Michael Spaulding-Barclay: 

Hello, and welcome to the Family Days Presentation on understanding the adolescent brain. I'm Michael Spaulding-Barclay. I'm an Adolescent Medicine Physician. Many of you won't know what I am and that's okay. I'll talk about that. I'm currently a Medical Director for Child and Adolescent Services. I realized I did not update my recent promotion, which is always fun, here at Eating Recovery Center in Denver. And I also function as an Adolescent Medicine Consultant over at ACUTE Center for Eating Disorders at Denver Health, which is an organization that treats the most severe eating disorders for adult patients, usually. And then they recently expanded down to teenagers and asked me to come aboard to help with some of that. So a little bit about me, now, there are three physicians here at ERC, Colorado in Denver. And so, I have about a third of the patients. 

Michael Spaulding-Barclay: 

And so for those of you who your kids talk about Dr. Mike, that's me. I grew up in Indiana. I went to IU Bloomington. So I'm a Hoosier. And then I got married after college and started medical school at Indiana University right there in Indianapolis. I also did my pediatric residency there. I thought about going up to Chicago for that, but my wife had her teaching certificate and there was not reciprocity between the states. So we stayed here. Then my wife had been willing to marry me and stuck in graduate school for seven years of training with me. So I told her I'd go anywhere in the country. She wanted to go. So she got into graduate school in Boston. So we moved out there. I was a primary pediatrician out in Boston for about three years. 

Michael Spaulding-Barclay: 

After that, we decided to move back to Indiana, originally, to be closer to our family. We wanted to start having kids of our own. And also I decided to do The Adolescent Medicine Fellowship there. And I chose Indiana University because it was one of seven sites that had a Maternal and Child Health Bureau grant to do a specific education called Leadership Education and Adolescent Health, which was a fantastic program for me to be involved in. There were only seven sites across the country that were allowed to do that. So that was great for me. I was also able to get a Master's Degree in Clinical Research during that time as well, and got to publish some of that... Or present some of that research. My first academic job was as the Medical Director of the Eating Disorder Center at the children's hospital in Kansas City, which is Children's Mercy Hospital. And that's affiliated with University of Missouri-Kansas City School of Medicine. I did that for five years. 

Michael Spaulding-Barclay: 

And then in 2012, I came here to Denver and joined The Child and Adolescent Center here, and was made Associate Medical Director in 2014. And then in 2019, I became the Medical Director of our program here. So when I was at the children's hospital in Kansas City, I had much more academic time. And so, I was a member of an adolescent research working group for the National Institute of Health. I was able to be much more involved in the Society of Adolescent Health and Medicine. I was President of our Midwest Chapter. I was a National Committee member. I used to lecture for the American Academy of Pediatrics a lot, the Society of Adolescent Health and Medicine frequently. I was on two not for profit eating disorder boards, the Eating Disorders Task Force in Indiana, and then the Body Balance Coalition in Missouri. 

Michael Spaulding-Barclay: 

And if you're familiar with USA Gymnastics, then Christy Henrich is a name you'll recognize. And she is very open that she had her eating disorder and she died from complications of her disease. And her family and her loved ones were from Missouri, and they set up that foundation. So I was a part of their board while I was there. And I've really cut down on a lot of that work since I've come to ERC because we believe in the docs in Denver being here full-time. And so I don't have a private practice. And pop in a day or two a week, I'm here full-time. So I've only kept up with, really, the Academy for Eating Disorders. Since then, I recently finished in May of 2019, my three year stint as the Co-Chair of the Medical Care Standards committee for that organization for both adults and children. 

Michael Spaulding-Barclay: 

So I get a little break from the administrative hassle for a little bit and hope to rejoin that committee next year. From a personal standpoint, I've been married, again, as I said, to my wife since 1994. We've got two kids, a fifth grader and an eighth grader. Usually, I wear bow ties. I didn't dress up as fancy for today's lecture. So that's me. I just wanted to give you a little background, so that you know, I actually know what I'm talking about, which is good, because it can be hard to hear multiple perspectives from different people in different treatment centers and maybe not know what people's background and training is. So that's why I shared that with you today. Okay. So today what we're going to talk about is, really, this overarching question, right? Which is, what does optimal nutrition status and normal weight have to do with brain development and brain wellness. 

Michael Spaulding-Barclay: 

And really, I separated those two, nutritional status and normal weight. Because technically, they're two separate things. And we're going to talk about that over time. And then they're linked to the brain development and why we care in eating disorders. So this slide was just to kind of orient you to... That's what a brain looks like. And of course that's a brain that's been preserved, because normally, they're very gelatinous and it would just kind of ooze over the table, but that's been a preserved brain. But really, we have that picture to kind of start us in recognizing how far the brain research has come. Not just in eating disorders, but even in adolescents. And so this allows us to realize and think about, in a very rudimentary way, we started with kind of looking at the brain. 

Michael Spaulding-Barclay: 

And it actually started within the 1700s, if you had a slanted forehead, you were probably a criminal. And if you had a smooth forehead, you were probably an aristocrat, right? And we've come a long way from there. But that still let us, kind of step back and think about where we started because that'll help us see how far we've come. So a little bit about the brain, for some of you this takes you back to, maybe, biochemistry or neuroanatomy, and that might be rather frightening. So we'll keep it pretty straightforward. On this slide, you'll see a couple of pictures and I'll get to those in a second. But to start with, the main components of the brain are divided into three, really three specific things, gray matter, white matter, and then fluid. And I'll talk a little bit later about why they're called gray and white. But the gray matter is really the nerve bodies, neuronal nerve brain cell. All of those mean the same thing. 

Michael Spaulding-Barclay: 

Neurophil which is dendrites and other cells that support of a function of the neuron cells or the nerve cells, and then capillaries or blood vessels that go through the brain. And then the white matter of the brain, are what are called myelinated axon tracks. And if you look at the upper right hand corner photo, you're going to see a black background and a white cell body. And then there all these kind of spicules that are spreading out from that cell body. And those are the white matter, the myelinated axon tracks. Now, you can also look at that. And if you think of the highway system for the United States, you'd see, "Okay, that's a city. And then there are highways that are leaving from that city and connecting to other cities along the way." And that's a great way of looking at how the brain functions. 

Michael Spaulding-Barclay: 

Now, the lower right hand picture is of the myelinated axon tract. And so what you'll see is that, the middle part is labeled axon and that's the nerve kind of track, that's running through the brain and throughout the body. And then surrounding that... And you'll see, it's kind of trying to give you a three dimensional picture surrounding that, wrapping that axon is something called myelin, the myelin sheath. The myelin functions kind of the insulation around the wires. And the way we talk about that is of course that increases the efficiency of the transmission and the information. So for instance, if I could do an experiment where I could actually slow down the speed of light, obviously you can't do that, but if I could, I could set up two lamps and the first lamp would have a light switch that was connected with a plug to the wall that had insulated wire. 

Michael Spaulding-Barclay: 

And so I would flip the switch and instantly the light would light up and it would light up very brightly. But if I had another lamp where I had a wire that was not insulated, number one, don't get shocked, so don't touch it, right? But I would flip on the light. And if we could actually see this, the light would turn on more slowly. And it would actually be a little bit dimmer because the speed of the electron flow across that wire would be slower than the insulated wire. And some of that energy would be lost or dissipated to the atmosphere. And so we would lose some of the efficiency of the transmission of that information. And so the myelinated axon tracks are how the information travels throughout our body on the nerve stream. 

Michael Spaulding-Barclay: 

And so the reason we talk about that and the reason we care is that myelin... And you'll see on the picture that myelin is yellow. And yellow, historically, in Atlases of Neuroanatomy and Anatomy is the function of depicting fat. And so myelin is actually supremely made of fat. Many of you, obviously you're watching this, you have a loved one or your child who has an eating disorder and all eating disorders share the hallmark of malnutrition. It doesn't matter if it's a restricting anorexia nervosa or a binge/purge subtype of anorexia nervosa, bulimia nervosa, binge eating disorder. It doesn't matter. There's no nutrition in all of them. And so if there's loss of fat content in the diet, then we're going to see a decrease or a loss of the myelin surrounding those myelinated tracks. 

Michael Spaulding-Barclay: 

Now, this slide you don't have to try to read it. It'll be very small on screen, but basically it says that high cholesterol level is essential for myelin membrane growth. And we highlighted the part and I'll read that sentence that says, "This shows that cholesterol is an indispensable component of myelin membranes and the cholesterol availability, oligodendrocytes is a rate limiting factor for brain maturation." So let's say that again, "Cholesterol availability is a rate limiting factor for brain maturation." Yet I just said, that you have a teenager who has an eating disorder, which means they're suffering from malnutrition. And so they've actually limited the brain's development. That's why we're so hardcore about our treatment approach in children and adolescents and why weight restoration is really starting to be called brain rescue. 

Michael Spaulding-Barclay: 

That's also why... I'll back up. It's called brain rescue. Now, that's also why we think FBT or family-based treatment can be so helpful. If you've heard of family-based treatment before, that's basically... For those of you who are very familiar with it, I apologize. I'm going to dumb it down quite a bit. But it's basically putting the parents back in charge of feeding their child and supporting their child during this process. Because of course, as we just talked about, their brain has been limited. They have malnutrition, so they have less cholesterol. They have myelin damage. Their brain is not functioning efficiently. It is a rate limiting step in ongoing brain maturation. They can't do this work. So that's why we love FBT. Now, this is a funny slide in some ways. 

Michael Spaulding-Barclay: 

Now, I love Time Magazine itself, because I think Time Magazine is the perfect combination of science and complete crap, right? Because you've got scientific articles which are great and well-researched, and very good. But then you've also got that annoying ad in the back. And for those of you who are women that carry a baby to term, you had that ad that always said, you're supposed to wear this necklace. And it has a jingly little charm and it bounces on your belly as you walk. And it stimulates the child's development of musical appreciation. And if you don't do that, you're a terrible mother to be, and if you do it for only 49.95 for three equal installments, you too can encourage your child's brain development. So that's the crap part of Time Magazine. But I love this because it was very simple and it had both, right? Eat butter, which is kind of a funny statement and we laugh, but in reality, butter is a fat source, right? 

Michael Spaulding-Barclay: 

And we talked about, without cholesterol, without our fat, to be able to do the myelin sheath, we're limiting our brain's development. So that's why I love this. But I also like it because in the smaller print, it says, "Scientists labeled fat the enemy, and why they were wrong." And I also like this because it allows me to remember to be humble because in reality scientists were wrong, right? But also, sometimes scientists were lying and that's always something we've got to watch out for. It's a problem, and we realize that, and that's not great. But it's competing interests, and we live in currently, in the United States. We live in a capitalistic society that's having to look at this. So I think it keeps us humble in several ways. One, is that we can be wrong. And the other is that we have to watch out to make sure that people are really caring about what's most important. 

Michael Spaulding-Barclay: 

Now, I said I'd talk about why we have gray matter and white matter. And in reality, I hope it will burst your bubble. But in some ways, as doctors, we're not that smart. Because on a MRI image or on the CAT scan image, sometimes, these look white and they look gray. And so this is a picture of three separate representations of what you can see in an MRI. And if we start on the right side of the screen, that is a depiction of a brain as if I was standing like this and you cut my brain in half like that. So you're looking from the side into the brain. The middle picture is actually lying down on the table and looking up. So I'd be lying like that, and you'd have cut me across that way. And the far left picture is looking directly out at you and having cut my face in this way. 

Michael Spaulding-Barclay: 

And so, CAT scans and MRI scans can give multiple views and pictures, so you can traverse through the brain and see three dimensional structures that way. Now, I feel very limited ability to do kind of spatial recognition. And I really struggled. My wife says that I cannot find the right size Tupperware for the leftovers for the life of me. And I think that's absolutely accurate. But when you're a radiologist, you can do this very well. And so, you can actually see these pictures by looking at three dimensional or two dimensional cuts repeatedly. You can make, in your mind, a three dimensional picture. And so we can see structures within the brain. Now, obviously, if you're thinking of a brain tumor, that would be helpful, but also it can be very helpful for tracking the development of the brain. And we'll talk about that. 

Michael Spaulding-Barclay: 

So this slide packs a lot into one slide. And so we'll stay on this slide for a little bit. What I want to start with is on the far left. And I'll read it to you because it might be hard to read on the screen. And it's a structural MRI to track changes in size and shape of neuroanatomical structures with development. Basically the original way that brain imaging was able to be used... Remember I had the picture of the brain that was outside and was being preserved, that was the lumpy bumpy brain in the forehead, and then we moved into brain imaging. And the first way we were able to image the brain was structurally. And so what you can see on the slide is that highlighted in red is a slightly inverted E-shape, and then maybe a long peanut or almond-shape that's near the center. 

Michael Spaulding-Barclay: 

So the concept of this was you would have a surgeon who has a patient who suffered a gunshot wound or was in a car crash, and they came in and had an abnormality or a destruction of brain tissue in the areas that are highlighted. And that physician realized, "Oh, this patient cannot do the following processes." Can't do XYZ, right? And so they realized, "Well, XYZ must be controlled in the brain, in that area." Which is great, right? Because then they publish that. And then some surgeon halfway across the country or the world, but say, "I saw the same thing." And then maybe a stroke specialist would say, "I had a patient who had a stroke. And they had destruction in the same area. And they too could not do XYZ." And so that's when we realized you can find out what areas of the brain tasked with certain areas of function. 

Michael Spaulding-Barclay: 

However, then even smarter people said, "Now, wait a minute. We know that inverted E and this long almond-shape are involved in doing this task. What does that area of the brain look like in an infant? What does it look like in a child? What does it look like in a teenager? What's it look like in adult or in a geriatric patient, because then you could track the brain's development over time, at least from a structural standpoint. And that can provide a lot of information and data, which is great." Now, obviously, not enough. And so that took us to the next phase. And the next phase is the middle picture. And the middle picture says, "Functional MRI imaging or FMRI, tracking changes in the brain and behavior with development." So in this instance, what this allows you to do, there are special MRIs where you can put someone in the scanner and you can have them do something like listen to music. 

Michael Spaulding-Barclay: 

And the area of the brain that is involved in the process of hearing and processing auditory information becomes active. It's using energy. You can have them do a math problem, and the area of the brain that's involved in doing mathematics would light up because it becomes active and it's using energy. You can show them pictures of kittens and puppy dogs and flowers, and the vision center will light up. What's interesting is that some studies have shown when you put patients with anorexia nervosa in that scanner and you show them either a picture of themselves, or they see a reflection of themselves, the vision center actually goes dormant or is not used very much. The area of the brain that actually lights up as being active is a very rudimentary central part of our brain. It functions as the fear and rage center, the fight or flight center. 

Michael Spaulding-Barclay: 

And that area of the brain lights up and it's processing the information. So we were really struck with that. We said, "Well, we always thought we knew you have distorted view of yourself..." Because a patient with anorexia nervosa, restricting type, might be appearing grossly underweight, right? Yet they see themselves as overweight. So we always knew they're clearly not seeing themselves appropriately, but we didn't really know what that meant. And then this brain imaging showed that they're not actually processing the information within the visual cortex. So in reality, it brings up the question of, do these patients even see? The old saying, "If a tree falls in the woods and no one is there to hear it, does it make a sound?" And of course, as a scientist, I'm like, "Of course it does. It causes vibrations in the air and that's how sound is transmitted." But it's an existential question, right? If no one's there to actually appreciate that that has happened or to hear it, it doesn't matter, right? So if patients aren't using the visual center of the brain to process the information, are they really seeing themselves? And we just don't know. 

Michael Spaulding-Barclay: 

Now, the other piece, looking at this functional brain imaging is, what this allowed us to do is... In this example I gave of the person that had a stroke or had a car crash or a gunshot wound. And they couldn't a certain action, right? Or couldn't do a certain task. Functional brain imaging allowed us to then look at healthy people and say, "Well, what portion of that inverted E? Is it the entire portion of the inverted E? The entire long almond or peanut-shaped segment of that that's involved in... Well, no, we highlighted in yellow. It's really the tips of the E, and the tip of that peanut, or that almond-shape structure that are involved in actually doing that task. And so, again, with functional MRI, then you could look at that task being performed at different ages across the spectrum, and see the change and the development of the brain over time, which really opened up our understanding in the brain and development. 

Michael Spaulding-Barclay: 

And actually, is one of the things that allowed us to realize that adolescence is a true period of development. It's actually not a social construct based off the bleeding heart liberals, right? Who wanted to stop people from having to be children and work. After the industrial revolution, and so they made up the construct of adolescents. Well, actually, no, it's not made up. There's a tremendous amount of adolescent brain development that does actually occur. And in the final, the right hand side of the screen is diffusion tensor imaging. And look, that's way above my pay grade. I am not a brain imager. I'm not a neuroscientist in that way. And so it's extremely complicated. But what it's looking at is actually, we've got these two areas, right? The inverted E and this almond-shape. And we know that really, it's just the tips of those two that are involved in these processes. 

Michael Spaulding-Barclay: 

Well, how are they connected? Well, if you reflect back on the slide before, when I told you that imaging and brain scans is actually cuts of the brain. And it's only by putting each of those images together, that you get a three dimensional picture, you can realize that, "Well, the transmission of information from the E to the almond might actually be going in a three-dimensional path." And so, on the right hand side of the screen, you can see these almost look like wires, blue, red, and green wires, and they're traversing. And that's just in one cut, they're traversing back and forth. If we were able to pile all the cuts on top of each other, you would see that that's a true three-dimensional pathway or structure. So diffusion tensor imaging is able to look at the connections, basically, the connections between the brain and the areas of the brain. 

Michael Spaulding-Barclay: 

And then again, you can look at the connection process and see, number one, is it different as the brain develops? And number two, how does that process develop? How do those connections start? When do they start? How strong are they? Did they become more stronger? Did they become less strong? And that's been a fascinating area of brain research. Again, way above my pay grade. And I can barely understand diffusion tensor imaging. But recognizing that it's allowing us to realize that it's the connections within the brain that are made that are actually important, really leads us into the next phase of our discussion. Now, this picture I love because... The first picture I had a gelatinous brain that was there and everybody thought, "Oh, that's the brain." Well, not really. The brain when we think about it, is the function of the brain. And I like this picture, because it's all of these wires, this massive millions and millions of wires, all passing and intertwined with each other into different areas, all of them connected. That lets you realize how complicated the brain is. 

Michael Spaulding-Barclay: 

And it also allows you to realize how destructive a process that hurts the brain can be. Because even if that process is as simple, and this is not simple, but as simple as a foreign object coming through the brain, like a gunshot, or blunt trauma that occurs to the brain in a car crash, or brain tumor that grows in an area of the brain. It's not just hurting that brain tissue, anything that was coming through there as a wire is being destroyed. And so that could be impacting the brain all over the place. And that's the concern that we have because of course, malnutrition, which we talked about is present in every single one of your family members or loved ones or your children's illnesses is damaging brain tissue. It's starving the brain and in adolescence, it's stopping brain development. 

Michael Spaulding-Barclay: 

Now, we're going to talk a little bit about the brain's development and we'll get down to kind of brass tacks here, right? So we're going to look at it in our outline here, we're going to look at the childhood process, and then adolescence. We're going to repeat the same ideas. We're going to use the idea of pruning, right? So proliferation or growth and then pruning or trimming away. And if you own any trees and bushes in your backyard, you know what this looks like, right? You actually have to cut some of the branches, destroying the tree. Cutting that branch, destroying that branch rather, to help the health of the tree or the bush overall. So you're actually doing good by pruning, even though you're destroying part of the tree at first, right? So that's the analogy or the metaphor rather, we're going to use to look at this. 

Michael Spaulding-Barclay: 

We're also going to talk about the sequential process of the brain's development. And hopefully that will give you a little bit of insight into your teenager, wherever they are. And that might, hopefully, give you a little compassion for yourself on your frustration level with your team. Because it might explain that in reality, we're going to, hopefully, shift the paradigm from, teenagers are annoying and act in stupid ways all the time to shifting... To realizing that in fact teenagers are highly impressive because most of them are functioning at peak brain developmental capacity at all times. Fascinating, right? Teenagers for years have been described as making bad decisions and poorly thought out decisions and are so annoying, yet in reality, they may be functioning even better than we are at times. So it's a humbling experience to think about. Then we're going to talk about the hormones and the environment and those influence on the brain's development. And then finally, we're going to talk about what's really important to you of course, it's the relationship of all these things to eating disorders. And how we can provide a developmental, any sensitive approach to eating disorders. And we'll talk about that. 

Michael Spaulding-Barclay: 

Now, let's look at childhood. So when does this start? So here's a pictorial representation of this process. And on the left side of the screen, you see a blue nerve cell, it's just in one nerve cell as an example. And then there are five surrounding orange cells, and there's a couple orange cells off on the left side of the screen. One on the top and one on the bottom that are not on there, but you can see the myelinated axon tracks have reached out like a hand. And this slide is to show the proliferation. Everybody's trying to touch each other. All the nerves as they're reaching out to make as many connections as they possibly can make. So there's all these little tiny red arrows that are touching and reaching out. That's proliferation, just growth and reach out, touch everything you can. 

Michael Spaulding-Barclay: 

The process of pruning is shown on the right hand side of the slide. And there's two things I want you to notice. Number one, is there's little scissors on there. They cut out most of the connections. So the bottom two orange nerves have been cut off. Those aren't needed. Top two are cut-off, those aren't needed. The bottom one that was coming in from the off the screen has been cut-off. And so really, the pathway is from the upper left hand corner of the screen, coming in to connect to the blue nerve cell, going straight across and connecting to the orange nerve cell at the end of the screen. What you'll also notice is that, we're trying to represent that by the thickening of those connections. So the yellow highlighting the connection to the pathway and literally, the little red arrows have become big blue feet that are connected to that next nerve. 

Michael Spaulding-Barclay: 

And so there's tons of proliferation and pruning, which may be weak connections, but they're everywhere possible. And then the pruning process cuts out what you don't need and strengthens what you have left. Now, back to a Time Magazine pictorial representation. And I love this because it's talking about how a child's brain develops. It was a great scientific article on brain development. And they have the little pictures in the brain of the child playing the violin. And again, in the back, you can buy the little dangly thing for 49.95 in three monthly installments. That makes you feel inadequate as a parent. But what I also like about this is it the bottom, and what it means for Child Care and Welfare Reform. Now, obviously, we're not going to talk about Child Care Welfare Reform. That's not the point, but it is the acknowledgement that even Time Magazine was able to realize that brain development of children is important and it starts in infancy. And we're going to talk about, and it actually starts before infancy. 

Michael Spaulding-Barclay: 

When you look at brain development, humans actually achieve maximum neuronal density during pregnancy. So the second trimester of pregnancy, between the third and six months of development in the uterus, and that's that upper picture of nerve proliferation, dramatic growth within the brain. And during the last trimester pruning has already started, we're already cutting out. I love this slide too, because it says, "Non-essential brain cells." Which I always think is a little scary to say, and perhaps a little bit arrogant on scientist's part to say those are non-essential. But we're trimming out areas of the brain that we don't think we're going to need to be using, that's already happening. The baby hasn't even been born and the process of both proliferation and pruning is already occurring. Now, this also highlights something else that we know, which is, children that are born prematurely are removed from the uterus during that pruning phase. 

Michael Spaulding-Barclay: 

And we do know that there are higher incidences of some developmental brain abnormalities that occur in children who were born severely prematurely and it may be because of part of that. So we already know this process happens and it's important, but it's fascinating that it happened before we're even out as a baby. Now, the second phase we look at, we're going to look at brain development from birth to age six. And this is where you need to cut us just a little bit of slack, and I'll guide you through the metaphor. But I'll explain why we chose this one later and you'll get it. But in the top of the slide, the first point, in early childhood, significant brain growth, so proliferation in the gray matter. So that actually, the 90 to 95% of our adult brain size is achieved by kindergarten. Now, that's partly why they call them toddlers, right? They're toddling about on their huge head for their tiny little body. 

Michael Spaulding-Barclay: 

But in reality, if proliferation was where it was at, then we would be at our maximum smartness in kindergarten, and we're obviously not. So the second bullet part says, "Of course the size of the brain has been attained." But not the power of the brain. And the power of the brain is actually going to be achieved through the interconnectivity. So we're going to have some pruning that occurs, and then the connections that are made within the brain. Now, the second phase of childhood from about age six to age 12, again, this time period of significant proliferation. So really, we've got proliferation from birth to 12, but we wanted to show you it's brain size achievement, birth to six. And in six to 12, there are significant connections that are being made. 

Michael Spaulding-Barclay: 

So proliferation could be put in quotations there, because it's not necessarily growing more brain cells, but it's thickening of this connectivity. So everything's coming together. And what's interesting is that this peaks slightly differently based on gender. So girls peak just a little bit earlier and that's done by about age 11 and for boys, it's done by about age 12 and a half, which is interesting because we know developmentally, girls develop both physically and also emotionally a little bit earlier than boys do. And they go through puberty a little bit earlier than boys do. So it's interesting that this occurs. And there are some correlates we'll talk about later. 

Michael Spaulding-Barclay: 

Now, what happens during adolescents? Overwhelming, and most of your children are already in adolescence. So let's talk about that. So I love this quote though, and you'll have to indulge me. So I'll use my old man cranky voice. And I had a neighbor who had this old man cranky voice. And I never knew why until my brothers explained to me that it was... When I was six, I think I was six because I think, it was kindergarten. I had climbed onto a shed in the backyard and peeled off every single one of the shingles because it was hot Pennsylvania summer, and they just peeled off so easily. And I was fascinated by that. 

Michael Spaulding-Barclay: 

But I'll use my cranky man voice because of that, because I too would have been angry at me. "Youth today loves luxury. They have bad manners, contempt for authority, no respect for older people or our elders. They talk nonsense when they should be working. They don't stand up when I walk in the room any more. They contradict their parents. They talk too much. They put their feet on the table. Ah, you dang kids get out of my yard." That's the classic explanation to that. So who wrote this? Was it my neighbor? I mean, it certainly could have been, in the seventies. Socrates. So we have teenagers for millennia, right? It's hilarious to think about this. So I love that this idea of teenagers have been a thorn in our backside forever, was there well before science was developed. Well before brain imaging was even thought of. Well before they knew the brain was anything important. So we've had that. 

Michael Spaulding-Barclay: 

That's why this paradigm shift of looking at adolescent brain development and recognizing that there may be functioning at peak developmental capacity instead of always making dumb decisions, and always being a thorn in our side is so profound. Because the paradigm has always been that, "They're annoying and make terrible decisions." And for any of you out there who are teenagers and are watching this to learn my heartfelt apologies, because I actually believe you are developing at peak development or operating at peak developmental brain capacity. But this idea of you always annoying us has been around forever. So this classic idea of adolescent behavior being influenced by raging hormones, and underdeveloped cognitive controls led to immature behavior. So it was this idea of teenagers always have a lot of go, go, go, but they never have the, "Whoa, whoa, hold on a second. I want to think that through." 

Michael Spaulding-Barclay: 

Well, part of that is influenced by hormones. Hormones, it turns out are incredibly active within the brain. When we look at hormones in general, we know hormones play a role throughout the body, particularly in the teenage years. And we know some of that. We have sexual characteristics that develop because of hormones. We also have some diseases that are very prominent or have spikes in change and their behavioral presentation during the adolescent years. So body composition, that's the difference between our muscle development and our growth. So for instance, my wife taught high school English, I said that prior, and the little freshmen would leave at the end of the school year, and they'd be like, "Bye Mrs. SB." And they'd walked down the hall. And then she said, sophomore year, she would start in the fall. And these giants would come thundering down the hall saying, "Hey, Mrs. SB, how was your summer?" And she was like, "Oh my gosh, what happened to little Timmy?" Well, he's body composition changed. He grew taller, his muscle mass shifted from fat mass, his voice deepened. All of these things that occur. And we know they're hormonally mediated. 

Michael Spaulding-Barclay: 

And we also know there are certain diseases that either present or change during the adolescent years, acne is a great example. If you are a 40 year old person and you've always had clear skin and all of a sudden you develop significant facial acne, you need to go to your doctor, because you have a tumor until proven otherwise. Because that's not supposed to happen at that age range. But when teenagers came into my office and they had acne, my first thought was not, "Oh my goodness, they have a brain tumor, or kidney tumor or technically, an adrenal tumor." My thought was, "Yeah, they have acne. Welcome to adolescence. We're going to give you some creams that you feel like don't work that well. And you will be annoyed and won't want to use them, and we'll constantly be in this battle of trying to get you to use them." 

Michael Spaulding-Barclay: 

But also there are certain cancers that are more active or become more diagnosed during the teenage years. A great example of that would be testicular cancer. It is a disease of young men. So I'm almost 50 I'm well out of the range of testicular cancer, I'm never going to get that. That's a teenager and mid-20s, early 30s disease. And then you're out of the woods. Certain types of epilepsy. Epilepsy is just a fancy word for seizure disorder. And so there are certain types of seizures or epilepsy that are prominent during the puberty years, or have a peak in development. Bipolar disorder, you can see that come on during late adolescence. Schizophrenia can present in the mid-20s, kind of the very end of adolescence, and it has to be during adulthood. 

Michael Spaulding-Barclay: 

So we've always known that there were certain diseases that were seen during adolescence. We knew it must be some sort of developmental phase. It wasn't just a social construct. It was something real. And then as we learn more and more about these things, we thought hormones are probably involved and it turns out they certainly are. Now, looking within adolescence, in this idea of proliferation and pruning, let's go on to that again. So again, the same picture, right? There's proliferation. And we talked about that by about age 11 to 12, a significant amount of proliferation in brain, both the volume of the brain was achieved by about eight, six, but then an increase in all of this connectivity. So that was another way we use the word proliferation. And then adolescence happens, and adolescence is that period of pruning. 

Michael Spaulding-Barclay: 

So again, the same slide we saw before, where you're cutting out connections to the brain that we don't think are important. So between the ages of 12 and the early twenties, almost a percent a year is cut away. So we lose about 15% of our gray matter. Now, this is a great example of when grandma's right. Grandmas usually are right. They may not always have the exact right thinking, but in general they're usually spot on. So use it or lose it. "If you stop taking your piano lessons now, you're going to regret it later." Yeah. Totally stopped taking my piano lessons. Totally regret it later. It's not impossible for me to learn to play piano now, but it's a lot harder, why? Well, you'll be happy to know because I'm caring for your child but I spend a lot more effort on science and math and thickening those connections. 

Michael Spaulding-Barclay: 

But I lost some of the ability to make those connections very thick along the artistic pathway that way. My oldest brother, he continued on with his piano lessons and he can still accompany his kids today when they play. So grandma was right about that. Use it or lose it, but it's that combination. You're using it. So not only are you losing the parts you're not using, but you're using the parts that are left. And so you're thickening those connections. So that's continuing to be kind of perfected throughout this process. So I did that with science and math and got better and better at it. And I got less and less good at like learning a foreign language and learning music. 

Michael Spaulding-Barclay: 

So, as the brain is becoming gradually more effective, trimming away areas we don't need, and thickening the connections of other areas, what we're realizing... The second bullet point is, this is at the expense of losing some of our ability to heal from injury to the brain. So for instance, if you look at a child who's two or three years old and they end up having a disease that impacts their brain as a stroke or brain tumor, and it impacts the area of learning to walk compared to me at 50, almost 50 years old, having the same thing happen to me, well, who is it going to be easier to train, to learn how to walk? Well, the two year old, because they were barely knowing how to do it anyway. And their brain is so plastic and they have so development ahead of them. They can find how to walk and learn and retrain their brain much easier than I can because I've already trimmed down most of that stuff that I didn't need anymore. 

Michael Spaulding-Barclay: 

So we know some basic examples of that from, again, looking at things structurally. Structural damage to the brain and how our bodies recovered from it. But then we can also look more at function of the brain. And so what about things that impact the way our brain functions? It may not be a blood loss or a blunt trauma, but injuries to the brain like a seizure disorder that alters the electrical conduction within the brain? Well, if that happens during childhood or adolescence where the brain is developing, that impacts the brain differently than if it happens at my age. What about damage to the brain that's emotional? And whether that's witnessing violence, being a part of a violence, whether it's anxiety or depressive disorders, which we know when you have anxiety, your brain is releasing chemicals that are actually neurotoxins. 

Michael Spaulding-Barclay: 

So your brain is anxious and you're releasing chemicals that actually are damaging your brain and making that worse. You're marinating in this sauce that's actually bad for your brain. It's impacting the way that develops. Again, very different than now for me, at almost age 50 when the brain development has been completed. Now, the good news is processing speed continues to increase till about age 25 or so though, and it's all downhill from there. So for most of you watching, sorry, we're on the bottom half, that's for sure. Now, just in case you're a pictorial person, or you learn visually, this is a picture of the brain and you'll notice on the left, it's labeled age five, then the bottom age eight, then up to age 12, down to 16, then back up to age 20. And you'll notice the color change, and the lighter colors, yellows, reds, oranges, and light greens are the very, very rudimentary or early phase of the brain that's not very developed. 

Michael Spaulding-Barclay: 

And the later phase of the brain is the dark blues and the purples. And those are the developed part of the brain. And what you see is, you see that trajectory, during adolescence, the brain is becoming much more developed and still even at age 20, there's a lot of red and some yellow and some green in there. Despite the fact that in the United States, we've said at age 18, you're an adult and you can make your own decisions and you can vote and you can be drafted in the army. You can join the army. Meanwhile, that also means we could be taking 18 year olds, putting them truly, in true life or death situations, where they truly have to make split second decisions that are incredibly important all while following rules of engagement or guidelines that are created by people, my age, drinking coffee, and eating pizza sitting out until we hash out the rules of engagement. 

Michael Spaulding-Barclay: 

My brain's fully developed and there's age 20 still not fully developed. Really makes us think about how we've made some decisions in our world. I'll read this, you don't have to read it on the slide. This is a quote from Jay Giedd, and he used to be the Chief of Brain Imaging through the National of Mental Health, which is one of the institutes within the National Institutes of Health. And this is why we chose proliferation and pruning. I think his is even more beautiful. He uses the idea of sculpting. And so I'll read this to you, "Right around the time of puberty and on into the adult years is a particularly critical time for brain sculpting to take place. Much like Michelangelo's David, that beautiful sculpture. You started with a huge block of granite. That's the brain at the peak of the pubertal years. 

Michael Spaulding-Barclay: 

The art then is created by removing pieces of the granite. And that is how the brain is sculpting itself. Bigger isn't necessarily better, otherwise, the peak and brain function would actually occur at age 11 or 12 and a half. Rather the advances in brain function by taking away and pruning down some of those connections themselves." So you start with a block of granite and by destroying some of the granted you release the beauty that is underneath that. So now let's look, take a breath. Now let's say, go to the bathroom, get some coffee, put me on pause, whatever you do. 

Michael Spaulding-Barclay: 

Now, we'll move into the sequential areas of the brain and how that maturational process occurs. I warn you, some of these slides have a lot of small print. You don't need to read it. If you can see it, that's great. I'll read the important parts to you, so no stress. But basically, we're going to talk about how the brain matures in a very sequential process. And it basically goes back to front. And so, let's look at some of those areas. So one of the first parts of the brain to develop is called the cerebellum. You'll see this list on the bottom right hand side of this screen, there's a large yellow area that's pointing at it. It's in the very back and the bottom of a brain. And in the small print that you probably can't read, basically, it talked about, initially, we thought the cerebellum was mostly involved within kind of physical coordination. And part of that was because they did studies on rat, where if they chopped off the cerebellum, they got all wonky and they couldn't control the limbs very well. 

Michael Spaulding-Barclay: 

But it turns out, of course, we needed to be humble because, once again, with more study and elaborate thought, we realized that actually the cerebellum is very involved in higher processes of learning, particularly within supporting functions of mathematics, music and advanced social skills. Now it's interesting, you could make the argument that some of the social skills may actually be through the recognition and interpretation of body language, and that's a movement-based process. So there is some possibility that would really make sense. And that we were a little foolish to think at first it was mostly just movement. What's also of interest about the cerebellum is that the cerebellum is really sensitive to the environment and even more so than specifically to our genes or the heredity. So it's taking input from the environment, is very sensitive to that. Talk about more about that in a second. 

Michael Spaulding-Barclay: 

Now, we're going to move back to front. It's kind of detouring. We're going into the deep part of the brain, but just go with it on me. And this is the amygdala, the yellow arrow pointing to it on the screen. The amygdala is the emotional center of the brain. That's the fear and rage center that I talked about before in a functional MRI scanning that lights up like a Christmas tree when patients with anorexia nervosa see themselves. It's not the vision center of the brain. It's this fear and rage center, this emotional center of the brain. What's important though, I just talked about the first part to develop as a cerebellum. The second is the emotional center of the brain. So of course, teenagers are functioning and reacting out of an emotional context. Makes total sense, it's the next thing to develop. 

Michael Spaulding-Barclay: 

Next we move on to the basal ganglia, which is an area of the brain. It's interesting. It's a little bit larger in females than male. So again, a different hormonal structure of set up there, which is interesting to think about. And basically the basal ganglia is trying to act as kind of the administrative assistant and the secretary that's kind of helping you to organize and prioritize some of this information. But again, isn't it interesting that you're starting to develop your emotional response system well before you have anything that organizes or prioritizes any of that. Which is why we get those beautiful times when we ask our kids, "Oh my gosh, what were you thinking? Ah!" And they say, "[inaudible 00:43:01]." And we're like, we want to pull our hair out. Maybe I already did pull my hair out. When in reality, now nobody talks like this, but wouldn't it be fascinating, if we went to visit our child and get them out of the jail because they'd been locked up and we let them sit overnight and we go there in the morning and we say, "Oh my gosh, son, daughter, what were you thinking?" 

Michael Spaulding-Barclay: 

And they say, "Mother, father allow me to explain. I was walking along the sidewalk with my peers, cajoling and prodding me forward. And I saw that brick on the ground and it's beautiful, perfectly rectangular shape, and has this hole drilled through it. So I knew it would really fly through the air with less friction and resistance. I've learned that in math recently, and I saw that plate glass window and I knew, Oh, those two were destined to join one another. And in fact, yes, father, I did actually see the police car across the street out of my peripheral vision, which I took note of. But also, I was recognizing my peers behind me laughing and building me up and saying that I wasn't brave enough. And my gosh, I'm going to show them. So I picked up that brick and I threw it with all my force and I made sure when I threw it, that I looked over my shoulder to make sure that the person I was interested in the most was taking notice of me. And I threw with all my might. And oh, father, mother, if you could have been there and heard the crash that it made and the stimulation to my brain and the sensory sensation, that's why I did that father. And it was totally worth it." 

Michael Spaulding-Barclay: 

That would be great. No one talks like that. It would still be terrible and it would be dumb and they still would have been arrested, but it would make a lot more sense for us. And then if they stopped to say even further, "Mother, I did that because I have a biological drive to provide my brain the input it needs to perform its brain development. And without getting this input and without developing, I'll be stunted forever. So I knew this was in best interest to pursue this incredibly emotionally engaging experience. That's why I did it." Although we don't like necessarily what it said, we like that a lot more than, "I don't know." Right? "Why did you do that?" "Oh, I don't know." Because they're annoyed and frustrated and feel they're so stupid, acting so dumb. When in reality, they're acting at peak developmental capacity and encouraging their ongoing brain development, which we'll hear about later is essential to mental health. 

Michael Spaulding-Barclay: 

Now, the corpus callosum is the next area of the brain that we talk about that develops, it's really... That's the connection between the two hemispheres of the brain. And it's really... Again, initially they just thought that wasn't that important. And it's incredibly important in processing brain information, particularly in the efficiency and the speed with which we can process that information. And then finally, the last part of the brain that develops is the prefrontal cortex. Now, the prefrontal cortex on this slide is described as the CEO of the brain or the area of sober second thought. Teenagers have tons of hormones that go, go, go the emotional center of the brain that go, go, go. The prefrontal cortex is our, whoa. "I saw the beauty of the brick and the plate glass window, and I wanted them to meet, but I realized not the best idea with a cop sitting over there. So I don't think I'm going to do that today." And the whoa, is the last thing to develop. And we know brain development isn't complete until nearly 25, maybe a little earlier in girls, 23, right? 

Michael Spaulding-Barclay: 

That's why teenagers are engaging in what we've call stupid behaviors. So again, it's from back to front, but we can also look at this differently, we can look at the back of the brain or posterior, in other words for back, don't worry about that. But the back of the brain, those areas of the brain development really mediate direct communication with the environment. So the area that involves vision or visual cortex is in the back of the brain, the auditory cortex. Some of the hearing or some of the touch and spatial processing are in the back of the brain. So the areas that are... It makes sense. They're involved in input of information from the environment and having to make decisions. And it also makes sense that it's very rudimentary, because any rudimentary animal knows, "Oh, all of a sudden it got dark, that could be a shadow. I got cold, I should move into the sun." So it's mediating contact with the environment and that's what the brain is functioning from. 

Michael Spaulding-Barclay: 

The mid point area of the brain, the midbrain that we talk about that functions next is really the input of coordinating that sensory input. It's the start of emotions and attaching value to some of these things that are coming. And so, "Oh, I really like that sound, or I really like that view." Artists that are can identify things that are aesthetically pleasing to them from a visual cortex standpoint. And they can start prioritizing that and making decisions based on the emotions surrounding those issues. And then finally the front or the anterior, or the front portion of the brain, which again, is the prefrontal cortex, the area of sober thought, putting all of that together, weighing the costs and benefits, the consequences to our behaviors. 

Michael Spaulding-Barclay: 

So go, go, go, at first, the whoa comes later. A finer a way of looking at this as the kind of trying brain way of looking. So reptiles share with us the reptilian brain or the internal structures of the back of the brain structures, mediating contact with the environment. Mammals, the limbic system. Limbic system is just another area for our emotional system. And then finally we say the Neo-mammalian or the humans are the only ones that develop a neocortex that allows us to think brilliantly and have this sober second thought. So big, deep breath. We'll summarize this very briefly. Again, we talked about this concept of proliferation and pruning. There's proliferation that occurs from birth to age six and then proliferation, again, that goes from age six to 12, which is the increasing, strengthening connectivity that's happening in the brain. 

Michael Spaulding-Barclay: 

And then fine tuning or the pruning process is what occurs during adolescents. The cutting away is what actually is that allowing the brain to fully come on line. But that it does so in a very sequential process, so that, it's the last thing to come on line is the thing we all wish they had first, which is the ability to weigh the consequences to their actions. But that actually comes later. And if you, that has a child, that's making these dumb decisions. Well, gosh, any of you that have a child or a loved one that has a disease that seems irrational, perfect explanation of eating disorders. They seem completely irrational. And in some ways it makes sense that there's a peak of onset of eating disorders during the adolescent time frame. Now, it doesn't just mean that maturation will make it all get better, but it's definitely interesting that occurs during this period of brain development. 

Michael Spaulding-Barclay: 

And finally, like I mentioned before, full brain maturation, isn't complete until about age 25. So now let's shift gears a little bit and let's talk about the hormonal and environmental influences on brain development. Now, I love this slide because we're going to... I highlighted a few things. But these are the steroid hormones. So we all know hormones like testosterone and estrogen. We've heard about those. Those are listed on the lower right hand side of the screen. Testosterone and estradiol is just a fancy name for estrogen. That's listed under the gonadal hormones. The gonads are our sex hormones. So the testes and the ovaries are what create those. But in reality, you'll see there's a bunch of arrows and there's these precursors. So estrone is what turns into estradiol and you can follow the arrows back and you'll end at cholesterol. 

Michael Spaulding-Barclay: 

And if you look at the bottom of the screen... We don't have time to talk about these today, very much, but also aldosterone and cortisol are adrenal steroids. Adrenal gland, is a different area of the body. And these create aldosterone and cortisol, which are very actually involved in the regulation of excitability and some impacts on mood and anxiety. However, we don't have time to talk about those. But those also come from cholesterol. So in reality, cholesterol is the building block for steroids. So we're always thinking of sex steroids as sexual characteristics, right? Breast tissue development, body, hair, body odor, all of that stuff, muscle mass changes. But in reality, these are involved in processes all over our body. All of them coming from the same fundamental building block of cholesterol, yet, your kids and loved ones have a disease that is marked by malnutrition, right? Malnutrition. Eat butter, joking aside, we'll move on. 

Michael Spaulding-Barclay: 

So let's look at the hormone influences on the brain. Again, the peak of brain proliferation is kind of correlated with that onset of puberty. The brain gets its peak at about 11 for girls, about 12 and a half for boys, that's about when puberty starts. So they're obviously linked. However, we also know there's variation in the timing of puberty. So there are kids who are late bloomers. There are kids who are early bloomers. And we know that, although these processes, brain development and sexual characteristics with hormones are linked, they're not a hundred percent tightly linked. So the process that occurs in the brain is going to occur, even if secondary sexual characteristics haven't yet developed. So if you have a late physical developer, you'll notice that their voice is still high. They don't have a lot of muscle development. They complain about being flat chested or whatever it is. 

Michael Spaulding-Barclay: 

Yet you know, that intellectually, socially, developmentally, they're still as advanced as their age match peers, right? And vice versa. If they're really early pubertal developers from a physical characteristic standpoint, their brain did not go faster. So in reality, they may look like a 16 year old girl or a 17 or 18 year old boy, but they're still functioning like the age they are, 11 or 12 year old, maybe 12 or 13 year old, if you're lucky. But you can imagine if you look like an older teenager, people are going to expect certain behavior on a view that you may not be developmentally ready to do, which also might put you in peril. There may be times that you're an early developer and you find yourself in a pseudo dating situation that catches you totally off guard because you didn't catch the cues that everybody else was leaving and you should leave too. And then you find yourself in the basement with an older boy or girl that you don't know. And so you can see where that might get kids into situations that are difficult to navigate for them. 

Michael Spaulding-Barclay: 

We also know that hormones, whether they're gonadal hormones or adrenal hormones, and again, we're not going to talk much about adrenal hormones, are very involved in all the organs developments throughout the entire body. So of course, they're involved in the brain. And where are these hormones involved? All over the body and all over the brain, but particularly in areas of the brain that regulate mood and excitability. Now on the screen, you'll see that it's talking about serotonin. There are several other neurotransmitters, norepinephrine, dopamine, all of them can be involved in this. Serotonin is just a very well known one that people have heard of, but they're involved in the mood and excitability pathway, which makes sense during adolescence, is the time period of high stimulation of the mood and anxiety standpoint, mood and anxiety center of the brain, of the emotional center of the brain it's being stimulated like gangbusters. So it makes sense that would be those where those receptors for hormones would be located. 

Michael Spaulding-Barclay: 

Now really, the next few slides are just if you're really a visual person, or if you happen to be a neuroanatomist out there, you'll recognize all of these areas of the brain. We're not going to go into them. But it's just showing that all of these areas are involved in hormone receptor interactions and influence brain development. Now, this slide is actually looking on the left hand side of the screen. What it's supposed to look like is kind of a tree branch, and that's a nerve and there's little spicules, right? Like those hands that we're reaching out to make connections with other nerves. And the right side of the brain is a slide that's supposed to represent a brain tissue that was just dipped in estrogen. And what it's supposed to see, if it shows up nicely on the screen like it does for my screen is that there's a lot more of these little spicules or thorns on the bush. Lots more hands reaching out to make connection just by dunking it in estrogen, fascinating process. 

Michael Spaulding-Barclay: 

Other areas of the brain, these are kind of central or limbic systems of the brain that are being looked at, obviously, anywhere in the brain that we look, it's been influenced by hormones, which is fascinating. So we know that sex hormones are especially active in this limbic center or this emotional center of the brain. And so partly, that's why it's creating this tinderbox of emotions. A lot of go, go, go, and very little of the whoa, that goes along with it. So adolescents are actively looking for experiences to create these intense feelings. So again, referring back to my parody of what the child should say, "Well, so father, mother, I was driven to have these experiences to create my further brain developmental process." Maddening and necessary. 

Michael Spaulding-Barclay: 

Now, let's look at the environment and how the environment affects the brain. Now, I share these slide sets with Dr. Ovidio Bermudez, who hopefully you get to hear one of his talks as well. He's a brilliant scientist. He's an incredible clinician and a wonderful man. And I don't know exactly how he came up with this slide, but I like to think it was this, because this a way of coming up with a definition for environment. And so the world we live in, our habitat, which kind of implies kind of home or where we want to be a little bit more or where we function, which shows that, well, maybe our environment can influence us. We might function better in different environments. And also may imply that we can be in different environments and still function even if they're not great for us. And then finally this, the world in which we feel comfortable. 

Michael Spaulding-Barclay: 

And again, I haven't run this by him, exactly, but I know him well enough to know that this could very well be plausible. So this is attributed to Nathan who was probably some dude who sat in seat 4C on this Southwest flight that Dr. B was on back in 2012. Again, I don't know if that's true, but I could totally see this. Dr. Bermudez is the amazing person that, you can all of the socially acceptable signs up while you're traveling that say, "Do not talk to me." And you know what these are, right? You're already sitting down, you've already got your seat belt on. You got your book open. You have your ear pods in, even if they're not plugged in, you have them. Everything is saying, "Don't talk to me" If Dr. Bermudez sits down beside you, he's going to start talking to you. And by, gosh, you're going to close the book. You're going to take out the headphones and you're going to find yourself, "Oh, it's time to descend into our landing city." And you're going to realize, where did the time go? I just had this amazingly stimulating conversation with this doctor from Denver. 

Michael Spaulding-Barclay: 

And so I can easily see this guy, Nathan and Dr. B, getting into this conversation about, "Well, how do we really define our environment and how it impacts us as kind of humans on the planet on a very existential standpoint? And Nathan saying, "What's the room which we feel comfortable?" And Dr. B being wise enough to latch onto that and realize, "That's the perfect definition." Because where we feel comfortable, we're going to gravitate to being in that environment. We're going to try and control that environment. It's going to influence us and we're going to influence it. So I love that definition. It really shows how the environment is incredibly impactful on all of us. 

Michael Spaulding-Barclay: 

Now, another way of looking at how the environment can impact us is looking at twins studies, right? And I tell you, twin studies are fascinating and I've gone down that rabbit hole before. And it is truly amazing because you can basically find a twin study that looks at anything and all of them, right? The twins that are identical twins that were raised by the same family. Fraternal twins, they're not identical, but they're fraternal twins. They were raised by the same family. Identical twins that were separated at birth and raised by different families who didn't know them. You can find it all. What's maddening about twin studies? Is that it shows how complex this is to study. Because in reality, many times you run up with, "Yeah, we're not sure." 

Michael Spaulding-Barclay: 

And one of the things that it'll say is in fact, "Sometimes, it is the unique experiences that twins have that actually shaped them or change them more than shared experiences do. However, even defining unique from shared experiences can be very difficult." Dr. B used to tell a story about, let's imagine two twins, identical, coming home from the library at night on campus. And somebody jumps out of the bushes and grabs both their purses and takes off. So they got mugged, or their wallets or whatever. It's a gender neutral story, I don't care. One twin whips out their cell phone from the back of their phone, clicks a selfie, puts it on Facebook or Instagram, or whatever kids use these days, and says, "Dude, just got mugged. Whoa." 

Michael Spaulding-Barclay: 

The other twin doesn't do that. They walk home together. It's a day later, the second twin couldn't go to class that day. The first twin's getting nervous. The second twin actually didn't leave the room, too scared. First twin calls their parents, parents come down to college, take the second twin, take them home, maybe enroll them in treatment program for severe anxiety because they've haven't even leave the home. They've been crippled with anxiety from that. A shared experience and identical twins, completely experienced differently. So in reality, I think the environment is incredibly difficult to evaluate how that's impacting us. Yet, we'll continue to try. But it brings up the question, to what extent may environmental and pathophysiological influences, hormones, malnutrition, brain tumor, all of that, negatively impact the brain if they occur during adolescence, because it's a period of development? So not only is it impacting the brain, but it's impacting the brain while the brain is attempting to become maximal in its power. 

Michael Spaulding-Barclay: 

So for instance, if these are brain exposures, like being exposed to repeated traumas, exposed to repeated violence, we know that's bad. That's why it's in every movie known to man. They'll have the montage flashback scene where the child hears themselves told that they're stupid and they're bad over and over and over again. And we're instantly able to say, "Oh, I get it." Right? Right. It's a device they'll use in a two hour movie, I realized that. But we immediately get it, "Yeah. That's inherently bad." So we know that. But what about when that happens during a period of adolescence and there's also malnutrition occurring. So their brain is telling them these things, how many of you have talked to your child and they've talked about the eating disorder voice? It's not psychotic, right? It's a well known kind of way of looking at the eating disorder and depersonalizing it. 

Michael Spaulding-Barclay: 

But a lot of them will experience it as this voice telling you things. And I got to tell you, it's almost never like, "Great job today. You've done enough. You're really good." It's not that. It's always negative, terrible things. So I was told to explain it to parents by saying, "Think of the worst possible thing you could hear that you never wanted people to know about you, and saying it over and over, and everybody's saying it." So you walk into work and your boss says, "Hey, you're a terrible father. You're a horrible provider. You can't support your wife very well." "By the way, Mike, you're the worst younger brother ever. And you're a terrible son." "You're a horrible doctor. And everybody at work is undermined by you." All the things I don't want to hear, over and over and over again. With depression, anxiety, we already know that it's causing a marinate, that's destructive to the brain tissue itself. And then on top of that, they're seeing the world through this depressed lens, which is dark and hopeless. Not seeing any way out, not wanting to do anything fun anymore because it doesn't have any joy or value in it anymore. Anxious and worried, retreating, isolating, protecting themselves as best they can. Obviously that makes things so much worse. 

 

Dr. Spaulding-Barclay:

We're going to shift gears a little bit more. Initially with malnutrition illnesses and originally in eating disorders, that's the only people that were able to present for care or people who are horribly malnourished. Luckily, we've come a long way, and we realize that malnourishment is a part of all eating disorders. We need to be helping everybody, but originally, people said, "Well, we know we're malnourished, and we know that's bad for us and it's bad for our body. Our muscle's wasting away. What's happening to the brain?"

Dr. Spaulding-Barclay:

The original brain research was done, and the brains all looked smaller. At first, we said we really hope that's more fluid. Remember, I said gray white matter and then fluid. We hope there's more fluid produced during malnutrition. It squishes the brain and makes it look smaller. Now, that was hopeful thinking. It wasn't that. It was actually loss of brain tissue, loss of brain matter because of the volume changes from malnutrition.

Dr. Spaulding-Barclay:

Then, the question was like, "Oh, my goodness. We're destroying brain tissue. Can it go back? Will my child's brain grow back? I don't care if they're 35 years old and they're your child or they're 14 and they're your child or they're 12, whatever, but is it going to grow back?" WE worry more during adolescence because of the impact on the brain development, but anytime, you have a disease that makes your brain get smaller because of destruction sounds terrible.

Dr. Spaulding-Barclay:

Well, you can tell from this slide that I've worked with therapists for years because it says, "Yes, the brain will grow back, and there's problems." The reason we use and, of course, if you use the word but, if I said, "Yes, but," yes the brain tissue goes back, but that's terrible anyway. Saying the but negates everything you just said beforehand. Saying an and allows you to still hold on to that hope of the yes, and it does get more thorny. Let's look at that.

Dr. Spaulding-Barclay:

Again, if you can't read the slide, that's okay. I'll read the important things for you. This is brain tissue volume changes following weight gain in adults with anorexia nervosa. In a nutshell, this was a study that looked at adults who had anorexia nervosa and said if they're starved and their brains are smaller, lower in volume, compared to normal people, what happens when you get their weight back on? Normalization of weight.

Dr. Spaulding-Barclay:

Remember at the very beginning, I talked about two things, normalization of weight and optimal nutritional status. This was looking at normalization of weight. This is a table one from that study which if you're a scientist out there, you'll appreciate because it showed that there were two groups. There was the sick group who were starved and the non-sick group. Otherwise, they looked the same other than their weight was supremely different.

Dr. Spaulding-Barclay:

They were horribly malnourished in one group and not in the second group. Let's get to the results. This is the white matter. The white matter volume changes. You'll see on this slide that there's a flat line on the top. That's the line, of course, for the control patients because their brains were the same at the start of the study and at the end of the study.

Dr. Spaulding-Barclay:

The slanted line shows that it starts lower. At the start of the study, the starved patients with anorexia nervosa had lower white matter brain volumes, smaller. Notice at the end of the study, they get back to basically the same point. It might look on the screen like it passes it a little bit. It's statistically insignificant. It gets back to the same point, really reassuring that's great. Proof the brain recovers, all as well. Shoot, now we see this slide.

Dr. Spaulding-Barclay:

This is the gray matter slide which is actually the cells of the brain, the actual brain nerves. We look at this slide. Again, you have a flat line along the top. That's the controls, normal brain at the start of the study and still normal brain at the end because they were not malnourished. The patients who were starved had lower gray matter volumes. You see it goes up, but it does not get to where it needs to be. That is a statistically significant gap.

Dr. Spaulding-Barclay:

The white matter recovered when you normalize their weight. Normalized weight according to these studies. The gray matter is not yet back to normal. It is not recovered. Well, that's horrifying news. Now, there is some hope. Don't worry. If we look down the road that does normalize, but you'll notice on the screen, it says two and a half to three years. What that means is it can take two and a half to three years of normalization of weight and nutrition to fix the brain.

Dr. Spaulding-Barclay:

Normalization of weight was not enough. You had to continue to normalize the nutrition over two to three years. This is a two to three-year long process of brain recovery which shows why we're so hardcore in adolescents because their brain is developing. We don't want to extend this to a six or eight-year process because we're interrupting over half the brain development. We want to make it as short as possible.

Dr. Spaulding-Barclay:

We want to get the nutrition fixed fast and hard and now. Good news, recovered patients with eating disorders, the length of recovery was about two to three years. They had both MRI and PET scans. You don't have to care about the difference. The scans were normal in patients, showed that long-term recovery of weight could lead to normalization of the structural brain changes that had been seen from the starvation. Great news. But the harder news was this.

Dr. Spaulding-Barclay:

This study looked at adolescent females with a past history of anorexia nervosa. The first thing they did is did a clinical examination to make sure are they really recovered or not. That was helpful. Then, they did MRI screening or scanning to look at structural abnormalities of the brain, but then, they also did very, very fancy neurocognitive evaluations. They're looking at brain function, not just brain structure,

but brain function. You remember back to that slide where we had three ways of looking at brain research, structural, function and then diffusion tensor imaging, the connectivity. This is looking at structural versus function.

Dr. Spaulding-Barclay:

Let's go through this. Subjects with persistent low weight, so teenagers who actually had never normalized their weight had abnormal MRI scans. Structurally, their brains were abnormal. We totally get that. Those with normal weight had normal brain structures, exactly what we just saw in the previous study. That replicated that. That's good news. I'm glad to hear that.

Dr. Spaulding-Barclay:

However, certain patients with anorexia nervosa in this study also had abnormal function, so structural brain abnormality. If you're still underweight, the structure is off. If you're normalized weight, the structure is normal just like the adult study had shown. Looking at the function of the brain, that was different.

Dr. Spaulding-Barclay:

Low weight was correlated with abnormal structure. Duh, we just talked about that. Also, cortisol again, we didn't have time to talk about that. So, we'll skip that, but those two were correlated. But what was interesting is looking at those patients who had abnormal function of the brain, participants were patients who were amenorrhea. That's a fancy word of saying they did not have their menses or period. This study was done only on girls or had irregular menses. This is a proxy, a way to evaluate the hormones, kind of a poor man's way of looking at the hormone tests. Kind of like I use hot chocolate mix with my coffee. It's a poor man's mocha, way cheaper than Starbucks, I got to tell you.

Dr. Spaulding-Barclay:

Patients who were amenorrhoeic or had irregular menses had significant cognitive defects in this fancy neuropsychological testing. It was across a range of tasks even if the structural brain changes has resolved. What that means is the patients who were normal weight, the structure of the brain was fine. They were normal weight. The structure of the brain was fine, but some of them still had abnormal function of the brain. It turns out those were the patients who had an abnormal hormonal status. Their hormones were abnormal. Hormone is a proxy or a marker of malnutrition because you could be normal weight and still be malnourished. That's what was happening to these patients.

Dr. Spaulding-Barclay:

What that brought up is this intra-player questionnaire dynamic between menstrual function, a proxy for hormonal status and cognitive performance. When we look at that, when we look at weight restoration, the first studies told us if you get a normal weight, everything's great. The study proved that's not true. Should we get marginal weight recovery?

Dr. Spaulding-Barclay:

Well, we know this is what they're really supposed to weigh. Let's only get part way there. We're almost there. It's probably good enough. For those of you who are parents of patients that I directly take care of, you've probably heard me say this before. Insurance companies like two phrases that I hate, and the first phrase is good enough, and the second phrase is probably. I hate that. I don't like probably within

medicine. I don't like good enough, in general. Now, that's got its own issues and problems, so sorry, but that's where we're all coming from.

Dr. Spaulding-Barclay:

If we already know weight alone only fixes the structural stuff, how on earth could weight alone not even be achieved? How could we be willing to not even achieve weight alone when we're looking at the adolescent brain development? Again, I realize this can be a different discussion for a true 35, 45, 55-year old woman or man with an eating disorder, and you're in a different conversation. I get that.

Dr. Spaulding-Barclay:

I'm focusing on the period of adolescent brain development and recognizing that if the brain structure is not normal, that could be devastating. We have to at least get that normal. That's why we're so hardcore at eating recovery center across the country on weight restoration for teenagers because we know that's a fundamental process for the recovery.

Dr. Spaulding-Barclay:

In summary, here's the challenge. The current data suggests there's this complex mix between normalization of stress responses that was a reference to the cortisol that we've talked about, but weight status and hormonal well-being, optimization of nutritional status, to combine, to give us optimal brain function, to allow ongoing brain maturation. Weight recovery alone, and I'm just going to directly read it.

Dr. Spaulding-Barclay:

Weight recovery alone may be insufficient, and recovery from a nutritional insult may require adequate body composition and hormonal function i.e. optimal nutritional status to support optimal brain function in all systems go brain environment.

Dr. Spaulding-Barclay:

Body composition is just a fancy way of saying fat, and nobody with eating disorders likes to talk about fat because they're scared, but when we look at it, we can't just have the weight number on the scale be correct. We have to have optimal nutritional status. That includes enough fat content, enough fat intake to be that building block of cholesterol to be able to get all the hormones, to be able to build and be online.

Dr. Spaulding-Barclay:

I'm just going to hammer home that point. Cholesterol, metabolism, and homeostasis in the brain, let me read that. The content of cholesterol in brain must be accurately maintained in order to keep brain function well. I don't know if you can say it more directly than that. Fascinating information. Therefore, I come back to our funny slide of eating butter. We have to have adequate fat content in our diet. It doesn't matter. The patients are afraid. We have to do it.

Dr. Spaulding-Barclay:

Now, shifting gears a little bit, let's talk a little more about research here. This article was looking at do end of treatment assessments predict outcome at follow-up and eating disorders. You might recognize some of these names from the adolescent literature including Dan Lagrange and specifically James Lock

or Jim Lock. Lock and Lagrange, some of the early pioneers in the United States at least a family-based treatment.

Dr. Spaulding-Barclay:

Dr. Mike's research 101. I'll catch you up. Look, you've got a patient is admitted because they're sick, and you've identified they're sick. You're going to do something to treat them. You have entrance into care. Then, you do something to treat them. At the end of your treatment, you evaluate if your treatment worked. That's called end of treatment assessments obviously. They've got better and you feel great about yourself. You're really impressed that you did good work.

Dr. Spaulding-Barclay:

You did. Don't get me wrong, but then what happens when they leave? Well, what we ideally want to do is do a follow-up study long after to see did my treatment and the change that it caused actually continue to help the patient later. That's follow-up now notoriously in eating disorders follow-up studies have been incredibly difficult to do now part of that is a function of our united states health care system you move you change jobs they don't cover that treatment center anymore. You have to go somewhere else. They didn't use exactly the same measures and all that stuff. It's very complex.

Dr. Spaulding-Barclay:

We're trying to do our part of ERC. Actually, you'll probably be communicated with after discharge asking you to do some follow-up questionnaires and things like that. It’s up to you, but, man, I would love it if you did. I'll just tell you this is a personal plea.

Dr. Spaulding-Barclay:

I've been in the field for almost two decades now. What I don't want to do is do the same year over and over and over again because 20 years later, that's not 20 years of experience. That's one year of experience repeated 20 times. 20 years of experience is reading the new literature that comes out and assimilating that evidence into your practice and changing what you do.

Dr. Spaulding-Barclay:

Then, the new literature comes out, and you do the same thing. ERC wants to contribute to that literature so that we can know what we're doing today. We can evaluate what is working of what we're doing today and what should be continued on.

Dr. Spaulding-Barclay:

If you get hassled, I know it's annoying. I know it has lots of pain that comes with it, but I'd love you to be involved so that when I retire in, like I don't know, eight years old or whenever I can finally stop tottering around here, I don't just have one year of experience from now repeated. I've built on the 20 years that we've already brought.

Dr. Spaulding-Barclay:

What they looked at was let's look at our patients when they come in. Let's treat them and let’s evaluate them when they leave. Then, let's see what is it about how they're doing when they leave that we've changed. We’ve improved their weight. Maybe, their depression scores are lower. Their anxiety scores are lower. All body images, sure, all that stuff.

Dr. Spaulding-Barclay:

What really matters when they finish and they get out there. What they found is this and it’s a beautiful sentence. I'm going to directly read it. Achieving a body weight of 95.2%, so clearly a statistician involved, a little dig for you statisticians out there, achieving a body weight of 95.2% of expected body weight by end of treatment is the best predictor of recovery for adolescents with anorexia nervosa. Did you hear that?

Dr. Spaulding-Barclay:

Achieving a weight of 95% of your expected weight that you're supposed to be, by end of treatment was the best predictor of recovery ongoing. Not body [inaudible 00:14:41] distress, not depression, not anxiety, not whether the parents got a divorce and that was hard, not whether they lost a friend to suicide, all these traumas that we think about, none of those panned out as being really important.

Dr. Spaulding-Barclay:

It’s achieving a body weight. Now, that doesn't mean that none of those things were important, but this was the best predictor. Weight normalization and achievement of an optimal nutritional status is the best predictor of outcome for patients with anorexia nervosa during adolescence.

Dr. Spaulding-Barclay:

It’s incredibly powerful study. That's why we are so hardcore about weight restoration. Now, we're going to shift again. I know we shift around a lot in this. We're covering a ton in a short amount of time, so bear with me.

Dr. Spaulding-Barclay:

We want to look a little bit about brain development and how it's helping kids interact. This is a great picture. I want to take just a second. I want you to look at this young woman. I want you to just think in your mind what are some possible feelings that she might be having now. I'm actually going to shut up. I know I talk a lot. I'm actually going to shut up and give you a few seconds here to think about that, what she could possibly be thinking.

Dr. Spaulding-Barclay:

Most adults when I give the talk in person, most people shout out things like scared, startled, surprised, worried, sad, maybe, maybe on the verge of tears. What teenagers tell us is that this girl is angry, hostile. They see anger and hostility where it doesn't exist. Now, that's a fancy way of saying everybody hates me. Have you ever heard that from your team?

Dr. Spaulding-Barclay:

Well, my teachers are all out to get me. Well, yeah, if I'm at a conference and I see it and I'm walking back from a dinner late and I'm going back to the hotel and it’s dark and I'm walking on the sidewalk and I see a young woman walking towards me with that expression on her face, I feel so bad for her because I'm like, "Oh, poor thing. She seems scared of me." I'll cross the street because I don't want her to have to feel scared at night.

Dr. Spaulding-Barclay:

I'm not thinking, "Oh, my gosh. She's going to jump me and mug me," because she doesn't look angry or hostile to me. She looks scared or nervous because of me, but teenagers are going to see anger and hostility where it doesn't exist. They're wired to interpret it that way. Now, it makes sense. That's probably safer from a developmental or evolutionary process. It's not very helpful. Oh, sorry. This is a pictorial representation of that in case you're really visual.

Dr. Spaulding-Barclay:

The blue line is the development of the prefrontal cortex. You'll notice that's the lowest line early in adolescence. The green line goes higher first. That's the amygdala or that emotional center of the brain that develops first. The red, shaded or scribbled area is that the amygdala is taking over and doing the brain decision making until late in adolescence when the prefrontal cortex comes on board, and that can take over the decision making.

Dr. Spaulding-Barclay:

The emotional response is she's angry at me, I'm going to hit her first. Mom, I hit her back first versus the sober second thought that says, "Oh, she looks angry. Well, maybe she's sad. Oh, I think she's scared actually." Oh, it's late at night. I'm an adult male. She's a young adolescent girl. Gosh maybe she's nervous.

Dr. Spaulding-Barclay:

Then, this slide we're looking at anxious teenagers versus teenagers who are not anxious. The reason we bring this up, of course, is how many of you out there have a child with an eating disorder who also struggles with anxiety in some form. It may not be enough to be a true anxiety disorder. Let's call it high strung at best. Almost all of you are out there raising your hands or nodding your hands or looking at your partner and saying, "Yes."

Dr. Spaulding-Barclay:

What they found is that anxiety actually makes this tendency to see anger and hostility where it doesn't exist worse. Then, you have a person who's already scared. They're seeing someone who appears scared, and they're interpreting it as that they're hostile against them. It's really going to ring out my protective resource or protective responses.

Dr. Spaulding-Barclay:

I'm really going to be trying to protect myself from this hostile attack. Why'd you get in the fight? Well, mother, I got in the fight because I interpreted his facial expression and body language as hostile. Unfortunately, they're realized there was hostility there that I thought there was. It actually wasn't there. I misinterpreted that.

Dr. Spaulding-Barclay:

However, I thought there was hostility there. Of course, in a protective mechanism, I immediately brought up my hand and a quick hook. Now, the good news is it was incredibly effective. He fell down. I was safe. Don't worry, mother. I know you were worried. That's not how they talk. Mumble, mumble, mumble, when in reality, they did it perfect. They did exactly what they're supposed to do. They saw a threat, and they reacted to it.

Dr. Spaulding-Barclay:

They can't help it that their brain hasn't developed enough to weigh the consequences then and bring it back a little bit. Then, you add anxiety in the mix. Then, you add malnutrition on top of that. It's a perfect tinderbox.

Dr. Spaulding-Barclay:

Now, this is another study. You don't have to look at this, and we'll skip through very quickly because basically it says what we've talked about. Basic configuration and functional networks in the brain have already been established by the age of age 12. Functional networks continue to change during adolescence, that pruning process. Important changes in these functional networks determine neurocognitive skills and psychosocial functioning all of those happen ongoing in late adolescence, blah, blah, blah, all that stuff.

Dr. Spaulding-Barclay:

Functional connectivity depends upon rapid accumulation of experiences, but also may be shaped by experiences and how they develop in relation to the environmental demands. Development of functional connectivity in the brain may be a prerequisite for the proper development of normal psychological functions. Breaking this down, you have to have experiences which will help shape your brain so that you can continue normal brain development, and that process is required to end up with a normal brain down the road, just like when you taught your child to walk, and they were toddling about, and you leaned over, and they grabbed your fingers, and you leaned over, and you had back pain for a while because they were walking.

Dr. Spaulding-Barclay:

If you're walking along the sidewalk with them in their bare feet and you see a shattered bottle on the... You didn't [inaudible 00:21:22] you pick them up, right? You put them back down when it was clear, and you kept on walking. Then, you're walking with their child when they're older and they may be barefoot. Let's say they're still barefoot, and you stop them, and you point out the broken glass. You say "Little Timmy or little Susie, we're going to walk around that broken glass. Daddy's going to take your hand. I'm going to hold your hand, and we're going to walk around it."

Dr. Spaulding-Barclay:

Then as they got older still, you put out your hand, you stopped him. You say, "Hey, do you see the glass?" Well, hey I had to stop you. We're going to walk around. Then, they got older still, and you said, "Hey, you see the glass." You see that go, "Yeah. Aww. Yeah. It hurts when you walk through the glass and flip-flops. Nice job. Let's take you home and clean you up." Eventually, they have to do the process on their own, but not when they're a two-year-old.

Dr. Spaulding-Barclay:

Teenage brain development is the same thing. They have to go through these processes You cannot carry them forever over the glass. If you're carrying a two-year-old over the broken bottle, I'm like, "Oh, it totally makes sense." If you're carrying your 16-year-old across the broken bottle, I'm a little bit like, "I don't mean to criticize, but you seem a little weird." You're obviously wanting to protect your child and we get it.

Dr. Spaulding-Barclay:

If they can't make the decision appropriately, you will swoop in when needed. Some people disparage parents and call that helicopter parents or enmeshed parents. I was actually thinking that was wise parenting realizing they're unable to make those decisions, so you're helping them, but you want to then take action to get them back to normal development, so they can make these decisions on their own.

Dr. Spaulding-Barclay:

They have to go through these processes to trigger brain development so that they have a chance to have normal psychological functioning later. Now, that was a lot. Now, how do we tie all this together with eating disorders because we've still got a lot to talk about. Well, let's look at that.

Dr. Spaulding-Barclay:

Historically, the eating disorders community has looked at willingness to get better. You've got to hit rock bottom. You got to be motivated for recovery. You got to believe. Great. Love that. In the adult literature, that's very well tied with outcome. I love that stuff.

Dr. Spaulding-Barclay:

However, in teenagers, when we're looking at brain development, if we're looking for them to be utilizing a prefrontal cortex that has not developed yet, that ain't going to happen. We're barking up the wrong tree. The past few decades, they've been able to realize that and say, "WE actually have to focus on ability, assessing where the brain is in development, supporting it getting back on track and being able to get back on that trajectory of normal development." Yeah. We may need to take over functions that the kids can't do.

Dr. Spaulding-Barclay:

Just like you did a graded response for walking through the broken bottle on the sidewalk, the same thing can happen with eating disorders. What does that mean in teenagers? Well, let's look at several things. Well, we know that teenagers are way more concrete. Come on. There we go, meaning they lack the capacity for abstract thinking.

Dr. Spaulding-Barclay:

One of the great ways of looking at this is that initially with smoking and realizing it was bad for everybody's health and wanting to decrease teen smoking, lots of campaigns were started educating teenagers about the risks of lung cancer down the road and teenagers didn't care. Then, people said, "Well, what if we tell them that your breath will stink and your fingertips will look yellow, and you won't get a date to the dance." Wow. That worked a lot better. That was focusing on what they needed right now and how they were thinking right now which was concrete.

Dr. Spaulding-Barclay:

Teenagers also tend to act out much more. It makes sense from a developmental standpoint. They have limited social cognition especially in large groups. That's why group think in teenagers is always worse. We know that. Set shifting difficulties is the idea of being able to really disconnect and change your perspective. That's very difficult for teenagers. Then, the two that were highlighted, we'll talk about a little bit more. The first of those... Oh sorry. Then, there's emotional dysregulation, of course. This tinder

box of emotions that's constantly being stimulated without much of the woe or the ability to reign that in and look at the consequences.

Dr. Spaulding-Barclay:

Then, distress intolerance. Part of that is developmentally. They've not learned those skills yet to tolerate distress. The distress they have as children is way different than we have as adults. Now, we don't want to undermine that and say it's no big deal. That's why kids always get mad when we say, "Oh, you broke up with your first love." It's devastating to them. We're like, "Right, but, I mean you weren't going to marry." But they thought they really were. We all went through that, and we know that.

Dr. Spaulding-Barclay:

They have to go through that process, but they're very unable to tolerate distress. Then, we put them in a distressing environment where they have an eating disorder where everything in their brain is telling them not to eat. Then, we're trying to get them to eat. Then, for your teenagers or adolescents or if you're adults watching this to get a perspective on the brain development, if you were ill during that time, you at that time, if you're an adult now and you just became an ill as an adult looking at the stress that you're under while in treatment is overwhelming.

Dr. Spaulding-Barclay:

Now, alexithymia is the first highlighted one I want to talk about more in depth, and we'll skip the first parts, but we'll look at that third hashtag which is the characters of alexithymia. It's this concept of basically the inability to accurately identify or describe your emotions very well. It also goes along with often being unable to distinguish body sensations that are developed in emotional responses from normal body sensations.

Dr. Spaulding-Barclay:

It's the I'm not nervous at all, I just have a terrible headache and can't go to school today. It has nothing to do with my midterm exams. I'm not worried about school. I just have this gnawing pain in my stomach. Now, some of us would say, "Oh, I had the sensation of butterflies before I went on stage. I was a high school actor. I get the sensation of butterflies before I'd go on stage." Well, I identified that as, oh, that's butterflies. That must be what anxiety feels like.

Dr. Spaulding-Barclay:

Then later way too much information, but I had diarrhea before every wrestling match in high school. I know way too much information. However, I think it lets you know. Obviously, looking back, that was anxiety driven. But at the time, I didn't realize that because it wasn't the butterfly sensation that I got before I went on stage. I thought that's what anxiety was. I literally and I granted I was a dumb kid, but I literally thought that my mom accidentally poisoned me, food poisoning every Friday night, but only November to February.

Dr. Spaulding-Barclay:

Now, I will reassure you again those of you whose child I'm actually involved in the care of, I got a lot smarter over time. I get that, but that was my body sensation. I didn't realize that was anxiety. Now, I knew I was worried I would lose all the time, but I never p

or anxiety. Now, there are some other things about fantasy and stuff, but they're the last bullet point being they're poorly introspective.

Dr. Spaulding-Barclay:

Often kids really struggling with a lot of time here, are not the ones that sit around and say, "You know what? I think these were my feelings today. I think this is what they meant." In reality, they're the avoiders. I'll brush it under the rug. It'll be decades before that comes back to haunt me, but then I don't remember what it was about again. Well, thanks for the advice, but that's not working for us.

Dr. Spaulding-Barclay:

Now, alexithymia can be twofold. It can be trait or you're kind of born with it. It's a temperamental characteristic. You're kind of a little bit more likely to see the world that way, or it can be secondary, meaning state. I'm old enough that I used to go to a bank. You took money on paper, and you wrote your name on it. Then, they put money into your account for it.

Dr. Spaulding-Barclay:

If I'm in line at the bank and somebody comes in with a gun to rob it, I am going to be dumbstruck. If then they run away and the news crew shows up and says, "Dr. Spaulding-Barclay, how did you feel?" I'll be, "Ah, ah." Not very articulate even though in general I like to think I'm an articulate person. But I was so overwhelmed with the stimulation of that event and that terror and that anxiety that I became in a state of alexithymia. Again, anybody whose kids have had a brain insult, malnutrition, anybody whose kids are more likely to be high struggling at best and probably on the anxiety spectrum, of course, we see it all the time.

Dr. Spaulding-Barclay:

Now, central cohesion, this is a function of the ability of teenagers to really be able to get it. This is the SAT English questions. Here's a paragraph. What do they really mean? You all took that SAT. You know that there's one right answer where it really gets to the meat of the matter, and all the other questions are like, "Well, I mean that's true. It said that, but that wasn't really the point." Here's a great example that Dr. B. came up with. Let me tell you about avocados. I'll read it for you.

Dr. Spaulding-Barclay:

Their avocados are a great source of healthy nutrients like potassium. They contain a great deal of healthy fats. They're a great source of energy, average sized ones providing 300 kilocalories each. They're excellent in salads or, oh, it's the main ingredient in delicious guacamole, man. Awesome. Those of us who have strong central cohesion, we're going to get that question on the SAT right because we're going to say, "Right. Avocados, great source of healthy nutrients, potassium, fats, energy, salads, delicious guacamole." We get it. WE got an A on the test.

Dr. Spaulding-Barclay:

An example of weak central cohesion which is basically all of your loved ones is that they're going to hear this in this paragraph, a great deal of fat, 300 calories each. Well, true. That was in there. Not really the point and really missing the thrust of that paragraph, but true. I guess, I can't say that's wrong. It's just not the best interpretation. That's central cohesion. How does that apply within the treatment of eating disorders when we look back at brain development, the maturational process, the seeing hostility

and anger where it doesn't exist, the amygdala being the decision maker for the longest part of adolescence?

Dr. Spaulding-Barclay:

Well, let's look at that. Again, that's the same slide of before. We looked at willingness when really we needed to be focusing on ability evaluation of where the brain is in this maturational process and meeting the brain where it's at and then help getting it back on track. What does that mean? Well, we've come up with this idea. It's opportunities for us as clinicians and you as families and loved ones or parents.

Dr. Spaulding-Barclay:

You can't be in a treatment center and not have a catchy phrase that focuses on alliteration. Ours is empathy with expectations. I don't care what you call it, but empathy with expectations works for us. But it's this concept of, right, I feel empathetic, and I have the expectation so I'm supportive. You still have to act right. I know you're distressed and scared to eat, and you have to be safe. I know you're depressed and upset. You can't commit suicide. Empathy with expectations.

Dr. Spaulding-Barclay:

Now, what does that mean for us? Well, we've come up with 12 golden ideas that we can capitalize on, putting all of this data and information together on how we approach children from a developmental perspective with eating disorders. One of the things that we identified that is for all of us, but also for you as parents is speaking for your child. You may hear from the therapist, "Hey, wow. That's a great point that your child brings up." Ask them to tell the team that.

Dr. Spaulding-Barclay:

Now, that doesn't mean we're not going to act on it if you alert us to a safety concern, we're not going to be like, "Tell your child to bring that up." Five days later, when they bring it up, we'll act on it. Of course not. But we can utilize that information. I'll go to meet with them. The very time I meet with them, I can be prodding and trying to pull this information out of them. If they still can't bring it up, I can say, "Hey, your parents brought this up as a concern."

Dr. Spaulding-Barclay:

But having them bring it up as a concern is starting that process of being able to advocate and talk for themselves. It allows us to help identify where are they on this perspective. Can they do any of that? Can they do none of it? Again are you still carrying them over the glass or did you appropriately stop them, point it out, maybe hold their hand. Let's make sure we're on the same track.

Dr. Spaulding-Barclay:

The second point up there is a child's need for reassurance. Now, reassurance seeking is very brutal. It's definitely within the construct of anxiety. It starts out feeling so normal. Hey, what am I going to get out of here? Oh, information gathering. You are wondering about your length of stay in my treatment program. Sounds completely normal because you have no idea.

Dr. Spaulding-Barclay:

Then, they ask you over and over and over again, or they ask you, "I'm so worried I'm going to gain weight. Did you think I was fat when you saw me? Do you think I'm fat now, mom? Do you see it? Do you think I'm fat? Well, what about my face, but what about my pants? Those pants didn't fit. What do you think about that?" They're asking for reassurance.

Dr. Spaulding-Barclay:

Now, the problem is within the anxiety world, we already know. When we provide reassurance about anxiety, at best, we leave the anxiety disorder as bad as it was. At worse, we actually make it worse. Challenging reassurance seeking and making people sit within the distress that they have without that reassurance or without that certainty is actually what leads to positive change in the treatment of anxiety.

Dr. Spaulding-Barclay:

Your child is going to be asking you everything and trying to put you on the spot, and you're going to start feeling very inadequate as a parent that I don't know when you get to leave. I don't know exactly what the criteria for discharge are. I didn't think to ask you. What kind of parent am I? I'm an idiot. I'm going to ask him next time I talk to him, son. Don't you worry. Actually, not the best because don't you worry. Last time I checked doesn't help people with anxiety not worry. That's like, "Turn your frown upside down." It doesn't actually work.

Dr. Spaulding-Barclay:

Did any of you get annoyed when you talked to friends or support systems and they said something like, "Oh, I mean yeah. You just got to get them to eat as if you hadn't thought about that as a parent." Oh I should get them to eat. Oh, Dave's my close friend from my small group at church. Thank you. I had never thought about it. That's just not how it works.

Dr. Spaulding-Barclay:

We've really got to worry about are we providing reassurance instead of information. Information seeking is one thing. Reassurance seeking is a negative. Pleasing your child, indulging your child, look, you love your kids, we know that, and it's horrible to be away from them. It was before my junior year in high school before I was away from my parents, I'd never done a summer camp. Then, that summer camp I went to was one of those nerdy leadership games. I get it. Your kid's a lot younger than that, and they're separated from their family, and they're scared, and they're upset, and you want to make them happy.

Dr. Spaulding-Barclay:

Your job as parents is not to make your child happy. Your job as parents is to equip them with the tools they need to develop into the people they want to become, not to make them happy. If you're working so hard to please them or indulge them or sending them extra gifts or making sure they always have visitors to keep them happy, well in reality, you're kind of distracting them. Before they were admitted to our program, if you found yourself constantly trying to allow them to keep doing their things they want to do and give them all of these rewards even though you knew they're not really eating enough, oh, they're not quite doing what they're supposed to do, you fell into that trap because you wanted them to be happy.

Dr. Spaulding-Barclay:

Now, you were in crisis mode. We get it. We're not upset with you. We would do the same thing, but you're in crisis mode. We're not in crisis mode now. We can get out of that. You can allow them to have some distress and not be indulged. That's okay.

Dr. Spaulding-Barclay:

Now, let's go back to central cohesion. The person with weak central cohesion heard a great deal of fats, 300 calories. Our intuitive response in trying to accommodate their anxiety wanting to make them feel better is that, oh, I see you're not understanding what I mean. I'll read this. Avocados are awesome. They're not really fattening as you thought. Look, you want avocados. You just don't know it now. You're confused. They're the best for your health.

Dr. Spaulding-Barclay:

Then, we walk to whoever else is involved in her life as a caregiver, a spouse or a friend or parent or whatever and we're like, Oh, don't worry, honey. I got this. They're okay." Then, they go in and talk to him. This is what they hear, "Mom, dad, grandma, whatever, they said avocados are really fattening. They're the worst thing for health." Then, that parent comes streaming out of the room to you. You're like, "Whoa, wait a minute." You guys go back in. That's your eating disorder talking. Right now is the time to start [inaudible 00:37:26] because things are probably going to be thrown across the room.

Dr. Spaulding-Barclay:

Now, I love the depersonalization of the eating disorder, is that the voice that you hear inside yourself that tells you all these negative things and is convincing you not to eat because I think that's a way of helping kids say we care about you and you're in there, and we know it. I hate the eating disorder, but sometimes, patients tell us. When we say things like that's the eating disorder talking, they feel very invalidated because they're in there too. They feel very minimized.

Dr. Spaulding-Barclay:

Of course, as they're working out of the emotional center of their underdeveloped brain, they're angry and they lash out. They're not able to have the understanding of, well, what I really meant was that portion of you is taking over right now and making most of the decisions. I wouldn't recommend that you say that's your eating disorder talking even though we talk about that functionally as a team all the time.

Dr. Spaulding-Barclay:

But we tried to reassure them, "Oh, you don't get it. You don't understand. Yeah, this is what it is." Reassurance seeking, actually worsening the anxiety, building it up even worse. What else can we look at? Well, setting boundaries, having consequences, and being consistent. Well, that's what a treatment program can do.

Dr. Spaulding-Barclay:

Look, I'm not the exhausted parent who's trying to do this while also working full-time taking care of the other children, being involved in your organizations that you're involved in at home, the stress of your child and taking them to appointments. I work here, high level of care. The doors are locked. We keep the kids separate. If the kids are in PHP at one of our sites across the country, it's a high level of care and support, but as clinicians, we get to go home every day in a 24-hour care setting. I have staff that comes

in. They work the night shift. They're not exhausted. They're ready to go. They're ready to provide care, love, and support. We have an unending stream of people who can do that.

Dr. Spaulding-Barclay:

Of course, we're able to be much more consistent and structured in our boundaries. Even, we screw it up. Absolutely, we're human. We're going to mess it up. Your kid's going to call you on the phone. They said this, and then they turned around and said this. Yeah, we're going to screw up.

Dr. Spaulding-Barclay:

I've done that. I've come into my weekly or my daily… Sorry, daily afternoon meeting. I come in. I say, "Oh, I just met with so and so, and they said this. So I told them we're going to do that." Then, the dietitian says, "Dr. Mike, I just met with them two hours beforehand, and they said this, and this is what the plan should be." I'm like, "Ah my bad. Yup. I did that too." Sorry.

Dr. Spaulding-Barclay:

Then, we go to the group and we meet the kid. I say, "Hey, sorry. You'd already talked with the dietitian." By then, the story had changed a little bit. Help me understand that. Why'd the story change, because I gave you advice based on what I understood, but I hadn't talked to the team member yet, so we may need to change that. We were inconsistent. We do the best we can. Obviously, we can be much more consistent in a higher level of care. That's one of the advantages of higher level of care, but really during development, the brain is craving that consistency. You'll remember this from when they were little kids, and you told them what to expect, and what the expectations for behavior were.

Dr. Spaulding-Barclay:

When they were engaging in positive behaviors, you were giving them reward and positive attention for that behavior. When they engaged in a behavior that was inappropriate, you pointed it out, reminded them of what the expectation was and they hand the punishment and the consequence. Totally makes sense. It totally makes sense.

Dr. Spaulding-Barclay:

Now, some other really important ones, this is the idea of alignment with the treatment team. That's looking at two ways that can appear. We're all of the treatment team. If you're a parent of a loved one, you're [inaudible 00:40:43], you're on the treatment team. When your kid says something like, "Were you going to tell my treatment team," I'm like, "Well, you just told your mom. So, yeah. The treatment team knows because your mom's on the treatment team."

Dr. Spaulding-Barclay:

Of course, you're going to tell us. You're not going to promise not to tell the treatment team something because you are the treatment team. I'm the treatment team, and the therapist, and the dietitian, and the outpatient team. We're all united together against the eating disorder. The reason I say that is to also let you know you're supported. You've got a treatment team with you that you're on.

Dr. Spaulding-Barclay:

When you start to feel like, "I don't know what to do," ask someone else on the team. Hey, I need spelled out. I'm tired. I need help. But the idea of questioning the treatment team, of course, you want a question the treatment team. If you don't know what's going on, ask questions.

Dr. Spaulding-Barclay:

This is more the idea of negative frame versus seeking clarification. Here are some examples, questioning calorie intake or weight or medication. An example of negative framing on calories would be 4500 calories. My kid's eating 4500 calories. That's ridiculous. Nobody eats 4500 calories. That's crazy. You guys are just nuts. That's just ridiculous. Of course, they're distressed. That's a little hostile and negative. Obviously, you're acting out of your own fear and distress. We know that. You love your kid. You're wanting to support them. You're petrified. You don't understand what's going on.

Dr. Spaulding-Barclay:

You're falling up into the emotional outburst part. We get it. I'm not worried. If you say that, "Don’t worry," I'm not going to be like, "Oh, I'm not sure. Do they really need 4500…" Of course, I know that already. I'm not threatened by that. We're not worried about that. What we can come back to and we can explain, "Oh, well here's why their body needs 4500 calories right now because it's burning so many calories to heal the damage that's happened."

Dr. Spaulding-Barclay:

Now, also that can be hard to hear emotionally because then you start to feel like, "Oh, my gosh. I let my kid get so malnourished." You didn't let your kid anything. The eating disorder came in and wrenched them away from you and put them in danger, but seeking clarification might be a different way of approaching it. It might be saying, "My kid said she's on 4500 calories." I'm overwhelmed. That seems way too much. Wouldn't anybody be unable to eat 4500 calories? Help me understand that.

Dr. Spaulding-Barclay:

You don't have to be perfect. The reason we're pointing this out is it lets you cut to the chase faster. When you come in, guns are blazing. I'm like, "Wow, Mama Bear and Papa Bear are here. We got to turn off the guns. We've got to get that down. We got to let everybody simmer. We got to peel through the layers of the armor that they've got up. We've got to show them that we care about their kid and we're all on the same team together." It takes more time.

Dr. Spaulding-Barclay:

We're happy to do it. If that's what you need, we're on it. We're skilled at that. If you're able to seek clarification, it cuts through that so much faster. It enables you to get the equip because, of course, I may be thinking your question about the medicines, "Why would anybody choose that medicine? That's ridiculous." I'm thinking, "Oh, I need to educate the parents about this medication." That wasn't what it was.

Dr. Spaulding-Barclay:

They were terrified because they saw on Oprah that this medication kills you. If they came saying, "I saw an Oprah that this medication kills you, and I'm terrified," oh my gosh, let me educate you on that Oprah special on how wrong it was. I love Oprah, but sometimes, just way out there. Trying to be clarification seeking instead of negative framing is great.

Dr. Spaulding-Barclay:

Then, the last bullet point under that is seeking repeated reassurance. If you're realizing, you have to ask the same question, "Are you sure it's not too much weight? Are you sure they're not going to be too heavy? Are you sure they're not going to be overweight? Are you sure..." We've already told you. Obviously, you're struggling to hold on to that information.

Dr. Spaulding-Barclay:

If you know that about yourself, if you know verbally I don't get information as well as I do written, ask your therapist, "Can you send me a written summary of what we talk about in therapy?" I'm like, "Right. That's what we covered today in our family session. This is what my homework is for next week," because otherwise, it'll go in one ear and out the other and they forget. That would help me. Plus, hey, I realized I'm distressed when I'm in therapy, and so I don't remember as well. That really helps me. Great. Happy to do that.

Dr. Spaulding-Barclay:

If you realize that you're constantly having to seek reassurance, find a way to get the support that you need because we need you strong. You're on the team. You're not a bystander, and we're the team. You're on the team. When you get home, you're the most important members of the team. You're the most important members now, but especially when you get home with the responsibility of the day-to-day management, every kid is back on your shoulders.

Dr. Spaulding-Barclay:

Looking at the last one, not last of these topics, but last on the slide, is addressing concerns about weight, shape, and size. This is the kid who's constantly asking for reassurance. Do I look fat? Do I look different? Do you think I look different? Why would you say that you think I look healthy? Why would you say… But also, your kids are going to look different. If they come to a 24-hour care setting and they were horrifically underweight and malnourished, we're going to put weight on them and fix their nourishment fast.

Dr. Spaulding-Barclay:

Yeah. Some kids arrive, and they need to gain 30 pounds, and we're going to do it not as fast as we can, but dang fast and so easily in seven or eight weeks, they put on 30 pounds. Of course, where are we going to see that? Well, the data from the rat studies says it's going to go intra-abdominally, and we know that because that's where... I mean everything is important from here to here except our brain. Your heart is there. The half of your lungs are there. Two kidneys, liver, intestines, stomach, pancreas, ovary, uterus, testicles are basically… Everything's happening right there. Of course, it's going to go right there to initially cause insulation, wrap those organs to keep them protected and safe again.

Dr. Spaulding-Barclay:

But also, it's going to go in our face because we can make expressions. Our face is very plastic. Yeah. If you drop your kid off and you can't come back until they weigh 30 pounds more and you see them, their face is going to look rounder, for sure.

Dr. Spaulding-Barclay:

You may be like, "Oh, my gosh. My kid looks different." If your kid doesn't look different in that long, I did something wrong. They should look different, but how are you approaching that because we already went through the data. A normalization of weight is not enough. We've also got to fully normalize the hormonal structure or the hormonal pathways. We need optimal nutritional rehabilitation.

Dr. Spaulding-Barclay:

We know the body is going through this process of storing it rapidly here and then accessing it to continue to heal. Most of it is immediately being burnt to heal, and the rest is being utilized and stored. But when you talk to your kid about it, what are you going to say? Well, we talk about the parents thoughts about the body, the appearance of your kid. You may be troubled by that.

Dr. Spaulding-Barclay:

Ask questions, saying, "My kid looks fat and overweight." Well, wow where's that coming from? No, cut that apart. Cut the fat and overweight part. Let's do it this way. We're looking at how the parents and the patients are looking at this, and the parent says, "Oh, my gosh. My kids face look so much more round." Of course, they're distressed. Well, yeah. Asking questions about why did that happen, we're happy to talk to you.

Dr. Spaulding-Barclay:

For you, we'll talk about the fourth bullet down, redistribution. There is a process of weight redistribution. Over the next year to year and a half or so, the body re-acclimates. In reality, it puts the appearance of the weight where it's supposed to actually be. However, I'm going to counsel you not to talk about weight redistribution with your kid because, remember, they don't have good cohesion, central cohesion.

Dr. Spaulding-Barclay:

What you're going to do is you're going to say, "I'm going to educate you. I just talked to the doctor." They told me there's this concept of weight redistribution. Over the next 12 to 18 weeks, don't worry, son, daughter, your body is going to redistribute and look very different. That's okay.

Dr. Spaulding-Barclay:

I guarantee you what your kid is going to tell me because they've done it for a decade and a half. They're going to say, "My dad said I am fat and disgusting and that in a year to a year and a half, it won't be as horrible," which is not at all what you said, but that might be what they interpret.

Dr. Spaulding-Barclay:

We're happy to provide that information for you as parents to help you understand why that process is going on, but talking to a kid who has an irrational disease, I don't care how rational your kid is normally. They have an irrational disease. That's not going to work very well, but what also happens when the patient sees their body differently because of course they have a view of distortion we talked about that, their brain interprets it incorrectly and abnormally.

Dr. Spaulding-Barclay:

But what about when parents see it differently? If one parent says, "Well, yeah. They look a little rounder right now." I get it. That's okay. The other pair is terrified, but they said, if they look like that again, they would kill themselves. Of course, you're terrified.

Dr. Spaulding-Barclay:

We'll be able to help support you with that process. That doesn't mean we don't treat your child. That doesn't mean we go to partial weight restoration. That slide, should we go to partial or margin or not good enough? Normalization of way to only fix the structural abnormalities of the brain. We've got to fix the function of the brain, so we've got to get them all the way there.

Dr. Spaulding-Barclay:

Then, of course, you've got to look at your own biases. What if you struggle with an eating disorder yourself? What if you see body weight, shape, size differently? What if you have an internal beauty idea that was drilled into you as a child and terrible things were said to you, who knows what your personal experience was.

Dr. Spaulding-Barclay:

We want to hear that because we want to support you with that, hello, we work in this field, but we'll also challenge you on that because you want us to because you apparently love your child. You want us to challenge you on the barriers that may be being put up for your child's recovery.

Dr. Spaulding-Barclay:

If we see that we'll let you know. It's a very low incidence rate. Overwhelmingly, parents are worried about their child's emotional response to gaining weight. They're afraid, but every now and then, it'll be the parent's response to their child and gaining weight. We'll let you know if we see that.

Dr. Spaulding-Barclay:

The last three that we put in our golden 12 were expectations of appropriateness that's really going to come from your therapist. It really breaks down into kind of communication, visiting in phone calls because a lot of time, oh my gosh, my child's far away from me. I have our uncles, cousins, brothers, best friends, wife's daughter is in college in Denver. You could come visit her.

Dr. Spaulding-Barclay:

Well, talk with your therapist because in reality, you might be thinking anybody coming and visiting is better. They won't be bored. They'll be connected to out of the real world. Not always. Patients are sometimes very clear with us that even having you, their loving immediate family, seeing their body is very difficult for them. They don't want to have any other visitors sometimes.

Dr. Spaulding-Barclay:

Sometimes, they don't even want siblings to come. Sometimes, they don't want grandparents to come even though they love their grandparents because it's too hard to have grandma or grandpa see me as horrible and disgusting as I look now. I'm so ashamed. It breaks my heart, and it may be true. And the therapist will have a little better insight on whether that's something we should challenge now or we should hold off on challenging.

Dr. Spaulding-Barclay:

Same thing with extended family making calls and things like that. The call list is really managed by you in Denver. If you think it's a person they shouldn't be communicating with, don't let them communicate them with. That's okay. Then, of course, managing your own distress particularly surrounding, visiting and calling. If you know that your distress is high enough that you can't immediately go right into a meeting, do not schedule the family therapy session for right before you have to give a big presentation.

Dr. Spaulding-Barclay:

Give yourself 15, 20, 30 minutes to be able to decompress so you can realize that, "Oh, my gosh. I'm so distressed, and I feel like my kid's so unsafe." Then you can process it and realize, "That's right. My kids at a higher level of care at PHP or residential." They're actually being cared for. It's okay. They're safe. They're there.

Dr. Spaulding-Barclay:

I can come down. I can go back to my meeting. You deserve that. We think you deserve that. We want to support you with that. Co-parenting, I don't care if you're actually married, not married, whatever. If there are two of you involved in the raising of your child, that's co-parenting. You got to get online... outlined, excuse me, not online. You got to get outlined. You're probably online for this. You're online. But you got to get in line. If one of you is thinking, "Well, , but I think that's okay. At my house, I'll let that slide. That's not going to work.

Dr. Spaulding-Barclay:

That's the classic, "Mom, can I go to this movie? Of course, you can't go to that movie. I just heard about it. It's way too violent for you. You're only 11, honey. No, you can't go to that movie. Hey, dad. Dave's parents are going to take us to this movie. Is that cool with you? Oh, yeah. Sure, you can go. Oops, I'm going to get an earful. I'm a lot better now.

Dr. Spaulding-Barclay:

I'm like, "Wait a minute. Wait a minute. What'd your mom say?" No, my mom said no. Well, why are you asking me? Your mom already said no. Of course, you can't go to that movie. If I disagree then, I think it'd be fine to go to that movie. I don't say, "Oh, your mother said that. Oh, you can go to the movie." No. I say, "Of course, you can't go. Your mother says you can't go to the movie."

Dr. Spaulding-Barclay:

Then later, when they're gone and it's quiet, and it's just my wife and I or the co-parent and you on the phone, hey, I thought that movie was going to be okay. Is there something you heard about it that I didn't? Then, my wife will usually educate me on all the things I missed, but I'm like, "Oh, you're right. Not good. Not good." You got to be aligned, consistency, expectations, consequences.

Dr. Spaulding-Barclay:

If you can't line up, it is not going to function very well. If you're divorced, there's probably a reason we get that, but you both love your kid. We know that. I've seen parents that are like, "We cannot stand each other." My god, to see them come together and be a united front against their eating disorder, that eating disorder had no chance. It got crushed right aw

Dr. Spaulding-Barclay:

Then, finally seeking your own support I don't care whether you're from Ohio and your kids getting admitted to the Ohio program or you're from Nebraska and you're going to get admitted to the Denver program or Florida and you're going to Illinois, whatever, you need to get support.

Dr. Spaulding-Barclay:

I will say one of the themes we've seen is that you've got to ask for support. If your kid had cancer, gosh, you come home from work one day, your lawn is mowed, the lemonade stand was... raising kids money for cancer and the t-shirts were already made and everybody's... Nobody knows what to say with eating disorder treatment. They get all worried and they don't say anything because they're worried about saying the wrong thing even though we know that's not the best.

Dr. Spaulding-Barclay:

Then, they're going to need your help, but our experience has been if you reach out for help, people will give it. Get that support because we believe in you and we know that you are the keys to your child's recovery in a family-based treatment model. Now, the model of care is a little bit different because they're a different developmental stage and brain development wise, we know they're ready to move into a more interdependent or independent model. Totally get it.

Dr. Spaulding-Barclay:

We're also going to give you tools to support yourself and support that better, but in a true FBT model phase one, you're the key to their success. If you're not taking care of yourself, it's not going to work. The mantra that all parents live by, I know you're going to say, but I got to put my kid first. I get it. Of course. I do the same thing.

Dr. Spaulding-Barclay:

With something that's important, the data has shown us you do have to be first to get your own care because we're going to lean on you so much to provide the support that your child needs. That's it. Thank you so much for paying attention and listening. Please, provide us feedback. I'm not used to like staring into a camera and trying to give a speech like this. I'm used to being like beside the screen and looking out at all of your faces and responding to you.

Dr. Spaulding-Barclay:

I use a lot of humor in conversations because these are such difficult conversations to have, but I think sometimes it helps us take a breath for a moment and use humor. It doesn't mean I'm being flippant at all. Hopefully, that went through as well. Hopefully, you've enjoyed the rest of the presentations as well. I know it's a lot to take in, and we can't wait to be involved in the question and answer sessions that happen as well. Thank you so much for your time. Take care.

Eating Recovery Center and Pathlight Mood and Anxiety Center are accredited through the Joint Commission. This organization seeks to enhance the lives of the persons served in healthcare settings through a consultative accreditation process emphasizing quality, value and optimal outcomes of services.

Organizations that earn the Gold Seal of Approval™ have met or exceeded The Joint Commission’s rigorous performance standards to obtain this distinctive and internationally recognized accreditation. Learn more about this accreditation here.

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