Treatment of Eating Disorders: Bridging the Research-practice Gap

Table of Contents

Cover image

Front Matter

Copyright

Biographies

Abbreviations

Introduction

Chapter 1. A Perfect Biopsychosocial Storm

Chapter 2. What's Weight Got to Do with It?

Chapter 3. Neuroscience

Chapter 4. Are Media an Important Medium for Clinicians?

Chapter 5. The Assessment Process

Chapter 6. Medical Assessment of Eating Disorders

Chapter 7. Psychiatric Medication

Chapter 8. Nutritional Impact on the Recovery Process

Chapter 9. Science or Art?

Chapter 10. New Pathways

Chapter 11. Outpatient Treatment of Anorexia Nervosa following Weight Restoration

Chapter 12. Recipe for Recovery

Chapter 13. Borderline Personality and Eating Disorders: A Chaotic Crossroads

Chapter 14. Managing the Eating Disorder Patient with a Comorbid Substance Use Disorder

Chapter 15. Comorbid Trauma and Eating Disorders

Chapter 16. Healing Self-Inflicted Violence in Adolescents with Eating Disorders

Chapter 17. The Weight-Bearing Years

Chapter 18. Men with Eating Disorders

Chapter 19. Mutuality and Motivation in the Treatment of Eating Disorders

Chapter 20. When Helping Hurts

Chapter 21. The Most Painful Gaps

Chapter 22. The Role of Spirituality in Eating Disorder Treatment and Recovery

Chapter 23. The Case for Integrating Mindfulness in the Treatment of Eating Disorders

Chapter 24. The Use of Holistic Methods to Integrate the Shattered Self

Chapter 25. Incorporating Exercise into Eating Disorder Treatment and Recovery

Chapter 26. Body Talk

Chapter 27. The Research–Practice Gap

Chapter 28. Call to Action

Index

Color Plates

Front Matter

Treatment of Eating Disorders

Bridging the Research - Practice Gap

Edited by

M

argo

M

aine

B

eth

H

artman

M

c

G

illey

D

ouglas

W. B

unnell

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Biographies

Senior Editor

Margo Maine, PhD, FAED, cofounder of the Maine & Weinstein Specialty Group, is a clinical psychologist who has specialized in eating disorders and related issues for 30 years. Author of: Effective Clinical Practice in the Treatment of Eating Disorders: The Heart of the Matter, co-edited with William Davis and Jane Shure (Routledge, 2009); The Body Myth: Adult Women and the Pressure to Be Perfect (with Joe Kelly, John Wiley, 2005); Father Hunger: Fathers, Daughters and the Pursuit of Thinness (Gurze, 2004); and Body Wars: Making Peace With Women's Bodies (Gurze, 2000), she is a senior editor of Eating Disorders: The Journal of Treatment and Prevention and vice president of the Eating Disorders Coalition for Research, Policy, and Action. A Founding Member and Fellow of the Academy for Eating Disorders and a member of the Founder's Council and past president of the National Eating Disorders Association, she is a member of the psychiatry departments at the Institute of Living/Hartford Hospital's Mental Health Network and at Connecticut Children's Medical Center, having previously directed their eating disorder programs. Dr Maine is the 2007 recipient of The Lori Irving Award for Excellence in Eating Disorders Awareness and Prevention, given by the National Eating Disorders Association. She lectures nationally and internationally on topics related to the treatment and prevention of eating disorders, female development, and women's health.

Editors

Douglas W. Bunnell, PhD, FAED, is a graduate of Yale University and received his doctoral degree from Northwestern University. He is a clinical psychologist and Vice President and Director of Outpatient Clinical Services for The Renfrew Center, overseeing the clinical programming and training for Renfrew's eight outpatient treatment centers. He is the editor of Renfrew's professional newsletter, Perspectives, and co-chairs their research committee. He serves on the editorial board of Eating Disorders: The Journal of Treatment and Prevention. A Fellow of the Academy for Eating Disorders, he is a former board president of the National Eating Disorders Association, a member of National Eating Disorder Association's Founders Council, and is the clinical advisor for the National Eating Disorder Association's Navigator program which trains parents and family members as resources for newly diagnosed patients and families. Dr. Bunnell also remains active in eating disorders advocacy and awareness. He has written and lectured, nationally and internationally, on eating disorders treatment, research, professional training, eating disorders in men, and the challenges of integrating science and practice. He is also a member of the Academy for Eating Disorders credentialing committee, working to develop practice standards for residential treatment of patients with eating disorders. In addition to his work with Renfrew, the Academy for Eating Disorders and National Eating Disorder Association, Dr. Bunnell maintains a private practice in Wilton, Connecticut specializing in the treatment of eating disorders, chronic illness, and the psychological aspects of Lyme Disease.

Beth Hartman McGilley, PhD, FAED, Associate Professor, University of Kansas School of Medicine-Wichita, is a psychologist in private practice, specializing in the treatment of eating and related disorders, body image, athletes, trauma, and grief. A Fellow of the Academy for Eating Disorders, she has practiced for 25 years, writing, lecturing, supervising, directing an inpatient eating disorders program, and providing individual, family and group therapy. She has published in academic journals and the popular media, as well as having contributed chapters to several books. She is an editor for Eating Disorders: The Journal of Treatment & Prevention, and is working on her first book, a tribute to the patients she has served over the course of her career.

Dr. McGilley also specializes in applications of sports psychology and performance enhancement techniques with athletes at the high school, collegiate, and professional levels. She was the sports psychology consultant for the Wichita State University Women's Basketball team from 2005 to 2008, and serves as the co-chair of the Association for Applied Sports Psychology (AASP) Eating Disorders Special Interest Group.

Dr. McGilley co-founded and is the current President of the Healing Path Foundation, a non-profit foundation dedicated to the prevention and treatment of eating disorders in Kansas. She is a recent graduate of the Kansas Health Foundation Leadership Fellows Training program. Her hobbies include competitive cycling, hiking, and writing.

Contributors

Diann M. Ackard, PhD, LP, FAED, is passionate about helping us be the best that we can be. She is a licensed psychologist in private practice, and is an Adjunct Assistant Professor in the Division of Epidemiology and Community Health at the University of Minnesota, and a Research Scientist at Melrose Institute in St Louis Park, Minnesota. She sits on the Boards for the Academy for Eating Disorders and Break the Cycle, and co-founded the Trauma and Eating Disorders Special Interest Group of the Academy for Eating Disorders. She regularly publishes articles in peer-reviewed journals and frequently contributes at meetings and conferences.

Drew Anderson, PhD, is an Associate Professor in the Department of Psychology at the University at Albany, State University of New York. His research focuses on assessment and treatment of eating disorders, body image disturbance, and psychological and medical problems associated with obesity.

Amy Baker Dennis, PhD, FAED, is a clinical and research psychologist who has maintained a clinical practice over 36 years. She was the founding Board Secretary and served on the Board of the Academy for Eating Disorders (AED) for 11 years. She is also a founding member of the Eating Disorder Research Society (EDRS), founding Board President of the Eating Disorder Awareness and Prevention (EDAP) and a member of the Founders Council, and currently serves on the Board of the National Eating Disorder Association (NEDA). She has published and lectured extensively and received numerous awards for her contributions to the field, including the Lifetime Achievement Award givn by NEDA. She is a certified cognitive therapist and has served on the faculties of University of South Florida, Department of Psychiatry and Behavioral Sciences, the Hamilton Holt graduate school at Rollins College in Orlando, Florida, and Wayne State University Department of Psychiatry in Detroit.

Judith Banker, MA, LLP, FAED, is the founder and executive director of the Center for Eating Disorders, a non-profit outpatient treatment center in Ann Arbor, Michigan. She is a Past President of the Academy for Eating Disorders and served as chair of the Academy for Eating Disorders Psychodynamic Psychotherapy Special Interest Group for 10 years. With over 35 years of clinical and training experience, Judith's teaching and writing focuses on the integrative clinical treatment of eating disorders and on research-practice integration in the eating disorders field.

Michael E. Berrett, PhD, received his PhD in Counseling Psychology in 1986 from Brigham Young University. He is CEO, Director, and Co-founder of Center For Change in Orem, Utah. Dr. Berrett has served as Chief of Psychology at Utah Valley Regional Medical Center and as Clinical Director of Aspen Achievement Academy. He has 25 years experience in the treatment of those struggling with eating disorders. He is co-author of the American Psychological Association book Spiritual Approaches in the Treatment of Women With Eating Disorders and multiple articles in professional journals.

Timothy D. Brewerton, MD, DFAPA, FAED, is Clinical Professor of Psychiatry and Behavioral Sciences at the Medical University of South Carolina in Charleston. He is triple board certified in general psychiatry, child/adolescent psychiatry and forensic psychiatry, Distinguished Fellow of the American Psychiatric Association and Founding Fellow of the Academy of Eating Disorders. Dr. Brewerton has published over 115 articles and book chapters, is editor of the book, Clinical Handbook of Eating Disorders: An Integrated Approach, and serves on the Editorial Boards of the International Journal of Eating Disorders and Eating Disorders: The Journal of Treatment and Prevention.

Judith Brisman, PhD, is Director and Co-Founder of the Eating Disorder Resource Center in New York City. She is co-author of Surviving an Eating Disorder: Strategies for Family and Friends (Collins Living, 2009, third edn), is an associate editor of Contemporary Psychoanalysis and is on the editorial board of the journal Eating Disorders: The Journal of Treatment and Prevention. Dr. Brisman is a supervisor of psychotherapy and a member of the teaching faculty of the William Alanson White Institute. She has published and lectured extensively regarding the interpersonal treatment of eating disorders and currently maintains a private practice in Manhattan, New York.

Deborah Burgard, PhD, specializes in the treatment of eating disorders and body image. She created www.BodyPositive.com and is one of the founding proponents of the Health at Every Size model. She co-wrote Great Shape: The First Fitness Guide for Large Women, and chapters in Effective Clinical Practice in the Treatment of Eating Disorders: The Heart of the Matter, Feminist Perspectives on Eating Disorders, and The Fat Studies Reader. Dr. Burgard is also a co-author of the Academy for Eating Disorder's Guidelines for Childhood Obesity Programs and co-leads the Sustainable Health Practices Registry, research on how people create ongoing practices that support their health.

Rachel Calogero, PhD, completed her M.A. at The College of William and Mary, and her doctoral and postdoctoral work in social psychology at the University of Kent in Canterbury, England. Currently, she is Assistant Professor of Psychology at Virginia Wesleyan College. Her primary interests cover a spectrum of socio-cultural factors that affect women's health and well-being, including the role of exercise in eating disorders treatment and recovery, the impact of sexual and self-objectification in girls' and women's daily lives, and the perpetuation of fat prejudice and stigmatization. She has published her research widely in peer-reviewed journals and book chapters, and is senior editor of the book, Self-Objectification in Women: Causes, Consequences, and Counteractions (APA, 2010). She presents her research frequently in Europe and North America, and offers workshops on mindful excercise in various clinical and community contexts.

Nancy Cloak, MD, attended medical school at the University of South Florida and did her psychiatric residency at the Menninger Clinic, where she was also a candidate in the Topeka Institute for Psychoanalysis. Following residency, she worked with eating disorder patients in a university health center, and then completed a fellowship in eating disorders at Sheppard-Pratt Hospital, after which she returned to Oregon to become the medical director of RainRock Treatment Center. Her professional interests include psychodynamic psychotherapy with eating disorder patients, the neurobiology of weight, appetite, and eating disorders, and medical complications of eating disorders.

Jillian Croll, PhD, MPH, RD, LD, is the Director of Communications, Outreach, and Research for the Emily Program. She is an Adjunct Assistant Professor in Department of Food Science and Nutrition at the University of Minnesota. She completed her MPH and PhD in Public Health Nutrition and Epidemiology at the University of Minnesota, and her MS in Nutritional Science at the University of Vermont. Her work in eating disorders includes program development, community education, teaching, research, clinical work, and advocacy.

Kimberly Dennis, MD, is the Medical Director at Timberline Knolls Residential Center for women with eating disorders and co-occurring disorders, and has a private practice with Working Sobriety Chicago. She specializes in group and individual treatment for patients with co-occurring eating and substance use disorders. She maintains a holistic perspective, and brings an awareness of the benefits of storytelling, creativity, and play in the recovery process. Dr. Dennis is a member of IAEDP, Academy for Eating Disorders, and ASAM. She is an editorial board member for Eating Disorders: The Journal of Treatment & Prevention.

Kyle P. De Young, MA, is currently an advanced graduate student in clinical psychology at the University at Albany, State University of New York. His research interests include the course and outcome of eating disorders, exercise, and assessment of eating and exercise-related constructs.

Richard A. Gordon, PhD, is Professor of Psychology at Bard College and a clinical psychologist in independent practice. He has treated patients with eating disorders for over 25 years. He is author of Eating Disorders: Anatomy of a Social Epidemic, Second Edition (Blackwell, 2000), and with Melanie Katzman and Mervat Nasser, Eating Disorders and Cultures in Transition (Brunner Routledge, 2001). He was made Honorary Fellow of the American Psychiatric Association for his contributions to the social understanding of eating disorders.

Randy K. Hardman, PhD, worked as a psychologist for 26 years. He was a co-founder and director of Center for Change, where he worked for 11 years. Dr. Hardman is currently working with students in the Counseling Center at Brigham Young University-Idaho in Rexburg, Idaho. He is a co-author of the book, Spiritual Approaches in the Treatment of Women with Eating Disorders (American Psychological Association, 2007). He has written and published articles on spirituality and other related eating disorder topics.

Bethany Helfman, PsyD, is a clinical psychologist who has practiced in the field for over 18 years. She is currently at Dennis & Moye & Associates in Bloomfield Hills, Michigan where she specializes in the treatment of adolescents, adults, and families affected by eating disorders and their comorbidities. She is a member of the Academy for Eating Disorders and the National Eating Disorder Association. Dr. Helfman supervises other professionals in the field, writes, lectures, and advocates for change related to the factors that make recovery from mental illness more difficult.

Anita Johnston, PhD, is Director of the Anorexia & Bulimia Center of Hawaii, which she co-founded in 1982, Clinical Director and Founder of Ai Pono Eating Disorders Programs in Honolulu, and Senior Advisor and Clinical Consultant for Focus Center for Eating Disorders in Tennessee. In 1986, she developed Hawaii's first in-patient eating disorders treatment program at Kahi Mohala Hospital. Dr. Johnston is the author of Eating in the Light of the Moon: How Women Can Transform Their Relationships with Food Through Myth, Metaphor, and Storytelling (Gurze, 2000) and an international speaker and workshop leader with a private practice in Kailua, Hawaii.

Kathy Kater, LICSW, is a St. Paul, Minnesota psychotherapist and an internationally known author, speaker, and consultant with over 30 years of experience specializing in the treatment and prevention of body image and eating-related disorders. Frustrated that progress in understanding these problems has not been matched by effective prevention, she authored Healthy Body Image: Teaching Kids to Eat and Love Their Bodies Too, a primary prevention curriculum for upper elementary school children, and Real Kids Come in All Sizes; Ten Essential Lessons to Build Your Child's Body Esteem, a companion guide for parents.

Susan Kleinman, MA, BC-DMT, NCC, is the dance/movement therapist for The Renfrew Center of Florida. She is a trustee of the Marian Chace Foundation, a past president of the American Dance Therapy Association, and a past Chair of The National Coalition for Creative Arts Therapies. She is a co-editor of The Renfrew Center Foundation's Healing Through Relationship, serves on the editorial board of the Journal of Creativity in Mental Health, and has published extensively on the use of dance/movement therapy in the treatment of eating disorders. She was the American Dance Therapy Association recipient of the 2009 Outstanding Achievement Award.

Kelly L. Klump, PhD, FAED, is an Associate Professor of Psychology at Michigan State University. Her research focuses on genetic and biological risk factors for eating disorders. Dr. Klump has published over 90 papers and has received a number of federal grants for her work. She has been honored with several awards including the David Shakow Award for Early Career Contributions to Clinical Psychology from the American Psychological Association and New Investigator Awards from the World Congress on Psychiatric Genetics and the Eating Disorders Research Society. Dr. Klump is a Past President of the Academy for Eating Disorders.

Francine Lapides, MFT, writes and teaches from attachment and psycho-neurobiological theories (including the arousal and regulation of affect) and their applications to relational and psychodynamic psychotherapy and adult romantic relationships. She supervised and taught psychotherapy through the 1970s and has been in private practice in Santa Cruz, California since 1980. She has trained with Daniel Siegel, is a member of Allan Schore's Berkeley study group, and has been strongly influenced by relational principles developed at The Stone Center at Wellesley College. She teaches workshops and conferences across the United States and provides an online seminar at www.PsyBC.com.

Jason M. Lavender, MA, is currently an advanced graduate student in clinical psychology at the University at Albany. His research interests include the functions of eating disorder behaviors, the course and outcome of eating disorders, and the assessment of body image and eating disorder behaviors.

Martha M. Peaslee Levine, MD, is Assistant Professor of Pediatrics, Psychiatry, and Humanities and the Director of the Partial Hospitalization and Intensive Outpatient Programs at Penn State Milton S. Hershey Medical Center.

Michael P. Levine, PhD, FAED, is Samuel B. Cummings Jr. Professor of Psychology at Kenyon College in Gambier, Ohio. His special interest is body image and eating problems and their links with preventive education, developmental psychology, and community psychology. His most recent book is Levine and Smolak's (2006) The Prevention of Eating Problems and Eating Disorders: Theory, Research, and Practice (Lawrence Erlbaum). Dr. Levine is a Fellow of the Academy for Eating Disorders. In June 2006 he received the Meehan-Hartley Award for Leadership in Public Awareness and Advocacy from the Academy for Eating Disorders.

Richard L. Levine, MD, is Professor of Pediatrics and Psychiatry and is the Chief of the Division of Adolescent Medicine and Eating Disorders at Penn State Milton S. Hershey Medical Center.

Kimberli McCallum, MD, CEDS, is a Fellow of the American Psychiatric Association and Associate Professor of Clinical Psychiatry at Washington University School of Medicine. She is a psychotherapist with a broad range of therapy skills, including dialectic behavior therapy, cognitive behavior therapy, family-based treatment, Family Systems Therapy, and psychoanalysis. She received her MD from Yale, general psychiatric training at UCLA, and child/adolescent training at Washington University. Dr. McCallum has co-founded several specialized eating disorders units, including inpatient, partial hospital, residential, and intensive outpatient programs. Her current programs include McCallum Place Treatment Center in St. Louis, MO, and Cedar Springs Treatment Center in Austin, TX.

Elisa Mott, MEd/EdS, a certified yoga teacher and graduate of University of Florida's Counselor Education program, also holds a Spirituality in Health Certificate. She was awarded an International Excellence in Counseling Research Grant from Chi Sigma Iota honor society for her study evaluating the use of yoga to improve wellness among females and presented this research at the 2010 ACA conference. She served as CSI's Wellness Committee chair and has presented on the use of yoga in the treatment of eating disorders at the International Association for Eating Disorder Professionals Conference and the University of Florida's Professional Development Day.

Robbie Munn, MA, MSW, is a clinical social worker who has spoken and written widely about the chaotic impact of eating disorders upon families and the challenges families face in obtaining appropriate treatment. Many women in her family have been affected by eating disorders, including her mother and daughter, nieces, and cousins. In 2000 she joined the Board of the National Eating Disorders Association (NEDA) as one of its first family members. In 2003 she helped to create and co-chair the first conference in the field to include families and individuals along with clinicians. This has become the esteemed annual conference hosted by NEDA.

Kelly N. Pedrotty-Stump, MS, is a high-school guidance counselor and an Exercise Consultant at the Renfrew Center. She co-developed the exercise program at Renfrew. Kelly is an experienced speaker on exercise and the treatment of eating disorders and has presented at national conferences including National Eating Disorder Association, Academy for Eating Disorders, and MEDA. She has taught workshops on various topics at West Chester University, Temple University and Philadelphia College of Osteopathic Medicine. She has published on the topic of exercise abuse and eating disorders. Kelly is also a certified yoga instructor.

Pauline Powers, MD, FAED, graduated from the University of Iowa College of Medicine and completed her residency at the University of California at Davis. She is Professor of Psychiatry and Behavioral Medicine in the Clinical and Translational Science Institute at the University of South Florida, Tampa, Florida. She was the Founding President of the Academy for Eating Disorders and was President of the National Eating Disorders Association 2005–2006. She has published three books on eating disorders and has reported research in several journals. She is currently Director of the University of South Florida Center for Eating and Weight Disorders and the Director of the USF Hope House for Eating Disorders.

Adrienne Ressler, MA, LMSW, CEDS, the National Training Director for The Renfrew Center Foundation, is the 2008–2010 president of the International Association for Eating Disorder Professionals board. She attended the University of Michigan and served as a faculty member in the School of Education. Her nationally renowned seminars reflect her background in gestalt, transactional analysis, psychodrama, bio-energetic analysis, and Alexander technique. She is published in the International Journal of Fertility and Women's Medicine, Social Work Today and authored the chapter BodyMind Treatment in Effective Clinical Practice in the Treatment of Eating Disorders. She is the featured body-image expert for documentaries on both cosmetic surgery and menopause.

P. Scott Richards, PhD, is a Professor of Counseling Psychology at Brigham Young University. He received his PhD in Counseling Psychology in 1988 from the University of Minnesota. He is the co-author of the book, Spiritual Approaches in the Treatment of Woman with Eating Disorders (American Psychological Association, 2007). He is also co-author of the book, A Spiritual Strategy for Counseling and Psychotherapy, which was published in 1997 and 2005 (2nd ed.) by the American Psychological Association. Dr. Richards has published on the topics of spirituality and eating disorders, religion and mental health, and spiritual issues in psychotherapy.

Jennifer Sanftner, PhD, is a Clinical Psychologist and tenured Associate Professor of Psychology at Slippery Rock University. She has been teaching in the areas of abnormal, clinical, health, and gender psychology, and directing the undergraduate practicum program at SRU for the last 8½ years. She has researched eating disorders for 19 years, resulting in publications in peer-reviewed journals and chapters. Her research focuses on the application of Relational Cultural Theory to understanding the etiology and maintenance of eating disorders. She is interested in using RCT to understand women's relationships with their bodies, with others, and with food, and to applying our understanding of RCT to treatment.

Lori A. Sansone, MD, is a civilian family medicine physician and the Medical Director for the Primary Care Clinic at Wright-Patterson Air Force Base in Dayton, Ohio. She has published over 100 refereed articles and 24 book chapters; co-authored the book, Borderline Personality Disorder in the Medical Setting; co-developed the Self-Harm Inventory; co-authors a professional column, The Interface, for the journal Psychiatry, and co-authors a local monthly newsletter, Mental Health Issues in Primary Care.

Randy A. Sansone, MD, is a professor at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center. He has published over 225 refereed articles and 33 book chapters; co-edited the books, Self-Harm Behavior and Eating Disorders and Personality Disorders and Eating Disorders; co-authored the book, Borderline Personality Disorder in the Medical Setting; co-developed the Self-Harm Inventory; and co-authors a professional column, The Interface, for the journal Psychiatry. Dr. Sansone is also the editor of the borderline personality module for the Physician Information and Education Resource and is on six journal editorial boards, including Eating Disorders: The Journal of Treatment and Prevention.

Doris and Tom Smeltzer, are career educators with master's degrees in education and counseling psychology, respectively. Tom is a college professor and Doris has taught throughout the K-12 spectrum. When their 19-year-old daughter Andrea died after 13 months of bulimic behaviors, Doris chose to leave her teaching position and has devoted her life to eating disorder prevention through Andrea's Voice Foundation, the non-profit organization she and Tom co-founded. Doris is the author of Andrea's Voice: Silenced by Bulimia and Gurze Books’ "Advice for Parents" blog and is developing an educational curriculum for the ED field based on her Internet radio show.

Jacqueline Szablewski, MTS, MAC, LAC, is a psychotherapist and licensed addictions counselor who resides in Boulder, Colorado. Combining study in psychology, counseling, and world religions with a self-designed concentration in pastoral counseling, Jackie earned her Masters degree in Theological Studies from Harvard University. She has worked along the continuum of care in agency and hospital settings. Specializing in eating disorders, addiction recovery, and life transitions, particularly with individuals challenged by concomitant mood disorders, trauma, and grief issues, Jackie has worked in the field for nearly two decades. She has maintained a private practice in Boulder, Colorado for the last 14 years.

Mary Tantillo, PhD, RN, CS, FAED, is the Director of the Western New York Comprehensive Care Center for Eating Disorders, an Associate Professor of Clinical Nursing at the University of Rochester School of Nursing, a Clinical Associate Professor in the Department of Psychiatry at the University of Rochester School of Medicine, and CEO/Clinical Director of a free-standing Eating Disorders Partial Hospitalization Program, The Healing Connection, LLC. She is a fellow of the Academy for Eating Disorders, as well as a previous board member, present chairperson for the Academy for Eating Disorders Credentialing Task Force, and co-chairperson for the Patient/Carer Task Force.

Edward P. Tyson, MD, has been treating eating disorders for more than 20 years and is board certified in both Family Medicine and Adolescent Medicine. After serving as Director of Adolescent Clinics for the Department of Pediatrics at Children's Hospital of Oklahoma, he opened a private practice in Austin, Texas specializing in eating disorders. Dr. Tyson is an active member and frequent presenter at the professional eating disorder organizations. He is an advocate for those with eating disorders and teaches residents and medical students, as well as undergraduate and graduate classes, at the University of Texas about eating disorders.

Kitty Westin is the founder and former President of the Anna Westin Foundation, which has now merged with the Emily Program Foundation. The Anna Westin Foundation was started by Anna's family after Anna died in 2000 as a direct result of anorexia. The Westins also started the first and only residential program to treat people with eating disorders in Minnesota. Kitty is also the past President of the Eating Disorders Coalition for Research, Policy & Action and she serves on the Academy for Eating Disorders Patient/Carer Task Force, and is the Co-chair of the Academy for Eating Disorders Advocacy/Communications Committee.

Jancey Wickstrom, AM, LCSW, is the Milieu Manager and DBT Specialist at Timberline Knolls Residential Center for women with eating disorders and co-occurring disorders. While a student at University of Chicago, she received training in DBT at the Emotion Management Program, and maintains a group and individual DBT practice there. Ms. Wickstrom firmly believes in the powerful effects of mindfulness meditation to help every person create a meaningful life.

Abbreviations

AA, alcoholics anonymous

ACC, anterior cingulate cortex

ACT, acceptance commitment therapies

ACTH, adrenocorticotropic hormone

ADHD, attention-deficit/hyperactivity disorder

AN, anorexia nervosa

ANBP, binge purge subtype of anorexia nervosa

ANS, autonomic nervous system

BED, binge eating disorder

BMI, body mass index

BN, bulimia nervosa

BPD, borderline personality disorder

CAT, cognitive analytic psychotherapy

CBC, complete blood cells

CBT, cognitive behavior therapy

CPT, cognitive processing therapy

CRF, corticotrophin releasing factor

DBT, dialetic behavior therapy

DE, disordered eating

DEX, dysfunctional exercise

DEXA, dual energy X-ray absorptiometry

DMT, dance/movement therapy

DSM, diagnostic and statistical manual

EBP, evidence-based practice

ED, eating disorder

EDI, Eating Disorder Inventory

EDNOS, eating disorder not otherwise specified

EST, empirically supported treatments

FBT, family-based treatment

fMRI, functional magnetic resonance imaging

fNIRS functional near-infrared spectroscopy

FRS, Refeeding Syndrome

FTT, Failure to Thrive

GABA, gamma-aminobutyric acid

GERD, gastroesophageal reflux disease

HPA, hypothalamic pituitary axis

IFT, internal family therapy

IPT, interpersonal psychotherapy

LH, left hemisphere

MAOI, monoamine oxidase inhibitors

MBCT, mindfulness-based cognitive therapy

MB-EAT, mindfulness-based eating disorder training

MBSR, mindfulness-based stress reduction

MET, motivational enhancement therapy

MI, motivational Interviewing

MPC, medial prefrontal cortex

NA, narcotics anonymous

NES, night eating syndrome

OA, overeaters anonymous

OCD, obsessive-compulsive disorder

OFC, orbital frontal cortex

OTC, over the counter

PET, positron emission tomography

PFC, prefrontal cortex

PM, perceived mutuality

PPI, proton pump inhibitors

PTSD, post-traumatic stress disorder

RBC, red blood cells

R/M, relational/motivational approach

RCT, relational-cultural theory

RCTs, randomized control trials

RH, right hemisphere

SD, standard deviation

SIV, self-inflicted violence

SMA, Superior mesenteric artery

SOC, stage of change

SOCT, stages of change theory

SNRI, Serotonin and norepinephrine reuptake inhibitors

SRED, Sleep-related eating disorder

SSRI, Selective serotonin reuptake inhibitors

SUD, subjective units of distress

TCA, Tricyclic antidepressants

WBC, white blood cells

Introduction

Eating Disorders as Biopsychosocial Illnesses

The point is that profound but contradictory ideas may exist side by side, if they are constructed from different materials and methods and have different purposes. Each tells us something important about where we stand in the universe and it is foolish to insist that they must despise each other.

Postman, 1995, p. 107

The idea for this volume, Treatment of Eating Disorders: Bridging the Research/Practice Gap, emanated from our experiences as clinicians facing the challenge of helping patients and their loved ones back from the precipice of self-destruction brought on by eating disorders (EDs). While we are each very active in our professional development and ongoing education, every day we experience the impact of the significant gap between what the research in journals, books, and conference presentations provides and how our patients present clinically. Their needs rarely match the theories or studies intended to explain them.

For example, although Eating Disorders Not Otherwise Specified (EDNOS) is the most commonly diagnosed ED in clinical settings, ranging from 50 to 70% of all ED cases (Walsh & Sysko, 2009), research studies rarely include this diagnostic category. While more recent research is beginning to explore the complexities of EDNOS (Agras et al., 2010, Walsh, 2009 and Wildes and Marcus, 2010), little is yet known about how this largest subgroup of ED patients progresses through the illness, responds to treatment, and fares in terms of outcome. Recent data seem to confirm what we have known clinically: many patients with EDNOS actually have poorer outcomes and higher mortality rates than patients with AN or BN (Crow, Peterson, Swanson, Raymond & Specker, 2009).

A multitude of other factors contribute to the research/practice gap. Despite the fact that many of our patients suffer from comorbid conditions, treatment research in our field tends to look at these problems more singularly (Haas and Clopton, 2003, Thompson-Brenner and Westen, 2005 and Tobin, 2007). In clinical practice, it is often these comorbid factors, including depression, anxiety, and post-traumatic stress disorder, that dominate the process of therapeutic engagement. The process of engagement is known to be difficult in patients with ED, and adapting to the special demands of a patient's comorbidities makes each treatment relationship unique. This sense of uniqueness can create the perception that research does not easily, or often, apply to the individual patient with whom we sit. Furthermore, in clinical research trials, relatively ‘pure’ groups of homogenous patients are selected for study, and are offered standardized treatment based on structured manuals. Everyone knows that therapy in the real world is far messier (Herbert, Neeren & Lowe, 2007, p. 15). We designed this book with the clear intention of trying to bridge such gaps so that research can better inform clinical work, and clinical work can better inform the research agenda and process.

A historical view may help us to create the most-informed approaches to the field's current dilemmas. In her review of four decades of work, Hilda Bruch (1985), the pioneer to whom the field owes great respect and gratitude, identified the nature/nurture debate as a concerning gap. In her hopeful assessment, the two dimensions had finally found common ground. Recent explorations of the neurochemical processes of the brain have revealed the close association of psychological experiences with alterations in brain metabolism, rendering the old dichotomy between physiological and psychological events untenable (Bruch, 1985, pp. 8–9). The biopsychosocial model (Johnson and Connors, 1987, Lucas, 1981, Yager, 1982 and Yager et al., 1981) advanced this perspective and our understanding of ED, laying the groundwork for prolific empirical contributions in the subsequent decades. The field rigorously researched areas of pressing concern including, but not limited to: prevention; medical and psychiatric management; therapeutic tools and approaches; neuroscience and epigenetics; and the essential role of the family in the ED treatment and recovery process. In the clinical realm, innovative treatment approaches began to yield more positive outcomes.

The dialectic of the past decade, the science/practice gap, parallels, if not harks back to, that of Bruch's generation of ED specialists. Despite Bruch's prescient respect for the neuroscientific basis of psychological experience, integration of this work, and its implications for the therapeutic process, is relatively recent in the ED field. Although we cannot expect neuroscience to be the ultimate mediator for researchers and clinicians of discrepant viewpoints, it has undoubtedly provided a language and medium for professionals in both camps to appreciate the other's contributions to the understanding of the etiology and treatment of ED. Nearly 30 years have passed since Bruch's review, and the resurgence of interest in neuroscientific applications/understandings of ED, and in patients’ subjective experiences, provides rich opportunities for collaboration between researchers and clinicians.

Today, we have the advantage of a knowledge base built on many more years of inquiry than Dr. Bruch and the other early writers had available to them. There are three scholarly journals dedicated solely to ED: Eating Disorders: The Journal of Treatment and Prevention (EDJTP), the International Journal of Eating Disorders (IJED), and the European Eating Disorders Review. Since the 1980s, approximately 1000 books have been published specifically regarding ED or closely related illnesses. EDJTP has published about 750 articles, and IJED has published approximately 1200 (L. Cohn, personal communication, January 28, 2010). Broadening the topic to body image, health psychology, obesity, or related areas, these numbers would vastly increase, but still do not reflect publications in a wide variety of basic science, psychiatric, medical, nutritional, and psychological journals. The point is that the ED field is relatively young and rapidly developing, with many talented clinicians and researchers whose contributions have the potential to bridge the current gaps, better serving the needs of our patients.

Helene Deutsch, the first psychoanalyst to specialize in the treatment of women, has been credited with saying, after all, the ultimate goal of all research is not objectivity, but truth (retrieved from: http://www.brainyquote.com/quotes/authors/h/helene_deutsch.html). Treatment of Eating Disorders: Bridging the Research/Practice Gap brings together the expertise of scientists and practitioners in an effort to further describe the truth about ED. Readers will find an unexpected irony: the effect of closing gaps also expands the realm of influence, information, and expertise across disciplines. Researchers will find accounts of the practiced experience and wisdom of clinicians who have been operating with skills and perspectives only partially informed by science. Likewise, clinicians will be exposed to scientific advances that have enriched our understanding of the biopsychosocial complexity of ED. Some of this research has substantiated the central role of the therapeutic relationship (American Psychiatric Association, 2006), and qualitative research is now giving the patient/subject an active voice and presence in the empirical process.

Readers will have access to chapters across a variety of topics where research and clinical work must come together to better shape the understanding, treatment, and outcome of ED. In light of the significant proportion of EDNOS cases, we encouraged our contributors to take a transdiagnostic approach (Fairburn & Cooper, 2007) when possible. We are also intrigued by the proposed alternative system for classification, Broad Categories for the Diagnosis of Eating Disorders (Walsh & Sysko, 2009). While the American Psychiatric Association refines its work on the DSM-V, many diagnostic issues are being considered, and it is premature to discuss the changes; however, we deeply appreciate the efforts of the ED work group.

The collaborative spirit of this book reflects our view that EDs are complex, multidetermined illnesses that must be understood and treated in the sociopolitical context. Effective treatment takes a team that includes the patient, the family, and a multidisciplinary group of clinicians working in concert. Successful recovery takes a village, interlocking communities of support (e.g. extended family, peers, team-mates, social networks, professional support) in which patients practice their recovery skills, and find vital sources of commonality, connection, optimism, and accountability. We hope that this book conveys respect for the daunting power of these illness processes, as well as the healing power of clinicians, researchers, patients, and families combining forces toward a common goal.

Readers will note recurring references to the importance of the clinical relationship, based on empathy, connection, compassion, respect, and affection, as well as the importance of using that relationship to best implement interventions that have demonstrated effectiveness (Zerbe, 2008). Furthermore, we hope a spirit of partnership emerges from this book—partnership between families and professionals, and between researchers and practitioners. Ideally, Treatment of Eating Disorders: Bridging the Research/Practice Gap, will help us to transcend the historical tensions and competitive relationships between researchers and practitioners in our field (Banker & Klump, 2007), and inspire us to proceed with collaborative efforts that appreciate and integrate the best from each domain's perspective. A paradigmatic shift of this magnitude, involving change in attitude and practice both within and between disciplines, will require more than an academic tome devoted to its necessity. As the final chapter of this book illustrates, we are called to action or we will remain a field destructively divided.

As editors, we also are aware of the limits of this volume. For example, the diversity, or the evolving face, of ED, is a critical issue beyond the scope of this book. Once the purview of young Caucasian women from higher socio-economic strata in the advanced technological nations, EDs are now global conditions occurring in over 40 countries, many of which are developing nations (Gordon, 2001). In their examination of how culture, ethnicity, difference, and EDs affect minority and non-western females, Nasser and Malson (2009) state:

The spread of thinness as a master signifier of feminine beauty, promulgated by the mass media and the post-colonial operations of transnational capital, across all sections of western societies and across the world has been devastatingly effective in the ‘globalisation’ of ‘eating disordered’ subjectivities and practices…Thinness as a gendered body ‘ideal’ and a signifier of a multiplicity of positively construed ‘attributes’ can clearly no longer be considered exclusively western or white (p. 82).

Confirming this significant change in the face of ED, Grabe and Hyde (2006) conducted a meta-analysis of 98 studies, finding no significant differences in body dissatisfaction between Caucasian, Hispanic, and Asian women in the USA. Also, Bisaga et al. (2005) found similar rates of disordered eating (DE) across ethnicities in adolescent girls. Despite clinical impressions clearly confirmed by research, regarding the diverse presentation of ED, minority women experience worrisome barriers to their access to care, especially due to lack of recognition by providers (Cachelin & Striegel-Moore, 2006). Many of these same issues are factors in the underdiagnosis and treatment of men with ED. We must challenge these outdated stereotypes so all patients will be able to receive appropriate diagnosis and care.

Clearly, the field has much to learn about how EDs present across culture, country, ethnicity, and other divisions. We must begin to acknowledge that EDs no longer belong to a place, but instead inhabit many different and constantly evolving global social spheres. Nasser and Malson (2009) advise us to attend to both global and local factors in our attempts to understand ED. They explain that the gendered aesthetics of thinness are not always central to the DE or self starvation and that other locally-specific discursive constructions of self-starvation may be more relevant (p. 82).

The above findings remind us that our culture continues to drive vulnerable men and women into DE and ED. Although there seems to be a decreased appreciation for these sociocultural forces, enduring gender role stereotypes remain influential. Culture and diversity are enormously complex issues and, while we believe strongly in their importance in a discussion about ED, we could not do them full justice in this volume.

Despite this noted limitation, Treatment of Eating Disorders: Bridging the Research/Practice Gap, presents a range of topics critically illuminating the challenge of clinical work with ED patients. The informed clinician needs to be conversant with multiple literatures including research on the cultural, psychological, behavioral, medical, genetic, neurological, and spiritual dimensions of ED. If nothing else, this volume should put to rest the notion that there is any real dichotomy between the biology and the psychology of lived experience. We believe, also, that there is no validity to the dichotomy between clinical practice and research; it is, rather, the lack of resources, inadequate dialogue, disparate languages, and varied systems of inquiry that create this divisive impression (Banker & Klump, 2007). Clinicians collect data every day informing their sense of what does and does not help particular patients and families. Meanwhile, researchers are developing and refining methods of inquiry that allow for more relevant applications of evidence-based practices into naturalistic settings (Lowe, Bunnell, Neeren, Chernyak & Greberman, 2010). Historical differences between the two camps regarding what constitutes meaningful evidence, or sources of information (e.g., clinical vs. empirical data) have impeded integrative, clinically driven investigations. Ad-vances in qualitative and phenomenological research have begun to mediate this impasse and should be further incorporated into formal quantitative explorations (Jarman and Walsh, 1999 and Kazdin, 2009). As Banker and Klump (2007) aptly state, it is time for a researcher-clinician rapprochement (p. 14).

Finally, the need to bridge the science/practice gap does not devalue either domain's distinct and relative merits, nor does it negate the necessity for interdisciplinary debate. In fact, as Nobel prize winner Ilya Prigogine has asserted, a certain degree of friction is vital for growth:

It is precisely the quality of fragility, the capacity for being ‘shaken up,’ that is paradoxically the key to growth. Any structure—whether at the molecular, chemical, physical, social, or psychological level—that is insulated from disturbance is also protected from change (Levoy, 1997, p. 8).

Change, and exchange—in perspectives, attitudes, and practices—is the bridge this volume endeavors to create. It is no longer acceptable to rely on research that does not reflect clinical realities; thanks to the efforts of our authors and many other colleagues, we see promising signs that this gap is closing. Nor is it acceptable for therapists to base their treatment approaches solely on their own clinical intuition (Herbert et al., 2007). The research cited in this volume supporting innovative clinical work demonstrates the merits of Evidence Based Treatment (EBT) and the importance of incorporating EBT into treatment plans (Haas and Clopton, 2003, Mussell et al., 2000 and Tobin et al., 2007). Working from one theoretical perspective because that is how you were trained is no longer defensible. Clinicians need to be able to explain their rationale for their treatment approach and recommendations, and those explanations need to incorporate both science and clinical intuition. The following contributions seek to insure that researchers and clinicians are cross-trained in the best practices of ED treatment, building bridges that can withstand the inherent friction required for growth, and paving the way for future advances.

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Chapter 1. A Perfect Biopsychosocial Storm

Gender, Culture, and Eating Disorders

Margo Maine and Douglas W. Bunnell

Although eating disorder(s) (ED) are multidetermined, biopsychosocial disorders, gender alone remains the single-best predictor of their risk (Striegel-Moore & Bulik, 2007). Most research asserts that anorexia nervosa (AN) and bulimia nervosa (BN) are 10 times more common in females than males, and binge-eating disorder (BED) is three times more common (Treasure, 2007). While some have argued that one in six cases occurs in males (Andersen, 2002), the gender disparity is still glaring. Furthermore, while ED is not the only gendered psychiatric condition, the degree of gender disparity is much greater than in most diagnoses (Levine & Smolak, 2006).

Now the third most common illness in adolescent females (Fisher et al., 1995), superseded only by diabetes and asthma, ED have become a major public health issue, affecting more and more women of all ages. Today they appear in every stratum of American culture and, with the impact of globalization, in more than 40 countries worldwide (Gordon, 2001). This exponential increase in a condition disproportionately affecting women must have its roots in the interplay of culture and gender, as a genetic mutation has not swept the globe. But media images of perfectly crafted female bodies and unprecedented role change have, in fact, swept the globe. The increased access to education and involvement in the workplace have transformed women’s social roles dramatically, with rapid technological and market changes introducing a powerful global consumer culture and relentless expectations about appearance and beauty (Gordon, 2001). As the social changes accelerate, many women seek solace and mastery by controlling their bodies (Maine & Kelly, 2005).

Quite simply, gender creates risk. The World Health Organization’s (WHO) evidence-based review of women’s mental health (World Health Organization, 2000) concludes that gender is the strongest determinant of mental health, social position, and status, as well as the strongest determinant of exposure to events and conditions endangering mental health and stability. Furthermore, the WHO notes a positive relationship between the frequency and severity of social stressors and the frequency and severity of mental health problems in women. Despite the importance of gender disparities in mental health and risk for ED, the recent emphasis on biogenetic research risks minimizing the importance of the role of culture and gender in their etiology. As clinicians, we understand that the biopsychosocial whole is greater than the sum of its parts, despite the challenges this presents to the traditional research paradigms. This chapter explores the interplay of biopsychosocial factors contributing to the perfect storm of ED, especially examining culture and gender.

NATURE VERSUS NURTURE: A FALSE DICHOTOMY

Delineations between the biological, psychological, and social forces underlying ED are false distinctions, as nature and nurture always go hand in hand. Genes code RNA and DNA, the building blocks of cells, creating variations associated with risk. While they do not code behavior or disease, genes create vulnerabilities which will be tempered or intensified by other factors (Chavez & Insel, 2007), such as the family, early development, social experiences and expectations, physical conditions, and gender. Increasingly sophisticated research models investigate the complicated interactions in which environmental experience can alter gene expression (Hunter, 2005). Although they are not destiny, genes shape vulnerability and resilience, affecting how we perceive, organize, and respond to experiences, and contributing to the perfect storm of ED.

The rapid decline in the age at which girls enter puberty is an apt example of such a biopsychosocial storm. A century ago, the average age for menarche was 14.2 and now it is 12.3. In the 1970s, the average age of breast development was 11.5, but by 1997, it was less than 10 years old for Caucasian girls and 9 years old for African American girls, with a significant number developing even before age 8 (Steingraber, 2009). Girls who enter puberty earlier than peers have more self-esteem issues, anxiety, depression, adjustment reactions, eating disorders, and suicide attempts (Graber, Seeley, Brooks-Gunn & Lewinsohn, 2004). They are more likely to use drugs, alcohol, and tobacco, have earlier sexual experiences, be at increased risk of physical violence, and, due to prolonged estrogen exposure, have a higher incidence of breast cancer (Steingraber, 2009).

Early puberty may be best understood as an ecological disorder, an interaction of psychosocial, nutritional and environmental triggers, such as pollutants or chemical exposure; while family stress or trauma may also play a part. Aptly describing the false dichotomy between nature and nurture, Steingraber states: The entire hormonal system has been subtly rewired by modern stimuli…female sexual maturation is not controlled by a ticking clock. It’s more like a musical performance with girls’ bodies as the keyboards and the environment as the pianist’s hands (2009, p. 52).

Sexual maturation brings increased attention to the body, sexuality, and the developmental pressures of adolescence, enhancing the impact of other ED risk-factors. Nature and nurture interact as girls’ lives unfold.

GENDER: DIFFERENCE OR SIMILARITY?

Culturally constructed sexism has led to intense divisions between men and women, as expressed in common concepts such as the war of the sexes, as if gender creates virtually different species with no hope of understanding each other. The media systematically promulgate gender differences, just as they have contributed to the objectification of women and sexism. Despite the popularity of books like Men Are from Mars, Women Are from Venus (Gray, 1995) and You Just Don’t Understand: Men and Women in Conversation (Tannen, 2001), decades of psychological research suggest that men and women and boys and girls are much more alike than different (Hyde, 2005).

In their epic work, The Psychology of Sex Differences, Maccoby and Jacklin (1974) reviewed more than 2000 studies, dismissing many popular beliefs and identifying only four areas of difference: (i) verbal ability; (ii) visual-spatial ability; (iii) mathematical ability; and (iv) aggression. In 2005, Hyde’s meta-analysis of the gender difference literature found that 78% of the differences are very small, actually close to zero, even in areas where gender differences have been consistently considered strong. The greatest gender difference is in motor performance, due to post-puberty differences in muscle mass and bone size. Measures of sexuality, especially the frequency of masturbation and attitudes toward casual sex, also reveal significant gender differences, but virtually no difference in reported sexual satisfaction. The meta-analysis of aggression indicates a strong gender difference in physical parameters, but less so with verbal aggression. Despite the suggestion in the popular press and media that girls have a higher level of relational aggression, the evidence is mixed.

As gender differences fluctuate over the course of development, Hyde (2005) suggests that they are not as fixed as many believe. She also notes that the surrounding context, such as the written instructions, interactions between participant and experimenter, or expectations of gender differences, significantly affect results. The fact that both their strength and their direction depends on context challenges the notion of strong, stable gender differences.

NATURE, NURTURE, AND THE BRAIN

Research on the brain indicates important gender differences, despite the behavioral similarities noted above. In a thorough review of gender, Cahill (2006) noted significant gendered patterns in brain structure and neurochemistry associated with a wide range of emotional and cognitive functions including learning, emotional and social processing, memory storage, and decision-making. Male and female brains react differently to stress. Chronic stress is more damaging to the male brain, particularly to the hippocampal area thought to be central to memory and learning, while transitory interpersonal stressors result in a stronger adrenocortical response in women’s brains (Stroud, 1999). At the neurochemical level, gender influences the ways in which our brains synthesize, metabolize, and respond to neurotransmitters such as serotonin, possibly helping to explain differential rates of mood disorders and substance addiction.

Brain differences have been disproportionately attributed to sex hormones, but research has now established that other distinctions exist. For example, the denser corpus callosum (the band of fibers bridging the brain’s hemispheres) in the female brain allows greater connection between the two hemispheres, so women have less lateral specialization, whereas men have more of a division between the brain hemispheres. These neuroanatomical differences may explain women’s superior language skills and men’s superior visual-spatial skills. The neuroanatomy of the hypothalamus, instrumental in hormonal functions and reproduction, is also different, resulting in neurophysiological differences that in turn affect behavior. The anterior cingulate gyrus, more active in women, is linked to nurturant social behaviors, while the amygdyla (more active in men) is linked to anger and rage. Although statistically significant, these differences are small (Solms & Turnbull, 2002). The environment and culture often intensify these differences with gender-laden messages, attitudes, and expectations, and thereby multiply their expression (Lee, 2007).

While the study of brain gender differences has been enhanced by technological developments, it has, perhaps, been retarded by the viewpoint that differences somehow imply deficiency. In a patriarchic culture, an androcentric bias may affect how scientific findings and models of psychopathology are interpreted.

GENDERING: A BIOPSYCHOSOCIAL PROCESS

Is it a boy or a girl? This is often the first question asked about the birth or pending birth of a baby. The answer shapes our reaction and expectations and impacts the child’s life story and experience in countless ways. Simply put, the impact of gender occurs early and