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A Seat at the Table: Supporting Siblings of Eating Disorder Patients

By Sarah Ravin, Ph.D, Licensed Psychologist and F.E.A.S.T. Advisor

Eating disorders can have profound effects on an entire family.  When a child is diagnosed with an eating disorder, parents may have many questions.  Should I tell my other children about their sibling’s eating disorder?  If so, what should I say?  How will the eating disorder impact my other kids?   What if my other child develops an eating disorder as well?

The Impact on Siblings

Eating disorders can impact the patient’s siblings from various angles:

  • Through their parents. When a child is ill with an eating disorder, the siblings often receive less attention from their parents.  The parents may be physically absent from the home, traveling to faraway treatment centers and attending many different appointments locally.  Parents often feel worried, stressed, and irritable, and these emotions can easily spill over into their relationships with their other children.
  • By impacting family life. Family meals with an eating disordered person can be tense or explosive.  For this reason, siblings may begin to dread family meals or avoid them altogether. Family trips may be cancelled or ruined by the eating disorder.  The financial burden of ED treatment impacts the entire family, including siblings.
  • Through their social environment. Parents may not be available to drive siblings to their usual activities when they are spending long hours preparing and supervising meals and driving the ill sibling to appointments.  Siblings may feel embarrassed to invite friends over when their ill sister or brother is acting particularly bizarre. Siblings may have to deal with gossip from friends and neighbors.  They may feel conflicted about telling their friends about their family’s situation, and they have to deal with the stigma of mental illness.
  • Through the change in eating habits. Parents are often encouraged to serve their children with eating disorder children high-calorie foods to restore their weight.  Parents, who may now be ultra-sensitive to issues of food and weight as a result of one child’s eating disorder diagnosis, can feel confused about how to handle new eating patterns or weight gain in their other children.
  • Through their genes. Biological siblings of eating disorder patients are 10 times more likely to develop an eating disorder compared to the general population.  Additionally, siblings of eating disorder patients may inherit genes that predispose them to other psychiatric illnesses, including depression, OCD and other anxiety disorders, substance abuse, ADHD, and autism. Siblings may also carry those genetic risks on when they have children.

Brothers and sisters may experience a variety of emotions while their sibling is ill with an eating disorder. They may worry that their sibling will get sicker or die. They may grieve for the loss of their sibling’s true personality while he or she is consumed by the illness, and they may miss them terribly if they are away from home for a lengthy hospitalization or residential treatment stay. They may worry about their own risk for developing an eating disorder. They may feel angry at their sibling for putting the family through hell or making mealtimes miserable.   They may feel jealous at all of the attention their ill sibling is getting.  Siblings may react by withdrawing from friends and family members, having difficulty at school, or acting out.  They may feel sad or hopeless.  They may have difficulty concentrating.  It is not uncommon for very young siblings to manifest their distress through physical symptoms (e.g., tummy aches, trouble sleeping).

Tips for Parents

It is usually not possible to shield siblings completely from the impact of the eating disorder.  However, there are some steps that parents can take to minimize the damage and help siblings cope:

  • Educate the siblings. Immediately upon diagnosis, provide siblings with age-appropriate information on their sibling’s diagnosis, symptoms, and treatment.  Explain that the disorder is biologically-based and that the child did not chose to have it.  Even preschool-age siblings can understand a few basic points.  For example: “Your brother has a disease in his brain called anorexia which has made him very sick.  He is acting different because of his sick brain; it is not his fault.  We need to help him get better.   Mommy and Daddy will be very busy taking care of him, and we still love you very much.”
  • Externalize the eating disorder. Separate the eating disorder from the patient.  Help your other children view the eating disorder as a force outside of their sibling that is causing him to think, feel, and act temporarily in uncharacteristic ways.   Many families give the eating disorder a name, such as “ED” or “the demon.”  By conceptualizing the eating disorder as a force outside of your ill child, you are helping siblings understand that your family is not fighting against the ill child, but rather fighting against the eating disorder.
  • Eliminate guilt and blame. Make sure your other children understand that the ill child did not chose to develop an eating disorder.  Siblings need to understand that the patient’s behavior, while under the influence of the eating disorder, is largely outside of their control.   Siblings should be reassured that no one is to blame for this eating disorder – not the siblings, not the parent, and certainly not the ill child themself.
  • Be honest. Some parents may minimize the seriousness of the eating disorder in attempt to protect their other children or preserve their ill child’s reputation, but this strategy often backfires.   Be frank with siblings about the seriousness of the eating disorder, including the possibility of death.  This honesty helps siblings understand why it is so important that the family intervenes immediately and aggressively, and why other activities have to take a back seat for now.
  • This is what families do. Make sure siblings know that it is normal for families to work together to care for those who are unwell, and that you will be there for them as needed as well.
  • Be realistic. Be honest with siblings about the reality of dealing with the eating disorder.  Acknowledge that, for a period of time, the whole family will be under stress, family life will change, and you may not be able to spend as much time with the siblings as you spend with the ill child.  Being honest with siblings about the severity of the illness can help them understand and accept this change of lifestyle.
  • Create and enforce firm rules around triggering behaviors. It goes without saying that many people with eating disorders are ultra-sensitive to issues of food, weight, exercise, and body image.  Siblings should be advised that they must avoid discussing this potentially triggering subject matter around the patient.  Judgments about foods and weight-related comments are completely off-limits.
  • Include siblings in treatment. Bring siblings to some family sessions so that the therapist can explain the eating disorder to them, describe the treatment process, answer their questions, and tell them how they can support their ill sister or brother.  While it is generally not necessary or helpful to include siblings in most treatment sessions, siblings can often benefit from just one or two sessions with the therapist.
  • Carve out quality time. When possible, make a point of scheduling one-on-one time with each sibling and talking with them about their lives apart from the eating disorder.
  • Encourage open communication. Talk with siblings about their feelings and reactions to the eating disorder. Let them know that it is totally normal and understandable for siblings to feel worried, angry, jealous, resentful, or sad in this type of situation.
  • Maintain appropriate boundaries. Ensure that siblings remain in a support role, rather than taking on a parent’s role.  Siblings can help their ill sibling by providing them with distraction before, during, and after meals, by being good listeners and providing empathy, and by engaging them in normal sibling activities.  Unless the siblings are adults, do not involve them in the actual process of re-feeding or supervising meals, as this can put them in a delicate position of being torn between “loyalty” to their ill sibling and the responsibility of reporting ED behaviors to their parents.
  • Feed each child according to his own needs. Teens who are recovering from eating disorders often need large amounts of very high calorie foods, or other personalized dietary requirements in order to restore health and healthy brain function.  When it comes to nutrition, the term “healthy” is relative. A healthy diet for a teen with an eating disorder is different from a healthy diet for a person without an eating disorder. Teach your children that nutritional needs differ from person to person based on age, activity level, health issues, body type, and other factors.  Do your best to ensure that each of your children are eating according to their own personal nutritional needs. Model this behavior yourself by eating in a way that is healthy for a middle-aged parent with your unique healthcare issues.
  • Make siblings aware of their own risk. Eating disorders are heritable conditions.  Between 53-83% of the risk of developing an eating disorder is genetic. For this reason, it is not uncommon for families to have more than one child who experiences an eating disorder. Let siblings know that their risk of developing an eating disorder is much higher than average because of their genetic predisposition. This information can be conveyed in a way that is empowering.  Knowing their risk factors, siblings of eating disorder patients should be mindful of ensuring that they keep their bodies well-nourished, avoid dieting and other weight-control behaviors, continue to grow and gain weight as expected throughout their childhood and adolescence, and seek treatment right away if they happen to develop symptoms.
  • Be watchful. If you notice any possible signs or symptoms of eating disorders in your other children, schedule them for an eating disorder evaluation promptly. Other psychiatric illnesses, such as depression and anxiety, are more common in siblings of eating disorder patients due to a shared genetic vulnerability combined with the stress of having an ill family member.  Any concerns of mental health problems in siblings should be identified and treated promptly.

The Upside

An eating disorder can also impact siblings in a positive way.  For example, they may grow closer to their ill sibling and value her more after almost losing her.  They may feel needed and important in the process of supporting their ill sister or brother.  Siblings may become more aware of eating disorders and other psychiatric illnesses in their friends and try to intervene whenever they see concerning behaviors.  They may have improved body image after witnessing the disturbing body image distress of their ill sibling. Often, siblings benefit from having more frequent family meals and structured eating habits.  They may grow and mature from the experience, developing more autonomy when parents’ focus is on the eating disorder treatment. Siblings benefit from strengthened parental unity.  If a sibling develops an eating disorder or another illness in the future, their parents tend to intervene immediately and are much more equipped to deal with it.

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