The Value of Developmental Conversations
By Leah L. Graves, RDN, LDN, hon CEDRD-S, FAED
One challenging and nuanced element of eating disorders nutrition practice is the determination and discussion of treatment targets for individuals whose eating disorder behavior has resulted in a need for nutritional rehabilitation including weight recovery. Clients and their families are affected by the weight-focused culture and may have established patterns of weight concern and bias. Many arrive at the treatment threshold with significant lived experiences to potentially color discussion of nutrition-related treatment targets, especially those involving weight. Developmental conversations offer a productive way to engage clients and families in discussing weight-related goals in a manner that places emphasis on overall development and well-being.
What Is a Developmental Conversation?
Developmental conversations present treatment recommendations and targets that consider a client’s current developmental stage, health status, and potential for growth, offering perspective that focusing on weight alone does not. In developmental conversations, weight and stature are considered vital signs to be viewed within the context of growth and development, much like heart rate and blood pressure. Other information, such as pubertal stage, genetic predisposition for height and shape, historic growth patterns, historic weight patterns, nutrition history, family eating culture, and patient-specific health needs, is addressed together to create a broad, inclusive recommendation that encompasses multiple facets of well-being. Families often respond well to the desire for a child to grow and develop completely. While developmental conversations incorporate many elements, they do address any recommendation regarding nutritional rehabilitation, including weight restoration.
What Do the Experts Say About Setting Weight Targets?
Weight targets are routinely set for clients who need nutritional rehabilitation. For children and adolescents, determining a target weight recommendation is particularly challenging because the onset of eating disorder behavior and treatment occurs during a time of significant growth and development. During puberty, adolescents experience changes in height, weight, and brain and bone development. Malnutrition during this phase can have lifelong consequences. To date, no empirically supported methods exist for determining weight-specific treatment targets in eating-disordered youth. A study of dietitians considered experts in eating disorders noted little consensus around setting target weights for adults with eating disorders; however, there was consensus regarding the need to set individualized weight targets considering historic trends and utilizing growth charts in eating-disordered youth.1 Supporting the monitoring of growth charts for early detection of eating disorders in children and adolescents, Marion et al. demonstrated that nearly half of the participants in their retrospective review showed deviation on their growth curve a median of 9.7 months prior to eating disorder symptoms being reported by parents.2 In other words, the shift in nutritional state was evidenced in growth records much earlier than symptoms were identified. Dietitians also agree that the focus of nutrition intervention should be on reaching a healthy nutrition state rather than on weight alone.1
How Would One Focus on Healthy State?
One way to focus on healthy state is to look at functioning and frame weight as only one of many factors that inform nutritional well-being. Children and adolescents who are in a healthy state have an ability to nourish themselves adequately with parental support. In addition, youth with a healthy state have normalized vital signs and labs, reinitiation of growth, psychological function that is on track for their age and developmental stage, shaving or return of menses in those who are at the appropriate pubertal stage, and interest in the ability to resume activity without nutrition compromise. During the developmental conversation, parents/carers—and clients when appropriate—learn of the need for any weight recovery as a part of the overall health picture, with a focus on functioning.
How Should One Prepare for a Developmental Conversation?
Preparing for the developmental conversation begins with a thorough assessment of the client’s current nutritional state within the context of historic growth and weight patterns. When looking at historic growth, the dietitian should factor in the pubertal stage with any additional information that may influence the pace and course of development, such as the developmental experiences of the biological parents. The dietitian can gather very basic information using the following questions:
- How tall are you now?
- How old were you when you had your adolescent growth spurt?
- How long did your growth spurt last?
- What do you remember about how your body changed during this time?
- How old were you when you began shaving/menstruating?
- What are your family patterns/tendencies regarding body shape/size?
One way to use the information gathered from biological parents in preparation for the developmental conversation is to complete a midparental height calculation on the client. The midparental height calculation utilizes the current height of both biological parents to predict how tall a child/adolescent will likely become. The result of the midparental height calculation can be plotted on the Centers for Disease Control and Prevention growth chart for stature at age 20 to estimate how tall the client should be at the completion of adolescent growth. The percentile line for the midparental height can then be traced backward to the current age and compared with the client’s current stature percentile to assess for growth disruption. The client’s current stature percentile would be expected to be near the midparental height percentile. If height is at a percentile significantly lower than expected, the client may have growth disruption.
Clients with growth disruption who have not completed puberty need weight targets that reflect a return to a weight beyond that indicated by the pre-eating-disorder weight percentile to allow for catch-up growth. Those who have completed puberty should return to the pre-eating-disorder weight percentile and may not have significant growth with nutritional rehabilitation. Recommendations should be discussed within the developmental conversation, with a focus on overall return to health and well-being.
Who Should Be in the Developmental Conversation, and When Should It Occur?
The timing of the developmental conversation is vitally important. Developmental conversations need to be planned as early as possible after thorough assessment, case conceptualization, and recommendations have been established by the treatment team. The aim is to have enough time to establish highly individualized recommendations while bearing in mind that letting too much time pass may challenge client and parent/carer tolerance of the treatment process.
Initially, developmental conversations include parents/carers and the treatment team—often the dietitian, therapist, and medical and psychiatric providers. This offers the parents/carers an opportunity to hear information, ask questions, and have a discussion with the treatment team without the patient present. Treatment recommendations affect parents/carers and other family members. Giving space to allow organic responses and challenging questions provides the whole team, including the parents/carers, the opportunity to align prior to bringing in the client. Once there is alignment, then a client who is therapeutically ready to hear recommendations can be brought into the meeting for their part of the developmental conversation. The client part of the discussion should be curated for their developmental stage. The time with the client is used to communicate treatment recommendations through an overall health and well-being paradigm, to allow for questions and discussion, and, most important, to demonstrate alignment of the parents/carers and the treatment team.
Developmental conversations offer eating disorder professionals a vehicle for discussing individual treatment recommendations with a client and their parents/carers while focusing on establishing a healthy nutritional state, considering growth and development and overall functioning. The developmental paradigm provides a well-accepted alternative to treatment recommendations that may be experienced as weight-based, which may unwittingly reinforce cultural weight bias and challenge alignment with the eating disorder treatment process.
About the author:
Leah Graves is Vice President of Nutrition and Culinary Services for Accanto Health with brands The Emily Program and Veritas Collaborative. She is a founding member and fellow of the Academy for Eating Disorders who has treated individuals with eating disorders for more than 30 years. Leah has presented at the International Conference on Eating Disorders, International Association of Eating Disorders Professionals Symposium, and the Academy of Nutrition and Dietetics in addition to numerous regional conferences and has written several publications pertaining to nutrition and eating disorders. She is highly respected within the eating disorders field for her expertise in nutrition therapy, nutrition counseling and clinical supervision.
1. Mittnacht, A. M., & Bulik, C. M. (2015). Best nutrition counseling practices for the treatment of anorexia nervosa: A Delphi study. International Journal of Eating Disorders, 48(1), 111-122.
2. Marion, M., Lacroix, S., Caquard, M., Dreno, L., Scherdel, P., Guen, C., Caldagues, E., & Launay, E. (2020). Earlier diagnosis in anorexia nervosa: Better watch growth charts! Journal of Eating Disorders, 8, 42.