“I’m Not Going!”:
How to Talk with Your Child About Hospitalization for an Eating Disorder
By Kelsey M. Latimer, PhD, Sonia Schwalen, PhD
Eating Disorders are among the most severe of all the psychiatric disorders. Individuals with eating disorders are at an increased risk for death, with anorexia nervosa having the highest mortality rate of all mental illnesses (Arcelus, Mitchell, Wales, & Nielsen, 2011). Literature reviews are consistent in stating that early intervention/treatment is key, as recovery becomes more difficult the longer the disorder endures (Rome, Ammerman, Rosen, et al., 2003). This means that it is very important for those who are interacting with the child daily to be early responders in seeing the signs (see www.nationaleatingdisorderassociation.org for an extensive list of warning signs) and responding with appropriate treatment to treat the issue.
However, even when we know treatment is necessary, making that decision to hospitalize your child for their eating disorder is still likely to be one of the scariest and most challenging things you will ever do as a parent. As psychologists in the Center for Pediatric Eating Disorders, Drs. Latimer and Schwalen understand these worries. As part of a family-centered treatment program, we consistently help families manage their concerns about having these conversations with children and we have some easy techniques that can assist in boosting parental confidence to address this issue (and others!). As such, this article will first address what the research indicates as effective communication strategies when working with children, knowing your parental power, how to translate skills into discussion about hospitalization, and finally the importance of self-care for parents during this process. Essentially, we want to help parents recognize that eating disorders happen to families, not just the individual – therefore, the family needs to learn how to take care of themselves as well to survive and thrive in this difficult time!
Communicating with children on difficult topics
How we approach challenging conversations is very impactful for a child, as researchers state that it can have influences on future relationships with clinicians, satisfaction of treatment, mothers’ perceptions of the illness, etc. (Aein & Delaram, 2014). Professionals who work in areas that often include difficult conversations agree on several factors that can assist with bearing the difficult news. For instance, specialists working in cancer treatment centers have to be very comfortable and strong in their ability to have extremely challenging conversations with patients/families that may even include end of life conversations; Boles (2015) speaks directly to this stating that several factors are associated with more positive outcomes in these discussions, including assertiveness, emotional support, active listening, empathy, and providing information to the patient. When speaking to a child, it is important to use all of these skills, which we will elaborate on below.
Non-judgmental assertive communication, active listening, and empathy.
Assertiveness is a communication style in which the person is direct in stating what their concerns are, while doing so in a non-judgmental and supportive manner. This is one of the most challenging clinical skills for any person to learn, as it requires us to not “push our power” on others and force them into making a decision (i.e., aggressiveness) or “sweeping things under the rug” and appeasing the other person’s needs while ignoring their own (i.e., passiveness). We often come in contact with caring and kind parents who are afraid to use assertiveness with their children for fear that they are going to make their child upset. This is when we teach parents (and children!) that it is quite likely that others may not be happy when we are assertive but they will learn to respect you for being assertive.
Using assertiveness skills with your children is also beneficial in the sense that it teaches your children to eventually set their own boundaries in relationships in their lives. Though passive behavior may appease your child in the moment, it will decrease feelings of emotional safety in the long-term (Boles, 2015) and create a sense of blurred boundaries in the parent-child relationship.
Assertive communication requires use of “I-statements,” rather than “you-statements.” When communicating concerning behaviors you are noticing with your children, the use of non-judgmental I-statements are very helpful as they remove the power-struggle from the situation and allow a person to communicate specific behaviors they are seeing that lead to the worries you are having as a parent. I-statements use the formula of, “I feel ———- when ———- happens,” which is in contrast to a you-statement of “you are making me feel —–.” In terms of noticing a concerning behavior from your child, the use of I-statements decreases the defensiveness of the child and helps them to understand the exact worrisome behaviors you are noticing them engage in while using a non-judgmental, caring tone. If you are worried about your child’s eating behaviors, you may say something like, “Your father and I are concerned about you [the I feel statement]. We have noticed that you seem to be decreasing your food and you are losing weight [the specific behaviors without judgment]. We love you and want to help you with these unhealthy behaviors by taking you to the hospital for treatment [supportive and solution-focused statement].” It is important again to use how you feel about the specific things you notice and how you are there to help your child in a supportive and solution-focused manner.
In addition, Boles (2015) notes that a very effective technique is to use “active listening,” in which we are actively engaged in hearing what the child is saying and responding appropriately to those concerns. This is where a “one size fits all” approach is not going to work but rather recognizing that instead how we respond must be tailored to meet the need. Sometimes the child needs reassurance, other times comfort or information-giving – the best way to know that is to ask the child what you can do to help them in the moment (e.g., “I know finding out you are going to the hospital can be overwhelming and you look upset right now. What can I do to help you right now?”). As clinicians we use active listening to tune into the child’s needs, but ultimately we always empower the child to tell us what they need in a high emotion situation.
Healthy limit setting and elimination of power struggles.
Utilizing clear and direct communication when setting limits is important to prevent confusion and set your child up for success. Ultimately, children and adolescents thrive in an environment characterized by structure and consistent feedback about what they are doing well (Barkley et al., 2014). This way, they understand how to gain the approval of their parents and develop a positive sense of self-efficacy and self-esteem. Healthy limit setting is characterized by directing your child with firm and clear statements of what you desire (e.g., “Please put your backpack away,” “Please look at me when I am speaking to you,” etc.). Parents should avoid giving directions by asking a question (e.g., “Can you put your backpack away?”) as it gives children the opportunity to disagree and implies there is room for non-compliance with your request. Healthy limit setting also encompasses providing feedback when your child has met your expectations with words of praise (e.g., “Thank you for you cleaning your room,” “You are so good at getting your homework done on time!” etc.) and recognition of their ability to comply with direction. Positive feedback when your child complies will help them easily differentiate from times when you provide constructive feedback or change your response to non-compliance. It is recommended to utilize a hierarchy of responses to redirect your child when they struggle to comply with clear and firm statements (e.g., “I need you to put your backpack away now!”). If their noncompliance persists or their behavior escalates it is recommended to use a positive behavior management strategy called planned ignoring. Essentially, if a child or adolescent continues to non-comply or escalate in behavior after being redirected, inform them that you will ignore him/her until they demonstrate age-appropriate behavior (define this for your child so they are clear on what is expected). If your child is a harm to him/herself or others during their escalation, do not ignore them. Intervene as necessary to keep your child safe. Lastly, tying your child’s behavior to the ability to earn privileges will help motivate them to be successful with meeting expectations. The elimination of power struggles is possible when all caregivers are consistent with expectations and diligent about following through.
Understanding your parental power
It is imperative that parents understand that their reactions to the eating disorder are very influential and that they indeed have a powerful influence on the outcome of an eating disorder. In fact, a systematic review of studies involving parents’ roles in preventing eating disorders showed that parents were indeed one of the most important factors involved in helping with unhealthy eating pathology (Hart, Cornell, Damiano, et al., 2015). At the point when you are considering hospitalization for your child’s eating disorder, you can no longer prevent it, but you can certainly have power over the way you choose to handle the treatment process.
The reality is that if your primary care physician or outpatient treatment team is stating that it is time to consider a higher level of care (e.g., inpatient or partial hospitalization level of care) please understand that it is very important to follow those recommendations. Clinicians always work to keep a patient at the least restrictive level of care, so having a conversation with you about hospitalization means that they are no longer feeling comfortable with the safety of treating that patient on an outpatient level of care and they are gravely concerned about your child’s welfare. Higher levels of care are designed to safely weight restore while monitoring any potential medical concerns in a way that a lower level of care is not able to do. Overall, it will lead to a quicker return to a normal living situation but in the current moment it will be very challenging for the child/family.
Parents helping their children to follow through with hospitalization is crucial, as research shows that patients with eating disorders when left to seek treatment on their own often will not do so – there are a number of factors that may influence this, including, fear of receiving treatment, worry about replacing their coping strategies, a lack of trust in others, fear of abandonment, high anxiety and depression, social and emotional avoidance, unhelpful previous experiences with mental health providers, and worry about stigma (Leavy, Vallianatou, Johnson-Sabine, et al., 2011). In addition, Leavy and colleagues (2011) also showed that cognitive dissonance was one of the main factors that stopped people from pursuing treatment, meaning that they did not view the problem as seriously as those around them; this is very consistent with stage of change theory (Prochaska & Velicer, 1997), which indicates that people who are deeply involved in their problem may be in “denial” or think others are dramatizing the issue – this speaks to the importance of parents not wavering when their child tells them that there is no problem. As experts working with children with eating disorders, we can tell you that most children enter treatment in the precontemplation stage of change (i.e., “in denial” or not believing there is a problem) and their disorder may be very convincing in trying to gain support for removing them from the hospital. We often see this leading to parents second-guessing their instincts and, therefore, allowing the disorder to make the decision for the family – your instincts are correct and we urge you not to listen to the pleading of the disorder (e.g., “I promise I’ll eat if you don’t take me to the hospital,” “You’re making a big deal out of nothing,” “I don’t need to stay at the hospital to get better,” etc.).
Putting skills into practice – telling your child about hospitalization for ED
So, now that we have discussed some of the principles associated with addressing hard topics with your child and why it is so important for you to follow your parental instincts and treatment provider recommendations, it is time to put these skills into practice! Specifically, we understand that it is very difficult to inform your child that you are concerned enough about them to have them go to the hospital for eating disorder treatment. Delivering this news can be incredibly overwhelming and worrisome for the parent. As treatment providers, we have examples of when this has gone very well and others where it has gone very poorly. There are several factors associated with positive delivery of this difficult news that we will talk about, which include remembering why you are having this conversation to begin with, using direct communication (e.g., do not lie to the child) and use age-appropriate delivery. We explore these factors below.
Remember the positive and ask for support if needed.
When you are getting ready to tell your child about eating disorder hospitalization expect yourself to be nervous. It is only natural to worry about how the conversation will go and what their reaction will be. It is critical to remind yourself that you are making a decision that will positively impact the rest of their lives, as studies have shown that focusing on the positive of the conversation will help facilitate the conversation (Edwards, Reis, Weber, 2013). In addition, other factors that have been shown to assist parents in having these difficult conversations include talking to your children on a regular basis about challenging topics and asking for support from professionals in delivering the news if needed (Edwards, et al., 2013). As professionals, your treatment team is likely well versed in discussing hospitalization with children and they may be able to provide you with the support you need if you are afraid to have the conversation on your own. If you choose to tell your child about hospitalization during a therapy session, please remember that it is important you are still the one delivering the news. As parents, take ownership that you have made this decision as a unified parental unit because you love your child, and use the therapy team as a support rather than the main discussant in the conversation. When parents do not take ownership of the decision (e.g., “Your therapist thinks you need hospitalization so we need to follow what they say…”), it provides an opportunity for your child’s eating disorder to try to split the team and parents from each other. When your child knows that you and the treatment team are on the same page, there is less opportunity for bargaining and focuses them on getting better rather than trying to leave treatment.
Direct communication of the difficult news.
When delivering the news that your child will need to be hospitalized for their eating disorder it is important to be both honest and hopeful (Hinds, Oakes, Hicks, et al., 2009). Remind your child that they are loved and this decision is being made by all parents/caregivers in the best interest of your child. Validate your child’s emotional response to hearing the news but do not participate in a power struggle (e.g., “We know this is difficult to hear but avoiding the hospital at this point is not an option. When you calm down, we can talk some more about how we are all here to support you as you go through treatment.”) (Boles, 2015). An unwavering stance will communicate confidence that your child is capable of getting better and you do not expect anything less. Communicate that you trust the treatment team and you plan to work closely with the medical providers to get your child better.
Always remember to keep your child’s age in mind when delivering the news about their upcoming hospitalization. Make sure you ask appropriate questions and gather information from the treatment program so you can let your child know what to expect when they arrive to the hospital (Boles, 2015). Give your child an opportunity to ask questions and be honest with your answers. You can help reduce anxiety for your child by providing him/her with a framework for what to expect, modeling that you are not scared and have confidence in their ability to get well. Helping a younger child develop a narrative for the upcoming experience and their feelings is recommended (Solberg, 2014). Communicating to your child that you have done the research upfront will help them develop confidence in your decision to seek treatment for their eating disorder and let them know that you will be the advocate in their treatment (Boles, 2015). Share your research with them and invite them to look over the website of the treatment facility if appropriate. Furthermore, avoid lying to your child (e.g., do not tell your child you are off to feed the ducks and really take them to get admitted into the hospital). As a treatment facility, we have actually seen the effects of examples exactly like this and children tend to show higher emotional escalation upon realizing the deceit. Lastly, reassure your child that they are not going through this major event in their life alone! Remind your child that he/she is supported and loved.
Now you have finally told your child that they are going to the hospital and you are probably mentally and physically exhausted by everything you have gone through. As a parent, you will likely focus on your child’s health and well-being and potentially forget about your own along the way. Therefore, one of the most important things we talk to families about in our family-based treatment program is to focus on self-care. As you learn to take care of yourself, there are several benefits to this (Patel, Shafer, Brown, et al., 2014 & Svensson, Nilsson, Levi, et al., 2013), including positive role modeling, decreased parental distress, and burnout. We understand your time is limited and you likely cannot take the day off from treatment to go to the spa or watch the game! Below are some self-care tips that take 60 seconds or less (or can be incorporated into the daily routine you are already doing!):
- 5 deep breaths (in through your nose 4 seconds, hold at the top for 7 seconds, out through your mouth for 8 seconds)
- Take a mini-mental vacation (e.g., think of your favorite relaxing place)
- Connect with nature (e.g., go outside, take in the fresh air, etc.,)
- Ask for support (e.g., talk to friends, gather support from your community, spent time with a pet, etc.)
- “Unplug” from technology and allow time for rest
We hope that the above content has helped you to increase your confidence and ability to have the difficult conversation with your child about eating disorder hospitalization. Remember, it is okay for your child to be in distress and it is important to remind yourself that you are doing this to save their life! A great analogy is to think about what you would do if your child were running in the middle of the street without seeing a car coming at them. You would run after them and do whatever you need to do in order to get them out of the way of the on-coming car even if they are upset because they wanted to play in the street. Later, you will teach them how to look both ways to before going in the street so they can keep themselves safe in the future. It is the same thing here with an eating disorder – your child is running into the on-coming danger of the eating disorder that they cannot see and you are going to be a factor in saving their lives. In treatment, they will see the triggers and learn how to protect themselves. Please be kind to yourself during this difficult time and know that it can get better and children do thrive in recovery!
About the authors:
Kelsey M. Latimer, PhD, completed her doctorate in Counseling Psychology at the University of North Texas in 2009, with emphasis areas in neuropsychology and child/adolescent development. She completed her pre-doctoral internship at the University of Texas at Austin Counseling and Mental Health Center, where she had focused preceptor ships in training/administration and eating disorders. Her post-doctoral work was done at Texas Christian University, where she provided specialized treatment in eating disorders, anxiety, and crisis management to the general student population and the Fraternity/Sorority Life community. She is now a licensed psychologist in the Center for Pediatric Eating Disorders of Children’s Health/Children’s Medical Center Plano. She works in all levels of care, including inpatient and partial hospitalization and leads the intensive outpatient program. Her research is focused on eating disorder prevention and intervention, and clinical outcomes of eating disorder programs. Dr. Latimer has presented at over 40 regional/national/international conferences on topics of eating disorder treatment, body image, and supervision/training. She has also been featured as a media expert source on Fox 4, Cosmopolitan.com, and yahoo style.
Sonia Schwalen, PhD, completed her Ph.D. in School Psychology at the University of Houston in 2013. She completed her APA accredited predoctoral internship at Fort Worth Independent School District in 2013 and her APA accredited postdoctoral fellowship at CMC in 2014, in the eating disorders concentration. Dr. Schwalen joined the Center for Pediatric Eating Disorders at Children’s Health Plano as full time psychologist and is an Assistant Professor in Psychiatry at UTSW. Beyond patient care, Dr. Schwalen provides supervision to practicum students and postdoctoral fellows, participates in program development, and is part of the leadership team on the unit. Her primary areas of research include the spectrum of pediatric eating disorders (e.g., anorexia nervosa, bulimia nervosa, binge eating disorder, and obesity), linking systems of care for parents and families, and issues in supervision.
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