Mental health · Aug 10, 2026

Eating disorders in adolescence, what can caregivers do?

The first question caregivers ask is usually about blame, and the science answers it clearly. Here is what the research shows about the role of home in treatment, about who actually gets ill, and about what to say at the table.

Dinner in that house had come to last an hour and forty minutes. It started at seven, with everyone seated, and ended with the plate almost the same size it had been when it was served. In between there was a fork separating the rice from the beans, a glass of water drunk far too slowly, a trip to the bathroom right afterwards, and the television turned up loud enough that nobody had to say anything. No one at that table talked about food, and food was still the only subject in the room.

The person who described the scene to me was not the fifteen-year-old sitting in the middle of it. It was the person who cares for her, who booked the appointment to talk about exactly this, said so on the phone, and arrived with the question already typed into the notes app on her phone. The question was not about tests or referrals, and it was not about what to do at the next dinner either. It was whether this had started because of something the family had done.

I have answered that question the same way for years, and the answer is not kindness on my part. In 2015 the Academy for Eating Disorders brought together international patient, family and advocacy organizations to write a short document with nine statements about eating disorders, now translated into more than 30 languages. The second of them says that families are not to blame and can be the patient’s and the provider’s best allies in treatment. In 2017, a team led by Katherine Schaumberg, at the University of North Carolina at Chapel Hill, published the review that examines the evidence behind each of the nine, and writes that pinning the development of an eating disorder on parental characteristics or family dynamics is a historical and dated model of psychopathology.

It is not the caregiver’s fault, and home is still where much of it happens

Lifting the blame off the family is not the same as taking the family out of the picture. It is closer to the opposite. The same statement that absolves says, in its second half, that families can be the best allies in treatment, and the best-supported treatment in adolescence is precisely the one that leans on the household.

In 2010, James Lock, at Stanford, and Daniel Le Grange, at the University of Chicago, published the trial that shaped what is recommended today for anorexia nervosa in adolescence. They randomized 121 adolescents aged 12 to 18 to two outpatient treatments with the same dose, 24 hours of care over one year. One is an individual therapy centered on the adolescent. The other, family-based treatment, opens with a move that still sounds strange to many people, which is telling the people who care for the young person that they did not cause this, and handing back to them, for a while, the responsibility for meals.

At the end of the treatment year the two groups looked alike. The difference showed up later. At the twelve-month follow-up, 49% of those who had family-based treatment were in full remission, against 23% of those in individual therapy. Among those already in full remission when treatment ended, relapse over the following year was 10% in the first group and 40% in the second. During treatment, 15% needed hospitalization in the family group, against 37% in the individual therapy group.

Six years later, Daniel Le Grange and Elizabeth Hughes, at the University of Melbourne, randomized 107 adolescents between that same treatment, with the family in the room, and a format in which the therapist sees only the caregivers while a nurse monitors the adolescent. At the end of treatment, remission was 43% in the caregiver-only format and 22% in the format with the family in the room, and that advantage was no longer statistically significant at the six- and twelve-month follow-ups. This is not a result that retires the first format. It is a result that takes some weight off families who cannot bring everyone, every week, into a consulting room.

You cannot tell by looking, and it does not only happen to girls

The first of the nine statements is that many people with an eating disorder look healthy and can still be gravely ill, and that this appearance, together with the difficulty of recognizing how serious it is, delays detection by friends, by family, by providers and by the person themselves. Weight does not work as a thermometer, and someone can sit anywhere on the growth chart and still be living through a severe episode.

The fifth statement is the one that changes the conversation at home the most, because it says that eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations and socioeconomic statuses. The review records that men are less likely to seek treatment, less likely to be diagnosed even when presenting with symptoms identical to those of women, and less likely to access treatment even with similar clinical severity. It also records that the classification of eating disorders itself evolved from female symptom profiles, and that normative data on males are lacking, which helps explain why the picture goes unnoticed in anyone who does not match the portrait everyone carries in their head.

A review led by Jason Nagata, at the University of California, San Francisco, with colleagues in Toronto and at Harvard, gathered in 2020 what is known about sexual and gender minorities. In the United States, the lifetime prevalence of an eating disorder diagnosis reported by a healthcare provider was 10.5% among transgender men and 8.1% among transgender women. The authors link part of this to minority stress and discrimination, and point to a practical problem that shows up in the clinic, which is the standard use of sex-based growth charts to follow transgender adolescents.

The conversation that protects is about food, not about bodies

In 2013, Jerica Berge and Dianne Neumark-Sztainer, at the University of Minnesota, linked two population studies in Minneapolis, with 2,793 adolescents of mean age 14.4 years and 3,709 mothers, fathers and guardians. They sorted household conversations into two kinds, those about healthful eating with no mention of weight, and those about weight, size or the need to lose weight. Among adolescents whose weight sat within the expected range, when the mother talked about eating, 23% dieted, against 35% when the conversation was about weight. Unhealthy weight-control behaviors appeared in 30% against 39%, and the extreme forms of those behaviors in 2% against 6%. Among adolescents above the 85th percentile, the gap widened, with 40% dieting when the conversation was about eating and 64% when it was about weight.

The study is cross-sectional, which means it measured the conversation and the behavior at the same moment, and the authors themselves note that it may be the adolescent’s eating behavior that prompts the weight conversation rather than the other way around. Even so, the direction of the finding repeats across the whole sample and holds equally for mothers and for fathers, since conversation about eating came out linked to less risky behavior, and conversation about weight to more.

Caregivers need care too

Supporting someone who lives with an eating disorder is tiring in its own particular way, because the conflict comes back three times a day and turns on something that cannot be suspended. A pilot study led by Yolanda Quiles Marcos, at Universidad Miguel Hernández in Spain, alongside Janet Treasure of King’s College London, randomized 64 caregivers to two workshop formats, one training collaborative care skills and one delivering psychoeducation. Both improved caregiver well-being. In the skills training group, anxiety, depression and psychological distress also fell among the patients themselves. It is a small study, with 37 patients assessed, and on its own it does not settle anything, but it points where daily practice already points, which is that nobody sustains this kind of care without being cared for.

The gap between noticing and seeking help is what weighs most

The ninth statement says that full recovery is possible and that early detection and intervention matter. The review records that ten years after onset 70% of people have recovered, and that in anorexia nervosa the probability of recovering decreases as a function of duration of illness, irrespective of treatment. The sixth statement is a reminder that eating disorders carry an increased risk of medical complications and of suicide, and that is why the physical assessment does not sit in a queue waiting for therapy to start. In the 2010 trial itself, the criteria that triggered admission for medical stabilization were concrete, with a temperature below 36.3 degrees Celsius, a heart rate below 50 beats per minute, a prolonged QT interval on the electrocardiogram, and a drop in blood pressure on standing. None of that is visible from looking at a plate.

If you have read this far looking for something to do today, the gesture fits into the next meal and does not depend on any diagnosis being in place yet. Sit at the table and say nothing about bodies, not yours, not anyone else’s, not the one on the screen. Talk about the food, about the day, about what happens tomorrow. And at some point, with no audience, say out loud what you have probably only thought so far, that this is nobody’s fault in that house and that you are going to look for help together. A tangled ball of yarn does not come undone by force. It comes undone when someone finds a loose end and pulls it slowly. Booking the assessment is the first end, and nothing written here replaces the individual assessment of whoever looks after your family.

Dr. Marcelo Gobbo Jr.
Family and Community Physician (CRM-MG 74.511 · RQE 69038), with a master’s degree in Psychology from the Federal University of Uberlândia and a Laboratory Associate appointment in the Department of Psychiatry at Yale School of Medicine, based at the Program for Recovery and Community Health. He cares for neurodiverse families and people living with severe mental illness, in person and remotely.