Q: My son has recently been excusing himself early from the dinner table, claiming he has a lot of homework to do. When he did this last night, I followed him upstairs and heard him vomiting in the bathroom. I asked him about it later, but he told me to mind my own business. I'm extremely worried and upset, but don't know how to approach the subject again. I need to talk to him soon'before this situation gets out of control. Do you have any suggestions?

A: Becoming aware that your child is demonstrating behavior suggestive of an eating disorder is an incredibly frightening experience for any parent. Asking your son about his recent pattern of leaving the dinner table early and vomiting in the bathroom was a courageous first step in the effort to help him.

The pattern of behavior you describe is typical of an eating disorder called bulimia nervosa. While bulimia nervosa is more common among females, there are a notable number of males who also struggle with this disorder. It is commendable that you were able to recognize the warning signs in your son and not assume that eating disorders are disorders only seen in girls and women.

Bulimia nervosa is characterized by regularly occurring episodes of eating large quantities of food, often secretly, followed routinely by compensatory behavior, such as self-induced vomiting, laxative abuse, and excessive exercising. Typically, these compensatory behaviors are attempts to ease the physical discomfort associated with consuming a large quantity of food, to erase or minimize the effects of the food consumed on the person's weight, or both. Aside from compensatory behavior being an unhealthy coping strategy, it is also not an effective approach for weight management. Nonetheless, individuals with bulimia nervosa often hold tightly onto this destructive pattern of behavior in an attempt to experience a sense of relief from the chaos they associate with their eating patterns, as well as some aspects of their emotional health.

It is typical for individuals with eating disorders to deny, ignore, or avoid attempts by family and friends to draw attention to their problematic eating behavior. They frequently feel guilty and shameful about their eating behavior, and many feel increasingly depressed as their struggles continue over time. In addition, they are often too embarrassed to admit to family or friends what is really happening. Eating disorders are very serious, however, and although it can be very difficult, continuing to approach your son about his behavior is critically important.

If your son is showing any signs of a medical condition needing immediate attention, (such as dizziness, chest pains, blood in the urine or stool, etc.) or a significant increase in depressive symptoms (such as sleep disturbances, problems with attention and concentration, decreased energy, decreased interest in enjoyable activities, increased sadness, etc.), take him to a professional for evaluation as soon as possible. Starting with a visit to your son's pediatrician or primary care physician is one way to begin. Sometimes individuals are able to admit to their physician that they may have a problem. Even if this is not the case, the physician will address or rule out significant medical conditions. Emotional conditions can also be identified or ruled out, and a referral to a mental health professional can be obtained during the visit. Of course, if your son is showing any signs of a medical or emotional emergency, call 911 for assistance.

If the above situations do not apply to your son at this time, you may decide that you have time to approach him more slowly. Doing so in a caring and non-confrontational manner is likely to be most effective. Perhaps starting with a general question about whether or not he has an eating problem will be better received than a question targeting a specific behavior, such as vomiting, as this may be too shameful to admit initially. If your son can admit to a general eating problem, he might agree to see someone with expertise in the area.

If he denies any eating problems, continuing to gently voice your concerns about his health and well-being can be helpful. Let him know that it is less common, but not unheard of, for males to struggle with eating disorders, as this may ease some of the shame he feels. You might also let him know that there is no easy solution or simple answer to overcoming eating problems. He may have tried to stop this behavior on his own without success. Remind him (and yourself, too) that interrupting disordered eating patterns can take time and often require the support of others.

If, over time, your son continues to deny any eating problems and you continue to observe behavior that suggest there is cause for concern, scheduling an appointment with his pediatrician or primary care doctor as described above would be warranted. If your son is 18 or older, you cannot require him to attend doctor's appointments, but you can strongly encourage him to do so.

You have described a highly stressful situation that can take a toll on you, as well as your son. It is important to seek support for yourself as a parent of a child with an eating disorder. A good place to start is the National Eating Disorders Association. NEDA can provide you with information on support services and eating disorder professionals in your area. Continuing to reach out for guidance and support can benefit both you and your son as you move through this process together.

Stuart Koman, Ph.D., is president and CEO of Walden Behavioral Care in Waltham, Massachusetts; a principal at the Executive Performance Group; and a senior clinical advisor to the Public Consulting Group. Before that time, he was president of Charles River Health Management, a psychiatric contract management division of Community Care, Inc., and served as a member of the Governing Board of the American Psychological Association's practice division from 1992 to 2000. Koman is also an author and co-editor of the Handbook of Adolescents and Family Therapy.