Category: Mental Health And Eating Disorders

We know that dieting for weight loss purposes is a major cause of eating disorders. But there are many different pathways to eating disorders that we’re still learning about, especially when it comes to neurodivergent kids.

These kids often don’t fit what we consider to be a “typical” eating disorder. They don’t begin by dieting to lose weight. They may not start with body image issues. (However, disordered eating often causes negative body image and more eating disorder behaviors.) 

The “story” of the eating disorder may be food and weight. However, the original cause of many eating disorders is being neurodivergent. Up to 37% of people with eating disorders have autism, and 31% of adults diagnosed with eating disorders also have ADHD. 

Research indicates that neurodivergent people benefit less and have poorer outcomes from traditional eating disorder treatment. Unless we address the neurodivergent pathways that lead to eating disorders, it’s much harder to achieve recovery.

There are many causes of eating disorders; they are complex and vary greatly. I put together the three pathways I see most often when working with parents who have neurodivergent kids.

Picky eating/food aversions

The neurotypical approach to food assumes that everyone enjoys eating and will eat most foods. We assume that most people can eat almost anything and that any quirks or preferences can be overcome by circumstance and social pressure. For example, we expect that if you don’t like cantaloupe, but that’s all there is, and your parents are telling you to eat it, you will eat cantaloupe. 

However, while this may be the dominant attitude towards food, it is far from universal. There are many people, particularly those who are neurodivergent and especially those with autism and ADHD, who have highly sensitive palates who are not just mildly averse to certain foods but who develop severe aversions to food based on their five senses (sight, smell, sound, taste, texture) as well as their memories of being pressured to eat the food even when they don’t like it. Combined, these aversions take a tendency to be picky about food to a full-blown food aversion. 

Once a person develops a serious food aversion, eating that food is not as simple as being hungry or receiving well-meaning pressure to try it. These people are strongly opposed to that food and may have physical symptoms like a racing heart, sweating, nausea, and even vomiting when faced with that food. Their list of “safe foods” may dwindle as they become more sensitive over time. This is how picky eating and food aversions can tumble into disordered eating and an eating disorder.

How to help

Parents can support recovery by feeding their neurodivergent child regular meals, having family meals, and gradually exposing them to more food variety in a non-pressured environment. They can support a child in exploring their food-based sensory and emotional issues and soothe them when emotional dysregulation makes eating hard. 

Parents also need to accept that kids like this are unlikely ever to have a neurotypical relationship with food and eating. Their recovery will not mean they become typical eaters. Parents who accept that food and eating are more complicated for neurodivergent kids help them learn to feed their bodies in light of their unique neurobiology and psychology.

Forgetting to eat/procrastinating eating

The neurotypical approach to food assumes that when you are hungry, you will eat. This idea assumes that anyone who skips meals or procrastinates eating is doing so because they want to lose weight. However, while this may be the neurotypical response to hunger, it is far from universal. Sometimes people assume a child who doesn’t eat is being stubborn, defiant, or lazy. However, there are many people, particularly those who are neurodivergent and especially those with ADHD, who don’t notice their hunger cues and/or are not motivated to interrupt what they are doing to eat. This is a neurological difference, not defiance or a choice. 

These people skip meals because they completely forget to eat or put eating off for a later time. This is a form of unintentional food restriction that can lead to a cascade of other eating disorder behaviors, including negative body image, more restriction, binge eating, and purging. It’s very easy to create the story that the reason they don’t eat is for weight loss. However, if we miss the essential lack of hunger cues and drive to eat, we will not truly address the cause of disordered eating.

How to help

People who don’t notice and respond to their hunger cues must address their underlying neurobiology and use intentional (vs. intuitive) eating to recover. Parents can support recovery by serving food regularly, having family meals, and prompting eating, especially when distraction is at play. They can also teach kids to prioritize eating and recognize non-typical signs of hunger. This is an essential skill that becomes particularly important when kids leave home.

Parents must accept that a child with this neurobiology will probably not turn into a neurotypical eater who intuitively feeds their body based on typical hunger cues. Instead, a person like this will need to learn how to feed themselves on purpose. 

Oppositional assertion of independence

When a child is picky and/or forgets to eat, parents tend to increase their focus on food and eating. This is appropriate, as we are responsible for helping our kids get the nutrition they need. Unfortunately, many times the way we go about this backfires. While parents need to support kids in eating, power struggles about eating are very common. They can compound the original issue that leads to picky eating and/or procrastinating eating. 

Psychiatrist William W. Dodson, MD, says that by age 12, kids with ADHD have heard about 20,000 more negative messages from adults compared to kids who don’t have ADHD. Since they are already highly sensitive to negative feedback, the level of negativity that they receive based on their neurodivergent qualities can be devastating and lead to oppositional defiance. 

Because they feel so criticized and marginalized, neurodivergent kids are often more resistant to even the mildest prompting from parents. Additionally, when food becomes an issue, parents can become hyper-focused on it, making eating even more stressful and, therefore, unlikely.

How to help

Parents can help a child who is oppositional and engaging in extended power struggles over food by learning how to co-regulate with their child before offering instruction. This means slowing the whole process of feeding down to attend to the child’s core need to feel connected to the parent before the parent tells them what to do.

It’s so crucial for parents to approach kids’ eating disorders with neurodivergent characteristics in mind. A child who is not eating because they are neurodivergent needs specialized care and treatment. Finding a therapist and/or dietitian who understands neurodivergence is essential.

The good news is that when parents learn to feed neurodivergent kids based on their unique symptoms and patterns, they can make a huge difference in eating disorders. A cookie-cutter approach doesn’t really work for anyone with eating disorders, but this is particularly true when neurodivergence is a factor. For example, CBT (cognitive behavioral therapy) is a gold standard treatment for eating disorders. However, it is unlikely to help someone who is neurodivergent unless neurodivergent causes are understood and addressed.

See Our Parent’s Guide To Mental Health And Eating Disorders

Your child’s eating disorder and depression are likely linked. Depression is both a risk factor and maintaining factor of an eating disorder. This is important, because both eating disorders and depression are common and increasing among all populations, particularly children and teens.

As with anxiety, your child’s treatment for depression first and foremost needs to focus on eating regular meals containing enough nutrition. If your child is weight suppressed, restricting, purging, and/or skipping meals, then the lack of nourishing food is likely contributing to and maintaining their depression symptoms. Even with treatment, it is unlikely that your child’s depression will decrease if they lack nutrition.

Additionally, depressive symptoms are strongly associated with both stress and a lack of sleep. Evaluate your child’s lifestyle right now and determine whether you need to take things off their plate to reduce stress and ensure they are able to get the hours of sleep recommended for their age. Few people get enough sleep, but impaired sleep is both a risk factor and a symptom of depression, and it must be addressed for any other attempts to treat depression to work.

Psychological symptoms of depression

Depression is both physical and psychological. Most people are familiar with and look for the psychological symptoms of depression, which include:

• Feelings of sadness, tearfulness, emptiness or hopelessness
• Angry outbursts, irritability or frustration, even over small matters
• Loss of interest or pleasure in most or all normal activities
• Anxiety, agitation or restlessness
• Feelings of worthlessness or guilt, fixating on past failures or self-blame
• Trouble thinking, concentrating, making decisions and remembering things
• Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide

Physical symptoms of depression

Parents should be aware that physical symptoms of depression are common. In fact, physical symptoms may be your child’s only symptoms of depression. There is a strong link between increased sensations of pain and depression based on a shared neurologic pathway. Physical symptoms of depression include: 

• Headache
• Joint pain
• Limb pain
• Back pain
• Fatigue
• Sleep disturbances
• Slowed thinking, speaking or body movements

Importantly, other physical symptoms of depression include gastrointestinal distress (stomachaches, nausea, etc.) and a change in appetite (either high or low), which makes it a major risk factor and maintaining factor for eating disorders.

Depression affects the way your child perceives food. Some kids with depression find that food looks and tastes “gray” and dull. This can exacerbate restrictive eating issues. Other kids will seek comfort and solace in food when they are depressed. It may be the one way they can “feel” something, which may lead to increased binge eating. In other words, your child’s depression is very likely interacting with their eating disorder behaviors.

What causes depression?

Many different factors cause depression. Like eating disorders, depression is a biopsychosocial disorder that combines biological, psychological and social risk factors, including:

Biological risk factors: Reduced production of the neurotransmitters in the brain including serotonin, norepinephrine, dopamine, gamma – aminobutyric acid (GABA), cerebral nerve growth factor and more.

Psychological risk factors: Other mental disorders including anxiety, eating disorders, and depression (people who have one depressive episode are more likely to have another). Low self-esteem, emotional repression, cognitive distortions, a lack of emotional regulation, and low self-efficacy or agency.

Social risk factors: Adverse childhood events, childhood trauma, early adversity including food insecurity, stress, parental depression and substance use, non-supportive school or family environments, and social forces of oppression like sexism, racism, weight stigma, etc.

How depression works

Like anxiety, depression occurs along a spectrum. Most people feel sadness and even despair regularly – even daily. Sadness is a natural human emotion that is ideally noticed and processed when it arises. However, if a person avoids feelings of sadness and represses their experiences of sadness, leaving those feelings unprocessed, they may experience a depressive episode.

“I often think of depression as “stuck sadness.” In fact, when clients come in for therapy and tell me that they are depressed, my first thought is, “What is the sadness they are not allowing themselves to experience?”

Elaine Carney Gibson / Your Family Revealed

In a depressive episode, clinically called “major depression,” a person has persistent symptoms for at least two weeks. However, if the episode extends to two years, it is called persistent depressive disorder. Depression is the most common psychiatric disorder in people who die by suicide, making it an important condition to treat, especially when combined with an eating disorder.  

Treating depression and your child’s eating disorder

If your child is in a depressive episode, they should receive therapy to treat it. The most common treatment for depression is cognitive behavioral therapy (CBT). Another evidence-based treatment for depression is interpersonal psychotherapy (IPT), which focuses on improving interpersonal functioning.

I have seen success in treating depression with Internal Family Systems (IFS) therapy as well as somatic therapies. Your child’s doctor may recommend psychiatric medications. These medications are short-term interventions and should be used in conjunction with psychotherapy and emotional development. If your child does not learn emotional processing skills they remain at risk for future depressive episodes.

Keep in mind that feeling sad sometimes – even every day – is not the same as being depressed. Sad is a core human emotion and is both normal and natural. Support your child in feeling their feelings and emotions during eating disorder recovery. Most feelings, even the hard ones like anger, jealousy, and sadness, pass in about 30-90 seconds. The danger is not feeling sadness, but rather repressing or getting lost in it. If your child’s sadness is persistent and feels hopeless for two weeks, seek professional support for depression. 

See Our Parent’s Guide To Mental Health And Eating Disorders

Anxiety disorders, which very often show up with an eating disorder, are both the most common and the most treatable mental disorders. And parents who have been trained in how to respond to kids’ anxiety are the most powerful treatment providers.

The biggest barrier to recovering from an anxiety disorder is the belief that “being anxious” is a personality type rather than a pattern that can be changed. When we have a child with an anxiety disorder and we say “oh, that’s just how they are,” we miss an important opportunity to help them learn the skills that will free them from the tyranny of an anxiety disorder.

Anxiety is a common underlying and co-occurring factor in eating disorders. And like eating disorders, anxiety is on the rise. Almost 12% of kids had anxiety in 2012, up 20% from 2007. In 2020, those numbers nearly doubled, with reports showing that more than 20% of kids struggle with anxiety symptoms.

The good news is that there are things that parents can do to reduce kids’ anxiety, and this work will benefit eating disorder recovery. The more parents understand and respond to anxiety strategically, the better their chances of success.

What is anxiety?

Anxiety is a feedback loop between the body and mind.  All animals have anxiety because it’s essential to survival. However, our modern lifestyles bear almost no resemblance to the environments in which our brains evolved. Today our most common threats are not to our bodies (predators, enemies, and natural disasters), but our emotional safety (attachment and self-worth). Instead of protecting us from physical danger and death, as they were designed to do, today our anxiety system reacts to non-deadly threats to emotional safety.

Our incredible minds are what makes us susceptible to anxiety disorders, and they are also the solution to anxiety disorders. Here’s how anxiety works:

1. Body-based anxiety

Anxiety is an emotion we feel in our bodies. It comes from the nervous system and is a body-based alert to perceived danger from things we see, smell, taste, touch, or hear, the sensation of our internal organs, and even other people’s emotional states.

When alerted to danger, our nervous system automatically sends an alert to the thinking mind. Think of it as a smoke alarm. There may be smoke, there may be fire, or the smoke alarm may be over-reacting. Regardless, the smoke alarm makes a noise to get the mind to pay attention to the risk and take action.

Something to consider is that a major reason for a smoke alarm to overreact is hunger. A hungry brain is an anxious brain. If your child is weight-suppressed, restricting, purging, and/or eating chaotically, this needs to be addressed immediately in order for anxiety symptoms to reduce. If you need help getting your child weight-restored, consider increasing their level of care. Weight gain and consistent eating should be a priority, since weight suppression and chaotic eating will interfere with all other treatment approaches. 

2. Mind-based anxiety

When the smoke alarm is triggered, the mind responds. This is a healthy response to feeling anxious. After all, if there’s fire, you need your mind to kick into action fast. If you are in physical danger, you need your mind to respond and tell your legs to run. But if there’s not actually a fire, the body and mind can get stuck in a loop of anxiety, ramping each other up. Here’s what this looks like:

Body: I sense danger!

Mind: We’re in danger!

Body: We’re in serious danger!

Mind: We’re going to die!

Body: Run!

But since we’re almost never in true physical danger, this is an over-reactive pattern. Here’s a more mindful response:

Body: I sense danger!

Mind: OK – let me look around and see if we’re in danger

Body: I feel nervous

Mind: Makes sense, but we’re actually safe. Thanks for the warning though!

Body: OK

Our bodies are going to alert us to danger because that’s what they are designed to do. Recovering from an anxiety disorder means learning to use the power of our minds to evaluate the risk rather than overreact to the body’s alarm system. Over time, our body’s alarm system learns that it doesn’t have to be quite so reactive, and our anxiety reduces though it never disappears because that would be dangerous. Anxiety is a feature, not a flaw. We just need to learn to work with it.

Luckily, there is a lot parents can do to reduce kids’ anxiety. Studies show that parents have a tremendous impact on kids’ anxiety. And the good news is that parents can learn to reliably reduce their kids’ anxiety by acknowledging it and helping kids mindfully engage with anxiety rather than automatically reacting to it. You can help your child interrupt the anxious body-mind loop and teach them to step back and recognize false alarms. With practice, the smoke alarm gets less alarming and life gets a lot easier.

What doesn’t work

There are a lot of things that parents do when anxiety shows up that are well-meaning and automatic but simply don’t work. If they worked, they would decrease anxiety, stress, and worry over time, but that’s not usually the case. They include:

• Reassuring, rescuing & overprotecting
• Providing certainty and making promises
• Identifying your child’s anxiety disorder as a personality trait rather than a treatable condition
• Allowing behavior like yelling, swearing, tantrums, hitting, refusing to eat, over-exercising, and purging because it’s driven by anxiety 
• Responding to your child’s anxiety with your anxiety 
• Pushing too hard to shut anxiety down, becoming angry, explosive, and punishing 

Unfortunately, most of the time, when we respond in these ways, our kids’ anxiety gets bigger (not smaller) over time.

An example of anxiety in an eating disorder

Anxiety feels terrible. There’s no fire, but the body and mind are activated. They want to take action. The want to DO SOMETHING! There are two ways people with anxiety disorders try to calm their anxiety. First, they seek certainty, and second, they seek reassurance. 

Seeking certainty typically looks like trying to control what’s happening or what could happen. For example, your child may feel anxious in fast food restaurants so they refuse to go into fast food restaurants. It seems like if they follow this rule, they will not feel anxious. But it doesn’t work. Soon it becomes all restaurants, then parties, then family meals. Their anxiety keeps expanding despite their best efforts to control it.

Seeking reassurance looks like getting people around you to tell you things are OK. For example, your child may complain about their body. You respond by engaging in long, fruitless conversations about their body, but it doesn’t make the anxiety go away. In fact, the more you debate, the worse it gets.

The key with anxiety is that the more your child tries to control things and seek certainty, the more anxious they will become. This is why anxiety and eating disorders typically worsen over time if this anxious pattern isn’t interrupted. 

An unintended impact

Well-meaning parents don’t want their kids to be anxious. Of course we don’t! Anxiety is terrible! But when we accommodate anxiety’s demands for certainty and control, we accidentally make it more likely the anxiety and eating disorder behaviors will get stronger over time. 

Parental accommodation looks like this: if the child is seeking certainty by not eating carbs, parents allow them not to eat carbs. If the child seeks reassurance by body-bashing themselves, parents engage in long, drawn-out conversations about how beautiful their child’s body is. 

Again, if these responses worked and made the anxiety and eating disorder better, that would be great. But typically, we see an increase in symptoms when we accommodate anxiety-driven eating disorder behaviors.

How parents can respond to anxiety differently

To help kids recover from their eating disorders, parents can respond to anxiety differently and ensure they aren’t accommodating certainty- and reassurance-seeking. Instead, try this:

1. Expect anxiety to show up. Stop being surprised by each new occurrence of anxiety. Look for anxiety, especially when your child is eating or thinking about their body.
2. Manage your emotions first. If you are anxious, your child’s anxiety is likely to get worse. Learn how to recognize your anxiety and respond to it with self-compassion.
3. Validate your child’s feelings of anxiety. Don’t ignore anxiety or jump into action with certainty and reassurance. Acknowledge that they are having feelings like worry, stress, and anxiety.
4. Support your child in doing and thinking things that make them feel anxious. Don’t accommodate them and help them avoid doing or feeling the things that make them feel anxious. 

My favorite phrase when validating and supporting a child through anxiety is: I get it – this is hard, but you can handle it.

Anxiety disorders are both the most common and the most treatable mental disorders. Anxiety disorders do not need to be a life sentence. Changing your natural, loving, and understandable accommodation patterns when your child is anxious is really hard. But it can also transform recovery and support your child in feeling much better. If you’d like to learn precisely how to stop parental accommodation, check out Supportive Parenting for Anxious Childhood Emotions (SPACE). Also, you can see our guide to psychology and eating disorders.

See Our Parent’s Guide To Mental Health And Eating Disorders

Jill is beside herself with worry. Her daughter Melody has an eating disorder and is struggling with loneliness. Between treatment, COVID restrictions, and starting high school, she has become very isolated. “She has always been more on the introverted side,” says Jill. “But it’s gotten to the point where I’m pretty sure she doesn’t have a single good friend.”

“She has people she talks to in class,” says Jill. “But there’s nobody she can call or share notes with or hang out with after class or on the weekend. I think that loneliness is making it harder to recover from her eating disorder. But loneliness is also partly driven by the eating disorder. I don’t know what to do.”

Jill’s worry makes a lot of sense. And she’s right that loneliness is both a contributing factor to and a symptom of an eating disorder. Melody is naturally introverted. But she’s also been hit with a triple whammy: a pandemic, the transition to high school, and eating disorder recovery.

Loneliness and social isolation

Loneliness is a major factor in mental and physical health. In fact, social relationships are the most important lifestyle factor in longevity. Social connections are even more important to health than avoiding tobacco and alcohol. Humans are social beings, and connecting with others is essential to our health and well-being.

How to help a child who has an eating disorder decrease loneliness

Of course parents like Jill desperately want their kids to form social connections and feel a sense of belonging. This is especially important during the teenage years, so it’s understandable that Jill is concerned. But what can she do? How can Jill help Melody reduce her loneliness during eating disorder recovery?

Friendships lead to positive life satisfaction, minimize stress, and even contribute to better physical health outcomes. And the good news is that there is a lot that parents can do to support social connections. Here are five places to start:

1. Reduce the pressure

The first thing to know is that every person has a different need in terms of social connections. And while most of us think about a large pack of kids getting together on the weekends, it’s perfectly acceptable if your teenager has just one or two good friends. In fact, set your sights very low: one.

“The biggest return we get in friendship is going from zero to one friend in terms of its impact on our mental health and well-being,”  says Marisa Franco, author of Platonic: How the Science of Attachment Can Help You Make — and Keep — Friends. “If you can get that deep with one person, it’s going to be powerful and it’s going to be impactful, and you don’t need to have a ton of friends.”

Taking the pressure off having a large number of friends can be a great place to start. Find ways to weave this idea into your conversations with your child. You can talk about your own friends individually vs. as a group. And when your child complains about having no friends (plural), help them understand that just one friend would be awesome. Encourage them to look around for just one person at school who they can eat lunch with. Set your sights low, and normalize the idea of just one friend.

2. Family relationships

Your child wants and needs peer friendships, but that doesn’t mean they can’t get a lot of benefits from their social connections with family.

Our first social group is our family. How strong are your family ties? Does your child feel integrated and as if they “belong” to your family? Start by building family traditions and telling stories that help your child see how they fit into the family. Spend time building family integration every single day. A great place to begin is a family meal, which has countless health benefits, probably in part because of the social belonging it builds.

If possible, schedule activities with extended family members. It’s OK if you don’t have a strong connection with biological family – can you build a family of friends? Do what you can to expand your child’s social interactions within the scope of your family. And don’t forget to help them integrate into family activities. This may be uncomfortable if your child is feeling lonely and vulnerable, but parents can help grease the wheels of interaction!

3. Social skills

If your child is struggling with loneliness and an eating disorder, combined with COVID and a major transition like starting high school, they may need to brush up on their social skills. This can be a tricky area for parents to get involved, but the first thing to consider is whether your family is upholding and modeling good social skills.

Many families slip into dysfunctional patterns of not being friendly, not speaking politely to each other, not managing their emotions, and acting out against other family members. If you see these dynamics in your family, then get some coaching or family counseling to work on interpersonal boundaries and emotional regulation. Before you decide that your child is the one who has a problem with social skills, consider whether this is a family dynamic. It will hurt your child’s chances of success if you treat a family problem as if it is a personal failure.

Next, talk to your child about social skills. The easiest way to do this is to talk about your own experiences or use characters on TV and movies. Ask questions like: How would that behavior make you feel? What do you like about that character? How do you think that character could be a better friend? Remind your child that relationships can’t be adequately portrayed in the media, and that just like bodies, we need to take media relationships with a grain of salt.

4. Formal social groups

Teens have undergone tremendous upheaval in the past few years, and lots of them are struggling with loneliness. This is the perfect time to use formal social groups and organizations to help support social development. Ask your child to investigate clubs at school.

Many schools have a wide variety of clubs that appeal to a broad array of personalities and interests, but you can also look for clubs in the community and at your place of worship if you have one.

Encourage your child to join at least one club. This may require some well-placed parental pressure. Someone who is lonely may resist the idea of joining a club because they are stuck in a cycle of feeling low. It’s OK for you to insist on some participation. You can’t force your child to go, but don’t underestimate the power you have to influence them to give it a try. Sometimes lonely kids need a lot of verbal encouragement and requests to get out of their rut.

5. Get help

If you do all these things and your child’s loneliness is not lifting at all, then you and your child need more help. Talk to your child’s eating disorder care team. They are probably as concerned about loneliness as you are. Find out if they have any suggestions or can help your child get involved in activities. Sometimes having a non-parent make these suggestions is the key to getting them done.

A worthy focus

Loneliness is a contributor to the psychology of an eating disorder, so supporting them in addressing this is a worthwhile activity. You want to understand your child’s loneliness and support them in feeling better. Loneliness has been correlated with eating disorders and other mental disorders. It is also correlated with the No. 2 and No. 3 mortality factors: tobacco and alcohol addiction.

Jill was relieved to know that she wasn’t being silly worrying about loneliness. “There was a part of me that thought maybe I was worrying about nothing,” she says. “Or that this is none of my business. But now I feel as if my worries make sense, and I’m going to take some action to start helping Melody feel better.”

See Our Parent’s Guide To Mental Health And Eating Disorders

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Research links

Social relationships and mortality risk: A meta-analytic review, Holt-Lunstad, Julianne, Smith, Timothy R., and Layton, Bradley J, PLOS Medicine, 2010

Loneliness and Social Isolation as Risk Factors for Mortality, Julianne Holt-Lunstad, Perspectives on Psychological Science, 2015.

Monique is very worried about her daughter Maya. After a few years of struggling to deal with stress, Maya is now deep into an eating disorder. Monique and her husband Leonard are dedicated to helping her recover, but they are worried that stress is a major ongoing problem. 

“I worry that unless we address her stress, she’s still going to struggle,” says Monique. “Eating disorder treatment is hard, and it seems to me like if we don’t figure out how to reduce her stress, we’re just treading water with her mental health. I just don’t know what to do about it.” 

Maya, 16, has always been a sensitive child. “When she was a toddler, she was really picky about her food and clothing,” says Monique. “So I adjusted her diet and made sure I didn’t buy her any clothes with tags. She seemed to do OK for years, but when puberty hit, she started spiraling into stress. Now it seems like she just can’t handle life, and it’s not as simple as it was when she was little and I could control everything and reduce the stressors.” 

Everything that Monique says makes sense. And she’s right: without addressing Maya’s struggles with stress, it will be hard to achieve eating disorder recovery and, ultimately, mental health. 

Why so stressed?

To get started, I asked Monique some questions about what stresses Maya out. Based on her childhood experiences, it sounds like Maya is a highly sensitive individual. This means that she is naturally more sensitive to stressors. But what exactly is creating so much stress for Maya right now?

I started by defining the three types of stress and how they appear when a person has an eating disorder. Stress is an important part of the psychology of an eating disorder. The three types of stress are:

1. Healthy stress

Not all stress is bad! We need stress to learn and grow. Without stress, we would never achieve maturity. This stress is healthy and adaptive, but that doesn’t mean it’s comfortable. In fact, healthy stress can trigger all the troubling signs of emotional dysregulation, including yelling, crying, and avoiding tasks that seem impossible. However, when a person faces their healthy stress with courage, their struggles build emotional resilience and maturity. A person cannot mature without healthy stress! 

It’s not really the type or size of the stress that you experience but your ability to cope with the stress that defines whether stress is helpful or toxic. 

Some forms of healthy stress that your child must navigate if they have an eating disorder include:

• Eating enough food
• Eating regularly throughout the day
• Body changes (e.g. weight gain)
• Going to therapy, medical, and nutrition appointments
• Disagreeing with parents and siblings
• Being assertive about needs and boundaries
• Going to school
• Completing difficult school tests and assignments 
• Studying
• Having reasonable expectations of extra curricular activities
• Making new friends and socializing
• Having social media limits
• Getting to bed at a healthy time each night

🔑 The key if your child is experiencing healthy stress is to validate their experience (e.g. “this is hard”) while also expressing confidence in their ability to handle it (e.g. “I know you can handle this.”). Seek ways to support your child through healthy stress daily, and get coaching and support if this is a struggle for you.

2. Traumatic stress

This sort of stress is related to a specific event or action. It overwhelms a person’s coping resources and may become stuck if not processed. Common forms of traumatic stress include:

• Serious accident 
• Physical or sexual assault
• Physical or emotional abuse
• Exposure to traumatic events at home, including domestic violence
• Serious health problems, such as heart surgery, cancer, etc.
• Having a sibling or parent with a chronic illness (physical or mental)
• The death of someone close, such as a parent or sibling
• Divorce
• Vomiting, choking, and painful gastrointestinal episodes

The interesting thing about traumatic stress is that it doesn’t impact everyone equally. Two people can face the same traumatic event, and one may develop traumatic stress symptoms while the other may not. The difference between ongoing symptoms after traumatic stress is whether the event is processed healthily. Some people can do this by themselves, but many others need a lot of emotional support to process a traumatic event. 

For example, many kids get through their parents’ divorce without any PTSD, while others need some help processing their feelings about the divorce and its impact on the family.

🔑 If your child is experiencing traumatic stress, the key is to get them professional support to process their trauma. A therapist specializing in PTSD will support your child in facing their fear and overcoming the long-term impacts of traumatic stress. You can also learn skills to respond to your child’s PTSD appropriately.

3. Chronic stress

Chronic stress builds over time. A person experiencing chronic stress often feels stuck and unable to make changes to improve their life. This sort of stress is often entrenched and hard to break out of, but parents can help. According to Yale Medicine, some symptoms of chronic stress include: 

• Aches and pains
• Insomnia or sleepiness
• A change in social behavior, such as staying in often
• Low energy
• Unfocused or cloudy thinking
• Change in appetite
• Increased alcohol or drug use
• Change in emotional responses to others
• Emotional withdrawal

Common stressors to be aware of in your child’s life include:

• Difficult family relationships, especially with parents and siblings
• Lack of sleep
• Lack of family structure and support
• A heavy workload at school 
• Pressure to achieve certain grades and achievements
• Intense sports activities/expectations
• Pressure to perform at very high levels at school or in extracurricular activities
• Bullying
• Overuse of social media 

Chronic stress needs to be addressed to recover from an eating disorder. Your child’s lifestyle must change to reduce chronic stress and build experiences of healthy stress. 

🔑 There are two keys if your child is experiencing chronic stress. The first is to reduce unnecessary stressors in your child’s life. This can begin by looking at their schedule and removing non-essential activities and pressure to perform. The second is to turn the necessary stressors of life (e.g. eating, going to school) into healthy stress. With the right approach, you can help your child gradually turn chronic stress about eating and other stressors into healthy stress. 

Maya’s stress and eating disorder

I reviewed Maya’s stress with Monique using a worksheet I created. Together, we identified three primary issues that need to be addressed right away: 

Eating Stress (chronic)

Maya feels tremendous stress about eating. She is worried about food all day, and it is hard for Monique to calm Maya enough to get the nutrition she needs to recover. 

🔑  This is chronic stress that can be turned into healthy stress. In combination with Maya’s eating disorder treatment team, Monique can support Maya and help her face the stress of eating with courage and determination. Over time, she will learn to face eating and mealtimes as healthy stress. While eating may continue to be challenging for her, she can transform it from chronic stress to healthy stress. 

Sibling Stress (chronic/traumatic)

Maya and her brother Victor have a negative relationship. Victor is aggressive with Maya and frequently criticizes her. Sometimes he even gets physically violent and pushes or pinches her. 

🔑  This is chronic stress that needs to be eliminated. Monique and Leonard need to immediately seek therapy for Victor and set firm boundaries around how he treats his sister. Monique and Leonard must intervene whenever they observe Victor being aggressive, critical, and violent with Maya. There should be a zero-tolerance policy for these behaviors in the household. Additionally, they should have Maya see a trauma specialist who can determine how best to address any trauma resulting from her brother’s treatment.

Performance Stress (chronic)

Maya feels overloaded with homework and tests. She has a lifelong dream of attending an Ivy League university. The pressure to perform has become overwhelming, and Maya spends hours trying to motivate herself to do homework and study. Her grades have been steadily slipping, and she often stays up until 2 a.m. trying to complete her work.

🔑  This chronic stress needs to be adjusted. While academic goals can be a healthy form of stress, it is clear that they have crossed the boundary and become chronic stress. Maya needs support from her therapist to re-evaluate her goals and get healthy study habits and boundaries in place. Monique and Leonard should meet with Maya’s school counselor to determine reasonable expectations and help Maya manage her academic goals. 

Moving forward

Understanding Maya’s stress helps Monique and Leonard see how stress affects Maya and how they can help her start having less toxic stress in her life. Knowing the three types of stress affecting eating disorder recovery has given them the confidence to start making changes at home and in Maya’s treatment program. 

For privacy, names and identifying details have been changed in this article.

See Our Parent’s Guide To Mental Health And Eating Disorders

If your child has an eating disorder, recovery means more than simply gaining weight and/or stopping eating disorder behaviors; it means becoming mentally healthy. Eating disorders are frequently misunderstood, and people don’t always realize that mental health, not just eating disorder recovery, is the goal. 

That’s why I’ve put together a mental health checklist to help you set expectations and goals as your child recovers from their eating disorder. This mental health checklist is especially important if your child is returning to college or independent living after undergoing recovery in your home and/or a treatment facility.

Eating disorders are often layered on top of poor mental health and other mental disorders, so if parents don’t pay attention to mental health overall, they risk having a boomerang effect of having a child leave and return to eating disorder treatment. While you can’t control their recovery, you can do your best to set your child up for success. Nobody wants your child to feel they are ready to return to independent living or go to college only to discover that they are not yet equipped to care for themselves, so the more you can help them build the skills they need to be mentally healthy, the better. A mental health checklist to be used during and after eating disorder recovery can help.

How to measure mental health

Mental health sometimes feels arbitrary. But in fact, we can measure mental health based on the behaviors that lead to and indicate mental health. It’s just like eating disorders. Except for medically-underweight anorexia, eating disorders don’t often have measurable physical symptoms. Instead, they are diagnosed based on the behaviors observed. 

For example, eating disorders are measured by how often a person eats, how much they eat, and how they feel about eating. Similarly, mental health can be measured by how well a person takes care of themselves and how they feel about themselves.

In addition to your child’s recovery process, they should be learning to take care of their physical health, which includes at a minimum: 

• Getting adequate food and water
• Moving their body appropriately
• Getting enough sleep
• Basic hygiene

Beyond basic physical healthcare, your child should also take care of their emotional health, which includes at a minimum: 

• Connecting with others
• Managing social media use
• Practicing mindfulness
• Getting outdoors
• Asking for help
• Taking breaks
• Having self-compassion

Physical self-care after an eating disorder

Even if your child is cleared of an active eating disorder diagnosis, they are still at risk of mental illness. They will need to care for their bodies and minds intentionally for life. This is important for every person, but particularly for someone who has/had an eating disorder. Here are the basic physical care steps that your child should take to improve mental health. 

Getting adequate food and water

All bodies need enough food and water to function. And a lack of food and water has a significant impact on both mental and physical health. When someone has/had an eating disorder, it’s an indication that they may need to be more vigilant than others about caring for this most basic element of self-care. As your child transitions to living independently from you, they should demonstrate an ability to feed themselves adequate quantities of food every 3-4 hours and drink at least 6-8 glasses of water daily. 

Moving their body appropriately

Our bodies are made to move. Regular movement is essential to both physical and mental health. The tricky part is that many people who have eating disorders incorporate excessive exercise and/or are at risk of serious health complications if they exercise. However, as your child recovers from their eating disorder, they should work in regular movement to maintain health. This can be functional like having a walking commute to work or school, going for a short walk each day, doing a brief home exercise routine, or joining a gym or attending fitness classes. Your child should demonstrate an ability to move their body regularly, not too much and not too little.

Getting enough sleep

Getting enough sleep is a cornerstone of mental health. Your child needs 8-9 hours of sleep per night. People with eating disorders and other behavioral and mental health problems often experience sleep loss. Your child may have insomnia or struggle to settle down and get to sleep. While it’s easy to dismiss sleep as unimportant, it is as important as food, water, and movement to the human body and mental health. Sleep loss is no joke for anyone, but it is particularly risky for someone who has been diagnosed with a mental disorder like an eating disorder. Losing sleep is a major risk for someone with a history of mental disorders. Therefore, your child should demonstrate an ability to get adequate sleep each night and wake up at an appropriate hour in the morning. 

Basic hygiene

While basic hygiene may seem like a given, it can be a major struggle for someone with an eating disorder, anxiety, depression, or other mental disorder. On the one hand, if your child has OCD, they may lead towards overdoing hygiene. Some people will wash and clean themselves excessively. On the other hand, someone who is depressed or has ADHD may feel unable to clean themselves adequately. Either way, taking care of basic hygiene is essential to mental health. Like exercise, you’ll need to measure whether your child’s challenge is doing too much or too little and work from there. Set some basic expectations, like flossing and brushing teeth twice daily. Bathing can vary per person, but discuss the maximum number of days between showers and/or the maximum number of showers per day. Your child should demonstrate an ability to take care of their basic hygiene. 

Emotional self-care after an eating disorder

An eating disorder is a mental illness. This means that while physical symptoms and/or behaviors are used to diagnose an eating disorder, it is emotional and mental in nature. This means that your child needs to care for their emotional health. This is important for everyone, but particularly for someone who has/had an eating disorder. Here are the basic emotional self-care steps that your child should take to maintain their mental health. 

Connecting with others

Human connection is as important as food, water, sleep, and movement. It is a sign of mental health to reach out to other people. It doesn’t have to be lengthy or intense. Still, you should feel confident that your child has some human connection daily. It might be a phone call to a loved one, but it could also be as simple as going in person to get groceries or food and speaking to someone while getting it instead of ordering contactless delivery. 

Managing social media use

Social media can be a major impediment to mental health for numerous reasons. It is particularly dangerous for people who have/had eating disorders due to the algorithmic preference for very thin people who promote “healthy lifestyles” that include eating disorder behaviors and beliefs. While zero social media use might be ideal for mental health, it’s not realistic or necessary for most people. Your child should demonstrate that they can set limits on their usage. 

Practicing mindfulness

One of the symptoms of an eating disorder is a disconnection between the mind and the body. It’s as if the brain-body connection is severed. To recover and maintain mental health, your child needs to practice a mindful connection between the brain and body. Your child should have a daily mindfulness practice that actively connects the brain and body.

Getting outdoors

Studies have shown that being in nature, even for a few minutes daily, has numerous physical benefits, including less pain and lower diastolic blood pressure. It improves mood and reduces the risk of mental illness. Support your child in getting outdoors for at least a few minutes daily. They can combine this with either exercise or mindfulness, or both. They should take a few moments to feel the air in their lungs and look at the sky, a tree, or anything natural and not human-made.

Asking for help

There is a tendency when someone has a mental disorder like an eating disorder, anxiety, depression, etc., to self-isolate. They reach out less to people who care about them and say less about how they are feeling. You want to support your child in reaching out for help when they feel sad, scared, or angry. Nobody can take their feelings away, but sharing our feelings with other people is soothing and improves mental health. 

Taking breaks

The brain-body disconnection common in eating disorders often translates to ignoring signs of mental or physical fatigue. A mentally healthy person recognizes when they need a break and takes breaks to improve their health and performance. Help your child learn to take breaks when they are overwhelmed or having physical or mental symptoms of fatigue.

Having self-compassion

A mentally healthy person has compassion for themselves. They don’t beat themselves up when they make mistakes and don’t speak cruelly or dismissively to themselves. They know how to soothe themselves when things go wrong and treat themselves as they would a good friend. Help your child learn to speak to themself with self-compassion and love.

Giving your child a mental health checklist for eating disorder recovery

Discussing mental health with your child while they are still recovering from an eating disorder and preparing to leave your daily care will help them build mental health. You can create your own checklist or use the one I created. The checklist I created includes both daily actions and warning signs to keep in mind. You can provide this to your child and talk with them regularly about both elements: are they doing daily self-care, and are there any warning signs to address? This can help you communicate your concern for their mental health, even if your child isn’t living with you.

See Our Parent’s Guide To Mental Health And Eating Disorders

If you have a child who has an eating disorder, then you should expect to see fear and worry. This is because eating disorders often show up with, and in response to, anxiety. Eating disorder behaviors can be an attempt to cope with anxious feelings and thoughts. And luckily, parents have a significant impact on kids’ anxiety.

But unfortunately, our instinctual responses to our kids’ anxiety can accidentally make it worse over time!

In fact, there are treatment programs in which parents of anxious kids are the only ones who are treated. That’s right: while it’s ideal if your child is also getting treatment for anxiety, it’s not a requirement for them to start feeling (and acting) better. You can do a lot to change the course of their anxiety. Anxiety is highly responsive to relationships. You will either see it grow or decrease depending on how you respond. 

What does anxiety look like in an eating disorder?

Anxiety can be a bit tricky to see without some practice. Many people who develop eating disorders have learned to cloak their anxiety with anger, sadness, fighting, and withdrawal. Here are the top signals of anxiety, fear, and worry when there’s an eating disorder:

1. Worry about weight
2. Fear of food
3. Anger about rules, restriction, and efforts to control eating disorder behaviors
4. Sadness about perceived failure and disappointing their parents, friends, etc.
5. Fighting and negotiating about recovery steps and expectations
6. Withdrawal, shutdown, or a refusal to talk or engage in family activities

Anger, fighting, and sadness are the most distracting versions of anxiety. And parents typically respond to them with confusion and surprise. It seems like you’re asking your child to do something that makes perfect logical sense, so why are they so upset about it? 

The key is to know that they are upset about it because their anxiety has been triggered, and one of the ways anxiety maintains control is to put out distractions from the bigger issue, which is the fact that their anxiety response is over-reactive. 

The solution if your child has a lot of worry and fear, or if they are angry, sad, fighting you, or withdrawing when they have an eating disorder, is to learn how to respond to anxiety better. 

How to deal with fear and worry in eating disorder recovery

First, let’s set the table. I want you to start talking about worry, fear, and other scary feelings regularly. Have regular conversations with your child about what anxiety is, how it shows up, and how you’re going to respond to it now that you know this. 

The most important message I’m sharing today is that worry, fear, and other big feelings will show up, and that’s OK, but we’re not going to let them make important decisions about what we do and don’t do.

Demystify anxiety. It follows a predictable pattern. It’s rarely helpful to be surprised by it, try to ignore it or force it to go away. Instead, it’s best to talk about it, recognize it, and even welcome it into your life without letting it control your life.

Never threaten anxiety. Let it exist; just don’t let it run the show.

1. Expect anxiety to show up (it will!)

One of the most confusing things about having a child with an eating disorder is how resistant they can be to recovery. Even if they say they want to recover, it may seem to you as if they are not taking the action they need to recover. 

It’s important to think a bit differently. While it’s true that your child may not be taking the action they need to recover, it’s not because they don’t want to. It’s because anxiety keeps showing up and telling them it’s not safe to recover. 

Anxiety’s job is to warn us of danger and keep us from doing things that make us uncomfortable. 

But the only way to heal from an eating disorder is to feel things like fear and worry and do the thing you need to do anyway. 

The only way out is through!

So the first thing you need to do as a parent is to stop being surprised by anxiety. Start to expect it. Expect anxiety to show up every time you put food in front of your child, and lots of other times, too. 

A child who has an eating disorder typically has a hair-trigger response to even small threats. Their amygdala is highly-responsive right now. So you’re going to see anxiety a lot. Don’t be surprised; expect it.

2. Tell your child that it’s OK to feel afraid and worried sometimes (it makes sense!)

Most parents automatically respond to anxiety reactions like worry, fear, and anger by trying to shut it down or ignore it. This makes sense because your own anxiety senses danger and wants to keep you safe. I get it.

But instead, you need to face your own anxiety about your child’s anxiety head-on. Remember: the only way out is through!

When you try to debate, diminish, or ignore anxiety, it gets stronger, digging in deeper and justifying its existence as the savior.

Instead, when you see your child getting anxious, name it. Say something like “oh look, here’s some worry. It makes sense that you get worried sometimes. I get it.” 

You can replace the word “worry” with other words like sad, angry, frustrated, irritated, scared, etc. Try to find the word that makes your child feel seen, heard, and understood. This takes some practice, but you can do it!

This removes the need for the child to justify and defend their anxiety. When you remove the opportunity for debate, you take away an essential part of anxiety escalation. 

3. Remind your child that the path to feeling better is not to avoid fear but to face fear (and do it anyway!)

Once you have acknowledged that anxiety is present in the form of worry, fear, anger, etc., take some time to let your child feel that you believe them when they say they feel however they feel. 

When you sense that they “feel felt,” then you can move on to the next stage. It’s OK if you need to try this a few times. This takes practice and is almost never perfect. That’s OK!

Now you want to remind your child that feeling worried and nervous is perfectly normal, but that we can’t live our lives according to anxiety’s demands. 

Of course, this means that you should have those pre-conversations with your child about what anxiety is, how it shows up, and how you’re going to respond to it now that you know this. 

Your response to anxiety is: worry, fear, and other big feelings will show up, and that’s OK, but we’re not going to let them make important decisions about what we do and don’t do.

4. Believe that your child can learn to tolerate their fear (they can!).

One of the biggest impediments to kids learning to tolerate anxiety is that parents worry it is not possible. Here again, we recognize that your worry as a parent can impact your child’s relationship with worry. 

So come up with a mantra for facing your fears and doing it anyway. The only proven way to reduce anxiety is to train the amygdala and your thoughts to face anxiety and build up the muscles of tolerance and acceptance.

Remember that trying to avoid anxiety will make it get stronger, but facing it and doing the scary thing anyway will build the muscles that are needed to respond to anxiety appropriately. With practice, your child will do this by themself over time. But it’s very hard to do this without help and support at home.

How this looks at the dinner table

Here’s a quick scenario about how worry and fear can show up at the dinner table with an eating disorder. 

Take 1: letting anxiety run the show

• Child: I can’t eat. I’m full. You can’t make me!
• Parent: You have to eat! It’s important! You promised! 
• Child: I already ate enough. You know I can’t handle more. I’ll throw up! 
• Parent: You have to eat this food. It’s good for you. Just eat it so we can get on with life, will you?
• Child: You gave me too much! I can tell you added butter and oil – look! It’s just sitting on top. Gross!
• Parent: No I didn’t! It’s the same thing I make every time. I didn’t change anything!

In this scenario, the parent is accidentally engaging in a debate with anxiety. This gives the anxiety a sense of power and control. And it usually makes the situation worse, not better.

Take 2: standing up to anxiety

• Child: I can’t eat. I’m full. You can’t make me!
• Parent: Yeah, you often feel this way at dinner. I get it. 
• Child: No you don’t! You don’t understand anything!
• Parent: It seems like you’re really upset.
• Child: Yes I am! I hate this!
• Parent: I get it. I really do. But remember that we talked about this, and we’re not letting worry run the show anymore. Let’s put worry aside for dinner tonight and we’ll talk to it some more after we eat if we need to.
• Child: You’re just trying to control me!
• Parent: Yeah, I know that’s what your worry says, and I understand that’s how it feels. Like I said, let’s get through dinner and then see what worry has to say to us later. 
• Child: that’s stupid (they take a bite).

In this scenario, the parent is not fighting with or trying to make the anxiety go away. They’re acknowledging and validating the existence of anxiety and asking the child to do the hard thing even though they feel anxious.

Practice, not perfect

This is a practice, and it takes time for parents to learn a different way of responding to anxiety. If this sounds impossible right now, I get it. But trust the process. It works.

Anxiety is one of the most common mental disorders, and we have thousands and thousands of research papers examining what it is and how it works. There is a lot of data to support this treatment approach to a child with anxiety. 

One of the things we know is that for most parents, their instinctual response to anxiety will accidentally increase a child’s anxiety over time rather than decrease it. But at the same time, when parents learn and practice new skills for responding to anxiety, they will see a decrease in anxious outbursts and behaviors. 

Anxiety is the most treatable psychological disorder, and since it underlies and drives so many other disorders, including eating disorders. Emotions during eating disorder recovery are hard to handle, so it makes sense to learn some new skills for responding to anxiety differently. 

See Our Parent’s Guide To Mental Health And Eating Disorders

Many parents find themselves at the crossroads of an eating disorder and a drinking problem. The disorders are linked and often seen together. So how can a parent help?

1. Understand why your child has an eating disorder and a drinking problem
2. Learn the steps to recovery
3. Support your child’s recovery

Many people who have eating disorders also have a problem with alcohol use disorders. It helps to understand the correlation between alcohol and eating disorders. This requires looking closely at the true reason for disordered behavior.

1. Understand why your child has an eating disorder and a drinking problem

Let’s start by understanding why your child has an eating disorder and a drinking problem.

Eating disorders typically involve an obsession and compulsion with eating and exercise behaviors. Similarly, alcohol and drinking also involve obsession and compulsion.

Both of these conditions can be seen as ways to regulate emotions. The unconscious drive may be to protect against uncomfortable feelings and emotions. Both eating disorders and drinking can be a way to avoid feelings of anger, loneliness, anxiety, and depression. They can be a way to feel less unhappy, lonely, or stressed.

Eating disorders and alcohol use can create a vicious cycle. The person avoids uncomfortable feelings and doesn’t develop healthy coping mechanisms. Instead of learning to process stress and discomfort, people who have eating disorders and drinking problems rely on coping behaviors.

People who have eating disorders and problems with alcohol have common personality traits. These include sensitive dispositions, anxiety and perfectionism. These traits are often considered the foundation on which eating disorders and alcoholism are founded.

People who have eating disorders and alcohol problems tend to use more even when they can see that it’s working against them. They may feel tremendous remorse and regret and promise to stop drinking forever, only to begin again later that same day. The notable exception to this is anorexia, which is “egosystonic” or fits the person’s view of themselves. While most other eating disorders and problem drinking are “egodystonic” and lead to feelings of shame, anorexia feels in-keeping with the person’s identity.

For example, someone who has bulimia may wake up feeling disgusted by their binge and purge episode the night before. They feel ashamed of their need for this devastating behavior and promise to stop. They start out being “good” by restricting food the next day. But they will likely return to binging and purging at night.

Regardless, both the person with the eating disorder and the person with alcohol addiction feels compelled to continue doing it.

Just like with eating disorders, trauma is highly linked to substance use disorders. In fact up to 70% of adolescents who are being treated for substance use disorders have a history of trauma. Teenagers who are exposed to physical or sexual abuse are even more likely (3x) to struggle with substances. And more than half of teens who have been diagnosed with Post Traumatic Stress Disorder (PTSD) develop substance use problems.

With all of this information, it’s important for parents to understand why these disorders arise. We often focus on the psychology of eating disorders and alcohol use without thinking about the underlying causes. However, when we pay attention to the causes of eating disorders and alcohol dependency, we can treat them with greater results.

2. Learn the steps to recovery

Now that you understand why your child has an eating disorder and a drinking problem, it’s time to look at recovery.

It makes sense to want to stop the behavior right away. But it’s important not to lose sight of how difficult this will be without learning new skills. And new skills require practice and reinforcement. Therefore, we like to look at recovery as having three parts:

1. Stopping the behavior: in this part, your child learns to live without their eating disorder behaviors and drinking. This may happen in an inpatient treatment center or at home. Many treatment approaches tackle this first. This is especially important if weight suppression is an issue. It will be hard to recover from an eating disorder when weight suppressed as it has physical and mental complications.
2. Learning emotional regulation: people who have eating disorders and drinking problems have trouble with emotional regulation. Emotional dysregulation is normal and natural. It’s a physiological response to stressors. Your child was using an eating disorder and drinking to regulate their emotions. So now they need to learn new skills.
3. Practice and reinforcement: traditional treatment usually ends before a person is fully recovered. Recovery can be practiced and reinforced at home. But many times a person returns to an unchanged environment. In these cases we know they are likely to pick up their old patterns and behaviors.

As you can see, the third stage of recovery is critical for ongoing success. And it’s primarily something that’s done at home with parents. This gets us to the next part …

3. Support your child’s recovery

You can support your child’s recovery at home by making some changes. Your main role is in the practice and reinforcement part of recovery. For instance, here’s what this might look like for someone who has an eating disorder and a drinking problem:

• Parents learn emotional co-regulation to help their child calm down when dysregulated
• Alcohol is removed from the home and nobody in the house drinks around the child
• Dieting is not allowed in the home. And nobody in the house talks about weight or labels food as good or bad
• The family regularly talks about and learns about the dangers of drinking and dieting. They take action to reduce harm in their community
• Parents address issues in the family dynamics that may contribute to stress. For example, treating siblings appropriately, maintaining healthy family leadership, the parental role, etc.
• The family focuses on building connection and belonging. In other words, they spend time talking and spending time together

Each family will do this a little bit differently. There is no one-size-fits all solution for eating disorders and alcoholism. But one thing is clear: parents should get help and support. Parents can can learn and grow and support their kids through recovery. If you’re facing this, consider getting a therapist or coach who can guide you.

See Our Parent’s Guide To Mental Health And Eating Disorders

References

Alcohol Use Disorder Comorbidity in Eating Disorders: A Multicenter Study

How do eating disorders and alcohol use disorder influence each other?

Eating Disorders and Addictions Cause a Deadly Combination

Alcohol and Trauma: Drinking as a Way to Cope with the Past

Dual Diagnosis – Addiction and Eating Disorders

National Institute on Alcohol Abuse and Alcoholism

What can you do if you love a perfectionist who has an eating disorder? Luckily, there’s a lot you can do! First, let’s take a look at some facts:

1. Perfectionism is both a risk factor for and commonly co-occurs with eating disorders. Many people who have an eating disorder also have perfectionism. And perfectionism is damaging to almost every aspect of mental health.
2. Perfectionism is preventable and treatable, especially in children and teens. Luckily, perfectionism, which is often a response to anxiety, is both preventable and treatable. Recovering from perfectionism is often a significant part of eating disorder recovery.
3. Parents can have a significant impact on reducing and treating perfectionism. Almost nobody is as important to reversing the effects of perfectionism as parents. Perfectionism is not hard-wired; it’s a response to environmental factors in the family. This means parents and the family can help reverse it.

When a person is both a perfectionist and has an eating disorder they are attempting to find safety through their eating disorder behaviors. Whether it’s making sure their hair and homework are just right (perfectionism) or limiting their food to only “healthy” choices (eating disorder), both impact quality of life and mental health.

Here are five ways that parents can help a perfectionist who has an eating disorder recover from both conditions. These efforts need to be done consistently and intentionally every day to help a child reduce performance anxiety and find peace.

1. Show your child that it’s safe to make mistakes

Many parents tell their kids they can make mistakes, but then when kids do make mistakes, parental behavior suggests that mistakes are unacceptable. Pay attention to how you feel and behave when your child makes a mistake. Loosen your body and face, and feel from within that your child is lovable and fabulous with their mistakes.

What this looks like: When a child comes home with a lower score than you would expect on a test, respond neutrally. Keep your face relaxed, and thank them for sharing their score with you. If they want to talk about it, keep your comments focused on reassuring them that everyone misses their goals sometimes. And one score doesn’t make a grade.

With an eating disorder: When a child complains that they didn’t “eat healthy” or don’t like their body, respond neutrally. Don’t try to convince them that they ate perfectly or look amazing. Instead, let them know that what they eat changes day to day, and food does not have the power to make or break their health. And remind them that looking perfect is an arbitrary, impossible goal, and there is no such thing in real life.

2. Hold off on fixing

Most parents jump in too quickly with advice and solutions. This perpetuates the belief that mistakes are intolerable. Part of how we show kids that mistakes are OK is by being supportive without trying to fix the problem. We can agree that making mistakes is hard, tell them we understand that it feels bad, and show them that we can handle any mistake without changing how we feel about them.

What it looks like: In the case of the lower score, you will be tempted to ask them about their studying techniques or how they can bring their grade up. Resist this temptation! A perfectionist does not need anyone to tell them how to fix mistakes. They need people who can accept their mistakes and trust that whatever happens next is all right. You generally don’t have to worry about a perfectionistic child under-performing unless they are suffering from performance anxiety induced by perfectionism.

With an eating disorder: Avoid trying to help them prepare the perfect meal or find the perfect outfit. Don’t get into long discussions about how they can achieve their goal weight. Let them find their own solutions to their problems rather than diving in to try and fix them.

3. Make mistakes & talk about them

Many parents try to hide their own mistakes or at least not talk about them. Normalize mistake-making by intentionally talking about how it feels when you make a mistake. Look for opportunities to talk about your mistakes on purpose. Make mistakes on purpose and talk about them. This may be challenging for you if you also have perfectionism. But most of us can achieve great things on behalf of our kids’ health.

What it looks like: Open the fridge and see that you forgot something. Say “Oops! I forgot milk again. Oh well, that’s OK, we can handle it.” Don’t say this to your child directly – it’s not an apology. Saying it out loud means they can hear how to handle mistakes with self-compassion.

With an eating disorder: If you make a mistake like commenting on someone’s body (including theirs or your own), just apologize and move on. You don’t have to make a big deal about it or over-apologize. Everyone makes mistakes, and every time you make a mistake is an opportunity to show your child that it’s OK.

4. Talk about other people’s mistakes with compassion

Many parents berate strangers, food servers, retail workers, drivers on the road, and others when they make mistakes. This is modeling to your child that mistakes are something to feel ashamed of.

What it looks like: Instead of criticizing others when they make a mistake, take a deep breath. If it’s your husband who forgot the milk, open the fridge door and say “Oops! Dan forgot milk again. Oh well, that’s OK, we can handle it.” Show your child that you accept other people’s mistakes readily and without criticism.

With an eating disorder: If someone talks about dieting or weight loss, you can recognize that it’s problematic but also normalized in our culture. You don’t need to get overly angry when people do this, though you should talk about it directly with your child. Let them know that you don’t blame the person for their comment, but you also don’t endorse weight loss in any way.

5. Talk about perfectionism

Talk about perfectionism with compassion and kindness. You don’t want to turn “being a perfectionist” into something your child feels ashamed of. Instead, you can treat perfectionism as a part of your child (not the whole). No child is all one thing. We want to be very careful about pathologizing our child and treating them as if they are a victim of their impulses or coping behaviors.

What it looks like: When your child is upset because they made a mistake you can say things like “oh, I see your perfectionism is feeling bad about this. Let’s talk about it.” Then let your child process and untangle their perfectionist part from the part of them that accepts mistakes and feels safe with you.

With an eating disorder: When your child is upset about their eating or body, say things like “oh, I understand what it’s like to have a perfectionist’s voice. I know how hard it is, so let’s talk about it.” Then talk about the part of themselves who criticizes their choices and body.

You are the difference-maker

If your child is both a perfectionist and has an eating disorder, follow these five steps to help them recover. Your child’s therapist cannot do this alone in a one-hour meeting. It’s really best if you can reinforce acceptance at home in every possible moment. This is an important part of treating the psychology of an eating disorder.

Perfectionism is a social response, so it’s best treated in social situations. Nobody is better situated to counteract perfectionism than a parent who has consciously and intentionally decided to help their child avoid the tendency toward and consequences of perfectionism. When parents take this on and learn new skills, kids feel better.

See Our Parent’s Guide To Mental Health And Eating Disorders

If your child in in recovery for an eating disorder, it’s very possible that they feel sad. And maybe this is making you sad, too. Most parents feel overwhelmed handling the eating disorder behavior, and don’t know what to do when sadness shows up.

As parents, we want to protect our children from uncomfortable feelings, especially sadness and despair. Most of us came into parenting during the time of a glut of Happiness books, speeches, and articles. Scientists explored exactly how we can increase our happiness with daily tasks, based on the assumption that being happier is always better.

Most of us, when asked, will say that what we want most of all is for our kids to be happy.

We may embrace sayings like “good vibes only” and strive every day to turn lemons into lemonade. When our children feel sad, we jump through hoops to try and remedy it as soon as possible – to return to happy.

The tyranny of happy

It sounds really nice to pursue happiness, but the fact is that many of us who pursue a happier life find ourselves actually feeling emptier and sadder. Why?

Because it turns out that sadness is a part of natural emotional hygiene. To expect ourselves – and our children – to live in a state of perpetual happiness is to deny the natural fluctuation of emotions.

Feeling sadness and any negative emotion is not only normal, it’s actually healthier than trying to force ourselves to remain in a constant state of bliss.

When we have a child who has an eating disorder, it’s hard not to think that we need to help our child find a higher state of happiness in life. We may think that recovery from their eating disorder will mean a return to happiness.

Certainly, if our child is depressed, we should seek treatment for that condition. But the opposite of depression is not eternal happiness. The opposite of depression is the ability to feel a full range of emotions, including sadness.

Recovery from an eating disorder does not mean happiness all the time or never feeling sad. It means we recognize and metabolize the full range of emotions including, but not limited to happiness. This means we need to feel free to experience anger, sadness, loneliness, jealousy, and the thousands of other emotions that make us human.

Parents who are afraid of the full range of human emotions are likely to get uncomfortable with this. They may accidentally try to interfere with natural emotional ranges by pursuing happiness rather than allowing sadness and other negative emotions.

But parents need to accept all mood states, not just the positive ones.

Acknowledge feelings

The first step in learning emotional hygiene – the natural metabolism of emotions throughout each and every day – is to acknowledge that our emotions run a wide range. We have to acknowledge that we are not meant to remain in a steady emotional state.

In fact, that is a clear sign of depression: the lack of emotional fluctuation. Take some time in your family to acknowledge that feelings come and go every single day. We all have a broad range of positive, negative and neutral feelings, and that is absolutely healthy.

Name feelings

Building emotional literacy, or the ability to put a name on your emotions, helps to build emotional resilience and reduce shame around negative emotional states. When we talk about our feelings, we allow them to exist without worrying that they will last forever. Talking about emotions is a daily practice that we can all work on in our families.

Some of us find it helpful to print out lists of emotions to help us name them. It’s too easy to call every negative feeling afraid, angry or sad. And that’s certainly a good place to start, but there are so many nuances to those feelings. We can add words like despair, fear, horror, and shame to help us better define our feelings. This will allow them out into the light where they can breathe and move on.

Don’t forget that sometimes we need to combine feelings to get an accurate picture. For example, before a big event, a child may say they feel scared. But upon deeper reflection, they are a combination of nervous and excited. You can even put these words together to form new feelings, like “nercited.”

Welcome feelings

Even if we are able to name our feelings and have a broad emotional vocabulary, we still have to work hard to welcome the negative feelings into our lives.

Almost all of us were taught to reject, deny and ignore negative emotions. A good reason for this is that negative feelings make parents very uncomfortable.

As little children, our parents, in wanting what was best for us, probably tried to get us to stop crying. A better approach would have been to welcome our tears and reassure us that they were perfectly natural and healthy. These lessons learned every day for many years, taught us to hide negative mood states.

We can learn to welcome the full gamut of our family’s feelings. Every member of our family is going to undergo mood states throughout the day. And a good portion of those feelings are going to be in the negative category.

Rather than not allowing negative feelings or trying to pretend that everything is just fine, practice instead welcoming these feelings.

Talk about the fact that life is challenging.

Sometimes it sucks.

But it will suck much, much more if feelings are repressed. In fact, repressed feelings are integral to almost all addictive and maladaptive behaviors, including eating disorders. Sadness is a common psychological symptom of eating disorders. Emotions run high in eating disorder recovery, so most people will be sad at times. But this doesn’t mean recovery is a failure. It means that recovery opens up a person to the full range of human emotion. And this is a sign of mental health.

See Our Parent’s Guide To Mental Health And Eating Disorders

Terri is worried. Her 14-year-old daughter Natalia had been struggling with an eating disorder for over a year. Terri feels like a helpless bystander and the whole family is suffering.

“Natalia was always so diligent, kind, and helpful,” says Terri. “I never thought she would be the one to struggle with anything. It seemed to me like she was doing so well. But now everything has been turned upside down.”

In addition to the terrifying eating disorder behaviors, Terri has also noticed that Natalia is dressing very differently and has developed a passion for tattoos and body piercing. “It’s all she can talk about,” says Terri. “She spends so much time looking at tattoos and piercings on TikTok. It’s become this new wild passion. She’s wearing dark, torn clothing and wants a green mohawk! She just looks nothing like the girl we knew before.”

I can understand Terri’s concerns, and I also sense that perhaps something related to identity and bodily autonomy is going on. In fact, eating disorders can be seen as a pursuit of bodily autonomy, so this is not unusual. But we need to understand why Natalia is seeking to assert her bodily autonomy. This will help us know how to help her feel better.

Eating disorders and bodily autonomy

It’s not uncommon for eating disorders to overlap with a pursuit of bodily autonomy. Seeking to change your body and control what it does and how it looks makes perfect sense, especially during adolescence. It’s a natural part of human development to test boundaries and try on different identities. But when trying things out involves a drastic change in appearance, using eating disorder behaviors, or otherwise interferes with life, we obviously want to understand more.

It’s not uncommon for people who have an eating disorder to also alter their bodies in other ways. More conventional people may spend time styling their hair, perfecting their makeup and nails, and finding the ideal outfit to fit in with their peers. On the other hand, less conventional teens may become interested in alternative clothing, hairstyles, piercings, and more. Of course, these teens are also “fitting in” with an image, just in a different way from the more conventional teen.

What we want to consider is whether their attention to appearance is normal teenage behavior. Or is it a deeper attempt to assert bodily autonomy?

Bodily autonomy is having ownership over your own body.

Bodily autonomy is an important part of developing into an independent and mentally-healthy person. It can be impacted by situations in which a person doesn’t feel they are in control of their own body. As a result, some people don’t feel they “own” or are in charge of their own bodies. They may seek to claim ownership through appearance and eating disorders.

Some reasons for low bodily autonomy include:

• Sexual trauma
• Physical abuse
• Medical trauma (even though they are life-saving interventions)
• Bullying
• Accidents such as nearly drowning, car accidents, bike accidents, etc.

Beyond these personal incidents, bodily autonomy can also be impacted by broader social conditions such as:

• Laws that prevent people from making decisions about their own body (e.g. anti-abortion laws, anti-gay-marriage laws, anti-trans laws, etc.)
• Institutions like patriarchy and white supremacy that devalue groups of people based on their race, gender, sexual orientation, etc.
• Beliefs like homophobia and transphobia that demonize people for who they love or which gender fits.
• If your child is non-white, female, and/or LGBTQ+, these social conditions reduce their bodily autonomy.

How parents impact a child’s bodily autonomy

Parents may accidentally make children feel they are not in charge of their own bodies. Often this makes perfect sense. For example, when kids are young, parents need to take steps to ensure their child’s safety. But in a highly sensitive child and/or in special cases, these interventions can create a sense of disconnection for the child. These kids need a little extra help to claim ownership of their bodies in a healthy, adaptive way.

There are three main ways that parents can accidentally impact bodily autonomy:

1. Life-saving interventions

Sometimes threats to bodily autonomy are medically necessary. For example, some parents must approve medical surgeries and interventions for their children. It may be a feeding tube for an eating disorder or surgery for a congenital defect. Regardless of why they are necessary, these medical interventions take away the child’s power to control their own bodies.

They are literally life-saving. And they still amount to a loss of bodily autonomy and thus can create trauma for the child. Trauma studies show that traumatic events impact different people in different ways. This is based on a combination of biology and how the trauma is dealt with or processed.

There are some people who are biologically more sensitive to bodily threats and trauma. But even for people who are not extra-sensitive, trauma tends to settle in if it’s not processed. Processing trauma with a professional can go a long way to preventing long-term post-traumatic traumatic stress.

2. Safety

There is a tricky boundary between keeping kids physically safe and allowing them to explore the world. This is an ongoing debate between parenting experts. Think of the difference between the bestselling books Free-Range Kids and Battle Hymn of the Tiger Mother. These promote completely opposite approaches to raising kids.

Free-Range Kids by Lenore Skenazy promotes complete bodily autonomy by allowing children to explore the world freely. Battle Hymn of the Tiger Mother by Amy Chua promotes very low bodily autonomy and high parent monitoring. It even includes rules like no sleepovers.

As with most divisive parenting approaches, something in between is probably a good approach for most kids. They need certain boundaries but should have enough bodily autonomy to feel as if they are in charge of themselves. This is especially important as they grow older. Figuring out these boundaries is an imperfect pursuit – we all do our best.

3. Lack of Awareness

There is a third, surprising way that parents can accidentally impact kids’ bodily autonomy, and it’s lack of awareness and understanding of the conditions that can reduce autonomy. For example, if parents are not informed and talking about racism, sexism, misogyny, homophobia and transphobia, then their child will grow up without the benefit of knowing that these issues are not their fault or a personal failure. They are a failure of our society. On the other hand, if parents talk about and educate their children about racism, sexism, misogyny, homophobia and transphobia, their children are more likely to develop bodily autonomy despite the social conditions. Similarly, traumatic experiences can be overcome if parents are educated about the impact of trauma on the sense of bodily autonomy and actively counteract it.

When eating disorders serve a purpose

There are many ways to look at an eating disorder. And no single view is going to address the full complexity of eating disorders. But one way to see an eating disorder is a way for a child to assert bodily autonomy and independence. As in: “You can’t tell me what to eat! Stop watching me! I’ll do it myself! I know best!”

When I talked about this with Terri, she felt an intuitive sense that we were onto something. “Natalia had a congenital heart defect that we had to have corrected when she was just two years old,” says Terri. “I can definitely see that the stress of having my baby get an operation influenced how I parented her. It caused me to be very anxious about her safety. I think most of it was unconscious. But as I look back, I know that I gave her brother a lot more freedom than I gave her.”

Terri was responding in a natural and intuitive way to the threat of medical complications. It makes perfect sense that, without realizing it, she was more nervous and cautious about Natalia.

When looking through this lens, we could consider how Natalia’s eating disorder behaviors and attention to her appearance were signaling that Natalia was craving her own independent identity. Also, we know that trauma often underlies eating disorders. We could hypothesize that the necessary surgery was likely a traumatic event for her. Trauma can be an issue even if she doesn’t consciously remember the details.

Eating disorder treatment often denies bodily autonomy

Terri also considered the impact of Natalia’s eating disorder treatment so far. “We took her to the emergency room against her will. And that began a series of medical and therapeutic interventions that were necessary but probably traumatic for her,” says Terri. “I’m so confused because we did what we had to do to keep her alive. But now it seems like maybe that made things worse?”

I assured Terri that many parents face this challenge. And she hadn’t done anything wrong. We have a responsibility to intervene to keep our kids as safe as possible. At the same time, while the interventions were medically necessary, they likely created additional trauma for Natalia. Both of these things can be true at the same time.

The solution is not to regret choices already made – they were necessary! Instead, focus on future action to address the trauma. Now that she’s out of medical danger, Terri can get help for Nadia’s trauma and help build her sense of bodily autonomy.

What parents can do to help

Parents can help their kids recover from an eating disorder by understanding the role of bodily autonomy in emotional health. Our ability to feel independent, strong, and in control of our circumstances is important. Parents who empower their children to claim their bodily autonomy will see positive results.

First, ask these questions:

1. Is my child showing signs of a need for greater bodily autonomy? (e.g. eating disorder, unusual hair and clothes, body modification such as tattoos and piercings, etc.)
2. Did my child experience trauma? Was there any situation in which they were physically out of control of their own body?
3. Have I been anxious as a parent and even over-parented in some ways?
4. Have I given my child ways to assert control over their own life and body?

If any of the above is true, then it makes sense to consider the role bodily autonomy is playing in your child’s recovery.

With these questions, Terri could connect some dots. She saw how situations that were out of her control had resulted in a lack of bodily autonomy for Natalia. This was a major breakthrough for her. We often feel helpless to help our kids until we understand what might have contributed to their troubles. Once we identify why things could be happening, we are better able to help.

Improving bodily autonomy when there’s an eating disorder

Here are some things that parents can do to increase their child’s sense of bodily autonomy:

1. Work on your own fears and worries. Get some help in building your anxiety tolerance so you avoid passing it along to your child.
2. If trauma is a factor in your child’s history, seek treatment for the trauma. Talk therapy may not be as effective as somatic (body) therapies for trauma, since trauma is held in the body.
3. Become educated about and talk to your child about racism, sexism, misogyny, homophobia, transphobia and other harmful and exclusionary systems so they are empowered to claim their right to exist as they are.
4. Seek ways to increase your child’s bodily autonomy. What choices can you allow them to make for themselves? In what ways can they be responsible for their own life choices?
5. Look for ways to gain consent and agreement before imposing rules, systems, and structures on your child.
6. Encourage your child to express themselves through their body without a sense of shame or rebellion. The more we allow healthy self-expression, the less likely it is to become a problem.
7. Let go of bothersome but not permanent and/or dangerous forms of expression. For example, allow strange clothing, nail polish, and hairstyles – they are temporary and harmless. On the other hand, it’s OK to hold boundaries on things like tattoos and piercings while your child is under 18 if that’s something you feel strongly about.
8. Consider how your child’s eating disorder treatment may contribute to a lack of bodily autonomy. Seek treatment providers who maximize personal responsibility and agency rather than those who seek to control your child’s behaviors.
9. Look for ways to improve your empathy, unconditional positive regard, and attunement to your child’s emotional needs. Seek support and guidance from a counselor, therapist, or coach to learn these skills.

Moving forward

If your child is in immediate medical danger, you may need to take control of their physical health. But you can still improve your child’s bodily autonomy through the process. Many parents have to make choices that impact their kids’ bodily autonomy. It’s OK! Just help your child process the trauma with the help of a trained trauma therapist.

Terri found a wonderful EMDR therapist for Natalia who worked with her medical trauma. Meanwhile, Terri worked on expanding Natalia’s sense of agency and control over her life. While she couldn’t release all oversight of Natalia’s health due to the eating disorder, we found lots of small ways to increase Natalia’s sense of freedom and choice in other areas of her life.

Recognizing the link between bodily autonomy and the psychology of eating disorders made a big difference. Within a few months, Terri felt closer and more connected to Natalia, and things were looking a whole lot better for the whole family!

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For privacy, names and identifying details have been changed in this article.

See Our Parent’s Guide To Mental Health And Eating Disorders

by Beth Mayer, LICSW

There is a high correlation between eating disorders and low self-worth. Because of this, when I’m working with clients who have eating disorders, I’m watching carefully for self-worth, self-compassion, and perfectionism. The more my clients build the first three and limit perfectionism, the greater their chance of entering recovery from their eating disorders. 

What is self-worth?

When you have self-worth, you believe that you are inherently valuable regardless of what you do or how you look. People who have low self-worth tend to look outside of themselves to feel worthy. This is really common among people who have eating disorders, and many of them are using their bodies as a way to pursue worthiness.

Unfortunately, low self-worth is pretty rampant. And what may be surprising is that often the people who look like they have high self-worth are actually suffering the most. These are the great students, powerful athletes, and leaders who get tons of accolades, yet many of them feel bad about themselves.

I worked with someone who was the top of her class, named the class president, and looked as if she should have been on top of the world. But she was depressed and had an eating disorder. The world just couldn’t see what she was feeling about herself.

These are tough cases, because we have to find a way to meet the person where they are while gradually supporting them in seeing their inherent self-worth, which must exist regardless of grades, awards, weight, or any other external measurement.

How parents can help kids develop higher self-worth

Lots of parents want to help their kids by jumping in with positive messages. But unfortunately this can exacerbate the problem, especially if they are focused on external measures of success.

For example, saying things like “you’re beautiful,” “you’re perfect,” “you’re a huge success,” can really backfire. This is because the person may come to believe that their parents’ love is dependent upon being those things.

What we need is for our kids to know that they are worthy for who they are, not what they look like or what they do to meet conventional standards of success.

This can be really hard for parents, but there’s a side door that can help. Start by recognizing them for their kindness rather than their appearance or accomplishments. For example, notice that they showed up for a friend when it was difficult, or they smiled at a child, or they gave a lovely hug.

The job of parents who want to increase their kids’ self-worth is to not try to convince a child that they are meeting conventional standards of success. Because that will just keep them on a hamster wheel forever, desperate to keep succeeding. Instead, parents should take tiny snippets of everyday kindnesses and work to feel good about them.

Self-worth and social media

People have always had low self-worth – it’s not a new thing. But something I’m seeing in my practice is that it’s easier than ever to fake happiness and self-worth. Social media makes it easy to seek social approval and look like you are successful. This can make it easy for people who are suffering to look like they’re living a great life.

On social media you can fake a vacation, fake happiness, and fake success. This makes it really easy to fake self-worth even when you feel completely empty.

At the same time, kids can see everyone else who looks like they’re living an even better life. The constant access to curated views of other people’s lives right at our fingertips means it’s hard to turn the volume down on the feeling that we’re not doing enough or good enough. 

Self-compassion and recovery

Possibly the best antidote to the low self-worth is self-compassion. The work that Kristin Neff has done to bring awareness to self-compassion is amazing.

Self-compassion means that even when the entire world seems to be screaming that we are not enough, we can reach inside and treat ourselves as we would a good friend.

I love this quote from Elisabeth Kübler-Ross:

People are like stained-glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.

Elisabeth Kübler-Ross

Lots of the people I work with are looking for the light to come from outside of themselves, when the light they need is already inside of them. Building self-worth and self-compassion are the keys to help them light up and see their value without the external measures.

Our society keeps telling people that they are not enough. This is leading to massive increases in all sorts of problems, including depression, anxiety, suicidality, and eating disorders. All of my colleagues who are eating disorder specialists are seeing an influx of patients – and at younger ages – than ever before. We are definitely struggling as a society, and I think that if we can address self-worth, we will make some progress.

Perfectionism is the enemy of self-worth

Perfectionistic tendencies are highly correlated with both eating disorders and low self-worth. Perfectionism is a personality trait in which a person strives to be flawless. They set very high performance standards for themselves. Unfortunately, they also are highly self-critical and are overly concerned with others’ evaluations of their performance.

It’s easy to see how this relates to eating disorders. It may be hard or out of reach for a person to achieve perfection in many areas, but most people believe that if they just work hard enough and control their behavior enough, they can have a “perfect” body.

So many people who have eating disorders feel they aren’t smart enough or good enough, but they can have a good enough body. They mistakenly believe that if they look good, they are good. That becomes their focus, and everything else becomes non-essential. They aren’t able to celebrate who they really are.

Of course, there is no such thing as a “perfect” body, and in my practice I see the damage done by the pursuit of bodily perfection every day.

One of the things I see a lot is that when people are feeling out of control, one of the things that they perceive that they can control is their body. They feel like if they can fix their bodies they can fix their lives. Our society has promoted the idea that bodies can and should be changed. But the truth is that nobody is going to like you any more or less with a different type of body.

Parents against perfectionism

One way that parents can help their kids avoid the trap of perfectionism is to let their kids have issues. Don’t protect them from everything, because that suggests to them (subconsciously) that they need to get things right to be safe and valued.

Parents should give their kids responsibilities, and not always protect and advocate for them. This builds up resilience. The fact is that nothing and nobody is perfect. Unless we model to our kids that it’s natural and safe to make mistakes – even to fail – they may lean towards perfectionism.

What I wish parents knew

If there were one thing I could pass along to parents, it would be to pay attention to how willing you are to get messy. We have become a very driven society that avoids mess. We want everything to be clean and straightforward, but that takes away our creativity and our very humanity. 

We’re teaching our kids to avoid getting messy, which keeps them in a tight box of right and wrong, good and bad, perfect and not-perfect. The world just isn’t organized that way, and it really limits our resilience when we believe it is. 

It helps when parents understand the psychology of eating disorders is important. I would love to see parents get comfortable with, model, and encourage their kids to embrace the messiness of our lives. To embrace the fact that we don’t need to be perfect to be loved. In fact, most people love us most when we are most authentic and least perfectionistic. 

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Beth Mayer, LICSW, has been working in the eating disorders field for 35 years. She is nationally recognized for her clinical work with eating disorders and has spoken at conferences around the country. In addition to eating disorders, Beth specializes in treating adolescents and families. Beth has served as an adjunct professor at Simmons College, Boston University, Boston College, Lesley University and Salem State College, supervising MSW and LMHC graduate student interns. She is currently the co-chair of the NEDA network and serves on many local and national committees. Beth holds a B.S. in Clinical Psychology from Quinnipiac University and a Master of Social Work Degree from Boston College. She can be reached at  bethmayerlicsw@gmail.com / 617-325-1013

See Our Parent’s Guide To Mental Health And Eating Disorders

There is a strong link between being depressed, having an eating disorder, and being female in a western industrialized country. Here are some facts about these conditions:

1. Females are twice as likely as males to be depressed, and the vast majority of eating disorder patients are female.

2. The depression sex difference emerges at puberty, and eating disorders emerge at puberty.

3. The depression sex difference is only found in western countries, and eating disorders are present in western countries and far less common/virtually absent in non-western countries.

4. There is more depression today, and there are more eating disorders today.

5. The average age of onset for depression is younger now than in the past, and the average age of onset for eating disorders is younger now than in the past.

Because of these correlations, it has been proposed that there is a relationship between the thin ideal that permeates western cultures, eating disorders and depression. Some studies report that episodes of depression precede the onset of the eating disorder and even that eating disorder behaviors are an attempt to combat depression.

In such a case, a person who is depressed subconsciously attempts to modify their mood state by utilizing eating disorder behaviors such as restriction, binge eating, purging, and over-exercising. By engaging in these behaviors, a person may feel a sense of taking corrective action to improve their life circumstances.

The thin ideal

The cultural ideal of hard-to-achieve thinness (the “thin ideal”) for women could be a driver of both depression and eating disorders. There are two ways this can happen.

First, if a girl perceives her body as not meeting the thin ideal, body dissatisfaction can arise. Since a very small proportion(~5%) of female bodies can meet the thin ideal without extreme control and modification, body dissatisfaction can occur at any body size, shape, and weight.

Second, there is a powerful belief that a thin body is the only way a woman can be attractive to others. The need to be seen as attractive to others is an element of self-esteem, and thus a pervasive sense of being unattractive (due to higher weight than is deemed “attractive”) may lead to eating disorder behaviors. This may also explain the observed trend of depression and eating disorder onset during puberty, a time when the body is changing at the exact same time as a desire to be attractive to others increases.

It has been shown that people who have eating disorders have high levels of body dissatisfaction coupled with low self-esteem and feelings of ineffectiveness and inadequacy. It has also been shown that people who are depressed tend to have higher levels of body dissatisfaction and feelings of ineffectiveness and inadequacy.

Diet culture

This is where diet culture comes into the picture since dieting is strongly associated with body dissatisfaction and feelings of ineffectiveness and inadequacy. First, dieting causes extreme psychic and physical stress, which can drastically impact mood states, leading to depression.

Second, dieting fails 95% of the time. A person may lose weight but will regain it all plus more almost every time. This failure is almost always attributed to personal behaviors rather than the fact that diets are proven to lead to weight gain. Feelings of ineffectiveness and inadequacy based on weight regain after weight loss almost always occur.

It has also been observed that one in four people who diet will develop an eating disorder. This may be a natural response to the proven weight cycling inherent in dieting. A person can quickly notice that unless they take extreme measures, they cannot control their weight. Those extreme measures are the primary eating disorder behaviors of restriction, purging, and over-exercising. Binge eating is a natural and primal response to all of these behaviors.

Lack of control

Western cultures believe that weight is something that can be controlled, and yet the evidence points in the exact opposite direction. Research has shown for more than 50 years that intentional weight loss almost always leads to weight gain. This disconnect between a cultural belief and the reality of weight control leads to feelings of failure.

Attempting to control weight, which is a fruitless effort, leads women to feel more dissatisfied with their bodies. Repeat dieters report lower self-esteem than do non-dieters, which can lead to both depression and eating disorders. In a cruel twist of fate, the more a person diets, the higher their weight climbs. Additionally, many people who are depressed turn to food to soothe their depression. This can create an endless and lifelong cycle of body dissatisfaction, dieting, and depression.

Puberty changes everything

Body dissatisfaction is a symptom of both depression and eating disorders, and both are more common in females and typically arise during puberty.

During puberty, the female body changes, often dramatically. The thin ideal resembles a pre-pubescent girl (flat stomach, long legs, slender hips, flat chest). The process of puberty includes weight gain and the addition of new curves and rolls, which can be destabilizing for many females. Puberty takes girls further from the thin ideal while it typically brings boys closer to the masculine ideal.

Several studies have noted that girls become increasingly less satisfied with their bodies as they progress through puberty. At every age, girls are less satisfied with their bodies than boys. Girls also have higher rates of body dysmorphia and the belief that their bodies are larger than they actually are.

Protecting females

The trends linking our societal beliefs, being female, depression and eating disorders need to be openly addressed in order to reverse worrying trends of increasing rates of both depression and eating disorders. Both depression and eating disorders are increasing, and beginning at younger ages. There are many societal factors to be considered in these conditions in western females, but one known factor is the thin ideal.

Some actions we should take to protect females from higher risk of depression and eating disorders include:

1. Talk to girls about the thin ideal and its dangers.

2. Talk about the devastating impact of dieting on the body and mental health.

3. Seek ways to show girls the diversity of body size, shape and weight in the real world compared to what we see on television, social media, advertising, etc.

4. Don’t ever diet, or allow dieting in your home.

5. Speak up against companies that use Photoshopping, editing, and other techniques to take an already unrealistic body ideal to new extremes.

6. Demand that companies feature diverse body types in advertising and in entertainment programs.

7. Support companies that promote body size diversity in their advertising, social media, etc.

8. Learn about Health at Every Size

Also, monitor for signs of depression and eating disorders, especially during puberty. Depression is an essential part of the psychology of eating disorders.

See Our Parent’s Guide To Mental Health And Eating Disorders

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Reference: McCarthy, M., The Thin Ideal, Depression and Eating Disorders in Women, Journal of Behavior Research and Therapy, 1990

People who have eating disorders often exhibit 10 common cognitive distortions that are well known in psychology. Cognitive distortions are a hallmark of anxiety, depression, eating disorders, and many other mental disorders. The good news is that cognitive therapy is very effective, and parents can do a lot at home. Counteracting cognitive distortions can help people gradually replace distorted thinking with healthy, adaptive thinking.

Cognitive distortions and eating disorders

Cognitive distortions both cause eating disorders and are a symptom of an eating disorder. That’s why changing cognitive distortions is a key part of treating eating disorders. There are 10 cognitive distortions that often lie beneath the surface of eating disorder behaviors. These cognitive distortions may linger after eating disorders have otherwise receded. It is a good idea to be aware of these cognitive distortions and continue your child’s therapy as long as these distortions are present.

1. All-or-nothing Thinking

Someone who has an eating disorder often has what is commonly called “black-or-white” thinking. Nothing in nature is only one way or another. We all exist in the gray areas in between.

Eating disorders are based on the concept that food and weight are black and white issues. For example, a child might think “I’m fat” if they have even an ounce of fat on their bodies. This is despite the fact that all bodies must have some fat in order to be alive. They think “I ate too much” if they have stomach fullness. But feelings of fullness and satiety are perfectly natural biological feedback. They think “sugar is bad” even though sugar is just a food and is part of a normal diet.

Try this: If you see your child suffering from all-or-nothing thinking, intentionally talk about the gray area. If you’re watching a TV show together and the characters believe there are only two options, talk about how there are always many options. Notice when you make statements that support all-or-nothing thinking and correct yourself out loud in front of your child. If your child shares all-or-nothing thinking like “if I start eating I’ll never stop,” respond with something like “I know it can feel that way, but I don’t think your only options are either eat nothing or eat everything. There’s so much space in between.”

2. Overgeneralization

Someone who has an eating disorder tends to take note of negative experiences. They conclude that if they happen once, they will happen over and over again.

For example, they may think “I always overeat, and that’s why I’m fat.” This is even if they barely eat anything most of the time and then, to compensate, occasionally binge eat. If they fail to meet an arbitrary weight goal, they think “I’m never going to lose weight and will be lonely and miserable my whole life.” Overgeneralization feels like the absolute truth. This is despite the fact that many people may tell them in specific terms that they are incorrect.

Try this: Notice when people make sweeping statements that overgeneralize the human experience. For example, if you’re talking about a neighbor who “never mows his lawn,” correct yourself and say “actually, that’s not true. He mows it, but just not as frequently as I’d like him to. If your child makes an overgeneralization like “Nobody recovers from eating disorders,” say something like “I know it can seem like an impossible task, but lots of people do recover.”

3. Mental Filter

When a child has an eating disorder, they tend to create an inaccurate mental filter of how they appear and who they are. They see themselves as if through a distorted fun-house mirror.

This is seen in body dysmorphia, which commonly occurs with eating disorders. They literally see their bodies in a way that they do not exist. They may see bulges and bumps that are not there to any but their own eyes. Over time, they find it almost impossible to view themselves in any other way. This happens even when others objectively and authoritatively tell them that they are incorrect.

Try this: The next time your child tells you their body is imperfect, don’t automatically tell them they are beautiful and perfect. Instead, let them know that you understand they see a distorted view in the mirror. Just like those warnings on car mirrors, “objects in mirror are closer than they appear,” the mirror is not an accurate representation of reality. If they are struggling to see themselves, tell them that you see their beauty – inside and out – and will hold that for them until they can do the same.

4. Disqualifying the positive

People who have an eating disorder have an amazing ability to take neutral or positive feedback and turn it into something that reflects negatively upon themselves.

For example, if someone tells them they look nice, they may say they gained weight. If someone tells them they’ve lost weight, they may say that it’s not enough – they still have more to go. If someone tells them they are a healthy eater, they tell them they are far from perfect and need to be better.

This becomes compulsive. They are unable to accept a neutral or positive comment without washing it away with something self-deprecating. The belief behind the disqualification is typically some “fatal flaw” or belief of being “less than.”

Try this: Rather than debate with your child when they disqualify the positive in themselves, let them know that you see it. You don’t have to convince them of their positive elements, but you can tell them that you hold them in your heart and mind. Tell them your vision of them is multifaceted and dynamic, and you will continue to hold that no matter what they say or do.

5. Jumping to conclusions

Many who have eating disorders believe they can read other people’s minds, especially when it comes to negative feelings towards themselves. They may “know” that someone thinks they’re fat and ugly, stupid and lazy, or any other negative belief.

Their mind-reading efforts are almost limitless. They will read the minds of people who are actually not even aware of their presence. And they can obsess about what a person who passed them in a hallway was thinking about them even when the other person actually had no thoughts at all! Sometimes they take mind-reading to epic proportions and confront people about their supposed thoughts with no evidence.

This can have disastrous effects and result in a self-fulfilling prophecy. They begin to shape the way people see them.

Try this: Listen for when your child jumps to conclusions about what other people think and believe. Say “I can understand why you think that, but I also believe we can’t read other people’s minds. Often when we think one thing, it turns out that we are wrong.” You don’t need to get into a debate about the validity of what you’ve just said. That will only weaken its power. Just let it stand.

6. Magnification and Minimization

This is a habit in which a person who has an eating disorder magnifies their perceived flaws while simultaneously minimizing the idea that there is a problem with how they perceive themselves.

For example, they may think “I’m so disgusting, nobody will ever love me, and I’m going to be sad and alone forever.” If they actually say this out loud, a loved one may become concerned and urge them to seek treatment.

At that point, they will switch to minimizing the problem. They may say “everyone feels like this, I’m nothing special. Life is just hard.” Minimization is partly how they deny the severity of an eating disorder. It gives them the belief that they are not sick enough to warrant treatment.

Try this: It’s important for parents to neither over- nor under-react to these situations. The more you can stay steady and calm in the face of magnification and minimization, the greater your chances of showing your child that there is always a middle ground. No, they may not be the sickest person ever, but they may still have some concerning behaviors that you believe deserve care and attention.

7. Emotional reasoning

When a person has an eating disorder, they take their emotions and emotional thoughts as evidence of the “truth.” This means that if they think they are fat, they must be fat. If they think they eat too much, they must eat too much.

This can also be seen in binge eating mentality, which can begin with “I’ve already broken the rules, I may as well keep eating.” Emotional reasoning is dangerous because thoughts and beliefs are not usually facts. In fact, usually the first, easiest thought that comes to mind is a societally-driven, conditioned thought.

This is classically experienced as “I feel fat.” In our society, “fat” is a euphemism for any number of emotions. These emotions include depressed, lonely, sad, angry, scared, etc. When someone gets stuck in emotional reasoning, they forget to look deeper at their thoughts. They take them at face value rather than utilizing them as signals pointing them towards what is really upsetting.

Try this: Talk to your child about the idea of having a first thought and a second thought. The first thought is a knee-jerk reaction based on our societal conditioning. We need to tap into our conscious thought and look for the second thought, which is almost always much more nuanced and realistic.

8. Should statements

Maintaining an eating disorder is often based on “shoulds.” The most common shoulds are “I should lose weight,” and “I should eat healthy/exercise more.” These shoulds come directly from our society. They are reinforced in almost every aspect of life until they become so pronounced that people notice them as the problematic beliefs they are.

The trouble with should statements is the shame that accompanies them. People inevitably break their shoulds. Our behavior will inevitably fall short of our expectations when we are should-ing all over ourselves.

When a person succeeds in meeting their shoulds, they may feel a temporary sense of self-righteousness. But this is always followed by the terrible fall into bitterness and shame when they inevitably fail something else.

Try this: When your child says “should,” gently remind them that they always have options, and there is rarely a single right solution to any problem. Encourage them to think more deeply about why they believe they “should” do something and help them loosen up those beliefs that are holding them hostage.

9. Labeling and mislabeling

The deeper a person gets into an eating disorder, the more they feel they need to label ourselves, and ultimately it comes down to whether they are “good” or “bad.”

They don’t say “I ate a big meal at lunch today.” They say “I always eat too much.” They don’t say “I carry my body weight in my hips.” They say “My hips are huge.”

These big labels help them feel we have some measure of control over their bodies. This is a false belief because except in very extreme cases our bodies will find a way to achieve the genetic blueprint that largely determines our weight and shape.

A person who has an eating disorder often mixes up who they are as a person with how they appear in their body. A person is not a body – we is infinitely more flexible, adaptable, and interesting. When we define ourselves based on our bodies, we suffer tremendously and deny the world of a bright mind and unique self.

Try this: When your child labels their whole self as some version of “good” or “bad,” talk to them about the idea of “parts of self.” All of us are multifaceted and dynamic. We are not a single monolithic being that can be labeled. If your child says “I’m angry,” say “it sounds like there’s a part of you that is angry right now.” This is a crucial reframing that takes them from a monolithic view to a parts-based, temporary view.

10. Personalization

Many people who have eating disorders take things very personally. They believe that they are personally responsible for other people’s feelings and actions. This means they carry a heavy emotional load that does not help anybody.

Personalization is a terrible situation in which a person gets stuck pointing our fingers at themself, no matter what happens. If they don’t lose weight because their body’s metabolism slowed down, it’s their fault. They also believe that the size of their bodies is responsible for how other people feel.

They may believe that if they maintain a thin body, their parents will feel good and other people will like them more.

Of course, this is not true. If people have any feelings about the weight of another person’s body, that is because they have weight stigma. It has nothing to do with the other person’s body, and everything to do with them. Other people are completely responsible for their own choices, beliefs, and behaviors. While we have influence in relationships, we are never responsible for another person’s feelings.

Try this: Remind your child that they are not personally responsible for anyone’s feelings and behavior except their own. When other people behave badly, that is their reaction to external factors. We do not control other people’s reactions. It’s important to model this in your parent-child relationship. Instead of saying “you make me so mad!” say “I’m feeling very mad right now, and I need a minute to settle myself down.” This way you show them that you are responsible for your feelings and for responding to them appropriately.

Parents can help reduce cognitive distortions

While food and weight issues are the symptoms, cognitive distortions are part of the psychology of eating disorders. The eating disorder behavior is an attempt to manage the cognitive distortions. When parents know to look behind the behaviors to the root causes, they can help their child recover. The more we understand and tend to our child’s emotional health, the better.

See Our Parent’s Guide To Mental Health And Eating Disorders

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Eating disorders are strongly associated with low self‐esteem and poor body image. [1, 2] Self-esteem and body image must be improved in order to heal fully from an eating disorder because we can’t change a behavior until we change the predisposing factors that drive that behavior. [3]

If we tell a child that she’s beautiful and doesn’t need to starve herself anymore, we are unlikely to help her recover from an eating disorder because we have maintained the focus on her body and done nothing to change her underlying beliefs about her body and her self.

We tend to think of girls when we think of body image problems, but poor body image impacts boys, too. Rates of male eating disorders are increasing rapidly, alongside studies finding that men’s bodies are increasingly being objectified in the media. Studies find that males display substantial body dissatisfaction and that this dissatisfaction is closely associated with eating disorders and low self-esteem. [4]

While we may think the best way to help our child recover from an eating disorder is to educate them about the dangers of eating disorder behaviors, what we really need to do is help our kids see themselves as worthy of love and respect regardless of their eating habits, weight, exercise patterns, or any other behavior. [5]

This is good news for parents. We don’t have to learn everything about nutrition and body image to have a positive impact on a child’s eating disorder recovery. We just need to learn how to help our child see themselves as worthy, and this is something that parents are uniquely positioned to do well.

But please use caution – parents can cause unintentional harm if they approach self-esteem automatically and without research. We need to learn about the words and behaviors that actually increase our children’s self-esteem rather than acting on instinct, not because we are bad people, but just because we live in a culture that inflicts accidental psychological damage on a daily basis.

Steps to improve a child’s self-esteem

Here are some things parents can do to improve a child’s self-esteem:

1. Offer choices. Help your child experience “agency” – the ability to influence their own life outcomes – by not limiting them to one option. They may need to do homework, but they can choose the order in which to do their homework. They may need to take out the trash by 9 p.m., but they can choose when they do it before then.

2. Don’t jump in. It can be tempting to jump in and solve problems for our kids or give them step by step instructions for solving a problem. This is especially hard when we are trying to help a child recover from an eating disorder. But self-esteem comes from believing that you can accomplish tasks by yourself. We have to be patient and let our kids solve their own problems whenever possible.

3. Work against perfectionism. Perfectionism is an underlying factor in many eating disorders. Perfectionism is the belief that if I do something wrong I will lose love and admiration. Parents can help kids recover from perfectionism by openly acknowledging mistakes without shame or blame and reminding kids who are suffering because they made a mistake that nobody is perfect and everybody makes mistakes.

4. Praise your child’s positive actions. Our kids crave our praise, but it’s important to avoid common praise pitfalls. Praise like “you’re so talented!” rings hollow and also demonstrates a fixed mindset: either you’re talented or you’re not. Parents should embrace the growth mindset by praising their children for how they approach difficult things in life. And it’s important to never praise a child for their body size or eating behaviors.

5. Give them responsibility. Even in the midst of eating disorder treatment, appropriate household chores should be a part of your child’s life. Participating in the household chores helps children feel they are competent and bolsters their problem-solving skills. Be careful about how you set this up – we don’t want to constantly remind our child of their responsibility – nagging has a negative impact on self-esteem.

6. Give them one-on-one time. Each child wants to feel unique and special in their parents’ eyes. Take time to spend time alone with your child at least once per week. Even if they resist your efforts, keep showing up. Our kids need us more than we (or they!) know, even as they grow up. Don’t let your child’s social schedule get in the way of time for you to connect with them and build your parent-child bond. Being close with a parent has a significant impact on lifetime self-esteem.

Unconditional acceptance

A child must work towards self-esteem on many levels, but a parent can impact a child’s self-esteem by providing consistent acceptance and reassurance. It’s important to know that “acceptance” is not the same as “approval.” For example, you may not approve of your child’s eating disorder, but you can still accept your child as they are. Here are some statements we can use to demonstrate unconditional acceptance:

1. I love you.
2. I admire you.
3. I accept you.
4. I hear you.
5. I believe you.
6. I understand.
7. I don’t need you to be perfect.

The only caveat is that you need to actually believe these things when you say them. Kids have a fine-tuned bullshit meter, so make sure you are speaking the truth. If you can’t say these things truthfully, then please seek help from a therapist or counselor. You may have some personal work you need to undergo before you can provide your child with unconditional acceptance.

Also, never add the word “but” to any of these statements. When we say “I love you, but I wish you would take the trash out,” we are suggesting that our love is conditional on our child’s behavior. The whole point of saying these things is to be unconditional in our love and approval.

“Loving someone fully and without judgment is the opposite of being a weak pushover. It requires tremendous strength, fortitude, emotional maturity, and self-awareness.” — Andrea Miller, Radical Acceptance: The Secret to Happy, Lasting Love

Avoid body image pitfalls

As we help a child build stronger self-esteem and body image, we must avoid giving body-based feedback. Here are a few rules about giving feedback to a child who has low self-esteem and negative body image:

1. Do not provide feedback on a body part (e.g. your legs are so strong! You have such a tiny waist! Your biceps are so big!)
2. Do not provide feedback on body weight (e.g. you’ve gained weight! You’ve lost weight!)
3. Do not provide feedback on physical appearance (e.g. that’s so slimming on you! You look fat in that!)
4. Avoid feedback on body and eating behaviors (e.g. you finished everything! You ran every day this week!)
5. Avoid the words “good” and “bad” (e.g. you’re such a good student! You ate really badly yesterday.)

To increase self-esteem in a child who has an eating disorder we must focus on the non-body and non-eating or exercise aspects of our child’s life. We also want to avoid triggering their desire to be “good” via behaviors. We want our child to believe they are inherently good, regardless of what they do or how they appear.

Positive feedback with the growth mindset

Giving positive feedback can be difficult so it can be helpful to review information about the “Growth Mindset” that many teachers are learning to help children go from feeling fixed and stuck to feeling they can accomplish hard things.

Fixed Mindset	Growth Mindset
You are so creative.	I love how you approached that project with so much patience and thought.
You are a great swimmer.	It’s great how you make time for swim practice.
You’re so smart.	You really studied for this test – I’m proud of you.
You’re so talented.	It makes me happy to hear you practicing the violin every day.
You’re so athletic.	You work so hard at soccer, and being on the team seems to make you happy.
I knew you could do it.	I like the way you tried all kinds of strategies until you finally got it.
You’re such a good friend.	I love the way you showed up for your friend when she really needed you.

Remember that building a child’s self-esteem and body image is not about telling them they are great – it’s about building their own perception of themselves as worthy human beings. Emotions and eating disorders are linked. Self-esteem and positive body image can be influenced by a parent’s unconditional love and approval, but it ultimately has to come from within the person. This is a long-term effort. Invest time and energy in learning more about self-esteem and body image and just keep working towards it.

See Our Guide to Emotions And Eating Disorders

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References

[1] Self‐esteem, eating problems, and psychological well‐being in a cohort of schoolgirls aged 15‐16: A questionnaire and interview study Eric J. Button Philippa Loan Jo Davies Edmund J. S. Sonuga‐Barke International Journal of Eating Disorders January 1997

[2] Self‐esteem, personality, and eating disorders: Baseline assessment of a prospective population‐based cohort, Pilar Gual Marta Pérez‐Gaspar Miguel Angel Martínez‐González Francisca Lahortiga Jokin de Irala‐Estévez Salvador Cervera‐Enguix, International Journal of Eating Disorders, March 2002

[3] e.g., body image; Bandura, 1986

[4] Biceps and Body Image: The Relationship Between Muscularity and Self-Esteem, Depression, and Eating Disorder Symptoms Roberto Olivardia, Harrison G. Pope Jr., John J. Borowiecki III, and Geoffrey H. Cohane Psychology of Men & Masculinity, 2004

[5] Garner, 1985; Carter, Stewart, Dunn, & Fairburn, 1997; Mann et al., 1997