Parents Enlisted to Fight Teens' Eating Disorders : Skills-training program gives families the tools and the support they need to address behavior at home.

A new group skills-training program is exploring the vital role of parents as part of the treatment team for adolescents with eating disorders.

“Most families have neither the skills nor the support to address eating disorders at home,” said Nancy Zucker, Ph.D., director of the eating disorders program at Duke University, Durham, N.C.

“Parents don't have the skills to reinforce behaviors consistently at each and every meal, and they don't have a lot of information, even on parenting in general or a forum to talk about what is happening to them and their children,” she said.

The need for a skills-building program has become even more apparent as reimbursement issues interfere with inpatient treatment for these adolescents. “Parents are now getting their children back at lower and lower weights, and the only validated treatment is renourishment,” she noted. But even after initial treatment, the task of renourishment is not an easy one for families.

Given the number of feedings necessary and the conflict they can arouse, it became increasingly obvious that families needed to be more involved in the child's recovery and “that parents needed a lot more support and guidance than they could get in a 1-hour therapy visit,” Dr. Zucker said.

Three years ago, she began meeting with some of her patients' parents in a structured, weekly group. The format was based on other successful parent-training models, such as those used with attention-deficit hyperactivity disorder, in which skills are taught in an atmosphere of support and accountability.

“We try to engage in a process-focused, rather than outcome-focused approach,” said Dr. Zucker, who directs the group. “It is without bias or judgment. That's the philosophy that underpins everything we do.”

Although there are dozens of support groups for parents whose children have eating disorders, Dr. Zucker's is one of the few with a set agenda of developing specific parenting skills aimed at helping modify eating behavior. “We teach what we call an 'off-the-cuff' approach to managing the behaviors of eating disorders,” she said.

Parents are asked not to enter into conflict with the child regarding eating, she explained: “These disorders are a metaphor for the child's emotional state. When they are at the peak of their anger, they can't hear anything. The parent needs to stay calm. Ninety-nine percent of the time, when they don't engage at the top of that emotional wave, the kids will come down, and the power struggle resolves.”

Parents in the group address three barriers that potentiate mealtime conflict: negative perfectionism, expressed negative emotion, and poor self-efficacy. Parents target negative perfectionism within themselves and learn how to create a home environment that doesn't foster that in them or in their children. They also work diligently on emotional regulation, learning to avoid the negative verbal communication that makes working with their children even more difficult.

Each session includes a three-part homework assignment. “They're assigned an eating disorder behavior to target, an adaptive skill in the child that they work on increasing by modeling a positive coping strategy, and a self-care assignment,” Dr. Zucker said. Parents are expected to present the results of that homework during the next group session, where they receive praise and advice from Dr. Zucker and their peers. Unconditional support is key. “It's a no-criticism environment, because our philosophy is, there are no mistakes.”

The group provides a critical stress-relief valve for parents up against a frightening and frustrating disorder, but the assignments aimed at improving parents' skills and their own sense of self-worth aren't easy, said Patty Hernandez, a group member.

Ms. Hernandez's 15-year-old daughter was diagnosed with anorexia nervosa after her weight dropped from 116 to 82 pounds in a 4-month period. The girl's primary care physician failed to recognize the problem, but her mother knew the signs all too well. “I'm anorexic, so I could see very early what was going on,” she said. “First, I saw her dropping out the after-school snacks that she really loved, and then one day I saw a piece of paper where she'd written, 'Nothing tastes as good as being thin.'”

After an unsuccessful hospitalization in a psychiatric ward and a protracted battle with an insurance company, Ms. Hernandez's daughter entered the Duke eating disorders program, and Ms. Hernandez and her husband entered the parent group. “It has been a savior for us,” she said. “It's so invaluable to listen to other parents every week going through the same thing and realize that you're not the only one, you're not crazy, you're not horrible parents,” she said.

Still, being in the group isn't easy, she said. Her own eating issues “became very loud” when she saw her daughter refusing to eat. “It's incredibly hard to remember that I have to take care of myself by getting my three meals and snacks in every day, in order to set a good example for my child.”

Ms. Hernandez isn't alone in expressing her positive experiences with the group. Dr. Zucker recently presented the results of the first of several studies on the group skills-training model. Fourteen caregivers and 10 adolescents were interviewed before and after the parents' 4 months of group work.

Among the patients, weight concern scores fell from 3.16 to 1.40, shape concern scores fell from 3.48 to 2.03, and restraint scores fell from 2.88 to 1.20. The patients' body mass indexes increased a mean of 2 kg/m

Among the parents, 91% strongly agreed that the group was essential for their children's improvement and 82% strongly agreed that their children would not be doing as well if they had not participated in the group.

Last spring, Dr. Zucker received a $10,000 grant from the National Eating Disorders Association (NEDA) for further research into the group model. Her ongoing studies compare the skills-training model to a parent education-only model, and she is investigating different methods of delivering the group content, perhaps via a Web-based program.

Dr. Zucker is now analyzing preliminary data from these studies, and the results will provide a key insight into the usefulness of her model in other practices, said James Mitchell, M.D., professor and chair of the department of neuroscience at the University of North Dakota and chairman of the NEDA grant awards committee that evaluated Dr. Zucker's program.

Sometimes, he said, group therapy models accomplish wonderful results under the hand of a particularly enthusiastic and inspiring leader, but those results turn out not to be reproducible with a different leader.

“Like everything else, initial results can look very good at the first pass, but sometimes don't stand up under scrutiny,” he said. “She needs to show that her results are due to the model itself and that others can use it just as well. Those questions need to be answered. But it looks like it has a lot of promise.”

The parent group model is just one facet of a comprehensive eating disorders treatment program that could include psychiatrists and other M.Ds., psychologists, dietitians, and exercise physiologists committed to working with both patient and family, Dr. Mitchell noted. “Research shows quite clearly that you have a better success rate if you involve the family of an adolescent. One question, however, is how to involve that family. Should it be included in the treatment as a unit, or should you work with the family separately? Dr. Zucker's program is one that's trying to answer that question.”

Dr. Zucker has applied her model's general tenets to two new pilot eating disorder programs: an intensive weekend parent training group for parents who live out of town and a prevention program aimed at high school freshmen. Presented as part of the school's health curriculum, the program focuses on building good mental health, including healthy attitudes about eating, within the family unit.

“We don't give information about eating disorders,” she said. “The key things we focus on are the importance of quality family interaction during consistent meals, separating the negative aspects of perfectionism from the positive, and taking the shame away from making mistakes. We try to help the kids look at mistakes as growth opportunities, instead.”

And she's not stopping with eating disorders—a group for parents with 8- to 10-year-olds at risk for overweight and obesity is in the works. That program, for which Dr. Zucker is recruiting right now, will be based on a similar parent-training format.

“I have lots of ideas—just not enough time,” she laughed.

A new group skills-training program is exploring the vital role of parents as part of the treatment team for adolescents with eating disorders.

“Most families have neither the skills nor the support to address eating disorders at home,” said Nancy Zucker, Ph.D., director of the eating disorders program at Duke University, Durham, N.C.

“Parents don't have the skills to reinforce behaviors consistently at each and every meal, and they don't have a lot of information, even on parenting in general or a forum to talk about what is happening to them and their children,” she said.

The need for a skills-building program has become even more apparent as reimbursement issues interfere with inpatient treatment for these adolescents. “Parents are now getting their children back at lower and lower weights, and the only validated treatment is renourishment,” she noted. But even after initial treatment, the task of renourishment is not an easy one for families.

Given the number of feedings necessary and the conflict they can arouse, it became increasingly obvious that families needed to be more involved in the child's recovery and “that parents needed a lot more support and guidance than they could get in a 1-hour therapy visit,” Dr. Zucker said.

Three years ago, she began meeting with some of her patients' parents in a structured, weekly group. The format was based on other successful parent-training models, such as those used with attention-deficit hyperactivity disorder, in which skills are taught in an atmosphere of support and accountability.

“We try to engage in a process-focused, rather than outcome-focused approach,” said Dr. Zucker, who directs the group. “It is without bias or judgment. That's the philosophy that underpins everything we do.”

Although there are dozens of support groups for parents whose children have eating disorders, Dr. Zucker's is one of the few with a set agenda of developing specific parenting skills aimed at helping modify eating behavior. “We teach what we call an 'off-the-cuff' approach to managing the behaviors of eating disorders,” she said.

Parents are asked not to enter into conflict with the child regarding eating, she explained: “These disorders are a metaphor for the child's emotional state. When they are at the peak of their anger, they can't hear anything. The parent needs to stay calm. Ninety-nine percent of the time, when they don't engage at the top of that emotional wave, the kids will come down, and the power struggle resolves.”

Parents in the group address three barriers that potentiate mealtime conflict: negative perfectionism, expressed negative emotion, and poor self-efficacy. Parents target negative perfectionism within themselves and learn how to create a home environment that doesn't foster that in them or in their children. They also work diligently on emotional regulation, learning to avoid the negative verbal communication that makes working with their children even more difficult.

Each session includes a three-part homework assignment. “They're assigned an eating disorder behavior to target, an adaptive skill in the child that they work on increasing by modeling a positive coping strategy, and a self-care assignment,” Dr. Zucker said. Parents are expected to present the results of that homework during the next group session, where they receive praise and advice from Dr. Zucker and their peers. Unconditional support is key. “It's a no-criticism environment, because our philosophy is, there are no mistakes.”

The group provides a critical stress-relief valve for parents up against a frightening and frustrating disorder, but the assignments aimed at improving parents' skills and their own sense of self-worth aren't easy, said Patty Hernandez, a group member.

Ms. Hernandez's 15-year-old daughter was diagnosed with anorexia nervosa after her weight dropped from 116 to 82 pounds in a 4-month period. The girl's primary care physician failed to recognize the problem, but her mother knew the signs all too well. “I'm anorexic, so I could see very early what was going on,” she said. “First, I saw her dropping out the after-school snacks that she really loved, and then one day I saw a piece of paper where she'd written, 'Nothing tastes as good as being thin.'”

After an unsuccessful hospitalization in a psychiatric ward and a protracted battle with an insurance company, Ms. Hernandez's daughter entered the Duke eating disorders program, and Ms. Hernandez and her husband entered the parent group. “It has been a savior for us,” she said. “It's so invaluable to listen to other parents every week going through the same thing and realize that you're not the only one, you're not crazy, you're not horrible parents,” she said.

Still, being in the group isn't easy, she said. Her own eating issues “became very loud” when she saw her daughter refusing to eat. “It's incredibly hard to remember that I have to take care of myself by getting my three meals and snacks in every day, in order to set a good example for my child.”

Ms. Hernandez isn't alone in expressing her positive experiences with the group. Dr. Zucker recently presented the results of the first of several studies on the group skills-training model. Fourteen caregivers and 10 adolescents were interviewed before and after the parents' 4 months of group work.

Among the patients, weight concern scores fell from 3.16 to 1.40, shape concern scores fell from 3.48 to 2.03, and restraint scores fell from 2.88 to 1.20. The patients' body mass indexes increased a mean of 2 kg/m

Among the parents, 91% strongly agreed that the group was essential for their children's improvement and 82% strongly agreed that their children would not be doing as well if they had not participated in the group.

Last spring, Dr. Zucker received a $10,000 grant from the National Eating Disorders Association (NEDA) for further research into the group model. Her ongoing studies compare the skills-training model to a parent education-only model, and she is investigating different methods of delivering the group content, perhaps via a Web-based program.

Dr. Zucker is now analyzing preliminary data from these studies, and the results will provide a key insight into the usefulness of her model in other practices, said James Mitchell, M.D., professor and chair of the department of neuroscience at the University of North Dakota and chairman of the NEDA grant awards committee that evaluated Dr. Zucker's program.

Sometimes, he said, group therapy models accomplish wonderful results under the hand of a particularly enthusiastic and inspiring leader, but those results turn out not to be reproducible with a different leader.

“Like everything else, initial results can look very good at the first pass, but sometimes don't stand up under scrutiny,” he said. “She needs to show that her results are due to the model itself and that others can use it just as well. Those questions need to be answered. But it looks like it has a lot of promise.”

The parent group model is just one facet of a comprehensive eating disorders treatment program that could include psychiatrists and other M.Ds., psychologists, dietitians, and exercise physiologists committed to working with both patient and family, Dr. Mitchell noted. “Research shows quite clearly that you have a better success rate if you involve the family of an adolescent. One question, however, is how to involve that family. Should it be included in the treatment as a unit, or should you work with the family separately? Dr. Zucker's program is one that's trying to answer that question.”

Dr. Zucker has applied her model's general tenets to two new pilot eating disorder programs: an intensive weekend parent training group for parents who live out of town and a prevention program aimed at high school freshmen. Presented as part of the school's health curriculum, the program focuses on building good mental health, including healthy attitudes about eating, within the family unit.

“We don't give information about eating disorders,” she said. “The key things we focus on are the importance of quality family interaction during consistent meals, separating the negative aspects of perfectionism from the positive, and taking the shame away from making mistakes. We try to help the kids look at mistakes as growth opportunities, instead.”

And she's not stopping with eating disorders—a group for parents with 8- to 10-year-olds at risk for overweight and obesity is in the works. That program, for which Dr. Zucker is recruiting right now, will be based on a similar parent-training format.

“I have lots of ideas—just not enough time,” she laughed.

A new group skills-training program is exploring the vital role of parents as part of the treatment team for adolescents with eating disorders.

“Most families have neither the skills nor the support to address eating disorders at home,” said Nancy Zucker, Ph.D., director of the eating disorders program at Duke University, Durham, N.C.

“Parents don't have the skills to reinforce behaviors consistently at each and every meal, and they don't have a lot of information, even on parenting in general or a forum to talk about what is happening to them and their children,” she said.

The need for a skills-building program has become even more apparent as reimbursement issues interfere with inpatient treatment for these adolescents. “Parents are now getting their children back at lower and lower weights, and the only validated treatment is renourishment,” she noted. But even after initial treatment, the task of renourishment is not an easy one for families.

Given the number of feedings necessary and the conflict they can arouse, it became increasingly obvious that families needed to be more involved in the child's recovery and “that parents needed a lot more support and guidance than they could get in a 1-hour therapy visit,” Dr. Zucker said.

Three years ago, she began meeting with some of her patients' parents in a structured, weekly group. The format was based on other successful parent-training models, such as those used with attention-deficit hyperactivity disorder, in which skills are taught in an atmosphere of support and accountability.

“We try to engage in a process-focused, rather than outcome-focused approach,” said Dr. Zucker, who directs the group. “It is without bias or judgment. That's the philosophy that underpins everything we do.”

Although there are dozens of support groups for parents whose children have eating disorders, Dr. Zucker's is one of the few with a set agenda of developing specific parenting skills aimed at helping modify eating behavior. “We teach what we call an 'off-the-cuff' approach to managing the behaviors of eating disorders,” she said.

Parents are asked not to enter into conflict with the child regarding eating, she explained: “These disorders are a metaphor for the child's emotional state. When they are at the peak of their anger, they can't hear anything. The parent needs to stay calm. Ninety-nine percent of the time, when they don't engage at the top of that emotional wave, the kids will come down, and the power struggle resolves.”

Parents in the group address three barriers that potentiate mealtime conflict: negative perfectionism, expressed negative emotion, and poor self-efficacy. Parents target negative perfectionism within themselves and learn how to create a home environment that doesn't foster that in them or in their children. They also work diligently on emotional regulation, learning to avoid the negative verbal communication that makes working with their children even more difficult.

Each session includes a three-part homework assignment. “They're assigned an eating disorder behavior to target, an adaptive skill in the child that they work on increasing by modeling a positive coping strategy, and a self-care assignment,” Dr. Zucker said. Parents are expected to present the results of that homework during the next group session, where they receive praise and advice from Dr. Zucker and their peers. Unconditional support is key. “It's a no-criticism environment, because our philosophy is, there are no mistakes.”

The group provides a critical stress-relief valve for parents up against a frightening and frustrating disorder, but the assignments aimed at improving parents' skills and their own sense of self-worth aren't easy, said Patty Hernandez, a group member.

Ms. Hernandez's 15-year-old daughter was diagnosed with anorexia nervosa after her weight dropped from 116 to 82 pounds in a 4-month period. The girl's primary care physician failed to recognize the problem, but her mother knew the signs all too well. “I'm anorexic, so I could see very early what was going on,” she said. “First, I saw her dropping out the after-school snacks that she really loved, and then one day I saw a piece of paper where she'd written, 'Nothing tastes as good as being thin.'”

After an unsuccessful hospitalization in a psychiatric ward and a protracted battle with an insurance company, Ms. Hernandez's daughter entered the Duke eating disorders program, and Ms. Hernandez and her husband entered the parent group. “It has been a savior for us,” she said. “It's so invaluable to listen to other parents every week going through the same thing and realize that you're not the only one, you're not crazy, you're not horrible parents,” she said.

Still, being in the group isn't easy, she said. Her own eating issues “became very loud” when she saw her daughter refusing to eat. “It's incredibly hard to remember that I have to take care of myself by getting my three meals and snacks in every day, in order to set a good example for my child.”

Ms. Hernandez isn't alone in expressing her positive experiences with the group. Dr. Zucker recently presented the results of the first of several studies on the group skills-training model. Fourteen caregivers and 10 adolescents were interviewed before and after the parents' 4 months of group work.

Among the patients, weight concern scores fell from 3.16 to 1.40, shape concern scores fell from 3.48 to 2.03, and restraint scores fell from 2.88 to 1.20. The patients' body mass indexes increased a mean of 2 kg/m

Among the parents, 91% strongly agreed that the group was essential for their children's improvement and 82% strongly agreed that their children would not be doing as well if they had not participated in the group.

Last spring, Dr. Zucker received a $10,000 grant from the National Eating Disorders Association (NEDA) for further research into the group model. Her ongoing studies compare the skills-training model to a parent education-only model, and she is investigating different methods of delivering the group content, perhaps via a Web-based program.

Dr. Zucker is now analyzing preliminary data from these studies, and the results will provide a key insight into the usefulness of her model in other practices, said James Mitchell, M.D., professor and chair of the department of neuroscience at the University of North Dakota and chairman of the NEDA grant awards committee that evaluated Dr. Zucker's program.

Sometimes, he said, group therapy models accomplish wonderful results under the hand of a particularly enthusiastic and inspiring leader, but those results turn out not to be reproducible with a different leader.

“Like everything else, initial results can look very good at the first pass, but sometimes don't stand up under scrutiny,” he said. “She needs to show that her results are due to the model itself and that others can use it just as well. Those questions need to be answered. But it looks like it has a lot of promise.”

The parent group model is just one facet of a comprehensive eating disorders treatment program that could include psychiatrists and other M.Ds., psychologists, dietitians, and exercise physiologists committed to working with both patient and family, Dr. Mitchell noted. “Research shows quite clearly that you have a better success rate if you involve the family of an adolescent. One question, however, is how to involve that family. Should it be included in the treatment as a unit, or should you work with the family separately? Dr. Zucker's program is one that's trying to answer that question.”

Dr. Zucker has applied her model's general tenets to two new pilot eating disorder programs: an intensive weekend parent training group for parents who live out of town and a prevention program aimed at high school freshmen. Presented as part of the school's health curriculum, the program focuses on building good mental health, including healthy attitudes about eating, within the family unit.

“We don't give information about eating disorders,” she said. “The key things we focus on are the importance of quality family interaction during consistent meals, separating the negative aspects of perfectionism from the positive, and taking the shame away from making mistakes. We try to help the kids look at mistakes as growth opportunities, instead.”

And she's not stopping with eating disorders—a group for parents with 8- to 10-year-olds at risk for overweight and obesity is in the works. That program, for which Dr. Zucker is recruiting right now, will be based on a similar parent-training format.

“I have lots of ideas—just not enough time,” she laughed.