Going to university while recovering from an eating disorder: Is your child ready?
(Prepared by Dr. Melissa Lieberman-Clinical director of the COPE CLINIC. Adapted from Lauren Muhlheim, Psy.D., FAED, CEDS-S, Owner, Carla Giddings OT Reg. (Ont.), Canadian Mental Health Association, Eating Disorders Program, Dr Melissa Lotmore, Highly Specialist Psychologist, Altum Health)
Sending a young adult to university is a significant milestone filled with excitement and challenges. For those with eating disorders, this transition requires careful consideration and planning. University life introduces many new experiences, including living away from home, giving up personal privacy, adjusting to unfamiliar environments and foods, and losing established routines. There is also pressure to fit in, academic demands, and participation in clubs and social events. For young adults with eating disorders, these added stressors can further complicate their recovery journey. As parents, understanding these challenges can help you provide the necessary support and guidance during this transitional time.
The university lifestyle can challenge your child's ability to maintain a healthy weight. Increased physical activity from navigating a large campus and irregular sleep patterns can increase their energy expenditure. Consequently, university students often have substantial caloric needs. Consuming enough food in the dining hall can be particularly challenging for students who feel uncomfortable eating in front of peers or struggle with eating variety. University culture can also add pressure on a student in recovery. Roommates and friends may be dieting, fear the "freshman 15" may circulate, and friendships may form around working out. As parents, not being able to monitor your child closely can be overwhelming, as you may fear missing signs that they're struggling or becoming more unwell. Awareness of these challenges can help you support your child in navigating university life while maintaining a healthy weight.
How do I know if my child is ready?
As your child prepares for university, you might feel a mix of pride and anxiety. If your child has an eating disorder, these feelings can be intensified. While many parents aspire to send their young adults off to university to experience important milestones and transformative experiences, it is essential to consider the timing carefully. Attending university while still grappling with intrusive eating disorder thoughts and behaviours can interfere with your child's ability to fully engage in and benefit from these experiences. Rushing to offer them a "normal" life too soon can lead to setbacks and further delays in their recovery.
Evaluating your child’s readiness involves considering how well they can manage their eating disorder, handle stress, and maintain healthy eating habits away from the comforts of home. Ensuring your child is stable in their recovery before leaving for university can make a significant difference. Open communication about their readiness and potential challenges can help them make informed decisions about their next steps. Approach these conversations with an openness to the possibility that university life might be postponed for a year. Your support and understanding can help them balance their desire for independence with the need to prioritize their health and well-being.
Determine if your child is ready for university by carefully assessing:
Food and Weight Management:
Can your child prepare their own food and manage their weight without supervision?
Can your child eat regularly, adequately, spontaneously, and with plenty of variety without being prompted or supervised?
Is your child free from compensatory or diet behaviours such as over-exercising, purging, restricting, or calorie counting?
Eating Independence:
Does your child eat meals independently while keeping their weight within a healthy range for their body, or do they need a lot of prompting and meal support?
If you step back, can they keep things going, or do they still need your help?
Stress Management:
How does your child manage stress? Have they developed healthy and helpful ways to cope with difficult situations?
A useful gauge might be how your child coped during and after the exam period; were they able to stay on track with their eating?
Insight and Awareness:
How much insight or awareness do they have about their difficulties?
Is your child engaged in their treatment and activities to support their mental health?
Can your child manage school, self-care, and social demands while maintaining recovery?
Help-Seeking:
Do they feel able to ask for help?
Is your child able to understand the things they find difficult and talk to you openly about their struggles?
Can your child advocate for their needs, whether that’s telling you or another trusted individual?
Lauren and Katie’s College Readiness Checklist
Lauren Muhlheim and Katie Grubiak (2015) recommend being symptom-free from an ED for six months before attending university. They offer a checklist to help decide if school is the best option for recovery and education/career goals. Considering the last six months, your young adult may be ready to transition if you can answer yes to all of the following questions. Unfortunately, if you answer no to any of these questions, it would be important to work with your treatment team and follow their suggestions for how to better prepare your young adult.
Has your young adult maintained a steady weight in the healthy range (according to childhood growth records) and (if female-bodied) menstruated consistently for six months? | ☐ Yes ☐ No |
Has your young adult been free of eating disorder behaviors such as bingeing, purging, laxative use, and excessive exercise for six months? | ☐ Yes ☐ No |
Is your young adult able to independently and consistently prepare and choose meals that contain enough energy-dense foods to maintain this weight? | ☐ Yes ☐ No |
Is your young adult able to serve themselves snacks and desserts? | ☐ Yes ☐ No |
Does your young adult consume beverages other than water (juice, milk, lattes)? | ☐ Yes ☐ No |
Is your young adult able to eat at a variety of restaurants, ordering and eating a balanced meal that is not the lowest-calorie item on the menu? | ☐ Yes ☐ No |
Is your young adult able to confidently eat from the different food stations at a cafeteria (sandwich bar, grill, etc.) and not just from the salad bar? | ☐ Yes ☐ No |
Is your young adult comfortable eating hot breakfasts (other than oatmeal)? | ☐ Yes ☐ No |
Does your young adult use condiments comfortably (dressing with fat, ketchup, mayonnaise, etc.)? | ☐ Yes ☐ No |
Is your young adult comfortable eating with friends? | ☐ Yes ☐ No |
Does your young adult eat at a normal pace? | ☐ Yes ☐ No |
Has your young adult reincorporated the majority of previously feared and avoided foods? | ☐ Yes ☐ No |
Is your young adult able to go without exercise at least every other day, or not at all if medically contraindicated? | ☐ Yes ☐ No |
If your young adult has returned to exercise, do they understand the need to add additional fuel following exercise? | ☐ Yes ☐ No |
Is your young adult able to eat in front of other people who aren’t eating? (There is no guarantee roommates will not be eating disordered, so taking care of one’s own needs and handling the self-consciousness inherent in doing so is an important recovery skill.) | ☐ Yes ☐ No |
Would your young adult be able to cope with having a scale in the room and roommates who weigh themselves and discuss weight or dieting? | ☐ Yes ☐ No |
If your young adult misses a meal for any reason at all, are they able to make it up that day or the next day at the latest? (Making it up may mean having larger portions at other meals, two extra snacks, or the equivalent of an extra meal across a twenty-four- to thirty-six-hour period.) | ☐ Yes ☐ No |
Is your young adult able to increase his or her daily calories substantially to account for mileage logged when walking around campus? | ☐ Yes ☐ No |
Can your young adult be restful? Do they sit when everyone else is sitting? | ☐ Yes ☐ No |
Is your young adult able to be alone around processed and highly palatable foods without having an urge to binge? | ☐ Yes ☐ No |
Has your young adult demonstrated an ability to tolerate anxiety without resorting to restriction, bingeing, or purging? | ☐ Yes ☐ No |
Does your young adult openly acknowledge their eating disorder and have insight into the need to construct a life and schedule that supports recovery? | ☐ Yes ☐ No |
Have you discussed with your young adult that any situation that puts them in a state of negative energy imbalance or weight loss could trigger a relapse? | ☐ Yes ☐ No |
Does your young adult understand that alcohol calories do not count toward energy needs? | ☐ Yes ☐ No |
Are temperamental traits (perfectionism, rigidity, comparing, etc.) acknowledged and appropriately managed? | ☐ Yes ☐ No |
Are you willing to step in and pull your young adult out of school if needed? (Remember, even though your young adult is over eighteen, you are still responsible for them. It is unrealistic to expect their college to, in the words of Laura Collins, “provide the kind of accountability and monitoring and personal support that a parent provides and an eating disorder patient deserves.”) | ☐ Yes ☐ No |
What if My Child Isn’t Ready to Attend University?
Being able to feed oneself regularly, adequately, flexibly, and with plenty of variety is essential for thriving in the university environment. If your loved one isn't quite ready to do this without your assistance, do not hesitate to wait. Postponing university for a semester or a year is manageable, whereas dealing with the consequences of an untreated eating disorder can be far more challenging. If your young adult isn't ready to transition to university, they don't have to abandon their plans. There are several ways to balance their needs and educational goals:
Deferred Entry:
Postponing Studies: If your child is not fully prepared to manage their eating disorder at university, postponing their studies can provide the opportunity to prioritize their health and well-being. Most universities allow students to defer their admission for a year, giving them time to focus on recovery at home. Deferring university for a year can be particularly beneficial for someone who is not fully recovered from their eating disorder.
Benefits of Delaying: It is better to delay starting university than to have your young adult start only to get overwhelmed by symptoms and drop out. Think of it as an investment in their long-term health and happiness; ensuring they thrive both academically and personally when they do start university.
Gap Year:
Taking a gap year: During this time, your young adult can travel, volunteer, or work, gaining maturity and preparing for university life. Encouraging them to get a part-time job and take on more responsibility at home can help them learn to cope with competing demands and prepare to live on their own.
Benefits of a Gap Year: A gap year can also be used to focus on recovery and developing more independence. Engaging in ongoing treatment or additional support during this time can help them prepare for the challenges of university life with an eating disorder.
Local University:
Closer to Home: If your young adult isn't ready to move away, consider having them attend a local university while living at home. This provides a smoother transition, allowing them to experience university life while still having the support of their family.
Online Courses:
Ease into University: Enrolling in online courses can help your young adult ease into university-level coursework without the immediate pressures of campus life.
By considering these options, you can support your child in balancing their educational goals with their need to prioritize health and well-being.
Potential Problem Areas to Address Before Transitioning to University
Reviewing the questions below can help identify potential problems to address before transitioning to university. They can be used as topics to revisit after the first semester to monitor any new developments. Open dialogue and ongoing support are essential for a successful transition.
Food Questions
What dining options are available on campus? Is there adequate variety? Does the dining facility offer extended hours, and is it conveniently located?
Is there an option for cooking in the dorms? Is it a shared space? How might the dorm room cooking options hinder or support my student’s food needs?
Will my child be prone to over-relying on food delivery services (e.g., DoorDash or Uber Eats)? Are there fast-food options on campus? Will access to these food options aid or hinder my student’s recovery?
Who will be living with my student? Whose food behaviours might influence them? Will they be encouraged to approach all foods with neutrality, or will they encounter discussions about “good” and “bad” foods?
Exercise Questions:
Is there 24-hour access to the campus gym? Will my student be encouraged to exercise when sleep, rest, or play might be better options?
What athletics does my adolescent plan to engage in?
How far apart are my student’s classes, dorm, and dining facilities? Is there a campus transportation system? Can my student manage the extended walking of a college campus and adequately feed themselves?
Social Eating and Drinking Questions:
Will my student be involved in a fraternity or sorority? How will the eating and drinking environment promote or hinder their recovery?
How will they approach party environments with a variety of foods? How will they respond to alcohol being offered?
In situations of overeating (such as after a party), can they listen to their hunger and fullness cues and appropriately feed themselves? Can they engage in overeating without compensating the next morning?
Is my student able to navigate their relationships in a healthy and balanced way? Can they express their preferences, desires, appetite, and feelings without fear?
Diet Culture Questions:
How does my student’s body compare to others their age? Will they be pressured to diet or change their body? How will they respond to this pressure?
Are different body types celebrated on this campus? Are there student organizations and safe spaces that include all genders, body shapes, and sizes?
How is thinness promoted on this campus? Is there extensive marketing around weight loss, dieting, and exercising?
Involving your child in these discussions and asking these critical questions can help you assess their readiness for university life.
How do I Prepare my Young Adult for University?
Before your child leaves for university:
After careful consideration, if you decide it's the right time for your child to attend university, thoughtful planning and support are essential. Here’s a comprehensive guide to navigate this transition.
Research University Resources:
Identify and contact student support services, including GP services and eating disorder services available on campus.
Communication:
Encourage your child to disclose their eating disorder on the occupational health questionnaire during enrollment.
Inform key individuals such as senior residents or course tutors about their condition.
Meal Planning:
Ensure your young adult has a meal plan that covers three meals a day in the dining hall to reduce the likelihood of missed meals.
Plan ahead for essential snacks and consider setting up regular grocery deliveries.
Create a Network:
Encourage your child to explore and join clubs or activities of interest to build a supportive network of friends with similar interests.
Develop a College Contract:
Create an agreement specifying expectations for maintaining health and managing the eating disorder while at university (e.g., maintaining a healthy weight, not engaging in eating disorder behaviours, having regular weigh-ins).
Outline consequences if these conditions are not met, such as increased supervision or returning home.
Practice Eating:
Practice eating with your young adult in different self-serve cafeteria-type settings and various restaurants for breakfast, lunch, and dinner (e.g., restaurants with buffets and hospital cafeterias).
Have your young adult practice building meals that meet their dietary needs and revisit the same places with the expectation of choosing different options each time.
Practice flexibility with mealtimes and managing food availability at home. For example, what should they do if the food they want isn’t in the fridge? Can they develop flexibility by adjusting their mealtimes?
Simulate Increased Walking:
Have your young adult practice walking 5 or more km per day for a week (to simulate the amount of physical activity they are likely to have on campus) and add sufficient calories to keep their weight steady.
Surprise Exposures:
Arrange spontaneous visits to various food locales to gauge their tolerance and readiness to handle unexpected eating situations. For example, make a spontaneous stop at an ice cream parlor or do a week of sauces and butter on everything, simulating more typical cafeteria meals (e.g., meats with gravy or sauce, pasta with cream sauces, salads already dressed).
By taking these steps, you can better prepare your young adult for the transition to university, ensuring they have the support and skills needed to manage their eating disorder while pursuing their education.
For Young Adults to Consider:
Match Your School Schedule to Your Recovery Needs:
Balancing school and recovery is crucial for your well-being. Going to school at your own pace can help you engage more fully in the university experience, including making new friends, exploring a new city, and discovering new interests, all while reducing the risk of relapse.
Steps to Plan Your Schedule:
Prioritize recovery by scheduling your “non-negotiables” like meals, snacks, meal planning/preparation, sleep, therapy, medical appointments, and support groups.
Add time for self-care, fun, and other responsibilities.
Consider having a full day off from school each week for rest, time with friends or family, exploring interests, and doing things you enjoy outside of school.
Assess Your Course Load:
Determine how many courses you can take while prioritizing your well-being.
Avoid “all or nothing” or perfectionist thoughts like “I need to attend university full-time in residence or not at all.” You have options! You might start with 1 or 2 courses through distance education or keep your living situation consistent for added structure and support.
Part-Time or Reduced Course Load:
A part-time course load can reduce academic and social pressures, allowing you to focus on recovery while gradually adapting to university life.
Students with eating disorders can register with the school’s Accessible Learning services for accommodations, including a reduced course load. This means you can still be considered a full-time student and maintain full-time financial support through programs like OSAP (Ontario Student Assistance Program).
Access Accommodations:
Academic accommodations ensure equitable access and opportunities for all students to succeed. It’s your right to have the necessary accommodations, which may include:
Reduced course load
Preferential seating
More frequent breaks for meals and snacks
Extensions on assignments
Separate location for exams
Registering for Accommodations:
All universities and colleges have Accessible Learning Services and Counselling Services. Register early to ensure your accommodations are in place when needed.
In Ontario, you have the choice to disclose information related to mental health. Your instructors will only receive a letter stating the accommodations you need, without details of your diagnosis.
Build Your Support Networks:
During times of transition, it’s important to consider the formal and informal supports available to you while at school. Formal supports might include:
Nurse Practitioner / Family Doctor
Therapist
Dietitian
Academic Advisor
Accessible Learning Advisor
University Counsellor
Crisis Resources:
Keep the local crisis line and ED helpline/instant chat easily accessible on your phone.
Navigating University Life:
University can expose you to oppressive messaging or behaviors about bodies, food, and diet culture. Build skills to identify unsafe situations, set clear boundaries, and connect with positive role models and peers.
Engage with campus spaces and supports, such as advocacy groups and organizations for gender empowerment and diversity.
By thoughtfully planning your schedule, utilizing accommodations, and building a support network, you can create a balanced and supportive environment for both your education and recovery journey.
Supporting Your Student with While at University
Supporting your child at university while they manage an eating disorder requires ongoing attention and communication. Here are some strategies to help:
Provide Ongoing Support:
Regularly check in via phone, text, or video calls.
Visit them at university if possible and coordinate visits home.
Encourage open communication about any concerns or challenges.
Recognize Signs of Struggle:
Be attentive to changes in mood, appearance, or eating habits that may indicate your child is struggling with their eating disorder.
Even with the best preparation, the first few months away from home can be challenging, especially for students with an eating disorder. It's crucial to continue providing support and ensure they know they’re not alone.
Effective Strategies:
Regular Check-ins:
Maintain consistent communication through phone, text, or video calls.
Plan visits to their university, if they are open to it, and keep them informed about their next trip home.
Encourage Open Dialogue:
Foster honest conversations, encouraging them to share any concerns.
Discuss how they can adapt the healthy coping strategies they used at home to their new university environment.
Knowing When to Step In:
It’s essential to recognize when your child may be struggling with their eating disorder at university. The transition can be tough, and while university is an exciting time, it also comes with new pressures and adjustments. Here are ways to assess how your child is coping:
Assess Their Mood:
When you talk to them, do they seem excited or withdrawn?
Ask about their eating habits and overall feelings, similar to the questions you’d ask at home.
Observe Their Appearance:
During video calls, notice any changes in their appearance, such as weight loss or changes in demeanour.
If you find your child is struggling at university, they may directly ask for help or show signs that they are becoming more unwell. In such cases, it might be necessary to bring them home temporarily.
For more detailed guidance on relapse and support plans, visit FEAST.
This resource was shared by Dr. Sarah Ravin at FEAST of Knowledge 2022, designed for a female patient who was heading off to college.
PART 1: ASSESSMENT TOOL:
Green Light Signs: Suggest that AN is in remission:
• Maintaining weight within ideal range• Getting regular menstrual periods• Consuming enough nutrition to meet her body’s needs• Serving herself appropriate portions to maintain weight• Energetic, social, and happy• Ability to tolerate a day without exercise• Good insight• Eats mostly with ease
Yellow Light Signs: Suggest that a person is struggling with AN symptoms and needs extra help:
• Weight drops• One missed menstrual period• One episode of purging• One or two skipped meals• Exercising more than 1 hour per day• Inability to tolerate a day without exercise• Social life limited by exercise or food compulsions• Irritability• Irrational or unreasonable thinking• Inadequate portion sizes; over-estimating the amount of food eaten• Defensiveness about food choices
Red Light Signs: Suggest that a person has relapsed:
• Weight drops significantly• Two or more missed menstrual periods• Major preoccupation with calories, body image, and exercise• Two or more episodes of purging• Social withdrawal• Significant food restriction• Several skipped meals
PART 2: INTERVENTIONS
Green Light Interventions:
• Weekly weigh-ins at student health center.• Takes medication daily.• In-person contact with a parent once a month.• Sticks to limit of no more than 1 hour of exercise per day.• Weekly FaceTime contact with at least one parent.• Monthly sessions with therapist from home.• Parents and therapist maintain weekly email contact.
Yellow Light Interventions:
• Student will tell a parent immediately if she notices yellow light signs in herself• Parents will talk with the student immediately if they observe yellow light signs in her• Phone session with student, parents, and therapist will be held within 72 hours of observing yellow light signs.• Weekly sessions with therapist until she returns to the green light zone.• If she remains in yellow light zone for three weeks, a parent will travel to the university to provide daily meal support and will remain there until there is significant improvement.
Red Light Interventions:
• If the student enters the red light zone, she will take a medical leave of absence from school immediately and will return home to focus on her recovery.• The family will attend an in-person session with therapist within one week of the student’s return home. The purpose of this session will be to create a treatment plan to help the student recover and return to college when she is well.
This plan shall remain in effect for the entirety of the student’s first semester of college. The family will meet with the therapist again during winter break to revise this plan based on the student’s progress.
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