When Your Child With an Eating Disorder is Sick….

Guest post by Dr. Jennifer Johnson

When Your Child with An Eating Disorder is Sick...
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When parents are renourishing a child with an eating disorder and that child gets sick, parents often don’t know what to do. Some families may back off on feeding every time a child gets any illness, which can be a risky practice. Especially during Phase 1 of FBT, ensuring eating is a priority. To help parents, I’ve asked Jennifer Johnson, MD, a medical doctor who specializes in treating patients with eating disorders, to share some advice.

First, let me say that in general, minor illness should not cause a kid with an eating disorder to lose weight. Parents who are refeeding their child know that even missing a meal or a snack makes a difference in their progress. Don’t let illness throw you off course. As you know, failure to gain as expected may occur if nutrition is even a bit compromised. It is absolutely not a given that illness or surgical procedure must cause weight loss. When I hear that someone has lost 3 pounds “because they had a cold” the previous week, I ask a lot of questions – that should not have happened.

Second, plan ahead. After you’ve read through my answers and looked at other parents’ recommendations, be proactive. Make a plan with your child and treatment team about what you will do if they get sick (which they inevitably WILL at some point during recovery). They should know that they WILL still be eating. But talk about what foods they tend to like when they are ill, and think about how to plug maximum nutrition into them. Buy any non-perishable supplies and stock up on over the counter medications for colds, coughs, and fever. (And please have a thermometer on hand! A $10 digital one is plenty good to give us doctors valuable information.)

What should parents do in terms of feeding when a child with an eating disorder has a head cold or sore throat and loses their appetite? Is it necessary to avoid dairy?

If your child is listless and feeling unwell, they will often not be very hungry for a couple of days. A sick child needs care and comfort. Caring for a sick child who has an eating disorder includes keeping up the nutritional intake. You don’t want the eating disorder to think that illness is a good way to sneak through the back door. And, there are other times when your child is not hungry, just from refeeding itself, and they have to eat anyway. So, push ahead, but gently. Present nutrition dense food and beverages that will be particularly appealing to your child. Does a milkshake sound appetizing? You can add a packet of Benecalorie. (There’s nothing wrong with dairy, by the way.) Chicken noodle soup? Maybe add some extra pasta. There are lots of helpful posts from parents on the Around the Dinner Table Parent Forum.

What about if they have a fever?

Having a significant fever (101 or above) increases fluid needs as well as metabolic rate (more calories are burned). Your child will feel better if you control the fever with regular doses of acetaminophen or ibuprofen. Giving the medication at regular intervals, say every 6 hours for acetaminophen, may prevent the fever from getting as high as it otherwise might. This also helps with the headaches that usually accompany fever. Keeping your child hydrated, particularly with something like Gatorade, will also help them feel better – and thus more likely to have some appetite. Some kids maintain their appetite when they have a fever and of course, it’s fine to continue refeeding. Otherwise, know that keeping up nutrition during an illness helps your child feel better sooner, and push on. Again, it’s helpful to adjust what you give them based on their preferences.

What about when kids in recovery have the stomach flu?

What do you do if they’re vomiting?

Generally, vomiting is worst at the onset of an episode of stomach flu and becomes less frequent over the next 24 hours. A parent’s main goal when a kid is vomiting is to keep them hydrated. I recommend not giving anything by mouth for 2 hours after they’ve thrown up. Then you can give them ice chips or a couple of teaspoons of water. This liquid will get absorbed from the mouth. Do this every 5 minutes or so for half an hour. If they haven’t vomited again, you can have them try slightly larger amounts of liquids at less frequent intervals. They should be able to keep down about 2/3 of a cup of liquid, and be hungry, before you try a very small amount of food. Slowly increase the amount you give them. Kids may become ravenous and eat a huge meal, but then throw up everything they’ve just eaten. A kid who throws up a day or two into recuperation may have just overdone it. In that case, you’ll need to let up a bit before pushing back into refeeding.

What about diarrhea?

For kids with diarrhea, we don’t generally recommend giving any medications that are designed to decrease the number of stools (bowel movements). No major food restrictions are needed. There is nothing magical or beneficial about the so-called BRAT diet (bananas, rice, applesauce, toast), which is of low nutritional density. Studies have shown that having diarrhea for a few days does not make someone lactose intolerant. We know that eating when you have a “stomach bug” with diarrhea will generally increase the number of diarrheal stools. But we also know that at the end of the illness, people who have continued to eat will end up better nourished (= digested more calories). And that, of course, is the ultimate goal.

One thought: you may want to speak with your child’s doctor about a proactive prescription for a small number of anti-emetic tablets (that dissolve in the mouth) to have on hand in case your child gets stomach flu. I don’t normally recommend this but refeeding is an exception. We want to minimize the duration of nausea and vomiting to make it easier for your child to eat. Also, many of my patients who have eating disorders are afraid of truly fearful of vomiting (a condition called emetophobia), which only makes stomach flu worse for everyone. If your doctor is willing to do this, they undoubtedly want you to call before you give the medication.

What if your child has no appetite (due to illness)

Biology is on our side. When a kid (or another human being) eats less due to a minor illness, appetite typically returns with a vengeance and we make up for what we’ve missed. For a kid in the early refeeding phase, of course, it is normal to not feel hungry. So you may not know whether your child is not hungry because they’re not feeling well or because they’re refeeding. In either case, your eating disordered child needs you to continue to push forward. Refeeding is the mainstay of treatment and you’re the team leader. Go for it!

Please note that none of the above should be construed as medical advice. If you have concerns about your child’s health, contact their doctor. Some examples of when you should call the doctor are: Bloody diarrhea, high fever (102 or above), vomiting that continues more than 24 hours, weakness, severe dizziness or fainting, or very little urine.

About Jennifer Johnson, M.D., MS, FAAP

Dr. Johnson is a medical doctor. She has more than 20 years’ experience as a pediatrician and adolescent medicine specialist. She practices in Newport Beach (Orange County), California.

Dr. Johnson is certified by the American Board of Pediatrics in Adolescent Medicine as well as in Pediatrics. Dr. Johnson also has an advanced degree in public health. She has been a professor in the Department of Pediatrics at the University of California, Irvine School of Medicine, where she served as director of the adolescent medicine program. Dr. Johnson has taught medical students, residents, faculty, and community physicians, for whom she continues to present educational programs. She has presented at national meetings of many organizations, including the American Academy of Pediatrics and the American Academy of Family Practice. Dr. Johnson has written many research articles and book chapters related to adolescent and young adult medicine.

Dr. Johnson is an advocate for adolescents and young adults. She is a Fellow of the American Academy of Pediatrics (AAP). She has led many activities in the Academy’s Section on Adolescent Health and served as its chairperson. Dr. Johnson is active in the Orange County chapter of the AAP, as well. Current projects include the Teen Safe Driving Initiative and healthcare for GLBTQ teens.

Dr. Johnson has also been active in the Society for Adolescent Medicine. As a member of the medical advisory board for Teengrowth, Dr. Johnson wrote many articles and answers to reader questions. Articles and webcasts by Dr. Johnson are posted at Healthology.com, medbroadcast.com, and the New York Daily News. 

Dr. Johnson is on the medical staff of Hoag Hospital in Newport Beach.

Parent Volunteers Needed for Eating Disorder Recovery Research Study

Parent Survey Eating Disorder

 

Mayo Clinic researchers are conducting a study examining parents’ perspectives on eating disorder recovery. We believe that parents have valuable information about their children that can help us better understand eating disorder recovery and improve treatment outcomes. If you are a parent of a child or a teen with an active or past eating disorder, we would appreciate your input by taking an online survey. If you are interested in participating, please click on this link:

Parent Survey of Recovery

You may share this message and link with anyone else or any group that you think might be interested in participating.

This survey is for parents who:

  • Have a child or a teen who was diagnosed with an eating disorder before the age of 18
  • Have access to some data about their child’s heights and weights prior to diagnosis, at diagnosis, and after diagnosis (any measurement system is fine!)

We will be asking you questions about your child’s illness and aspects of recovery, including weights and heights if you have them. If you have growth records, it would be helpful to gather them before taking the online survey. The survey should take about 30 minutes to complete and will be anonymous.

Study Information

Understanding Carers’ Experience in Treatment for Their Child’s Eating Disorder

Principal Investigator: Jocelyn Lebow, Ph.D.

Additional Investigators: Erin Accurso, Ph.D., Leslie Sim, Ph.D., and Lauren Muhlheim, Psy.D.

You are being asked to participate in a research study to understand carers’ experience in treatment for your child’s eating disorder. This invitation is being posted on blogs, social media groups and sent to listservs for parents of children or adolescents who have had/ currently suffer from an eating disorder.  If you agree to participate, you will be asked to spend approximately 30 minutes completing an online survey. We will ask you questions about your experiences during your child’s treatment and your personal definition of “recovery” for your child. The survey is anonymous, so your answers cannot be identified or traced back to you.  The risks and burden associated with this research study are minimal. While there is no direct benefit to you if you choose to take this survey, we believe that this research study will provide a better understanding of carers’ perspectives of their children’s treatment and recovery, with the goal of improving treatment and outcome assessment.  Please understand that this is a voluntary study and your current and future medical care at Mayo Clinic will not be affected by whether or not you participate. Contact the Mayo Clinic Institutional Review Board (IRB) to speak to someone independent of the research team at 507-266-4000 or toll-free at 866-273-4681 if you have questions about rights of a research participant. Thank you for sharing your time and expertise.

 

The researchers

Weight Gain in Bulimia Recovery

by Elisha Carcieri, Ph.D., a former associate therapist at EDTLA

Weight Gain in Bulimia RecoveryOne of the hallmark features of eating disorders is placing a high value on body weight and shape in determining one’s self-worth. In addition, people with eating disorders often believe that body shape and weight can be controlled through diet, exercise, or, in the case of bulimia nervosa, purging. Individuals with bulimia nervosa purge in an attempt to eliminate calories consumed (which is actually ineffective), empty or flatten the stomach, modulate mood, or as a self-imposed negative consequence for binging. Bulimia carries serious mental and medical health risks. The road to recovery from bulimia usually involves (at least) outpatient therapy with a qualified mental health professional such as a psychologist.

Bulimia Treatment

Cognitive behavioral therapy (CBT) is the most well-researched and effective treatment for bulimia. Therapy begins with an initial goal to immediately stop purging, monitoring weight and food intake and implementing regular eating, which usually looks like three meals and two snacks spread out over the course of the day. Over the course of therapy, the patient and therapist address the various factors that keep the eating disorder going including the over-evaluation of weight, shape, and one’s ability to control these factors, dietary restraint and restricting food intake, and mood and anxiety-related factors associated with the eating problem.

Most patients with bulimia nervosa present to treatment at a weight that is in a “normal” range for their height. This is in contrast to those with anorexia nervosa, who are typically underweight. Despite being at a normal weight, the characteristic weight and body dissatisfaction associated with bulimia is strong at the beginning of treatment, and patients believe that they are controlling their weight via their purging behaviors. People with bulimia often restrict food intake in various ways, only to eventually binge and purge. Because treatment involves eating meals at regular intervals without purging, a common fear at the outset of treatment is whether changing eating patterns will result in weight gain. The answer is…maybe.

For most patients with bulimia nervosa, treatment will not result in a significant change in weight. However, some patients may gain weight and a small percentage of patients will lose weight as a result of eliminating binge eating. It is not advisable for patients in recovery from an eating disorder (or anyone, for that matter) to have a specific goal weight in mind. Focusing on weight loss is incompatible with CBT strategies to eat balanced and sustaining meals at regular intervals. Weight may fluctuate over the course of treatment, and, when a person is eating normally, the body naturally gravitates toward a biologically determined weight that is largely out of our control. Indeed, learning to focus less on body weight as a determinant of achievement or self-worth is a valuable treatment goal.

What is Weight Suppression?

Some patients with bulimia may start treatment at a weight that is in the normal range for their height or even on the high side but low in the context of their adult weight history. Weight suppression is maintaining a body weight that is lower than an individual’s highest adult weight. Recent research has begun to shed light on the effects of weight suppression on eating disorders, especially bulimia. Bulimia is often kick-started with a desire to lose weight and attempt at weight loss through dieting. Research has demonstrated that living at a suppressed weight has a significant impact on bulimic behaviors, increasing the likelihood of binge eating (potentially through a brain-based biobehavioral self-preservation mechanism), and subsequently purging. Relatedly, and counterintuitive to what people with bulimia believe about their ability to control their weight, weight suppression is associated with weight gain over time, which further promotes dieting and purging given the strong aversion to weight gain that most sufferers experience.

Will I Gain Weight?

So, what does this mean for treatment and recovery? For patients seeking treatment, this means that yes, you may gain weight, especially if your weight is lower than a previous higher adult weight. This may feel scary, especially at first. Clinicians may even feel uncomfortable having this discussion and feel tempted to reassure patients that they will not gain weight. However, this message is inconsistent with what we now know about weight suppression and reinforces the idea that gaining weight is to be feared and avoided at all costs. Gaining some weight may actually be the key to breaking the cycle of binging and purging, which is much more valuable than maintaining a lower weight.

Greater weight suppression is associated with persistent bulimia symptoms and relapse, so gaining some weight may actually increase the likelihood of recovery from bulimia and also serve as protection against future eating disorder relapse. Weight gain may not just be a side effect of treatment, but it may be an appropriate treatment goal if you have bulimia and are living at a suppressed weight, just as it is an important goal for someone recovering from anorexia.

In Conclusion

If you have had previous treatment, but are still binging and/or purging, it is important to explore whether weight suppression might be a contributing factor. You can discuss whether gaining some weight might be appropriate with your clinician. Understanding the role of weight suppression on maintenance of the eating disorder should serve as motivation to continue treatment and work toward managing negative feelings related to weight gain. Indeed, it is helpful to explore the motivation behind the importance of thinness or maintaining a certain weight and challenging fears associated with gaining weight. You may find that living at a slightly higher weight, once acceptance is achieved, can be much less stressful and time-consuming than forcing your body to weigh less than it is biologically programmed to.

References

Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York, NY: Guilford.

Juarascio, A., Lantz, E. L., Muratore, A. F., & Lowe, M. R. (2018). Addressing weight suppression to improve treatment outcome for bulimia nervosa. Cognitive and behavioral practice, 25(3), 391-401.

Lowe, M. R., Piers, A. D., & Benson, L. (2018). Weight suppression in eating disorders: a research and conceptual update. Current psychiatry reports, 20(10), 80.

 

Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716). Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she is also a proponent of alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size. She is currently living in Charleston and working as a full-time mom to her two sons, ages 3 and 1. Dr. Carcieri is a member of the Academy for Eating Disorders (AED). She can be reached via email at dr.elishacarcieri@gmail.com.

Recovery When Grieving by Carolyn Hersh, LCSW

Grief and Eating Disorder Recovery On May 8th, 2017 my mother died due to complications from cancer. It was an unexpected death. I still cannot believe she died. My mom was diagnosed in January and passed away in May. She had gone to the hospital for trouble breathing and never left.

I can clearly remember going back to my childhood home and seeing her sneakers in her room waiting for her to return to them. I cried so hard seeing everything she had touched just days before but left, never to feel her embrace again. I was one of those things she left.

It’s been more than a year now since I lost my mom. It was a year that tested me in so many ways: emotionally, physically, and spiritually. One thing I had to face was how my eating disorder and my longstanding recovery would play out through the worst thing that has ever happened to me.

I have my own history of emotional eating and bulimia nervosa. It started at a young age. Whenever I was sad as a child my mom’s solution to cheer me up was a trip to the bakery for a giant cookie. My emotional eating and my hatred of being the larger kid was just one of many factors that led me to a path of destructive behaviors of binging, purging, and restricting.

I’ve been through enough therapy and treatment that I am able to recognize moments when I find myself starting to eat mindlessly. I check in with what emotions or events are going on. I have, for the most part, overcome being an emotional eater. But, then I was hit with an intensity of emotions that I had never felt before. The seven stages of grief are very real and I definitely went through and felt each of them.

My anger, my sadness, my pleading to bring my mom back, to having brief moments of acceptance washed over me on a daily basis. My sadness felt like someone placed a brick on top of my heart. Trying to breathe became difficult at times. I was angry, intensely angry, at cancer, the doctors, the hospital, at God, at my mother, and at myself. We hear so often how eating disorders fester when we feel a loss of control. Losing my mother was the ultimate reminder “you have absolutely no control over this.”

In the early weeks and even months of living in a world where my mother no longer existed, I wanted comfort and distraction. I wanted food. I wanted alcohol. I wanted anything that would take this pain away. And in those moments of pure sadness, I consumed. I knew full well this wasn’t the way to handle my emotions. I decided I need to reach out to my dietitian because yes, even professionals need tune-ups. I remember sitting in my dietitian’s office crying because I gained weight and was feeling out of control with my body and my feelings. I quickly felt hypocritical as an advocate for all bodies are beautiful and guilty because a weight gain should not be something I should be crying about. I lost my mother. Worse things have occurred other than gaining a few pounds. My dietitian reminded me that I know how to eat and that my body will go back to where it should be when I honor my hunger and satiety cues. But, then she shocked me by saying, “Carolyn, maybe you needed to allow yourself to binge in those moments. So it happened. You binged. It’s done. Now, go back to your real coping skills.”

My dietitian gave me permission to accept my binges. She demonstrated compassion for me when I had no self-compassion. She was right. Sometimes we have to be okay with where we are at. My dietitian did not give me the green light to revert back to maladaptive behaviors. She pushed me back on a path of not beating myself up during a time where the last thing I needed was to hurt myself more.

So, how do you manage recovery in a time of grief?

  • Don’t go back to your eating disorder. Just don’t. You know it won’t help and when you are feeling low why make yourself feel lower? But, if you skip a meal or eat a few extra cookies just know that it is not a relapse. I do not consider my binging moments a relapse. They happened. I engaged and then I stepped away. Be gentle toward yourself and give yourself permission to say “It’s okay it happened. Now, what can I do to get back to my recovery?”
  • Go back to your coping skills. Maybe I could have engaged in binging and purging. Maybe I could have thrown my hands in the air and said: “what’s the point?” But I didn’t. In all honesty, I knew this wasn’t something I wanted. So, I made a list of things for me to do to help me through those really tough moments. I took time off from work and went figure skating with friends. The ice was always a very therapeutic place for me, and just being able to feel that cold air whip across my face me feel happy. I spent time journaling, cuddling with my dog, and reaching out to friends and family when I needed to talk. I began nightly walks with one of my girlfriends where we had heart to hearts. I made self-care a priority. You have to. The small lapses that I fell into never once trumped the real self-care that I was doing for myself. If I had beaten myself up for binges and weight gain then it could have sent me on that spiral back to a full relapse. Self-care may mean forgiving yourself for your lapses. Forgiving myself helped me continue to move forward.
  • Death really sucks. Losing someone you love is painful. It can be a torturous pain. There is no way around that. Losing my mother and thinking about her still to this very moment makes my stomach twist, my heart pound, and my eyes water. There will be bad days. I use a lot of radical acceptance in my grief where I acknowledge this is how it is and I have to figure out now how I continue to live in a world where my mom isn’t calling me. It’s hard to do. Believe me, there are days I do not want to accept this, but if I have to pull from my DBT workbook, acting the opposite is what gets me through the rough days. I don’t want to accept my mother is gone, but that is the reality. I do not, however, have to forget her and how she has impacted my life.
  • It’s okay to cry. It’s okay to feel whatever it is you are feeling and it is okay if those feelings come and go in minutes or if they last for days. There is no wrong way to grieve. During my grief I went to Nashville for a vacation, I would go out on weekends with friends and laugh, and I eventually moved to California. I managed to feel happy on some holidays and cried on others. I did not stop living, but I allowed for my grief to take space in my life.

In the end, going back to my eating disorder would just have caused more chaos in an already chaotic time in my life. I know it won’t give me control, it won’t make me happy, and it certainly will not bring my mother back. I have this blue butterfly pendant necklace my mom bought me before I went into an intensive outpatient program. It gave me strength then and I wear it now to continue to remind myself that my mother was every bit a part of my recovery and is every bit still a part of me. Now, why would I want to throw all that away?

Carolyn Hersh is available to see patients with eating disorders and has Saturday hours. Contact us for more information. 323-743-1122 or lmuhlheim@eatingdisordertherapyla.com 

This Halloween, Serve Candy to Your Teen in Recovery

A Family-Based Treatment (FBT)-approach

Fear FoodFor 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.

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!

Is the (Eating Disorder) Treatment Your Child is Getting FBT?

When new families talk to me about Family-Based Treatment (FBT), I often find that they are confused about what it is and what it isn’t.

FBT is a type of evidence-based treatment for adolescent eating disorders. This treatment was developed at the Maudsley Hospital in London in the 1970s and 1980s; Doctors Lock and Le Grange manualized it into its current form in 2001. Because of its name, FBT is often confused with more general “family therapy.” Be careful, because these are not the same thing—while both involve the family, FBT is a very specific, behaviorally-focused therapy.

While a treatment that includes some elements of FBT—but falls short of the full manualized treatment—may work for some eating disorder cases, it may not work for more difficult cases. When FBT doesn’t work it is important to know whether the child has had an adequate course of the true treatment in its evidence-based form. This can be tricky—in the field of psychotherapy, most therapists identify as eclectic, meaning they adhere to no single therapeutic orientation but combine techniques from several (just scroll through any Psychology Today therapist profile to get a taste for how many different theoretical approaches most therapists endorse). We don’t yet know which elements of FBT are critical to its efficacy and make it such a successful treatment. This would take expensive dismantling studies in which different partial treatments are tested against each other. Except for studies documenting a separated FBT (where only the parents attend sessions), no such study has been cited in the literature. Until we have good evidence that suggests otherwise, treatments that stay true to the original, already-tested treatments are the safest bet.

I once worked with a patient with panic disorder who had had previous treatment. He told me that his previous therapist had conducted cognitive-behavioral therapy (CBT), widely accepted as the best evidence-based treatment for panic disorder. When I dug deeper, I found that his therapy had included no exposure to the sensations of panic—considered to be the core element of CBT treatment for panic disorder.  Instead, the treatment had focused on discussing his anxiety thoughts—a very different protocol. From this experience I learned to inquire carefully about the treatment my patients have previously received before accepting that it cannot work for them.

So it is with Family-Based Treatment. Sometimes parents tell me that they think they tried FBT but are not sure. If your child was treated in an academic center, it’s more likely they got the evidence-based treatment of FBT in its full form. However, some parents who tell me that FBT didn’t work also tell me:

  • They did FBT on their own, with no therapeutic support
  • They had meals with their child, but that the therapist met primarily with the adolescent alone
  • They didn’t supervise all meals because their child resisted it. 

In each of these situations, it is obvious to me that the treatment is not what I would consider FBT. And while it is true that including some aspects of FBT or even a “watered down” FBT may be better than no FBT or parent inclusion at all, it’s important to know whether your child had the real thing or not, especially if they end up needing more or different treatment.

Often, parents who tell me they struggled with renourishing a child on their own find that things go much better once they started working with me or another therapist. That’s not to say that parents should never try to renourish a teen on their own—just that supporting a child with an eating disorder is extremely hard work and best done with the support and guidance of a professional at their side.

Signs Your Child Received FBT

Accordingly, I created the checklist below for parents to determine whether the treatment their child received (or is receiving) is really FBT. To how many of the following statements can you answer “YES” (the more the better)?

  • My therapist received training through the Training Institute for Child and Adolescent Eating Disorders.
    • The basic training is a 2-day workshop. Have they attended one?
    • Have they received or are they receiving clinical consultation or supervision by a staff member of the institute?
    • Are they certified in FBT by the Training Institute (meaning they have completed the 2-day training and received 25 hours of consultation by a staff member around their treatment of 5 patients)?
  • My therapist owns, seems familiar with, and refers to the FBT treatment manual.
  • My therapist refers to and acknowledges the three phases of FBT:
    • Phase 1 —full parental control
    • Phase 2 — a gradual return of control to the teen
    • Phase 3 —establishing healthy independence
  • My therapist is familiar with the work of Drs. James Lock and Daniel Le Grange, developers of the FBT treatment.
  • My therapist adheres to the five principles of FBT:
    • I was specifically told I was responsible for restoring my teen nutritionally and interrupting behaviors that interfere with recovery (including bingeing, purging, and overexercise). I was specifically told I was responsible for planning, preparing, serving, and supervising all meals.
    • I was told we don’t know for sure what causes an eating disorder and it doesn’t matter.
    • Initial attention of treatment focused solely on restoring health including weight gain and stopping eating disorder behaviors.
    • Rather than being given prescriptive tasks, I was empowered to play an active role and to discover those strategies that worked best for my family and the child whom I know best.
    • I was taught to externalize the illness and see it as an outside force that has hijacked my child, threatens his or her life, and makes my child do things he or she wouldn’t normally do. My child did not choose the eating disorder.
  • I have had a family meal at the therapist’s office.
  • My therapist spends most of the time with the full family, meeting only briefly with the adolescent alone at the beginning of the session (or in the case of “separated FBT,” all of the time with parents).
  • My therapist or another member of the treatment team tracks my child’s weight and gives me feedback after every weigh-in on how he or she is doing.
  • I was specifically told I am responsible for supervising all meals and snacks to ensure completion. If purging has been a problem, I was told to supervise the child after eating to prevent purging.
  • If my child has been exercising excessively, I was told to prevent this.
  • After weight was restored and bingeing and purging and other behaviors had ceased, my therapist guided me in gradually returning my teen control over their own eating.
  • I was told it was important to be direct with my teen about eating adequate amounts of food.
  • My therapist discusses the importance of both “state” and weight to recovery—meaning my therapist explains that weight recovery is a step towards psychological recovery, but not an end goal in itself.

Dead giveaways your child did not get FBT

Below are some indicators that your child might not have “gotten FBT” and might be receiving some conflicting messages:

  • I have been told that we, the parents, had caused the eating disorder.
  • My therapist spends the majority of therapy time alone with the teen.
  • My therapist spends a lot of time talking about the past and reasons my child wanted, needed, or otherwise developed the disorder.
  • A dietitian has met alone with my teen and given him or her nutritional recommendations.
  • My child has been given a meal plan.
  • I have been told that it is an option to not supervise all meals or prevent all purging.
  • The FBT therapist has provided individual CBT, DBT, or ACT with the teen during the weight restoration phase.
  • I have been told from the start of treatment to “not be the food police” (in FBT, this might happen toward the end of treatment, or in Phase 2 with an older teen).
  • My child has been in charge of making his or her own meals from the outset of treatment.

Summary

In conclusion, FBT has been proven to be the most effective treatment for adolescents in clinical trials. That said, not every treatment works for everyone. In my opinion, it is best to start with something that has a backing and then try something else if that doesn’t work. When you have sought out an evidence-based treatment, it’s important to make sure you’re getting the treatment in its researched form.

Family-Based Treatment Can Help Depression and Self-Esteem Too!

FBT Depression and Self-Esteem

Family-based treatment (FBT) is a relatively new evidence-based treatment for adolescent eating disorders. It represents a paradigm shift from older treatments that focused on helping adolescents become independent from parents in order to recover from their eating disorder. In FBT, parents are central members of the treatment team and they are charged with guiding and changing their adolescent’s eating disorder behaviors. In FBT, the therapist meets weekly with the entire family, spending only about 5 minutes alone with the adolescent at the start of each session. It is designed as a standalone treatment. The adolescent is also followed by a medical doctor, but does not have additional appointments with a therapist or a dietitian.

Symptoms of depression and low self-esteem are common in adolescents with bulimia nervosa. One of the many concerns that I hear from parents considering Family-Based Treatment (FBT) for their child with anorexia or bulimia is that FBT won’t address other symptoms the child may have like depression or anxiety. Furthermore, families who are receiving FBT often feel pressured to add additional treatments such as individual psychotherapy for their adolescents to address these other issues. Even other non-FBT clinicians continue to be incredulous that adolescents can improve without other treatment. Fortunately, Cara Bohon, Ph.D. and colleagues at Stanford University recently published a paper that addresses this concern for adolescents with bulimia nervosa.

In their study, 110 adolescents with bulimia nervosa from two sites were randomly assigned to receive either individual Cognitive Behavioral Therapy (CBT) for adolescents or FBT. Cognitive-Behavioral Therapy (CBT), which is the most successful treatment for adults with eating disorders, focuses on understanding the factors maintaining the bulimia symptoms and developing strategies to challenge problematic thoughts and change behaviors. The therapist meets weekly with the adolescent. The two treatments are of comparable lengths.

Results showed that both FBT and CBT significantly reduced symptoms of depression and improved self-esteem. Previous papers suggest that abstinence from eating disorder symptoms occurs faster in FBT when compared with CBT for adolescents with bulimia nervosa. Thus, FBT may be a better option in many cases.

It is important to dispel parents’ fears that FBT will not adequately address depression and self-esteem. The authors state in the paper, “This concern can subsequently steer families away from an evidence‐supported approach in favor of therapies that may not be as successful in reducing binge eating and purging.”

In fact, the researchers point out that it may be that the cycles of binge eating and purging of bulimia serve to maintain depressive symptoms and poor self-esteem. Thus, one may not need a treatment that directly targets depression.

Dr. Bohon stated, “The reason we conducted this study is because comorbid depression is the norm with bulimia nervosa, and it was important to establish that you don’t automatically need any extra treatment to see improvement in the context of FBT. Obviously, if someone is still struggling after completing FBT, a referral for CBT for depression or another evidence-based treatment would be important, but it is likely not needed for most individuals.”

Source

Valenzuela, Fabiola, James Lock, Daniel Le Grange, and Cara Bohon. 2018. “Comorbid Depressive Symptoms and Self-Esteem Improve after Either Cognitive-Behavioural Therapy or Family-Based Treatment for Adolescent Bulimia Nervosa.” European Eating Disorders Review: The Journal of the Eating Disorders Association26 (3): 253–58. https://doi.org/10.1002/erv.2582.

A More Diverse Eating Disorder Film

Eating Disorder film Tchaiko Omawale
with Tchaiko

In the wake of the premiere on Netflix of another eating disorder film, my friend, JD Ouellette, reminded me that the frustration over another stereotypical narrative about eating disorders could provide an opportunity. At the NEDA Conference in 2014, both JD and I (as well as many other attendees) were impressed by Tchaiko Omawale’s sharing of her inspiring story of recovery on the Friends and Family Panel. Later, we learned about her work (writing, directing, and producing) on Solace, a coming of age feature film inspired by Tchaiko’s journey with an eating disorder and self-harm. In April, I had the opportunity to attend a fundraiser for Solace and preview a scene. I spoke about the need for more films, stories, and images of people from diverse backgrounds with eating disorders, reading some parts of this article.

Eating Disorder film presentation
Speaking at the fundraiser

As summarized in Truth #5 of the collaborative consensus document, the Nine Truths, “Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.” When I work with people of diverse backgrounds, they consistently tell me they are frustrated that mainstream eating disorder narratives do not portray people who resemble them. Not only the popular media — television, film, print articles, online publications — but even the marketing materials of many eating disorder treatment centers continue to depict eating disorder sufferers mostly as the common stereotype: female, white, and thin.

To those interested in supporting a film that doesn’t reinforce stereotypes, Tchaiko Omawale has made such a film. She needs additional funding to complete the film, which is in post-production. Visit Solace Film page to learn more and, if you are so inclined, join me in supporting this important project. She has a donation page.

Eating Disorder film Tchaiko Omawale and cast
Tchaiko speaking with cast members on her right

2017 Spring LACPA Eating Disorder SIG Open (to non-LACPA members) events

Michael Levine, Ph.D., FAED Date: Tuesday, March 7 at 7:30 pm.

Title: Thinking Critically and Cautiously About the Phrase “Eating Disorders Are Biologically-Based Mental Illnesses

Presenter:  Michael Levine, Ph.D., FAED

Description: It has become a foundational “truth” among many clinicians, researchers, patients, family members, and advocates that, in accordance with the 2009 position statement of the Academy for Eating Disorders (AED), eating disorders are “biologically-based mental illnesses.” In fact, number 4 of the AED’s “Nine Truths about Eating Disorders” is “Eating disorders are not choices, but serious biologically influenced illnesses.”

Dr. Michael Levine has for many years studied sociocultural factors and their relationship to the prevention of eating disorders and disordered eating. In this talk, Levine offers a critical evaluation of this contention, in so far as one meaning of “critical” is “exercising or involving careful judgment or judicious evaluation” (Mirriam-Webster On-Line Dictionary; www.m-w.com).

Levine begins by addressing important general concepts, such as “illness” and “biologically-based,” as well as “scientific,” “evidence-based,” and “risk factor.” This sets the stage for a description of the Biopsychiatric/Neuroscientific paradigm in the eating disorders field. He will then consider the evidence for “biological causes” in the development of eating disorders, and its implications for two important challenges in the field: prevention and talking with patients, families, and the media. Throughout his presentation, Levine will compare and contrast the Biopsychiatric/Neuroscientific paradigm with the Sociocultural paradigm. Thus, his concluding remarks will consider what if anything is gained (and/or lost) by applying phrases such as “biopsychosocial” and “gene-environment interactions.”

Bio: Michael P. Levine, Ph.D., is Emeritus Professor of Psychology at Kenyon College in Gambier, Ohio, where he taught 33 years (1979-2012). In the field of eating disorders, his commitment to research, writing, and activism focuses on the intersection between sociocultural risk factors, prevention, community psychology, and developmental psychology. He has authored two books and three prevention curriculum guides, and he has co-edited three books on prevention. In August 2015, as co-editor with his long-time collaborator and colleague Dr. Linda Smolak, he published a two-volume Handbook of Eating Disorders (Wiley & Sons Publishing). He and Dr. Smolak are currently working on a second, updated edition of their 2006 book The Prevention of Eating Problems and Eating Disorders (Erlbaum/Routledge/Taylor & Francis). In addition, he has authored or co-authored approximately 110 articles and book chapters, and he has presented his work throughout the United States, as well as in Canada, England, Spain, Austria, and Australia. He is a member of the advisory councils of The National Eating Disorders Association (NEDA), the Center for Study of Anorexia and Bulimia (CSAB, NY), the Center for Balanced Living (CBL, Columbus, Ohio) and Monte Nido & Affiliates—Eating Disorder Treatment Centers.

Dr. Levine is a Fellow of the Academy for Eating Disorders (AED), which has awarded him their Meehan-Hartley Award for Leadership in Public Awareness and Advocacy (2006), and their Research-Practice Partnership Award (2008). Dr. Levine is also a member of the Founders Council of the National Eating Disorders Association, which awarded him the Lori Irving Award for Excellence in Eating Disorders Prevention and Awareness (2004) and the Nielsen Award for Lifetime Achievement (2013). After living for 37 years in Mount Vernon, OH, with his wife, Dr. Mary A. Suydam, a retired (as of May 2015) Kenyon religious studies and women and gender studies professor, they moved to California in late June 2016, to live near UC Santa Barbara, where they both obtained all their degrees.

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to: drmuhlheim@gmail.com

March and April SIG meetings are open to all professionals.   During other months SIG meetings are open to all LACPA members.  Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org


Date: Thursday, April 20 at 7:30 pm.

Title: Medical Complications of Eating Disorders

Presenter:  Margherita Mascolo, MD, ACUTE Medical Director

Description:  Dr. Mascolo is the medical director of ACUTE. She will discuss the medical complications of severe restricting as well as purging. The presentation will include a broad review of the pathophysiology of starvation as well as the organ systems affected. There will be case-based discussion and presentation based on real patients seen on the ACUTE unit. Target audience is mental health professionals, dietitians, and allied professionals who need a broad understanding of the medical complications of restricting and purging.

Bio: Dr. Mascolo is the Medical Director at the ACUTE Center for Eating Disorders at Denver Health, where she has been a member of the ACUTE team since its beginning in 2008. She has trained under Dr. Philip S. Mehler for the past 8 years to become one of the country’s leading experts in the medical care of patients with severe eating disorders and served as Associate Medical Director under Dr. Jennifer Gaudiani for the past 3 years.

Dr. Mascolo completed her undergraduate work at the University of St. Thomas in Houston, Texas and earned her medical degree at the University of Texas Health Sciences Center. She completed her residency in Internal Medicine at the University of Colorado in Denver. She is board certified in Internal Medicine, is an Associate Professor in the Department of Medicine at the University of Colorado. Dr. Mascolo has published multiple peer-reviewed articles on the medical complications of eating disorders and is currently working to complete her Certified Eating Disorder Specialist certification.

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to: drmuhlheim@gmail.com

March and April SIG meetings are open to all professionals.   During other months SIG meetings are open to all LACPA members.  Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org

December 2016 LACPA Eating Disorder SIG

Shannon-Kopp-Headshot-e1444137530220Date: Wednesday, December 7 at 7:30 pm (Note: new date)

Presenter: Shannon Kopp – Author of Pound for Pound: A Story of One Woman’s Recovery and the Shelter Dogs Who Loved Her Back to Life (HarperCollins Publishers) and Founder of SoulPaws Recovery Project.

Title: The Healing Power of the Paw: How Animals Can Play a Vital Role in Eating Disorder Recovery

With the highest mortality rate of any mental illness and afflicting up to 30 million people in America, eating disorders can have heartbreaking consequences. For eight years, Shannon Kopp battled the silent, horrific, and all-too-common disease of bulimia. Despite a near decade of weekly therapy, medication, loving support from family, and a hospitalization and rehab stay at Rosewood Center for Eating Disorders, she continued to grow progressively sicker.

Then, at twenty-four, she began working with shelter dogs at the San Diego Humane Society, where she felt a deep sense of calm and comfort around the animals. Gradually over time, when Shannon wrestled with anxiety, she began turning to the loving presence of a dog (rather than to the eating disorder). A dog’s ability to live in the present moment helped to pull her out of her head and back down to earth. The dogs grounded her, and they created a vital sense of emotional security.

Shannon adopted a dog and began bringing her dog with her to therapy, and soon, Shannon was sharing on a deeper and more honest level than ever before. This marked the beginning of her eating disorder recovery—she will celebrate seven years free from bulimia on August 28th.

Research on the human-animal bond (known as Anthrozoology) has increased steadily over the years. Studies have shown that the presence of an animal may decrease stress levels by lowering blood pressure and creating a sense of general well-being—for the both human and animal!

Today, Shannon offers free animal therapy—SoulPaws Workshops— to those suffering from eating disorders in her community. (Learn More About SoulPaws Workshops Here: http://shannonkopp.com/workshops/)

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio – Shannon Kopp is an eating disorder survivor, animal welfare advocate, and the best-selling author of Pound for Pound: A Story of One Woman’s Recovery and the Shelter Dogs Who Loved Her Back to Life (HarperCollins Publishers). She is also the founder of SoulPaws Recovery Project, offering free animal therapy to those suffering from eating disorders. Shannon’s story has been featured on CNN, Fox News, Huffington Post, Salon, NPR and more. www.shannonkopp.com

http://www.harpercollinsspeakersbureau.com/speaker/shannon-kopp/

RSVP to: drmuhlheim@gmail.com

SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org