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NASP Communiqué, Vol. 34, #5
February 2006

Pediatric School Psychology

The Prevention and Treatment of Eating Disorders: An Overview for School Psychologists

By Catherine Cook-Cottone & Melinda Scime

Eating disorders are disruptive to psychological and social development, interfere with learning, and place students at medical risk (Hoek & van Hoeken, 2003). They can be difficult to prevent and treat, chronic, and present along with Depressive Disorders, Obsessive Compulsive Disorder, and Personality Disorder as well as an increased likelihood of diagnosis with Anxiety Disorders and/or Substance Abuse (American Psychiatric Association [APA], 2000).

Generally, the statistics are not encouraging. Body dissatisfaction and dieting, the two strongest predictors of eating disordered behaviors, have become nearly normative (e.g., Cook-Cottone & Phelps, in press). The prevalence rate for Anorexia Nervosa (AN) is 0.3% for young women and, for males, approximately 3 in 10,000 (APA). The prevalence rate for Bulimia Nervosa (BN) is estimated at 1% in young women and 0.1% in young men (Hoek & van Hoeken, 2003). From 1953-1999, the mortality rate for those diagnosed with AN averaged around 5%, the worst of any clinical disorder (Steinhausen, 2002). In a study of AN survivors, less than 50% recovered, 33% improved but were not considered recovered, and 20% remained chronically ill (Steinhausen, 2002). Outcomes have been relatively promising for those diagnosed with BN, with evidence of up to 75% of those diagnosed not meeting criteria at 5 years (Ben-Tovim, 2003). In response, efforts have begun to demonstrate the efficacy of school-based prevention and treatment-support efforts (Cook-Cottone, Kane, Scime, & Beck, 2004). This overview provides a description of symptoms and etiological research, and addresses practical prevention and intervention support strategies, with the role of the school psychologist explicated.

Symptom Overview

Eating disordered behavior is characterized by an intense preoccupation to be thin accompanied by a pathological fear of gaining weight and a severe disturbance in eating behavior (i.e., self-starvation, food restriction, purging of food, and/or a cyclic binging and purging of food). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, APA, 2000) currently lists Anorexia Nervosa and Bulimia Nervosa.

Anorexia Nervosa. Individuals with AN pursue and/or maintain excessively low body weight (i.e., 85% of normal weight) through a reduction in food intake (other methods may include self-induced vomiting, misuse of laxatives or diuretics, and/or excessive exercise). Often, they are intensely afraid of gaining weight and demonstrate a significant perceptual disturbance regarding the size or shape of their body. Younger children may fail to make expected weight gains as they increase in age and height. There are two subtypes: Restricting Type (primarily restriction of food intake) and Binge-Eating/Purging Type (purging with/without binging).

Bulimia Nervosa.  Individuals with BN also place an excessive emphasis on body shape and weight in their self evaluation (APA, 2000). However, individuals with BN struggle with recurrent episodes of binge eating and use inappropriate compensatory behaviors to prevent associated weight gain (e.g., self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, or obligatory exercise). There are two subtypes: Purging Type (regular engagement in the use of vomiting, laxatives, diuretics, or enemas) and Nonpurging Type (use of other compensatory behaviors such as fasting or exercise; APA, 2000).

Etiology Research Brief

Although etiology is not well understood, researchers are working toward a well-integrated, comprehensive model that accounts for the variables associated with eating disorders (Myers, Wonderlich, Norton, & Crosby, 2004). Empirically-identified risk factors related to onset include biological, psychological, and social factors. At the individual level, these factors include self-regulation, dieting and set-point related physiological disruptions, pubertal onset, and the disordered development of self-concept (Jacobi, Paul, deZwaan, Nutzinger, & Dahme, 2004; Wisniewski & Kelly, 2003). Gender is also a strong risk factor as only a small proportion of clinical cases are male (APA, 2000). Both genders show increases in incidence in specific weight-sensitive, athletic or social contexts (e.g., boxing, dancing, gymnastics; Patel, Greydanus, Pratt, & Phillips, 2003).

At the interpersonal level, eating disorders are associated with a variety of familial factors such as low levels of parental attunement, poor communication, and physical and sexual abuse (Wonderlich et al., 2000). In some cases, specific family characteristics may protect against eating disordered behavior and encourage the development of emotion regulation and problem solving (Wisniewski & Kelly, 2003). The importance of media influence is illustrated by a now-world famous study: Becker, Burwell, Gilman, Herzog, and Hamburg (2002) measured the eating disordered behavior of two cohorts of Fijian adolescents: one cohort had been exposed to television for only a few weeks while the other cohort had been exposed for 3 years. Eleven percent of those who had been exposed for 3 years reported engaging in self-induced vomiting, 74% reported feeling fat, 69% stated they had dieted to lose weight, and 29% were assessed to be at risk for a clinically significant eating disorder. This is in contrast to the group briefly exposed, who reported no eating disordered behavior and general satisfaction with their bodies.

The School Psychologist’s Role in Prevention and Intervention Support

School psychologists play a key role in facilitating ecological continuity of care for children and adolescents with health-based issues. The school psychologist’s ability to consult (with teachers, families, and medical personnel), intervene (through prevention, individual and family counseling, and support), and assess (cognitive, emotional, and behavioral domains) makes the school psychologist uniquely critical to the prevention of support for those with eating disorder symptomatology.

Prevention and the Three Tier Service Delivery Model: Developmental Implications

Using mental health prevention terminology, primary prevention efforts focus on the promotion and maintenance of healthy development and the prevention of eating disordered attitudes and behaviors (i.e., before symptoms begin; Cook-Cottone & Phelps, in press). This is consistent with the tier 1 service delivery approach, school-wide prevention services available for all students (e.g., National Joint Committee on Learning Disabilities, 2005). Secondary prevention efforts are meant to target the identification and correction of eating disordered attitudes and behaviors in the very early stages, before a full clinical disorder manifests (Cook-Cottone & Phelps, in press). Such efforts are more consistent with the tier 2 and tier 3 levels of service delivery. That is, tier 2 prevention efforts are specifically designed for, and delivered to, at-risk students. A referral and/or more comprehensive assessment (tier 3) is completed for students who continue to need services beyond tier 2 specialized prevention efforts.

Traditional primary prevention programs may be most effective in the lower elementary years before the crystallization of the preoccupation with body shape and weight within the construct of self (Piran, 2001). For many years, prevention efforts have been aimed at later middle school and high school students because it was believed that eating disordered behaviors and beliefs were rare among prepubertal children (Thelen, Powell, Lawrence, & Kulnert, 1992). However, research reveals that eating disordered behaviors and risk factors associated with their development may emerge as early as fourth grade (Thelen et al.).

Regarding older students, there is an increasing likelihood of internalization of the thin-ideal, dieting, and experimentation with eating disordered behaviors. Accordingly, the notion of a pure primary prevention program is not realistic. It may be effective to combine primary (tier 1) and secondary prevention (tiers 2 and 3) efforts (Piran, 2001). To illustrate, a yoga and wellness group run as part of the school’s wellness program is open to all interested students (tier 1, primary prevention). However, teachers, staff, parents, and administrators are also encouraged to refer students with whom they are concerned (tier 2, secondary prevention). Group curriculum includes: self-care (e.g., yoga/relaxation), life skills (e.g., assertiveness), self-skills (e.g., emotional regulation), and community-based skills (e.g., media literacy). The emotion regulation curriculum covers topics such as how to make healthy behavioral choices while struggling with difficult emotions. Although this is a common adolescent challenge (tier 1), it is also a specific skill deficit believed to be connected to those at-risk for symptomatic expression (tier 2).

Implementation of a prevention program. Traditionally, eating disorder prevention programs have been didactic and psychoeducational, showing little efficacy (Littleton & Ollendick, 2003) and, in some cases, increasing symptomatology (Carter, Stewart, Dunn, & Fairburn, 1997). Thus, the current trend in prevention is an interactive, experiential approach, embracing the positive psychology paradigm. Active learning is believed to increase content acquisition and the positive psychology model may reduce symptom learning (Cook-Cottone & Phelps, in press). Keeping groups small and single-gender has also been effective (Franko, 2001).

Identify at-risk individuals. The earlier an eating disorder is detected and treated, the better the prognosis. A strong behavioral indicator of risk is dieting (Thomas, Ricciardelli, & Williams, 2000). Dieting behaviors are not limited to adolescents and adults; they occur in children as young as 8 years-old (Thomas et al., 2000). Some other risk signs include excessive exercising; losing weight; eating only certain foods; obsessing over food, body, weight, or dieting; adopting odd eating rituals; lying or making excuses about eating; hiding weight loss with loose clothing; refusing to eat in front of others; frequenting bathroom after meals; and exhibiting moodiness and withdrawal.

Make referrals/be aware of resources. To facilitate a timely referral process, each school should have a resource person (e.g., the school psychologist) to handle eating disorder concerns (Smolak, Harris, Levine, & Shisslak, 2001). This resource person should be knowledgeable about how to approach individuals at-risk for an eating disorder, how to communicate with parents, and how to make referrals to an appropriate professional practitioner or agency (Smolak et al., 2001). It is essential that school psychologists be prepared with information about community resources.

Intervention Overview

Once symptomatology reaches clinical levels, individuals with eating disorders require comprehensive and multifaceted care (American Academy of Pediatrics [AAP], 2003). School psychologists can play a critical role in intervention and must be aware of current best practice in treatment so that they may support children and families struggling with and recovering from eating disorders. Treatment may be done either on an inpatient or outpatient basis depending on the level of symptomatology and the patient’s health status. Current best practice in treatment recommends a multidisciplinary team to attend to health status and medication issues, nutrition and meal planning, and psychosocial treatment (American Psychiatric Association Work Group on Eating Disorders, 2000).

Health status and medication issues. A physician specifically trained to work with individuals with eating disorders should provide medical treatment. Outpatient medical treatment typically involves the monitoring and treatment of physiological status (e.g., electrolyte levels, weight, vital signs, medications). Although concerned with the patient’s holistic wellness, primary medical treatment goals involve the normalization of weight and stabilization physiological status. Of note, medication management (e.g., antidepressants) is known to be efficacious in the treatment of BN, with limited efficacy found among inpatients with AN (ADA, 200). Hospitalization is used to stabilize physiological processes and symptoms and/or provide nourishment through a refeeding process (AAP, 2003).

The school psychologist should be mindful of the variety of medical complications associated with eating disorders. Medical complications consistent with caloric restriction or starvation include moderate to severe cardiovascular complications, gastrointestinal problems (e.g., constipation, bloating, liver malfunction), renal difficulties, anemia, endocrine problems, and neurological irregularities (AAP, 2003).Regarding BN, medical complications include electrolyte imbalance and depletion of key nutrients, irreversible myocardial damage with use of Ipecac (a product used to induce vomiting), esophageal damage, dental erosion, gastric rupture, metabolic acidosis, chronic dehydration, menstrual irregularities, and amenorrhea (AAP).

Nutrition and meal planning. A nutritionist often works with the individual to develop a nutrition plan. Typically, meal planning consists of three meals a day with snacks. A structured plan for eating is created to address chaotic eating patterns that can trigger binging and purging cycles or restriction, and to prevent hunger. Food logs are often used to record food intake, behaviors, feelings, and associated thoughts. Nutritionists may also offer nutritional guidance about issues such as weight regulation, starvation effects, energy stasis, dieting and weight control misnomers, and consequences of purging behaviors (American Dietetic Association, 2001).         

Psychological treatment. Psychosocial issues are typically addressed by a licensed mental heath professional with training in the treatment of eating disorders.Treatment may include individual, group therapy, support groups, and/or family therapy. For the treatment of BN, research supports the efficacy of cognitive behavioral and individual psychotherapy modalities (Rosenblum & Forman, 2002). For the treatment of AN, individual and family therapy are often recommended (American Psychiatric Association Work Group on Eating Disorders [APAWGED], 2000). However, no specific type of individual therapy has been identified by research as most efficacious in the treatment of AN (APAWGED).

School Supports and Transitions

Adequate support in the school setting can be a critical part of the treatment and recovery process (Manley, Rickson, & Standeven, 2000). This is most effectively accomplished within the context of a prevention-oriented school atmosphere already promoting zero tolerance of in-school advertising, body teasing, harassment, and gender-biased discourse, and by encouraging healthy nutritional behaviors and opportunities for positive physical and expressive experiences (e.g., soccer, yoga classes, track, swimming, art, and music; Cook-Cottone et al., 2004). Whether the student is being reintegrated into school, is in treatment, or is in recovery, the school psychologist can serve several supportive roles. The roles include school contact to treatment team, student advocate, supportive in-school counselor, and consultation with school faculty, administration, and staff (Cook-Cottone et al., 2004).

Work with treatment team members. The school contact person should communicate with the treatment team and coordinate necessary treatments and supports in the school (Manlely et al., 2000). Releases of information should be completed for all members of the treatment team. Consistent communication with treatment providers facilitates meeting the student’s academic, social-emotional, and physical needs. In some cases, educational classification (e.g., Other Health Impaired) or a Section 504 plan and services may be required. In cases of an extended inpatient hospitalization, academic consultation may also be necessary. Of note, some extended stay hospitalization programs include an academic component that collaborates with the school to maintain the student’s academic growth.

School reintegration. If a student requires hospitalization or day treatment, his or her re-entry to school is an important transition. Providing support for this transition is vital to recovery (Manley et al., 2000). The school psychologist should work with the treatment team and the school to plan for reintegration and address the student’s medical, psychological, and academic needs. Student needs may include supportive counseling, medical monitoring, release from physical education classes, meal monitoring, and communication with the treatment team and family. Special academic accommodations may be necessary such as reduced workload, alternative assignments for some physical education requirements, extended time on assignments and tests, peer tutoring for missed coursework, copies of class notes, and access to quiet study locations (Manley et al., 2000). The school nurse plays an important role in the reintegration of students, and may be needed to check pulse, blood pressure, or other medical issues. He or she also manages the medical releases and restriction information for activities and meals. Some students prefer the school nurse for mandated meal monitoring.

The school psychologist may also act as a student advocate. Advocacy issues include eliciting support for accommodations, describing medication side effects to increase teacher empathy, and helping students negotiate scheduling complications. For example, because of treatment team appointments and visits to medical specialists, students may have 3 to 6 weekly appointments that can be socially and psychologically stressful. This schedule may disrupt academic functioning and cause frustration among school personnel (Manlely et al., 2000). By working with the family, treatment team members, and teachers, the school psychologist can help create a schedule that minimizes academic impact and stress.

In-school counseling can augment out-of-school efforts (Cook-Cottone et al., 2004). Helpful techniques include relaxation work, supportive and reflective listening, and short-term, solution-focused or problem-solving approaches for in-school issues. In addition, the treatment team psychologist may have specific objectives for which the school psychologist can offer assistance within the school.

While school psychologists can be a central resource for eating disorder prevention and intervention, other school-based staff may also play important roles. First, school psychologists can work with administrators to encourage a healthy school climate by supporting zero-tolerance policies related to appearance-based teasing, encouraging the appropriate school personnel to evaluate school lunches to ensure inclusion of healthy options, and scheduling in-services to develop a school-wide plan for dealing with concerns related to eating disorders.

Second, school psychologists can work with teachers to include prevention information in the curriculum (e.g., media literacy, nutrition); discipline students who discriminate or harass others based on size; model healthy attitudes (e.g., eating and exercising with a goal of health rather than a goal of weight loss); refer at-risk students for prevention programs, screening, and referral; allow alternative assignments for class activities that may be triggers for those with eating disorders such as weighing-in, co-education swimming classes, or a calorie counting nutrition class; and focus on an individualized approach to curricular goals that provides the flexibility needed by those struggling with eating disorders.

Conclusion

School psychologists play a vital role in the prevention and treatment of eating disorders through school-based prevention and treatment-support efforts. This role includes active and developmentally appropriate prevention strategies. It also includes identification and specialized prevention for students at risk for eating disorders, and assessment and/or referral for those with emerging clinical symptoms. Finally, this role includes collaboration and consultation with all school personnel to create a healthy and responsible school environment that supports treatment and maintenance of recovery efforts.

References

American Academy of Pediatrics [AAP]. (2003). Identifying and treating eating disorders: Policy statement by the Committee on Adolescence. Pediatrics, 111, 204-211.

American Dietetic Association. (2001). Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified. Journal of the American Dietetic Association, 101, 810-819.

American Psychiatric Association [APA]. (2000). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR). Washington, DC:  American Psychiatric Association.

American Psychiatric Association Work Group on Eating Disorders [APAWGED]. (2000). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, 157, 1-39.

Becker, A. E., Burwell, R. A., Gilman, S. E., Herzog, D. B., & Hamburg, P. (2002). Eating behaviors and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls. British Journal of Psychiatry, 180, 509-514.

Ben-Tovim, D. I. (2003). Eating disorders: Outcome, prevention and treatment of eating disorders. Current Opinion in Psychiatry, 16, 65-69.

Journal of Eating Disorders, 28, 155-164.

Byely, L., Archibald, A. B., Graber, J., & Brooks-Gunn, J. (2000). A prospective study of familial and social influences on girls’ body image and dieting. International Journal of Eating Disorders, 28, 155-164.

Carter, J. C., Stewart, D. A., Dunn, V. J., & Fairburn, C. G.  (1997). Primary prevention of eating disorders: Might it do more harm than good? International Journal of Eating Disorders, 22, 167-172.

Cook-Cottone, C. P., Kane, L., Scime, M., & Beck, M. (2004). Group prevention and  treatment of  eating disorders: A constructivist integration of mind and body strategies. Paperpresented at the Annual New York Association for Specialists in Group Work, Buffalo, NY.

Cook-Cottone, C. P., & Phelps, L. (in press). Adolescent eating disorders. In G. Bear, K. Minke, & A. Thomas (Eds.), Children’s Needs III. Bethesda, MD: National Association of School Psychologists.

Hoek, H. W., & van Hoeken, D. (2003). Review of the Prevalence and incidence of eating disorders. International Journal of Eating Disorders, 24, 383-396.

Jacobi, C., Paul, T., deZwaan, M., Nutzinger, D. O., Dahme, B. (2004). Specificity of self-concept disturbances in eating disorders. International Journal of Eating Disorders, 35, 204-210.

Littleton, H. L., & Ollendick, T. (2003). Negative body image and disordered eating behavior in children and adolescents: What places youth at risk and how can these problems be prevented? Clinical and Child and Family Psychology Review, 6, 51-66.

Manley, R. S., Rickson, H., & Standeven, B. (2000). Children and adolescents with eating disorders: Strategies for teachers and school counselors. Intervention in School & Clinic, 35, 228-231.

Myers, T. C., Wonderlich, S., Norton, M., & Crosby, R. D. (2004). An integrative cognitive approach to the treatment of multi-impulsive bulimia nervosa. In J. L. Levitt, R. A. Sansone, & L. Cohn (Eds.),  Self-harm behavior and eating disorders: Dynamics, assessment, and treatment (pp. 163-173). New York: Routledge.

National Joint Committee on Learning Disabilities (2005). Responsiveness to Intervention and Learning Disabilities. Author.

Patel, D. P., Greydanus, D. E., Pratt, H. D., & Phillips, E. L. (2003). Eating disorders in adolescent athletes. Journal of Adolescent Research, 18, 280-296.

Piran, N. (2001). The body logic program: Discussions and reflections. Cognitive and Behavioral Practice, 8, 259-264.

Rosenblum, J., & Forman, S. (2002). Evidence-based treatment of eating disorders. Current Opinion in Pediatrics, 14, 379-383.

Thomas, K., Ricciardelli, L. A., & Williams, R. J. (2000). Gender traits and self-concept as indicators of problem eating and body dissatisfaction among children. Sex Roles, 43, 441-458.

Wisniewski, L., & Kelly, E. (2003). The application of dialectic behavior therapy to the treatment of eating disorders. Cognitive and Behavioral Practice, 10, 131-138.

© 2006, National Association of School Psychologists. Catherine Cook-Cottone, PhD is an Assistant Professor and Director of School Psychology at the StateUniversity of New York at Buffalo. Melinda Scime is a Doctoral Candidate at the StateUniversity of New York at Buffalo. Thanks to Assistant Editor Steve Landau for coordinating reviews of this column for this issue.