Running head: UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 1

Utilizing MTSS for Eating Disorder in Schools

Thien Do

Chapman University
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 2

Abstract

Eating disorders have a detrimental impact on students’ well-being and academic achievement.

School counselors are responsible for implementing prevention programs and interventions to

help these students. In this paper, we will discuss how school counselors can use a multi-tiered

system of support (MTSS) to decrease the impact of eating disorders. This paper discusses the

effectiveness of each of the three tiers of prevention and intervention and the role school

counselors play in each tier.

Keywords: students with eating disorders, school counselors, intervention, prevention

UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 3

Introduction

The American Psychological Association (2013) defines eating disorders (ED) as a

“persistent disturbance of eating or eating-related behavior that results in the altered consumption

or absorption of food and that significantly impairs physical health or psychosocial functioning.”

According to Ray (2004), 9% to 11% of students meet the diagnostic criterion for ED. ED in

students are often associated with physical consequences as well as high rates of mortality and

morbidity (Buerger, Ernst, Wolter, Huss, Kaess, & Hammerle, 2019). Media use, negative affect,

body dissatisfaction, and reduced self-esteem are some of the crucial predictors for the

development of eating disorder-related behaviors. ED can negatively affect students’ academic

performance. For example, students may be distracted with thoughts of hunger or their body

image, which could prevent them from giving their full attention in class. According to Bardick,

Berries, McCullough, Witko, Spriddle, and Roest (2004), starvation prevents students with ED

from being able to critically think, which hinders their academic performance.

School counselors need to be able to identify the different symptoms that accompany the

three most prevalent eating disorders found in students: anorexia nervosa, bulimia nervosa, and

binge-eating disorder.

Anorexia Nervosa

According to Comer (2014), anorexia nervosa is a disorder in which individuals desire to

have a thin body and engage in extreme weight loss. Individuals with this disorder restrict dietary

intake, have an intense fear of gaining weight, and have a distorted perception of their bodies.

According to the APA (2013), this disorder is more prevalent in the female population (10:1

female-to-male ratio). The two types of anorexia nervosa are restricting and binge-eating/purging

type. Individuals with the restricting type of anorexia nervosa, experience weight loss through
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 4

dieting, fasting, and excessive exercise (APA, 2013). On the other hand, people diagnosed with

the other form of anorexia engage in binge eating or compensatory behavior. These

compensatory behaviors include making themselves vomit or misusing diuretics, enemas, or

laxatives.

The age that students develop anorexia nervosa is typically around the adolescent years.

Children and adolescents with anorexia have a low weight that is less than expected of a person

their age (APA, 2013). Their normal developmental trajectory, which includes growing in height,

is also affected. Children with anorexia nervosa experience numerous medical problems. Female

adolescents may experience amenorrhea, which is the absence of menstrual cycles. They may

also experience reduced bone mineral density, lowered body temperature, body swelling, slow

heart rate, and low blood pressure. Other consequences that individuals with anorexia nervosa

can experience are brittle nails; cold and blue hands and feet; hair loss; and rough, dry, and

cracked skin. In severe cases, people with anorexia nervosa may experience metabolic and

electrolyte imbalance, which can lead to death by heart failure or circulatory collapse (Comer,

2014).

There are many unique characteristics that individuals with anorexia nervosa possess.

They are described to be rigid when it comes to food preparation or cutting food into specific

shapes. Many individuals with anorexia nervosa also display obsessive-compulsive behaviors.

For example, they would exercise compulsively and prioritize exercise over other activities in

their lives (Comer, 2014). Perfectionism is another characteristic that would be used to describe

individuals with anorexia nervosa.

Bulimia Nervosa
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 5

Individuals diagnosed with bulimia nervosa engage in binge eating and perform purging

behaviors afterward. Binges are episodes of uncontrollable eating during which a person

consumes an excessive amount of food. Compensatory behaviors are used to prevent weight gain

from the binges (Comer, 2014). In order to be diagnosed, both of these behaviors have to occur,

on average, at least once a week for three months (APA, 2013). People with bulimia nervosa are

able to maintain a weight that is within a normal range. They are also characterized as having

multiple mood swings and low impulse control.

There are many medical complications that result from bulimia nervosa. Like anorexia

nervosa, 50% of the female population with bulimia nervosa experience amenorrhea. Due to

repeated vomiting, individuals with bulimia nervosa experience dental complications, such as

weakened enamel and erosion of teeth (Comer, 2014). Frequent use of laxatives to induce

defecation and self-induce vomiting can result in dangerous potassium deficiencies, which may

cause intestinal disorders, heart damage, or kidney disease. Binge eating can lead to stomach

rupture in some individuals.

Binge eating disorder

Individuals with binge eating disorder have recurrent episodes of binge eating in which

they do not participate in compensatory behavior afterward. Binge eating episodes are associated

with three or more of the following: eating more rapidly than usual; eating large amounts of food

without physical hunger; eating until feeling uncomfortably full; eating alone because of the

embarrassment of how much one is consuming; and feeling very guilty afterward, disgusted with

oneself, or depressed (Comer, 2014). These individuals experience significant distress after

engaging in binge eating. Like bulimia nervosa, the binge eating pattern has to occur, on average,
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 6

at least once a week for three months for an individual to be diagnosed with binge eating

disorder.

School counselors need to be able to identify the different contributing factors that may

cause students to have ED. Research shows that Western standards of female beauty are a

significant factor that influences the development of these disorders (Comer, 2013). Many

female adolescents are affected by the media, where they are exposed to models and celebrities

who have thin bodies. Because of this, they strive for thinness, which may cause them to take

measures, such as purging, to obtain this ideal body. The family environment can be another

factor that influences the development and continuation of ED. Typically, families of students

with bulimia nervosa or anorexia nervosa emphasize the importance of dieting, thinness, and

physical appearance. Students who are in an enmeshed family system are more likely to develop

an eating disorder. In this system, family members are extremely worried about each other’s

welfare and overinvolved with each other’s affairs. When a child reaches adolescence, they

usually push for independence, which threatens the harmony of this type of system (Comer,

2013). Because of this, the family forces the child to take a “sick role,” in this case an eating

disorder.

There are also biological factors that play a role in students developing ED. For example,

there might be a malfunction within the hypothalamus, which regulates hunger. Another

biological factor that can impact the development of ED is having a lower level of serotonin,

which can contribute to binge eating (Comer, 2013).

Given the possible adverse effects of youth ED, school counselors need to examine

programs and interventions targeted towards preventing and treating early eating disorder

behaviors. This research paper will help identify effective prevention and intervention methods
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 7

that school counselors can use for responding to ED in students through a multi-tiered system of

support (MTSS). According to McIntosh and Goodman (2016), the MTSS model gives students

the best opportunities to flourish behaviorally and academically. The first tier of support is aimed

at preventing particular conditions from occurring (McIntosh & Goodman, 2016). Tier 1 is

intended for every student in the school. In tier 1, school counselors provide all students with

core curriculum programs. The goal of tier 2 support is to provide services to individuals who are

at risk of contracting the condition (McIntosh & Goodman, 2016). School counselors’ role in this

tier is to provide at-risk students with targeted data-driven interventions. Tier 3 support is used to

lessen the effect of the condition in the individuals who have contracted the condition (McIntosh

& Goodman, 2016). In tier 3, school counselors provide students with individualized

interventions and referrals to outside resources for services or treatment.

Youth ED fits into the MTSS model because different intervention programs are

addressed in each tier (i.e., prevention of ED, early intervention/secondary prevention of ED, and

treatment/intervention of youth with ED). Primary prevention programs for ED (e.g., The Body

Project, “My Body and I”, GGWB) educate students of behaviors that protects them from

developing risk factors, such as thin-ideal ideation and body dissatisfaction. Secondary

interventions include counseling interventions for students who are at risk for developing ED

(e.g., guided imagery, group counseling, individual counseling). Tertiary treatment interventions

are for students with ED, which include outside referrals, cognitive behavioral therapy (CBT),

and school accommodations.

Method

Research on prevention and intervention programs targeting students with ED was

collected using the ProQUEST and EBSCOhost databases through the Chapman University
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 8

Library website. The keywords used the most in the search included: “students with eating

disorders,” “prevention programs for students with eating disorders,” “intervention program for

students with eating disorders,” and “role of school counselor with students with eating

disorders.” Search parameters were set to generate articles published in the last 17 years (from

2002-present) to narrow the research results. The literature will be organized based on where the

research fits in the MTSS model of intervention and analyzed based on the efficacy of the

program. The literature will also include how the role of school counselors interacts with the

three-tiered model in assisting students with eating disorders.

First Tier Intervention

School counselors implement primary prevention programs that are aimed at reducing

ED in all students. The goal of these programs is to prevent students from developing body

dissatisfaction, striving for thinness, and forming unhealthy eating patterns. Students are also

taught coping strategies to prevent the development of ED risk factors.

Girls Growing in Wellness and Balance (GGWB) is a yoga-based prevention program

that targets female students who attend intermediate school. The goal of this study was to see

whether or not the program will decrease ED risk factors, such as the drive for thinness or body

dissatisfaction (Cook-Cottone, Talebkhah, Guyker, & Keddie, 2017). GGWB is a fourteen-week

program, and each session is ninety minutes long. The program integrates yoga, group

processing, meditative relaxation, journaling, and delivery and practice of protective life skills,

such as stress reduction (Cook-Cottone et al., 2017). Other skills that students learn from this

program are mindfulness, assertiveness training, media literacy, positive self-talk, and boundary

setting (Cook-Cottone et al., 2017). The findings of the study show that the GGWB program was

effective in reducing students’ dissatisfaction with the body (F(1, 130) = 6.31, p = .013) and
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 9

drive for thinness (F(1, 130) = 10.94, p = .001). The results also showed that there was an

increase in students engaging in self-care behaviors. These self-care behaviors include

exercising, getting a make-up session, and staying hydrated.

The Body Project is an example of a dissonance-based eating disorder prevention

program that is effective in decreasing ED symptoms in students (Christian, Brosof, Vanzhula,

Williams, Ram, & Levinson, 2019). According to Stice, Rohde, Shaw, and Gau (2011),

dissonance-based eating disorder prevention programs are successful in decreasing ED risk

factors and symptoms, the future onset of ED, and functional impairment. In this program,

female participants analyze the thin ideal adopted by females in written, behavioral, and verbal

exercises. These activities aim to create cognitive dissonance and motivate them to reduce their

pursuit of the thin ideal (Stice et al., 2011). Because of this, participants showed a decrease in

ED symptoms, negative affect, unhealthy weight control behaviors, and body dissatisfaction.

Christian et al. (2019) have found that students who participated in the Body Project have a

decrease in comorbid symptoms of ED, such as guilt, worry, perfectionism, social and physical

anxiety sensitivity, rumination, and social appearance anxiety. Results have indicated that

students who participate in the Body Project were able to speak, act, and write against the thin

ideal or other appearance-based pressures imposed by society.

In Atkinson and Wade’s study (2015), they compared the Body Project and a

mindfulness-based intervention in reducing the risk factors in students. Their prevention

programs lasted for three sessions. In the mindfulness-based prevention program, the students

were taught present-moment awareness through the raisin exercise and using the breath as an

anchor. In the raisin exercise, an individual has a raisin in his or her mouth and holds the raisin in

there for ten seconds. The goal of this exercise is to have the individual feel the sensations of the
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 10

raisin, such as the texture, before chewing it. Using breath as an anchor is a breathing exercise in

which individuals inhale and exhale for a set amount of time. Students also practiced non-

judgment and acceptance towards body-related feelings and thoughts in this prevention program.

The results indicated that students in the mindfulness-based prevention program showed a

significant decrease in psychosocial impairment, thin-ideal ideation, dietary restraint, and weight

and shape concerns (Atkinson & Wade, 2015). On the other hand, students in the Body Project

demonstrated significant reductions in socio-cultural pressure.

“My Body and I” is a coeducational, school-based primary prevention program that

targets preadolescent students, specifically fourth and fifth graders (Hinz, 2017). The goal of the

programs is to increase body satisfaction in the students. “My Body and I” is a five-hour

program that is split into six 45-minute lessons, which is incorporated into the students’ normal

class time (Hinz, 2017). Students are taught relaxation exercises and guided meditation to

promote body satisfaction. Lessons include education on puberty and the normalization of

pubertal growth, such as the fat increase in certain areas of girls’ bodies. Normalization of

pubertal growth is important since studies show that 40% to 70% of female adolescents are

dissatisfied by the parts of their bodies that are affected by puberty (Choate, 2007). Students are

also trained in media literacy in which they are informed about how images are digitally altered

and that the body images that are portrayed are unattainable. Findings show that “My Body and

I” is effective in enhancing students’ knowledge (effect size = 0.89) in puberty development and

media literacy and decreasing body dissatisfaction (ES = 0.12), thin-ideal internalization (ES =

0.13), and body shape concerns (ES = 0.11) (Hinz, 2017).

Before implementing a prevention program for ED, school counselors need to evaluate

their practices, values, and beliefs regarding dieting, weight, and body image in order to
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recognize how their attitudes may unintentionally influence children (Bardick et al., 2004).

According to ASCA Standard A.1.f, school counselors should avoid imposing their personal

beliefs and values on students. When it comes to prevention programs, school counselors should

encourage body acceptance, decrease appearance-related teasing, address nutrition and physical

activity, and increase coping strategies (Cook-Cottone, 2009). In order to address body

acceptance, school counselors must educate their students on self-concept, media literacy, and

media policy (Cook-Cottone, 2009). Students will develop critical thinking skills that will help

them decode media messages about the ideal body (Bardick et al., 2004). To decrease

appearance-related teasing, school counselors should collaborate with administrators to

implement a zero-tolerance policy and consequences for teasing behaviors. They should also

educate students on how to respond to teasing and to search for supportive adults that students

can go to during school hours (Cook-Cottone, 2009). Counselors can collaborate with science,

health, and physical education teachers to implement lessons to address nutrition and physical

activity. These lessons would include long term effects of exercise and dietary intake and basic

nutrition information (Cook-Cottone, 2009). School counselors can also advocate for school

lunch plans that will provide students with healthy food options. Counselors can teach students

stress management skills to help them cope. These can range from breathing exercises to yoga

classes. These types of activities can be implemented in students’ daily school routines or be

offered after school (Cook-Cottone, 2009).

Second Tier Intervention

Tier 2 interventions are directed towards at-risk students who have a higher chance of

developing ED. Before school counselors implement their second-tier intervention, they should

be able to identify individuals who exhibit the risk factors of ED. According to Harshbarger,
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Ahlers-Schmidt, Atif, Allred, Carroll, and Hauser (2011), 94% of school counselors reported that

they lacked basic understanding and low confidence in identifying and helping students with ED.

According to ASCA Standard B3.e, school counselors should engage in professional

development to learn how to identify at-risk students, so that they can serve this population

effectively. According to Bardick et al. (2004), school counselors should pay attention to

students’ dieting patterns. At-risk students tend to count calories; skip meals or refuse to eat,

especially in social settings; obsessively ruminate about food; and have a strict diet in which they

consume certain healthy foods (Bardick et al., 2004). Other risk factors that school counselors

should look out for are individuals who wear oversized clothing. They wear these types of

clothing to hide their body, or they think that they have to be that size (Bardick et al., 2004).

Some psychological warning signs that at-risk students exhibit are competitiveness,

perfectionism, conformity, emotional distress, and low self-esteem (Bardick et al., 2004). These

types of students may also isolate or withdraw from their friends and family because they want to

maintain a strict exercise and dieting schedule or hide their compulsive behaviors. According to

Ray (2004), at-risk students include athletes (wrestlers, swimmers, runners, gymnasts),

homosexuals, those with mental disorders (mood disorders, substance abuse, personality

disorder), or individuals who have a history of family issues. School counselors and school-

based mental health practitioners should keep in mind that these are general warning signs to

look out for. School counselors may risk hindering a relationship with a student if they falsely

identify the student of having ED.

When confronting an at-risk student, school counselors should show support and concern

and convey understanding and empathy (Bardick et al., 2004). The first reaction of at-risk
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 13

students, when confronted about their ED, is denial. They are in denial because they fear

irreversible weight gain, change, and loss of control (Bardick et al., 2004).

According to Giles and Hass (2008), school counselors should use the Eating Disorder

Examination (EDE), which is a screening tool that assesses the value that students place on body

shape. School counselors can consult the school nurse to help them with the assessment (Owens-

Gary & Shea, 2014). Using the EDE can also help school counselors identify concerns that they

can address through individual counseling (Akos & Levitt, 2002). Another screening tool that

school counselors can utilize is the Eating Attitudes Test (EAT-26) (Haines, Ziyadeh, Franko,

McDonald, Mond, & Austin, 2011). The EAT-26 was designed to assess body image, students’

vomiting and binge eating frequency, unhealthy dieting practices, and students’ preoccupation

regarding weight and food.

Individual counseling is a tier two intervention that school counselors can provide for at-

risk students. In individual counseling, school counselors encourage students to engage in action-

oriented activities that allow them to feel good about themselves and their bodies. These

activities include physical exercises, such as riding a bike (Akos & Levitt, 2002). Guided

imagery is another technique that school counselors can utilize during individual counseling.

With guided imagery, school counselors can help students by teaching them relaxation or coping

skills and helping them imagine different outcomes for stressful situations (Bardick et al, 2004).

Students who go through this guided imagery exercise with school counselors show a decrease in

anxiety (Bardick et al, 2004). School counselors can also provide students with educational

information on body image, investigate stressors that contribute to students’ body dissatisfaction,

and introduce activities to promote self-acceptance (Akos & Levitt, 2002). In individual

counseling with elementary students, school counselors can use bibliotherapy. With
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 14

bibliotherapy, school counselors use stories to help students open up dialogue regarding their

unhealthy eating patterns (Springer & Levitt, 2016). School counselors can then educate students

about healthy eating patterns, different coping strategies that they can use, and positive body

image.

According to Stout and Frame (2004), school counselors can facilitate groups to

encourage a healthy body image for students at risk. Students try to maintain their ED in silence;

however, with group counseling, they are able to see that their peers suffer from the same

insecurities as they do (Stout & Frame, 2004). Because of this, they do not feel as though they

are alone in their struggle. Group counseling allows students to receive support from their peers

(Giles & Hass, 2008). When running group counseling sessions, school counselors need to

provide structure in which the focus of the group is to have students promote their own and

others’ body images (Akos & Levitt, 2002). School counselors also need to keep in mind to

prevent discussions about specific ED behaviors, so that the rest of the group does not learn new

behaviors (Giles & Hass, 2008). According to Sink, Edwards, and Eppler (2012), students who

participated in group counseling interventions reported better functioning than 73% of their peers

who did not.

Third Tier Intervention

In Tier 3, more extensive treatment and proper referrals are required for students with

severe ED. As aforementioned, when students are confronted about their ED, their first reaction

is denial (Bardick et al, 2004). School counselors need to keep in mind to approach the student

with genuine concern and support. School counselors also need to contact the parent or guardian

to let them know that they are worried about the child’s health and well-being (Carney & Scott,

2012). If families need referrals, school counselors have to assume the role of the school-based
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 15

resource person (Cook-Cottone, 2009). According to Giles and Hass (2008), as a school-based

resource person, school counselors should provide support to the student and parents by giving

them appropriate referrals so that the student may get the treatment he or she needs. ASCA

Standard A.6.b. states that school counselors should have a list of resources and agencies

available in the community for students and parents, which include the names and phone

numbers of mental health facilities, local hospitals, or eating disorder specialists (Bardick et al.,

2004). School counselors should consult the school nurse if they are unable to provide families

with health care or community resources (Owens-Gary & Shea, 2014).

There are three phases of treatment that students with severe ED must go through. In the

first phase of treatment, the goal is to stabilize the student’s weight and normalize his or her

eating or exercising patterns (Bardick et al., 2004). This is accomplished through hospitalization

or specialized treatment since patients with ED may be severely malnourished. School

counselors are not involved in the weight recovery process, but can provide support in other

ways. They can come up with an individual education plan (IEP) or a 504 plan with academic

accommodations for the student when he or she reenters the school (Carney & Scott, 2012).

According to Cook-Cottone (2009), these accommodations include alternative assignments for

physical education, reduced workload, peer tutoring for missed assignments, copies of class

notes, extended time for assignments and exams, and access to quiet study locations. A meeting

between the student, parent, school counselor, teachers, and therapist is recommended to

collaborate on the necessary accommodations that will benefit the student at school (Carney &

Scott, 2012). With the consent of the parent, school counselors should also collaborate with

outside resources, such as the student’s clinician or physician, regarding the student’s diagnosis

and treatment plan.

UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 16

Phase 2 treatment of ED is changing the student’s thoughts and behaviors after he or she

is released from the hospital (Giles & Hass, 2008). The school counselor’s role in this phase is to

take a psychoeducational approach to help students challenge their irrational thinking related to

their ED behaviors (Bardick et al., 2004). This includes teaching students coping strategies and

problem-solving and addressing some topics, such as self-esteem, impulse regulation, and shape

and weight concerns. A therapy technique that school counselors can utilize is cognitive-

behavioral therapy (CBT). According to Bardick et al. (2004), CBT is an effective treatment for

students with ED because it addresses the cognitive, behavioral, and affective areas of the

disorder, which include body dissatisfaction, low self-esteem, self-defeating thoughts, strict

dieting, and compensatory behaviors. School counselors who use CBT help students identify

their automatic negative thoughts, dispute the validity of those thoughts, and shift their thinking.

For example, school counselors use CBT to help students with anorexia nervosa modify their

behaviors and thought processes that maintain their restrictive eating behavior (Comer, 2014).

Narrative therapy is another therapy technique that school counselors can use to have students

with ED retell or rewrite their story (Bardick et al., 2004). In narrative therapy, school counselors

encourage students to share their stories honestly, openly, and without judgment to develop self-

acceptance and to begin to construct a positive outcome to their personal story. According to

Bardick et al. (2004), this is an antecedent to goal-setting, as students can imagine an alternative

situation they would like to have and begin to set goals to create a healthy and balanced life.

School counselors can help students come up with this alternative situation by asking them the

miracle question, which is a technique that is used in solution-based focus therapy (SFBT) (De

Jong & Kim Berg, 2013).

UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 17

In the third phase of treatment, school counselors collaborate with students to create

strategies to prevent relapse, which is very common in individuals who recuperate from ED

(Bardick et al., 2004). School counselors and students must come up with a maintenance plan

that includes continual self-monitoring of thoughts and behaviors, engaging in coping skills and

problem-solving strategies, practicing cognitive restructuring strategies learned from CBT, and

setting short-term, realistic goals (Bardick et al., 2004). For students with bulimia nervosa,

school counselors recommend them to keep a diary to track their eating behaviors and emotions

(Comer, 2014). The purpose of this is to discover the stressors that may trigger the student so

that they can create strategies to help the student overcome them.

Conclusion

There are many prevention programs that are designed to prevent eating disorders in

students. There are also many interventions that school counselors can choose from to support at-

risk students and assist those who need treatment. In summary, this paper argues that school

counselors should use a three-tiered model of intervention when approaching eating disorders in

schools.

Due to the advancement of technology in school settings, future research should consider

an online resource as a prevention program. This online resource could provide the same kind of

information that in-person prevention programs provide to students. This could be very

beneficial for students because it would not take away class time. This could be assigned and

implemented in a health or physical education class. Future research should also focus on yoga

or stress reduction prevention programs that are geared toward male students. This would

address the sociocultural stigma that male students encounter regarding their body image.
UTILIZING MTSS FOR EATING DISORDER IN SCHOOLS 18

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