Adolescent Brain and Eating Disorders (Part 2) - Dr. Spaulding-Barclay

By Michael Spaulding-Barclay, MS, MD, CEDS
Dr. Spaulding-Barclay, adolescent medicine physician, is the Medical Director of medical services of Eating Recovery Center’s Child and Adolescent program in Denver, CO. His presentation addresses the question “What do optimal nutritional status and normal weight have to do with brain development and wellness?” Watch this presentation to learn how eating disorders impact developing brains and what this means for treatment.


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?"

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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?

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.

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.

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.

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.

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.

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.

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.

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. 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.

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.

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.

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.

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.

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.

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.

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?

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.

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.

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.

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.

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?

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.

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.

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.

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.

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."

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.

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.

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.

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.

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.

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.

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."

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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?

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.

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.

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.

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."

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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."

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.

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.

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.

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."

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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."

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.

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

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.

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.

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.

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.

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.

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.

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