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!

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.

Are We Setting Recovery Weights Too Low?

 

At the recent International Conference on Eating Disorders in Chicago, I attended a plenary, Recovery from an Eating Disorder: How Do We Define It? What Does It Look Like? And Should It Always be the Focus? During this plenary, Anna Bardone-Cone, PhD spoke about the essential components of recovery from an eating disorder. She indicated that definitions of recovery should include the following three domains and proposed the following criteria for each domain of eating disorder recovery:

  • Physical — defined as BMI greater than 18.5
  • Behavioral— defined as absence of any binge eating, vomiting, laxative use, or fasting within the past 3 months
  • Cognitive — defined as EDE-Q subscales within 1 standard deviation of age-matched community norms.

Hold on a second—the weight criterion used to define recovery from anorexia nervosa in most studies is a BMI of only 18.5?

Most in the full plenary room agreed that for anorexia nervosa recovery, a BMI of 18.5 is too low a criterion to declare all people recovered. I agree with Laura Collins Lyster-Mensh, who made the following tweets:

  • Isn’t it possible that by setting target weights at the low end of the tail we are holding patients in chronic mental illness.
  • Setting low, population-based weight targets for ALL EATING DISORDERS means weight suppression and malnourishment and prevents psychiatric recovery for all but those who are genetically designed to be in smaller bodies, IMO.

I totally agree. If we now acknowledge that anorexia can occur in people of higher weights—a phenomenon often, and problematically, called “Atypical Anorexia”—then shouldn’t a BMI target as low as 18.5 be abandoned in favor of individualized recovery weights?

In fact, weight suppression researcher Michael Lowe was present at the plenary.  During the Q&A he proposed that rather than using a categorical definition of weight recovery (a single BMI number) we should use a continuum—for example, the recovered patient’s BMI relative to their pre-illness BMI.

How Are Recovery Weights Established?

Unfortunately, there is very little consensus on how to determine whether a patient with a restrictive eating disorder is at a recovered or healthy weight. This affects research and practice. If researchers define recovery based on an 18.5 BMI and this weight is really too low for many people with anorexia, what does this mean for the research studies? For one thing, in clinical trials a lower percentage of people would be deemed “recovered”, showing our treatments to be even less successful than we believe them to be.

But it has bigger implications for the potential for patients to truly recover. If we set recovery weights higher, maybe more people will be treated to full recovery. Setting the BMI bar so low means we’re not insisting on full weight recovery for all people. As Laura Collins points out, the effect of this is that only those who are privileged enough to be in genetically smaller bodies may ever actually reach recovery.

And what are the ramifications for practitioners? There may not yet be an established way to determine a recovery weight—consequently, many patients may never recover. If we acknowledge that gaining to a healthy body weight is a prerequisite for full psychological recovery, then we are dooming many people in larger bodies to a life of purgatory in which they remain insufficiently sick to need intensive treatment, but never achieve full recovery.

In one recent paper, Jocelyn Lebow, Leslie A. Sim, and Erin C. Accurso survey 113 child and adolescent eating disorder treatment providers inquiring about the methods used to determine weight restoration in clinical practice. Their findings show:

  • 40.7% of practitioners used growth curve data
  • the remaining (nearly 60%) employed a diverse range of approaches
  • providers who specialize in Family-Based Treatment were significantly more likely to use an individualized approach versus considering adolescent preference

Lebow and colleagues concluded that:

Although there is a modicum of endorsement for using growth curves to predict expected body weight, this is not universal practice and is inconsistent with methods used in treatment studies. The lack of an evidence-based method to calculate expected body weight—or even a best practice consensus for calculating this number—is a major oversight in the field that requires empirical attention.

Why Might Providers Set Recovery Weights Too Low?

What are some of the reasons providers might be setting recovery weights too low?

  • No empirical consensus or guidelines on how to set target weight
  • Lack of available growth records data to determine an individualized recovery weight
  • Financial limitations—insurance companies reduce costs by lower treatment limits, which are facilitated by lower weight goals
  • Client resistance—pushing for higher weights requires overcoming greater resistance and anxiety from the patient and sometimes family over higher weights.
  • Weight stigma—even treatment providers may be susceptible to society’s war on obesity, and consequently may err on the side of under-restoring a teen in recovery.

Over twitter, one mother responded to my conference tweets about an 18.5 BMI recovery goal as being too low and tweeted the following:

  • We need all professionals to understand the need for higher recovery weights. Recovery is about state not weight. So many parents know this but are stuck with uneducated team members who undermine their work.
  • If professionals consider a return to pre-eating disorder growth patterns for height and weight to be weight restoration, we parents are saying wrong. Eating disorder voices are very loud at this weight. We recommend an additional 10% for the first few years of recovery at least. This quiets the eating disorder voice and patients are more likely to stay recovered.
  • I want all current professionals worldwide to understand this. There are so many parents in our international group whose professionals are not getting it. Maybe it has not been studied officially but anecdotally we are seeing this in high numbers. 
  • If it’s not part of their training, providers should at least listen to and support parents in this. We are committed to our kids’ recovery every bit as they are. 
  • It takes parents a while to get it too. It’s frustrating for professionals when parents undermine. I was horrified at the first proposed recovery weight and was afraid of my child being made fat. But I got educated pretty quickly, opened my eyes and realized I needed to take it further in order to achieve full recovery.

Stephanie Zerwas, Ph.D. (not at the conference) chimed in over Twitter and asked the parent:

  • What language helped you as a parent to “get it? Parents often have a belief that being a little underweight can help their child not worry about weight gain, not realizing that it keeps kids stuck in limbo and hypervigilant.

The parent responded:

  • What helped us parents “get it” was seeing those in our support group brave enough to take their kids to higher weights reporting their kids’ eating disorder voices finally quiet down. We keep repeating state, not weight = recovery and realized goal weights are set mostly too low 
  • Too many parents are upset that eating disorder professionals are saying their kids are recovered and not listening to them when they say their kids are still vulnerable, using behaviors, and need to be a higher weight. This is the power of parent groups. We know this needs to change. 
  • Parents also not understanding weight restoration is a moving target. They come to our group stating their child is weight restored and still struggling and often clinging to a weight goal given years ago. There is no “Weight Restored” in eating disorder recovery only “state restored.” 
  • We are seeing this extra 10% to be effective in many of our children who still struggle with eating disorder behaviors at 100% pre-illness percentile of growth. In the meantime, if patients are still struggling and parents want this, we should be supported. But yes, bring on the studies!!

What Do Parents Say About Recovery Weights?

So, believing that parents do indeed know their children best and are an untapped resource to study this further, I took to Twitter to ask parents to share their experiences about recovery weights being set too low. I got an overwhelming response. Below are some excerpts of what parents sent to me:

  • At her lowest weight, our daughter was BMI of 21.9. Our doctor told us “she is not at an anorexic weight.” She is currently BMI 31.6. We felt she was finally starting to shift her thinking when she was at around a BMI of 29.5.
  • When my daughter was 17, she lost 25 pounds. At her lowest, her BMI never fell below 20. Yet she was extremely ill. After she had regained about 14 pounds, her period returned, but her “state” was still awful. She is now in a range of BMI 25.5 to 26. The difference this last 5 pounds has made had been amazing. Her level of insight and flexibility is much higher. Amazingly, the higher her weight, the happier she is with herself and her body. Reflecting back, I am grateful that no one told us she was “recovered” when she got her period back. She needed to get and stay back up to the 80 to 85%ile as per her personal growth curve. At the age of 19.75 she grew another .25 inch. If that isn’t proof she needed more weight, I don’t know what is! I hear so many stories in our group of parents being told to stop refeeding too early. Teams are generally not comfortable pushing weights back up to or above personal growth curves. We are lucky our team was an exception! In our online support group, we have seen time and time again that higher weights make a difference. And the extra weight generally comes with little risk.
  • My daughter was diagnosed at the age of 10.5 with anorexia. The original goal was to get my daughter at a BMI of 15.5 to a BMI of 18. In the next 2.5 years my daughter needed 6000 calories a day and a very high fat diet. She grew nearly 9 inches, went through full puberty, and doubled her initial body weight. Once her growth slowed and her metabolism went down and stabilized, we were able to get her weight up to around a BMI of 22 and that is when we saw TRUE RECOVERY begin. She began to eat “extra.” She began to ask for things. She began to be able to eat independently. Over the last 4 years she has put on around 20 to 25 pounds on her own, naturally. Her BMI is now around 24 – 25 and she is in a 100% solid recovery. She eats intuitively, independently, and reports being free of the eating disorder voice. Fats, high calories, and a MUCH higher weight were essential to getting our daughter into recovery. If I would have listened to the “experts” I believe she would still be struggling.  
  • My daughter was 24.2 BMI at 13 years old when she started exercising excessively and then restricting. She lost a quarter of her body weight in 7 months and our new pediatrician told her to gain 10 pounds and come back in 6 weeks. We fed her 6 times for a total of 4000 calories a day. She finally got her period at BMI 21.8 and within a few months, her anxiety was high and the team suggested it was time to start exercising. My online support group spent a long time helping me understand my own fat phobia and really worked to help me set a higher target weight. My daughter grew another three inches. She is now BMI 23.5 and this is the healthiest I have ever seen her. If I had listened to the specialists, she would be just as sick as she was before.  
  • At her lowest weight and her sickest, my daughter’s BMI was 19.3. We saw improvements in her state once she was over 25 BMI and in the “overweight” range. Had I allowed a reduction in her food intake at 23 BMI when it was suggested to me, my daughter would have been in a perpetual eating disorder purgatory.
  • My daughter’s current BMI is 24.6. Lower than that or increasing muscle over fat, it is as if her body goes into ‘starvation mode’ and she gets all silly and cranky and her period is delayed.
  • My son was given a target BMI of 19 by his clinician. This was not from a growth chart, it was from a generic BMI chart. My son was still very unwell at that BMI. Thoughts were very strong, and the desire to restrict was high. He was living a half-life, tormented with the anorexia. He was throwing away his lunch and manipulating weight. His clinician was adamant that he did not need more weight, and did not need more food, although I could see he was actually starving. She would not support me to take his weight higher or increase his meal plan. My online support group warned me that this was a common mistake with clinicians. I got my son (with great difficulty, after the clinician had insisted lower was okay), to a BMI of 24. We have never looked back. We have our kid back, he is 16 years old, he is in very strong recovery for some time now. I know the extra weight is what he needed to see recovery. He is living a normal teen life now, is happy and fully functional. We are into year 3 now, and he still needs 3 meals and 2 snacks per day of at least 4000 calories to stay in recovery. We owe our son’s recovery to the wonderful advice from parents that had been in our situation before us. They knew from other parents before them that a generic BMI figure is not recovery. Recovery is a state and not a weight. It makes perfect sense too. After all we do not expect everybody to have the same shoe size.  
  • My daughter was diagnosed approximately 18 months ago with Atypical Anorexia and was very unwell at a BMI of 19. I joined a support group just prior to her entering into treatment. In large part due to the anecdotal advice and experience of others in the group, I was of the firm belief that we needed to weight restore my girl to her own individual weight, not to a particular BMI or any particular upper number. Fortunately, our team was happy for me to take the lead with this approach, and we encouraged weight gain to wherever her behaviors began to abate and her weight settled naturally on its own, with NO reduction in intake. This ended up being at a BMI of around 26, which I do not believe most clinicians would encourage. However, I truly do have my happy girl back and I do not regret any one of those extra kilos. Her body has settled at a weight at which her mind is very well. I believe that if we had been given an upper number that she couldn’t go above, that we would have trapped her in her anorexia needlessly for so much longer.
  • My daughter did not seem to actually begin true recovery until she was at 23.5 BMI.  This was higher than the professionals in her life seemed comfortable with, but I proceeded with semi-confidence (having seen the results of higher weights in other patients, through their carers’ stories) and was never challenged.  Before this higher BMI she struggled so much with ED thoughts and behaviors – very little could get through to her…. therapy, talking, coaching, none was very helpful… only FOOD, in larger amounts that some professionals recommend (specifically with regards to fats – avocados, ghee/butter, olive oil).  At 23.5 something seemed to just “lift”.  She began to be able to participate for herself. She still had many ED behaviors and thoughts, but could push them aside much of the time.  She lost most of her body image issues, and began asking for food outside of the meal plan – especially things she used to enjoy (chocolate, etc.).  Unbelievably, she began asking for MORE food. Consensus among carers in the groups seems to be that 22-25 BMI is where most sufferers see true strides in recovery.  It is very, very rare that BMI under 22 is successful, at least when polled on the peer-to-peer carer support groups.  Most often, it seems as though 23-24 is the “sweet spot” for many.  My daughter has remained at this BMI (just shy of 24) for almost 6 months.

Summary of Recovery BMI

One online support group did their own survey: ” at what BMI did you see real recovery?”

Here are the responses ( note that most were given a target bmi of 19 by their clinician, and had to fight against that, or had to walk away from their provider to get their child into recovery)

BMI 21-22      4

BMI 22            3

BMI 22-23      4

BMI 23            1

BMI 23-34      5

BMI 24            4

BMI 24-25      4

BMI 25            4

So out of 29 respondents,  none got their kid into recovery at BMI 19 OR 20.

Stay Tuned for A Survey For Parents

I think this is an important issue that deserves more attention. I am working with the same researchers who did the above study to more formally study parents’ perceptions of their childrens’ recovery. Stay tuned for a survey so we can continue to learn from your parental wisdom.

If you interested in learning more about this study, please click here.

Sources

Jocelyn Lebow, Leslie A. Sim & Erin C. Accurso (2017): Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa?, Eating Disorders, DOI: 10.1080/10640266.2017.1388664

On Empowering Parents—Not Pathologizing Them

Empowering Parents 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.

A Viewing Guide for “To The Bone”

Ten Things I Want Viewers of To the Bone to Know

Eating Disorder Film Guide“To The Bone,” Marti Noxon’s semi-autobiographical film about her experience as a young adult living with anorexia, was released today on Netflix and has already stirred up much controversy within the eating disorder community. As a general rule, I do not see things in black and white. As with anything, I see this film in shades of grey – it handles some things well and some things poorly. Many concerns have already been aired widely in both mainstream and social media.  Foremost among these concerns is the movie’s reinforcement of the anorexia nervosa stereotype by portraying an emaciated white female and the weight loss that lead actress Lily Collins underwent to play the role. I will not rehash these here; instead, I hope to shed light on some other important issues and to provide an educational piece to accompany the film.

  1. This film may be triggering. It shows images of severe emaciation and may either be upsetting to those vulnerable to eating disorders, or inspire a competitive desire to be “as skinny”. Often, people with eating disorders don’t feel “sick enough”; anorexia nervosa can be a competitive illness. (Reports are that pro-ana sites are already using images of Lily from the film. While it’s concerning that the film adds to the available library of these sorts of images, this library is already huge – if they didn’t use this image, it would be easy to find another.) Those susceptible must exercise caution when viewing this film and if they are triggered, they should contact their treatment team or contact an organization such as the National Eating Disorders Association for help.
  2. It is difficult to make a film that accurately portrays eating disorders. To depict eating disorders on film, behaviors must be shown. Yet much of the suffering from an eating disorder is internal and harder to depict. This film is not an educational film – it is a piece of entertainment. Nevertheless, I think it does bring eating disorders into the mainstream. The film portrays some things accurately – with others it takes great liberties. Even with these departures, I do think it has virtues that can do some good. I will discuss these more below.
  3. This is one person’s story. Marti Noxon’s aim is to tell her story and she has a right to do so. She has been public that many years ago she suffered from an eating disorder and wanted to both shed light on and draw more attention to the issue. And that she has done! Based on the talkback I attended with Marti Noxon and actors Lily Collins and Alex Sharp, Marti recognizes that she can neither represent the diversity of all people with eating disorders nor speak for the range of people affected. She hopes that her work will open the door for others to tell their own stories, a hope I share. For those interested in a more diverse story about eating disorders, check out the work of Tchaiko Omwale, who is working to complete her film Solace. If you are committed to helping bring more diverse voices forward, you can contribute to help her complete her film.
  4. To The Bone accurately portrays some of the aspects of living with an eating disorder. I do not believe the film overly glamorizes anorexia. It illustrates the mindset and some of the mental anguish of someone with an eating disorder. The film displays a number of common eating disorder behaviors. We see Ellen and her peers engaging in behaviors such as calorie-counting, dietary restriction, overexercise, bingeing and purging, and chewing and spitting. Chewing and spitting is displayed in a restaurant scene in which Ellen goes out to eat with Lucas, her friend from treatment. Chewing and spitting is a lesser-known, but significant eating disorder behavior that is not commonly talked about or assessed by professionals. It is a frequently associated with more severe eating disorder symptoms and suicidal ideation. However, the behavior is more likely to occur in private than in public. It can occur in the context of anorexia nervosa as well as bulimia nervosa or other disorders.
  1. Eating disorders are serious mental illnesses and can be life-threatening. The movie shows Ellen and some of her peers needing medical attention and carefully balances showing the gravity of their situation with building hope for recovery.
  2. To the Bone paints a very Hollywood picture of recovery. While the movie adequately portrays Ellen’s ambivalence about treatment, it implies that things shift when Ellen “decides” she wants to recover. It disturbs me greatly that Dr. Beckham tells Ellen, “I’m not going to treat you if you aren’t interested in living.” Many people with anorexia nervosa have anosognosia, a symptom that causes patients to deny their illness and refuse treatment as a result. We now know that enough food, weight gain, and a cessation of eating disorder behaviors are prerequisites for recovery from anorexia nervosa. Usually some physical restoration is required before a patient can really want to recover – Dr. Ovidio Bermudez calls this a “brain rescue.”
  3. The movie does not model modern eating disorder treatment practices. But realistic treatment would probably not make a good Hollywood story. For starters, I would never suggest a therapy patient change his/her name! More seriously, in eating disorder treatment we prioritize nutritional recovery. This refers not to specific nutrients, but to the development of healthy eating habits including regular meals and adequate amounts of food. This applies to people with all eating disorders, not just anorexia nervosa. People with eating disorders need as a primary element of treatment food – balanced, sufficient, and regular eating. The movie portrays the patients in the residential treatment center as each able to choose their own food. While some patients eat some portion of the meals served, other patients eat nothing (or the one character with BED repeatedly eats only peanut butter out of the jar). I know of no treatment setting that would not have a primary focus on structured regular meals and patients having requirements for meals that can become less restrictive as they progress in treatment.
  4. I worry that the portrayal of Ellen’s family reinforces old myths about eating disorders being caused by families. To reiterate, families do not cause eating disorders. Ellen’s father is unavailable (and never even appears), her mother has had mental health problems (and is involved in a new relationship) and no one is really there for Ellen, except her stepmother who takes her to treatment and her half-sister. I do love the portrayal of the relationship between Ellen and her half-sister. I think this relationship captures the mixture of love, concern, and anger experienced by siblings.
  5. The movie misses the opportunity to depict the family as important allies in treatment. No one is really involved in Ellen’s treatment beyond the family session, and Dr. Beckham states there is no need for any future family sessions on the basis of how badly it went. None of the young people in this house have their parents involved in their treatment (at least that we see). This is very unrealistic in this day and age. Almost every treatment center involves family members to a greater or lesser degree. In reality, parents can play a central role in the treatment of adolescents and young adults, are usually included in treatment, and can even drive the treatment when their youngsters are incapable of seeking treatment on their own or have anosognosia. Parents can also help with nourishing their youngsters back to health (but not in the dramatic way it was portrayed in the film…with a baby bottle). Family-based treatment (also referred to as the Maudsley method and mentioned in passing in the scene where the moms are in the waiting room waiting for their daughters to have an intake with Dr. Beckham as something they have tried) is actually the leading treatment for adolescents and is also effective for many young adults. It focuses on empowering the family to be an important part of the treatment team and able to fight for recovery on behalf of an unwilling or unmotivated youngster and also provide meal support.
  1. Three Things I really like about the film:
    1. I love that Dr. Beckham says, “There is never one cause.” This is true.
    2. I love that it builds hope for recovery by showing Lucas as doing well and actively working on recovery.
    3. I love that it shows a male and an African-American with eating disorders.

Although I was a consultant for the film, I had no influence on the story.

In conclusion, please View the Nine Truths PSA the cast and crew of To the Bone produced for World Eating Disorders Action Day. While aspects of the film veer far from reality, the filmmakers are committed to the cause and, to support eating disorder education, they made this PSA which aligns with the best current evidence on eating disorders. Most of the messages I would want viewers of the film to come away with would be covered in this fabulous video. You can also read the Nine Truths About Eating Disorders:

Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.

Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.

Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.

Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.

Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.

Truth #7: Genes and environment play important roles in the development of eating disorders.

Truth #8: Genes alone do not predict who will develop eating disorders.

Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.

Produced in collaboration with Dr. Cynthia Bulik, PhD, FAED, who serves as distinguished Professor of Eating Disorders in the School of Medicine at the University of North Carolina at Chapel Hill and Professor of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. “Nine Truths” is based on Dr. Bulik’s 2014 “9 Eating Disorders Myths Busted” talk at the National Institute of Mental Health Alliance for Research Progress meeting.

Checking Our Own Weight Biases as Parents

 

Weight bias parentingWeight bias is a preference for thinness. In the words of psychologist Ashley Solomon, Psy.D., CEDS, “Weight bias is insidiously interwoven into the fabric of our culture.”

Like many of us, I grew up in a family that possesses a great deal of weight bias. When I gained weight just before puberty my mother put me on diets. My paternal grandfather bribed me to lose weight with the offer of a car. I realize my family members meant well. They stated at the time they were worried I would not be well-liked if I was overweight. At 101 years of age, my maternal grandmother still weighs herself daily and credits the diet she started in high school as the cause of my grandfather falling in love with her.

I have already recounted how I helped my older daughter gain weight when she fell off her weight curve at the age of 12—despite her pediatrician’s misplaced admiration, “You’re just how we all want to be,” (75%ile for height and 25%ile for weight [= thin for your height])” My son and younger daughter gained weight before their growth spurts, which led to that same pediatrician warning me about weight gain and risk of obesity for the two of them. This succinctly illuminates our culture’s weight bias: obesity is a far greater concern than anorexia nervosa.

Now let’s fast-forward to 2 years after the obesity warning for my younger daughter. Nearing the end of her height growth spurt, she has fallen off her weight curve. What is an FBT-trained professional therapist and enlightened mother to do?

She is about 10 pounds below where she should be according to the weight graphs (ignoring the single spurious plot point when I got the obesity warning). She is definitely slender. She does take a medication that could reduce appetite. However, even when she doesn’t take it, she has a small appetite. She does not show any other signs of weight or body concern, eats a range of foods, and is not very active (unlike her older sister when I intervened on her behalf to restore weight).

I notice my admiration for her current shape. I notice the temptation to leave her alone and let her remain on the thin side. After all, my son has gained weight now that he is no longer in high school sports. I notice a stronger urge to react to his food choices than I did when he was thinner. And with some larger relatives in their genetic heritage, I have had the fleeting thought that I would rather keep my daughter thin. WHAT?! I caught my thoughts unconsciously falling into programmed family and societal beliefs that I do not actually agree with on an aware and conscious level.

I examine my feelings and beliefs about what weight gain means for my daughter. I quickly recognized my over-valuing of her slenderness and my own projected anxiety about her potentially being larger. After questioning her pediatrician, who is, not surprisingly, unconcerned, and obtaining a print-out of her growth and weight curves, together we (my daughter and I) settled on adding a daily liquid supplement and mild encouragement to eat more. And, my daughter seems to feel it is a fun challenge.

I do what I ask the families I work with do, which is challenge the bias that thin is better and focus on keeping my daughter on track on her own weight curve, which I know is healthiest for her long term.

Five Reasons Parents Should be Included in the Treatment of Children and Adolescents With Eating Disorders

I had the honor of presenting a workshop yesterday along with Therese Waterhous, PhD/RDN, CEDRD. and Lisa LaBorde, Outreach Director for Families Empowered and Supporting Treatment of Eating Disorders (FEAST) at the IAEDP Symposium 2016. Our workshop was entitled, From “Worst Attendants” to Partners in Recovery: Empowering Parents as Agents of Change for Children and Adolescents with Eating Disorders.

Slide1

A growing body of scientific research demonstrates that parents and caregivers can be a powerful support for a child in recovery from an eating disorder. This model of care is a radical shift from the traditional individually focused therapeutic approach and requires significant changes in how patients and families are treated within a clinical practice.

During my section of the presentation, I presented Five Reasons to Include Parents in treatment for youngsters with eating disorders. I share them here:

  1. The reason to exclude parents was based on theories that have now been debunked.

In the late 1800s Gull suggested that families were “the worst attendants” for their children with anorexia nervosa, and this set the tone for many years. More recent perpetrators of this viewpoint were Hilda Bruch and Salvador Minuchin. In the historical treatment of eating disorders, parents were blamed and the children were taken away to be fixed by professionals. When ultimately sent back home, parents were told, “Step back,” “Don’t get into a battle for independence, “ and “Don’t be the food police.”

These practices were based on early theoretical models for eating disorders that have not been supported by empirical studies. Research has not been able to identify any particular family pattern that contributes to a child’s eating disorder.

  1. Best practices now state to include parents (and not blame them).

As the following clinical guidelines demonstrate, it is no longer the appropriate standard of care to exclude families from treatment.

The Academy for Eating Disorders’ position paper on The Role of the Family in Eating Disorders:

  • The AED stands firmly against any model of eating disorders in which family influences are seen as the primary cause of eating disorders, condemns statements that blame families for their child’s illness, and recommends that families be included in the treatment of younger patients, unless this is clearly ill advised on clinical grounds. 

The Nine Truths About Eating Disorders consensus document, produced in collaboration with Dr. Cynthia Bulik, PhD, FAED states:

  • Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

The American Psychiatric Association (APA) Guidelines for Eating Disorders also advises:

  • For children and adolescents with anorexia nervosa, family involvement and treatment are essential. For older patients, family assessment and involvement may be useful and should be considered on a case-by-case basis. (p.12)
  1. Research shows better and faster results when parents are included in mental health treatment for their children.

Randomized controlled trials of adolescents with anorexia nervosa and bulimia nervosa show that adolescents who receive family-based treatment, in which parents play a central role, achieve higher rates of recovery and recover faster than adolescents who receive individual adolescent focused therapy. This result is consistent with findings for other psychological disorders, including Obsessive-Compulsive Disorder (improved outcome is found when families are included in treatment) and schizophrenia (a large scale study found greater improvement when treatment included family education and support as part of more comprehensive care).

  1. Parents are often good allies in fighting eating disorders.

On the one hand, patients with eating disorders (and especially younger patients) are often significantly impacted by malnutrition. Research shows they commonly have a decrease in brain grey matter, cognitive deficits and anosognosia—a lack of awareness that they are ill. Recovering on one’s own is commonly difficult for an adolescent whose brain is not fully developed and may lack the cognitive ability to challenge negative thoughts, change behavior patterns, and resist urges. Furthermore, they commonly lack the independence adult clients have to purchase and prepare their own food.

On the other hand, parents are there to take care of their children. They can do the heavy lifting. They can be authoritative and require children to eat. It can be difficult for a therapist to develop rapport with a reluctant and resistant adolescent; it is much easier for a therapist to develop a therapeutic alliance with the parents who do want their child to recover. In situations where there are multiple treatment providers, parents can help with the communication between team members as they will likely be seeing them all. Lastly, parents typically buy the food for the household so they have the ability to execute the meal plan.

Eating disorders often take years, not months, to fully resolve. There will rarely be a scenario in which a patient leaves home for a residential setting and comes home “cured.” The reality is that any treatment is only the first stop on the road to recovery–full recovery takes sustained full nutrition and cessation of behaviors for an extended time period and the family, in many cases, can help that happen. So whatever treatment model is used, FBT principles and training are vitally important for families.

  1. Parents are powerful.

In the past, mental health treatment was primarily private; the internet has changed that. Parent support and activist groups such as FEAST, Eating Disorder Parent Support (EDPS), March Against Eating Disorders, International Eating Disorder Action,and Mothers Against Eating Disorders have connected parents, given them access to scientific information that was not available to parents pre-internet, and given them the tools to organize. Social media has increased the pace of this information. Parents have access to evidence-based information and are demanding treatment that aligns with it. If they are shut out from treatment, they will hear from other parents that this is problematic. They may change providers if they are dissatisfied with the treatment their child is receiving

There is no greater love than the love of a parent for their child. To work with parents and empower them to help their children get well is one of the most rewarding aspects of my work.

Condiments, the Final Frontier of Eating Disorder Recovery

By Katie Grubiak, RDN, Director of Nutrition Services

Katherine Grubiak is a Registered Dietitian with a focus on blending Western & Eastern philosophies regarding nutritional healing.

Condiments in Eating Disorder Recovery

In our work with clients with eating disorders, we help them to reintroduce recently eliminated and avoided foods that present as part of the eating disorder. We notice that as clients (both adult and child) reintroduce foods, it is often the condiments and sauces that are the last to be confronted. In some situations, clients never successfully spontaneously reintroduce these foods; we have to strongly encourage them.

“Normal” eaters enjoy ketchup on French fries, mayonnaise on a sandwich, and dressing (with oil) on salads. In fine cooking, sauces such as Hollandaise are elements that complete the dish. Watch any cooking show and you will see how integral the sauces are to the meals.

In addition to adding needed flavor and creaminess to dishes, these sauces and condiments also add the necessary dietary fat that is essential to metabolic function, hormone balance, absorption of fat soluble vitamins (Vitamins A, D, E, K), nerve coating, and ultimately brain healing.  It is said that even after weight restoration, for 6 months the body & brain are still recovering.  Gray matter, which is severely compromised in anorexia, only can be re-layered through the help of essential fatty acids. Recommendations are between 30-40% of total calories coming from dietary fat. How about we rename this macro-nutrient “essential fuels” (EFs) to honor its positive and real use in recovery?

We think it is worth pushing these condiments and sauces as one step towards a full recovery for our clients. If you are a person in recovery or a parent of a person in recovery, we hope you will consider the following suggestions:

  • Try one new condiment on a sandwich or side dish per week. This may include: ketchup, mayonnaise, mustard, aioli, etc.
  • Try dipping chips or vegetables in sauces such as Ranch dressing, salsa, or guacamole.
  • Experiment with one new creamy salad dressing (not fat free) on a salad.
  • Eat a meal that has one new sauce, such as a cream sauce on pasta, a sauce on steak, or an Asian curry.

Here are some recipes:

Chimichurri Sauce-with Argentinian roots its used as both a marinade and a sauce for grilled steak. Also try it with fish, chicken, or even pasta (like a pesto). Chimichurri also makes a great dipping sauce for french bread or a yummy spread on a sandwich! 

  • Prep Time: 8-10 minutes
  • Serves 4

Ingredients:

  • 1 cup firmly packed fresh flat-leaf parsley trimmed of stems
  • 3-4 garlic cloves
  • 2 TBSP fresh or 2 TSP dried oregano leaves
  • 1/2 cup olive oil (extra virgin cold pressed)
  • 2 TBSP red or white wine vinegar-maybe a rice vinegar
  • 1 TSP sea salt
  • 1/4 TSP ground black pepper
  • 1/4 TSP red pepper flakes (amount depending on level of heat desired)

Finely chop the parsley, fresh oregano, & garlic or place all in a food processor with just a few pushes. Place in a small bowl. Stir in the olive oil, vinegar, salt, pepper, and red pepper flakes to taste. Serve immediately or refrigerate. Perishable-so avoid keeping longer than two days.

Chili Aoli

Condiments in eating disorder recoveryUse on top of meatloaf, meatballs, or on a sandwich.

Total time: 10 minutes | Makes 1 cup.

  • 1 cup mayonnaise
  • 2 cloves garlic, peeled and minced
  • 3 1/2 tablespoons canola oil
  • 1/2 teaspoon ground cumin
  • 3/4 teaspoon lemon juice
  • 1 1/2 tablespoons dark chili powder
  • 3/4 tablespoon paprika
  • Salt and pepper

In a small bowl, whisk together all ingredients until smooth. Taste and season as desired with salt and pepper.

Trader Joe’s Wasabi Mayo can really spruce up a turkey sandwich!  

For Teens With Bulimia, Family Based Treatment is Recommended

Teens With Bulimia Family Based TreatmentMy original eating disorder training began in 1991 with learning Cognitive Behavioral Therapy (CBT) for bulimia nervosa (BN) under G. Terence Wilson, the co-author with Dr. Christopher G. Fairburn, of the treatment approach that preceded CBT-E. In 2010 I underwent training in Family Based Treatment (FBT) for Adolescent Anorexia Nervosa (AN) and became certified in FBT by the Training Institute for Child and Adolescent Eating Disorders.

CBT is the most effective treatment for adults with bulimia nervosa. It is an individual approach that focuses on reducing dieting and changing unhelpful thinking patterns that maintain the behavior. FBT is the most successful treatment for adolescents with AN. FBT encourages parental control and management of eating disorder behaviors, but does not address distorted thinking regarding shape and weight. Over the last five years, there has been no clear guideline on which treatment I should offer to adolescents with BN.

This changed in September 2015 with the online publication of “Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa” by Daniel Le Grange, Ph.D., James Lock, M.D., W. Stewart Agras, M.D., Susan Bryson, M.A., M.S., and Booil Jo, Ph.D. which has been published in the November Journal of the American Academy of Child and Adolescent Psychiatry.

In this study, researchers at the University of Chicago and Stanford randomly assigned 130 teens between the ages of 12 and 18 years old with BN to receive either CBT-A (CBT adapted for adolescents) or FBT-BN (FBT for adolescent bulimia). The teens received 18 outpatient sessions over the course of six months. Assessments were conducted at end of treatment and at six and twelve month follow-ups. After the completion of the treatment, bulimia abstinence rates were 39% for FBT patients and 20% for CBT patients. By the six-month follow up, these rates rose to 44% for FBT patients and 25% for CBT patients. These differences were statistically significant. By 12 month follow up, while the bulimia abstinence rate continued to rise for both populations, the difference was no longer statistically significant.

The researchers concluded,

FBT-BN is likely a better initial treatment option compared to CBT-A for those adolescents with clinically significant bulimia behaviors. FBT-BN leads to quicker and higher sustained abstinence rates that are maintained up to 12 months posttreatment…It appears that, similar to their adolescent peers with AN, adolescents with BN can benefit from an approach that actively involves their families in the treatment process. However, given that there were no statistical differences between these 2 treatments at 12 months post-treatment, CBT-A remains a viable alternative treatment for this patient population, especially for those families who would prefer a largely individual treatment or when there is no family available to be of help.

In interviews about the study, Dr. Le Grange said, “Parents need to be actively involved in the treatment of kids and teens with eating disorders.”

This study reinforces my experience. Although I have employed CBT for bulimia in working with adolescents, rarely do adolescents fully embrace the work required on their part for CBT to be successful. I have found it more effective to use FBT with their family and to supplement with some individual CBT if the adolescent appears ready and motivated for additional independent work. Bingeing and purging are serious symptoms carrying the risk of heart and esophageal problems and death. Thus administering a treatment that brings a faster rate of remission of symptoms is a priority.

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

Is My 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 sororities and fraternities. If a young adult has been struggling in recovery, these additional stressors typically make life even harder.

Young adults who are not completely recovered struggle in situations that healthy adults navigate with ease. Consuming enough food in a dining hall can pose a big challenge to students with eating disorders characterized by inflexible eating. In our experience, students who are not comfortable eating with peers and not comfortable eating a variety of foods (including starches, fats, and desserts) lose weight rapidly in this environment.

The patterns of college life can make it harder to maintain a healthy weight. Students are likely much more active as they walk from place to place over a large campus. Different sleep patterns (all-nighters among them) 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 the 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 to a student in recovery. Roommates and peers may be dieting, there is fear of the “freshman 15,” and friendships may bond around visits to the gym and yoga classes. It can be harder to refrain from exercise when it is the place that socializing occurs.

Many parents want to send their young adults to school so as not to have them miss out on common milestones and universal 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 them to have. Returning to a “normal” life too soon is a common cause of relapse, further delaying their ability to live a “normal” life.

From our experiences with the preparation of high school seniors to go off to college and the reception of incoming freshman from other eating disorder teams, we have developed the following list of questions for parents to ask when deciding whether a young adult is prepared for a healthy transition to college:

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 menstruated consistently (if female-bodied) for six months?
  • Has your young adult been free of eating-disordered behaviors such as bingeing, purging, laxative use, and excessive exercise for six months?
  • Is your young adult able to independently and consistently prepare/choose meals (in a variety of settings) that contain enough energy-dense foods to maintain this weight?
  • Is your young adult able to serve themselves snacks and desserts?
  • Does your young adult consume beverages other than water (juice, milk, lattes)?
  • Is your young adult able to eat at a variety of restaurants, ordering and eating a balanced meal that is not simply the lowest calorie item on the menu?
  • Is your young adult able to go into a cafeteria and eat from the different food stations comfortably (sandwich bar, grill, etc.) and not just from the salad bar?
  • Is your young adult comfortable eating hot breakfasts (other than oatmeal)?
  • Does your young adult use condiments comfortably (dressing with fat, ketchup, mayonnaise, etc.)?
  • Is your young adult comfortable eating with friends?
  • Does your young adult eat at a normal pace?
  • Has your young adult reincorporated the majority of previously feared and avoided foods?
  • Is your young adult able to go without exercise at least every other day, or not at all if medically contraindicated?
  • If your young adult has returned to exercise, do they understand the need to add additional fuel following exercise?
  • 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.)
  • Will your young adult be able to cope with potentially having a scale in the room and roommates who weigh themselves and discuss weight/dieting?
  • 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 24- to 36-hour period.
  • Is your young adult able to increase their daily calories substantially to account for mileage logged when walking around campus?
  • Can your young adult be restful? Does he or she sit when everyone else is sitting?
  • Is your young adult able to be alone around processed and highly-palatable foods without having an urge to binge?
  • Has your young adult demonstrated an ability to tolerate anxiety without resorting to restriction, bingeing, or purging?
  • Does your young adult openly acknowledge their eating disorder and have insight about the need to construct a life and schedule that supports recovery?
  • 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?
  • Does your young adult understand that alcohol calories “do not count” towards energy needs?
  • Are temperamental traits (perfectionism, rigidity, comparing, etc.) acknowledged and appropriately managed?

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.

  1. Practice eating with them in different self-serve cafeteria-type settings including a variety of restaurants for breakfast, lunch, and dinner. Good options include Souplantation, Indian restaurants that have lunch buffets, and hospital cafeterias. Have them practice building a meal that will meet their dietary needs. Revisit the same places again with the expectation that they will choose different options.
  2. Have them practice walking five miles per day for a week (to simulate the amount of physical activity they’re likely to have on a college campus) and adding sufficient calories to keep weight steady.
  3. Do ‘surprise’ food exposures for a few months – at random times take your young adult to unexpected food locales/situations and make sure they can tolerate it. For example, make a spontaneous stop at Cold Stone Creamery and offer them a snack.
  4. Do a week of sauces and butter on everything.
  5. It is a good idea to have a college contract in place. This is an agreement between the parents and the student that specifies criteria required for staying in college (things like maintaining a healthy weight, not engaging in eating disorder behaviors, and having regular weigh-ins) and what the parents will do if these things are not met (for example, increase supervision, bring the child home, etc.).  A sample college contract can be found here.
  6. 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 their starting than to have them start and get overwhelmed by their 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 she or he is fully recovered. By contrast, sending them to college when they are not ready may reduce their chance for a full recovery.

Thanks to Rebecka Peebles, MD, Therese Waterhous, PhD/RDN, CEDRD, and JD Ouellette for their helpful feedback and contributions to this piece.

Download copy of article here: Is your young adult ready for college?