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College Mental Health Eating Disorders Family based treatment

Eating Disorder College Contracts

Eating Disorder College ContractIf you are sending a young adult with a history of an eating disorder to college (or seminary or another away program), it is a good idea to have a college contract in place. This is our recommendation for young adults with anorexia, bulimia, binge eating disorder, ARFID, and OSFED.

College and living away from home for the first time brings novel stressors and recovery challenges. Any transition can challenge the most stable of recoveries. The freedom and independence can provide a breeding ground for an eating disorder. Your young adult will be eating in an entirely different context than the one they have practiced recovery in. Relapses during college or the first period of independence are not uncommon.

Prior to sending your young adult with an eating disorder off to college or a similar independent experience you will want to ensure that your young adult is ready for the challenge of being away from home. A contract is NOT a substitute for readiness. Read more about our criteria for readiness in our post about college readiness. If you deem them ready, a college contract can be very helpful.

A contract is an agreement between the parents and the student—obviously not a legally binding document. Treatment professionals may help develop the contract or play a role in supporting the contract, but they are not parties thereto. I think about a contract as a safety net rather than something adversarial. Parents are on the side of their young adult—and are merely saying, “We want you to be in college, but we want to ensure that you are healthy enough to stay there in order to fully benefit from the college experience.” They then use the contract to specify the criteria required for the student to stay in college, as well as the consequences if those criteria are not met.

As long as you are paying for some of your young adult’s school or living expenses, you have leverage and can require a contract. I do not advise counting on the school to ensure your young adult stays well. No college, even those with excellent mental and physical health resources, is able to provide the level of oversight that parents do.

A contract should include the following:

  • A minimum healthy weight for your student based on optimal physical and psychological recovery and historic weight patterns, ideally developed with a treatment team and taking into account that young people are expected to gain weight until about age 20
  • A release of information signed by your student, allowing treatment professionals to communicate with you
  • A plan and cadence for your student to get weighed and have their vitals checked
    • Some families are able to set this up with the college health center; others with private practice professionals (MD, RDN, or therapist)
    • The frequency of weighings and vitals will be determined based on length in recovery and stability
  • A plan for consistent communication of the above weights and vitals information (i.e., each time it’s checked, or only if concerning; to whom on the team and when to parents).
  • Recommended treatment follow-up with various professionals. This ideally follows the recommendation of the prior treatment team and may include as many team members as necessary. Some individuals may need a full team; others may just need weights and vitals.
  • An expectation regarding behaviors:
    • Meals—how many meals and snacks the student is expected to have and any associated guidelines, such as a meal plan.
    • Exercise—any appropriate restrictions.
    • Any other behaviors of concern, such as purging
  • The specific steps parents will take if there is a lapse including weight loss or an increase in eating disorder behaviors.
    • For smaller lapses, parents may give the young adult some time to self-correct or regain weight independently and maybe increase sessions with team members before initiating other steps.
    • Some parents specify that they will come to school and stay with the student and try to help them for a time to get on track while staying in school.
    • If these steps are not working and for more significant lapses, parents may require the student to come live at home or go to residential treatment.

As with any consequence, parents should not include anything in the contract on which they are unwilling or unable to follow through.

I recommend that parents and their students start talking about the college contract and college readiness at least six months before the start of college, so the young adult is not surprised by the idea of a contract. I suggest parents write the first draft and then share it with their treatment team and their young adults and then incorporate feedback. The agreement should be signed by the parents and the student and the current treatment team members may also sign it showing their endorsement.

Sample College Contract:

In order for Mary to be successful at college, we agree to all the terms set out in this agreement and will not take action beyond what is prescribed in the agreement without a review with Mary and her team first.

  • We will treat Mary like a responsible adult.
  • We will not show up at college unannounced.
  • We will give 24 hours’ notice before visiting.

In order to remain at college:

  • Mary will be weighed weekly at her counseling sessions with Dr. Freud. Dr. Freud will communicate her weight to her parents each week.
  • Mary will attend weekly counseling sessions with Dr. Freud and bi-weekly appointments with dietitian Nancy.
  • Mary will eat 3 meals in the dining hall and 3 snacks daily containing appropriate amounts of fats, carbs, and protein in order to maintain her weight. She will eat a dessert daily.
  • Mary will not become a vegetarian.
  • Mary will maintain a minimum weight of 140 pounds.
  • If Mary binges/purges, she will discuss it with Dr. Freud and Nancy and develop a plan.
  • Mary agrees that physical and emotional health and safety are a higher priority than educational progress or participation.
  • Mary will be mindful of exercise as a potential trigger and will limit exercise to no more than 3 times a week for 30 minutes. Mary agrees she needs to consume sufficient food to fuel her level of exercise.

The following backup plan is not a punishment but a safety net to facilitate ongoing progress:

  • If Mary’s weight drops below 140 pounds, she has 2 weeks to regain the lost weight. Her parents and dietitian will help with suggestions and provide more snacks.
  • If lost weight is not regained by the 2-week mark, one of her parents will come to college at the end of classes for the week and all meals and snacks will be supervised by her parents for the weekend, even if Mary has to cancel something. Mary can return to classes after the weekend after the Sunday evening snack. Supervised weekends will continue until weight is back above 140 pounds. Once the weight is regained, Mary can remain at school without parental supervision.
  • If supervised weekends do not result in expected weight regain in 2 weeks, Mary will return home until weight is regained.
  • If Mary fails to comply with any of this agreement, she will need to withdraw and either enter residential treatment or seek employment.

We will review this contract at the beginning of each academic semester and revise it as needed to help Mary maintain healthy eating habits.

Signed:______________________                Date:_______________

 

Signed:______________________                Date: _______________

 

 

Witness: ­­­­­­­­­­­­_______________________           Date:­­­­­­­­­­­­­­_______________

Categories
College Mental Health Eating Disorders Uncategorized

College, COVID, and Eating Disorders: What You Need to Know

Photo by engin akyurt on Unsplash

As I’ve talked about in depth here, the transition to college away from home is challenging for most young adults. It is especially fraught for young adults with eating disorders. In that article I provided a College Readiness Checklist for students who are either considering their first move away from home after a history of an eating disorder or returning to college after being diagnosed with an eating disorder. I have learned the hard way. I’ve witnessed the heartbreaking reality of what can happen to students who go away before they’re ready. I may seem stringent, but we’re talking about one of the most deadly mental illnesses and this is your child’s life and future.

I was recently asked whether the same standards should apply in the current climate. I replied that I thought the standards should actually be more stringent given the pandemic. This has been on my mind all summer; now, I am prepared to sound the alarm.

Students with eating disorders of all types—anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder (ARFID)—often have a narrow range of foods they are comfortable eating. They often struggle with flexibility.

The pandemic has thrown a wrench—really, a whole toolbox—into the college experience. Among the changes this fall is that most dining halls have pivoted to prepackaged meals. This will be an added challenge for students with eating disorders. Students have already reported that the results are long lines as they wait for food, far fewer food choices, no option to portion their meals themselves, and no option to mix and match. These prepackaged meals may be insufficient in nutrients or energy, especially for students in recovery who have high energy needs.

Add to this the experience of students who are quarantining either due to outbreak or exposure, or as required by the college upon return to campus as a preventative measure.  Most are in dorm rooms without access to a kitchen. Social media has exploded with unfortunate food stories:

These stories are garnering attention, people find it laughable, and the colleges are receiving criticism, but I can only think about how the students with eating disorders are impacted.

Eating disorder recovery requires eating at regular intervals and meals sufficient to maintain recovery. Even a small negative energy balance can increase the risk for relapse in individuals with anorexia nervosa or increase the risk of binge eating for those with bulimia nervosa or binge eating disorder.

Students who are not very stable in their recovery may not be able to handle the current climate. They may not be able to seek additional food if portions are too small. People early in recovery often experience shame about hunger. It could be very triggering to receive portions that are not satisfying. Patients with eating disorders may not be able to advocate for their nutritional needs or do the problem-solving required to make sure the meals are sufficient. Finally, receiving an entire day’s worth of meals at the end of the day would be a natural trigger for those who have struggled with binge eating—or for most people!

Add to this the stress of academics and social issues and the uncertainty about the rest of the semester, and you have a perfect storm for relapse.

If you have any doubts about whether your student may be ready for college under these challenging circumstances, I strongly encourage you to consider keeping them home this semester. If there ever was a time to err on the side of caution, it is now.

With most classes online and social options at college significantly limited, this provides a unique opportunity to keep them home so they have more recovery time under their belt before they have to face such eating challenges. They will not be missing much, and you can work on strengthening recovery so that when the pandemic is over they can return as a healthier student capable of embracing the full college experience. You can use my article—which outlines steps to prepare a student for the challenges of navigating recovery in college— to make sure they are fully prepared when the time is right.

Categories
College Mental Health Family based treatment Family-Based Therapy

On Empowering Parents—Not Pathologizing Them

I often write about the importance of including parents in the treatment of adolescents and young adults. My work is informed by my training in Family-based Treatment (FBT), which as a central part of treatment seeks to empower parents to help their ailing children with eating disorders to return to health. When asked why families should be the center of treatment, I usually cite the AED guidelines on the role of the family, The Nine Truths About Eating Disorders, and the vast evidence base underlying FBT. I often discuss how providers who see families with children with eating disorders get a distorted view of the family: they do not have the benefit of having seen how it functioned prior to the eating disorder. Parents’ behaviors are often pathologized when they are actually the normal response of healthy parents to a child in distress.

This post is different—here I will share a more personal perspective.

Recently, one of my children (anonymized here because the story is theirs to tell) stumbled. My child was fighting a mental health issue that was not an eating disorder. The experience of watching my child struggle, and struggling to help my child, has further informed my thinking on this issue.

Sadly, it remains common for parents of children, adolescents, and young adults with mental health problems to be judged, labeled, blamed, and excised from the child’s treatment. This has happened to families with whom I have worked. Parents have sometimes been labeled as “enmeshed” or “overprotective.” This is not productive.

I’m writing this blog to share how beneficial it was personally to be included in my young adult child’s treatment. First, let me give you some background.

For Most of My Parenting Years, I Was Balanced

I care for my children deeply and have chosen a career that has allowed me the flexibility to be present in their lives and to be their primary caretaker. At the same time, I have been anything but a coddler. All three of my children were sleep-trained at less than six months, left at a young age with non-family babysitters, and dropped at preschool on the first day. I shed some tears, but I was not a parent who stayed and watched outside of the classroom for months; I went to work.

I also developed a certain toughness to set limits. During my kids’ early years, I worked at Los Angeles County Jail, where I encountered numerous inmates demanding sleeping medications or “more desirable” housing assignments and then threatening suicide when they didn’t get their way. I became a pro at placing inmates on suicide watch and walking away despite their sometimes yelling at the top of their lungs that they would tell the entire jail, “It’s because of you, Dr. Muhlheim, that I will kill myself.”

I am not a perfect mother, but I am a highly dedicated, devoted one. I have sought to balance my joy in raising my children with time to pursue my own interests and career.

When My Child Started to Struggle I Became Highly Involved

When I work with parents of teens and young adults with eating disorders, I encourage parents to trust their instincts. “Parents know their kids best,” I tell them. During the transition to college, when my child was supposed to be individuating, I knew something was amiss, so I hovered more than usual.

Fortunately, when my child wobbled, I was prepared. I trusted my instincts. I was fully present: watching, standing close, getting my child help. I helped save my child’s life. There are powerful cultural expectations that parents should back off and allow their child to individuate. There is less support for parents who choose to step in at this moment. Observing my behavior at that time, I may have been labeled as overprotective.

Even my child, who recognized the need for parental help, was fighting against it. This was confusing to their therapist, who later wrote in a report, “There is a weird dichotomy between the child and the parents. The child refuses to sign a release of information for the therapist to speak to the parents, but the child appears to reach out to the mother for support.”

Rather than pathologizing hovering parents, we need to recognize that they are doing it for a reason.

Professionals Supporting, Not Blaming Parents

The hardest moments of this whole journey were those times that, on top of his worry for our child and whether they could or would actually recover, my husband blamed himself for causing the problems our child was facing. This tendency of parents—to blame themselves for any problem that befalls a child—is typical, whether or not the problem could be attributed to parenting. I noticed that when my husband started to blame himself, we both became hopeless and lost focus on helping our child. These were dark times—it was hard to have our own faith and be present for our child.

Fortunately, we had the means to seek out high-quality treatment. Our child was treated in a center that specializes in treatment often used for a problem for which parents have historically been blamed. In this program, we as parents were given much-needed support and services as well. Importantly, the clinicians never indicated they believed that we had caused our child’s problems. Instead, we were validated, supported, and given a framework for understanding our child’s problems that did not point the finger at us.

Made/Makes All the Difference

Further, our responses to our struggling child were validated as a reasonable response to experiencing our child’s struggles. We were supported in our child’s recovery, empowered to play a role, included in the treatment, and seen as parents doing our best. This was profound. I think it made all the difference.

Our child worked hard and so did we. With the proper help and our support, our child is now healthy and firmly back on track. My hope for other parents of floundering adolescents and young adults is that they are treated with the same respect that we were.

Categories
College Mental Health Eating Disorders Family based treatment

Is Your Young Adult with an Eating Disorder Ready for College?

You may be wondering: is my young adult with an eating disorder ready for college? Starting college is stressful for even the most well-adjusted young adult. Young adults with eating disorders often have trouble with transitions. Add an active eating disorder on top of the college transition, and you have a potential time bomb.

College brings a multitude of new situations to navigate: living away from parents; living with strangers; loss of personal space and privacy; unfamiliar environment; unfamiliar foods; loss of structure; drugs and alcohol; pressure to fit in; academic pressure; and social organizations and events. If a young adult has been struggling in recovery, these additional stressors typically add to the challenge.

Young adults who are not completely recovered struggle in situations that healthy adults navigate with ease. For example, consuming enough food in a dining hall can pose a big challenge for inflexible eaters. In our experience, students who are uncomfortable eating with peers or eating a variety of foods (including starches, fats, and desserts) may lose weight rapidly in this environment.

The patterns of college life can complicate the maintenance of a healthy weight. Students are likely much more active as they walk from place to place across a large campus. Different sleep patterns (including all-nighters) can also increase energy expenditure. For these reasons, the caloric needs of college students are often substantial; 3000-3500 kcal per day baseline is not unusual. This would translate to needing over 100 fat grams per day. These factors should be considered when evaluating whether your young adult can eat enough calorically dense food on their own to sustain a healthy weight or refrain from bingeing and purging.

College culture brings additional pressure on a student in recovery. Roommates and peers may be dieting, fear of the “freshman 15” may circulate, and friendships may bond around visits to the gym and yoga classes. It can be harder to refrain from exercise when it’s at the center of socializing.

Many parents want to send their young adults away to school so that they can achieve important milestones and participate in transformative experiences. However, the reality is that attending school while still plagued by intrusive eating disorder thoughts and behaviors will rob them of the very aspects of the experience you want your child to have. Offering your young adult a “normal” life too soon is a common cause of relapse, further delaying their ability to live a “normal” life.

So how do you know if your young adult is ready for college? If you can answer yes to all of the following questions—considering the last six months—then your young adult may be ready to transition. Yes, that’s right: a solid six months of recovery is recommended to ensure your young adult does not relapse. If you answer no to any of these questions, you are strongly encouraged to work with a treatment team and follow our suggestions for how to prepare your young adult.

Six months of solid recovery is needed, meaning the young adult has consistently displayed the behaviors included in the checklist over that period of time.

Lauren and Katie’s College Readiness Checklist

Has your young adult maintained a steady weight in the healthy range (according to childhood growth records) and (if female-bodied) menstruated consistently for six months? Yes No
Has your young adult been free of eating disorder behaviors such as bingeing, purging, laxative use, and excessive exercise for six months? Yes No
Is your young adult able to independently and consistently prepare and choose meals that contain enough energy-dense foods to maintain this weight? Yes No
Is your young adult able to serve themselves snacks and desserts? Yes No
Does your young adult consume beverages other than water (juice, milk, lattes)? Yes No
Is your young adult able to eat at a variety of restaurants, ordering and eating a balanced meal that is not the lowest-calorie item on the menu? Yes No
Is your young adult able to confidently eat from the different food stations at a cafeteria (sandwich bar, grill, etc.) and not just from the salad bar? Yes No
Is your young adult comfortable eating hot breakfasts (other than oatmeal)? Yes No
Does your young adult use condiments comfortably (dressing with fat, ketchup, mayonnaise, etc.)? Yes No
Is your young adult comfortable eating with friends? Yes No
Does your young adult eat at a normal pace? Yes No
Has your young adult reincorporated the majority of previously feared and avoided foods? Yes No
Is your young adult able to go without exercise at least every other day, or not at all if medically contraindicated? Yes No
If your young adult has returned to exercise, do they understand the need to add additional fuel following exercise? Yes No
Is your young adult able to eat in front of other people who aren’t eating? (There is no guarantee roommates will not be eating disordered, so taking care of one’s own needs and handling the self-consciousness inherent in doing so is an important recovery skill.) Yes No
Would your young adult be able to cope with having a scale in the room and roommates who weigh themselves and discuss weight or dieting? Yes No
If your young adult misses a meal for any reason at all, are they able to make it up that day or the next day at the latest? (Making it up may mean having larger portions at other meals, two extra snacks, or the equivalent of an extra meal across a twenty-four- to thirty-six-hour period.) Yes No
Is your young adult able to increase his or her daily calories substantially to account for mileage logged when walking around campus? Yes No
Can your young adult be restful? Do they sit when everyone else is sitting? Yes No
Is your young adult able to be alone around processed and highly palatable foods without having an urge to binge? Yes No
Has your young adult demonstrated an ability to tolerate anxiety without resorting to restriction, bingeing, or purging? Yes No
Does your young adult openly acknowledge their eating disorder and have insight about the need to construct a life and schedule that supports recovery? Yes No
Have you discussed with your young adult that any situation that puts them in a state of negative energy imbalance or weight loss could trigger a relapse? Yes No
Does your young adult understand that alcohol calories do not count toward energy needs? Yes No
Are temperamental traits (perfectionism, rigidity, comparing, etc.) acknowledged and appropriately managed? Yes No
Are you willing to step in and pull your young adult out of school if needed? (Remember, even though your young adult is over eighteen, you are still responsible for them. It is unrealistic to expect their college to, in the words of Laura Collins, “provide the kind of accountability and monitoring and personal support that a parent provides and an eating disorder patient deserves.”) Yes No

    How to Prepare a Young Adult for College

    If your young adult meets most of the above criteria and there is still time before they are expected to leave for college, there are things you can do to prepare them.

    • Practice eating with your young adult in different self-serve cafeteria-type settings, as well as a variety of restaurants, for breakfast, lunch, and dinner. Good options include Indian restaurants that offer lunch buffets and hospital cafeterias. Have your young adult practice building a meal that will meet their dietary needs. Revisit the same places again with the expectation that they will choose different options.
    • Have your young adult practice walking five miles per day for a week (to simulate the amount of physical activity they are likely to have on a college campus) and add sufficient calories to keep weight steady.
    • Arrange “surprise” food exposures for a few months. At random times take your young adult to unexpected food locales and make sure they can tolerate it. For example, make a spontaneous stop at an ice cream parlor.
    • Do a week of sauces and butter on everything, simulating more typical cafeteria meals (e.g., meats with gravy or sauce, pasta with cream sauces, salads already dressed).
    • Enter into a college contract. This is an agreement between you and your young adult that specifies the criteria required for staying in college (such as maintaining a healthy weight, not engaging in eating disorder behaviors, and having regular weigh-ins) and what you will do if these things are not met (for example, increase supervision, bring your child home, etc.). A sample college contract is available here.
    • Make sure they have a meal plan that includes three meals per day in the dining hall.

    If your young adult does not meet the criteria listed above, then please consider having them defer college, or start at a local college while living at home. It is better to delay starting college than to have them start only to get overwhelmed by symptoms and need to drop out. Life is not a race. College can wait. Your young adult will get more out of the experience when they are fully recovered. By contrast, sending them to college before full readiness may reduce chances for a full recovery.

    For an update on how COVID is impacting the college experience, read about additional considerations.

    Thanks to Katie Grubiak, RDN, who co-authored this piece in its initial form, and Rebecka Peebles, MD, Therese Waterhous, PhD/RDN, CEDRD, and JD Ouellette for their helpful feedback and contributions to this piece.

    Download copy of article Is Your Young Adult With an Eating Disorder Ready for College: Is Your Young Adult Ready for College?

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