“I keep trying to motivate my daughter into eating disorder recovery, but nothing I say seems to make a difference,” says Angela. “I need her to eat more and with less fuss, but it’s as if the more I tell her what to do, the less she listens. It’s incredibly frustrating and I don’t know what to do differently.”
Like many parents, Angela has tried educating her daughter about the importance of nutrition and the value of recovering from her eating disorder. She wants to motivate recovery but has a feeling she needs to change her approach.
As she’s experienced first-hand, motivating a child into eating disorder recovery isn’t usually accomplished by creating the perfect argument. While food is important for treatment, eating disorders are about much more than food and are often tangled up in relational dynamics.
This is why nutrition information and speeches usually backfire. Motivating someone requires trust and emotional connection, and an authoritarian approach creates distrust and relational discord.
A powerful way to motivate your child’s eating disorder recovery is to feed your relationship.
How can parents motivate eating disorder recovery?
Motivating someone requires trust, safety, connection, and autonomy. It begins not with telling but withlistening andmeetingyour child’s deepest hunger for a secure relationship.
“A lot of the parent’s role in recovery comes down to connection, the relationship, and emotional regulation,” says Rebecca Manley, founder of the Multi-Service Eating Disorders Association (MEDA), who has been working in the field of eating disorders for 34 years.
“A child is not a behavior,” she says. “So what is beneath the behavior? Instead of focusing so much on, ‘She just won’t do what she’s supposed to do,’ or, ‘I can’t believe she’s doing this,’ let’s focus on the behavior and why it’s there. What does she need? What’s missing here? Because the eating disorder is the voice of the unmet need.”
The deepest hunger is a secure relationship
A child’s deepest hunger is a secure relationship with their parent. Feeding this hunger means being confident and attuned, providing a consistent, respectful, positive environment, and helping your child feel understood and accepted.
Feeding your relationship increases your influence and motivates the behavior change you want. Eating gets easier when your child is emotionally and physically regulated with you. Combined with professional treatment and a good feeding strategy, your relationship can supercharge recovery.
Under every behavior is a need
When your child has disordered eating behaviors, it’s natural to think that the problem is what they’re doing with food. Indeed, we need to address their eating behaviors and regulate their eating environment as much as possible. This is what’s behind FBT and other feeding strategies.
But there’s more. Because very few eating behaviors show up in a vacuum, and most eating behaviors get a response from you and other important people in your child’s life. These responses shape the future of the disordered pattern.
“Food is a big communicator, and how your child is eating can be anxiety-producing for parents,” says Rebecca. “An anxious parent will literally telegraph their anxiety to their kids without saying a word. And when anxiety gets telegraphed to the kid, they don’t feel safe. And if they don’t feel safe, they’re not going to eat in a regulated way.”
9 ways to feed your relationship
Here are a few ways parents can feed their relationship with their child, creating a more stable, secure connection:
Increase your emotional literacy and use emotional language with your child so they learn to express their emotional needs and ask for what they need
Regulate your emotions, which creates the foundation for your child’s ability to self-regulate (your child can’t be more regulated than you are)
Uphold high standards and a growth mindset, so they know you believe in their abilities and support them
Maintain interpersonal boundaries, so they know you believe they can tolerate distress and builds resilience
Show delight upon seeing your child so they know you enjoy their presence
Be an active listener and listen more than you speak so your child feels heard and understood
Show empathy and understanding of your child’s inner world and experience so they know they’re safe with you
Avoid giving unsolicited advice unless it’s absolutely necessary and explicitly requested so they feel trusted and admired
Control your need to control the situation so they learn to manage their own experience rather than rely on you to fix things
Build a more trusting and secure relationship
Of course handling a child with an eating disorder is tricky. “In every case, it’s a matter of tuning in and personalizing treatment,” says Rebecca. “But the common theme is helping the parent and child build a more trusting, secure relationship in which the parent can care for the child, and the child can receive that care and feel safe enough to eat.”
When parents feel confident, kids sense safety rather than fear. When we calm down, they calm down. Of course, they may still struggle, but you can handle their feelings without becoming part of an anxious relational pattern.
“If you think about it, the fundamental action of feeding your child is to want to meet their needs,” says Rebecca. “And when that doesn’t happen, it can feel like you were unsuccessful in doing the very thing you want to do most. Of course that creates anxiety for parents, which can be transmitted to the child”
But when you learn your triggers and regulate your emotional responses to your child’s eating behaviors, you’ll meet your child’s deepest hunger for safety and a secure relationship with you. This will allow you to influence and motivate eating disorder recovery.
That’s what happened to Angela. “All this time I was unaware of how much my anxiety was affecting her eating,” she says. “Now that I see it, I’m feeding our relationship first. When I get frustrated about meals, I go back to our relationship and usually find the issue there rather than what’s on the plate.”
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
Embodiment is the sensation of being in your own body and trusting the body’s signals, desires, and demands, and it’s very helpful in eating disorder recovery. An embodied person has a respectful, trusting, and kind relationship with their body. For centuries, Western culture has promoted the separation of mind and body, suggesting that the body is an inconvenient and unruly child, while the mind is the wise and knowing grownup who should dominate and control it.
This approach is everywhere, from education to medicine and psychology. It encourages the separation of body and mind. However, physically and emotionally we are one body-mind. There is no separation between the mind and body. They are one.
Emotions begin in the body and travel up to the mind. The body provides the mind with critical information about safety and threat. In our mind-first culture, people learn to ignore these essential signals and prioritize the mind’s thoughts, which are not always accurate or appropriate responses to the body’s signals.
Humans evolved with an intricate emotional system to keep us safe and healthy, but Western culture has worked to disembody us. Our culture has prioritized the mind as smarter than the body. This disconnect supports racism, sexism, heteronormativism, anti-trans bias, anti-fat bias, and other systems of oppression. It also leads to mental and physical illness. Almost all mental illnesses trace to a disconnect between body and mind. And the solution to many mental disorders, including eating disorders, is embodiment.
Why is embodiment helpful for eating disorder recovery?
Eating disorders almost always begin with the suppression of bodily signals. Rather than feed the body adequately, the mind intervenes and creates rules and shame around the most natural and necessary act of staying alive: eating. Hunger exists to keep us alive. Eating feels good because it is essential to living. And yet societal messages turn our minds against these natural instincts.
These messages are planted by diet culture, which exists in every corner of our society. Diet messages are taught in schools, promoted in doctors’ offices, and perpetuated at almost all family dinner tables. These messages say the body is not to be trusted. Instead, diet culture says the mind must ignore bodily hunger cues, appetite, and cravings and control and limit food.
When an eating disorder takes hold, it whispers these beliefs repeatedly, leading the person to avoid food and eating. Because the body has needs, often it will react to deprivation by binge eating. Sometimes the person will compensate for eating by purging and/or over-exercising.
The body is a resource, not an obstacle, in the recovery process and often needs to be resourced directly through a wide variety of body-based interventions before it can effectively metabolize food.
Embodiment is essential for eating disorder recovery because it returns the person to a respectful and honest relationship between the mind and body. Rather than allowing the mind to dominate and control the body, with embodiment we trust the body’s signals and aren’t afraid to respond to its needs with intelligence, love and care. Embodiment means approaching recovery with more ease and confidence and the belief that the body is wise and trustworthy. The mind is part of embodiment, but it does not ignore the body’s messages.
What are some embodiment practices?
Many people with eating disorders describe themselves as disembodied. They find themselves unable to connect with how they feel in their body, what their body wants, or to take cues from their body. Rebuilding the brain-body connection takes time and practice, but anyone can do it.
The core skill of becoming embodied is mindful attention. With an eating disorder, people become intentionally disconnected from their bodily sensations. Mindful attention to what the senses are taking in and how your body is experiencing the world can begin the reconnection process. Here are a few ways to begin:
5 senses scan
Look around and notice five things that you can see. Tune into your sense of touch and notice four things you can feel. Listen carefully and notice three things you can hear. Bring your attention to your nose and notice two things you can smell. Focus on your tongue and mouth and notice one thing you can taste.
Body scan
Get comfortable and tune into the sensation of your breath going in and out of your body. Repeat this for several breaths. Now notice how your body feels in space. Depending on your position, feel your feet on the ground, the places where the floor or cushion touches the backs of your legs, back, etc. Beginning at the top of your head, slowly bring your attention to different body parts, making your way down to your toes. What do you feel in each body part? Repeat this with your internal organs.
Yoga
Many yoga poses can support embodiment. For example, savasana, or corpse pose, can be a way to tune into the body and become aligned with how it feels. Additional poses commonly used in embodiment practices include downward dog, tree pose, and crocodile pose. The important part is to notice how the body feels within the pose and remain mindful of your body’s signals throughout your practice.
Barefoot grounding
Grounding, also known as earthing, is mindfully standing or walking barefoot. It’s often done outdoors on grass, mud, or sand. Ideally, it’s in a park, forest, beach, or lakeside. While outdoors is typically preferred, indoor surfaces like carpet, wood, or concrete work. The goal is to notice how it feels, down to the minute detail, when your bare feet connect with the Earth’s surface.
Why is yoga such a good practice for eating disorder embodiment?
Embodiment is essential for eating disorder treatment and recovery because it reconnects the body and mind. And yoga is a common way to build embodiment during recovery. Research indicates that yoga is an effective tool for eating disorder treatment. This is likely due to its ability to shift from a negative to a positive relationship with the body. It also nurtures self-respect, well-being, and embodiment.
To learn more about the connection between yoga and eating disorder recovery I talked to Julia Oliver, RD, LDN, RYT. Her practice, Rooted Recovery, offers yoga and nutrition services for people in recovery. She also runs Embodied Yoga on Demand, an online library of yoga and meditation classes to support eating disorder recovery.
“Since it can be gentle in nature, yoga is a supportive option for individuals who need a recovery-centered reentry into movement” says Julia. “Yoga offers a stepping stone as individuals begin to safely enter back into their relationship with their body and reconnect with body signals.”
Julia describes an eating disorder as a disembodying disorder. “It takes the person out of their body and turns the mind against the body,” she says. “In the midst of an eating disorder, the body is something that is often manipulated, taken control of, and pushed around by a dictating mind.”
During recovery, reconnecting with the body’s signals is necessary to start feeling bodily cues like hunger and fullness. Yoga can help people begin this reconnection process. “By cultivating embodiment in yoga, sensations may become more apparent during the practice,” says Julia. “It can also get us more tuned into our nervous system. It provides a practice field for the grounding skills and regulation techniques individuals may be working on with their therapist.”
“Yoga in its Eastern roots is all about stilling the fluctuations of the mind (aka thoughts) so that we realize we are not our thoughts,” she says. “Yoga, when taught well, can guide us to practice presence, using the breath and sensations as anchors to the present moment where we can then find the space to let go, and not attach to thoughts. Challenging harmful thoughts and beliefs is a foundational part of the recovery process, so you can imagine how the yoga practice, when taught in a way that does not just focus on the physical shapes, can be an inherently supportive part of eating disorder recovery.”
Sample yoga session for early eating disorder recovery
In this vinyasa yoga class, you will be guided through twists, balancing postures, and supported backbends to begin noticing and responding to the unique cues of the body in each pose. As in every ‘Exploration Phase’ class, you will be prompted to use the breath and sensations in the body as anchors to the present moment. Here, you will become more attuned to the balance of effort and ease in your body.
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
Gloria has been in recovery from an eating disorder for years, but she feels hopeless. “It’s just that I have all these personality traits that doom me to a life with this problem,” she says. “I don’t see how I can possibly escape from my eating disorder because I’m such a perfectionist.”
I completely understand. Our personalities are a very important part of our identity. And it’s true that certain personality traits are associated with eating disorders. Eating disorders are “biopsychosocial,” which means they have biological, psychological, and social causes. Personality traits are some of the psychological causes of eating disorders. The stronger a trait is, the more likely it will be considered a “maintaining factor” in an eating disorder. In other words, a trait like perfectionism can drive an eating disorder to develop. And if it’s unmanaged it can also makes the eating disorder more likely to stick around.
However, I think viewing personality traits as purely negative is both inaccurate and unhelpful. Many people like Gloria feel like being labeled “perfectionistic” is a life sentence. This does not help Gloria achieve recovery. And in fact, it keeps her focused on what she doesn’t have rather than what she does have. A strengths-based approach to eating disorder recovery is much more hopeful and helpful.
Personality traits associated with eating disorders
There are several key personality traits associated with eating disorders: perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, anxiety avoidance, low self-directedness, low cooperativeness, high impulsivity, sensation seeking, and novelty seeking.
These personality traits are commonly perceived as negative and seen as weaknesses. But every personality trait contains both strengths and weaknesses. And continuing to focus on weaknesses keeps people stuck in endless loops of self-recrimination.
NOTE: self-recrimination does not help people recover from an eating disorder.
A strengths-based approach to eating disorder recovery
Of course the so-called negative personality traits have downsides. But that’s because great strengths cast long shadows. Research shows that focusing on weaknesses is de-motivating. Conversely, focusing and building on strengths is motivating. It’s better to focus on what’s right with someone than what’s wrong with them.
“Many health systems have traditionally adopted a view of mental disorders based on pathologies and the risk individuals have towards mental disorders,” says Huiting Xie. “However, with this approach, mental disorders continue to cost billions a year for the healthcare system.”
The deficit-based approach to recovery damages recovery because it is inherently unmotivating. If Gloria believes she has a “fatal flaw,” she’s unlikely to embrace the resources available and fully engage in the recovery process. However, if she is confident that can apply her natural and intrinsic strengths to recovery, she’s more likely to embrace recovery.
A strengths-based approach to eating disorder recovery doesn’t pretend there aren’t difficulties to be faced, but it mobilizes a person’s strengths rather than focusing on what is wrong with them. Mental health issues like eating disorders can be seen as a normal part of human life that can be managed and overcome. This treatment approach focuses on a person’s abilities rather than their shortcomings, symptoms, and difficulties.
Here are four personality traits and examples of how we can take a strengths-based approach to eating disorder recovery:
1. Perfectionism
Perfectionism meaningfully and consistently predicts employees who are more motivated on the job, work longer hours, and can be more engaged at work. These strengths can clearly lead to eating disorder behaviors if they are focused on eating and body weight. However, they can become a driver of eating disorder recovery, too. For example, if a person with an eating disorder focuses on their strength of being highly motivated, they can become deeply engaged in recovery.
Typically treatment focuses on the negative fact that a person has become overly-engaged in their eating disorder behaviors. A strengths-based approach means we focus on their ability to deeply and passionately engage in things that matter to them. If they become deeply and passionately engaged in recovery, they can do anything!
2. Obsessive-compulsiveness
People with obsessive-compulsive personality traits are often confident, warm, organized, and high-achieving. They have meticulous standards of behavior and high expectations that can benefit them in every area of life. When these standards are applied to eating and body weight, they can drive eating disorder behaviors. However, this person has a strong ability to organize and make strategic decisions. When this strength is harnessed, they can become strongly motivated to recover.
This trait likely drives the people who “spontaneously recover” from their eating disorders. This really happens! Some people wake up one day and decide they don’t want to have an eating disorder anymore. Once an eating disorder no longer fits their rules of “good behavior,” recovery can be easier for people with this trait.
3. Neuroticism
The word “neurotic” is one of the worst-sounding personality traits, but, like all personality traits, it has strengths. People who have a more “neurotic” personality tend to be intelligent and funny, have more realistic expectations, and have greater self-awareness. They are also highly creative thinkers and tend to possess more emotional depth. Their emotional depth is likely what makes people with neurotic personalities more susceptible to eating disorders. Because they are more sensitive, they are more likely to need coping strategies for their big emotions.
However, when their creativity and intelligence are applied to building healthy coping strategies to replace their eating disorder behaviors, they can find deep and meaningful recovery. Additionally, embracing their neurotic tendencies can provide tremendous freedom and allow them to embrace themselves as they truly are, rather than try to fit into a socially-acceptable version of themselves. Recovery requires a person to embrace their body as it is. And it also requires embracing their SELF as it is.
4. Negative emotionality
Most personality traits arise as a combination of nature and nurture. But negative emotionality is a personality trait that is usually hardwired in the brain. We are all born with brain structures that determine whether we have a generally negative or positive temperament. And we have no control over our natural tendency towards negativity. Assuming that a negative temperament is bad is harmful and inaccurate. Negative emotions are adaptive, normal, and necessary. They are also highly motivating. Negative emotions prompt us to take action and provide valuable information about the inner and outer environment.
Someone with a more negative emotional state is better positioned to recognize when something is dangerous. Once danger is identified, they are motivated to build new skills and stop risking endangerment. But this is not a matter of “scaring people straight.” Adding more negativity to someone with negative emotionality will not support recovery. Rather, we need to support people in tuning into the messages their negative emotions are trying to send them. We can empower people to listen to their negative emotions with critical insight and use their intelligence and creative problem-solving abilities to embrace recovery.
Empowering recovery
Seeing personality traits as negative when treating an eating disorder is unmotivating and unsuccessful. Instead, seeing personality traits as strengths can support recovery. They can help a person find greater motivation and success.
That’s what happened to Gloria. “I found a new therapist who focused on my strengths and empowered me to claim recovery on my terms,” she says. “With her I found that my perfectionistic tendencies were actually exactly what I needed to recover.” She is now engaged in the process of recovering. And Gloria feels more hopeful and optimistic now that she’s using a strengths-based approach. By embracing her personality rather than rejecting it, she’s embracing recovery.
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
Many studies have found tremendous benefits in the Mediterranean Diet, but it may surprise you to know that it’s about so much more than food, and its social aspects can help with eating disorders.
The word diet literally means the food we eat. But none of us eat food without cultural forces that shape how we feel about food, ourselves, and each other. And today the word diet typically means eating in a certain way to achieve weight loss. Most mainstream diets (e.g. Atkins, Noom, Intermittent Fasting, Weight Watchers, etc.) prescribe detailed food plans as the path to weight loss. They rarely address the social aspects of eating, and in fact their rigid programs often interfere with socializing.
Conversely, the Mediterranean Diet does not have rigid food rules and has not been strongly branded and capitalized on as a path to weight loss. While the Mediterranean Diet does suggest general types of food, the important detail is that in the Mediterranean region food is social and cultural. We can apply the social aspects of a Mediterranean style of eating to eating disorder recovery and feeding. This means the focus is not on the food, but rather on how food is prepared, shared, and eaten in community with others.
We aren’t supposed to eat alone!
Humans are highly social animals. We evolved to procure our diets, prepare food, and eat food together as a group. We were never meant to eat alone, but rather as a part of our social activity. Yet today, most of us shop for food, prepare food, and eat food alone. And we do this often while heavily distracted by non-human social proxies like social media or television.
Have you noticed how hard it is to eat food without the distraction of other people, even if they are virtual and through a screen? That’s a biological adaptation. We aren’t supposed to eat alone!
What is the Mediterranean Diet?
In its simplest form, the Mediterranean Diet is described as a diet rich in fruits and vegetables, grains, seafood, nuts, and fats. From a nutritional standpoint, the Mediterranean Diet prioritizes plants over animals, locally-sourced and in-season food, and foods that are close to their natural state vs. highly processed.
When seen this way, the Mediterranean Diet is not limited to a specific cuisine and can be applied within many other cultural food traditions. In other words, you don’t have to eat Mediterranean foods to benefit from the Mediterranean approach to food.
Beyond food, the Mediterranean Diet is also strongly associated with the following lifestyle factors:
Shared meals: people are more likely to eat together and treat food as an important part of their day
Family and food traditions: people are more likely to see food as a family activity that is an essential tradition and bonding opportunity
Social activity: people gather together socially and have stronger social networks
Life/work balance: people take a full lunch break, take Sundays off, and generally protect the balance between life and work
These key elements of the Mediterranean lifestyle are not common in American families, even if they are eating Mediterranean food.
Pro-health benefits of the Mediterranean lifestyle
The health benefits of following a Mediterranean lifestyle include:
However, focusing solely on the nutrients involved misses the potential opportunity for using the Mediterranean lifestyle on a broader scale. Simply adding walnut oil to your cooking is unlikely to bring the full benefits of the Mediterranean Diet, since the true value likely lies in the overall lifestyle, including social connections and food traditions.
We know, for example, that actual and perceived social isolation are associated with increased risk for early mortality. In fact, the quality of social relationships far outweighs other factors we frequently associate with a healthy lifestyle, like not smoking and physical activity.
There is evidence that the Mediterranean focus on the social aspects of eating is associated with better health for adolescents. This lines up with the research supporting family meals as a way to improve nutrition and mental health in children and teens:
“The frequency of shared family meals is significantly related to nutritional health in children and adolescents. Children and adolescents who share family meals 3 or more times per week are more likely to … have healthier dietary and eating patterns than those who share fewer than 3 family meals together. In addition, they are less likely to engage in disordered eating.” Pediatrics
“[R]egular family meals were a protective factor for mental health.” This includes mood, anxiety, and substance use disorders as well as fatigue, forgetfulness, irritability, concentration, and sleep difficulties. PLoS One
The Mediterranean lifestyle for treating eating disorders
The true value in the Mediterranean Diet is not just about what is eaten, but how we eat and how we feel when we eat, which is why it can help with eating disorders. Feeding a child with an eating disorder is not easy, but using the social elements of the Mediterranean lifestyle can help.
To apply the principles of the Mediterranean Diet in eating disorders treatment and recovery, consider the following steps:
Daily family meals
Socializing when eating
Cooking and preparing food together*
Sitting together at the same table to eat
Sharing meals with family and friends
Establishing a sense of community and well-being when eating
Talking about the sensations of hunger, satiety, appetite and preferences without judgment or criticism
Not using devices and distractions at the table*
*Unless prohibited/prescribed as part of FBT treatment for an eating disorder
The simplest strategy you can implement is focusing on family meals in eating disorder recovery. These should include the following elements:
Everyone (or as many family members as possible) eat together
Same time, same place, same food
Parents focus on positive environment for everyone
Any meal works! If you can’t do dinner, can you do breakfast or a late snack? Adding family meals may seem like a major hurdle for your family, but it will likely make a big impact on your child’s mental and physical health. Is there some small step you can take today to help your family benefit from this aspect of the Mediterranean lifestyle?
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
Gita has tried everything to help her daughter recover from an eating disorder. “I feel like there are so many options, and so little evidence of anything that is the magic bullet for eating disorders,” she says. But a few weeks ago her daughter’s therapist recommended trying EMDR, so Gita is curious about the treatment and wants to know if EMDR can work to treat an eating disorder.
Parents like Gita feel desperate to find the treatment that will break through the eating disorder and trigger their child’s motivation to heal and recover. And while EMDR is far from a universal “magic bullet” for eating disorders, it has some evidence of being helpful for some people.
What all of us want is clear evidence of a treatment that works for everyone. But eating disorders are complex and research on eating disorder treatment is vastly underfunded. So for now parents are left with trying multiple treatment modalities to see what works best for their situation.
What is EMDR?
Eye movement desensitization and reprocessing therapy, or EMDR, seems strange, maybe even outlandish at first. And it was considered very fringe for decades. However, it has gained popularity and is supported by scientific studies as an effective method for treating traumatic memories. The treatment seems helpful especially when traumatic memories drive coping behaviors like eating disorders.
An EMDR therapist first works with a client to build a sense of safety and security. Once a positive therapeutic relationship is established, the therapist will help the client remember a traumatic memory while simultaneously stimulating the right and left sides of the brain. This can be done using their fingers, sound, a light board, or other devices. The idea is that stimulating the right and left sides of the brain while thinking about a traumatic memory integrates and stabilizes the brain.
EMDR shows promise as an eating disorder treatment. This is most likely because many people who have eating disorders also have PTSD and/or complex, relational trauma. Additionally, it is virtually impossible to live in our culture without encountering negative food and body experiences. Up to 90% of women have disordered thoughts about their bodies and food. Negative food and body experiences, compounded over years and even decades of a person’s life, are toxic and can contribute to disordered eating and weight behaviors.
Food and body experiences as trauma
EMDR helps people process fear and trauma in an adaptive, helpful way. The idea is that by processing their trauma, a person will no longer use eating disorder behaviors to deal with the lingering impact of traumatic experiences.
In our culture, food and body experiences are very often traumatic. Almost everyone can think of many situations in which their body was observed and judged as either good or bad. This is particularly true for people who are on the higher end of the weight chart. And most people have heard countless statements about how eating is either good or bad, healthy or unhealthy. These normalized behaviors are extremely common in our culture, and they contribute to disordered eating behaviors.
Many eating disorder therapists try to address disordered food and body thoughts with cognitive behavioral therapy (CBT), and that can be effective. But EMDR is designed to reach beneath cognition and support subconscious processing and resolution.
How EMDR works for eating disorder treatment
EMDR helps people identify a core fear that is driving behavior, find the touchstone memory that lies at the heart of the fear, and then process the memory in a safe, secure environment. The goal is that by processing the touchstone memory using the EMDR technique, the person will no longer feel so sensitive to the fear and may be able to cope with the urge to use eating disorder behaviors.
Messages from parents (e.g. don’t eat too much or you’ll get fat, etc.)
Negative feedback for weight gain (e.g. you need to watch your weight, I’m worried about your health, etc.)
Positive reinforcement for weight loss (e.g. you look great! Keep it up! etc.)
Eating food resulted in negative feedback (e.g. that’s bad for you! You eat too much junk food! etc.)
Restricting food resulted in positive feedback (e.g. you’re so healthy! I wish I could be as good as you!)
There are countless experiences that shape how kids feel about food and their bodies. This is hard for anyone, but it is especially traumatic for kids who live in larger bodies.
Lived experience
Many people who have recovered from an eating disorders credit their recovery in part to EMDR. For example, Shayna, a high school senior in recovery from an eating disorder, says it helped her. “When you have an eating disorder you constantly have these pressures in your head for one of the most seemingly basic needs,” she says. “But your mind is telling you that you don’t deserve to eat, you don’t deserve to exist in your body, that you won’t be accepted in this society. It’s a very difficult thing to grapple with.”
Shayna was in treatment for years, feeling stuck. In residential treatment she was exposed to the competitive nature of eating disorders. “I felt like my identity was being a person with an eating disorder,” she says. “My whole life revolved around my eating disorder. My mind was consumed by how can I lose more weight, how can I sneak around, how many calories is this, constantly feeling like I wasn’t good enough.”
After residential treatment
When she left residential treatment and went to high school, she continued working with a therapist, who introduced EMDR as a part of treatment. Shayna says EMDR has helped her in recovery. “I talk about my trauma or certain events that have happened, and she’ll ask me to think about an event and on a scale of 1-10 how disturbing it is, and connect it to how I feel in my body.” she says. “She either gives me tappers that vibrate back and forth or she’ll move her hand and I’m supposed to follow it eye to eye. It helps me get balanced and grounded. You can’t be anxious because you’re going to lose focus on the patterned practice.”
Shayna says the most valuable part of EMDR has been feeling more grounded. “I struggle with anxiety,” she says. “EMDR helps me feel grounded in the present. Instead of feeling washed away by my worries, I’m in the present with what’s happening. I feel safe and calm and present.”
Checking in with Gita
Gita’s daughter is medically stable, which is a prerequisite for EMDR. Gita’s main hesitation is that she’s worried the treatment may re-traumatize her daughter at a time when recovery is still very early and unsure. This makes sense, and it’s good to be cautious. It’s important to find a therapist who has training in EMDR and is trained in eating disorders. It’s a lot to ask for, but it’s more likely today than it was five years ago.
Gita found a provider who fit the bill and her daughter has attended four EMDR sessions so far. “I think it’s helpful for her so far,” says Gita. “The eating disorder is still there. We’re still working on it. But I’ve noticed that she’s much calmer now, and it seems like the negative food and body thoughts aren’t quite so loud anymore. I can see this possibly helping her feel better.”
Guidelines for using EMDR with eating disorders
If you are considering EMDR for your child who has an eating disorder, please keep in mind the following guidelines:
Your child should be medically stable, not weight-suppressed, and eating regular meals and snacks.
The therapist should have specific training in both EMDR and eating disorders. They should follow the EMDR protocol and practice from a non-diet perspective.
The therapist should invest in building a therapeutic relationship that is safe and secure for your child. They should not rush too fast into traumatic memories without building a solid relationship first.
You should be able to support your child’s emotional wellbeing and emotional regulation after and in between sessions. (Get help with this)
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
Dan reached out to me for some help with his son Braden, who has ADHD and needs to gain weight. “I’m not sure when it started, but suddenly Braden lost weight and his doctor tells us that we have to do something about it right away,” says Dan. “We’re really trying, but we feel totally stuck. Braden says he’s not hungry and rejects almost everything we offer him. We don’t know what else to do!”
I get it. Eating issues are common when you have a child with ADHD. And while it’s not easy, Dan and his partner Eric can make a big difference. They can improve Braden’s lifelong health by addressing this right away.
The link between ADHD and eating issues
People with ADHD are more likely to develop eating disorders than the general population. One study found that 31% of adults diagnosed with eating disorders also had ADHD. This is much higher than the general population, of which 3-10% of people have ADHD. About 36% of people who have bulimia and anorexia with a binging/purging subtype and 18% of people with anorexia have ADHD. Eating disorders have been described both as a symptom of and/or a coping mechanism for the emotional dysregulation that is common with ADHD.
Why it can be hard for a child with ADHD to eat
There are many reasons why eating issues are associated with ADHD. First, people with ADHD are usually highly sensitive to their five senses (smell, touch, taste, sound, and sight), all of which are involved in eating. This can lead to picky eating and a limited palate. They are also more sensitive to their interoceptive state, especially their digestive system, which can lead to disorganized hunger and fullness cues and/or feelings of nausea and other gastrointestinal distress.
They are also highly attuned to neuroception, the sensation of other people’s emotional states, which can impact eating habits especially if family meals are stressful or chaotic. Together, these sensitivities combine to increase emotional dysregulation, making eating more difficult. A child who is both highly sensitive and has low emotional regulation skills is more likely to adopt coping behaviors like an eating disorder.
Also, a person with ADHD may not notice they are hungry or, even if they do, they may not be motivated to feed themselves. This tendency to be distracted and/or procrastinate eating can cascade into eating disorder behaviors. Most eating disorders begin with under-eating, either intentionally for weight loss or unintentionally due to distraction or avoidance.
In cases of anorexia and ARFID, the person continues to eat too little. In cases of binge eating, the person restricts then binge eats. And in cases of bulimia, the binge eating episode is followed by purging. Either way, postponing and avoiding eating is a precursor to most eating disorder behaviors.
Finally, the medication used to treat ADHD can interfere with hunger cues, further affecting eating, weight, and digestion. This does not mean you need to discontinue medication, but it’s a good idea to check with your child’s psychiatrist to see if there are any adjustments that might help with eating.
Your child’s weight curve
A big thing to keep an eye on is your child’s weight and height curve. You should see a nice growth curve from birth through today, with your child staying approximately within their natural weight and height curve. This indicates your child is growing according to their body’s unique genetic blueprint.
For example, if your child was born at the 95th percentile for weight and was there at age 2, 4, 6, and 8, but they have now dropped to the 65th percentile, your child may be weight suppressed. Though it surprises many parents, we don’t want a child from the 95th percentile to drop down to the 65th percentile. And if they do, you’ll likely see an increase in disruptive behaviors and a lower appetite, which leads to more weight suppression, more disordered eating, etc.
If your child has dropped off their weight curve, they will need help eating enough food to get back to their healthy weight. The further they are from their natural weight, the harder it may be for them to eat. Nonetheless, it’s essential that you step in and intervene, as it is a serious medical and psychological issue. If your child has ADHD and needs to gain weight, please keep in close contact with your child’s doctor to monitor their health.
How to get a child with ADHD to eat
Getting a child with ADHD who has fallen off their growth curve to eat is extremely challenging. It’s also essential medical therapy. Start by seeking advice from a physician and/or registered dietitian (RD). However, beware of a professional who thinks it’s a good thing if your child has dropped off their childhood growth curve. That just means they’re stuck in outdated understanding of weight and health. Find a provider who recognizes that your child’s historical growth path should inform their weight trajectory.
Assuming they agree that your child needs to gain weight, you can work with them on a plan for feeding. If your child is medically compromised, they may need residential treatment. But in most cases you will be told to feed your child more regular meals. You may get a meal plan with ideas for what to feed your child. But in my experience most parents already know what to feed their child. What you really need to know is how, given ADHD, you can feed your child enough food for them to gain weight. In these cases, parents need a behavioral intervention that won’t trigger their child’s oppositional tendencies or emotional dysregulation.
Here are my top four tips for feeding kids with ADHD:
1. Structure
It’s common in our culture for meals to be chaotic and grab-and-go style. Everyone eats separately and parents may be short-order cooks, feeding each child a different meal at a different time. However, a child with ADHD who needs to gain weight needs structured meals that acknowledge the ritual of eating as important and meaningful. We are social animals – we were never meant to eat alone.
Create an eating and feeding schedule that involves you serving your child food on a plate, at the table, together with other family members as often as possible. Meals should feature high-calorie foods you know your child will accept as well as other foods they may currently avoid like fruits and vegetables. This will model for your child what a healthy meal looks like even if they are not ready to expand their palate yet.
Keep the atmosphere at the table “light, bright, and polite.” Any criticism or negative discussions will result in emotional dysregulation and either a loss of appetite or a tendency to binge eat.
2. Fed is best
If your child is weight-suppressed they need a lot of calories to make up the deficit and get back on their growth curve. While it’s common for parents to worry a lot about the nutritional content of their kids’ diets, at this point your main focus is on feeding a lot of calories as efficiently as possible. Worry less about the nutritional content and instead use the saying “fed is best” to remember that your primary goal is to feed your child enough food regularly so they gain weight.
Offer fruits and vegetables and other non-preferred foods at every meal. Put them on the table so your child sees them. But your focus is high-calorie, high-fat foods that will help them gain weight. You will have a lot more flexibility and can expand their palate more as they gain weight.
As your child with ADHD achieves weight gain, you will notice that rigid or chaotic eating patterns reduce and you’ll have a lot more leeway for increasing food flexibility.
3. Validation + Expectation
Kids with ADHD are extremely sensitive to demands and criticism, and yet many adults use these techniques to try and motivate them to do things. You will have a lot more success if you change your approach and consistently use a combination of validation and expectation. Here’s how this works:
Validate that they have an opinion, complaint, or resistance
State your request or expectation
Always do these two things together, not apart. And resist the temptation to add defensive arguments or compelling incentives. Keep your communication kind, short, and direct.
Here’s a good example of validation + expectation: “I understand that you’re playing a video game right now, but I’d like you to come to the table.” Or “I get it, you don’t want to eat right now, but I think you can handle it.” You may have to repeat yourself several times, varying the words a bit, but this technique is 100% more effective than arguing, negotiating, and debating with a child who doesn’t want to come to the table.
4. Build emotional regulation skills
While eating and weight gain are the outcome we’re seeking, emotional regulation is the underlying skill that will keep eating and weight, and therefore health, on track for life. Building emotional regulation skills is essential for any child with ADHD, and it will make a difference in every aspect of their health, including their ability to maintain a healthy weight. Parents can do this by building kids’ emotional regulation skills, and we are actually the best people to do this since we’re biologically wired with our kids. Building emotional regulation skills includes:
Emotional literacy – building an emotional vocabulary so kids can label, name, and talk about their feelings.
Emotional co-regulation – regulating your child’s emotional state with your calm, regulated emotional state. You may want to get some training and coaching to do this.
Skill-building – teaching your child the emotional regulation skills they need to process their emotions rather than coping with automatic, subconscious behaviors. My emotional regulation worksheets can help with this.
Measuring success
If your child with ADHD is weight suppressed it’s important that you restore their weight as quickly as possible. This will not be easy, but it is possible. And many times parents are the best people to help a child in this situation because you know your child best. Your aim is to achieve steady weight gain every week until weight restoration (getting back in their original growth curve) is achieved. Please remember to maintain close contact with your child’s medical and therapeutic providers and get support for yourself, too!
Checking back with Braden
Dan and his partner Eric met with me over the course of several months to optimize their meal structure, behavioral interventions, and emotional regulation skills. They put tremendous effort into Braden’s health, and it paid off. Braden slowly but steadily restored his weight and is back on his growth curve. And the family structure is now set up to support Braden’s nutritional needs.
They have noticed a big difference in Braden’s emotional regulation skills, and their own! Braden is still fairly picky, so Dan and Eric are working on food flexibility, but overall he’s doing great, and the family is closer and more connected than before. “The best part of all of this is that we’ve become much better parents to Braden and partners to each other,” says Dan. “We feel a whole lot more confident about what we’re doing now.”
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
For privacy, names and identifying details have been changed in this article.
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Whether your child is refusing to eat, binge eating, purging, or using other eating disorder behaviors, emotional dysregulation may be at the heart of it. And the good news is that emotional regulation skills can be built. These skills are key to reducing stress and anxiety at the table and helping your child relax enough to eat (and hopefully enjoy!) food.
Emotional regulation is part of our neurobiology, which is the biology of the nervous system. Recent scientific advances have revealed that the nervous system is incredibly complex and influences everything we think and do. The breakthroughs we’ve made in neurobiology have been led by the invention of the functional magnetic resonance imaging (fMRI) technique in 1990, which has driven a startling amount of progress in understanding our brains and nervous systems. This technique facilitates many insights into emotional dysregulation, and helps us understand why certain eating disorder behaviors show up.
People used to think eating disorder behavior was driven by the mind, something called top-down thinking. This is best shown by the common accusation that having an eating disorder is a vanity-driven choice – it’s not! Instead, what we’ve learned is that most disordered behavior comes from the bottom-up. It begins in the nervous system, which is constantly scanning the environment for threats and triggering emotional dysregulation when threats are detected.
Emotional dysregulation and eating disorders
Emotional regulation is a state in which we feel calm, engaged, and in balance. In this state, we have a healthy appetite, are happy to eat a variety of foods, and are pleasant dinner table company. However, when our nervous system perceives a threat, all that goes out the window. Instead of being emotionally regulated, we become dysregulated, which makes us either over-active (fight/flight) or under-active (freeze/shutdown).
A person who is dysregulated may feel nauseated and have no appetite. They may be sobbing uncontrollably. They may be disassociating with food and not even notice how much and how fast they’re eating. You can try to force them to eat or tell them to stop eating, but it’s unlikely you’ll be successful. Because until your child is emotionally regulated, they’re going to have a really hard time eating well.
Emotional dysregulation is both a cause and a symptom of an eating disorder. People who are frequently emotionally dysregulated are more likely to develop an eating disorder. But also, once an eating disorder develops it becomes a way to cope with emotional dysregulation. Thus, eating disorders and emotional dysregulation can grow together in a feedback loop.
Signs of emotional dysregulation
Most people describe someone in a regulated state as calm, confident, and engaged. This is when we get along with people and feel pretty good in our bodies and about ourselves. Eating is easy and delicious in this state and we are in tune with our hunger and fullness cues. When we become emotionally dysregulated, we either go to fight/flight or freeze/shutdown state. Here’s what this looks like:
Fight/Flight
Most people describe someone in a fight/flight state as either angry or anxious. Eating is extremely hard in this state. The digestive system is shut down and all the blood is diverted to the limbs for running and fighting. Most people can’t eat. Those who do may eat very fast, but since the digestive system is shut down they will become very uncomfortable and even less regulated. Symptoms include:
Racing heart
Nausea
Sweating
Anxiety
Anger
Arguing and negotiating
Freeze/Shutdown
Most people describe someone in a freeze/shutdown state as either depressed or zoned out. Eating is extremely hard in this state. Some people just don’t care about food, feel physically incapable, and are completely uninterested in eating. Others will eat food, sometimes a lot of it, as a way to try and get back to a regulated state. But food doesn’t work well for this purpose, and they usually end up even less regulated. Symptoms include:
Slow, sluggish movements
Dissociation
Emotional withdrawal
Depression
Suicidal thoughts*
*If you or your child are feeling unsafe or in crisis, please call, text, or chat the 988 Suicide and Crisis Lifeline to communicate with a trained professional.
What causes emotional dysregulation?
Our nervous system is attuned to internal and external threats. Threats can come from inside or outside of the body. When a threat is detected, our nervous system signals the amygdala, raises cortisol levels, and triggers emotional dysregulation. This is a physiological response meant to protect us from bodily harm.
We get activated into a fight/flight state when our nervous system drives us to run from or fight off a threat. And we go into a freeze/shutdown state when our nervous system drives us to hide to avoid a threat. This system was developed to protect us from predators, enemies, and natural disasters. However, in our modern world it’s more likely to sense threats in less-dangerous things like a food we don’t like or a situation that makes us uncomfortable.
People with highly sensitive nervous systems are more likely to be triggered into emotional dysregulation. Everyone can learn to get better at emotional regulation. However, people with a highly-sensitive nervous system who don’t intentionally build emotional regulation skills will tend to get more emotionally dysregulated over time.
Here are the benefits of having better emotional regulation skills:
More balanced and calm state of mind
Able to cope with worry, negative thoughts, and difficult emotions
Greater self-awareness
Able to think more clearly and make better decisions
Greater emotional balance
Able to respond rather than react in stressful situations
More fulfilling relationships
Greater self-acceptance and self-compassion
Less embarrassment and shame
Also, when a person is emotionally regulated, they are able to eat regular, healthy meals and snacks to fuel their bodies and minds. Eating well both improves emotional regulation and is improved by emotional regulation.
Foundations of emotional regulation
Physical health is a foundational requirement of emotional regulation. Your child needs to meet their basic physical requirements to achieve emotional regulation:
Enough food, regularly throughout the day (every 2-4 hours)
Even though it is harder for someone who is emotionally dysregulated to eat, it is also part of their recovery to eat. It will be very hard for your child to be emotionally regulated if they aren’t eating enough food regularly throughout the day.
If this is an issue, increase the number of structured meals and snacks, which will reduce massive physiological spikes and dips. If your child is currently weight suppressed, then weight restoration is a priority.
Improving your child’s emotional dysregulation
If your child is in therapy, their therapist will teach and model emotional regulation skills like reframing thoughts, naming feelings, having self-compassion, and more.
Your child can also improve self regulation skills with activities like meditation, yoga, breathing exercises, and other things that connect the mind and body and develop a felt sense of safety. My emotional regulation worksheets also help your child build these skills.
Best of all, your nervous system has shaped your child’s nervous system, so you are deeply attuned and responsive to each other. If you learn skillful co-regulation, you can help your child build their emotional regulation skills. This will make mealtimes much less stressful and help your child get the healthy nutrition they need. You can learn to more effectively co-regulate with your child to support them as they build emotional regulation skills.
When we co-regulate with children, we help them to feel safe, and to tolerate and make sense of their sensations and basic feelings.
Dr. Mona Delahooke
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
The return from residential eating disorder treatment can be a hard thing for parents. When you enrolled your child in treatment, they were probably physically and emotionally at a low point. You probably spent significant time making the decision to send them to treatment and agonized over the details. And the weeks or even months apart have probably been intensely stressful for you and your child as well. So while there is relief and hope when they come home, there’s also trepidation and worry that treatment won’t stick.
This guide is designed to help you prepare for the reality of your child’s return from residential eating disorder treatment. For most families, this stage of recovery requires a tremendous amount of effort. But the payoff can also be tremendous.
You can approach eating disorder recovery much as you would any other serious health rehabilitation and recovery. Don’t underestimate what is involved, but also don’t be afraid. I am 100% confident that you have what it taks to support your child’s recovery from an eating disorder. Here are some ways you can prepare for your child’s return from eating disorder residential treatment.
Education
Become educated about eating disorders, their causes, symptoms, and recovery. Imagine if your child had cancer. You would learn about their cancer, become informed about symptoms and treatment, and be engaged in recovery tasks.
Your education about eating disorders is even more important than if your child had cancer because of two things. First, there is tremendous stigma and misunderstanding about eating disorders. You need to uncover your own biases and misunderstandings to support your child’s recovery. Second, treatment for cancer is based on vast evidence and clinical trials. Unfortunately, eating disorders suffer from a deep lack of funding and knowledge. This makes your education more important than for almost any other type of illness.
Parents need a lot of knowledge and new skills to support eating disorder recovery. If your child returns to the exact same home and family dynamics in which their eating disorder developed, they are very likely to relapse right back into their eating disorder when they come home.
Reasonable expectations
The hard truth is that your child will still need a lot of ongoing support and treatment when they return from a treatment program.
You should be prepared for a minimum recovery time of 6-12 months. Under the best circumstances, that’s how long it takes for a person to fully recover psychologically and physically from an eating disorder. This recovery period will be challenging, and your child will need your family’s support. During early recovery, it is easier to return to eating disorder behaviors than to abstain from using them. They will need your constant, confident support.
Imagine your child had a stroke and is now living with you. They’ve returned home from hospitalization or rehab, but they still need daily support to get to and from physical therapy appointments. They need mobility aids, and you may need to learn new ways of communicating with them while they regain skills, mobility, language, and more post-stroke.
You can’t anticipate everything about what recovery will entail, but you know that your life will continue to be disrupted. Eating disorders require a long recovery with ongoing care and new skills to support the reality that early recovery is harder than relapse. Luckily, full recovery is completely possible and gets easier over time and with the right support.
Structure
Residential treatment is highly structured. From sleeping to eating and activities, everything is planned out in advance. Even free time is scheduled. This is because any stress and chaos increase eating disorder urges and behaviors. And the return home after residential eating disorder treatment will be a major stressor. Therefore, you want to minimize stress and chaos by having a good schedule in place.
While you may be relieved to have your child home and they may want to have freedom and little oversight, a lack of scheduled eating and activities will likely make recovery harder. It’s best if you have a firm schedule at least for the first 30 days after they return home and then taper off as long as recovery stays on track. Most people are doing some form of ongoing outpatient treatment, so this may take up several hours of their day. But avoid being too flexible with the remainder of the day.
Remember: they will not come home wholly recovered and will need your ongoing support. Structure is a big part of that.
At a minimum, they should have structured meal times for three meals and three snacks daily. These should be planned times that your child can eat with at least one other person who will uphold the expectation that they eat. It’s best if you replicate treatment by planning, preparing, and serving all meals at a structured time and – importantly – expecting your child to eat every 2-4 hours without fail.
Empathy
Eating disorder recovery is hard on everyone. It’s hard on the person going through it, and it’s hard on every family member. So it’s essential to have an intentional empathy practice. This means understanding that everyone is trying their best and is not intentionally being difficult.
Practicing empathy is not easy in the best of times. Most of us subconsciously assume that when people frustrate or hurt us that they are doing it on purpose or have ill intentions. But most of the time when people frustrate or hurt us, it’s because they are having a hard time. And this is almost always the case with our kids.
Kids are biologically driven to seek care and attention from their parents. One of the key ways they do this is with behavior. They act out so we know they’re having a hard time within. When your child does something “bad,” they are showing you they feel really, really bad.
Empathy means you realize this and try to respond from a place of calm curiosity rather than defensiveness and criticism. One way to do this is to remember, no matter what your child is doing at the moment, that they are “good inside” and worthy of your love and affection.
Importantly, self-criticism (a lack of empathy) is a significant cause and symptom of an eating disorder. Your ability to practice empathy with your child will model for them how to have empathy for themselves.
Relationships
Eating disorders are complex because they are “biopsychosocial” disorders. This means they combine biological, psychological, and social influences. Most eating disorder treatment focuses primarily on the biological and psychological drivers. But social factors, especially your child’s relationship with you and others in your family, are critical.
An eating disorder is not your fault. It’s not your child’s fault. But it’s also true that you have tremendous influence over your child’s psychology and environment. Parents matter a lot. Don’t lose sight of the fact that while your child has an eating disorder, everyone needs to “recover” by increasing mental health and learning new ways of communicating and relating to each other.
Focus on building your relational skills and deepening your relationship with your child. Learn active listening skills and emotion coaching. How well you learn and grow as a parent in the next 6-12 months will impact how well your family functions far into the future.
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
Brandon has been worried that his child Michael is addicted to sugar for a few years. “He’s always been really into sugar, sweets, and junk food,” says Brandon. “I’ve tried to tell him he needs to avoid sugar. Telling him it’s bad for him doesn’t change anything. I’ve tried hiding the sweets, not buying sweets at all, and even punishing him for eating too many sweets. It seems like my child is addicted to sugar, but is it actually an eating disorder?”
I can understand where Brandon is coming from. There’s a lot of fear about sugar right now. In fact, there’s a lot of common knowledge saying that sugar is a direct cause of disease and weight gain. But the first thing to know is that scientifically sugar is a causal factor in tooth decay, but it is only correlated with other health issues. The truth about sugar is complex and nuanced.
But the media hates nuance and loves a bad guy, and sugar is it right now. Most of us parents were raised to fear fat, but sugar has taken over as the new nutritional evil. Imagine if we’d heard about a butter board in 1998! The horror! Meanwhile, our “healthy” Snackwells fat-free cookies were loaded with sugar. Nutrition is subject to trends, so it’s a good idea to keep this in mind every time we meet a new nutritional bad guy.
Why does he feel addicted to sugar?
Look, nobody’s saying we want our kids to eat only sugar all the time. That doesn’t make any sense. But there’s a huge distance between banning sugar and eating only sugar all the time. And that’s what I want to explore with Brandon. Just how often is Michael eating sugar? What’s happening when he eats sugar? Does his child show symptoms of being addicted to sugar? Are there symptoms of withdrawal? Does he feel addicted to sugar? Let’s tease this apart a little bit.
“I guess he eats sugar a few times a week,” says Brandon. “Since I rarely have sweets, cookies, and candy in the house now, it’s definitely a special occasion thing. For example, after baseball practice they always get a snack, and it’s often cookies or something like that. And of course there are birthday parties and family events. Stuff like that.”
Brandon has banned sugary foods from the house. It sounds like he’s concerned about how Michael responds when he gets access to it out of the house.
“He goes crazy for the cookies,” says Brandon. “I see him taking more than his share and it’s embarrassing. And at family parties when there’s a cake, he’ll have two or three slices if I don’t stop him.”
Got it. So the big question for Brandon is whether his child is addicted to sugar, if he has an eating disorder, or something else.
What is the truth about sugar addiction?
I checked in with registered dietitian Marci Evans to find out more about sugar addiction. “I’ve been carefully watching the science of food addiction for years,” she says. “And aside from the fact that the “news” about sugar as an addictive substance sounds a lot like fear-mongering to me, it also doesn’t square with my clinical experience as a dietitian. My quick answer is that I don’t believe that sugar is addictive in the same way as caffeine, alcohol, tobacco, cocaine, and other substances.”
Many dietitians, especially those who work with eating disorder populations, are deeply uncomfortable with the vilification of sugar in our culture. They don’t agree with the idea that a child is technically addicted to sugar. And they worry that fear of sugar can lead to an eating disorder.
“I think that the biggest issue with sugar is that, like everything, once a human is told that something is “off limits,” our brain kicks into deprivation mode,” says Marci. “I frequently hear people talking about food, including sugar, and telling me they feel as if they are addicted, by which they mean they feel they cannot stop themselves, and they would really like to stop. It’s important to note here that someone feeling as if they are addicted to something is not the same as being physically addicted to something.”
The body’s need for food is a biological necessity. The drive for food – including sugary food – is not the same as a drive for optional substances like alcohol, tobacco, and cocaine. Putting sugar in the same category as these substances is chemically inaccurate.
Why is my child so obsessed with sugar?
But it’s also true that food can feel addictive. Behavioral addictions are an obsession with and compulsion to do a certain behavior. And eating can certainly become a behavioral addiction. But it’s important to separate behavioral addictions from substance addictions. This is because the treatment for substance addictions usually involves not taking the substance anymore. But most behavioral addictions require at least some continuation of the behavior.
For example, an eating disorder may be viewed as a behavioral addiction. But recovery is not about never eating or always eating. It’s about finding balance in your approach to the behavior of eating. Recovery from a behavioral addiction is not about abstinence, but acceptance and modulation of urges and desires.
“So far, there is absolutely no scientific evidence that any food is addictive,” says Marci. “Humans must eat food to survive. No specific compounds have been found in food that are like the compounds found in drugs and alcohol. The human drive for food is considered adaptive, while the drive for addictive substances is considered maladaptive.”
What does it mean when craving sugar?
“But what about the research showing that rats get addicted to sugar?” asks Brandon.
“There has been research showing that rodents consume sugar in an “addictive-like” way,” says Marci. “But this only occurs in settings that involve sugar restriction. This is critical because it is the reason I don’t promote restricting any food items, including sugar. When rats are kept in captivity and offered sugar on an intermittent basis, they exhibit binge-like eating, which researchers identify as addictive behavior. However, when the rats are offered sugar constantly, they do not exhibit this behavior, nor do they eat excessive amounts of sugar.”
“From my perspective, the study of the rats actually supports not vilifying sugar, since doing so can lead to binge behaviors that may look and feel like an addiction,” says Marci. “Again, there is no proof that this behavior is based on the substance itself, but rather the restriction of the substance.”
Ah! That is the key here.
Why does he have no self control with sugar?
Sugary foods are delicious and compelling for most people, especially children. But there are plenty of children and adults who eat sugar regularly without any signs of addiction or disordered eating. And the secret is that these people are allowed to eat sugar regularly. Without restriction, sugar is delicious, but it’s not compelling. It’s not an obsession or compulsion. We’ve seen this with rats. And dietitians who practice the Ellyn Satter method and/or Intuitive Eating see it every day, too.
We’ve all seen the kids who dive for the cookies or brownies at the party. What makes them different from the kids who could take it or leave it? Usually it’s the amount of sugar restriction they’re experiencing at home. Because kids who have access to cookies regularly are not likely to feel obsessive, compulsive, or addicted to cookies.
“Higher weight and binge eating disorder, both of which are frequently associated with “sugar addiction” are far more complex than any single food item,” says Marci. “What I see clinically is that food restriction is a more significant problem and a precursor to weight gain and eating disorders than sugar.”
Advice for Brandon
I can understand why Brandon is concerned about whether his child is addicted to sugar and the potential for an eating disorder. But Michael’s excited behavior around sugary foods is most likely being driven by restriction. We can’t rule out an eating disorder. But we do know that restricting foods at home is a risk factor for eating disorders. So I have some advice for Brandon:
1. Relax the rules
First, relax your at-home rules around sugar. Remember there is a huge space between no sugar and only sugar. Introduce dessert occasionally or even every day and start normalizing sugary foods as part of a balanced diet. That’s right: sugar can be part of a very healthy diet. Incorporate sugar into your regular diet. This will remove the sense of restriction that may be driving the addicted-like behavior you’re seeing in Michael.
2. Add in more nutrients, structure, and pleasure
Next, focus more on what you add than what you take away. I’ve said to incorporate sugary foods, but also seek ways to add in more nutritious foods. Expand your family’s daily intake of whole grains, nuts, seeds, fruits, and vegetables. Now, add in is more structure around food and eating. Many families lack feeding structure. But structure has been shown to have a much greater impact on lifelong health than any diet. Do you have at least one family meal per day? If not, add that in! Finally, add in more pleasure! Eating is a social behavior in human beings. Enjoy food, enjoy eating, and enjoy each other.
3. Talk about balance
Once you’ve had sugar incorporated in your diet for a while, if Michael is still acting like he’s “addicted” to sugar, talk about specific behaviors you’re seeing. Make sure you’re coming from a neutral, non-judgmental standpoint. Michael may need help noticing that he is taking more than his share at practice. And maybe cake at a party is totally OK. But then he could add in something with greater nutritional value and then re-evaluate whether he wants a second slice. These conversations will go much better if you’re already modeling this behavior with sweets at home.
4. Stop food shaming
Finally, stop food shaming and any negative talk about food. All foods fit in a healthy diet. Brandon loves Michael and wants what’s best for him, but badmouthing food and calling it junk makes it feel restricted. We crave foods when they are restricted. When all foods are allowed, they are no longer worthy of obsession and compulsion. And never punish a child for eating. When you punish a child for seeking comfort and joy in food you support a disordered relationship with food that can have a lifetime impact on health. Accusing a child of being addicted to sugar usually causes more harm than good.
Up for the challenge
It’s a lot to take in, but Brandon seems up for the challenge. “I can relate most of all to the kids who don’t get sugar at home grabbing all the cookies when they have a chance,” he says. “I remember kids like that when I was growing up. This one kid was on a really strict diet at home and he was seriously crazy about food. Give him access to pizza or M&Ms and he was all over it. The rest of us knew it was because he didn’t get it at home. I guess I’d forgotten about that until right now.”
Brandon’s going to give this advice a try and watch carefully for a reduction in how is child behaves around sugar and track the signs either addiction or disordered eating. Then we’ll re-evaluate whether there’s something more serious going on for Michael. Feeding a child can be complicated in our culture!
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
For privacy, names and identifying details have been changed in this article.
This is an update to an article published March 13, 2018 called “But, seriously, my kid is addicted to sugar. A discussion about sugar addiction with dietitian Marci Evans”
Marci Evans, MS, CEDRD, LDN, has dedicated her career to counseling, supervising, and teaching in the field of eating disorders. She is a Certified Eating Disorder Registered Dietitian and Supervisor, certified Intuitive Eating Counselor and Certified ACSM personal trainer. In addition to her private practice and three adjunct teaching positions, Marci launched an online eating disorders training for dietitians in 2015 and is co-developing a specialized eating disorder internship at Simmons College.
Erin was terrified when her 13-year-old daughter was diagnosed with anorexia. She spent a few months just trying to get her feet under her as she navigated the care system and tried to figure out what she was supposed to do to help her daughter get better.
“I felt like I was running through quicksand,” she says. “It was awful. Professional advice ranged from ‘wait and see’ to residential treatment, and neither option felt like the right one for us.”
Eventually, she was relieved when she was referred to a practice providing family-based treatment (FBT) for anorexia. “When I found FBT I just knew that was what we needed,” she says. “Our therapist helped us get our arms around the disorder and treat our child with respect and firmness. It made a world of difference, and she started to get better faster than I thought was possible.”
Erin’s experience with FBT is what every parent who has a child with an eating disorder wishes for: efficient recovery at home. And while FBT isn’t a fit for every child who has an eating disorder, it has been very effective for many families facing anorexia.
Eating disorder recovery
Approximately 13% of adolescents will develop an eating disorder by the age of 20. Eating disorders have been reported to be the third-most common chronic condition among adolescents. Despite this, research into the best treatment for eating disorders has been chronically underfunded. Therefore, evidence-based treatment trials for adolescents with anorexia nervosa are few, and study sizes tend to be small. As a result, many parents facing an eating disorder feel isolated and frustrated with the system of care.
Because it is one of the few anorexia treatments with scientific validation, FBT is considered by many to be the first-line treatment for adolescents with anorexia. There is also some evidence for its use with adolescents with bulimia. In this article, I’ll review:
The evidence for FBT for eating disorders
How FBT can be used to treat eating disorders
What you should know if you’re thinking about FBT for your child’s eating disorder
What is FBT?
Family-based treatment (FBT) is also sometimes known as the Maudsley method or Maudsley approach. It is considered by many to be the first treatment of choice for adolescents with anorexia. FBT is a manualized outpatient therapy designed to restore adolescents to health with the support of their parents. The primary focus of FBT is weight gain and it is seen as a viable alternative to residential treatment for that outcome.
Qualified therapists use FBT with all sorts of eating disorder populations. As of 2018, eight scientific studies have evaluated FBT in 657 patients with anorexia. And while it has been tested in multiple demographics, the majority of scientific evidence so far indicates positive outcomes for people who fit these criteria:
Adolescents <18
Female
Anorexia
Illness duration <3 years
Medically stable and fit for outpatient treatment
FBT has also been evaluated for bulimia. As of 2018, three randomized controlled studies have evaluated 295 patients. These studies have indicated positive outcomes compared to individual therapy, though the results are less dramatic than those for anorexia.
How to provide Family-Based Treatment
Many parents will cobble together an FBT-like treatment for their child with an eating disorder. However, true FBT is a detailed program based on a manual. Therefore, it contains specific elements in an outpatient setting and requires sessions with a trained therapist. Studies have evaluated short-term FBT (10 sessions over 6 months) and long-term FBT (20 sessions over 12 months). FBT is delivered in 3 stages with decreasing levels of parental control over feeding.
The second session of treatment includes a family meal. During this meal the therapist can observe the child’s eating patterns and family behaviors. At each session, the therapist will weigh the person who has an eating disorder. Following that, they meet with the family to discuss progress, including a review of weight gain. These meetings begin on a weekly schedule and decrease over time.
The central premise of FBT is that families can be central to eating disorder recovery. And while it is not a fit for every family, many find it very helpful.
Stage 1 of FBT is designed to replace inpatient treatment for an eating disorder. Eating and weight gain are the priority, similar to how they form the foundation of inpatient treatment. Typically the person with the eating disorder is able to continue attending school and participating in activities as long as they are eating and gaining weight.
Family-based treatment for eating disorders is organized around a few basic principles:
1. Agnostic view of the illness
FBT makes no assumptions about the cause of the illness. Previously, families were blamed for eating disorders. To counteract this, FBT takes a strong position that families are not to blame. Rather, FBT focuses entirely on resolving the primary symptom of not eating. FBT is not concerned with identifying the underlying factors. Instead, it aims to get adolescents to gain weight and stop using their eating disorder behaviors.
2. Externalize the illness from the patient
FBT emphasizes that the eating disorder and the child are not one and the same. The idea is that the eating disorder has “taken over” the child and is driving their thoughts, feelings, and behaviors. Parents are asked not to blame their child or believe that the eating disorder is the child’s choice. The goal of externalizing the illness is to reduce parental criticism, which has been shown to harm treatment outcomes.
3. The therapist takes a nonauthoritarian stance
The role of the FBT therapist is to take an active role in guiding the family through the recovery process. However, an FBT therapist does not tell the family exactly how to go about helping their child recover. The therapist partners with the family to help them figure out how best to refeed their child. The therapist models an uncritical, supportive, and compassionate stance toward the patient. Meanwhile, they take a firm, zero-tolerance approach toward eating disorder behaviors.
4. Parents are empowered
In FBT, parents are empowered as the best resource for their child’s recovery. Essentially, they are seen as the main agents of change in their child’s therapeutic process. Therefore, FBT success rests in the parents’ confidence that they can handle the eating disorder. The therapist works to put the parents in charge and communicate confidence in their ability to beat the eating disorder.
5. Unwavering focus
FBT has a pragmatic, unwavering focus on symptom reduction. It is designed to quickly and single-mindedly focus on weight gain. And, in the case of bulimia, ending binging and purging. Therefore, problems associated with the eating disorder like depression, anxiety, irritability, body image issues, trauma, loneliness, and more are not addressed in the first phase of FBT. The belief is that many of these secondary problems will lessen with the return to physical health.
What are the three phases of family-based treatment?
The FBT treatment for anorexia consists of three phases.
Phase 1
Phase 1 focuses on rapid weight gain. In cases of bulimia, the focus is on ending binge and purge behaviors. Parents are told that the disorder makes it hard for the child to make healthy decisions about food and eating. They are empowered to take over decisions about eating, much as would be done in inpatient care. Parents are responsible for deciding what their child eats, when, and how much is eaten. They typically also curtail any physical activity, much as would take place in residential treatment.
In the second session of FBT, the therapist will coordinate a family meal. During this meal, they will instruct the family on how to be more effective with the eating disorder. The goal of this meal is to give parents the confidence that they can encourage their child to eat more than they intended.
Phase 1 continues until the following conditions are met:
Steady weight gain
Eating disorder symptoms have begun to recede
The child is eating without significant resistance
Phase 2
During the second phase, parents will gradually give eating decisions back to the adolescent based on what is age-appropriate. This phase is introduced gradually and managed carefully.
Phase 3
During the third phase, the therapist reviews the adolescent’s progress and ensures the family is on track to get back to normal family life. The therapist offers skills to support ongoing development. Additionally, they will help the child navigate change without reverting to eating disorder behaviors to cope.
Is FBT right for your family?
Family-based treatment can be more effective than other treatments for anorexia, especially in cases where it’s caught early. However, if it’s not a good fit for you and your child is not gaining weight, you should know within four weeks. If that is the case, you may want to try other treatment options. It’s not a failure on your part, it just means FBT is not the right treatment for your family. FBT is great when it works, but it’s not the only path to recovery. There are alternatives, and you should not feel ashamed if FBT is not the right fit for you.
What do parents say about FBT?
When it is a good fit, FBT is very effective, and parents rave about it. Parents who succeed with FBT say recovery is faster and more effective than alternative treatments. But even parents who found FBT efficacious say it is time-consuming and emotionally challenging. Implementing Phase 1 of FBT can be a full-time job for parents, and it can last up to 3 months or even longer. Therefore, in some families, one partner will take a leave of absence from work to administer the treatment.
The risk of parental burnout with FBT is high. Burnout is a major risk for any parent who has a child with an eating disorder. Also, it’s serious because parental burnout has negative consequences for eating disorder treatment outcomes, whatever the modality. Therefore, parents report that having support makes the job easier.
That’s what Erin found helpful. “We had a great therapist, and I was active on parent message boards,” she says. “But I found that parent coaching was the real game-changer for me personally. Having a coach helped me work on my side of the equation and learn better communication skills. It made me much more influential over the eating disorder.”
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
For privacy, names and identifying details have been changed in this article.
Emotion coaching is a 5-step method developed for parents by John Gottman, PhD that can be applied to eating disorder recovery. The emotion coaching method builds emotional intelligence and creates positive, long-lasting effects for children, from toddlers to teens and young adults. It’s evidence-based, easy to learn, and regularly used by parents, educators, therapists, and caregivers in many different settings.
When parents learn the emotion coaching method, they identify how best to respond when a child is sad, angry, scared, or emotionally dysregulated and having big emotions. Once parents understand emotion coaching, they recognize that emotions, even the big, scary ones, are opportunities to build connection and emotional resilience.
Parents also learn that emotion coaching doesn’t let the child “off the hook” when they have big emotions, but rather that the child gets to have big emotions, and the parent also gets to set clear, consistent limits on behavior.
The five steps of emotion coaching are:
Be aware of your child’s emotions
Recognize your child’s expression of emotions as a perfect moment for intimacy and teaching
Listen with empathy and validate your child’s feelings
Help your child learn to label their emotions with words
Set limits and problem-solve
Emotional literacy is critical in eating disorder recovery
Often eating disorder behaviors are a way for a person to cope with difficult and uncomfortable emotions. Thus, eating disorder recovery necessarily involves learning how to feel big and uncomfortable emotions without using eating disorder behaviors.
This is why parental emotion coaching is so helpful for recovery. You are spending far more time with your child and seeing a greater range of emotions than their therapist. Therefore, if you can help your child learn to tolerate and process difficult emotions, you can help them recover from their eating disorder.
But tolerating and processing emotions is not something that most of us do naturally. In fact, many parents do the exact opposite. For many parents, when a child has uncomfortable emotions, the goal is to settle the emotions and move on as quickly as possible.
Here are the three most common techniques parents use to settle emotions quickly:
Accommodating: Your child is afraid of heights, so you avoid heights
Authoritarian: Your child gets angry when you ask them to take out the trash, and you yell back that they are ungrateful and need just to do the job without complaint
Reassurance/Facts: Your child doesn’t want to do something, so you provide them with facts and reassurance that it’s a good thing to do and that everything will be OK
These are just three ways that parents try to avoid emotions. Most parents who do this believe they are making the only rational choice. They believe that the rational way to handle emotions is to settle and/or avoid them. However, we know that the opposite is true. Repressed and avoided emotions tend to get bigger and more disruptive over time, not smaller.
That’s why emotional regulation is a core element of eating disorder recovery. To recover from an eating disorder, your child must cope with big and disruptive emotions without their eating disorder behaviors. The only way to do this is to build emotional resilience, which can be achieved with emotion coaching.
Emotion coaching when parenting a child with an eating disorder
Parents can support recovery by working with their kids’ emotions rather than denying, avoiding, or accommodating them.
1. Be aware of your child’s emotions
The first step in providing emotion coaching for a child who has an eating disorder is to recognize when your child is having emotions. This may seem obvious, but it is both essential and easy to miss.
You need to tune into your child’s emotional state to do this. Consider these questions:
Do you know when your child is angry, sad, scared, or feeling another emotion?
If so, how do you know? What are the signs of the different emotions your child feels? (hint: don’t focus on words alone. Emotional expression is much deeper than language, so look for physical signs like eyes, facial expression, posture, vocal tone, gestures, etc.)
Do you understand that often there is a presenting emotion (e.g., anger, stubbornness) that is covering a primary emotion like fear, worry, and shame?
It helps to build your emotional literacy, or ability to recognize and label emotions. There are several tools to help identify feelings:
Print out one of these tools and use it to help you recognize your child’s different emotional states. Look for opportunities to use more emotional language with your child. Show your child how often we have more than one emotion at the same time. For example, it’s normal to feel both nervous and excited at the same time. We may also have a presenting feeling like anger that’s hiding a core feeling like sadness.
2. Recognize your child’s expression of emotion as a perfect moment for intimacy and teaching
Most parents become alarmed and maybe defensive when a child has big emotions. But emotions are a perfectly natural and normal part of being human. There are a few different theories, but a common one developed by Paul Ekman, suggests we have six basic emotions. They are:
Sadness
Happiness
Fear
Anger
Surprise
Disgust
If you consider that there is also a state of neutral emotion, it’s safe to assume that most humans spend less time being happy than they do the many other emotions. Having a child who is not always happy is not a problem: it’s normal.
Uncomfortable emotions like sadness and anger are natural and normal. And your child needs you most when they are sad, angry, afraid, or experiencing other “negative” emotions. It’s not that your child needs to stop having the emotion. It’s that they need to have it safely, ideally with you until they learn to handle it by themselves without their eating disorder behaviors.
When your child has big emotions in your presence, it’s best if you acknowledge the emotions and see them as an opportunity to build your connection with your child. Don’t push the feelings away or avoid them, but rather to step into your role as an emotional caregiver and soothe your child’s emotions.
Soothing does not occur when you accommodate, make demands, bribe, or convince your child not to have their emotions. It takes place when you acknowledge their feelings and respond to them. Soothing can be both verbal and physical. For example, you can begin with labeling the feelings, but you can also start by reaching out to them, hugging them, and giving them gentle eye contact to let them know you are there with them in their pain.
When parents soothe their kids’ emotions, kids learn over time to soothe themselves. And this is the true growth opportunity of emotion coaching and why it’s so important in eating disorder recovery. When you coach your child, they learn to do it for themselves.
3. Listen with empathy and validate your child’s feelings
Emotion coaching is a highly attuned, challenging task. Parents who want to emotion coach their kids through eating disorder recovery need to practice listening and validating. Here are some tips for this:
Listening
Make sure you are listening to understand, not listening to respond.
Relax your desire to give solutions or convince your child of anything.
Breathe deeply and calmly while you listen to your child.
Remain emotionally regulated.
Mindfully “listen” to your child’s body language, not just their words.
Validating
Mirror what your child said by repeating a few of their words or summarizing what you heard without judging, editorializing, problem-solving, or debating the “facts.” Say things like “It sounds like …” and “Let me know if I’m understanding how you feel, you’re …”
Say things like “I get it” and “that makes sense.”
Don’t discount feelings, tell them how they should feel, use logic, or try to fix anything.
Attend to your body language: have soft eyes, a relaxed but firm posture, and an engaged and open facial expression.
Avoid “why” questions, which will put your child on the defensive.
You need to validate your child’s emotions, not their behaviors. There’s a big difference. For example, you don’t need to say, “I can understand why you didn’t eat today.” Instead, say, “It sounds like you felt overwhelmed by everything you had to do today (and didn’t eat).”
4. Help your child learn to label their emotions with words
Consistently work with your child to label their emotions with words. This powerful way to integrate the mind is essential to mental health. Use the feelings tools from earlier and keep steering conversations with your child towards feelings.
You can ask questions like:
Tell me more
What was/is that like for you?
What did that make you think?
How did/does that make you feel?
How did/does that affect you?
What did/does that mean to you?
When your child gives you an answer, try to pick out the feeling words or add some of your own to make sure the conversation is emotion-focused.
Most of us want to focus on “facts” and details. But with emotion coaching, you’re working to help your child identify their feelings, which will help them deal with distress without their eating disorder behaviors in the long term.
5. Set limits and problem solve
Emotion coaching is not permissive. In other words, while you are validating and accepting all of your child’s emotions, that does not mean that all behaviors are acceptable.
For example, your child with an eating disorder might prefer to eat alone in their room. You can validate that they prefer to do that, but in your home, you insist on eating at the table as a family. Just because your child has feelings does not mean feelings should dictate behavior. This is very important when a child is dealing with dangerous behaviors like restricting, binge eating, and purging.
You can set clear boundaries and expectations that may include things like:
Family meals
Not going in the bathroom after eating
Therapy appointments
No swearing at people or calling people names
Not hitting things or people
When things get hard, you can validate the feelings for why your child doesn’t want to or can’t meet the boundary but still uphold the boundary you have set. This is what parents learn to do in the highly effective and evidence-based SPACE Training.
If your child has expressed their emotions and feels validated, you may move into problem-solving. But be careful about problem-solving, as most adolescents and young adults do not actually want you to problem-solve. Most of the time they want to express themselves and then solve their problems by themselves.
Surprisingly, the more room you give your adolescent/young adult to solve their own problems, the more likely they will seek your advice. So hold back unless it’s specifically requested.
If you are sure that your child really wants you to problem-solve with them, here are the steps:
Identify goals
What is the problem we are trying to fix?
Think of possible solutions
Brainstorm – no idea is too silly or stupid to consider
Write them all down
Remind your adolescent/young adult of past success and how he/she handled it
Evaluate proposed solutions based on family values
Is the solution fair?
Will it work?
Is it safe?
How am I likely to feel?
How will other people feel?
Help your adolescent/young adult choose a solution if they want help doing so.
If your child has an eating disorder, then it may help you to keep a log of eating disorder symptoms and treatment. This is a useful tool to support you in seeking treatment, recognizing progress, and, when necessary, making decisions to switch to new or different treatment. A mental health log can help parents keep track of their kids’ mental health and support them in making strategic decisions to support recovery.
There are many benefits to keeping a mental health log of eating disorder behaviors and treatment. The three most important reasons are so you can:
Maintain your focus and know what’s working and what’s not working
Share your notes with treatment providers to keep treatment on-track
Recognize when things are getting better or worse
An eating disorder is a constantly moving target, and getting from day to day can be a major undertaking. But if you don’t have a tool to pull yourself up from the weeds and see the big picture, you can’t make strategic decisions. And impulsive decisions based on your feelings alone are often much less effective than decisions that are made in a more strategic manner. A log that tracks symptoms and eating disorder treatment will help you keep everything straight.
Why keep an eating disorder treatment log?
Managing a child’s eating disorder is a big undertaking. There is so much information and many details to keep track of. Since you have other things on your plate and you’re more likely to forget details in stressful situations, it helps to write down what is going on. Doing this will help you keep track of medications, rules, and expectations so that you aren’t wasting time trying to remember what was said or tracking down different pieces of paper, medication bottles, and other things to help jog your memory.
In times of stress, it can be dangerous to rely on memory, since facts become distorted with pressure and time. Keeping a detailed log of eating disorder symptoms and treatment means you have the information you need at your fingertips.
What is an eating disorder tracking log?
A log for eating disorder symptoms and treatment can help parents keep track of all the little and big things that take place during the various stages of having an eating disorder. Whether your child is in a very active eating disorder or in early, mid, or full recovery from an eating disorder, a log can be helpful.
An eating disorder symptom log should track the following:
Eating: for example, what and when did you serve food, and what was eaten. You may also include how it was eaten (e.g. easily, slowly, fast, reluctantly, etc.)
Other behaviors: for example, track whether your child is purging and, if so, how often. Same with over-exercise. You can also observe whether body image issues are becoming more or less frequent.
Conversations you have with professionals: this should include notes from your meetings with therapists, doctors, dietitians, etc. This should include information about the treatment they recommend and suggest and why you did or did not follow it.
Distressing events: you should take note of major events such as self-harming, anxiety attacks, and aggressive behavior. Describe what happened and approximately how long it lasted and its intensity.
Conversations with important adults: note things that people like coaches, teachers, family members, etc. have said to you about your child’s behavior. Sometimes it’s hard for us to see what’s going on, and these comments, when written down, give us insight.
Appointment notes: if your child is being monitored by a medical doctor you can keep track of vital signs like weight, heart rate, etc. Also, take note of any recommendations and suggestions. If you chose not to follow the doctor’s advice, state why.
Medications recommended and/or prescribed: keep track of what was prescribed, when, why, by whom, and at what dosage. Also track when providers adjust medication or if they make a recommendation that you disagreed with. Note any positive impact of medication and possible side effects.
In addition, you should have a quick-reference sheet showing you the providers’ names and phone numbers and any medications your child is on.
How to keep a quality log
You already have a lot on your plate. A parent who has a child with an eating disorder is facing tremendous work in terms of treatment and care. You’re already doing the planning, scheduling, coordinating, budgeting, and decision-making. This is a lot of work.
So you don’t have to turn keeping a mental health log into another tedious job for yourself. But you should have a system for jotting down your notes at the end of every day. As things improve, you can reduce this to every other day, then once per week, and so on. Remember that eating disorders can be effectively treated and you probably won’t have to do this forever. But it will be a tremendous help to you if you keep track of what’s going on. Aside from anything else, a good mental health log will give you the peace of mind that you are on top of your child’s care.
What format to use
Start by thinking through the format you will use for your log.
Some people really like paper and a pen for keeping notes. If so, get yourself a dedicated notebook and a pen and put them in a place where your child will not find them. Unless you are approaching the log as a group effort, you might want to hide it so your child cannot stumble across it. For some kids, a treatment and symptom log will bring on feelings of being vulnerable, observed, and exposed.
If you prefer a digital record, then you have several options. You can set up a spreadsheet or a document, or even just use your note-taking app on your smartphone. Whatever you use, keep in mind privacy concerns, and password-protect your devices so your child doesn’t accidentally see your log if you don’t want them to.
Once you know whether you’re going paper or digital, consider a standardized format. Not everyone likes this, but many people find it helpful to have a list of what they should be logging. To help, I’ve created a document with everything you need to get started.
Getting in the habit
In the beginning, make it a habit to jot down a few notes every day. New habits are hard to start, but once you get going, they get easier. Here are some tips for starting a new habit:
Get ready: gather the supplies you need and set up your worksheet, cheat sheet, or whatever you’re using to keep your log
Set a goal: it’s very hard to build a habit if your goal is undefined. Commit to daily notes or, if that’s not possible, a note every time you do something like visiting the pediatrician or dietitian.
Set up a cue: if your goal is to make a note every day, set up the specific time and location. Many people will set a reminder on their smartphones to make sure this happens. Another option is to make the cue something like when your child goes to their therapy session, after dinner, or something else that reliably happens.
Set up a reward: it’s best if you feel successful when you complete your habit each day. This could be something simple like giving yourself a quick hand or temple massage, scrolling through your phone for 5 minutes, or getting a hug from your partner.
Have a plan B: while you really want to stick to a regular plan to create a habit, it can be helpful to build in your plan B. This is what you will do if you don’t meet your goal. For example, can you set a second reminder on your phone? If you forget to do it after dinner, can you do it before you go to bed? Establish this in advance so it feels like a more formal and thus acceptable backup plan.
The log is not a journal for your feelings
Journaling your feelings about the eating disorder might be very helpful for you. A journal can help you process your difficult emotions and thoughts about your child’s disorder. However, this mental health log is not the same thing as a journal. I suggest you keep the two concepts separate. Remember that a good log might be helpful for you to show to your child’s treatment providers. So you want to limit your personal thoughts and feelings.
Keep the log factual, and process your feelings elsewhere. Use a reporting approach: stick to the facts! You can even use a reporter’s prompts to structure your notes:
What happened?
Where did it happen?
How did it happen?
Who was involved?
Why did it happen?
Privacy considerations
Your child’s private health information is sacred. I already mentioned this, but carefully consider whether you plan to share your log with your kid. And, if not, make sure they have no way to accidentally stumble upon it. I really can’t overstate this. What you are doing is not wrong. However, it could be hurtful for your child to discover your log without adequate preparation. Here are a few options for thinking about how you set this up:
Keeping an open log
You may choose to make the log open and accessible to your child. This means you share with them that you are keeping the log and are willing to show it to them upon request. However, it does not mean your child is keeping the log for themselves. If their therapist suggests they journal or maintain their own notes, that’s separate from what you are doing. Even if you are providing your child with access to the log, make sure that it is your responsibility to record your observations and notes.
Keeping a private log
A more common approach is to keep a private log. In this case, you keep your log private and in a secure location that your child cannot access. You are gathering very personal information, so it is essential that you take this very seriously. There are ways in which an eating disorder symptoms log can go awry, including:
The child with the eating disorder finds it and feels criticized, triggering a relapse or new symptoms
Siblings find the log and make fun of the child or become worried about the child’s health
Other people, from nosy neighbors to extended family members find the log and catastrophize the situation, possibly even accusing you of wrongdoing if they don’t understand what’s going on
This is why it cannot be overstated: if you keep a handwritten log, make sure that it is hidden securely in a place that nobody will find. If you keep your log on digital devices, make sure they are password-protected to make sure nobody can access them except for you. Don’t fall into the trap of relying on weak passwords that your children are likely to guess! Do not use anyone’s birthday, name, or classic combinations like 12345, abcdef, or the all-too-common mistake of using the word “password” as your password.🤣
Get started!
Keeping a mental health log of eating disorder symptoms and treatment can really help you uncover patterns of behavior. It will also help you recall facts and information that you’ve received in the past and jog your memory about why you have made the decisions you have made. Finally, it can be very helpful when you’re talking to new treatment providers who need a history of what has taken place so far.
Vicky is feeling really nervous because her 19-year-old Alex (they/them) wants to go back to college after eating disorder treatment. Alex is highly motivated to get back to school and manage their own life, but Vicky feels deeply unsure about exactly how that will work.
“I can’t get over the memory of having to hospitalize them and put them in inpatient treatment last year,” says Vicky. “It was traumatic for all of us, and right now I can’t even imagine feeling good enough to send them back to school even though they say that’s what’s motivating them to recover right now.”
Vicky struggles to balance being a responsible mom with the freedom Alex wants. She wants to get clear about what Alex needs to do to show her that they are ready to go back to college.
I suggested coming up with some goals that will help Vicky feel better about sending Alex so far away again. I recommend using SMART goals for eating disorder recovery, since they are specific and attainable, and there can be no doubt as to whether they are achieved. They’re also motivating because Alex will be able to see a pathway to freedom from parental oversight.
What are SMART goals?
SMART goals are often used in business and education settings to help employees and students set and achieve measurable goals. The key to SMART goals is that they are very specific and work well when you have large goals that you want to break down into smaller steps.
SMART is an acronym that stands for “specific,” “measurable,” “attainable,” “relevant,” and “time-bound.” Every SMART goal features these essential elements to ensure the goal can be reached to satisfy both the child who will take action towards the goal and the parent who wants to see the goal achieved.
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Free Guide: How Parents Can Help A Child With An Eating Disorder
Master the secrets to supporting a child with an eating disorder. Thousands of families like yours are stronger today because of these six vital lessons drawn from lived experience, best practices, and extensive study.
The goal should be well-defined, clear, and unambiguous. For example, it’s not enough to say “eat enough.” If the goal is to eat, get specific, like “eat 3 meals and 2 snacks every day.”
Measurable: How will I measure progress?
The goal should have specific criteria that measure progress. For example, if the goal is 3 meals and 2 snacks daily, the child could text a photo of each to their parent or dietitian.
Attainable: Do I have the resources & skills for it?
The goal should be something that is attainable and not impossible. It should be within the child’s capacity to do. In the eating example, the child needs access to food and a smartphone.
Relevant: Why is this goal important?
The goal should be an important step toward self-management. It should matter to you and your child. In the eating example, maintaining regular meals and snacks is a major part of being a competent eater, and thus makes sense as a relevant goal.
Time-Bound: When will I achieve the goal I’ve set?
The goal should have a clearly defined timeline, including a start date and a target date. For example, if they send photos of all three meals and snacks every day for eight weeks, you may set a new SMART goal that gives them less oversight in the next stage.
Why are SMART goals important?
SMART goals are important because they help parents:
Set clear intentions, not broad or vague goals
Feel confident about the child’s path to self-management
Focus on the specific behaviors that support recovery
Measure progress with specific benchmarks
Provide sensible objectives that are realistic and achievable
Avoid the distraction of a long list of goals that is hard to manage
Be clear about the timeline and next steps if goals are met
SMART goals increase your child’s pursuit of self-management by making your expectations really clear and unambiguous. Your college-age child wants to get out from under parental control, so setting SMART goals gives them a clear path to doing that. These goals communicate that you believe your child can succeed but also gives you the confidence to let them go away to college.
How can SMART goals help with eating disorder recovery?
SMART goals can help with eating disorder recovery, especially for college students, because they help both the child and the parents get what they need. The child wants autonomy and to return to their life back at college. But the parents want assurance that the eating disorder is not active and putting their child in danger.
Vicky was really excited about using SMART goals for Alex. “I feel like this is going to really help us put together a plan that feels good for all of us,” she says. “Alex would much prefer zero controls, and I get that, but I need something to make sure I’m not being reckless or thoughtless when sending them back to school.”
Working on SMART goals
Vicky worked on three SMART goals that she felt were important. Since they are in family therapy and Vicky was unsure how Alex would respond, she brought up the idea during a family therapy session. The therapist was encouraging and supportive of the idea, and Alex didn’t hate it. So the next week Vicky brought in the SMART goals worksheet. Together they worked with the therapist and Alex to make adjustments that felt good for everyone.
“A big deal for Alex was the time-bound aspect, of course,” says Vicky. “Alex just wants to see a path out of being monitored all the time, and I feel like these SMART goals give us all the confidence to move forward. I want Alex to feel independent and free … and I want to be free of the eating disorder, too! This has absolutely taken over our lives, and I can’t wait to move into the next stage and reduce our monitoring.”
This steady and clear approach to eating disorder recovery adds a lot of confidence and security for parents while also showing kids the steps they need to take to reclaim the independence they crave.
SMART goal template & examples
SMART goals for recovery example: eating
PLEASE NOTE: this is not intended as or delivered as medical advice. Please don’t make choices about your child’s recovery without consulting their treatment team. Make sure your SMART goals are appropriate and make sense in the context of your child’s eating disorder recovery.
How to make a SMART goal for eating disorder recovery
Like Vicky, you may be excited about SMART goals and want to dive right in. I get it! I love SMART goals! Please just remember that while Vicky drafted some SMART goals, she checked with her family therapist before introducing them to her child. Depending on your child’s eating disorder recovery status, SMART goals may not be the right approach right now. Check with your child’s eating disorder treatment team before presenting your child with SMART goals.
To make a SMART goal, begin by thinking of your big goal, then breaking it down into behaviors that will get you closer to the goal. With eating disorders, the big goal is “recovery,” but that’s hard to measure and it’s a state of being, not a behavior with measurable steps. If we make recovery the goal, we will struggle to measure and monitor it. Instead, break it down into attainable, measurable, and observable behaviors like:
Eating regular meals and snacks
Checking vital signs of health such as heart rate, blood pressure, etc.
Going to therapy and nutrition appointments
Getting blind-weighed if appropriate/necessary
Next, write down a few SMART goals that are “specific,” “measurable,” “attainable,” “relevant,” and “time-bound.” If the goal is eating regular meals and snacks, detail how many meals and snacks, and how the goal will be measured. The most common mistake is not being very specific about the goal. The more specific and measurable the goal, the greater your chances of success.
Examples of SMART goals for eating disorder recovery
Vague Goals
Specific Goals
Eat regularly
Text photos of 3 meals and 2 snacks every day
Don’t lose weight
Get blind-weighed once every two weeks*
Stay healthy
Get your vital signs checked once every two weeks*
Take care of yourself
Attend weekly therapy and nutrition sessions
*the frequency will vary based on your child’s current medical status and is here as an example only. Please consult your child’s treatment team to set goals that make sense for their individual recovery path.
Measuring success
The most motivating eating disorder goals are those that provide a pathway out of being monitored. Show your child the path to self-management by setting multi-stage SMART goals.
For example, if the first goal is for them to attend therapy weekly for 8 weeks, that doesn’t mean you stop all therapy if they reach that goal. Maybe the next goal is that they switch to every 2 weeks for 8 weeks after that, then monthly. A stepped approach will provide the safest structure for recovery
SMART goals should never feel punitive or shameful. The value of providing time-bound goals is so your child knows what will happen when they meet the goal. But you should not say you are disappointed if your child does not achieve the goal by a certain date. That’s why I suggest using consecutive weeks rather than a specific date. Just count the weeks that they do accomplish the goal. If they skip a week, then you start again at 0. Once they do it every week in a row for the number of weeks specified you can celebrate and set a new goal.
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Free Guide: How Parents Can Help A Child With An Eating Disorder
Master the secrets to supporting a child with an eating disorder. Thousands of families like yours are stronger today because of these six vital lessons drawn from lived experience, best practices, and extensive study.
For example, Alex might text photos of their meals every day for two weeks in a row, then skip a few days during the third week. Alex is not bad for doing this. It’s understandable. However, that resets the clock back to 0. Once Alex texts all meals/snacks for 7 days, that puts the clock at 1. If the goal is 8 weeks, then Alex must text all meals/snacks for 7 days in a row for 8 weeks in a row to meet the goal.
Avoid being flexible or changing the goal, because it will show your child that the goals are open for negotiation and debate. This is a slippery slope that eating disorders love to take advantage of. Instead, maintain clear, compassionate boundaries. It sucks for all of you to start at 0 again. But that’s how you make sure you aren’t accidentally accommodating the eating disorder.
Celebrating success
I checked in with Vicky after Alex had been back at college for a semester. She had been both hopeful and terrified of the return to college. And I’m pretty sure Alex felt many of the same feelings!
Alex struggled a little bit with the transition back to school, which we expected and had prepared for. But after 4 weeks of being inconsistent with their progress, Alex stayed on track and they are almost ready to set new SMART goals that give Alex more freedom and autonomy.
Vicky says that having SMART goals is a huge relief for her. “I just feel like I have some level of insight into what’s going on for them at college. Now I can keep an eye on their health and safety when they’re so far away from me.”
FAQs: SMART goals for eating disorder recovery
Which goal is appropriate when treating anorexia nervosa?
Setting goals when treating anorexia nervosa tend to focus on eating enough food regularly throughout the day, limiting exercise unless safe, and weight restoration. These goals are ideally set with a treatment provider like a therapist, physician, or Registered Dietitian (RD).
What are realistic eating disorder recovery goals?
Setting realistic eating disorder recovery goals is an important part of treatment, and is best done in consultation with an experienced professional. Each eating disorder is different, and circumstances vary greatly. In general, recovery goals should be challenging enough to feel energizing but not so challenging that they feel hopeless or unattainable. Finding the right balance is the key to setting realistic eating disorder recovery goals.
Can SMART goals help with eating disorder recovery?
SMART goals can help with eating disorder recovery because they support appropriate targets without being vague or pushing too hard. Finding the right level of difficulty is key to successful SMART goals in eating disorder recovery.
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
For privacy, names and identifying details have been changed in this article.
Alicia knew she had to do something soon. Her daughter Eden had been stuck in a restrictive eating disorder for a few years. Eden was medically stable and in treatment. But Alicia knew that she was still deeply affected by her eating disorder. And the eating disorder was taking up a lot of space in the family and for Alicia personally. Alicia wanted to make sure she was doing everything in her power to keep things from getting worse.
Alicia started a parent-based treatment called SPACE (Supportive Parenting for Anxious Childhood Emotions). The program included 12 Zoom calls, plus homework and practice in between. Alicia learned ways to support Eden without accommodating anxiety-driven eating disorder behaviors. At the end of the program, Alicia noticed improvements in her daughters’ eating disorder behaviors. And she gained a new perspective on how she was parenting and skills to support Eden’s recovery.
“I was unsure how I could actually do anything to change the eating disorder. Mostly I was afraid to even try. But deep down I had a suspicion (A dream! A fear!) that there was more I could do. In SPACE training I became aware of how much I was accidentally accommodating the disorder. And in fact, it was those moments when I felt like I was being most supportive and loving that I was accidentally making things worse,” says Alicia.
“Now, I am really supportive … even more supportive than before. But I also have really good boundaries and I’m not getting into dangerous waters by accommodating Eden’s anxiety. I no longer avoid the hard things we need to do to get better,” says Alicia. “When I first learned what I had to do I thought it would be harder to parent this way. But in fact, things are running more smoothly now than they were before.”
Parent training for eating disorder recovery
As a parent, you did not cause your child’s eating disorder, but you have a critical role in recovery. New research is revealing that you can help treat your kids’ anxiety-driven eating disorder behaviors, improve your relationship, and boost your child’s flexibility and resilience by participating in SPACE parent-based treatment. These skills will last a lifetime and might change the course of your child’s recovery from their eating disorder.
SPACE is about learning to recognize parental accommodation and establish a new way of responding to anxious behaviors. When applied in eating disorder situations, SPACE can address anxious behaviors like food restriction and rituals, body-checking, and body comments. It teaches you to focus on your behavior rather than your child’s behavior since that is what is within your control. Parent training can be done either as part of a group or one-on-one. The skills taught in SPACE for eating disorders include:
1. Creating a daily routine of consistent family meals and building family connections.
2. Identifying which eating disorder behaviors are coming from anxiety and how your responses accommodate the anxiety.
3. Creating a plan for which accommodations you want to target and how you will respond differently to anxiety in the future.
4. Implementing your plan and removing your accommodation for one anxiety-driven behavior at a time.
5. Practicing and refining your approach and choosing additional targets.
How SPACE works
The SPACE parent treatment program was developed and validated by scientists at Yale University. Its original use was with kids who have anxiety disorders and obsessive-compulsive disorder (OCD). A more recent version of SPACE was developed specifically for kids with avoidant restrictive feeding intake disorder (ARFID). SPACE has also been evaluated in children who have ASD, ADHD, and challenging behaviors like physical violence and threats of suicide.
The evidence-based parent treatment usually takes place over the course of 8-16 weeks. Parents join one 1-hour meeting per week and complete homework and practice between sessions. The first several sessions focus on parent education, and the additional sessions involve the parents implementing their plans and refining their skills.
Is anxiety a factor?
If anxiety is a factor in your child’s eating disorder behaviors, then SPACE can be appropriate. Many eating disorder behaviors are driven by anxiety, including:
Food avoidance: eating only at particular times, in particular places, a very limited list of foods, etc.
Food rituals: measuring, counting, arranging, hiding, mashing, throwing food, etc.
Body checking: weighing, pinching, measuring, etc.
Body talk: frequent questions like “am I fat?” “will this make me fat?” “I’m so fat” etc.
If your child is not medically stable and/or is in Stage 1 of family-based treatment (FBT), then your targets will not be food behaviors. But if your child is home with you then it may be appropriate to apply the treatment to body checking, body talk, or other anxious behaviors that are not directly linked to the eating disorder.
Why SPACE?
I provide SPACE parent-based treatment for eating disorders because it gives parents evidence-based skills to treat anxiety-driven eating disorder behaviors. It’s an excellent option for dedicated parents who want to do more.
“There’s a sense of action and empowerment in SPACE, and I found myself feeling more hopeful than I’ve felt since Eden first started showing signs of an eating disorder,” says Alicia. “I felt so powerless so many times in the past few years, and this is the first time I’ve seen real progress in a long time.”
“I felt really connected to the other parents in my SPACE group,” says Alicia. “It was as if we could all take a collective deep breath and feel less alone in all of this. I think we were all like shaken soda cans in the beginning. We looked fine on the outside but we were ready to burst. By the end, we were sharing our successes and sometimes laughing together. There was a real sense of community and shared safety.”
Setting goals
A key goal of SPACE parent training is seeing a reduction in anxious behaviors. Parents identify the eating disorder behaviors they want to see reduced and then work towards their goals by changing their (the parents’) behavior. You can help treat your kids’ anxiety-driven eating disorder behaviors with this parent-based treatment. Target behaviors might include:
1. Food refusal goals might include expanding the list of “safe” foods.
2. Food ritual goals might include eating a meal without hiding food.
3. Weight ritual goals might include not using the bathroom scale.
4. Body talk goals might include fewer meltdowns over body appearance.
5. Treatment resistance goals might include less debate and negotiation about treatment plans and participation.
At the end of SPACE treatment, parents review the goals they are achieving and the goals they still have. The parents’ focus remains on ending their accommodation of anxiety-driven eating disorder behaviors since parental accommodation is a “maintaining factor” in eating disorders. But the results of the treatment will also be apparent in the child. There is good evidence showing that SPACE parent treatment results in a reduction in the quantity and severity of anxious behaviors by the child.
What results can I expect?
Could SPACE parent treatment be what your child needs to get further into their recovery? That depends on many factors, including how entrenched your child’s eating disorder is, your own ability to commit to and follow the treatment, and the consistency with which you practice your new skills at home.
Kids may need to continue their own treatment even when parents change their behavior. Eating disorders are complex and multi-factorial, so the ongoing involvement of a therapist, dietitian, and physician may be necessary for the foreseeable future. The main opportunity with SPACE parent treatment is for you to know that you are doing everything in your power to support your child’s recovery and nothing that will interfere with recovery.
Some parents who complete SPACE treatment see improvements very quickly, but while things will feel easier and you’ll feel more confident in your own behavior, this is not a miracle treatment. It will take time for you and your child to learn a new way of relating to anxiety-driven eating disorder behaviors.
Facing difficulties
Sometimes your child’s behavior may get worse before you see improvements. This is a known phenomenon called an “extinction burst.” You’ll learn the skills you need to stay steady in the face of anxiety escalations and will work on your own emotional regulation in times of stress. Anxious behaviors are driven by “body-up” sensations and are therefore not intentionally manipulative or coercive, but to parents, that’s exactly what they feel like.
Your desire to reduce your child’s distress and disruption will feel overwhelming at times, but you’ll have the knowledge and skills you need to respond without accommodation. Being a sturdy, strong parent when your child desperately wants you to accommodate their anxious demands will take time and practice. The SPACE parent-based treatment helps you treat your kids’ eating disorder behaviors and face these difficulties with confidence.
Extinction bursts don’t typically last long, and if you can stay the course, maintain the plan, and practice your skills, both you and your child will feel better soon. The result is fewer anxiety-driven eating disorder behaviors, confidence that you are doing the right thing, and a more connected and relaxed relationship with your child.
Give it time
Learning to hold yourself steady in the face of a powerful anxiety-driven eating disorder escalation is hard. While every parent wishes for overnight success, SPACE parent-based treatment is more about consistent improvement. You might not see the magic happening every day, but if you stick with the plan you’ll see big changes over time.
A major side effect of SPACE treatment is a reduction of “caregiver burden,” which is significant with eating disorders and can impede recovery. You’ll feel more confident and less overwhelmed and hopeless. And that alone is a major benefit of the SPACE parent-based treatment to treat your kids’ anxious eating disorder behaviors.
That’s what happened with Alicia. The first few weeks of SPACE challenged everything she thought she should be doing to support Eden. But a few weeks later, she could sense a difference in their relationship. “There was a lot less stress at mealtimes and other times we spent together,” she said. “I didn’t even realize the burden I was carrying. But now I see that I was trying to do everything right, and I was constantly walking on eggshells, afraid to make things worse. I worried all the time. But then I learned that my avoidance had actually empowered the eating disorder. Now that I know how to safely stand up to anxiety, I feel stronger and more effective.”
“Eden is still seeing her therapist weekly, but she is firmly in recovery now,” says Alicia. “We still have work to do individually and as a family, but I’m at least sure that I’ve reduced my accommodations and am doing everything in my power to keep Eden healthy through eating disorder treatment.”
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
For privacy, names and identifying details have been changed in this article.
Sometimes when a child has an eating disorder they get aggressive and even violent with family members. This is a deeply upsetting situation for parents. It’s especially hard if you’re already worn out from months or even years of caring for a child with an eating disorder.
The first thing to know is that getting angry, aggressive, and even physically violent are known symptoms that can accompany an eating disorder. They have been studied and observed in anorexia and bulimia. The most common symptoms are verbal and physical aggression against relatives and others who are close.
During eating disorder treatment, your child may have verbal or physical outbursts for seemingly minor things. The key is to work on understanding why they are getting so upset and to manage your own reaction to their emotional outburst. Trying to shut down violet behavior during eating disorder recovery isn’t typically effective, but managing your reactions to the behavior can defuse the situation and make things much better.
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Free Guide: How Parents Can Help A Child With An Eating Disorder
Master the secrets to supporting a child with an eating disorder. Thousands of families like yours are stronger today because of these six vital lessons drawn from lived experience, best practices, and extensive study.
Someone with an eating disorder is living in a state of extremely high emotional dysregulation. This is a physiological state that is designed to keep us safe from predators. When it goes into overdrive, it can lead to a near-constant state of fight, flight, or freeze.
When your child is violent and aggressive in eating disorder recovery, it means they’re in a fight response. It is a signal that they are experiencing extreme fear and anxiety. It is not a sign that they have a character flaw or aren’t trying hard enough. When we soothe their physiological state, they will start to feel better and the violence will reduce.
What happens when a child with an eating disorder gets violent
When a child gets physically violent during eating disorder recovery, parents can feel shocked, overwhelmed, and afraid. There’s so much shame and stigma around kids hurting their parents, and it’s rarely spoken about.
Violent behavior does happen during eating disorder recovery, but it’s also something that needs to stop. There are no conditions under which a parent should accept violence. Additionally, your child’s violence is a symptom of extreme emotional distress. Living in a state of constant “fight” is not healthy. This means that ignoring it or pretending violence isn’t happening is dangerous for both your child and you.
Often it feels like the only possible responses to violence are to fight back, endure/ignore the violence, or call the police. Fighting back rarely ends well for anyone. And it can add to the shame involved for both parent and the child. And enduring or ignoring violence is unacceptable and, like fighting back, is dangerous for both the child and the parent.
The other response, calling the police, is something you may need to do at some point in the future. But most parents want to avoid that. And there are some steps between doing what you’re doing right now and calling the police.
How to prevent and handle violence during eating disorder recovery
Here are some steps you can take to help prevent and respond to violent behavior during eating disorder recovery and keep yourself and your child safe:
1. Respond to food aggression
The most common response to violent outbursts is to fight back with some form of physical or verbal wrestling about food and eating. However, when parents do this it rarely defuses the emotional tension that drove your child to their violent outburst. Fighting back is ineffective and often makes the outburst worse.
Violent outbursts are usually the result of extreme emotional disruption. And while it may feel as if it comes out of nowhere, there are usually patterns and signs that a violent outburst is coming.
Before a violent outburst, your child will show symptoms of emotional dysregulation. These may include shifty eyes, tense body posture, pacing, or loud voice. Some kids will signal their dysregulation by swearing or name-calling.
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Free Guide: How Parents Can Help A Child With An Eating Disorder
Master the secrets to supporting a child with an eating disorder. Thousands of families like yours are stronger today because of these six vital lessons drawn from lived experience, best practices, and extensive study.
Parents should be aware of the signs of patterns that signal a violent outburst is building and take steps to try and soothe their child’s nervous system as soon as possible.
2. Manage your own emotional dysregulation
Possibly the hardest thing to do when your child is getting aggressive and violent is to maintain your own emotional regulation. But if you are not emotionally regulated then your child will have a very hard time becoming regulated in your presence.
Work with a professional coach, therapist, or guide who can help you identify your common forms of emotional dysregulation and learn to regulate yourself with self-compassion and mindfulness.
If at any point during an aggressive confrontation you notice yourself becoming dysregulated, try to calm yourself. But if you can’t, take a break. Don’t blame your child for this by saying something like “You’re out of control so I’m leaving!” Instead, tell your child “I’m very upset right now so I’m going to take a break.” Then leave. Give yourself at least 20 minutes, which is how long it typically takes to soothe your nervous system.
Always come back to your child and talk about what happened. Leaving is not a problem, but if you leave without talking about it later, that will put your relationship at risk.
3. Label and mirror their feelings
An essential emotional regulation skill is to label and mirror your child’s feelings. This is a way of soothing your child. It shows that you are attuned to them and accept their feelings as valid and real. This step alone can transform your relationship with your child. This may not work if your child is already at the point of violence. But it can be used very effectively in the moments leading up to violence and may even prevent it.
Labeling is when you name your child’s feelings. You could say something like “I can see how angry you feel right now. You’re pacing and look agitated.” This video about the concept “name it to tame it” might be helpful:
Mirroring is when you repeat some of your child’s words back to them. For example, if your child says “you never listen to me and you’re always telling me what to do!” You could mirror back something like “it feels like I don’t listen to you.” If your child says “you can’t make me do it if I don’t want to!” You could mirror back “you don’t want to.”
When mirroring, your tone of voice matters just as much, and maybe more, than the words you say. Use what Chris Voss in his book Never Split the Difference: Negotiating As If Your Life Depended On It calls the “late-night DJ voice.” Imitate the voice of a late-night DJ: slow, steady, and soothing. With this voice, you comfort both your child’s and your own nervous system. It taps into your shared neurobiology to soothe and reassure. It communicates: we can handle this.
4. Narrate what’s going on
If your child does not calm down and moves aggressively towards you, calmly narrate what is happening in a supportive and non-judgmental manner. You could say things like:
I sense how furious you feel, but it’s not OK to push me. I’m confident we can get through this without pushing.
I can see that you are very angry, but I will not allow you to hit me, so I’m going to leave now. I’ll come back in about 20 minutes and we can try again.
I understand that this is making you feel very upset, and you get to feel that way, but I’m not OK with you threatening me. Let’s sit here together and I know we can get through it.
These statements do the following:
Label the child’s feelings and name the inappropriate behavior
Set a clear boundary
Show confidence that you can handle it
Take responsibility for your safety by leaving if necessary
Your child may not like it when you do this, but that doesn’t mean you’re doing it wrong.
Keep your narration short, simple, and factual. Don’t editorialize or debate what you’re saying with your child. Use the “late-night DJ voice” and keep your voice calm and regulated.
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Free Guide: How Parents Can Help A Child With An Eating Disorder
Master the secrets to supporting a child with an eating disorder. Thousands of families like yours are stronger today because of these six vital lessons drawn from lived experience, best practices, and extensive study.
One key in responding to anger is not to engage in debates with it. You will never win a debate when a person is in extreme emotional dysregulation. Most parents believe there must be a perfect verbal response to violence that will stop it. They think that other parents have figured it out and are doing better than them. But that’s simply not the case.
“Parents are not expected to be able to manage the disruptive situation, and instead focus on getting through it. Their only role while the child is acting in the disruptive manner is to ensure physical safety and resist being drawn into the interaction.” – Eli Lebowitz & Haim Ober, Treating Childhood and Adolescent Anxiety
The passage continues with this advice: “remain silent, or state in a quiet way that the behavior is unacceptable. If necessary, parents should attempt to distance themselves from the child in order to minimize the potential for escalation.”
6. Follow up
Once everyone has calmed down, talk about what happened. Begin by telling your child that you know they are a good kid who was having a hard time. Tell them you are going to work with them on this because even though you know how angry they get, you know that they can handle their anger without getting violent.
Violence must be named clearly and in a detailed but non-emotional manner. Avoid pointing fingers, blaming, or criticizing. Think of yourself as a dispassionate reporter. State what you observed during the violent episode.
Don’t ask questions like “What were you thinking?” or say things like “How dare you!” Because these will shut the conversation down or escalate another outburst. They will not be useful in preventing future violence. Maintain your own emotional regulation.
Talk through what you did in response to their outburst, and why. For example, if you narrated what was going on, tell them you did that because it’s important to name feelings and behaviors. If you left the room, tell them you needed to do that because violence is not acceptable.
If you did something that you regret, like wrestle with them verbally or physically, take responsibility for that and apologize for it without defending yourself. “When you approached me with your fist raised, I pushed you away. I’m sorry for doing that, as I have no intention of wrestling with you.” Or “When you called me that name, I cursed at you. I’m sorry for doing that, as I have no intention of swearing at you.”
You will need to follow all of these steps consistently before you see a change in behavior. The longer violence has been a dynamic in your relationship, the more patience and commitment you need to give this new approach.
If violence continues: write a letter
If you have consistently responded to your child’s outbursts as described above, a written letter might be the next step. This is a way to make clear your beliefs and what you intend to do in response to violence. It is a way to formally escalate your attempt to solve this problem and make it clear to your child that you take it seriously.
The letter I’m describing here and the next section about calling in supporters is largely based on a treatment called SPACE developed and scientifically tested by Eli Lebowitz and his colleagues. The process is much more extensive than what I’ve written in this article. If this sounds like something that may help you, please consider reading his books, Breaking Free of Childhood Anxiety and Treating Childhood and Adolescent Anxiety.
Lebowitz suggests printing this letter and giving it to your child, then reading it aloud. He also says that even if your child’s response is to put their fingers in their ears and rip the letter into pieces, it has still sent a meaningful signal to your child that you are serious about ending the violence.
The goals of the letter are to clearly define the specific problem of physical violence and say exactly what will happen in response. This makes clear exactly what is happening and escalates the situation in your child’s mind.
One of the biggest problems with physical violence and intimidation is that families don’t talk about it. This letter states clearly what the behavior is and how the parents are going to respond from now on.
There is a very important thing that the letter does not do. It does not tell the child what they need to do differently. This is strategic and by design. Lebowitz says that the parents need to take responsibility for what the parent will do and how they will respond, but they should not tell the child what they should do, as this will be perceived as criticism and blaming, no matter how carefully done.
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Free Guide: How Parents Can Help A Child With An Eating Disorder
Master the secrets to supporting a child with an eating disorder. Thousands of families like yours are stronger today because of these six vital lessons drawn from lived experience, best practices, and extensive study.
If your child continues to physically threaten and attack you, then it’s time to enlist help from your community. This may feel like an extreme response, but it’s much less extreme and often more effective than calling the police.
This is based on the strength of our social and community relationships. We are social beings, and the thought of someone outside the family witnessing the child’s violence can help end unacceptable patterns of violence. When done with support and love, bringing in supporters can make a huge difference.
“The role of supporters is not to shame children or embarrass them but rather to rally round the children, giving them the message ‘We all care about you, believe in you, and are going to help you.’” – Eli Lebowitz & Haim Ober, Treating Childhood and Adolescent Anxiety
Make a list of people in your family and community who might be able to help you. You are looking for people who have high levels of compassion and a good relationship with your child. Possible options include grandparents, uncles, aunts, friends and family, sports coaches, teachers, school psychologists, guidance counselors, your child’s eating disorder treatment team, and others.
Lebowitz suggests a list of 5-10 supporters, at least some of whom are in your physical community. Then reach out to them and explain the reason for your request.
Telling your child about supporters
Once you have contacted your supporters, tell your child what you have done. You can say something like “August, your violent behavior has been escalating, so we have decided to get some community support. We have contacted [list the names] and told them about what’s going on. They’re going to contact you in the next few days, and we will also tell them each time you get violent with us.”
Your child will not like that you have told outsiders about their violent behavior. Be unwavering in your belief that this is the best approach, as your next option is calling the police, which is really a last resort. Don’t debate why you did this, who you chose, or whether it’s a terrible idea. Stay firm in your conviction that this is the right thing to do.
“Any objection on the part of the child to this step should be met with a simple statement: ‘When you act in a violent way, we will not keep that a secret.’ Parents should adamantly avoid any further discussion of this point.” – Eli Lebowitz & Haim Ober, Treating Childhood and Adolescent Anxiety
When things get violent during eating disorder recovery
This article is designed to give you ideas about how to handle violent and aggressive behavior during eating disorder recovery. If your child is struggling with emotions in eating disorder recovery, then I encourage you to seek professional coaching and support for yourself as you navigate this difficult situation. You will likely need it, and you definitely deserve support. You will also be more effective if you have someone who can help you weather this storm.
Ginny Jones is the founder of More-Love.org, and a Parent Coach who helps parents who have kids with eating disorders.
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