Friday, June 12, 2015

Outpatient Treatment, from the Adolescent Patient's Viewpoint: Any progress involved trust.

Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP
When Swedish researchers evaluated adolescents' perceptions of their experience with outpatient treatment, two clear results stood out. The first was the importance of involving parents in treatment, particularly with anorexia nervosa (AN), and the second was the importance of trust. Dr. Katarina Lindsted and colleagues at Orebro University, Sweden, reported the results of their small study of 15 eating disorders patients recruited from four specialized eating disorder units. The researchers' goal was to develop an understanding of the treatment experience, this time from the patient's viewpoint (J Eat Disord. 2015; 3:9)
Dr. Lindsted and colleagues used a hermeneutic phenomenological approach with the subjects, which involves an attempt to understand how people give meaning to their experiences of significant events, and depends on narratives gained from interviews (M. van Manen, Researching lived experience: Human science for an action sensitive pedagogy, 2nd ed. Ontario: Althouse Press, 1997). The 15 patients enrolled in the study were 13 to 18 years of age; 6 had been treated for AN, and 9 had been treated for restrictive-type eating disorders not otherwise specified (EDNOS). Most had been in treatment for 1 to 2 years and had participated in 11 to 30 therapy sessions. Most of the authors' interviews were conducted 1 to 3 years after the individual had completed treatment. All interviews were recorded and transcribed verbatim; participants were allowed to read the transcripts and were invited to add or change any part of the transcript.
The interviewees were asked to speak openly about their treatment experience, and the interviewer started with the question, “Can you tell me about your time in treatment?” To carry the interview forward, the therapists had follow-on questions such as asking about the parents' role and the patient's relationship with the therapist. Most interviews lasted from 45 to 90 minutes.

Overall themes that emerged

According to the authors, the one overriding theme that emerged was the importance of family participation in treatment, especially at the very beginning of treatment. Most patients felt that they were more or less forced into treatment, and they had strongly ambivalent feelings about whether and how they should participate. Many reported that their first encounter with the therapist produced shame, relief, frustration, and exhaustion. Typically, parents brought their child to treatment, and many teens were angry and strongly resistant. Initially patients recalled having strong feelings of denial and resistance to change. Some also reported that they wished their siblings were involved in some way, since siblings were rarely involved in the family sessions.

Strong alliance was built on trust

As to be expected, a strong therapeutic alliance based on trust was very important to the outcome. The first meeting was especially significant, and the teens reported that the manner in which the therapist acted, spoke, and treated them made a huge difference in generating trust. They noted that when the therapist issued an invitation to cooperate, and continued to do so during their sessions, along with clarifying treatment goals and creating a shared view of the situation, there was a much greater chance of overall success. One notable finding was that focusing on weight gain as a goal for treatment did not sit well with the teens. Some felt unprepared to end treatment and expressed disappointment that the therapist was not more interested in their thoughts and feelings. 

Honesty and respect also emerged as important ingredients in the patient-therapist relationship; the teens needed to feel competent and to have their feelings validated. The results of these analyses reinforce the important role of nonspecific therapy factors in treatment outcome.

A New Scale Measures Compulsive Food Restriction: The Self-Starvation Scale may be very helpful for patients with extreme food restriction.

Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP
Self-starvation by patients with anorexia nervosa (AN) is one of the most striking features of the disorder. It has been viewed as rewarding or habit-based, and at times is likened to compulsive drug-seeking behavior. Drs. Lauren R. Godier and Rebecca J. Park, of Oxford University, developed a novel measure of self-starvation, the Self-Starvation Scale (SS), to better understand the extent to which self-starvation may show addiction-like qualities (Eating Behavior. 2015. 17:10). The scale was partially adapted from the Yale Food Addiction Scale (YFAS) (Appetite.2009; 52:430). 
The SS asks a series of 17 questions about behavior during the previous 4 weeks, and each question has a different factor loading. The SS uses a 7-point Likert-like rating scale, from 0 (never) to 6 (every day) to record how many of the previous 28 days a behavior has occurred. For example, Question 8 states, ‘I have restricted my food intake so much that I have concentrated on this instead of doing other activities.' 
The Oxford researchers tested the scale among four groups of volunteers. The first group included 126 healthy volunteers with no prior eating disorders. Then, 78 individuals between 18 and 65 were recruited in three study groups: (1) persons with acute AN (n=41); (2) weight-restored individuals with a history of AN (n=18); and (3) individuals fully recovered from AN (n=19) The questionnaire was created using Bristol Online Surveys (University of Bristol, England). In addition to the SS, the Eating Disorder Examination Questionnaire (EDE-Q) and the Clinical Impairment Assessment, the Patient Health Questionnaire, and the Generalized Anxiety Disorder Assessment were included. Other questionnaires measured food addiction, excessive exercise, and impulsivity, and participants also provided demographic information, including height and weight (to calculate body mass index, or BMI, kg/m2); in addition, patients in the AN sample reported their lowest BMI, age of onset of the disorder, duration of illness, and treatment received.

The scale showed good reliability

The SS, which was developed to provide a tool to further assess the concept of compulsive dependence on starvation, showed good reliability and was significantly related to measures of eating disorder symptoms, compulsive exercise, depression, and anxiety. SS scores also correlated significantly with scores of food addiction, as measured by the Yale Food Addiction Scale. Because that scale centers on the rigid control of eating behavior seen in eating disorders, they add that “the result is likely to reflect the compulsive and rule-driven nature of self-starvation.” The predictive ability was greatest for the group with current AN, suggesting that the SS may be particularly helpful as an index of extreme food restriction in AN. The availability of this scale should increase attention on the potentially addictive qualities of self-starvation.

Short-term Intensive Family Therapy : A helpful approach, particularly when access to a specialist is limited.

Accumulating evidence supports family-based therapy (FBT) for treating eating disorders during adolescence. However, just as for other manualized therapies, successful FBT depends on the availability of trained FBT therapists. Unfortunately, trained FBT therapists are not widely distributed, even though adolescents with eating disorders are found everywhere.
One approach to this problem is to have families travel to specialized centers for short-term, intensive treatment. To test the concept, researchers at the University of California-San Diego (UCSD) developed a 5-day intensive treatment program for teens, designed around the principles of FBT (Eur Eat Disord Rev. 2015 Mar 16. Doi:10.1002/erv.2353[Epub ahead of print]. 

Testing the concept in two types of family settings

Erica Marzola, MD, and her colleagues retrospectively examined the long-term efficacy of intensive family therapy in both single-family and multi-family settings. Their subjects were 74 adolescents with eating disorders who participated in a 5-day intensive treatment program at UCSD between 2006 and 2013. A stringent definition of full remission was used: >=95% of weight expected for gender, age, and height; a global score on the EDE-Q within 1 standard deviation of norms; and absence of binge-purge behaviors. Partial remission was defined as weight ≥ 85% of expected weight or ≥ 95% but with an elevated EDE-Q global score and presence of binge-purge symptoms less than once per week.

The researchers followed the adolescents for 30 months. During that time, 60.8% of the teens reached full remission, and 27% got to partial remission. Poor outcome occurred in 12.2%. The program used single-family and multifamily formats, and these appeared comparable. These preliminary results suggest that intensive FBT may be a useful strategy, particularly when access to specialized treatment is limited by geography.

Saliva May Hold Clues to Undiagnosed Eating Disorders: Levels of two chemicals were particularly helpful.

Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP

Clues to an undetected eating disorder may literally be on the tip of the tongue, according to Dr. Ann-Katrin Johansson and a team of clinical dentists at the University of Bergen, Norway (Eur J Oral Sci. 2015; Mar 17. Doi:10.1111/eos.12179 [epub ahead of print]. Dr. Johansson and her colleagues recently compared the biochemical composition of saliva from 54 women and 4 male outpatients with eating disorders (mean age: 21.5 years). Fifty-four sex- and age-matched healthy controls were added from a dental health clinic. All participants in the study filled out a questionnaire, underwent dental examinations, and had laboratory analysis of their saliva. Hyposalivation, or low saliva production, was less common in the eating disorders group.

Significant differences were found

The composition of saliva was quite different in the two groups. Albumin, inorganic phosphate, aspartate aminotransferase (AST; formerly known as serum glutamic oxaloacetic transaminase, or SGOT), chloride, magnesium, and total protein levels were all significantly higher in the eating disorders group than in controls. The researchers were particularly interested in the higher-than-normal AST and total protein levels.
Statistical analyses (using logistic regression) showed that higher AST and total protein concentrations were relatively good predictors of an eating disorder (sensitivity, 65%; specificity, 67%). Thus, elevated salivary AST and total protein levels may be two more useful markers of an eating disorder.

Tracking the Night Eating Syndrome A host of approaches, but not much consensus, on this elusive syndrome.

Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP
The hidden nature of night eating syndrome, or NES, is one reason this disorder is frequently overlooked by health care professionals and patients alike. Although the syndrome of morning anorexia, evening hyperphagia and/or insomnia was first reported by Stunkard and his colleagues at least 60 years ago, lack of a standard definition has impeded recognition of NES comparison and comparison of study results.
The DSM-5 has helped somewhat by listing three main diagnostic criteria for NES: (1) recurrent episodes of night eating, shown by eating after awakening from sleep or by excessive eating after the evening meal; (2) awareness of those eating episodes; and (3) significant distress or impairment brought on by the disorder. Another disorder, sleep-related eating disorder, or SRED, is also characterized by recurrent episodes of involuntary eating or drinking during sleep, but is considered as a type of parasomnia, or primary sleep disorder in which physiology or behaviors are affected by sleep, the stage of sleep, or the transition from sleeping to waking, rather than to an eating disorder.

A new instrument designed to detect NES

Suat Kucukgoncu, MD, and colleagues at Yale University recently evaluated the assessment and management of NES (Neuropsychiatr Dis Treat. 2015; 11:751). The authors note that although the Night Eating Questionnaire (NEQ) is widely used to detect NES, it often yields false-positive results in selected groups, such as obese patients and those who have had gastric bypasses, and thus a second interview component may be helpful. The Night Eating Syndrome History and Inventory is one useful addition to existing tests. This semi-structured interview also includes questions about the history of night eating symptoms, the amount of food eaten per day, sleep patterns, mood symptoms, life stressors, weight and diet history, and previous treatment for NES.

A multitude of treatment approaches 

Treatment approaches for NES have included pharmacologic agents, cognitive behavioral therapy, light therapy, and muscle relaxation therapy, according to Dr. Kucukgoncu and his coauthors. The serotonin system was a natural target for pharmacologic treatment, and just as for bulimia nervosa, clinical trials have primarily involved antidepressants, particularly the selective serotonin re-uptake inhibitors (SSRIs) sertraline and escitalopram.
Uncontrolled studies with sertraline showed that the SSRI improved NES symptoms, mood, and quality of life. Subsequently, an 8-week blinded, randomized trial of sertraline significantly improved both NES symptoms and quality of life (Am J Psychiatry. 2006; 67:1568). Caloric intake after the evening meal also decreased in patients receiving sertraline compared to those receiving a placebo. A randomized trial with escitalopram showed improvements in night eating symptoms as well as modest weight loss, but the active drug results were not significantly better than with placebo (Eat Behav. 2013; 14:199). 
Topiramate, a glucocerebrosidase (GBA) agonist and glutamate antagonist, has also been beneficial for treating NES. [See “Update,” earlier in this issue.] However, in one study, once the drug was discontinued, symptoms of NES returned (Sleep Med. 2003; 4:243). Because to date there are no guidelines or data on the duration of the therapeutic benefit of medications for NES, Dr. Kucukgoncu and colleagues recommend that any medication be used at least 8 weeks before reaching conclusions about its effects. They also suggest considering a total treatment period of at least one year if a medication proves beneficial before determining if it is successful or unsuccessful for treating NES.

Psychological interventions

Psychological interventions have also been used with some success to treat patients with NES. In particular, Allison and colleagues have developed a cognitive behavioral therapy program for NES. During an uncontrolled CBT trial conducted in patients with NES (Am J Psychother. 2010; 64:91), 14 of 25 patients participated in 10 hours of CBT sessions over 12 weeks. CBT treatment led to significant reductions in evening hyperphagia, reduced the number of nocturnal eating episodes and total caloric intake, and diminished depressive symptoms. Interestingly, the authors noted that CBT reduced excessive eating most markedly during the night but not right after the evening meal.

Italian Researchers: Poor Sleep Predicts Poorer Outcome

A recent study of 562 patients with eating disorders showed that when patients reported having poor sleep when they were first admitted for treatment, their poor quality of sleep predicted the severity of eating disorder symptoms. 
Persistence of poor sleep 6 months later directly predicted the severity of eating disorder symptoms and suggested that addressing poor sleep early may benefit patients because its presence and persistence increase comorbidity and failure on standard treatment (Eat Behav. 2015; 18:16).

Personality and Eating Disorders Swedish researchers: Better understanding of personality could improve outcome.

Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP
Personality can play several major roles for those with eating disorders: as a risk factor, as a moderator of symptomatic expression, in choice of treatment, and also as a predictive factor in outcome. Some personality traits are common to all eating disorders, while others are strongly related only to certain types of eating disorders, such as high perfectionism in anorexia nervosa (AN) and increased sensation-seeking in binge eating disorder.
Researchers at Sweden's largest eating disorder center, the Stockholm Centre for Eating Disorders, recently explored ways in which patients with non-anorexic eating disorders differ from controls in personality, and to examine whether facets of personality can be paired with psychopathology (J Eat Disord. 2015; 3:3). The Stockholm Centre admits about 700 patients each year to its inpatient, outpatient, day, and family units, and it also has a mobile acute treatment team. 
Patients with non-anorexic eating disorders who were treated at the Stockholm Centre between 2010 and 2013 were enrolled in the study. This group had severe disease, as shown by mean scores on the Eating Disorder Examination (EDE) corresponding to the 95th percentile in young adult women. Potential participants had either been enrolled in a randomized control trial of Internet-based cognitive behavior therapy (n=150) or were enrolled in a multimodal day—patient treatment program (n=129). All patients were females and had a DSM-IV diagnosis of bulimia nervosa (BN) or eating disorder not otherwise specified (EDNOS). After eliminating 3 patients (2 who failed to complete the personality inventory and 1 who was diagnosed with AN), 208 persons were enrolled in the study. 
The participants completed a series of online questionnaires, including the Eating Disorder Questionnaire (EDE-Q), the Comprehensive Psychiatric Rating Scale-Self-rating Scale for Affective Syndromes (CPRS), and the Structured Eating Disorder Interview, a 20- to 30-question instrument based directly on DSM-IV eating disorder criteria. They also completed the NEO Personality Inventory, Revised, a 240-item self-report measure designed to assess five dimensions and 30 facets of the Five Factor Model. The Five-Factor Model is comprised of five personality dimensions: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism.

Personality differed between patients and controls

Compared to the controls, the patient group was characterized by pervasive negative affect and vulnerability, and displayed few positive emotions such as joy, warmth, or love. They were also significantly less sociable and showed less trust, competence, and self-discipline. While they were more closed to feelings, ideas and new experiences, they were more open in expressing their values. Patients also reported a tendency to doubt their own capacity to deal with life challengers, were self-effacing, and believed other people could not be trusted. They rated themselves as non-dogmatic and as less traditional than others. They also reported having a tendency to procrastinate and had trouble controlling their desires, which led to rash action, often followed by regret.

The authors stressed that knowledge of facets of personality, especially trust, striving to achieve, and neuroticism, can lead to better understanding of eating disorders. By identifying and focusing on personality traits, it might be possible to enhance the treatment alliance, address underlying problems, and improve outcomes.

UPDATE: Topiramate May Trigger Eating Disorder Symptoms An anticonvulsant used for migraine deserves careful monitoring.

Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP
In 2014, the US Food and Drug Administration approved the use of the anticonvulsant topiramate (Topamax®) for treating migraine in adolescents. One well-known side effect of the drug is appetite suppression. Despite the fact that topiramate has been studied for treating binge eating disorder (BED) and bulimia nervosa (BN), the drug's appetite-suppressant effect raises the possibility of development of or worsening of disordered eating among young patients. This risk may be further highlighted by the fact that while symptoms improved in the published BN topiramate trial, weight loss was also observed (in a fairly lean sample; Hoopes et al., J Clin Psychiatry. 2003; 64:1335).
Researchers at the University of Miami and the Mayo College of Medicine, Rochester, MN, recently evaluated seven cases of teens who developed disordered eating patterns after treatment with topiramate (Pediatrics.2015; 135:1). Dr. Jocelyn Lebow and her fellow researchers used a retrospective chart review of adolescent patients taking topiramate who were seen at the Mayo Clinic Eating Disorder Program between November 2008 and June 2013. During that time, 7 topiramate-treated female adolescents 13 to 18 years of age were diagnosed with eating disorders: 4 with eating disorder not otherwise specified, 2 with anorexia nervosa, and 1 with BN. All had been given topiramate for migraine or chronic headache, and the dosages ranged from 25 mg twice daily to 150 mg daily.
Three of the girls estimated that their eating disorder had preceded treatment with topiramate; 1 was in remission from an eating disorder when the agent was prescribed and then the disorder recurred, and 3 other girls developed their eating disorder only after starting topiramate. In all cases, dietary restriction was the primary eating disorder symptom; 5 also reported purging and 3 had binge eating. One young patient had marked weight gain after taking the anticonvulsant but all others reported weight loss.

The authors note that migraine is very common among individuals with eating disorders, and that results of one study showed that at least 74% of patients with eating disorders also had migraines (Neurol Sci. 2009; 30 (suppl): S5). Thus, the potential for exposure in teens with an established eating disorder (or risk for one) exists. Inherent in a case series of this sort is that the group of teens receiving topiramate without developing symptoms is not represented, so the actual frequency of this is unknown. The authors suggest that careful monitoring of patient weight gain and eating behaviors continue after topiramate is given and weight loss should not be dismissed as a temporary side effect of the anticonvulsant.

Long-Term Treatment of Eating Disorders: Tools for a Journey

Part 2: A Perspective from Research

By Kathryn Zerbe, MD
Oregon Health and Science University and Oregon Psychoanalytic Center, Portland, Oregon
Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP
In this article I'll describe four principles I find useful in working with patients who come to us in need of longer-term psychotherapy, or who tend to stay in our practice for at least one year. Even in an age with impactful reimbursement constrictions from third parties and pressure to ensure that our efforts are ‘evidence based,' and thereby explicitly scientific and worthy of payment, a significant number of patients benefit from a treatment process when a “longer dose” from “50 to 100s of visits” is given.4 These patients tend to have histories of early attachment difficulties, trauma and maltreatment, co-occurring personality disorders, substance abuse, and severe anxiety or depression. They have not been adequately helped by less-intensive psychoeducational, or exclusively manualized cognitive-behavioral, pharmacological, and family-based interventions.5, 6
For these patients, who have many symptomatic difficulties and who have not yet formed a core sense of themselves, research demonstrates that experienced clinicians consciously and intuitively blend psychodynamic and cognitive behavioral methods, regardless of the theoretical orientation that we may consciously espouse.4, 7, 8 This crucial research data from “real-world” practice is beginning to tell us much about the technical skills, personal attributes, and treatment stance clinicians bring to the treatment setting that can engage a patient in need of therapy that promotes the development of a sense of self and heralds better self-care overall.4, 6-8

Four Principles Can Guide Our Therapy

The research perspective also tells us a bit about how we engage with our patients and technically blend skills to keep the process going. Yet, to fully understand how patients actually get better and change over time, as well as those quagmires a therapist likely encounters while on the journey with them, continues to beguile us. The four principles I describe below by no means form an exhaustive list, but they have helped me to stay sane and somewhat steady when working with eating disorder problems that appear refractory to intervention or when treatment appears to be at a stalemate. They are also principles that students and staff members find helpful and salutary, even as they gainsay an easy answer to sticking with a patient when life itself seems to be on the line, precious monies for care may be limited, and the treatment process may appear to be deadlocked. 

Principle 1: Patience in Practice, or the ‘Resistance Phase' of Treatment

Drawing upon his experience of working intensively on an inpatient unit with highly disturbed adolescent girls, psychiatrist Donald B. Rinsley coined the term ‘resistance phase of treatment' in the late 1970s.9 He observed that teens with severe interpersonal and family difficulties often needed up to 16 months of persistence by staff members on the residential unit to help them work through numerous resistances and behaviors before they could actually begin what he called ‘definitive treatment.' In other words, resistance is not a single behavior or maneuver to be overcome, such as curtailing one's denial of emaciation or refusal to stop binge eating, but a multiplicity of self-destructive patterns, secondary gains from illness, and other impoverished adaptations to constructive living. 
Once the therapist understands that resistance is a phase to be weathered more than an action to be overcome, she is able to wait out and work with the patient's tendency to try to defeat the treatment. While trying her best to be useful to the patient in providing new tools and simply listening to the patient's story unfold, she is also inclined to be less self-critical when her patient does not immediately benefit. She understands that the resistance phase of treatment is where she and her patient are, and that it cannot be rushed. When a therapist can be less critical of herself, her patient has a new object of hope to identity with in a constructive way that will serve him better in life. To such patients in this stage I often find myself saying over and over again, “I can wait longer than you!” and “Remember, we are aiming at improvement, not perfection.” 
During the resistance phase of treatment the therapist is also gaining essential data about the patient that will be useful later. On the surface the patient may not seem to be taking anything in, but in reality an attachment relationship is unfolding and gaining strength. As feelings of safety increase, the patient may reveal a little more about her history. With both a safer attachment and more knowledge of the patient's life comes the opportunity to speak to the problems with which the person struggles. When the patient is manifestly resisting in this phase, the therapist is not curtailed from responding in a very human way by asking questions, making simple observations, nodding and affirming, uttering subtle “umms” or “ahhs,” and zeroing in on past and present losses. Why is it particularly important to talk about loss? Loss is the most ubiquitous of psychological issues. None of us escape it. Even positive changes are filled with a sense of leaving something of value behind. Letting patients know that their losses can be expressed and not dodged is one of the gifts of the therapeutic process, and may accelerate movement into a more active treatment phase when grief may be more actively expressed and worked on. 

Principle 2: Permission to Feel and Express Pain

Regardless of our professional discipline, imbued in our training is the concept of reducing suffering to a minimum. Even as we all appreciate that life is hardly a pain-free enterprise, we undertake our work as healers to defeat it. Counterintuitive is the notion gaining traction in contemporary psychoanalysis and psychodynamic psychotherapy that the best way to alleviate suffering is to actually help the patient “observe, process, speak about, draw attention to, and bear”10 emotional pain in order to eventually transform it. 
“When we find we can face our fears, a sense of confidence and acceptance begins to grow naturally,” writes psychoanalyst Jeffrey Eaton.10 He continues to provide balm for therapists as he continues, “I have no magic answers or solutions. Part of my pain is that I cannot simply remove the pain my patients must face...Over the years of work together people grow a deeper capacity for loving connections, and perhaps most importantly, some soften into strength and become curious about, even compassionate toward, some of the most pained parts of themselves. The pain is not gone, but one has a very different relationship to it, and to the idea of how others might experience it.” 
Sitting with, processing, and containing pain is some of the hardest work that we therapists do. Patients often want and need to stay in treatment longer because the therapist's office is the safest and really the only place they have to pour out their angst. We bear witness to their cumulative losses and their life transitions. How many culturally sanctioned places are available where one's private self is held sacred? One patient in my practice who made substantial progress early on with her eating problems continues to make an investment in herself by coming weekly. She calls psychotherapy a place where she “drinks water from a well,” and likens her thirst to a lifetime draught to speak her truth. Most therapists who do longer-term work will resonate with this example because they hear similar tales daily and absorb the shock waves of the other person's anguish and joys. “Today I need containment” is the plaintive cry of many an experienced clinician who seeks out supervision or consultation less for concrete direction or specific advice than for the place it provides to feel, to express, and to work on the pain of others that accompanies our tasks.

Principle 3: Staying the Course. Expectable ‘Plateau Phases'

One of the most valuable lessons I have learned about life from my patients is that there are inevitable and necessary plateau phases where nothing much seems to be going on in therapy and where patient and therapist both feel stalled. In part these plateau phases occur because on the surface nothing is going on. In reality the action is happening below the surface, as a kind of consolidation of gains before a new growth spurt occurs. The problem for the therapist is that it may be difficult to ‘hold' a patient in treatment at these times and to have any faith that something will enfold anew with the fullness of time. 
In the therapeutic work the patient retreads old ground, may even complain that she is growing bored and impatient, and wonders if she has achieved maximum benefit, and is ready to quit. The therapist also has her doubts and is wondering similarly: The pair appear to have caught the same virus — the ‘hurry-up and move-on' virus — but in the best of scenarios they find a way to slow down, to wonder what is happening, and perhaps to even enjoy a bit of a slower pace. Then, imperceptibly, something shifts, and the pair is on another incline pathway -- delving into a new issue, confronting an old source of discomfort with new resources, and deciding on a different venue for work or in personal life. Something new has sprouted —magically and mysteriously — and we are as amazed as when we were as preschoolers who left the classroom in the afternoon and returned to school the next morning to find that a baby pea plant peeks out from the egg carton garden we and the teacher had planted the week before.
Therapists and patients would never fault a farmer who left her garden fallow for a season or two, because we know that crop rotation is essential to keep the soil vibrant. Yet we expect ourselves to have no fallow periods of our own, periods when we can replenish our stock and ourselves before something new can emerge in its season. Supervisors can also be pushy about progress and not see the need and value of plateau phases. As a result the staff member feels an anxious need to make things happen and pushes the patient, when exactly the opposite is needed. This can intensify resistance and lead the patient to experience more shame and guilt even when the therapist is trying her best to be benevolent. While a plateau phase must be judiciously teased out from an actual resistance to taking a new step, requiring judgment and tact, pausing in psychological work and making space is part of the process that has been given too short shrift in psychotherapy. 

Principle 4: Noticing Growth/Valuing Grit

One unfortunate legacy of early psychoanalytic theory is the notion that the therapist should ‘maintain neutrality' except in the most extreme situations, such as a suicidal crisis or medical emergency. Yet consider how many times, even in Sigmund Freud's most famous cases, the importance of providing support and affirmation was noted. When Freud failed to understand this need, the case faltered. Also consider the personal history of Freud himself. Although Freud had difficulty sustaining professional relationships with some of his creative partners like Alfred Adler and Carl Jung when they differed with him, his work flourished when he had a partner who served in part as an ancillary therapist and facilitating other. One need only scratch the surface of the lives of many creative and productive artists, scientists, and authors to see that there is often a person behind the scenes who is noticing and valuing an individual's talent and ability long before it is recognized by the public at large.
If this necessary function is sought after and found to be essential to our most able and laudable achievers, how important might it be for our patients, who come to us with stormy histories bereft of stable attachment and love? While a therapist or supervisor should never offer false praise, recognizing steps forward and commenting on perseverance and resolve offer those in our care hope and emotional sustenance in real time. When I listen to a staff member present a case that is going reasonably well despite inevitable symptomatic regressions on the part of the patient, I invariably find myself saying, “Don't forget to comment on how far the two of you have come together. Be as specific as you can be. Remember the initial sessions and recall some developmental leap that you have witnessed.” Almost invariably the staff member will return and let me know that the patient lit up at being recognized for the progress and was “amazed” or “touched” that the therapist had cared enough to notice. The universal need for recognition, particularly when undertaking all the difficult tasks inherent in deeper psychotherapeutic work, needs to become an essential part of our everyday practice. 
Increasing evidence from neurobiology supports the concept that support is good for the brain as much as the soul. When the brain's seeking,' ‘loving,' and ‘playing' regulatory systems are aroused at the level of the prefrontal cortex, positive affective circuits of the brain are strengthened.11 While each of these systems has highly specific individual pathways still to be completely ferreted out, current data suggest that they culminate in dopaminergic neurons at the level of the prefrontal cortex and oxytocin release in the medial subcortex. Dopamine generates enhanced self-esteem, and oxytocin promotes social bonding and nurturance. Both neurochemicals facilitate emotional readiness for prosocial growth we hope to help induce in our patients. Noticing our patients' growth and valuing their grit is both a neurobiological and psychological intervention and bedrock upon which lasting change is likely built. And, like our patients, therapists also derive similar benefits from having those in our circle that value these qualities in us. Creative partnerships in the form of peer supervision, ongoing consultation, and study groups are just some of the arenas that enable therapists to value ourselves, and that have the potential to nurture our growth by mirroring grit and determination.


These four principles that guide longer-term treatment of eating disorders are offered to assist therapists in negotiating stalemates and fallow periods of the work. Sometimes we are unable to help patients relieve their suffering directly but we can assist them in changing their relationship to their pain and sense of loss. This process is more difficult than it appears because remediation of symptoms and relief of suffering are what we are taught to do in our training and encouraged to try to emulate from studying the scientific literature.
Cultivating a therapeutic stance wherein the patient can bring forth inner pain that may not be superficially apparent fosters resilience over time. Recent studies in neuroscience support this approach as having substantial benefits for the brain. Both therapist and patient are likely to maintain a healthier sense of well-being when we pay attention to our need for secure spaces to process emotional needs, respect phases of resistance when not much may be directly happening in the therapeutic work, and cultivate supportive people and ‘creative partnerships' who value and encourage us during the most inscrutable periods of the journey. 

About the Author

Dr. Zerbe is professor of psychiatry and obstetrics and genecology at the University of Oregon School of Medicine, Portland. She also is the author of numerous books, including the best-seller, The Body Betrayed.


  1. Bakewell, S. (2010). How to Live: Or a Life of Montaigne. New York: Other Press.
  2. Zerbe, K. J. (1995). The body betrayed: Woman, eating disorders, and treatment. Carlsbad, CA: Gurze Books (original edition published 1993, American Psychiatric Press).
  3.  Zerbe, K. J. (2008). Integrated treatment of eating disordersBeyond the body betrayed: New York: W. W. Norton.
  4.  Tobin, D. L. (2012). The rationale for psychodynamic psychotherapy of eating disorders: An empirically constructed approach. In D. Stein & Y. Latzer (Eds.), Treatment and Recovery of Eating Disorders (pp. 97-108). New York: Nova Science Publishers.
  5. Tasca, G. A., Ritchie, K., & Balfour, L. (2011). Practice review: Implications of attachment theory and research for the assessment and treatment of eating disorders. Psychotherapy, 48, 249-259.
  6. Tobin, D. L., Banker, J. D., Weisberg, L., & Bowers, W. (2007). I know what you did last summer (and it was not CBT): A factor analytic model of international psychotherapeutic practice in eating disorders. International Journal of Eating Disorders40, 754-757.
  7. Thompson-Brenner, H. & Westen, D. (2005a). A naturalistic study for
    bulimia nervosa, Part 1, Comorbidity and therapeutic outcome. Journal of Nervous and Mental Diseases. 193:9, 573-584.
  8. Thompson-Brenner, H. & Westen, D. (2005b). A naturalistic study for bulimia nervosa, Part 2: Therapeutic interventions in the community. Journal of Nervous and Mental Diseases. 193:585-595).
  9. Rinsley, D.B. (1980). Treatment of the severely disturbed  adolescent. New York: Aronson.
  10. Eaton, J. L. (2011). The Fate of Pain. In A Fruitful Harvest: Essays after Bion. Seattle. Alliance Press.
  11. Panksepp, J., Biven, L. (2012). The Archaeology of Mind: Neuroevolutionary Origins of Human Emotions. New York: W. W. Norton.

Friday, June 5, 2015

May 2015 Family Meals Focus #100 Doctors and weight: Helping without harming

Ellyn Satter, Registered Dietitian and Family Therapist
To comment on this issue, please join us on Facebook

Satter’s Division of Responsibility in Feeding(sDOR) is recognized as best practice by the AAP: 7th edition, Pediatric Nutrition.
sDOR: The parent is responsible for the whatwhenwhere of feeding and the child is responsible for the how much and whether of eating.
To prevent child overweight and obesity from birth, support parents in following sDOR.
To treat child overweight and obesity at any age, restore sDOR and trust the child’s own homeostasis to restore appropriate growth. 
For a PDF on this article, click here
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Standard food advice is negative

For the policy makers and consensus-arrivers, child obesity prevention is about eating the right food and avoiding the wrong food, with a bit of “restrict portion size” and “move more” thrown in.  
  • Limit sugar-sweetened beverages1-5
  • Encourage fruits and vegetables1-5
  • Encourage low-fat dairy foods and whole grains4
  • Limit portion sizes1-3,5 

Negative food advice does harm

Less than 10% of adults can follow this drab and negative advice6 for themselves, let alone for their children, and they feel bad about it. Imposing food rules makes it harder for parents to get a meal on the table, even when you try to soft-pedal by saying  "watch what he eats," or "follow the Food Pyramid," or “follow MyPlate," or “don’t let him eat so much starch—so many sweets—so many fried foods." You know by the dread and consternation on a parent’s face. Parents want to nurture. This advice makes them food cops. No more relaxed and enjoyable family meals, holidays, and birthday parties.  Parents brace themselves to get their child to eat vegetables, to eat less, to stay away from high-fat, high-sugar food. At the next appointment, the parent won’t meet your eyes and the child’s weight gain has accelerated. Or they simply don’t show up.
Some parents tell you: just-don’t-mention-weight! Parents’ intuitive wisdom is backed by evidence: children who are labeled overweight feel flawed in every way—not smart, not physically capable, and not worthy.7  Five to nine year olds characterized as being at risk for overweight ( ≥85th BMI percentile) say they eat only a little bit on purpose so they don’t get fat.8 That’s pretty sad, isn’t it? Children are entitled to be free from worry about eating, moving, and weight. 

Put a positive spin on the standard advice

You can do what the policy-makers say, just do it so it helps. In the midst of its own negative food selection advice, the American Academy of Pediatrics (AAP) puts forth this possibility: “Empower parents to promote children's ability to self-regulate energy intake while providing appropriate structure and boundaries around eating.”4  Essentially, AAP recommends sDOR. To translate, consider this advice from the handout, Your Child’s Weight: Helping without Harming and the book of the same name.
  • Have regular, reliable, and rewarding sit-down family meals and sit-down snacks. This would be AAP’s “appropriate structure and boundaries around eating.” The rewarding part is important. Consistently providing family meals is a lot of work. Parents who are freed to provide food the family enjoys get intrinsic reinforcement for making meals a priority.
  • Include a variety of good-tasting, wholesome foods. Families who eat regular meals get around to including fruits, vegetables, and other wholesome foods. And they eat them because they enjoy them, not because they have to.
  • Include “forbidden foods” in meals and snacks. Making sugar-sweetened beverages a sit-down, rather than a carry-around beverage limits consumption. A lot. Giving a time and place to enjoy high-sugar, high-fat snack foods also limits consumption. More importantly, children come to regard high-calorie, low nutrient foods and beverages as everyday food that they consume the same as other food: sometimes a little, sometimes a lot.   
  • Trust the child to decide what and how much to eat from the food parents provide. The food cops emphasize limiting portion sizes, which is, of course, a form of restriction. Children whose food intake is restricted become food preoccupied and are prone to overeat when they get the chance.  Children whose parents follow sDOR do a good job of managing their own portion sizes.
  • Forget about encouraging “slimming” foods. The evidence doesn’t support recommending low-fat dairy foods.9  Whole grains are nutritious, but they aren’t slimming.

Focus on the parents’ feeding, not the child’s eating   

Encourage parents to do a good job with feeding, not to try to fix their child’s eating. Be persistent in your encouragement, and keep your nerve. It takes parents time to establish family meals and more time to stop interfering with what and how much their child eats.  sDOR is working when family meals are pleasant and the child is relaxed and positive about eating. Keep your nerve about weight as well. Until the middle grades, children have a greater than even chance of slimming down.10,11  In the process of making change on behalf of their child, many parents will improve their own eating competence. Parents who are eating competent follow sDOR12 and their children show better nutrition profiles.13 The Joy of Eating translates sDOR in feeding children into guidelines for adults’ feeding themselves.  

 The 15 minute intervention


  1. CDC. Overweight and Obesity: Strategies and Solutions. Accessed March 22 2015.
  2. Barlow SE, and the Expert C. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120(Supplement_4):S164-192.
  3. USDA, FNS. Maximizing the message: Helping moms and kids make healthier food choices. FNS-409. 2012 Accessed May 8, 2015.
  4. American Academy of Pediatrics Committee on N. Prevention of pediatric overweight and obesity. Pediatrics. 2003/2007;112:424-430.
  5. USDA, USHHS. Dietary Guidelines for Americans. 2010 U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans, 2010 Accessed May 8 2015.
  6. Laster LE, Lovelady CA, West DG, et al. Diet quality of overweight and obese mothers and their preschool children. Journal of the Academy of Nutrition and Dietetics. 2013;113(11):1476-1483.
  7. Davison KK, Birch LL. Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics. 2001;107:46-53.
  8. Shunk JA, Birch LL. Girls at risk for overweight at age 5 are at risk for dietary restraint, disinhibited overeating, weight concerns, and greater weight gain from 5 to 9 years. J Am Diet Assoc. 2004;104(7):1120-1126.
  9. Satter E. Family Meals Focus #98. Should you put your child on skim milk?  . 2015;
  10. Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US preventive services task force. Pediatrics. 2005;116:e125-e144.
  11. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Preventive Medicine. 1993;22:167-177.
  12. Tylka TL, Eneli IU, Kroon Van Diest AM, Lumeng JC. Which adaptive maternal eating behaviors predict child feeding practices? An examination with mothers of 2- to 5-year-old children. Eat Behav. 2013;14:57-63.
  13. Lohse B, Satter E, Arnold K. Development of a tool to assess adherence to a model of the division of responsibility in feeding young children: using response mapping to capacitate validation measures. Child Obes. 2014;10(2):153-168.
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Monday, June 1, 2015

The Use of Arts In Awareness & Prevention of Eating Disorders

A 3-part series by Robyn Hussa Farrell, Founder and CEO of mental fitness
This is the third and final part in a series (View Part 1 View Part 2)
Summary: It has been an 8-year journey to evolve an evidence-based model of building and delivering award-winning prevention-focused programs in collaboration with educators, researchers and practitioners.
These arts-infused programs are created with five main elements:
- documentary style films featuring the nation’s researchers in prevention
- handouts written by researchers and practitioners
- resources
- strategies for finding CEDS and FAED specialists
- links to validated screeners and more.
Most importantly, creating and delivering the programs requires a community effort and multiple collaborations.
Today we offer an array of online and live courses. A complete listing is available here. Mental Fitness live programs have been implemented in the following school districts across the country:
  • Greendale, Wisconsin
  • Central Wisconsin (in collaboration with WI American Academy of Child and Adolescent Psychiatrists and Wisconsin School Nursing Association)
  • Spartanburg, South Carolina (in collaboration with Veritas Collaborative, Judy Bradshaw Children’s Foundation and Mary Black Foundation)
  • Columbia, South Carolina (in collaboration with Hearth Center and SCEDA)
  • Weston, Connecticut (in collaboration with Weston, CT Youth Services)
  • Western Suffolk, New York (in collaboration with NY AHPERD)
  • Reading, Pennsylvania (in collaboration with Veritas Collaborative, Perfect as You Are and Reading Hospital)
But leading professional development workshops that educate about disordered eating awareness and prevention is only the beginning. As with many things, the more we know, the more we learn what we don’t know. The real work still lies ahead of us …
(PLEASE NOTE: the remainder of this article contains confidential information that is property of Robyn Hussa Farrell, Mental Fitness, Inc., and various research teams. For permissions or more information, please contact Robyn Hussa Farrell at
Inspired by Dianne Neumark-Sztainer’s research[1], in 2012 we began to further investigate the shared risk and protective factors that underlie serious mental illnesses, eating disorders, obesity and addictions. We pulled together research from developmental psychology, looking at the overlap between prevention and kindergarten readiness. Gathering publications from multiple areas of science, we located validated assessments, evidence-based interventions and put them together into our Mental Fitness Map. This has become our mechanism for linking evidence-based prevention programs to schools and universities.
To help us bring together these resources, we built a prevention site ( and the NOURISH prevention center (, where parents and children can take classes and attend workshops.
Generally, we are in the process of investigating and learning that communities can improve behavioral health, overall health and improve kindergarten readiness by focusing on the shared protective factors that can be taught to children ages 0-5 and their parents. In addition to Mental Fitness’s findings in Spartanburg schools in 2013-2014 (see Part 2 for complete detail), the below appendix contains supporting data emphasizing the overlap in four key areas. The below hypotheses have led to our key research and design projects for 2015-2016 which are available on our website at
We are especially grateful to the primary researchers with whom we have had the privilege of collaborating on the below report; including, Christina Anderson, Ph.D., Cynthia Bulik, Ph.D., Deb Burgard, Ph.D., Melissa DeRosier, Ph.D., Camden Elliott, MD., and Christine Peat, Ph.D.
  1. The Mental Fitness “Map” is based on the below research at University of Minnesota, emphasizing the importance of focusing on the shared risk and protective factors for mental health and obesity as the new way for preventing obesity, mental illnesses, and improving health outcomes. [2]
o   “A major challenge to developing interventions that are able to prevent both obesity and eating disorders is the identification of potent and modifiable factors that have relevance for both conditions[3]. Identification of appropriate risk factors for the condition being targeted is essential to developing effective prevention interventions[4].”
o   “Other potential shared risk and protective factors that may be worthy of further etiologic inquiry include self-esteem, depression, dietary intake patterns (e.g. meal patterns), the role of parental encouragement or role modeling of weight-related behaviors and the role of a home environment that is supportive of healthy eating and physical activity behaviors.[5]” (these have all been integrated into our Mental Fitness map)
  1. Studies that look at the long-term impact on individuals who benefitted from early childhood education at ages 0-5, show profound improvement in social and emotional learning skills, less crime, higher graduation rates and increased employment.[6]
o   “The High/Scope Perry Preschool study followed 123 children from preschool well into adulthood. … the study found a persistent effect on achievement tests through middle school, a finding consistent with results from the meta-analysis of all relevant research literature. In addition, the preschool group had better classroom and personal behavior as reported by teachers, less involvement in delinquency and crime, fewer special education placements, and a higher high school graduation rate.[7] Through age 40, the program was associated with increased employment and earnings, decreased welfare dependency, and reduced arrests. Long-term effect sizes are in the range from 0.30 to 0.50 standard deviations. High school graduation increased from half to two-thirds, the number of arrests by age 27 fell by half, and employment at age 40 showed an increase of 14 percentage points.[8]”
o   “Multiple meta-analyses conducted over the past 25 years have found preschool education to produce an average immediate effect of about half (0.50) a standard deviation on cognitive development.[9] This is the equivalent of 7 or 8 points on an IQ test, or a move from the 30th to the 50th percentile for achievement test scores. For the social and emotional domains, estimated effects have been somewhat smaller but still practically meaningful, averaging about 0.33 standard deviations.[10] To put these gains in perspective, it’s important to realize that on many measures, a half standard deviation is enough to reduce by half the school readiness gap between children in poverty and the national average.”
  1. Social and emotional learning skills, similar to those taught through the Mental Fitness programs, contribute to the prevention of obesity.[11]
o   “There is tremendous overlap between the social skills targeted in Social Skills Training programs and the skills necessary to produce lifelong change in obesogenic habits. For example, in order to change dietary habits, children need to have nutritional knowledge, as well as impulse control to resist energy dense foods. The impulse control strategies used for maintenance of a healthy diet are parallel to the impulse control and emotion regulation strategies used in social interactions wherein children may need to resist aggressive impulses and maintain a calm and cooperative attitude. In addition, learning respect for oneself and others, improving perspective taking ability, maintaining a positive attitude, understanding responsibility, and learning to use action plans to achieve short and long-term goals are important skills for obesity prevention and the development of positive peer relations and provide benefit when used in an independent social skill intervention[12] or when used in conjunction with other intervention program components[13]. Given the strong evidence supporting the positive and reinforcing effect of peers on diet and activity, the novel, collaborative approach combining the best practices in obesity prevention with complimentary social skill training can provide potent, long-lasting effects for all children, regardless of weight, and therefore can contribute to the prevention of obesity.”
  1. Emotional well-being, social competence, and cognitive abilities – together – are the brick and mortar that comprise the foundation of human development.[14] These have been linked to improving mental fitness, obesity prevention and children’s readiness for school.
o   “Being able to regulate emotion, pay attention, work independently and with peers, and make good choices are paramount in determining children’s readiness for school[15]. These early SEB skills are critical prerequisites for school entry [16]. Young children with low SEB skills are more likely to display antisocial behaviors, dislike school, perform poorly on academic tasks, and experience grade retention and drop out [17], and are more likely to be inattentive, disruptive, or withdrawn in the classroom[18].”
The Mental Fitness national nonprofit is devoted to prevention research that expressly serves children, educators and families. We hope that you will join us in our mission of building mental fitness in all youth through evidence-based prevention programs.
  • – main website 
  • – prevention tools, curricula and trainings by national prevention researchers
  • – optimizing athlete health
  • – top rated body image site featuring 40+ contributors
  • – live prevention center in Spartanburg’s Chapman Cultural Center
  • – an annual fun walk for families
Watch the 3-minute trailer of NORMAL (the musical that began this process), featuring Robyn Hussa Farrell by clicking here.
About the author:
ROBYN HUSSA FARRELL is an award-winning New York producer and performer, educator and author. She is co-Adaptor of the Jonathan Larson award-winning musical, NORMAL, which she has been producing and performing in for 7 years to educate about mental fitness in schools … and which is the inspiration for forming mentalfitness, inc. (formerly called NORMAL In Schools).  As a writer, she re-imagined and is Author/Editor of the award-winning body image blog site, she is Author of the books Healthy Selfitude and Meditation & Mindfulness For Eating Disorder Recovery.  Hussa Farrell also has collaborated as investigator and author on several research publications.  Her work in this area is in collaboration with more than 50 researchers; including those from Harvard School of Public Health, UNC Chapel Hill, Coastal Carolina University, MUSC and others.
As an E-RYT yoga instructor, Hussa created eating disorder recovery yoga programs for inpatient, partial and outpatient treatment programs and has offered free recovery yoga to patients (and their families) in recovery for over a decade in Wisconsin, New York City and in Spartanburg, South Carolina.  The “NOURISH” recovery yoga workshops infuse arts, writing, poetry and movement to support the recovery journey.  She has led seminars for treatment professionals to highlight how to lead safe and effective recovery yoga and mindfulness workshops.  She was invited to provide a chapter in a new book by Carolyn Costin about yoga for recovery that will be published in 2016 by Routledge.
For years Robyn has also been co-creating and producing documentary films with her husband Tim Farrell, through their production company whitelephant.  Some of the documentary films she has co-directed; include, Speaking Out About Edand ED 101 – and both are the result of her interviewing national experts in the fields of neurobiology, eating disorders, obesity and nutrition.  Their next documentary film is Beneath The Floorboards – a commissioned project through ANAD and BEDA.  Hussa Farrell is also responsible for creating and implementing the more than 25 award-winning mentalfitness programs that serve as content to more than 20 national nonprofits, corporations and that are created in collaboration with more than 50 national researchers in medicine, nutrition, mental health and wellness. She recently co-created the ThinkEatPlay program to optimize health in athletes and created the 5 Minute Mindfulness program for classroom educators.
In 2014, Hussa Farrell and her husband launched Resiliency Technologies to provide mental health prevention tools to corporations.  More information is available at
For her work creating mentalfitness, inc. and its programs and initiatives, Robyn received the 2014 Peace Award from Converse College Westgate Family Therapy and 2010 Champion in Women’s Health award from Wisconsin First Lady, Ms. Sue Ann Thompson.
Prior to her work with mentalfitness, inc., Robyn was co-Founder of the award winning New York Theatre Company, Transport Group.  During her six year tenure as Founding Executive Director, the company won the 2007 Drama Desk award for the company’s breadth of vision and challenging productions and more than 20 nominations from Drama Desk, Obie and others.  Transport Group continues to thrive in the West Village of Manhattan.  Please visit them at
Robyn holds an MFA-Acting from the University of Virginia, is a member of AEA, AFTRA/SAG, the Academy for Eating Disorders (AED), The International Association for Eating Disorders Professionals (IAEDP), Women In Film and Television (NYWIFT), and is an E-RYT Certified Yoga Teacher with the Yoga Alliance.  She and her husband recently relocated to Spartanburg, SC where she runs the Mental Fitness NOURISH prevention center and is a proud board member of the Spartanburg Philharmonic Orchestra.
[1] Haines, J., and Neumark-Sztainer, D. (2006). Prevention of Obesity and Eating Disorders: A Consideration of Shared Risk Factors. Published by Oxford University Press. Health Education Research Vol. 21 no. 6, p. 770-782. Retrieved from:
[2] Haines, J., and Neumark-Sztainer, D. (2006). Prevention of Obesity and Eating Disorders: A Consideration of Shared Risk Factors. Published by Oxford University Press. Health Education Research Vol. 21 no. 6, p. 770-782. Retrieved from:
[3] Neumark-Sztainer D. Can we simultaneously work toward the prevention of obesity and eating disorders in children and adolescents. Int J Eat Disord 2005; 38: 220–7.
[4] Perry C. Creating Health Behavior Change: How to Develop Community-Wide Programs for Youth. Thousand Oaks, CA: Sage Publications, 1999.
[5] Haines, J., and Neumark-Sztainer, D. (2006). Prevention of Obesity and Eating Disorders: A Consideration of Shared Risk Factors. Published by Oxford University Press. Health Education Research Vol. 21 no. 6, p. 770-782. Retrieved from:
[6] From Barnett, W. S. (2008). Preschool Education and Its Lasting Effects: Research and Policy Implications. Boulder and Tempe: Education and the Public Interest Center & Education Policy Research Unit. Retrieved 8/1/2014 from:
[7] Berrueta-Clement, J.R., Scwheinhart, L.L., Barnett, W.S., Epstein, A.S., & Weikart, D.P. (1984). Changed lives: The effects of the Perry Preschool program on youths through age 19. Ypsilanti, MI: High/Scope Press.
Schweinhart, L.J, Barnes, H.V., Weikart, D.P. (1993). Significant benefits: The High/Scope Perry
Preschool study through age 27. Ypsilanti, MI: High/Scope Press.
[8] Schweinhart, L.J., Montie, J., Xiang, Z., Barnett, W.S., Belfield, C.R., & Nores, M. (2005). Lifetime effects: The High/Scope Perry Preschool study through age 40 (Monographs of the High/Scope Educational Research Foundation, 14). Ypsilanti, MI: High/Scope Press.
Karoly, L.A., Kilburn, M.R., & Cannon, J.S. (2005). Early childhood interventions: Proven results, future
promise. Santa Monica, CA: Rand Corporation.
[9] Camilli, G., Vargas, S., Ryan, S., & Barnett, W.S. (in press). Meta-analysis of the effects of early education interventions on cognitive and social development. Teachers College Record.
Gorey, K. M. (2001). Early childhood education: A meta-analytic affirmation of the short- and long-term benefits of educational opportunity. School Psychology Quarterly, 16 (1), 9-30.
Guralnick, M.J., & Bennett, F.C. (Eds.),(1987). The effectiveness of early intervention for at-risk and handicapped children. New York, NY: Academy Press.
McKey, R.H., Condelli, L., Ganson, H., Barrett, B.J., McConkey, C., & Planz, M.C. (1985). The impact of Head Start on children, families, and communities. Washington, DC: Head Start Evaluation Synthesis and Utilization Project.
Nelson , G., Westhues, A., & MacLeod, J. (2003). A meta-analysis of longitudinal research on preschool prevention programs for children. Prevention and Treatment, 6, 1-34.
Ramey, C.T., Bryant, D.M., & Suarez, T. M. (1985). Preschool compensatory education and the modifiability of intelligence: A critical review. In D. Detterman (Ed.) Current topics in human intelligence (pp.247-296). Norwood, NJ: Ablex.
White, K., & Casto, G. (1985). An integrative review of early intervention efficacy studies with at-risk children: Implications for the handicapped. Analysis and Intervention in Developmental Disabilities, 5, 7-31.
[10] Camilli, G., Vargas, S., Ryan, S., & Barnett, W.S. (in press). Meta-analysis of the effects of early education interventions on cognitive and social development. Teachers College Record..
McKey, R.H., Condelli, L., Ganson, H., Barrett, B.J., McConkey, C., & Planz, M.C. (1985). The impact of Head Start on children, families, and communities. Washington, DC: Head Start Evaluation Synthesis and Utilization Project.
White, K., & Casto, G.(1985). An integrative review of early intervention efficacy studies with at-risk children: Implications for the handicapped. Analysis and Intervention in Developmental Disabilities, 5, 7-31.
[11] From Sarah Salvy, Ph.D., University of Southern California, California Obesity Prevention Program
[12] Brightwood LH, DeRosier ME. LifeStories for Kids: Enhancing character development and social skills through storytelling (Grades 3-5). Cary, NC: 3-C Institute for Social Development. 2007.
DeRosier ME. Social Skills GRoup INtervention (S.S. GRIN) – Parent Guide (S.S. GRIN – PG). Cary, NC: 3-C Institute for Social Development. 2006.
DeRosier, M. E. Social Skills GRoup INtervention (S.S.GRIN): Group interventions and exercises for enhancing children’s communication, cooperation, and confidence (Grades K-2) (4th Edition). Cary, NC: 3-C Institute for Social Development. 2007.
DeRosier ME. Social Skills GRoup INtervention (S.S.GRIN): Group interventions and exercises for enhancing children’s communication, cooperation, and confidence (Grades 3-5) (4th Edition). Cary, NC: 3-C Institute for Social Development. 2007.
DeRosier ME, Brightwood LH. LifeStories for Kids: Enhancing character development and social skills through storytelling (Grades K-2). Cary, NC: 3-C Institute for Social Development. 2007.
Harrell A, DeRosier ME. Social Skills GRoup INtervention – Adolescents (S.S. GRIN – A). Cary, NC: 3-C Institute for Social Development. 2007.
[13] Botvin GJ. Preventing drug use in schools: Social and competence enhancement approaches targeting individual-level ecological factors. Add Behav. 2000; 25: 887-897.
[14] National Scientific Council on the Developing Child, Harvard University (2007). The Science of Early Childhood Development: Closing the Gap Between What We Know and What We Do.
[15] Pianta, R. C., Cox, M.J., Taylor, L., & Early, D. (1999). Kindergarten teachers’ practices related to the transition to school: Results of a national survey. The Elementary School Journal, 100, 71-86.
[16] Pianta, R. C., & Kraft-Sayre, M. (2003). Successful Kindergarten Transition: Your Guide to Connecting Children, Families, & Schools. Baltimore, MD: Paul H Brookes Pub Co.
[17] Raver, C., & Knitzer, J. (2002). Ready to enter: What research tells policy makers about strategies to promote social and emotional school readiness among three- and four-year-old children. NY: NCCP.
[18] Raver, C., & Knitzer, J. (2002). Ready to enter: What research tells policy makers about strategies to promote social and emotional school readiness among three- and four-year-old children. NY: NCCP.