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Ep 40 : Driving the conversation around eating disorders in teens and adults: Ashley Ariail

Updated: May 28, 2023


This week is National Eating Disorder Association(NEDA) Awareness Week. Introduction:

  • Highlighting the prevalence and seriousness of eating disorders

  • Discussing the importance of addressing the mental health component of these disorders

Eating Disorders as a Mental Health Issue:

  • Defining eating disorders and their impact on mental health

  • Addressing common misconceptions and stereotypes about who can develop eating disorders

The Impact on Individuals and Families:

  • Discussing the emotional and physical toll of eating disorders

  • Highlighting the importance of early detection and intervention

The Role of Language:

  • The impact of societal language around food and body image on eating disorders

  • Addressing ways to promote healthy language and attitudes

Addressing Eating Disorders in Teens and Adults:

  • Highlighting the unique challenges of addressing eating disorders in different age groups

  • Discussing treatment options and resources available

Preventing Eating Disorders:

  • The importance of promoting positive body image and healthy relationships with food

  • Strategies for preventing the development of eating disorders

Supporting Individuals and Families:

  • Discussing ways to support individuals and families affected by eating disorders

  • Highlighting the importance of access to resources and support groups


  • Recap of the key takeaways and the importance of addressing eating disorders as a mental health issue

  • Encouragement to continue the conversation and promote awareness and understanding.

An eating disorder is a mental health issue not just a manifestation of body or food challenges. Eating disorders can be typecast as afflicting teenage girls or by income level. It has a significant impact on the individual and family and can have extreme consequences, not a matter to be taken lightly. As a society, our language around food and body is very important.

Ashley Ariail is a Bloomberg Fellow, a licensed counsellor, and an eating disorder specialist from Children's Hospital, Plano. She works with children and teens and families as they work through eating disorder issues and body image issues as well. She's a passionate advocate doing outreach programs in the community and across the board with schools as well as talks in-depth about how the eating disorder affects teenagers and adults, how we should talk about it, what types of disorders exist, and potential treatments for them. Connect with Ashley:

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Sirisha: Hello everyone and welcome to the Women Career and Life Podcast where I share stories and practical advice for women to achieve their career and life goals as they strive towards financial independence. I'm your host, Dr Sirisha Kuchimanchi, a former tech executive at Texas Instruments, a Fortune 200 company, a speaker, a working mom, and an avid reader. I definitely wanna thank our listeners for supporting this podcast and enabling it to be in the top 30% of Spotify podcasts. In this podcast, I interview guests and share personal stories so that we can move further towards achieving our corporate and personal goals, and also empowering and enabling other women to achieve theirs while we all lift ourselves together.

In today's episode, I will be talking to Ashley Ariel. This is National Eating Disorder Association's Awareness Week, and this is a topic that we rarely touch upon and can be quite difficult. This is our series on health and we are talking about mental health, I have Ashley Ariail with us, who's a licensed counsellor and also an eating disorder specialist. Ashley works with children and teens and families as they work through eating disorder issues and body image issues as well. She's a passionate advocate for doing outreach programs in the community and across the board with schools as well. Ashley, welcome. I'm looking forward to today's conversation.

Ashley: Thank you for having me.

Sirisha: To get started, how did you get into this field? Can you walk us through your background, what you do currently?

Ashley: Yes. I started at Children's Health and I was in our behavioral psych unit where we were treating, everything we're treating suicidality, non-suicidal, self-injury and then that was the only place at the time to treat eating disorders. That's where I was first exposed to treating them. That's not something that most counselling programs offer a lot of input on. You have, one class perhaps on eating disorders as part of psychopathology, and then that's it. So my career started at Children's Health and then later children's built an entire program out in Plano, and so I'm now with Children's medical Centre Plano. We have a 12-bed unit to treat kids inpatient, and then we also have a partial hospitalization program and an IOP program, or the kids go home at the end of the day, but we're still providing services for either most of the day or half day.

Sirisha: You work in a children's hospital, but is that the demographic that is most impacted, and when do you start to see manifestations of eating disorders usually?

Ashley: So most eating disorders develop in adolescence, and the tricky thing is, do you catch it in adolescents or not? So even when you have an adult presentation of an eating disorder where it's identified, let's say you're in your twenties or thirties, most people can go back to sometime in their preteen or adolescent years. I will say in the past, I've been at Children's for 12 years, I have seen kids come in younger and I have seen kids as young as seven or eight. So most of the eating disorders develop at the younger ages, and we're really lucky that we have a lot of programs now that are catching it at those younger ages before it gets to adulthood where it's very difficult.

Sirisha: So what usually are the reasons for it? We've seen a lot of coverage in social media now about body shaming, body issues and just Instagram and so many pictures, I think that creates this image that people aspire to, which is not necessarily normal. So what can we do to detect that early on?

Ashley: It's a great question, it's a question every parent asks us when I get there because they say, what could we have done to prevent this? What is the root cause of this? And the frustrating answer is that we're not always, really sure. So we go by the bio-psycho-social model. So what we would say, biologically speaking, obviously some people have a predisposition in their family, so someone in the family may have an eating disorder, but they may not. Similar to people with a cancer diagnosis, sometimes you can trace that back in the family, sometimes this is the first person and so we look at its biology, we also look at temperament. It can be different depending on the different diagnoses. Most of our kids are highly perfectionistic. They're very smart. They're very rule-following and they're very compliant and they're usually fairly aware of other people's feelings, and they're very compassionate towards others but not necessarily compassionate to themselves. Then you have, their social environment. This happened to me in high school. I did not develop an eating disorder, but I had friends who spent their lunch, restricting their lunch and only drinking a diet soda and talking about their weight and disparaging their bodies. So it could come from friends, honestly. One of the reasons I am a big advocate is that I do feel, unfortunately, there are adults in kids' lives that say things. So I do know at school, even my I have a seven-year-old daughter and a four-year-old daughter. My seven-year-old, we've run into two instances, even at her age where she has been told at school that food is not good for you. And she is very assertive and she raised her hand and she said, my motto, "which is all food is good food", we do say in variety and moderation, but she just raised her hand and assertively told them. So I do think, sometimes in schools, depending on athletics, it could be coaches. Sometimes it's the paediatrician the kid goes in and the paediatrician says, "Hey, they need to watch their weight" and the kid hears that. Sometimes parents are dieting themselves and then obviously social media. The impact of COVID is something that we're continuing to study because of kid's screen time initially, when kids were home from school at the beginning of March 20 20, they were on their phones a lot more as they weren't doing social activities and so obviously, Fair tik-talkers and influencers and YouTubers and all of these things where people are putting their diets out there, their exercise routines. So we just call it the perfect storm. Kids may be going through a difficult time in their life, whether it's a move or they've lost a family member or they're being bullied. Then they may have, some of these psych-social stressors and it culminates in the development of an eating disorder. And that is a very frustrating answer for most of our parents, because they want to know, what is the one thing that caused it, and we can't always give that to them, but I would say that those are the biggest factors.

Sirisha: It's not surprising, especially when you're talking about a dollar since then, the peer group has had a much bigger influence than the adults in the life. So they are taking their cues and learning from their friends and now social media is that peer group as well, so there's a lot of influence coming from there. I think it's saddening and disheartening when you hear that your seven-year-old is hearing this at school, and that ties into where you said you see it starting at eight and nine-year-old's, they're already hearing the conversation. Before we deep dive, do you see teenage girls?

Ashley: Before COVID children would have an eating disorder symposium each year where we would cover different topics. I think that what most people think of is it is an adolescent wealthy girl. This happens for people, who maybe have the luxury of open access to food and then are just really choosing not to, and I think one of the things that I like about working at children's where we see all demographics are we see males and females. I would say, at the highest I've seen our unit split is about 40, 60 with 40% male. That's not always the case. I will say we see kids from all socioeconomic statuses. So sometimes we have kids who are food insecure, and that may have played a role in their restriction. We see kids from all religions, all ethnicities, we see kids across gender identity and sexual orientation. A lot of the time students in their programs have to interview, therapists in the field and they will ask me, what's the typical eating disorder, and again I say, I can't tell you.

Sirisha: I think it's a disorder with no specificity and I'm glad you're sharing that because anyone can have it or anyone can manifest symptoms. So what are the types of eating disorders and what are the symptoms for someone to detect it?

Ashley: The most common one that people seem to be familiar with and perhaps is portrayed the most in some of the movies and TV shows is anorexia nervosa. You will typically see a kid restricting and which means not eating. Now, some people think, okay. If I see my kid eat at all, I see my kid eat dinner at home, so they can't possibly have anorexia, but that kid may have skipped breakfast, cause some kids don't eat breakfast. They may have then skipped their lunch at school, they may have not had a snack on athletics and then that dinner, which may be not that big, but not that small could be their only meals a day and they could still be dropping weight and getting to a point where it's very dangerous and they're in the hospital. So what anorexia is is a restrictive pattern of behavior's. So where someone is not intaking enough calories to support their weight, they are losing weight. It used to the DSM is how we do, all of the disorders. and so there was a change made in the fifth edition. It used to say you had to be under 85% of your ideal body weight. So whatever the weight for your gender, age and height you should be, you had to be under 85% of that. They have taken that off and I think that's important, but it is basically that you are under your expected weight or you have dropped weight.

Kids who are gaining and growing, like my seven-year-old should be gaining every year and growing. Anorexia nervosa in younger kids, because it looked like they haven't lost weight, but they have failed to gain in a year, which would be troublesome. Or it could look like someone has begun to lose weight and is now underweight. It has to come with a preoccupation with weight and shapes. There has to be this drive for thinness or this drive for sometimes with the males. It's not necessarily a drive for thinness, but it's a drive for a certain body aesthetic. So it could be that they quote unquote, want to look muscular. So we would still fall that a drive for thinness, even though that may be like a waiflike model body, isn't what they're after. And it usually comes with body distortions where the person as they are losing weight or failing to gain and grow, they do not see themselves as underweight. They see themselves as either an average weight or sometimes see themselves as overweight. So for anorexia nervosa that is the primary presentation, but then bulimia nervosa is where you're seeing kids who sometimes they're underweight, but most of the time, their average weight could be overweight. Those are the kids that are going through patterns of binge eating and purging behavior's and so they're eating more than what we would consider a normal amount of food in a specific amount of time. Stereotypically again in the movies, it's like they ate a tub of ice cream or they ate a whole bag of chips. The interesting thing is that a lot of the anti-diet dieticians, who there's a ton of them that I could tell you about they're coming out and they're there. They're using social media positively. They're using tech talk and Instagram positively to say, Hey, most people who are Benji. That binge-eating oftentimes follows restrictions. So kids will try to restrict and restrict your body's built to override that and get you, get food into you. And so some kids can't go through that restriction and we'll flip into binge eating, then they will feel guilty and they will purge. Purging could be emphasized. It could be a flax.

It is, it could be the use of diuretics or it could be the kids. They binge eat and then they will run or exercise, for an hour to get those calories off. And so those kids. It can be very dangerous. I think most people focus on anorexia nervosa because their weight is so low for the kids. With bulimia nervosa, their electrolyte levels are often very off and that can be very dangerous. All of us know, about potassium, phosphorus, and magnesium, when you're purging, those things can be very off and it can be very life-threatening. We have a diagnosis called otherwise specified feeding and eating disorder where you have symptoms of anorexia or bulimia. But you're not meeting maybe the clinical criteria. So sometimes we see kids come in who are not quite at the threshold for that diagnosis. And so it's otherwise specified feeding and eating disorder. And then the other thing we treat that I think people are not as familiar with is avoidant restrictive food intake disorder. We do have, I would say, when we have young kids Most of the time, that's the diagnosis. Although I have seen young kids with, what we would call a traditional eating disorder. So our fit-avoidant, restrictive food intake disorder is not weight or shape driven. Those kids do not have concerns about calories. They are not worried about any of that. What they have had is either a traumatic event. So they may have choked and now be afraid to eat certain foods. They may have we've had kids that had the flu, and they threw up. Now they're terrified of throwing up. They don't want to intake food. We have kids who have medical conditions. They may have. GI issues. They may have severe food allergies and now they're afraid to eat because it causes them pain or they could have an anaphylactic reaction a bunch of different ways that you could get to ARFID. But the key component is that they have a restricted pattern of eating that is impacting their kind of normal weight and growth trajectory, or they have lost weight, but there are no body distortions and no drive for thinness. Then there is binge eating disorder. Children do not treat that. That is not my specialty, but that is where people have binge eating, but they do not have any purging behavior's.

Sirisha: So what as parents, family members, and the community surrounding these children or teenagers, can we do? What are the signs we would look for and how do we integrate?

Ashley: Before I could answer as a professional, now that I'm a mom I'm recognizing a lot of ways you can intervene. I always tell this story. So when my daughter is in kindergarten, she was in virtual kindergarten and the PE teacher had sent home these activities, and one of them was you need to karate squat good foods and you need to karate chop bad foods. And my daughter, let me tell you, my family knows the only F word in our family is fat, right? And so she said, wait, Mom, they're saying chicken nuggets are bad... They're saying pizza's bad food. No food is bad food, all food is good food for your body, and I said, yes and so I cut off the video. I said we're not doing this. I emailed the coach. And I said, if there is any kind of nutrition advice that's coming towards my child, she will not be participating in that. That is reserved for licensed dieticians and registered dieticians. And the coach was very nice and understanding when I explained my specialty. Again with this other comment, I think for parents, when you begin to hear those things at whatever age, you may hear them. My daughter is very young, you may not hear them later. I think you can just talk to your kid very openly. And some of these things, aren't, it's not an eating disorder. There are kids who, in adolescents are like maybe I'm not eating a dessert three times a day. Is that unhealthy? No, but I think you do have to watch those trends because what I hear a lot from parents is my kid decided to be healthy. And they cut out desserts and parents are like, okay, that's fine. Do I want my kids having sugar at seven 30 right before bed? No, I don't. But we also don't, no food's off limit in our house. It starts with desserts and then kids will move into, "Okay I'm not going to have chips, I'm not going to have fast food, I'm never eating fried here, there's no more pizza". So I would just keep an ear out and do some kids, maybe change their food intake and it's not dangerous... But I think parents usually, I would say there, there is a warning bell and it's hard to train yourself to look out for it because one thing I'm very passionate about is our society has, I think, demonized and weaponized food.

I think everybody has something wrong with food and people are making a lot of money off of Tik TOK and I'm not going to call out any store chain in particular. I'm not saying you shouldn't buy organic food, but again, there are billions of dollars in the health and wellness industry being made by labelling foods as clean or dirty or safe or unsafe. And it's also, and one of the things I'm passionate about, it's an equity issue. So they're demonizing foods that some families need because that may be all they have access to. Or if you're a single working mother, you may have to stop by Chick-fil-A and that's the only thing you can get your kid and fast food. Doesn't have to be bad food. So I would look out for that. I would look out for kids skipping meals. I would look out for kids exercising more, more than you would expect. So for instance, a kid who has soccer practice, I played soccer, right? I did not have the energy to go running after I had already spent an hour and a half soccer. So we have parents who have said they had, track practice, then they're still running, or then they're still doing crunches. Or they get really upset if they miss one day of working out. If you have a kid who's working out and they're injured, but they're so worried about getting out of shape that they're pushing or injured, that's also something. And because we're in Texas and Texas is a very sports-focused state, I think we do see that come up. Wearing baggy clothes kids, ironically, that lose this weight, don't want anybody to see it. They are satisfied by seeing it, but they want to hide it from people. And I know sometimes the styles go away from these oversize, extra-large t-shirts and leggings, but if you see your kid wearing baggy clothing or layers in the summer, these kids are cold because they don't have body fat and so they'll be wearing a sweatshirt in like June when it's 90 degrees outside. So I would say those things. And then one of the things I think, in mental health we've always talked about family meals are so important. They're protective against a variety of different mental health disorders and so if you're having family meals, just paying attention to you as your kid eating or just pushing their food around if you see maybe some of these other signs, just start to pay attention to the record.

Sirisha: I think it's very subtle signals sometimes, you have to be aware. You have to be cognizant and it's a slow change or a slow drift in the conversation. So you're talking about what the kids are saying, but as parents, you made this comment, all food is good food and how we address it, how we talk about ourselves, how we talk about our eating habits. What do we do at home? How should we be talking about ourselves or our conversation and our relationship with food as well?

Ashley: I think that, and this is the question I get from parents the most, what can I do now? And so as a woman, I am, 38 now and I would say my metabolism changed at about 35. I think that we just have to be kind to our bodies. I do not disparage my body. If I have gained weight, I'm not going to talk about that in front of my kids. If maybe I'm going to eat, I'm Italian., I love food. I've never had an eating disorder and I do try to live by the motto" All food is good food". I do recognize as we are not teenagers, we are not gaining and growing. We have different caloric needs than our kids, right? So there are certain things, my kids can have an ice cream every single day after school. I don't call attention to that, I don't say I can't have this. I'm not going to or when I do workouts at home during COVID, I have a weight routine and they said why are you doing that? I said I have to be strong enough to pick you up. One of my daughters, we were in Santa Fe, she caught her knee on a cactus and so I had to carry her down a mountain. So I say remember the time mommy had to carry you back down the mountain when we were hiking, I have to be strong. So I don't focus on weight loss, I focus on strength and, I want my body to live a long time and I want my body to be able to do the things that I like to do. I do play soccer at 30 and I don't play soccer to manage my weight. I play soccer because it's very fun and I enjoy something my kids play. So I focus on any activity that isn't about punishment for eating this or, 'oh, Thanksgiving', so now I better work out tomorrow. Just I stay away from tying food to exercise. I stay away from any disparaging remarks about my body. I do not comment on their bodies and then I think, my kids, we talk about protein is to build your muscles, carbohydrates are for your brain. There are vitamins in fruits and vegetables that your body needs and then dairy is for your bones to make your bones strong. You can only store calcium till age 30, that's a very big, important thing for bone health is to get in those dairies and so that's how we talk about foods. Even at the hospital, we call them meats, milk, grains, fruits, and vegetables. So when I talked to my kids, If they're trying to eat a cookie after they've already had cookies and then they've already had maybe spaghetti, I'll say, Hey, you need some protein. And so I don't talk to them about healthier, unhealthy. I tell them we have to eat out of all of those five food groups in the day because they each have something their body needs. And I will tell you even my four-year-old understands that. I don't think you can do any damage by talking about these five food groups and all food is good food. I don't think kids are going to binge eat ice cream because you say all food is good food. The caveat for older kids is variety and moderation. I think we all know we can't eat McDonald's every day of the week, but I will tell you we have pizza night every Friday, and no one in our family is overweight from that and so I think we have to de-stigmatize what society says is if you eat this will drastically impact your weight. That's not true and we have good dieticians who work with families on these food myths. A lot of families do have a lot of anxiety about the way that we're weight-restoring their kids in treatment and the types of foods we're exposing them to. And based on the anxiety I have seen in the families, I recognize that this is a problem in our society. There's a dietician. I follow her, her name is dietician Anna, and, she says, our body is our earth, it's the only body we will get. So for people, who are worried about protecting the earth, like this earth is the only earth we have, right, we need to treat it kindly. Same thing for your body, your body is the only body that you have and if you don't treat it with kindness or respect, you can't get another one. And so I really, think that the kids that I counsel that, that resonates with them, that it is the only form they're going to have and being kind to it is very important.

Sirisha: Two things come to mind when you're saying this, kids are also well aware of having a whole plate, like the five food groups you're talking about because there have been times when I've gone out, especially during vacation offered my kids to start with dessert. For some reason, they don't seem to still want to start with dessert or ice cream at the meal and rather have dinner first, but that's a choice they make, right, it's not restrictive as you speak.

Ashley: My daughter loves vegetables she loves carrot sticks and she doesn't, we've offered ranch for the carrot sticks, but she eats them plain. I don't understand that, she also eats a wide variety of other things. So I'm not very worried about it, for her snack if she chose carrot sticks. That's great. Kids may move towards dessert, salt to your sweet food, and I think as long as it's not that food, they're not associating it with something negative and saying, I don't want dessert because of this, but they just maybe don't want something sweet. I think that's fine. And it is, and they get to make those choices as long as they're out of health.

Sirisha: Yes. The other comment you made was about the earth suit. I had one of these forwards, I saw this comment, which ties it well for someone who's a numbers person. If your body was number one and you added all the zeros after it be it wealth to be it education, be it everything that you're trying to aspire to, you can remove all those zeros and still have the one, but if you remove the one, the zeros have no meaning.

Ashley: So it's a different station, you get one body and you have to take care of it , I would almost say nothing matters if you don't. We talk to kids about this, If you're in eating disorder treatment because we're trying to save your life. How are you going to college? How are you hanging out with your friends? How are you going to prom with your boyfriend? If you're a parent, how are you taking care of your kids? Because you may end up being in treatment and away from them, or, we've had people who have lost a kid, teenagers have lost their jobs, but I work with other clinicians who work with adults, They have lost their jobs because they were in treatment and asset for so long. So I agree with you, this thing will steal everything and I think that the biggest misconception that I have seen is that, the teenagers that we have, and I've treated a couple of adults in private practice before children think that they can control the eating disorder and that they can have just enough restrictive eating or just enough bingeing and purging that it will get in the way of their life. That is not the case, it will eventually overtake the person, there is no middle ground with eating disorders.

Sirisha: When you practice, children, you're working with the whole family. I as an individual might have an eating disorder, but it's a family dynamic that sets it up and I think it goes to everything you've been talking about, right? The dinner table conversations, how you talk about yourself, how you treat yourself. What does that intervention that families do? And I'm also very interested in learning, we talking about young children and teenagers, they have siblings. So what impact does it have on the siblings in specific and how can we have that conversation with them? Because they're much closer than age, much closer to them, right? It's a different relationship between a parent and a child and a sibling and a child.

Ashley: One of the biggest things that we say to the parents when they come in because a lot of the times, what did I do? And we work hard to say you didn't do anything again. And there are social media, there are friends, or, if a parent did go on a diet and did lose weight, there are people whose parents dieted their whole lives that don't have eating disorders. So we try really to shift them from like blame of themselves or others and into, Hey, you are our biggest source of support as we restore healing. Pediatrics for adolescents and younger kids is a family-based treatment where the family is part of the treatment and we do family therapy. That is the gold standard of care. In addition to what we call a multidisciplinary team, meaning there's a therapist, dietician, nurses, and doctors everybody's working together. Family therapy is structured so that parents can learn about the eating disorder, cause I don't see a lot of parents that are coming in with a lot of knowledge. It's a lot about helping parents set limits on the eating disorder. So parents have become very afraid of upsetting their children because these kids who before had been very compliant, and very rule-following are all of a sudden lying. They may be yelling, they may be hiding food or throwing food and so the parents come in and think, okay if I push on the kid at all, I'm setting them back and we have to coach parents that no, we've got to nip this in the bud, we've got to get on top of this. We have to make sure that the limits are there and the biggest thing with eating disorders, we do not threaten or bribe or guilt or negotiate for our program. Specifically, we have expectations of the patient for, how many meals they need to be eating and if they eat them, that's great. They get certain privileges that they want and if they're not eating and they're not nourishing their body, they're not getting certain privileges. And so sometimes the kids come back and they say you're punishing me for having this disorder, but I tell them, "Was what if I didn't show up at work for two weeks? Like I didn't tell my manager didn't show up, and didn't do my job. Would it be a punishment that I didn't get my paycheck? Or did I decide to not show up? No one can make me go to work, no one can force me out of my house ever into work, I make that decision because I have chosen to have a job and I've chosen to get a paycheck. If I ceased to do those things, I won't get those other things and so we teach the kids a lot that, Hey, we're removing the stress. Because a lot of times parents are they're desperate, they are scared. Can you imagine, this is a life-threatening disorder? Parents have said, I'll buy you a ticket to New York if you eat, we'll go on a cruise or it could be something smaller, like a board game or a video game, or they have guilted their kid, don't you know, kids are starving in another country, or they've yelled at their kids in moments of stress and frustration.

I think every parent probably has raised their voice at their kid. I have, but none of those strategies work, the kid has to decide to make this decision. However, I tell parents, if their kid was failing out of school, there may be some natural consequences, right? They may have to go to tutoring or they may have to go to summer school, or you may not let them go to all of their extracurricular activities if they have F in every subject. Even sports teams, you can't play if you don't have certain grades. So there are natural consequences and we do have families enforce those natural consequences. When a kid is not eating and doing what they need to do, there will be either privileges they get or privileges that they don't get, or natural consequences and building the distress tolerance in the family so that the family can handle that pushback from the eating disorder externalizing, the eating disorder is something else we do. We talk about there's your kid and there's the eating disorder. We don't think that there's some sort of split personality, but for most of our kids, there's a clear timeline where the family says, I know when this eating disorder started and the behavior's changed. My kid was never screaming at me about food before, my kid wasn't lying to me before that and so we'll say, 'Hey parents, you can be very mad at the eating disorder. You can be so frustrated, we're going to choose to externalize that so that you can talk about your frustration with the eating disorder, without the kid feeling like you were mad specifically at them, because we do understand that this is a mental illness and this is not something that kids just voluntarily are choosing to do to be defiant. It very much feels outside of their control until they can get the support. To overcome it and we talk with parents. One of the phrases I always say to parents. I say to parents, you can't do this for them, but they can't do it without you. And the parents also are a source of encouragement and motivation and help the kids cope.

When they see their kid distressed, be able to come in and provide either encouragement or calm, Parents then learn about their coping skills and we'll practice coping skills with their child. And then we also talk about the family dynamics, are there disruptions or barriers to treatment, has the family gotten away from communicating? Is there, to your point about siblings or is there another sibling, who maybe needs a lot of attention in the family and this kid has gotten used to not asking parents for some is there a conflict between parents where's their conflict between siblings, where that is creating more stress for the kid with the eating disorder? Yes. We want to address that and decrease the stress in the house. I could probably talk forever but that's basically what we're doing is we're educating the family. We're identifying barriers at home to recovery and identifying stressors and then we are very much building up parents and their knowledge and teaching them all of the skills that we as a program have so that when the kid leaves the program, we don't want them dependent on us. We want them to go out and be successful after they leave us.

Sirisha: I think it's a perception change, right, for anyone listening to this or learning about it. Eating disorders we very much think of it as body and body issues, but to your point, it's also mental health issues. It's not so much just a physical appearance thing, but that part of it and families, it is a stressor for everyone going through this experience. So how do we learn to cope with it, get knowledge around it and learn to share that as well? And even when families are going through this they are going to have meetings with friends, and go for Thanksgiving with their family, so making everyone else in your community, around you aware of it so that you can still have the conversation, but not talk about food and others. Say you're visiting your grandparents, are you visiting your aunts and uncles or just friends, and family? So how do you have that conversation around that? And just normalizing it in a way. And the other part of it that I thought you were mentioning is just, as a parent you do feel the guilt. You feel that blame, and I'm glad you addressed that because parenting is challenging. And you're always going to question yourself whether you made the right thing, especially when you denied something or when you went through a certain thing. So it's hard enough to do without having that guilt and blame because you have to separate that from what you are going through at this point. After all, you have to help your child, enable the change and as a family unit come together to figure out how to do it or not. And I think the sibling part, I also was wondering the other way, as the person who is going through an eating disorder, sometimes the other sibling might also get less attention, but how to make sure that they are part of it because that is also a stressor for another child. So they're going to any other incident or trauma that they can themselves itself feel marginalized, that they should somehow be included in this discussion and just other things and have a say in everything that's going through.

Ashley: Yes. And, I feel like every conversation I have, I feel like I have to talk about COVID and, I'm ready for when it's safe for us to be able to relax some of the restrictions. That we have. Children's has a two-visitor policy right now because we treat medically fragile kids, both on the eating disorder unit and in other areas. So siblings haven't been allowed before we would have siblings in family therapy, and I've had parents who have wanted the siblings and for exactly the reason that you said, where they have said this has impacted all of us, siblings very worried, we're worried they might develop an eating disorder. They're worried they're going to trigger their sibling by saying something, as simple as, oh, I went to soccer practice today. The eating disorder hears that and that is why they get to exercise and I don't. I've also had parents that said, I don't want my nine or 10-year-old in because I don't think they understand and I always tell them, I think that they do, they have a high capability to understand, and they've also been seeing the behavior's. And so I would like for them to be here because they have observed what's going on at home and I bet they know more than you think they do and so that has been one of the downfalls of COVID is the sibling component. I do think though that we have tried hard to have parents have those conversations with their kids and bring their kids into the loop. And also to explain the biggest thing is, siblings are not responsible for the child who has an eating disorder. And sometimes kids feel that they need to follow their sibling around the house and make sure they're not exercising or purging, or sometimes parents mistakenly think, maybe an older sibling 15,16 is the one who can make sure that the child eats. And I say, no, I don't kids to end up in a parent role, I want to make sure that they understand that they are still in a sibling role. They can support, there are lots of age, appropriate ways for them to support their brother or sister, but they do not have to be in a parent role of supervising and I do think that's very helpful. Those conversations are very helpful for the sibling and then we refer them to outpatient family therapy after treatment. And I tell the parents, this is like crisis time, partials or inpatient, your outpatient family therapist will be addressing how this stay in this treatment has impacted the whole family and what steps going forward, need to be addressed. So to your point, how siblings are feeling and how it's changed their family system, how it's changed their family dynamics at the outpatient level of care, we recommend three to six months of family therapy to address all of these changes and how the family is functioning in this new model and in this new way, and to identify, If, maybe there has been a negative impact like you said, where siblings feel left out or they feel like they don't have enough time with parents.

Sirisha: So that's right. Children here in Plano have a dedicated program, right, but people around the world, don't have access to resources. You may not know where to go, if you'll figure out that you need help, what is the best way to get access to resources? Is there a helpline? I was watching in February, there's a national eating disorder awareness week. Are there helplines for other things, is there a way to access resources?

Ashley: So you're talking about a NEDA, which is the national eating disorder association, so they have parent booklets on their website or toolkits. They have parent tool kits, What to look out for, and it even goes through if your kid's getting hospitalized, how do you talk to insurance? How do you get them in? It's great. They also have teacher tool kits. I have had teachers and coaches reach out to me before when we've come to speak to the school. But again, if you're someone that you don't live in DFW and you want those resources. There are other resources on NEDA for people that may be in a kid's life that are not there. I am part of, I adapt the international association for eating disorder professionals and so there is a place where you can search for people who are what we call CEDS certified, which is certified eating disorder specialist. I'm also a certified eating disorder specialist supervisor and so you can search on their psychology today. You can usually type in eating disorder specialty to get resources, for therapists and then there is another one and it's called the Texas eating disorder association. It used to be called the Elisa Project, but it's now called the Texas eating disorder association. So if you're in the state of Texas, they have a lot of very good resources. I will put out a plug we're not the only eating disorder place in DFW and there are national eating disorder places. So for instance, the eating recovery Centre is also in Plano, they treat kids and adults, Center for Discoveries is also in Plano, they treat adolescents and adults. So, if you're in a different state other national places are specific eating disorder programs. Ours is in a children's hospital, embedded in a children's hospital. They have residential levels of care where people can go for up to three months and then they usually do have inpatient, partial and IOP programs as well and so I would never, deter someone from seeking those resources. I think we all have a passion for treating this disorder. I think because we're a hospital, we get a lot of very medically complex kids and when we are full, we refer out to those facilities and we spend a lot of time talking about kids.

Sirisha: but you also refer to adults. So what should adults be doing differently? What kind of treatment? How can we help them?

Ashley: Adults are a little bit trickier because kids, they can't say I'm not going to treatment. They maybe could protest, but the parent ultimately can sign them into treatment. I think the biggest thing is to still involve their family. So whether. It's a college-aged kid, parents may still have some leverage. They may still be financially supporting that kid. For adults, that are married, the spouses are included. They still will do family therapy. The research on it is a little bit different, it may not be quote-unquote evidence-based treatment, but including the family and the spouse is always important. And sometimes the children, I would say, if you see signs of an eating disorder, my recommendation is to see your pediatrician and, possibly a dietician. The pediatrician will usually say, Hey, yes, this is concerning and then refer you to a dietician to monitor the weight. Those are the people who need to build the meal plan and be the ones in charge of that, therapists do not do that. And even our physicians on the unit, they're not the ones building the meal plan, it's the dietician and then also of course, I would say, see a therapist, bare minimum therapist and dietician. For adults, I would say the same thing. You could start with an outpatient therapist and a dietician to monitor your weight and make sure it's safe and then those people will normally recognize if a step up in level of care is needed, whereas with all the outpatient intervention it's still not, enough and if the person isn't safe, they will then refer them to a facility and help you get connected. Most everyone I know that works in this field is very aware of resources because it's such a dangerous disease.

Sirisha: Actually, this is a very important topic. There's so much to talk about and I'm sure if we spend time, we could talk about the types of treatment and inpatient and outpatient therapy and other treatments available as we discuss it. Is there anything else you wanted to share before I ask you the final two questions?

Ashley: My biggest thing would be, don't be afraid to talk to your kid. As part of treating eating disorders, we do treat a lot of kids who, have suicidal ideation or non-suicidal self-injury and in the education for those things, the biggest thing is don't be afraid to ask your kid, if you think your kid's having thoughts of suicide or self-harm, you can not hurt them by asking and I would say the same thing for eating disorders. You are not going to do something wrong by expressing your concern. I do think you should go you know. gently, but straight at it and be very clear about what you've noticed and what your concerns are. I think, to be very patient and to be very empathic, but to address it. And for parents to know it is something that can escalate very quickly. So it's not something that we want to wait on. The disease will usually, progress slowly, but then once it gets going, it's like a snowball downhill. And so I think parents, oftentimes I hear them say, I wish I had done something earlier, I didn't anticipate it going south this quickly and so just not to be afraid, I think in general, as a mental health clinician, I think we're good at talking about medical issues, but we're not very good at talking about mental health. People get squirmy about it and uncomfortable and so my biggest advice would be to try to put yourself in a good space to be as comfortable as you can be and just to be very open about anything related to mental health and that as calm as you're able to be, that also helps others. If they need to disclose something to you, they'll be able to do that, if they feel like it's a non-judgmental and safe space.

Sirisha: That's very important, like you said, we do feel squirmy talking about mental health and asking if someone is going through an eating disorder issue or having suicidal tendencies or ideation. We hesitate to discuss it or bring it up because we think that will generate the idea, generate the thought. But what you're saying is, that is not going to be the trigger. If you're just going to speak to it, that is to find out if some thoughts are going on, so you can catch it early nip it, as you said earlier on to intervene before it starts to escalate very fast, go out of control at that point. Yeah. So this is a question I ask all my guests. What advice would you give yourself for your career in life?

Ashley: Perseverance, most people have run into something. I remember mine was grad school was fine, but there's all there are these 3000 hours you have to get after becoming a counsellor and sometimes it's harder to get those. I remember doubting myself a lot and I wish I adjust and I did persevere smear. I am. But I think just maybe confidence that it will if you love something. Keep your confidence that there's a reason that you started the process and follow it out to the end. Don't jump ship when it gets hard to persevere through it, because, I have a career now that we love what we do. We love our coworkers. We are passionate about the care that we give. And I would hate to think that I could have missed out on this just because it was hard for a few years. Like confidence in your dreams. Like I know that sounds very cliché, but keep going even when it's hard, if you're, if your gut intuition tells you, this is the thing you're supposed to do, not as if you can always defer your career, but that inner knowing to follow that inner knowing that's telling you, this is what you're called to and just keep pushing through.

Sirisha: You're saying believe in yourself and follow your inner compass because there are other things to be had, like the relationships, the community, the outreach, just think back about, what you're having. You did it for yourself, but you are having this huge impact now in what you're doing and, even this discussion we are having, I'm learning from it. Hopefully, others will get to hear and listen and help themselves and others as well and just spread the message. What is the one word you would use to describe yourself?

Ashley: That's very hard to boil that down into one word. And I would say boldly probably.

Sirisha: I can see that from what I know of you, which is good. So thank you, Ashley. This was very informative and I'm so glad we got to talk about this because I have only read a little bit.

There's a lot of discussion around it and the most important thing that I took away from this conversation. So a couple of things is it is not just a physical man gestation, but a mental health issue. And it's separate from the identity of the person and how you as a community of family can support the discussion that we are having to enable them to address it and just talk about it early on like we talked about it right. And directly asking them is better than thinking that's going to be the seed of an idea. Go down that fat. If they're thinking about it, they've already thought about it. There's nothing you by asking, you're going to change that you might as well address it and have treatment go through early. So I'm so glad we got to chat with you and share your immense knowledge. And thank you so much.

Ashley: Thank you for having me. I appreciate opportunities like this. I think that this is such a delicate subject that I hear parents all the time say I wish, there were more resources and so I think when people like you, invite people like me to discuss this and you're reaching a wider audience than I reaching, in the hospital, I'm just really grateful for that.

Sirisha: This is an indie podcast, and if you enjoy the content, you can help me with production by supporting me. You can buy me a cup of chai. I'm not a coffee drinker, or you can enable me by subscribing to either a monthly or an annual plan as well. Thank you for doing this, and don't forget to share this episode and put in this reviews what you liked, and what was your key takeaway.

That's really what I wanna know. I wanna know how this is impacting you, and what changes you're seeing in your life. You can always reach me through Instagram by sending me a DM at Women Career and Life. Thank you so much for tuning in. See you next time.

Guest : Ashley Ariail

Host: Sirisha

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