Background: Eating disorders (ED) have a peak rate of onset in school-aged children. Little is known about teachers’ experiences of ED. Method: A total of 826 school staff completed an online questionnaire exploring their Eating Disorder experiences. Responses were analysed using content analysis principles. Results: 74 per cent of respondents’ schools had received no training on ED, 40% did not know how to follow up pupils’ Eating Disorder concerns and 89% of respondents felt uncomfortable teaching pupils about ED. Conclusions: School staff feel ill-equipped to support ED. Training in the recognition, support and teaching of ED would be welcomed and could improve outcomes for young people.

1. We don’t know how to help: an online survey of
school staff
Pooky Knightsmith, Janet Treasure & Ulrike Schmidt
Division of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crepsigny Park, London, SE5 8AF,
UK. E-mail: jodi.knightsmith@kcl.ac.uk
Background: Eating disorders (ED) have a peak rate of onset in school-aged children. Little is known about
teachers’ experiences of ED. Method: A total of 826 school staff completed an online questionnaire exploring
their Eating Disorder experiences. Responses were analysed using content analysis principles. Results: 74 per
cent of respondents’ schools had received no training on ED, 40% did not know how to follow up
pupils’ Eating Disorder concerns and 89% of respondents felt uncomfortable teaching pupils about ED.
Conclusions: School staff feel ill-equipped to support ED. Training in the recognition, support and teaching of
ED would be welcomed and could improve outcomes for young people.
Key Practitioner Message
• Eating disorders have a peak onset in school-aged children
• School staff can play an important role in recognising and supporting children and adolescents with eating
disorders
• School staff currently feel unable to adequately support children and adolescents with eating disorders.
Training is not widely available and most schools have no policies or procedures in place for managing eating
disorders
• Reintegration of students who have been absent from school receiving eating disorder treatment poses a par-
ticular challenge. Schools would welcome tailored support to ease the transition
Keywords: Anorexia; bulimia; binge eating disorder; eating disorders; teacher; school
Introduction
Mental health issues are highly prevalent amongst ado-
lescents with between 10% and 20% suffering from a
diagnosable mental disorder (Kataoka, Zhang, & Wells,
2002; Green, McGinnity, Meltzer, Ford, & Goodman,
2005).
It is well documented that children with mental
health problems do less well in terms of academic and
social development with lasting implications for later
life (Farrington, Healey, & Knapp, 2004; Colman et al.,
2009). Numerous education policy initiatives in the
United Kingdom have sought to implement an
enhanced role for schools in the mental health and
well-being of their pupils, with a particular emphasis
on the prevention of mental health difficulties. This
includes ‘Every Child Matters’ (Department for Educa-
tion and Skills, 2003), ‘National Healthy Schools’
(Department for Education and Employment, 1999)
‘Social and Emotional Aspects of Learning’ (Depart-
ment for Children, Schools and Families, 2007) and
the ‘Targeted Mental Health in Schools Project’
(Department for Children, Schools and Families,
2008). Of all of the mental disorders arising in adoles-
cence, eating disorders (ED) have the highest rate of
morbidity and mortality due to complications of the
disorder and completed suicide (Rome et al., 2003).
The peak onset of Eating Disorders is between the ages
of 10 and 19 (Currin, Schmidt, Treasure, & &Jick,
2005) and recent statistics show a dramatic increase
in hospital admissions for patients with ED of this age
in England (Health and Social Care Information Cen-
tre, 2012).
When ED are treated early, outcomes can be very posi-
tive with a good chance of full recovery (Treasure, Clau-
dino, & Zucker, 2010). Therefore, Eating Disorder
prevention and early intervention are key to ensuring
successful long-term outcomes and school staff are in
an excellent position to facilitate this process (McVey,
Lieberman, Voorberg, Wardrope, & Blackmore, 2003;
Shaw, Stice, & Becker, 2009), provided they have the
appropriate knowledge and understanding (Knight-
smith, Sharpe, Breen, Treasure, & Schmidt, in press).
Unfortunately, training on Eating Disorders is often
limited (Neumark-Sztainer, Story, & Coller, 1999; Piran,
2004) and ED and mental health, in general, are often
not readily talked about in schools and seeking support
can have a significant stigma attached (Bowers, Manion,
Papadopoulos, & Gauvreau, 2012).
The current study aimed to gain an understanding of
UK school staff experiences of ED in school, including
access to training to assess whether they are adequately
equipped to support children at risk of, or currently suf-
fering from, disordered eating. We also aimed to generate
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
Child and Adolescent Mental Health Volume **, No. *, 2013, pp. **–** doi:10.1111/camh.12039

2. recommendations from school staff about how they
could be best supported in helping young people with
ED.
Methods
Design
The study comprised an anonymous online questionnaire
aimed at school staff in UK schools. A convenience sample of
1250 school staff were invited to participate.
Institutional review board approval and informed
consent procedures
Ethical approval was obtained from King’s College London
Research Ethics Committee (Ref PNM/09/10-110). Once they
had logged into the questionnaire, participants were provided
with detailed information about the study and were given the
opportunity to contact the research team about the project. It
was made clear to participants that by completing the survey,
they were giving their consent to participate in the study.
Survey content
The survey explored school staff experiences of ED, including
access to training and support. It also asked for recommenda-
tions about how they could best be supported in helping young
people with ED. The items included in the questionnaire are
summarised in Tables 1 and 2.
Development and pretesting
The online survey was developed following consultation with
teachers and pupils. Face validity was judged by a panel of
school staff who met as a focus group to discuss the structure
and content of items in the survey. The panel provided useful
comments for wording and restructuring of items to improve
the ease of understanding and completion, but reported no
technical difficulties or problems with comprehension. The
panel agreed that the survey had adequate content validity in
that it contained a representative sample of items relevant to
staff experiences of ED in school. 26 teachers completed the
survey 10 days apart with kappa coefficients ranging from 0.78
to 0.88 for the closed questions outlined in Table 2.
Recruitment process
A database of school staff email addresses was obtained from a
teacher training provider. All staff on the list had previously
expressed interest in mental health training and came from a
variety of primary, secondary and special schools from through-
out the United Kingdom.
Staff were eligible for inclusion if they were currently
employed, or on a placement, with a UK mainstream or private
school of any type.
Survey administration
The study consisted of an anonymous self-report online ques-
tionnaire, which took between 10 and 30 min to complete. Com-
pletion of the questionnaires was voluntary and no incentives
were offered for participation. The data were collected between
September 2010 and April 2011.
The questionnaire was hosted on a survey website, which
was not password protected. The questionnaires consisted of a
cover page containing the information sheet and 19 question-
naire items, each of which appeared on a screen alone. Only
questions relating to the participant’s school type and role were
compulsory. There was no randomisation of items. There was
adaptive questioning such that, based on their previous
answers, only relevant questions were presented. Participants
were given the opportunity to review and amend their answers
prior to submitting their responses.
Response rates
1250 school staff were invited to participate and, of these, 826
(66%) chose to complete the questionnaire.
Preventing multiple entries from the same individu-
als
Multiple responses from the same IP address (same computer)
were prohibited to prevent multiple entries from the same indi-
viduals.
Table 1. Summary of Staff Responses to Eating Disorders (ED) Experience Survey – Closed Questions
Does your school have an Eating Disorder
policy? (774 respondents)
No Yes – part of
another policy
Unsure Yes – specific policy
320 (41%) 208 (27%) 205 (26%) 41 (5%)
Are Eating Disorder policies effective?
(519 respondents)
Effective Ineffective Very effective Very ineffective
317 (61%) 148 (29%) 42 (8%) 12 (2%)
Has your school offered ED training?
(791 respondents)
No Yes
583 (74%) 208 (26%)
Who attended the training? (147 respondents) 3 of fewer
staff members
Whole staff All pastoral staff All middle and
senior managers
82 (56%) 43 (29%) 19 (13%) 3 (2%)
Training delivery method (161 respondents) Seminar Lecture Written materials
107 (66%) 37 (23%) 17 (11%)
If you have not received any training, do you think
you would find training useful?(346 respondents)
Very useful Quite useful Not very useful Not at all useful
160 (46%) 156 (45%) 30 (9%) 0 (0%)
Are you aware of any current or past cases of Eating
Disorders in your school? (530 respondents)
Yes, directly involved Yes, not involved No
266 (50%) 181 (34%) 83 (16%)
if a student is concerned a friend may have an ED Talk to any
member of staff
Never been
discussed
Concerns go
to specific
staff member
Use anonymous
service (e.g. SMS)
364 (47%) 287 (37%) 112 (14%) 18 (2%)
Would you feel comfortable teaching students
about Eating Disorders? (785 respondents)
Very uncomfortable Uncomfortable Comfortable Very comfortable
419 (54%) 273 (35%) 84 (11%) 9 (1%)
Has your school reintegrated students following
absence due to ED? (487 respondents)
Yes No
329 (68%) 158 (32%)
Did staff/students receive any advice on how to
support returning students? (317 respondents)
Yes No
240 (76%) 77 (24%)
All questions were optional. When not all participants recorded a response to a question, percentages were calculated according to the
number of respondents to the specific question.
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
2 Pooky Knightsmith, Janet Treasure, & Ulrike Schmidt Child Adolesc Ment Health 2013; *(*): **–**

3. Analysis
The questionnaire generated quantitative and qualitative data.
The quantitative data were responses to multiple questions.
These data were summed and the raw number of responses cal-
culated for each item was recorded as well as a percentage. All
questions were optional. When not all participants recorded a
response to a question, the percentages were calculated accord-
ing to the number of respondents to the specific question.
Much of the data generated were in the form of free text.
These data were analysed using content analysis – a process by
which the ‘many words of texts are classified into much fewer
categories’ enabling analysis, examination and verification
(Weber, 1990; Flick, 1998; Mayring, 2004).
A categorisation system was developed by analysing
responses and classifying them into categories with care being
taken to ensure that the coding system was comprehensive
whilst avoiding overlapping of categories. A second researcher
independently applied the categories, blind to the original
researcher’s decisions. An interrater reliability of 89% was
achieved [(1808 of 2032 decisions were identical –
Kappa = 0.471 (p < .001)].
Results
Demographic information
The 826 participants completed our questionnaire in a
variety of roles and phases. They comprised members of
school staff from 548 individual schools and colleges.
Participants came from secondary (n = 531), primary
(n = 116), special schools (n = 102) and further educa-
tion colleges (n = 77).
The majority of participants were teachers [35%
(n = 286)] or middle leaders [24% (n = 196)]. 17 per cent
(n = 137) of respondents were senior leaders, 15%
(n = 127) were pastoral leaders and 10% (n = 80) were
support staff including school nurses and teaching
assistants.
84 per cent (n = 447/530) of respondents were aware
of current or past cases of ED in their schools and 50%
(266/530) had been directly involved with cases.
School staff experiences and recommendations
Full results are outlined in Tables 1 and 2 below.
Table 1 outlines the quantitative results recorded
from closed questions. Table 2 shows categorised results
of free-text questions.
Four topics were repeatedly referred to in the free text
responses. These were:
• Lack of clarity over how to support students with ED
• Lack of ED training and policies available in schools
• Staff feel uncomfortable teaching students about ED
Table 2. Summary of Staff Responses to Eating Disorders (ED) Experience Survey – Free Text
Benefits of ED
training (142
respondents)
Increased confidence
supporting ED
Learnt how to
support sufferers
Learnt Eating
Disorder
warning signs
Sharing
ideas/experiences
with others
Generally
Useful
39 (27%) 31 (22%) 21 (15%) 15 (11%) 14 (10%)
Learnt about
referral processes
Raised
awareness of ED
Not useful
12 (8%) 7 (5%) 3 (2%)
What would have
made training
more useful?
(96 respondents)
Longer/more in-depth More staff
attending
Repeat, refresher
or regular sessions
Case studies Training was
comprehensive
24 (25%) 17 (18%) 10 (10%) 10 (10%) 7 (7%)
Practical support
suggestions
More relevant to
specific student
Better
trainer/presentation
Policy/referrals info Smaller groups
7 (7%) 6 (6%) 6 (6%) 5 (5%) 4 (4%)
What you would do
if you had Eating
Disorder concerns
about a student
(782 respondents)
I don’t know Refer to
colleague/Follow
policy
Seek advice from
colleagues
Talk to the pupil Work with
parents
316 (40%) 168 (21%) 146 (19%) 107 (14%) 25 (3%)
External referral Monitor pupil
13 (2%) 7 (1%)
Reasons some staff
would feel
uncomfortable
teaching about
Eating Disorders
(546 respondents)
Lack of knowledge It would lead to a
rise in eating
disorders
Students already
have a good
understanding
Worried
about difficult
questions/disclosures
312 (57%) 109 (20%) 64 (12%) 61 (11%)
Experiences of
communicating
Eating Disorder
concerns with
parents (781
respondents)
Denial/Refusal to
communicate/cooperate
Mixed reactions First contact
difficult, but
became supportive
Anger – parent thinks
it is an accusation
of poor parenting
364 (47%) 287 (37%) 112 (14%) 18 (2%)
Support that would
be useful when
reintegrating a
student following
absence due to an
Eating Disorder
(105 respondents)
Information about
the specific case
Increased
quantity/quality
of training
Involve more
stakeholders
All relevant staff
to receive
training/support
Ongoing help
& support from
professionals
30 (29%) 25 (24%) 17 (16%) 13 (12%) 8 (8%)
Prepare peers for
pupil return
Other
8 (8%) 4 (4%)
All questions were optional. When not all participants recorded a response to a question, percentages were calculated according to the
number of respondents to the specific question.
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12039 We don’t know how to help 3

4. • The reintegration of students following absence
needs specific support
Lack of clarity over how to support students with
eating disorders
Although the majority of participants had encountered a
student with ED in their school, 40% (n = 316/782) of
staff said they would not know how to follow up Eating
Disorder concerns.
“We don’t know how to help. No one has told us what to say or
do and you’re always scared of saying the wrong thing and
making it worse.” (Biology teacher)
Lack of ED training and policies currently
available in schools
41 per cent (n = 320) of respondents’ schools had no ref-
erence to Eating Disorders in any policy. Only 5%
(n = 41) of respondents’ schools had implemented spe-
cific Eating Disorder policies, although the majority of
participants considered Eating Disorder policies to be
effective [61% (n = 317)].
“Having a policy in place has enabled us to clear up questions
over how referrals should be made and to whom. We no longer
have concerns about pupils slipping through the gaps.” (Head
of pastoral care)
“An ED policy would be highly effective as long as it was written
as a practical document and gave clear guidance.” (Maths tea-
cher)
Of those who thought that Eating Disorder policies
would prove ineffective [31% (n = 160)], many cited the
difficulties of working with a policy designed by senior
staff, but meant for implementation by teaching or sup-
port staff:
“It would just be another box ticking exercise done by the head
teacher to please the inspectors. There wouldn’t be anything
actually useful in it.” (Year 6 teacher)
“What usually happens with these things is that the senior
leadership team writes them and we’re all supposed to jump in
line even though what they’ve put together is completely
impractical and can’t be used for its intended purpose.” (Geog-
raphy teacher).
74 per cent (n = 583) of respondents’ schools had
provided no training on ED and of the 26% (n = 208)
of respondents whose schools had provided training,
in the majority of cases [56% (n = 82)], this training
had been made available to three members of staff or
fewer. Staff who had received training found it useful
for a range of reasons, including increased confidence
in supporting Eating Disorders [27% (n = 39)], a
source of practical support ideas [22% (n = 31)] and
an increased awareness of Eating Disorder warning
signs [11% (n = 15)].
“Being able to share ideas was incredibly helpful. I went away
feeling more confident that I could provide good support to
pupils with EDs in the future.” (Head of PE)
“Now I know what to look out for I think I’ll be able to spot the
early warning signs and hopefully help move things on before
the ED really takes grip.” (Head of Year 9)
Some of those who had received training felt that it
could be improved by being more in-depth [25%
(n = 24)], available to more staff [18% (n = 17)] or
repeated on a regular basis [10% (n = 10)].
“I was left with more questions than answers, I felt like I’d just
started learning. It was useful but I’d have liked a lot longer.
Refresher sessions would be useful too as it’s a huge amount to
take in.” (Assistant Head)
91 per cent (n = 316) of staff who had not received
training said that they would find ED training useful or
very useful.
“This doesn’t feel like the sort of thing you should be learning
on the job – we should get proper training. After all, there’s so
much potential to say or do something harmful completely by
mistake.” (Learning support assistant).
Staff feel uncomfortable teaching students about
ED
Majority of staff felt either very uncomfortable [54%
(n = 419)] or uncomfortable [35% (n = 273)] teaching
their students about ED. A wide range of reasons were
given for this – the most repeated being a lack of knowl-
edge [57% (n = 312)]:
“It’s something I know so little about myself that it just wouldn’t
be appropriate for me to lead a class on it.” (French teacher)
Many teachers felt that it was inappropriate to teach
students about ED because it may increase their preva-
lence [20% (n = 109)]:
“My understanding has always been that if you teach a pupil
about ED, you give them the tools to develop that disorder
themselves.” (Year 5 teacher)
Others were worried about how they would answer
students’ questions or deal with disclosures [11%
(n = 61)]:
“I could probably teach a basic lesson but I’d be clueless when
it came to answering probing questions.” (Maths teacher)
“I’d be worried in case one of my students talked about their ED in
class. I wouldn’t know how to handle that situation.” (RE teacher)
Some teachers simply believed that it was unneces-
sary to teach students about Eating Disorders as they
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
4 Pooky Knightsmith, Janet Treasure, & Ulrike Schmidt Child Adolesc Ment Health 2013; *(*): **–**

5. thought students already had a secure knowledge of the
subject [12% (n = 64)]
“What can I teach them that they haven’t already learnt from
Heat magazine or The Sun? They’re walking encyclopaedias on
this topic.” (Chemistry teacher)
“If anything, they should be teaching us. One of my students
did a project on anorexia recently, I learnt a lot from her.” (Year
10 form tutor)
Around one third of respondents [37% (n = 287)] said
that it had not been made clear to students what they
should do, or whom they should tell if they were con-
cerned about a friend’s eating behaviour.
The reintegration of students following absence
needs specific support
The majority [68% (n = 329)] of respondents reported
that their school had had to reintegrate a pupil into
school following a period of absence caused by an Eating
Disorder. 24 per cent (n = 77) reported receiving no sup-
port or advice about how to support the returning stu-
dent.
“I will always feel guilty about it. We did our best to help her but
we’d had no support, no training, and ultimately we didn’t rec-
ognise that things weren’t going okay. She was more clever in
her deceit this time, she hid the signs better and told us what
she knew we wanted to hear. She seemed more or less okay.
She died in her sleep.” (Deputy Head).
76 per cent (n = 240) of respondents’ schools did
receive some form of training or advice; there were sev-
eral suggestions about how this training could be devel-
oped to be more effective. The most cited potential
improvement was an increase in the quantity or quality
of training [28% (n = 30)].
“She’d been out of school 6 months – a 30 min briefing prior to
her return wasn’t enough.” (Head teacher)
“We were provided with advice but it felt really generic and
didn’t answer any of our school specific questions. Above all
we were panicked about what to do at mealtimes.” (Form
tutor)
Several respondents highlighted the need for tailored
training that prepared staff to deal with the specifics of
the individual case [24% (n = 25)]:
“Every case is different, we needed to know exactly how we
could help her. Was she allowed to do PE? What should we say
if she asked to join the gymnastics team again? Did it matter
that she was spending hours on her homework? The training
didn’t answer any of these questions. It would have been help-
ful as a general session for staff but it didn’t prepare us for the
difficult journey we had ahead of us trying to keep her in recov-
ery.”(Head of pastoral care)
Other respondents felt that the training should involve
a broader range of people – including parents, pupils
and the health provider as well as teachers [16%
(n = 17)]
“In the end we managed to help him fight his illness by working
together with his parents, friends and counsellor – the training
could have been a real opportunity to get us all in a room and
figure out how we were going to do it. Instead it was just a
missed opportunity and we learnt the hard way.” (Head of PE)
Discussion
This study was the first of its size and type to investigate
school staff experiences of ED in the United Kingdom.
Participants shared a wide range of experiences and also
made recommendations about how school staff might be
best supported in helping young people with Eating Dis-
orders.
The large volume of qualitative data available in the
current study provided a high degree of insight into the
issues explored. However, the results of the current
study are based on a fairly basic content analysis – fur-
ther studies could usefully expand upon the findings.
Participant characteristics
Participants were recruited from a database of UK
school staff who had previously expressed an interest
in mental health training. Therefore, there was a sam-
pling bias, with the participants likely to have more
experience of, or interest in, mental health issues than
average. Whilst their views may not have been entirely
representative, participants were in a particularly
strong position to share insight into the experience of
supporting pupils with ED. The responses generated
were relevant, specific and included detailed descrip-
tions of personal experiences across a range of scenar-
ios.
The sample represented a wide range of schools within
the United Kingdom, with the majority of respondents
from secondary schools. This bias towards secondary
schools reflects the typical teenage onset of ED.
Participants’ roles within schools were varied and
included support staff, senior leaders and class teach-
ers. The broad spectrum of roles represented lends
weight to the representativeness of the current study.
Eating Disorder prevalence
Recent prevalence estimates in adolescents (Swanson,
Crow, Le Grange, Swendsen, & Merikangas, 2011;
Machado, Machado, Goncßalves, & Hoek, 2007) suggest
that ED affect every secondary school in the United King-
dom. Therefore, it is of importance that staff are
equipped to respond appropriately to pupils causing
concern. Our findings indicated that this is not the case,
as 40% of respondents said ‘I don’t know’ when asked
what their next steps would be if they had Eating Disor-
der concerns about a pupil. This is in line with earlier
studies (Piran, 2004), but is worrying, given the vital role
of early intervention in improving Eating Disorder out-
comes (Treasure et al., 2010).
Access to training
Majority of staff in the current sample did not have any
training about Eating Disorders and where training was
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12039 We don’t know how to help 5

6. provided it was often delivered to small numbers of staff,
limiting its reach and impact.
Lack of teacher knowledge and confidence has been
cited in past studies as a major barrier to Eating Disor-
der prevention and intervention (Price, Desmond, Price,
& Mossing, 1990; Yager & O’Dea, 2005). Those staff who
had attended training, cited an increase in Eating Disor-
der knowledge and confidence as key benefits. Partici-
pants specifically found that being briefed about Eating
Disorder warning signs was helpful and welcomed prac-
tical strategies that they could implement at school.
Some suggested that training should be more in-depth,
made more widely available and/or repeated on a regu-
lar basis. However, pressures of time and resources
available for continuing professional development and
competing demands on school staff to develop their skills
and expertise in a wide range of areas need to be consid-
ered (Kennedy & McKay, 2011).
Nearly all respondents who had not had access to ED
training said that they would welcome it. Other studies
from the United States and Canada have shown similar
results (Neumark-Sztainer et al., 1999; Piran, 2004).
School policies
Very few schools had an Eating Disorder policy in place,
either as a stand-alone policy or as part of another pol-
icy. Several respondents highlighted that a lack of stan-
dardised policies or procedures surrounding Eating
Disorder referrals could lead to pupils ‘falling through
the gaps’ with staff failing to address their concerns
appropriately. School staff may find it helpful if clear
referral pathways were set up within school with a
named person being made responsible for mental
health. Where school policies are implemented, respon-
dents made it clear that these would be effective only if
they were highly practical in nature and appropriately
disseminated with briefing or training.
Teaching students about ED
In addition to a lack of confidence in following up Eating
Disorder concerns, respondents were uneasy about the
idea of teaching lessons about ED. Their concern was
largely due to a lack of knowledge, which could be
addressed easily through training. Many of the school
staff we surveyed considered the teaching of ED inappro-
priate for students, believing that it may lead to an
increase in cases. There is evidence that some strategies
for teaching about ED may increase body dissatisfaction
or Eating Disorder symptoms (Yager, 2007; Carter,
Stewart, Dunn, & Fairburn, 1997; O’Dea, 2000). How-
ever, teaching students about ED within appropriate
guidelines or as part of a positive body image programme
should have more positive than negative outcomes
(O’Dea, 2000). This is in line with UK government recom-
mendations following a recent report, which suggested
the need for mandatory body image and self-esteem les-
sons for children at primary and secondary school (All
Parliamentary Group on Body image, 2012).
Teachers can play an important role in dispelling
myths associated with weight loss and ED and empha-
sise their severity as serious psychological disorders
(O’Dea, 2000, 2005). It is also important that pupils are
taught how to support a friend who may be causing them
concern – in a parallel study many students said that
they did not alert a member of staff about a friend’s dis-
ordered eating simply because they did not know whom
to tell and did not know whether the situation would be
taken seriously (Knightsmith et al., in press).
Student reintegration following illness
A majority of respondents reported that their school had
reintegrated a pupil into school following a period of
absence caused by an Eating Disorder, but training and
support around this issue were inconsistent. Relapse is
common in people recovering from ED (Keel & Brown,
2010), and returning to school after a period of treat-
ment can be daunting for all involved. Several partici-
pants in this study suggested that they would like
tailored help, which would inform them exactly how to
support the student who was returning. It was also sug-
gested that the school should work alongside parents
and the healthcare provider to support the pupil as a
team and that staff should be made aware of relapse
indicators. The importance of clear lines of communica-
tion with the student’s healthcare provider was high-
lighted so that the school had someone to whom they
could turn if they had concerns.
Implications and core recommendations
ED were encountered by a majority of school staff in the
current sample. Despite this, many school staff reported
that they were ill-equipped to support students at risk of,
or suffering from, ED either in the early stages of the disor-
der or during the recovery period. Many staff had received
inadequatetrainingornoneatallandwouldwelcomemore
in-depth, practical training tailored to the school environ-
ment. However, such enthusiasm for training must be
tempered with the need to fit within school curricula as
well as time and budgetary constraints. The efficacy of a
short (1 day or less), but highly focused, ED training pro-
gramme aimed specifically at school staff would be worth
exploring. Ideally, such a programme would specifically
address the most common warning signs for ED, how to
follow up on Eating Disorder concerns with students and
parents and look at ways in which schools can support
pupilsduringthe recovery period.
Some participants in the current study encouraged
the designation of a person responsible for ED (or per-
haps all mental health issues) to whom all cases should
be referred to prevent pupils falling through the gaps.
Some schools may find the adoption of a specific Eating
Disorder policy useful, providing it is highly practical in
nature and implemented effectively.
School staff felt uncomfortable teaching pupils about
ED and expressed some valid concerns. It is clear from
current research that it is possible to cause harm whilst
teaching students about ED, which has resulted in guid-
ance on what not to do (Yager, 2007). However, school
staff can play an important role in dispelling myths pur-
veyed by the media and educating young people that an
Eating Disorder is a serious psychological illness. Future
studies are needed to look at how school staff can most
appropriately teach comprehensive practical guidance
on this difficult subject.
Acknowledgements
This work was supported by the National Institute for Health
Research (NIHR) under its Programme Grants for Applied
Research Scheme (RP-PG-0606-1043). Ulrike Schmidt receives
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
6 Pooky Knightsmith, Janet Treasure, & Ulrike Schmidt Child Adolesc Ment Health 2013; *(*): **–**

7. salary support from the National Institute for Health Research
(NIHR) [Mental Health Biomedical Research Centre] at South
London and Maudsley NHS Foundation Trust and King’s Col-
lege London. The views expressed herein are not necessarily
those of the NHS, the NIHR or Department of Health. The
authors would like to thank the young people who participated
in the study, and the school staff and parents who supported.
The authors have declared that they have no competing or
potential conflicts of interest.
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Accepted for publication: 25 June 2013
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12039 We don’t know how to help 7