Therapeutic Interventions

1. Review the family history and determine the current status of the child's eating disorder and its effects on the child and the family. (1, 2)

2. Arrange for a complete medical, dental, and

1. Meet with the parents and the child, if appropriate, to review the family history and to determine the social, emotional, and cultural environment in which the eating disorder developed.

2. Define an eating disorder as a real and treatable disease and ask the parents and the child to list the existing symptoms, describe the severity of the disorder, and indicate the effects on the child and family.

3. Instruct the parents to schedule a complete medical and dental psychological exam for the child by licensed health professionals. (3, 4, 5)

3. Communicate regularly with the child's treatment team and assist the child to implement all treatment recommendations. (6, 7)

4. Arrange for the child to receive the recommended treatment and level of care for the eating disorder. (8, 9)

examination for the child to determine the physical effects of the eating disorder and to accompany the child to the appointments.

4. Assign the parents to schedule a complete psychological evaluation for the child by a recommended hospital, clinic, or private therapist specializing in the area of eating disorders.

5. Refer the parents to local resources for treatment or assist them in locating treatment by accessing local treatment centers through a referral helpline (e.g., National Eating Disorders Association Information and Referral Helpline; (800) 931-2237 or the "Referral" area of their Web site,

www.NationalEatingDisorders org).

6. Instruct the parents to interview potential treatment providers and ask questions relevant to their treatment approach (e.g., treatment experience, field of expertise, treatment methods, length of treatment).

7. Assign the parents to attend regularly scheduled appointments with the child's treatment team and to record all recommended treatment interventions in a treatment journal.

8. Assist the parents in becoming familiar with and accessing the level of care recommended for the child's eating disorder depending on the critical nature of the illness (e.g., inpatient,

Examine and list the family attitudes, values, and expectations that may be contributing to the child's eating disorder. (10, 11)

Identify and affirm the many character strengths of the child and other family members. (12, 13)

residential, partial hospital, outpatient).

9. Instruct the parents to evaluate their ability to pay for the child's treatment by determining insurance coverage, applying for state assistance through Medicaid or Medicare, seeking treatment from local mental health clinics or medical schools, and/or by seeking information from a patient advocacy group (e.g., Patient Advocate Foundation, (800)532-5274;

10. Assign the parents to list all personal and family attitudes and values that could be contributing to the child's eating disorder (e.g., thin equals attractive or successful, overweight equals lazy and lacking control).

11. Challenge the parents to create a list of values and expectations that promote character and self-esteem based on inner qualities (or assign the "Beautiful on the Inside" activity from the Parenting Skills Homework Planner by Knapp).

12. Council the parents to recognize and affirm the child's unique contribution to the family and community (e.g., "Jimmy is dependable and does many chores without being asked; Rose follows through with her commitments.") to help the child value internal character assets.

13. Encourage the parents to celebrate the character

7. Help the child change perceptions about body image through affirmations and reinforcement of healthy behaviors and positive self-talk. (14, 15)

Become educated about eating disorders by reading information from professional organizations, recommended books, and by talking with treatment professionals. (16, 17)

9. Talk with the child about the dysfunctional eating behavior, perceptions, and expectations of self, and how the disorder is affecting the quality of life. (18, 19)

accomplishments of each family member with a family outing or recognition at the weekly family meeting.

14. Assign the parents to brainstorm with their child a list of personal assets unrelated to body image and encourage the child to use the positive assets as self-talk to replace negative self-statements.

15. Instruct the parents to encourage the child's behavior that supports a healthy perception of body image and promotes self-acceptance (e.g., eliminate chronic weighing, less time spent in front of mirrors, wear comfortable clothes).

16. Assign the parents to read literature that defines eating disorders and offers treatment options and strategies for children and their families (e.g., Surviving an Eating Disorder by Siegel, Brisman, and Weinshel).

17. Assign the parents to participate in local support groups for families of children with eating disorders sponsored by hospitals, clinics, or the community mental health organization.

18. Instruct the parents to discuss the eating disorder with the child privately in a nonjudgmental manner and to use the communication tools suggested in How to Talk so Kids Will Listen and Listen so Kids Will Talk (Faber and Mazlish).

19. Instruct the parents to discuss critical areas of concern and

10. Engage in family activities that promote a healthy level of eating, exercise, and socialization. (20, 21)

11. Assess personal values regarding diet and exercise and verbalize a commitment to modeling a positive, healthy attitude and behavior toward body size and image. (22, 23)

12. Verbalize appreciation for the individual physical conflict with the child's therapist rather than being drawn into an argument or power struggle with the child.

20. Assign the parents to organize and attend, with the child, activities and outings that promote a healthy level of exercise and encourage nutritious eating habits in a social setting.

21. Instruct the parents to schedule regular family meals when the whole family sits down at the table and eats together in a stress-free environment free of television, video, phone calls, and other media interruption.

22. Assign the parents to record their personal eating habits and comments about weight and body image in a personal journal (or assign the "Modeling Healthy Attitudes about Nutrition, Exercise, and Body Image" activity from the Parenting Skills Homework Planner by Knapp).

23. Instruct the parents to read "No Weigh! A Declaration of Independence from a Weight-Obsessed World" from the National Eating Disorders Association (www.nationaleatingdisorders .org/p.asp or phone (206) 382.3587) with their child and pledge to adhere to the proposals to accept their body's natural shape and size by signing the declaration.

24. Brainstorm with the parents a list of positive physical attributes of all family members. (24, 25)

13. Verbalize an objective assessment of how the media and other cultural influences have affected the perceptions of the child and other family members regarding the ideal body. (26, 27)

14. Reduce the level of family exposure to television and videos, movies, the Internet, and magazines and assist the child in becoming a discriminating consumer of all media. (28, 29)

attributes for each family member (e.g., "Arnold has lots of energy, Carla has a winning smile.") and instruct them to verbalize these assets frequently to express an appreciation of the family's diverse physical characteristics.

25. Instruct the parents to devote weekly time for each family member to count their physical blessings and express appreciation and thanks for their own body and how it supports their activities and lifestyle.

26. Assign the parents to watch television programs and videos with their child to gain an understanding of how the media is distorting the child's view of what is culturally appropriate, desirable, and acceptable.

27. Instruct the parents to talk with their child about how the media influences their lives by presenting abnormally thin, overly energetic, unusually beautiful and highly sexualized models as culturally normal and to encourage their child to select role models from people in their everyday life.

28. Instruct the parents to limit family television and video time to one to two hours per day and to encourage other worthwhile activities as a substitute that promote self-acceptance and physical affirmation.

29. Assign the parents to monitor the child's exposure to fashion

15. Implement positive discipline strategies that share control and empower the child to function responsibly and independently. (30, 31, 32)

information and Web sites that promote excessive thinness and instructions for extreme dieting, exercise, and bulimic behavior.

30. Teach the parents to avoid taking responsibility for solving the child's eating disorder problems by providing empathetic listening rather than rushing to give advice.

31. Instruct the parents to set reasonable limits for the child by using statements that make the child's desired privileges contingent upon the child's appropriate behavior and responsible decisions (e.g., "Feel free to use the computer as soon as we've all finished dinner; We can go shopping as soon as you've helped me plan the meals for next week.").

32. Assist the parents in developing limited choices to share control and facilitate responsible decision making by their child; advise them that choices should be framed so that either option is acceptable to them (e.g., "Would you like to have meat and potatoes or fish and rice for dinner?"), should be limited to specific stated alternatives (e.g., "Would you like to eat in the kitchen or at the dining room table tonight?"), and the parent should be prepared to choose if the child refuses to choose.

16. Affirm the child for each 33. Instruct the parents to verbally step taken toward establish- affirm the child for each positive ing healthy self-esteem, step taken to control the eating body image, and lifestyle. (33, 34)

disorder, to establish a healthy lifestyle, and to develop an attitude of self-acceptance.

Assist the parents in understanding that treatment of an eating disorder is usually a long-term process that requires the support and cooperation of all family members, however the major responsibility for overcoming the disorder and establishing a healthy lifestyle rests with the child.

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