Practical measures schools take to support pupils with an eating disorder

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A pupil’s treatment for an eating disorder will usually involve eating regularly and reducing exercise. Your school’s support is often essential. There may also be particular stressors related to school life that you can help with.

The practical measures you take will make all the difference to whether a pupil can safely attend school, and whether their speed of recovery.

How eating disorder treatment affects a pupil’s school work

To appreciate the kind of support a pupil needs, it’s useful that you step into their shoes for a moment.

An eating disorder is usually linked with higher levels of anxiety or depression. Hunger, irregular eating, nutrient deficiency and weight loss affect people emotionally as well as physically.

On top of that, treatment involves doing what is most feared: eating what needs to be eaten, re-gaining weight, abstaining from purging and from over-exercise, eating to schedule even after a binge.

It is a bit like asking someone who is scared of heights to take a bungee jump several times a day.

The most effective treatment for anorexia and bulimia is parent-led, with specialist mental health professionals supporting parents to take charge of treatment at home. The parents will be making sure that their child eats for weight restoration and normalises behaviours. At times there will be major resistance from the young person at home. Occasionally the person will be in crisis. Homework will be the last thing on anybody’s mind. Getting great grades becomes less important than saving a life.

Some pupils will be getting individual therapy instead of a family-based approach. In this case they will be battling their own demons, doing their best to find the willpower to eat (or avoid purging, bingeing or exercising) according to a plan agreed with their therapist.

It is hard for pupils to concentrate on their studies when they are going through all this, often with nobody but their family in the know. They may be very ashamed of how the illness makes them behave, and insist on secrecy. Yet in school they often continue to be model pupils – high-achieving and well-loved by teachers and peers.

How the school can remove unnecessary stressors

The pupil is likely to be in a near-constant state of anxiety and alarm. This leaves little room for extra stressors in school. When the person can’t cope with stress they resort to eating disorder behaviours, or some may tip into self-harm, suicidal ideation or even suicide attempts. And during all this time they may still be getting great grades…

Discuss with parents what is needed. For instance some young people with an eating disorder have moments of high anxiety, and the parents may give you the information you need to deal with it.

One way the school can help is shuffle the composition of various classes so that a pupil is with peers or teachers they feel safe with.

“The educational psychologist did a great coordinating job, especially ahead of the move from primary to secondary school. Staff from both schools met with us and the treatment team. The school hadn’t realised how ongoing peer tensions were making our daughter suicidal. The new school bent the rules so that she would transition to a class with only her best friends.”

I suggest that your school be ready to stretch deadlines. It is not helpful for a pupil to have extra stress about homework when they are also having meltdowns at home because they are made to eat or prevented from bingeing, vomiting or exercising. Pupils may be driven by a strong need to please teachers, so reassure them that a piece of work can wait.

You can help a person’s recovery by being flexible around some of the rules that normally apply. This will not be for ever, so don’t worry about the ‘slippery slope’ argument. Pupils with an eating disorder are often conscientious and anything but ‘soft’ on themselves.

“My daughter was getting awfully stressed about a new maths teacher, and I worried that this would interfere with her brave efforts to eat. She plucked up the courage to speak to her head of year, who discretely moved her to another class. It’s one of a small number of accommodations she ever needed, and I think she gave plenty in return, as later she was voted head girl by staff and peers.”

Academic ambitions

Relax about the pupil’s academic progress. Health is the priority. A ‘First’ at Oxford is no use to someone incapacitated by a chronic eating disorder. Besides if a pupil hasn’t secured a strong recovery by the time school ends, they cannot safely leave home to go to university as the illness is highly likely to grip them again.

Many of your pupils will catch up after time off – they have the abilities and personality type. Many people who have suffered from anorexia are high achievers.

The stress of achieving top marks gets in the way of recovery. The drive to do everything to the highest standard contributes to the risk of an eating disorder. Part of what the pupil will practice in treatment is to be less of a perfectionist. It is not helpful when teachers cheer the pupil on to be the best. Getting a C and coping with it, for someone who is used to getting A’s everywhere, is a mark of progress.

With careers counselling, be aware that someone with an eating disorder (especially anorexia) may be drawn towards hard, prestigious, high-status subjects (medicine, dentistry). It may take some work to discover what they actually enjoy.

Punctuality

Be flexible about pupils’ punctuality at classes. The pupil is likely to have weekly appointments – sometimes more – during school hours. They may leave a therapy session in tears, causing further delays.

A difficult meal can also cause delays.

“Breakfast was more important than punctuality. It could take time to make sure my son ate, and sometimes there were fireworks and tears. Whether he was 10mn late or missed all morning, the school was sympathetic.”

How the school can support a pupil to eat

Why pupils need mealtime support in school

Food is central to treatment. A pupil cannot recover unless they reach a healthy weight and unless they eat regularly. Someone in treatment for anorexia normally needs 3 meals and 3 snacks a day, regularly spaced out. Regular eating is also crucial for those who would otherwise binge and/or purge. For those who restrict, it isn’t enough for parents to feed a whole day’s calories at breakfast and after school, because the eating disorder tends to get activated when there’s more than 3 or 4 hours without food.

When schools provide the right level of support around meals and snacks, the pupil can resume normal life sooner – and normal life is part of recovery. Without school support, pupils may need to stay at home for a long time. Or if they go to school and don’t eat what’s required, the eating disorder is likely to get worse.

Different levels of support during school meals

There are different levels of support required from the school at different times. The parents and clinicians will work this out with you.

Level 1: the pupil stays away from school

The pupil may stay at home or in hospital because of their medical condition, or because eating is so hard that they need intense support. The pupil may or may not benefit from contact with the school. Sometimes, studying provides a welcome distraction, and sometimes it’s just too much. When they are ready to return to school they usually need a well-planned phased return.

Level 2: the parents feed their child at school

The pupil can attend school as long as a parent helps them to eat – often in a private room or in the car park. Or the parent takes their child home to eat. A meal may take longer than a normal break time so you may need to agree with the pupil that they may leave class early or join the next class late.

Level 3: the school gives one-on-one meal supervision

The pupil may be able to get through a meal without prompts or encouragement, but left to their own devices they would skip meals or reduce quantities and would become very ill again. Your support is to provide some one-on-one supervision. Have a well-informed member of staff sit with them at each meal or snack.

“The school had a rota of 3 teaching assistants, who would sit with my daughter in a quiet room while she ate lunch.”

When you’re sitting with a pupil, your role is simply to check that they are eating what they’re supposed to eat, and to notify parents after the meal of what was or wasn’t eaten successfully.

“The school wanted the support teacher to be a single point of contact. As a result I rarely knew if my son had managed lunch because he was supervised by another staff member. I couldn’t assume that no news was good news. It was really helpful when they agreed that this person would text me after each lunch."

You are not expected to coax a pupil to eat. It’s too demanding and you could make things worse if you don’t do it skilfully. You are providing precious help simply by being there, observing that food is eaten.

Check with parents or clinicians (and possibly with the pupil) what to say and what not to say. In general, you should be attentive enough to see if any food is being hidden, while adopting a non-judgemental and kind stance. You don’t want to be so kind that the pupil feels humiliated or patronised, and at the same time do bear in mind that for the pupil, getting through this food may take tremendous courage. Think of eating as a heroic act. You should not comment on the food (you never know what difficult thoughts can be triggered by innocent comments like ‘That looks nice’ or ‘Is that a cheese sandwich?’). Some pupils may enjoy engaging in light chat, while you may discover that others prefer silence.

Check with the parents, but if the pupil stops eating, you might ask, ‘Are you able to continue?’ If the answer is no, don’t signal any disapproval. Make an agreement with the parents what you say or do next. Agree with them how quickly they want to be notified. Some may want to come to the school right away help their child finish the meal. It may be a question of principle or of health.

If a pupil has previously been undernourished, expect packed lunches and snacks to contain more food than other pupils eat, and be careful not to comment. Fast weight gain supports full recovery. The body needs a lot of calories to repair, and metabolism may not return to normal for many months. These quantities of food might seem excessive to you, but the pupil’s needs at this stage are very special. Besides, their earlier period of starvation may cause them to now be extremely hungry and ready to eat more.

Note that at some stages of the illness a pupil may try to secretly bin some of the contents of their lunchbox as soon as they get into school. One solution is for the parents to drop the lunchbox off directly at the school reception.

Level 4: the school keeps an eye on the pupil in the dining hall

You provide low-level supervision. This works when the pupil can eat with ease and is unlikely to restrict. They are in a treatment phase where they are practising autonomy and normality, while parents continue some level of supervision and are ready to rein the young person back in if it’s too much too soon. The member of staff doing the supervision could be whoever normally oversees the pupils in the dining room. It could be one or two of the catering staff, who keep an eye on the choices the pupil makes at the servery. These details need to be worked out with the parents.

What matters is that the pupil knows they are being monitored and that their parents will be notified if they don’t eat as expected.

“Even once my daughter stopped needing supervision, the main dinner lady took it upon herself to keep an eye on her. If she saw my daughter bin food she told the Head. I was touched by her care and it was reassuring to know that thanks of her, any setback would be nipped in the bud.”

With an eating disorder, it can be very hard to stand at a self-service and make food choices quickly. In their panic a young person may choose just a side salad. In that case, see if you can give the parents the week’s menu ahead of time so that they can help their child to plan. For pupils who cannot yet bear to serve themselves a normal-size portion, it helps when the parents notify catering staff of their child’s choice, so that the staff can plate up a sensible amount.

Occasionally parents may ask you to discreetly monitor their child’s food intake. This is when they suspect that that their child has an eating disorder or is in relapse. Their child may be telling them they had a full hot meal, when they only had an apple.

The parents will let you know what level of support is needed at any time.

“Every Friday the support teacher emailed me the computer records of my child’s purchases in the canteen. This helped us step in and avert a relapse: at one stage my child was telling me he was eating hot meals yet only buying diet coke.”

How the school can support a pupil to not exercise

Exercise is not automatically a good thing and with an eating disorder, it can be anything but ‘healthy’.  Exercise can be as much part of an eating disorder as food. A person may be secretly exercising to excess. They may be unable to find any peace until they have satisfied an ever-increasing, self-imposed quota. The smiley pupil you see in class may have exercised in their bedroom till late at night. They may have woken an hour early to secretly get through a regime of squats and sit-ups or to go for a run.

People who are malnourished must not exercise on medical grounds. yet the compulsion is such that some try to go running against a cardiologist’s orders.

Also, there is a stage in treatment where rapid weight gain may be a priority, and some forms of exercise would be ‘wasting’ calories.

People with an eating disorder often use exercise to regulate their weight or change their body shape. It’s a source of intense misery – they may be exhausted and weak, yet only feel relieved once they’ve gone through an exercise routine. They need help to break the pattern of compulsive exercising or muscle-building. In treatment they practice other ways of dealing with thoughts and feelings, and may experiment with new forms of exercise — those that are fun, sociable or relaxing, and that are not related to changing body shape or controlling weight.

For all these reasons, at some phases of treatment the parents or clinicians may ask you to keep a pupil away from exercise classes. Sometimes the child needs to redirect their passion from a competitive sport to something that will better serve them in recovery. Do suggest any school clubs that the pupil may enjoy that are not about exercise, such as art or music.

For educate yourselves and get great tips on the school’s role around exercise, see NEDA’s ‘Coach and Trainer toolkit’

How else can your school help a pupil in treatment for an eating disorder?

You can help prevent vomiting

Parents may ask you to supervise that their child doesn’t go to the toilet after a snack or lunch. Vomiting is quite an addictive behaviour and it may take some teamwork to stop it.

You can help prevent bingeing

Likewise parents or clinicians may make specific requests to reduce a pupil’s bingeing or other eating disorder behaviours. Such measures are only needed for a while until a particular habit is broken and the pupil moves onto another phase of treatment.

Deal with bullying, weight teasing, fat shaming

Sometimes an eating disorder begins with a diet triggered by name-calling or bullying. Whether or not you classify an incident as bullying, if it is making the pupil regularly feel unsafe, the eating disorder will be hard to shift.

You can prevent access to harmful websites

Check that your school’s internet system is, as far as possible, blocking access to sites that encourage eating disorders or give tips for self-harm or suicide.

For pupils who are in treatment, recovery is difficult when they obsessively consult dieting or ‘fitness’ websites. Instagram images can be problematic too.  The parents may have blocked internet access from their child’s phone, and may ask for your collaboration in keeping their child supervised while on the school’s internet.

Do not comment on weight gain

While a pupil is in treatment it’s crucial that they regain weight fast. To maintain health they may need to reach a weight that is significantly higher than their previous weight. Weight is not a question of looks — the parents and clinicians will be working on a weight that corresponds to full recovery of the pupil’s physical and mental processes. If any of the staff are uncomfortable with the pupil becoming curvy, please remember that this is a health issue. The young person will most likely want to remain much thinner, partly because of the illness and partly because of our society’s bias towards thinness. Any well-meaning comment you make on a pupil’s increasing weight could jeopardise treatment.

“I asked for support to make sure my son didn’t bin his lunch. The teacher’s response was that he wasn’t skinny any more and ‘looked fine’.”

Do flag up apparent weight loss

While I recommend  you abstain from commenting on weight gain, it is helpful if you flag up weight loss to the parents. It may highlight a blip in treatment or a relapse. It may be obvious to you that a pupil has become thinner (especially after a holiday), but sometimes parents don’t see gradual weight loss.

“My daughter seemed to be in stable recovery. She looked happy and said all the right things about enjoying her food. Yet through all this she was massively cheating the scales. I thought she looked thin but assumed I had lost my objectivity. When one of the teachers privately told me she looked very thin again, it was a precious wake-up call for all of us.”

School trips during treatment for an eating disorder

When the class is due to go on a school trip, the parents will need extra information about it to assess whether to allow their child to go. A poorly planned school trip could result in weight loss and a worsening of symptoms.

On the other hand a school trip might be perfectly safe, and a source of enjoyment, normality, and motivation to engage with treatment.

Discuss with the parents what support the pupil will need, especially at mealtimes. Parents may need to know what types of meals are served, whether served or self-service. The pupil may need to bring some supplies of their own food in case they can’t cope with the food on offer.

My daughter could only cope with a rigid meal schedule. She had a class trip coming home late at night and I knew she wouldn’t be able to handle it.

Agree with the parents what support, if any, is required. Be clear on what signs would indicate that the pupil is not coping. The parents should be ready to travel over and take their child home quickly if he or she is deteriorating.

“Our school were really good at planning with us and allowed my girls to go on all sorts of school trips, having a BRILLIANT time and giving a real fun quality to their lives. Quality of life is massively important in recovery.”

* Link: School trip or summer camp: a helpful flow chart when your child is recovering from an eating disorder *

School interventions that are NOT useful

Too many cooks

With eating disorders, it is best that school staff don’t engage in counselling (unless, of course, the parents tell you differently). The pupil should already have a specialised team and that is enough. The danger, if you are tempted to counsel a pupil, is that they will not tell you the whole truth about their behaviours, so you will have an incomplete picture of what’s going on. They may draw you to pronounce on issues of weight, body shape or calories. They may tell you how awful their parents are. They will then use innocent remarks you made to fight their treatment team.

What you can do is treat the pupil with kindness and non-judgement, make them feel valued and remind them they’re wonderful and courageous. And that they have a great life ahead of them.

No weighing

The school should not do any weight checks (unless by agreement with the care team, who will advise on how to do it and what to say and what to not say). And as mentioned earlier, when a pupil is in treatment, do not comment on their weight gain.

How the school can maintain links with an absent pupil

For young people who are in hospital or who have to stay at home, it is helpful when the school maintains links. In some cases the young person is not in any fit state to study and needs to concentrate on their health. Other times, school work is part of their morale and sense of hope. You might provide study materials or arrange visits from teachers.

You could also consult parents and clinicians to see if it would be helpful to have peers make some sort of gesture, such as a get-well card.

Pupils who have been away usually need a phased return to school. Plan this in collaboration with parents and clinicians.

Support siblings of a pupil with an eating disorder

Siblings of someone suffering from an eating disorder can be strongly affected, because the whole family is in a state of emergency around the care of the ill person. If siblings are pupils in your school, find out from parents if they have any particular needs. Even if all seems well, be aware that some youngsters work hard at not being a burden on their parents, at the expense of their own age-appropriate needs.

Boarding schools

Pupils in boarding schools often need to go home for the first phase of treatment. After that they can only safely be in school if staff can support meals and promote normal behaviours in a way that is similar to what parents do.

A boarding school may detect an eating disorder in the same way that a parent would. I suggest you read materials designed for parents, such as my book.

Does your school HAVE to do all this? Yes!

Most schools willingly and enthusiastically work with clinicians and parents to give the pupil every chance of recovering, while having equal access to education.

But some don’t — they say they don’t have the staff to supervise lunch, or that it is not their job.

Actually, schools have a legal obligation in regards to children with medical conditions. I outline these for you here.

* Next: What do pupils and school staff need to know about eating disorders? *

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* School support: a checklist for parents* : if you’re a parent this will help you discuss with staff your child’s needs and what support is needed.