By Marguerite Kelly
Special to The Washington Post
Friday, July 25, 2008

Q. My 14-year-old niece -- my brother's daughter -- has been treated for anorexia for a year but she still hasn't gained any weight. Now she will have to see the nurse every day when she's in school to make sure that she eats her lunch. She's also too thin to play sports anymore, which makes her quite unhappy, since her athletic activities pleased her father so much.

I don't know this child well, as I live in another state, but my brother and sister-in-law are much more controlling and protective than I am. I do know, however, that she and her big sister are excellent students, well-behaved and do whatever is expected of them and that the whole family is showing signs of stress.

My brother is a workaholic; his stay-at-home wife micromanages the children; they both consume a lot of alcohol. The older daughter is being treated for anxiety because she thinks that she won't be accepted by the best colleges.

My sister-in-law attends therapy sessions for self-discovery and improvement, but my brother refuses to go to family therapy because he doesn't think it works.

I've learned about these problems from my mother, but I don't mention them to my brother because he gets angry if I make any comments or suggestions, and I don't say anything personal to his wife either.

I will be going home to visit my parents soon, however, and wonder what I might do to help the younger child overcome her anorexia and feel more secure.

A. This family has too many serious problems to solve by themselves. If the father won't go to family therapy, the mother and daughters should go alone.

If the therapy is successful, the ones who attend will discover that their behavior is affecting others much more than they realized and that they can change it to a significant extent.

Family therapy may inspire your sister-in-law to drink -- and to micromanage -- a little less, which should make your older niece less anxious, but it may not help your 14-year-old niece all that much. Anorexia can have a wicked grip on a teenager, and she may also need individual therapy, empathetic support and maybe even hospitalization before she can beat it.

Doctors still don't know the cause of this eating disorder, but they say it often hits teenage girls and young women who are white, high achievers in school and come from a goal-oriented family.

For some reason, they start thinking they're fat, no matter what they weigh or what anyone says, and it can take years for them to change their minds. In the meantime, they eat as little as possible and may exercise excessively or use laxatives or diuretics to lose weight. In time, they may become depressed, and their periods may stop, their blood pressure fall, their skin turn blotchy or yellow, their teeth may rot, their muscles may atrophy and if they lose enough weight, one out of 10 will die from this mysterious illness.

While your brother and his wife can choose a treatment for their daughter, you can support her with your friendship, which could be almost as valuable.

Begin by asking the parents if you can give her a round-trip plane ticket, so she can visit you when you both have a three- or four-day weekend. This will give you enough time to invite a few of your friends for brunch, to take her to a college play and go to a restaurant where the aromas are almost as enticing as the food and the conversation will be even better.

That's when you can remind her that she owns her own future and that -- with a little luck and a lot of work -- she can be whatever she wants to be when she grows up. A teenager can't hear that enough.

When your niece goes home, you should keep encouraging her with frequent e-mails and postcards and try to see her as much as you can, both in your town and hers. This will give her the friend she needs more than ever, and maybe more than she ever will again.

In time you should be able to talk with her about her illness, but don't lecture her endlessly. You'll be more effective if you print out some material on anorexia for her, which you can find on the National Library of Medicine Web site ( http://www.nlm.nih.gov/medlineplus) and also on the one sponsored by the National Association of Anorexia Nervosa and Associated Eating Disorders ( http://www.anad.org). Facts can be more persuasive than a doting aunt.

Questions? Send them toadvice@margueritekelly.comor to Box 15310, Washington, D.C. 20003.