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Family based treatment Family-Based Therapy teen eating disorder

Supporting your Child or Other Loved One with an Eating Disorder Through the Holidays

Supporting Child with Eating Disorder Over Holiday
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By Carly Poynter, AMFT, staff therapist

The holidays are a challenging time to navigate for most people. The holidays are even more challenging for those who struggle with their relationship with food. As we prepare for the holiday feasts and festivities, there are a few things to consider, especially when you have a child or other loved one with an eating disorder. While this list is not all-encompassing, it can serve as a thoughtful reminder to be aware of the challenges others may face this holiday season and some strategies to support them.

Things to Do

Plan ahead. With the holiday season ahead of us, the best thing we can do to support someone struggling with an eating disorder is to plan ahead. Planning ahead includes identifying what could be triggering for your child and developing strategies to deal with these triggers appropriately. Here are some common holiday triggers to consider: buffet-style eating and a surplus or different types of food, expectations from others, comments about food choices and appearance, comments about being overly full or eating too much, fasting for religious reasons, etc. One of the best ways to plan ahead is to talk to your child about what they are most worried about for the upcoming holidays.

Talk about the holidays and traditions that have been triggering in the past. Part of planning ahead is knowing and understanding what your child is anticipating to be anxiety-provoking. One way to identify potential triggers is to ask what was challenging about the holiday in previous years. While your child may be doing better or even be in recovery, holidays pose many challenges that your child may not have practiced in treatment yet. If any specific holiday foods are triggering, this is an excellent time to start practicing with these foods. Your child’s therapist or dietitian can help plan exposures to fear foods.

Ask what support your child needs from you or others. What does your child anticipate needing from you during the holiday season? The conversation about support is part of planning ahead. Some ways you can help support your child include: steering conversations away from talking about food and appearance, making a plate for them (if that help is needed), helping with coping skills before or after meals (discussed later), etc.

Model appropriate eating. While there may be adults and other children around the dinner table who are engaging in dieting or disordered eating, having your child have a good role model will be helpful. Appropriate eating does not mean you have to eat exactly what your child is eating. Appropriate eating means honoring your hunger and fullness cues, choosing a variety of foods, and demonstrating enjoyment of your meal.

Provide distraction or additional support during or after meals. As discussed above, one of the most supportive things you can do is help your child cope effectively. It can be helpful to ask your child what coping skills work best and practice these skills before the holidays. Rather than rushing from one activity to the next, provide time for your child to regulate their emotions. Distraction can take many forms, so you can get creative and plan for things that will engage your child. Some of the best distractions include things that require extra mental effort, such as a game of Scrabble or Bananagrams. Other distractions include watching movies or TV, playing with the family pet, board games, arts/crafts, etc.

Prepare other family members (and set up a family session if possible). Recovery takes the support of many people. While you, as a parent, may know the most about your child’s eating disorder and how to best support them, having others learn how to support your child can be helpful. Preparing other family members can include setting boundaries with specific conversational topics, such as diets and the appearance of others. It can also involve having others help support your child during or after meals or navigating other conversations that may be anxiety-provoking for your child. If your child is in treatment, this is a great time to request a family session to help plan ahead for the holidays and elicit extra support.

Have conversations when you notice eating disorder behavior. The holidays are challenging. You will likely notice increased anxiety or some eating-disordered behavior. While it may feel overwhelming to discuss these behaviors with your child in the moment, it is important to address them. To discuss behavior you are noticing, you should talk to your child away from the meal or anxiety-inducing situation (i.e., the meal, conversation, person, etc.) and then discuss what you are noticing and ask how you can help support them (or suggest a coping skill if your child is overwhelmed).

Things to Avoid Doing

Don’t make comments about appearance. It is never helpful to comment on your child’s appearance or the appearance of others. During this time of recovery, your child is likely hyper-fixated on their appearance and is likely engaging in social comparison more frequently. Due to the preoccupation with thoughts about body weight and shape, it is best to steer the conversation away from how someone looks. Instead of discussing appearance, you can model interest in other characteristics such as hobbies, school or work, or other passions of the person.

Don’t make negative comments about food or food choices. It can feel natural to say things like “I am so full,” “I overate,” “I can’t believe I had another piece of pie,” and other comments after eating. However, your child is listening and likely internalizing comments like this. It is important to note that when comments like this slip, you can correct them. If you or anyone else makes a comment like this, you can say something like, “while I am full, I enjoyed my meal,” or change your narrative to something more neutral.

Don’t expect your child to eat or try everything. While your child may be doing better or be in recovery, the holidays or certain food served at the holidays are likely triggering. Your child should still eat their meal plan, but they should not be expected to try everything. Part of planning ahead can include discussing what their plate should look like based on their meal plan. If your child needs to eat before or away from the guests, arrange for that to happen to ensure they complete the meal.

Other Considerations

  • Your child should still follow their meal plan (i.e., 3 meals and 3 snacks). While some people engage in restriction before a holiday meal, your child should still eat all meals and snacks as indicated by their meal plan. It can be helpful to discuss and meal plan with your child’s therapist and dietitian before the holidays.
  • This holiday may not go perfectly. Spend time identifying what went well, and times you noticed that they used coping skills.

Holidays are stressful for most people. As a parent of a child with an eating disorder, ensure you also take time to engage in self-care.

If you have an eating disorder yourself, learn strategies to support yourself over the holiday.

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teen eating disorder teen group

Teen Eating Disorder Recovery Group

 

As we have written elsewhere, we believe Family-Based Treatment (FBT) is a complete treatment for teens with eating disorders. Most teens will not need (or want) additional therapy. The one area where we think teens could use a little more support is in developing a strong anti-diet stance to stand up to weight stigma in our fat-phobic society. Teens who are in family-based treatment may also not have any interaction with peers who are also working towards recovery. Community in recovery can be a powerful support if teens are motivated and working together.

To fill these potential gaps in FBT we have developed a group to supplement FBT and help put a strong anti-diet finish on the treatment. This group is for teens of all genders in California, ages 13 to 18, who are in Phase 2 of FBT and are weight recovered and abstinent from eating disorder behaviors. Teens who are not in treatment with us, but who show similar signs of recovery will be assessed for readiness for our group.

The group is 6 weeks and is held on Tuesdays from 5:00 to 6:15. The group aims to help teens in recovery develop connections and build a strong anti-diet HAES (R) stance. The group explores how media messaging, diet culture, and weight stigma impact body image through a Health at Every Size (R) -informed approach. Teens will be able to share and connect through discussion, art, and advocacy, all while developing strategies to promote empowerment and body acceptance.

Feedback from participants has been positive. Teens have shared that it has been helpful to connect with other teens who have shared the same struggles and support each other in standing up to diet culture. They have also found the educational component helpful and take away strategies to continue to support their recovery.

The group is led by Lauren Barker, LMFT who has a lot of experience with this population. Space is limited. This group is offered several times a year. Next projected start date is September 13th.

Pricing: $270 for 6 weeks. Or in-network for teens with Anthem, Aetna, Anthem medi-Cal, and Beacon Partners health insurance

To register or for more information, email Hello@EDTLA.com and put “teen girl group” in the subject line.

 

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Family-Based Therapy teen eating disorder Uncategorized

When to Add an Individual Therapist in FBT-Phase 1

Photo by Priscilla Du Preez on Unsplash

When I am working as the Family-Based Treatment (FBT) therapist for a teen in recovery, their parents will often ask whether the teen should also see a therapist individually. Unlike other therapy situations, in FBT there is no expectation that there is both an individual therapist and a family therapist. It’s there in the name: “Family-Based Treatment.” FBT is not just “family therapy” aimed at solving family problems—it is a specific, comprehensive, evidence-based treatment. In fact, the developers state that they called it Family-Based Treatment when they were manualizing the approach because they wanted to distinguish it from being viewed as a type of family therapy.

As I have stated elsewhere, I think most teens who receive FBT will never need individual therapy for an eating disorder. I actively discourage the addition of an individual therapist in Phase 1 (nutritional rehabilitation). When we arrive at Phase 2 (handing back of control to the teen), we can better assess which issues remain unresolved with weight restoration. This is the point at which the adolescent is likely to be more receptive and able to benefit from individual therapy. Even here, I think additional therapy is only needed when there is a specific additional diagnosis or specific problem. Adding an individual therapist when one is not needed adds risk and can even undermine the FBT.

Among the reasons I discourage adding an individual therapist in Phase 1 is that the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, in one case series of families with “failed FBT”, does not believe in or support FBT. Additionally, in one case series of families with “failed FBT” teens later admitted asking for individual therapy as a deliberate strategy to exclude their parents and reduce the pressure for weight gain. I have observed teens who ask for individual therapists in Phase 1 and by Phase 2 no longer make such a request.

Reasons parents sometimes cite for wanting their teen to have an individual therapist include processing the underlying issue and having someone to listen. I do not think these are valid reasons for adding an individual therapist during Phase 1, given the risks that it could deflect from the focus on nutritional restoration. And, as discussed elsewhere, there is not usually an underlying issue to process.

Curious where other providers stand on the issue, I asked a few colleagues under what circumstances they would add an individual therapist in Phase 1 of FBT. These were their replies.

Never, if there isn’t a comorbid issue. I would not ever add an individual therapist to address the eating disorder during FBT treatment. The only time I do it is for some kind of comorbid issue, and even then, I usually don’t do it during phase 1. – Natalie Wingfield, LPC

I strongly discourage it and talk a lot about fidelity to treatment, commitment to the program, and how we want to ensure they are getting the full benefits of FBT. I also talk a lot about lack of research support for adding a therapist and the potential for therapy burnout from seeing multiple providers. But, I’ve had some families where they were very resistant to pausing individual work and I thought a lot about the cost/benefits of them not getting any eating disorder treatment if I remained rigid in my stance. In those rare circumstances, I’ve had success in asking to talk to the individual therapist about the treatment and role delineation/expectations. In my experiences so far, this has resulted in the other therapist either voluntarily pausing their treatment in support of FBT or really good communication between myself and the other therapist to help prevent mixed messages. I could definitely see it going sideways though and it’s not something I casually agree to with families. And it’s always a red flag to me when families won’t back down because it usually means they will be asking for additional changes to the treatment and will struggle with the structure. – Amy Henke, Psy.D.

I wouldn’t for the reasons stated above and more. If they are in phase 1 and therefore undernourished, they are not likely going to be able to engage productively in therapy anyway. I can see a lot of processing how difficult phase 1 of FBT is, and expressing a ton of distress which naturally most therapists would feel compelled to solve. This could only lead to the individual therapist interfering in the FBT process or at the very least introducing doubt about its usefulness to the client and family. Overall, “0/10 would not recommend” is my stance. I think it also confuses the idea that renourishment is really the key to resolving many of the presenting behavioral and psychological symptoms. If one therapist is talking about regular meals and the other is talking about self-esteem, 9 times out of 10, an overwhelmed parent is going to pick self-esteem as the issue to address. Then we risk losing the client to something that is not going to help them. – Christine Knorr, LCSW, CEDS

Usually I don’t recommend that as it creates a lot of cooks in the kitchen. We know how challenging the beginning of FBT can be for the whole family, I think as clinicians we just support them. – Shelly Bar, MD

Agree with recommendation to hold off adding an individual therapist in Phase I. I haven’t seen that ever go well. I have a few cases now where the individual therapist was brought in Phase I. I’m constantly trying to uphold the power to the parents, because therapists want to find a way to give voice and choices to the child. – Katie Grubiak, RDN

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Dieting Eating Disorders Family based treatment teen eating disorder

What Parents of Teens with Eating Disorders Need to Understand About Diet Culture

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Many parents experience guilt when their teen is diagnosed with an eating disorder. Nearly every parent can point to a time they themselves dieted, opted not to have a dessert they really wanted, expressed a preference toward thinness, or discouraged their child from keeping eating. You may have done things to try to keep your teen’s weight down and you likely did it with love and good intention—to protect your child from weight stigma and perceived subsequent health and social consequences.

It is common to wonder whether such actions contributed to the development of your teen’s eating disorder. Guilt is common for parents to experience when their child has any illness. In the case of eating disorders, many of the behaviors that are part of the disorder are reinforced by our culture’s preference for thinness and so blame is even more compelling.

What is Diet Culture?

Diet culture is a system of beliefs that values thinness and promotes it as a way to increase one’s worth. It creates rules about what type of eating is “healthy” and oppresses people who don’t meet the thin ideal.

Diet culture messages are everywhere, so it’s not your fault that you’ve absorbed them and subscribed to these beliefs without ever thinking twice about them. Diet culture is the soup in which we all swim. It’s the dominant paradigm. You likely have heard fear-mongering messages from other health professionals. You see it in the news.

Why is this system of beliefs so dominant? It’s promoted by a $70 billion diet industry. It’s entrenched in our fatphobic healthcare system. It’s reinforced by the media.

Parents often become the unwitting messengers of the dominant cultural message they hear from other health professionals. But this is an important turning point. Now that you are helping your teen with an eating disorder, it’s time to question what you think you know about health and weight and eating. You were not born hating your body. You developed these beliefs and you can unlearn them. It is never too late to start unlearning and unsubscribing to diet culture. We want you to join us in helping to break down the institutions that reinforce fatphobia and contribute to the development and maintenance of eating disorders and make your teen’s recovery harder. Your teen needs you fighting for their liberation.

We believe that parents are important allies for their teens with eating disorders. Even if you have disparaged your own body, dieted, cheered when your teen started eating healthier, or encouraged them to exercise in the early development of their eating disorder, we want you to know that you are not to blame for your teen’s eating disorder. Please show yourself compassion. Your teen needs you.

This also applies if your teen has Avoidant Restrictive Food Intake Disorder (ARFID), an eating disorder not typically driven by weight and shape concerns. Diet culture equally impacts people with ARFID.

How to Do This

  • Learn about how health is much broader than weight. Read the resources on our website about Health at Every Size ® to expose yourself to messages that challenge the weight-normative paradigm.
  • Stop talking critically about any body, including your own body and especially fat bodies. Model body appreciation and respect for all bodies and for body diversity.
  • Accept that your teen likely needs to gain weight and examine your fears about what that means for them and for you. Read our article on recovery weights.
  • Encourage your teen to see fat not as something to be feared. We don’t want to reinforce what the eating disorder is afraid of. We need to make it safe for people to be fat.
  • Curate your social media feed. The mainstream media images we see are not diverse, and the images we do see of larger bodies are often portrayed in a particularly negative and stigmatizing way, adding fuel to the fire. One way to build your own acceptance of body diversity is to acclimate to seeing a broader range of bodies portrayed in a desirable way.
  • Refrain from categorizing foods as healthy or unhealthy, good or bad. Model eating a variety of foods including foods you may have previously demonized, including desserts. Model eating with enjoyment and the social connection that comes from sharing meals.
  • If you previously promoted leaner, restrictive or “healthy” eating and are worried about creating confusion or appearing hypocritical with a new message around more flexible eating and more calorically dense foods, you can unapologetically explain to your teen that, in light of their eating disorder and what you are now learning, that you are also working towards a broader understanding of health and nutrition and becoming a more flexible eater. Some of the more powerful situations I’ve encountered include when a parent shares their own process in rethinking their relationship with food and their body while simultaneously doing their own work alongside their teen in recovery.
  • Teach your teen to think more critically about health and media messages they observe.
  • Take the Weight Implicit Association Test. Be gentle with yourself and remember we all have weight bias.

It’s never too late to change your thinking about weight and food. Many parents of teens who’ve had eating disorders have become great advocates for size diversity. Please join us in the anti-diet movement.

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Eating Disorders teen eating disorder

Parents, Don’t Let Your Kids Download Kurbo!

A disclaimer: I have no vested interest in Weight Watchers’ new Kurbo app. This app will in fact create more work for me. But let me be clear: I do not want this kind of work!

I know that you mean well and are merely concerned about your child’s health, but I can assure you that Weight Watchers does not share your concern. They are a commercial enterprise interested in making money and their business model is based on preying upon insecurities.

You would only need to spend a short time in my waiting room to hear from other parents who were once like you—moderately concerned (or maybe unconcerned) about their child’s weight and happy when their child committed to “eating healthier.” The story is nearly always the same. This child has been in what I would call a larger body—you might have called them “overweight”, pediatricians might have labeled them “obese”. It starts with them giving up sweets and then progresses. They start to restrict meat and starches and exercise more. It looks healthy. Over time, some switch gets tripped, and with very little warning the kid has anorexia, a lethal mental illness.

While most cases of anorexia are triggered by dieting, unintentional weight loss can be a trigger as well. It appears that people predisposed to anorexia respond to a negative energy balance in a way that flips this switch and they cross a dieting point of no return. Many of the teens I work with have been hospitalized for life-threatening low heart rates and electrolyte imbalances.

I cannot adequately express the guilt that parents feel from having allowed their teens to start these diets. I don’t blame them. I understand the pressure they are under.

Two of my three children grew out before they grew up. They had gained the weight their bodies needed to fuel puberty and impending growth spurts. I too received the warning from my well-intentioned pediatrician about their weights and weight gain. I knew enough to ignore the implied suggestion of helping them trim down. I cringe to think what might have happened if I had followed it. My children grew just fine and became more proportional according to their genetic predisposition.

My other child was lauded by the same pediatrician for growing up before growing out. It was only years later when I plotted her growth that I realized she had totally fallen off her expected weight curve at the time the pediatrician praised her weight. Yet, I did notice that she didn’t seem to be eating enough. (For more information on the intervention I did with her, read this post.)

The Kurbo app should come with the following warning:

“This app may trigger an eating disorder
from which your child could take 22 years to recover.”

Yes, 22 years! The most rigorous longitudinal study we have of anorexia has shown that at 9 years, only 31% of individuals with anorexia nervosa had recovered. Almost 63% had recovered at 22 years. If this is the path you follow, you may be facing many long years in and out of costly treatments to help your child recover.

Incidentally, Kurbo has made my job tougher. It classifies foods as “green”, “yellow”, or “red”. “Red” foods, such as ice cream, fried chicken, and pizza are “bad” — Kurbo advises kids to avoid them.

I work with children who suffer from anorexia, may be hypermetabolic, and may require ingesting upwards of 6000 kcal per day for several years to recover. I can’t express the difficulty of convincing an anorexic child to eat highly caloric foods to recover, when they immediately parrot back all the health messages they’ve received about these foods being dangerous. It’s terribly confusing to be told that the foods they’ve learned are bad for them are in fact the medicine that will cure them. This is but one reason why we cannot take a one size fits all approach to foods.

Back in my waiting room, maybe you would hear from some of the adults with eating disorders. They might tell you that years of dieting have contributed to weight gain, weight cycling, binge eating, and misery. They will typically remember that this pattern started in childhood with a diet. Dieting disconnects people from their own internal regulatory system (as does tracking calories and exercise).

What Can Parents Do Instead?  The following advice is for parents of kids of all sizes.

I suggest teaching kids that bodies naturally come in all shapes and sizes and that body size is largely genetically determined. I recommend viewing the Poodle Science video from ASDAH. This video does a great job illustrating body diversity and the risks of subjecting everyone to a single body standard. I suggest teaching kids that fat bodies are great too. We have to make it safe for people to be fat in order to prevent and treat eating disorders. Eating disorders are a more lethal problem. Parents can avoid judging or criticizing their own or other peoples’ bodies.

I suggest giving kids access to a range of foods — prohibiting “fun” foods leads kids to overvalue and overeat them. We don’t need to label foods as good or bad. Parents can serve nutritious food as well as fun food and model that they are of equal moral value. They can also model that food is supposed to be pleasurable and offers the opportunity for social and cultural connections.

Parents can also help children to move in ways that are fun, rather than teaching that exercise is penance for eating.

For more specific advice on helping kids develop as strong intuitive eaters with healthy body images, I suggest the work of dietitian Ellyn Satter and my psychotherapist colleagues, Zoe Bisbing and Leslie Bloch, The Full Bloom Project.

To Learn More

I recommend reading the statement from the National Eating Disorders Association: NEDA Statement on Kurbo by WW App.

And also The New York Times Op-Ed by dietitian, Christy Harrison: Our Kids Do Not Need A Weight Watchers App.

 

Categories
Eating Disorders teen eating disorder

This Halloween, Serve Candy to Your Teen in Recovery

A Family-Based Treatment (FBT)-approach

For teens with eating disorders, Halloween can be scary for the wrong reason: the candy! Most teens with eating disorders are only willing to eat a restricted range of foods. Expanding this range is an important goal of treatment, with the reintroduction of fear foods being a key step. Candy tends to be high on the fear food lists of many teens.

Halloween presents an ideal opportunity for families who are working with an FBT approach.

A Taste of Recovery

Most teens in America are excited for Halloween and its bounty of candy. By incorporating some candy during your teen’s Halloween week you can help them approximate the lives of teens who do not have eating disorders. This step can give them a taste of the full life you want for them—a life where they are unencumbered by food restrictions, a life where they can enjoy all foods, a life where they can travel the world confident that they will easily be able to meet their nutritional needs, and a life where they won’t feel the need to shun social events for fear of facing the foods there.

I know that I’m painting a beautiful picture and that this is easier said than done. Teens with eating disorders will deny that the disorder is driving their food preferences. Instead, they claim they simply don’t like candy anymore. Or that candy was the preference of a child and since then their palates have matured. But don’t believe them—you have crucial parental memory and knowledge. You know which foods your teen actually liked a few years back. You also probably know the foods on which he or she binged if they binged. And it is not credible that any teen really hates all candy!

Especially if your teen had a great many fear foods, you may already have experience reintroducing some of them. But once meals start going more smoothly, some weight has been restored, and binges and purges have subsided, many parents are reluctant to push further. Why rock the boat when your teen seems to be doing well? You may be wondering: Is candy really necessary?

In fact, this Halloween is exactly the right time to introduce candy.

Exposure

It is much easier to introduce fear foods before your teen is completely independent in their eating. Right now, you are still overseeing meals and your teen does not yet have their independent life back. Pushing the issue of fear foods becomes more challenging when your teen has regained most of their freedom.

When you introduce fear foods to your teen, you will probably feel anxious. Your teen will too. You may even feel like you are going back a step. This is how exposure works—it is supposed to raise your teen’s anxiety. When your teen avoids these fear foods, their anxiety decreases, reinforcing the avoidant behavior and justifying the anxiety response. This perpetuates both the emotion and the behavior. But the food is not truly dangerous—if the teen were to eat the food, they would learn that nothing catastrophic happens. In exposure, the teen is required to eat the food, and the anxiety response shows itself to be baseless. With repeated exposure, the brain habituates, learns that the food is not harmful, and loses the anxiety response.

Exposure works through repetition over a sustained period of time—not all at once. It’s likely that each food on your teen’s feared list will need to be presented several times before the thought of eating it no longer causes extreme anxiety.

You may feel that requiring your teen to eat candy is extreme. However, remember: the healthy part of your teen probably wants to eat candy, but the eating disorder would beat them up if they ate it willingly. By requiring your teen to eat candy, you are actually granting your teen permission to eat it—permission they are unable to grant themselves. After recovery, many teens report that they really wanted the fear food but were too afraid—it was only when their parents made them eat it that they were able to.

And I would argue that fearlessness in the face of candy is important for your child. So be brave about facing potentially increased resistance by your teen and model facing your own fear.

Here’s How to Incorporate Candy During Halloween:

  1. Choose a few types of candy based on your teen’s preferences about three years before they developed their eating disorder. (If you can’t remember, ask one of their siblings or just pick a few options, maybe one chocolate-based and a non-chocolate alternative.) Make your choice based on providing your teen with the typical American teen experience. (American teens will typically collect a lot of candy on Halloween, have a few pieces that night, and then have candy as snacks a few times during the following week.)
  2. You may choose to tell your teen about the candy ahead of time or not. Some families find that telling teens about exposure to fear foods ahead of time is helpful; other families find that it is better to just present a fear food without warning. But note that you are not required to ask their permission; FBT is a parent-driven treatment.
  3. Serve a single serving of candy during dessert or snack a few times during the week of Halloween. Plan carefully and be thoughtful. Do this with the same resolve that you use when you serve them any starches or proteins. You may want to introduce the candy on a day when you feel more confident, will have more time to manage potential resistance, or can be sure a second caregiver will be present. You may not want to present candy, or any fear food, before an event that you are not willing to miss in case you encounter an extreme reaction.
  4. If your teen binges or purges, make sure to sit with them for an hour after they eat the candy.
  5. Plan for what will happen if your teen refuses to eat the candy. For example, will you offer something else instead and try the candy again tomorrow? Offer a reward for eating the candy? Create a consequence for noncompletion? Whatever you decide, be consistent and follow through.

If you do this-this year, there is a good chance that by next Halloween your teen will be eating candy independently!

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