Mental health providers

• Be empathetic
• Be nonjudgmental and non-blaming of all family members
• Use person-first language and non-stigmatizing words to describe symptoms or concerns
• Use weight-neutral language

Caregiver(s) Role

• Caregiver(s) are the enforcers of the recovery rules and structure they create.  
• Here are some of the responsibilities that feeding a child or teenager with anorexia will entail: 

Preparing caregiver(s) for the journey ahead

• Remember that recovery is not linear.
• Things may get worse before they get better. Educate caregivers on extinction bursts of undesired behavior.
  
  

Caregiver(s) can support their child at home by:

• Being completely in charge of meal and snack preparation, portioning, and serving
• Keeping the child out of the kitchen during meal preparation
• Providing one to one supervision for all meals and snacks
• Keeping firm expectations that the child must complete 100% of nutrition

During the meal or snack:

• Use verbal prompting to direct patient to eat if necessary
• Say encouraging statements like, “I know you can do this”
• Avoid negotiating or debating with the eating disorder about the food
• Monitor for hiding or throwing away food
• Use consequences if a child refuses nutrition, such as staying at the table until the meal is completed or removing screen time until the next meal or snack
• Use physical prompts such as pushing a child’s chair in or taking the lid off of a food container
• Reminding the child of a privilege or rewarding activity that may be accessed after completing the meal

• Family-Based Treatment (FBT; outpatient approach) – First-line treatment recommended by American Psychological Association (APA) and Society for Adolescent Health and Medicine (SAHM) 
• Enhanced Cognitive Behavioral Therapy (CBT-E; outpatient approach)
• Cognitive Behavior Therapy for ARFID (CBT-AR; outpatient approach)
• Dialectical Behavioral Therapy (DBT; often found in higher levels of care)
• Radically Open Dialectical Behavioral Therapy (RO-DBT)
• Exposure and Response Prevention (ERP; often found in higher levels of care)
• Cognitive Behavioral Therapy (CBT; often found in higher levels of care and in individual outpatient therapy)

It is important that a patient sees a therapist who specializes in eating disorders.

Caregiver(s) can seek a therapist by:

• Calling their insurance directly or searching on the insurance portal (specific age range and presenting concern)
• Go to psychologytoday.com and search for providers using the location, insurance, age, and presenting concern filters. Then verify that selected provider is in-network with insurance
• Other websites to seek eating disorder therapists: eatingdisorderhope.com, https://map.nationaleatingdisorders.org/, edreferral.com

Questions to ask a potential therapist:

• What treatment approach do you use?
• What age range do you typically work with?
• How do you include caregiver(s) in treatment?
• How do you collaborate with medical and nutrition providers?

It is recommended that caregiver(s) be involved in treatment as much as possible so they can learn techniques for supporting their child’s recovery at home.

• If you are referring a patient to a higher level of care (HLOC), the HLOC facility will determine which level of care (LOC) they deem most appropriate for each patient based on information that is gathered during a phone screen (typically with patient and caregiver). 
• A phone screen for HLOC does not commit a patient to HLOC.  
• A HLOC phone screen recommendation can be very helpful for patient/family and treatment team to get another opinion on the recommended LOC so an informed decision can be made. 

Below are some important considerations that higher level of care (HLOC) facilities may take into account when determining appropriate LOC for a patient with an eating disorder.  

Patient’s age, developmental level, and other factors

How old is patient? 

A younger child may be more appropriate for a level of care that keeps them at home, such as outpatient or PHP. Younger children or teens may struggle more with out of home placement, may be more at risk for contagion effects in inpatient setting. Caregiver(s) may have more ability to exert authoritative control over a younger child in FBT. 

How would they cope in an out-of-home placement with other teens of various ages? 

Consider cost/benefit of intensive treatment versus missing out on school and other normal life activities and being away from home and family. Consider risk for contagion effects especially for naïve, younger, or newer diagnosis patients. 

Do they demonstrate cognitive ability to participate meaningfully in CBT? 

A younger child (e.g., ages 8-11) may not be able to obtain benefit from CBT. Co-occurring autism, other neurodivergence, or cognitive rigidities may also be a barrier to gaining benefit from CBT. 

If considering outpatient care, does patient’s PCP feel comfortable with continuing to follow? 

Sometimes a PCP may not be comfortable closely following the patient. Often, they will feel comfortable as long as a therapist and dietitian is in place. 

Caregivers

Are the caregiver(s) well-resourced, supportive, and involved? 

FBT requires involved caregiver(s) who are willing to take on extra effort and dedicate time to their child’s recovery. Individual adolescent-focused therapy would place less burden on caregiver(s), but is not as empirically supported for patients with anorexia; may be more appropriate for patients with bulimia nervosa or binge eating disorder. Consider costs to the family for higher levels of care, as well. Outpatient may be more cost-effective.

Do caregiver(s) demonstrate high expressed emotion, discord, conflict, or parental serious mental illness? 

Proceed with caution in recommending FBT to a family with the above concerns. Patient may benefit from PHP, residential, or inpatient over FBT if there are ongoing psychosocial concerns such as those listed above.

What are caregiver(s)’ attitudes towards healthy eating? 

Caregiver(s) need to buy into the idea that food is medicine, that their child requires a higher calorie daily intake for the foreseeable future, and all foods fit and will be encouraged. Sometimes caregiver(s) with high internalized diet culture or their own disordered eating may not be helpful in the context of FBT (but some can learn to adjust their language and habits). 

Do caregiver(s) have flexibility in their schedules to provide supervision for all meals and snacks? 

Caregiver(s) may have competing responsibilities that make it difficult to supervise all meals and snacks, e.g., work, other children, single-parent household.

What insurance does family have? 

It may be harder to find an appropriate community therapist for patients with Medicaid. Families with HMO may face high copays or other out of pocket expenses for treatment. 

Severity of illness

How long has patient been ill with the eating disorder? 

Treatment within year of onset is associated with better prognosis. Treatment after three years duration of illness is associated with worsened outcomes. Newer diagnosis could be factor supporting outpatient level of care. 

Does patient want to recover? 

Verbalized desire to recover and get rid of the eating disorder can be a factor supporting outpatient level of care. A strong “no” in desire to recover would support higher level of care. 

Is patient very entrenched in their eating disorder such that they have difficulty differentiating their identity from that of the eating disorder? 

Entrenchment with the eating disorder might support higher level of care, likely inpatient, depending on other factors. 

Are there significant and persistent eating disorder behaviors such as compulsive exercising, laxative use, or frequent intentional vomiting? 

Such behaviors might necessitate higher level of care particularly if they are hard to manage in hospital setting or would be difficult for caregiver(s) to manage at home.

How underweight is patient? 

Eating disorder programs often have cut-offs for minimum percent of ideal body weight to be eligible for each level of care. The lower the weight, the more likely a higher level of care is needed in some cases (again, in consideration of other factors). For FBT, patient must be at 75% of ideal body weight or above. Often PHP criteria would 80-85% or above.