (1993) drew a parallel between young girls and the mythological creature called mermaid. Much like women and young girls in our society, the mermaid is all too familiar with the hardships of living in a masculine world. Ariel, from Disney’s Little Mermaid, had no healthy female relationships in her life. The primary relationships she had with other women were laced with rivalry, jealousy, betrayal, and pain. Her sisters were competitive and self-absorbed. They stared into the mirror every morning, wondering which one was the most beautiful sister of all. The sea-witch was jealous of the mermaid. She tricked her, coerced her, stole her voice, and then she used the little mermaid’s voice to put the prince under her spell. Clearly, the little mermaid had no healthy female relationships and a distorted perception of feminine qualities. On the contrary, Hans Christen Andersen’s original fairy tale had a mother figure for the little mermaid. In Andersen’s novel, there was a wise and loving grandmother who offered guidance and support to the little mermaid. However, the feminine spirit is entirely absent in Disney’s version of The Little Mermaid. Much like the feminine spirit is absent in our culture (Leadbeater & Wilson, 1993).

Clausen and Kielbasa (2001) have used the metaphor of the mermaid in their work with adolescent girls. They suggested that our culture socializes girls to relinquish their voices, give up their families and friends, and change their bodies in the pursuit of boys and beauty. Clausen and Kielbasa highlighted two crucial steps in working with adolescent girls. The first step is awakening to the problem. This stage is characterized by fostering critical thinking skills in young girls and by raising consciousness and awareness of problems. The most important part of this step is to help girls find their voice and convince them that their voice is important. One way Clausen and Kielbasa have achieved this goal is through exposing young girls to Disney’s Little Mermaid and then asking them to talk about how they feel when the little mermaid exchanges her voice for human legs. The second step is taking action. This stage is characterized by teaching girls how to produce change in their own lives and how to strive for change in their society as a whole. When using creative modalities such as art therapy, myths, and fairy tales, young girls are given the opportunity to identify, explore, question, challenge, transform, and change.


Body image disturbances and eating disorders are painfully present in children and adolescents. There are several factors that can influence the development and maintenance of body image disturbances and eating disorders (e.g., family and culture). Thus, it is essential to provide the appropriate treatment to persons with body image disturbances and eating disorders. Conventional modalities for body image disturbances and eating disorders have long been behavioral, cognitive behavioral, interpersonal, and family therapies. However, art therapy and other creative modalities have become popular adjunct methods of treatment. Makin (2000) pointed out the efficacy of using art therapy and other creative modalities with clients who have body image disturbance and eating disorders. Creative therapies foster self-exploration, self-understanding, catharsis, and change. These are all important parts of the recovery process in body image disturbance and eating-disordered persons. In conjunction with conventional therapies, creative therapies appear to be promising in treating persons with body image disturbances and eating disorders (Makin, 2000).


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