Help For Parents Of Children With Eating Disorders

Dr. Ted Weltzinjoined us to discuss what you, as a parent, can do for your eating disordered child. Whether it be anorexia or bulimia (binging and purging) that your child suffers from, there are many different treatment options for eating disorders available. These include inpatient, outpatient, and residential. Dr. Weltzin explored the traits and costs of each of these options.

 

We also talked about:

• how to ask your child if she/he is having an eating problem.
• what to do if your child has an eating problem but insists that they don't.
• how parents can better cope with their own concerns, frustration and even anger in dealing with their eating disordered child.
• the relationship between obsessive-compulsive disorder and eating disorders.
• and why, no matter how much money you spend on outpatient treatment for eating disorders, inpatient eating disorders treatment, or weekly therapy, your child may not be ready to get better.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Help For Parents Of Children With Eating Disorders."

Our guest is Dr. Ted Weltzin, Medical Director of The Eating Disorder Center at Rogers Memorial Hospital. Dr. Weltzin is a licensed psychiatrist. Before coming to Rogers Memorial Hospital, he was an assistant clinical professor of psychiatry at the University of Wisconsin Medical School. Prior to that, Dr. Weltzin was the medical director of the Center for Overcoming Problem Eating, an inpatient program at the University of Pittsburgh.

Good evening Dr. Weltzin, and welcome to HealthyPlace.com. Many parents with eating disordered children seem to go through a cycle. First denial, then being scared. Later, if there isn't a relatively quick recovery, some move onto frustration, anger, resentment, and even resignation that things will never get better. These are some of the issues I want to address tonight. For parents who are just getting into the process, what should a parent do when they first think their daughter or son has an eating disorder?

Dr. Weltzin: The first thing to do is to ask him or her if they are having an eating problem. As you mentioned, they may not admit to the eating problems but this begins to open a dialogue about a potential problem. Approaching them in a caring and non-confrontational manner is the best approach unless their disordered eating behavior is very out of control.

David: Let's say the child says that nothing is wrong, but you can tell that something is wrong. What should a parent do at that point? Should the parent press further? Be confrontational?

Dr. Weltzin: Probably the next thing to do is to bring them into see their pediatrician or medical doctor. A lot of times they will admit to their doctor that they have a problem. Also, this is a good start at determining if there are any serious medical problems, which are common in eating disorders.

Persistence is the key in terms of this phase of a problem: the denial phase. Trying to avoid arguments and anger can help the child to talk about the problem. If this does not work, then bringing them to an eating disorder specialist can help to determine how problematic their eating is.

David: There are some parents, I'm sure, who are wondering how long you should try and talk to your child before actually "forcing" them in to be evaluated by a doctor?

Dr. Weltzin: This depends on how serious the eating problem appears. If there are clear medical problems, such as passing out, dizziness, or other medical problems, then it should happen quickly. The same goes for if they are becoming increasingly depressed, isolated, or having problems in school or work. These are also signs that the eating disorder has probably gone on for a while. An interesting fact: the average length of time from the onset of bulimia to seeking help is about 5 years.

David: And that's a good point, Dr. Weltzin. When is an eating problem serious? There are certainly some kids who start cutting down on meals, or throw up once or twice (that the parents know about). At that point, some parents may just say "my child is going through a phase."

Dr. Weltzin: It is true that some children do go through periods of infrequent vomiting to lose weight. However, this often predicts later worsening of symptoms, particularly with a stressful event such as a relationship problem, school stress, moving, etc.

David: So, you've determined that your child has an eating problem. You've tried to talk to your child about it, but that's not working. What about when your child is insistent that nothing is wrong, that they don't have an eating disorder? Then what do you do?

Dr. Weltzin: Get information from the school or other sources that might be available. Sometimes a school counselor, clergy, or friend will be willing to approach them about the problem. If this does not work then they should be taken to see a specialist. Eating disorder specialists see many patients like this and an important part of eating disorders treatment is working on denial and building a relationship in which the patient feels comfortable with talking about the problem.

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David: We all hear about the worst cases of anorexia or bulimia. As far as treatment goes, what should a parent do to help their child? How do you determine if your child just needs weekly therapy, outpatient treatment or inpatient eating disorders treatment?

Dr. Weltzin: This really depends on the severity of the eating disorder symptoms. Often times, this advice will come from a specialist who has done a referral. The majority of patients can improve in an outpatient setting, especially if they are not severely underweight or if they are not severely depressed or unable to control their eating at all. Patients with anorexia, in general, need inpatient and residential treatment as they tend to be unable to correct their eating without specialized help during meals. Patients with bulimia, or those who binge and purge and are at a normal weight, typically fail at outpatient treatment before a more intense treatment like residential is needed. If there are medical problems, which can be life threatening, then inpatient should be done immediately.

David: One of the scariest things for parents, I think, is the idea that their child will either die from an eating disorder or suffer with it for the rest of their lives. Can you speak to that, please?

Dr. Weltzin: It is important to emphasize that the mortality rate for anorexia remains about 10%. People do die from these illness and the majority are not in treatment or have left a treatment program. It is also important that the treatment team includes a physician with some experience in eating disorders, especially their medical complications, a dietitian and therapist.

As to the prognosis for eating disorders, only about 1/3 of anorexic patients recover in general. With intensive treatment this percentage can be increased to over 60%. Therefore, treatment can have a great impact on outcome. As for bulimia, often times patients do have relapses, but with treatment these tend to be time limited and do not lead to a severe loss of function. Over 50% of patients with bulimia will have a significant improvement and often recover with treatment.

David: When you use the word "recover," can you define that?

Dr. Weltzin: Recovery, at its best, means healthy nutrition. This can be defined as healthy meal patterns, such as three meals a day, and maintaining a normal weight. What is a normal weight can vary depending on who you are talking to, but generally this is a weight in which there are no physical problems, including a loss of menstrual function, decreased energy, or feeling run down. More important to recovery, however, is the psychological aspects including body image, self acceptance, improved mood, healthy relationship, and function in school and work. If patients are at a healthy weight and able to junction in their lives, this is recovery, even if there may be brief episodes of abnormal eating or distorted thoughts.

David: We have a lot of audience questions. Let's get to a few of those and then we'll continue:

hwheeler: What do you do when you live in a small town and no one seem to understand eating disorders? My daughter is 20 years old and went to Toronto General Hospital Eating Disorders program, but we live 3 hours away and no doctor here seems to understand how serious this can get.

Dr. Weltzin: Unfortunately, services for these problems cannot be provided in smaller communities. There are a couple of options. First, have a specialist work with a local doctor as a consultant, in which your daughter sees the specialist for updates and progress can sometimes be effective. This can also help the local treaters be able to work with these problems effectively. Alternatively, patients can go to residential programs like the one we have a Rogers and live there and get treatment. This does work, but it also creates some hardship in terms of missing home and also cost.

niko: What do you mean by intensive treatment? Is it normal for people with eating disorders to have periods of seeming normalcy and then slip back into it?

Dr. Weltzin: Intensive treatment is generally more than a weekly therapy session and meeting with a dietitian. An intensive eating disroders treatment program may be a partial hospital program or day treatment program at which the patient may go for most of the day and eat 1-3 meals at the program from 2 to 5 times a week. Residential is the next level of intensity in which patients live in a facility and have 24-hour staff supervision and work in a setting with other patients trying to recover. This has a number of advantages as eating disorders tend to be 24-hour problems. Finally, inpatient treatment, which is very costly, is reserved for those patients who are medically unstable or unable to have any control over their eating. Patients in inpatient programs tend to transition to residential or partial programs.

Regarding the question about people looking like they are doing well, it is true for many patients with anorexia or bulimia. They will have periods of doing well. Under stress, their symptoms tend to worsen and they often have an up and down course because of their illness which can be destructive. If this is the case, they often seek treatment because they are tired of their eating disorder having a negative i: mpact on family, friends, jobs, or school.

David: Approximately how much is outpatient day treatment and inpatient treatment? I'm talking about the cost?

Dr. Weltzin: The cost for outpatient treatment for eating disorders tends to be the cost of the outpatient therapy session (which can vary depending on location or specialist). Typically the cost is between $100 and $150 per session (maybe less in some cases). Inpatient treatment for eating disorders is very costly with daily costs being between $700 to $1,500 and sometimes higher. Residential treatment is about 1/3 the cost of inpatient treatment. Therefore, outpatient, which is often covered by insurance, should be tried first. However, if this is not effective, avoiding inpatient treatment by trying residential or partial can allow many more patients to get treatment for a long enough amount of time to be effective.

David: Here's the link to the HealthyPlace.com Eating Disorders Community.

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David: Dr. Weltzin, is inpatient eating disorders treatment covered by insurance and/or Medicare, or do parents have to pay for it out of pocket?

Dr. Weltzin: This really varies in terms of the policy. Some policies have unlimited coverage; however, this is rare. Often times, families do have to pay, and this is the reason why it is often not possible for people to receive inpatient care. Historically, this change occurred in the mid to late 80's, and at that time, most inpatient units were not able to continue to provide as high quality of care and alternative treatment models were developed that were less costly but effective.

David: The Rogers Memorial Hospital website is here.

Let's get to some more audience questions:

brendajoy: What if your child is over 18. Is there any legal way to force them into treatment?

Dr. Weltzin: They can be forced into eating disorders treatment, depending on state mental health statutes, if their symptoms are so severe as to be life threatening. This generally occurs when they have had the problem for a while. This is the main reason why children tend to have a better chance at recovery. There is more pressure for them to get into or stay in treatment even if they do not want to recover. For patients over 18, it is very important for families to support the eating disorders treatment as much as they can to keep them in treatment. This often boils down to the patient having to make a choice to stay in treatment because of someone else, initially. For those patients who make this choice, they often are able to see the need for treatment after a period of time in treatment.

Jem42: My daughter is getting better in some ways but still holds on to pretty rigid food rituals. She also does not eat any of the food we fix for dinner. Since she is gaining weight slowly by doing it her way, should we press the issue? Also, my daughter was at Rogers. One year ago, we were putting her into the inpatient facility.

Dr. Weltzin: If your daughter is gaining weight, then I would not push the issue of the rigid thinking and some ritualistic eating behavior. If she is gaining weight, then it may take a while for the anorexic thinking to change. Parents often get frustrated that the thinking does not change even with behavior changes, such as weight gain. You need to tolerate this. I encourage you to focus on a few important changes. It sounds like your daughter needs to gain weight. As her weight gets higher, the thinking will change. Also, good luck with your daughter's treatment.

David: Here's the next question:

jerrym: David, our daughter just left Rogers about 6 weeks ago. Great staff and people! She's doing well overall and we're adjusting. What can parents expect to see after treatment?

Dr. Weltzin: The main thing that I emphasize to parents is that they need to try to remove barriers to recovery. This initially means to let go of blaming yourself for the problem and attend therapy sessions, even though they may be difficult. Being able to change how you approach your son or daughter with the help of the treatment team can make a big difference in how things go when they are home. At Rogers, we strongly encourage family involvement for this very reason. Jerry, I am glad to hear that this seems to be going well thus far.

LilstElf: What is the general length of stay for residential treatment?

Dr. Weltzin: It really depends on the problems. For bulimia, in which weight gain is not needed, the stays tend to be 30 to 60 days, while with anorexia it may be 3-4 months, depending on weight. This tends to seem like a long time but usually patients and families have had to experience years of the problem and the sacrifice for what is generally a short period of time, if we look at effective treatment leading to a healthy long life, is justified if possible.

rkhamlett: After hospitalization and being in an institution, what is there left to do for a 13 year old?

Dr. Weltzin: The main thing is whether she was able to function in terms of her eating in the hospital. If she was able to gain healthy eating habits and be motivated to try and recover then setting up a structured treatment (including close monitoring of weight in addition to intensive therapy) is important. The reason for weight monitoring is so that if things are not going well, she can be readmitted without a major loss of ground in terms of recovery. Not letting things get to the point of being as bad as they were before intervening is critical.

David: I'm getting a few comments that fall along this line: If you spend $21K-45K per month for 1-4 months (depending on the seriousness of your child's eating disorder) and then your child comes home and you see the disordered eating behaviors start all over again, it is extremely frustrating and causes a lot of anger. How is a parent supposed to handle that? One parent says she followed her daughter to the bathroom and the child started screaming at her.

Dr. Weltzin: This is very frustrating for parents, as it is often a major sacrifice that affects the whole family when this type of treatment is decided upon. I can say that we are very aware of this. For this reason, when I was the medical director of the inpatient program at Pittsburgh, we followed up our patients and had less than a 10% rehospitalization rate after one year.

As I have been the medical director at Rogers since February of this year, one of my main initiatives is to reduce relapse after treatment so that this story becomes less common for the patients that we treat. It is important to emphasize that planning after an intensive treatment should focus, to a large extent, on what types of things should be done (depending on how the patient is doing at the time of discharge) and how to give parents guidelines to improve the chances that relapse does not occur. Finally, sometimes going back inpatient or residential is needed. Having a discussion with the treaters at the beginning of treatment about this concern and what you, the parent, thinks could have been done differently often helps to avoid this happening again.

David: So are you saying that the inpatient treatment is just the very beginning of the eating disorders treatment process? Do you think a parent shouldn't expect their child to be "healed" or "cured" of the eating disorder, even if they spent $21-200,000 dollars?

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Dr. Weltzin: What parents should expect is that their child and the family knows what it takes to recover from the illness. With an illness, where denial is a major problem, often times the current treatment can be done but if the patient does not want to apply what they have learned, then it will not work. No matter how frustrating it is, it is important to keep in mind that patients often refer to their attitude during a previous treatment and say that "now I am ready to get better." While it can be costly and frustrating that a second or even third treatment is needed, if it is effective, parents will say it was worth it to have their child healthy.

David: That's a very straight answer, Dr. Weltzin. And I guess you are right. If the patient isn't ready to get better, or doesn't want to get better, it doesn't matter how much money you spend, you won't see great results if little or no effort is put into the treatment by the patient.

Here's the next question:

CAS284: Dr. Weltzin, my daughter has been free of bulimia for over a year now, but after the bulimia ended, Obsessive Compulsive Disorder (OCD) has became evident. We are now struggling with this and depression. Is this common and how would you suggest we treat these disorders? Thank you.

Dr. Weltzin: There is a strong link between Obsessive Compulsive Disorder and eating disorders and depression. It also does happen that, as the eating disorder gets better, some of these other problems become more noticeable or, at times, more severe. Depression and OCD are very treatable. Treatment for both OCD and Depression require a combination of therapy and medication (if severe). If moderate to mild, then therapy or medication can be used. Because of the specialized nature of OCD, you may want to seek out a specialist. YOU may want to access our web site to ask for a specialist near you. With depression, if this is still present after the eating disorder is improved, then it should be treated as a separate problem.

David: For those of you who want more info on OCD, please visit the HealthyPlace.com OCD Community.

I know that you have done research on the relationship between eating disorders and OCD. Could you explain how that relationship between eating disorders and OCD works?

Dr. Weltzin: What is more likely the case is that OCD or perfectionism (what we call OCD related symptoms) likely increase the risk for eating disorders. Often there is a family history of OCD or perfectionism in patients with anorexia. There also seems to be a link between bulimia and OCD. This is not surprising as serotonin, a brain chemical linked to appetite and eating disorders, is also a major factor in OCD.

alexand1972: What should someone who has been in and out of hospitals do differently to attempt recovery? What are the chances of that person's niece living in the same household and going through the same thing getting better? Or is it too unhealthy for her to be in that sort of situation?

Dr. Weltzin: Depending on how long the hospital stays are, you may want to consider a residential program that is longer and can help you develop and practice the changes you need to make in your eating, problem solving, and approach to recovery that will allow you to be able to implement these changes in an effective way at home. This often works, although (as I stated above) it requires a significant sacrifice. If you are not doing well, it will likely not help your niece.

David: I just want to post this comment from an audience member who has an eating disorder. I'm posting it to give the parents some insight into what your children may be thinking and I hope Dr. Weltzin might speak to that:

waterlilly: My mom, who is an RN, flipped out when she knew I was making myself vomit. She began hitting me and sent me to my Dad's. I don't understand why she didn't support me.

Dr. Weltzin: The stress that this problem puts on parents is quite intense and often times they say or do things that are quite shocking. It would appear that, at that moment, your mom was not able to support you. This is unfortunate, however, she may feel quite bad about what she did and be able to support you now in your recovery. You need to work through your feelings about this with your therapist, then have family sessions with your mom to express to her how this made your feel and to determine if you want her as a resource for your recovery and if she is willing.

David: Rogers is in what part of Wisconsin, Dr. Weltzin?

Dr. Weltzin: Rogers is in Oconomowoc, which is about 30 minutes from Milwaukee on I94 between Madison and Milwaukee.

muddog: My daughter started at 16 and is now 23. She is seeing a therapist. Do you feel she can get well without being in an eating disorder treatment center? Also, my daughter is considering marriage. He knows about her Bulimia. Is the marriage doomed if she doesn't get well first?

Dr. Weltzin: It really depends on how she is doing with her illness. Often times, the therapist can be of help in this - if your daughter is willing to invite you to a session. It is important to mention that the longer an eating disorder goes on the more difficult it is to recover. People begin to have the eating disorder define their way of life and this is hard to break. If she is not better, then a treatment program should be considered.

As to the marriage, an important part of recovery at our program at Rogers is responsibility. It would seem to me that starting out in a life long relationship should be done with it having the best chance of success. If she is not doing better, then this would likely be a very significant stress on this relationship - one that may be too much. Might it not be better to get her eating under control first?

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hwheeler: Does it put more pressure or stress on the ED person when a parent knows what they are doing in the washroom and nags at them?

Dr. Weltzin: Yes, this is often stressful. However, there may not be any reasonable alternative if the person is not trying to get help. If the person is in eating disorder treatment, then having a family session to discuss this stress and workout compromises to decrease stress is the best way to deal with this, in my opinion.

David: I'm sure it's very difficult to watch your child engage in destructive behaviors and not say ANYTHING. Is that even a reasonable expectation, and is not saying anything a signal to the child that they can either get away with it or that it's okay with the parent?

Dr. Weltzin: That is a good point. Children will often say (after the fact) that their parent must not have cared if they did not do anything. This brings up a very important point in terms of saying or doing things that are aimed at helping a child but make the child angry. In my experience, children are thankful that their parents cared enough to try and help even though it led to arguments and anger. Unfortunately, this thanks may not come for a while and may be years after the fact, but parents need to have faith that trying to help their children, even if it makes the children angry, is the right thing to do when it comes to problems as serious as eating disorders.

David: Thank you, Dr. Weltzin, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people interacting with various sites. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Thanks for staying so late and answering everyone's questions, Dr. Weltzin.

Dr. Weltzin: Thank you for having me and I hope that this was helpful.

David: It was. Good night, everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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