In the second half of our interview (check out part 1 of the interview here), Sari Fine Shepphird, Ph.D, clinical psychologist and author of 100 Questions & Answers about Anorexia Nervosa, offers important information about eating disorders and their treatment. For more information about Shepphird and her book, please visit her website.
Q: Can you talk about the warning signs for eating disorders?
A: Some of the more obvious signs include: the person avoids eating with others; starts to restrict the types of foods they eat (not just the quantity); becomes secretive (e.g., is evasive when asked what they had for lunch); skips meals; makes frequent trips to the bathroom after meals; starts to exercise excessively; begins to weigh themselves frequently; makes negative comments about their own bodies or other people’s bodies; seems to idealize thin celebs or thin friends; compares themselves to others (which actually isn’t a normal thing to do, even though we’re conditioned to do this by our society); starts to count calories frequently; comments about certain foods being “bad” foods and feels like a “bad person” for eating these foods.
The more subtle signs include: the person starts to dress in very baggy clothes to hide their frame; develops strange behaviors around food (e.g., only eats at a certain time of day, or in a certain order); shows great concern about weight gain and makes a lot of weight-related comments; loses or gains a significant amount of weight; begins to make general self-critical comments; develops perfectionistic tendencies; shows signs of low self-esteem; is embarrassed or ashamed after eating; puts pressure on themselves to exercise, even when they’re tired or injured.
Q: Recently, the news has reported that kids as young as five are being diagnosed with eating disorders. Why do you think patients are getting younger? Aside from general warning signs, are there specific things to watch out for with kids?
A: It is disconcerting indeed that patients with eating disorders are seemingly getting younger. Interestingly, older patients are being diagnosed with greater frequency as well. The emphasis on thinness in our culture has only gotten stronger in the past decade. Children are exposed to greater amounts of media and role models, including children’s role models, are themselves feeling a greater pressure toward thinness. Parents also feel that pressure to a greater degree and perhaps unwittingly convey their own body image concerns to their kids through their actions and words.
Parents may want to let their child’s pediatrician know if they notice any unusual behaviors around food. Picky eating is normal for children, but any behaviors that persist or seem odd or extreme should be brought to their doctor’s attention. Feeding disorders of childhood can be ruled out by their doctors, and treatment is important. Such disorders can also be precursors to later eating disorders.
Parents should be sure to start their kids off early with a healthy approach to eating, rather than a restrictive one. Children naturally have hunger and fullness cues that help to regulate their eating. These cues can become skewed if children are made to feel guilty for eating a healthy diet, or if unhealthy behaviors around food are modeled in the home.
Q: What are some ways family and friends can approach their loved one if they notice warning signs?
A: It’s difficult to approach someone who has an eating disorder. Most people are afraid that they’ll lose the friend or the loved one will be angry with them or defensive. But it’s worth the risk to express your love and concern. One thing I recommend is that people use “I” statements, so it doesn’t seem like you’re somehow attacking their behavior. This way, you come across like you’re expressing your concern. I suggest this formula, “I feel ___ when ______ because ____.” For instance, “I feel frightened when I see you skip meals, because I’m concerned that you’re losing too much weight.” Start by talking about how you feel rather than accusing the person, which is more likely to make them defensive.
I also recommend this often: You may wish to avoid addressing the eating disorder directly if you feel they may become defensive, but instead talk about something related, such as “I’ve been noticing you’re under a lot of stress lately. I can see it in your behavior. Can I help?” This approach becomes sort of a dance, take a step forward, and take a step back and perhaps even let it be for awhile. Give your loved one time to absorb what has been said, time to react and think about it. Be caring and very gentle, without feeling like you need to hammer in the point. Instead of saying, “You have a problem. You have to get help or I can’t be your friend anymore,” you can say, “If you’d like to talk more, I’m here for you.”
Q: What can you do if a loved one refuses treatment?
A: A child can be brought by their parents for involuntary treatment. However, it is difficult with an adult, because you cannot force someone into treatment unless perhaps they are gravely disabled. People with an eating disorder often feel that their eating disorder has benefits, or fear the thought of recovery. This fear of not wanting to recover is actually a symptom of the illness. The person isn’t necessarily going to consider change when they might not see the need for it.
One thing that a person can do is to point out how their (loved one’s) life would improve if they were to get treatment. Perhaps they’d have more energy to meet their goals, feel a greater sense of calm or improve their sense of self-esteem and self-worth. People with eating disorders are under a great deal of stress. Getting help will allow them to develop other kinds of coping skills to reduce stress and improve their lives. I have many patients who start going to therapy for depression, anxiety or stressful life circumstances. They don’t tell me about their eating disorder at first, or don’t want to talk about it. At a later point in treatment, they’re ready to address it. So, a great way to get someone to seek help is to offer help for or suggest discussing a different issue. Once they’re in treatment, they might be more open.
Q: Finding out your child has an eating disorder can be incredibly overwhelming and parents might not know where to start. Can you take us through the steps in finding a treatment team and helping your child through recovery?
A: It can be hard to know where to find a good professional. Oftentimes the best thing to do is to ask your primary care doctor if they know someone who specializes in eating disorders. Or, ask another trusted source, such as a religious leader or a close friend, for a recommendation. There are also specialized treatment Web sites that list people who are specifically trained in eating disorders, including: ED Referral, the Gurze Website, National Eating Disorder Association, and the National Association of Anorexia Nervosa and Associated Eating Disorders.
Even when you find a recommendation for a professional, it’s best to ask a series of questions to make sure they’re a good fit for you. Just because they’re trained in eating disorders doesn’t mean they’re automatically a good fit. Have an initial phone call to get a sense of the practitioner’s personality; ask about training and level of experience; and practical things like whether they accept your insurance, how long they’ve been treating eating disorders and if they treat your child’s specific type of eating disorder. (For questions to ask your therapist, download Shepphird’s form here.)
The best way to approach treatment is through a team approach, so make sure that person usually works with a multidisciplinary team of professionals.
If you need to find a treatment center, the same suggestions apply. You may even want to visit the treatment center and ask questions about their approach to treatment. If a treatment center has a policy that doesn’t allow parents to visit, then I would generally not recommend that center.
Once a child starts treatment, then the parents can choose various forms of support. For an adolescent or child with an eating disorder, one of the best ways we know through research for parents to be involved is a very hands-on approach. For instance, in the Maudsley approach, parents take an active approach in helping to re-feed their child and teach them about being healthy. Before, parents used to be on the sidelines, but now for younger patients, parents are encouraged to be part of the recovery.
For an older patient, Maudsley doesn’t necessarily apply. However, loved ones are still encouraged to be supportive and compassionate. It means a great deal to patients to know that people love and support them, even though they may seem uninterested or unfazed by the offer of support.
Further along the process, once a loved one is in recovery, there are some things to keep in mind. Unless it’s Maudsley therapy, where parents encourage weight gain directly, refrain from making comments about a person’s weight, such as “You’re losing weight. Are you sure you’re eating enough?” or “You look like you’ve gained some weight.” Instead, comment on other changes: “You seem happier, more energized.” “I’m so proud of you for all your hard work.”