Background: Eating disorders (ED) have a peak rate of onset in school-aged children. Little is known about pupils’ experiences of ED within a school setting. Method: Five hundred and eleven 11- to 19-year-old school pupils completed an online questionnaire exploring their experiences of ED (72% female, 28% male). Responses were analysed using content analysis principles. Results: Of the participants, 38% had a current or past ED, 49% of these had never received a formal diagnosis. Of the respondents, 59% saw a need to raise ED awareness. Only 7% would confide in a teacher about an ED. Conclusions: Efforts are needed to break down barriers to disclosure and support teachers to play an effective role in the detection and early intervention for ED.

1. ‘My teacher saved my life’ versus ‘Teachers don’t
have a clue’: an online survey of pupils’ experiences
of eating disorders
Pooky Knightsmith, Helen Sharpe, Olivia Breen, Janet Treasure & Ulrike Schmidt
Division of Psychological Medicine, Institute of Psychiatry, King’s College London, 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
pupils’ experiences of ED within a school setting. Method: Five hundred and eleven 11- to 19-year-old school
pupils completed an online questionnaire exploring their experiences of ED (72% female, 28% male).
Responses were analysed using content analysis principles. Results: Of the participants, 38% had a current or
past ED, 49% of these had never received a formal diagnosis. Of the respondents, 59% saw a need to raise ED
awareness. Only 7% would confide in a teacher about an ED. Conclusions: Efforts are needed to break down
barriers to disclosure and support teachers to play an effective role in the detection and early intervention for
ED.
Key Practitioner Message
• Eating disorders are at their most prevalent amongst young people of secondary school age
• Early recognition and intervention lead to far more successful outcomes both short term and long term
• Teachers are in an excellent position to spot eating disorder warning signs but currently do not do so consis-
tently
• Whilst pupils feel confident in spotting eating disorder warning signs, they are reluctant to report concerns to a
teacher due to fears around confidentiality, inappropriate reactions and perceived stigma
• Teachers and peers can play an important role in eating disorder recognition and recovery; improved education
and training is needed for both school staff and students in order for this potential to be realised
Keywords: Anorexia; bulimia; binge-eating disorder; eating disorders; teacher; school
Introduction
Eating disorders (ED) affect a significant proportion of
the school population; they are most likely to strike
between the ages of 10 and 19 (Currin, Schmidt, Trea-
sure, & Jick, 2005). A recent study found the median
ages at onset of anorexia nervosa (AN), bulimia nervosa
(BN) and binge-eating disorder (BED), were 12.3, 12.4
and 12.6 years, respectively, with lifetime prevalence
estimates AN .3%, BN .9% and BED 1.6%, respectively
(Swanson, Crow, Le Grange, Swendsen, & Merikangas,
2011). Up to a further 2.37% of 12- to 23-year-old
females may meet the criteria for ED not otherwise speci-
fied (Machado, Machado, Goncßalves, & Hoek, 2007).
Early recognition of ED is key in ensuring successful
long-term outcomes (Treasure, Claudino, & Zucker,
2010), and poor mental health literacy regarding the effi-
cacy of treatments has been presented as a barrier to
treatment seeking (Mond, Hay, Rodgers, & Owen, 2008).
As such, schools potentially have an important role to
play in ED detection and early intervention. Pupils and
teachers are in an excellent position to notice the physi-
cal and behavioural changes that accompany the early
stages of ED (McVey, Lieberman, Voorberg, Wardrope, &
Blackmore, 2003; Neumark-Sztainer, 1996; Shaw,
Stice, & Becker, 2009). Unfortunately, ED mental health
literacy in adolescents may be low (Mond et al., 2007),
and the knowledge and confidence of school staff,
regarding ED recognition and support is a cause for con-
cern (Price, Desmond, Price, & Mossing, 1990; Yager &
O’Dea, 2005). Many staff would welcome more training
in this area (Neumark-Sztainer, Story, & Coller, 1999;
Piran, 2004).
There has been little research reported into pupil
experiences of ED, although some studies have explored
pupil experiences of weight-related issues (Haines, Neu-
mark-Sztainer, & Thiel, 2007) and the precursors of ED
(Sharpe, Damazer, Treasure, & Schmidt, in press). This
study aimed to evaluate pupil understanding of ED, to
determine the common course of action for a pupil who
believed a friend was suffering and to understand the
school’s role in working with sufferers from a pupil’s
point of view. Finally, we aimed to generate recommen-
dations from pupils about how schools could improve
the support they offer to pupils’ suffering or recovering
from ED.
© 2013 The Authors. Child and Adolescent Mental Health. © 2013 Association for Child and Adolescent Mental Health.
Published by John Wiley & Sons, 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.12027

2. Methods
Design
The study consisted of an anonymous online question-
naire aimed at adolescents in UK secondary schools. A
convenience sample of 23 institutions was recruited and
pupils within those institutions were invited to partici-
pate.
Institutional Review Board approval and informed
consent procedures
Ethical approval was obtained from King’s College Lon-
don Research Ethics Committee (Ref PNM/09/10-110).
Opt-in written informed consent was obtained from stu-
dents’ parents. For those students with parental con-
sent, verbal informed assent was also obtained.
Survey content
The survey explored student experiences of ED in school
and their perceptions of how their school could support
students with ED, and finally what ideas they had about
how schools could become more supportive to sufferers.
Development and pretesting
The online questionnaire was developed following con-
sultation with teachers and pupils. An initial version
was piloted with 25 pupils. No technical problems or dif-
ficulties in comprehension were reported.
Recruitment process
Twenty-three Mainstream Secondary Schools and Fur-
ther Education Colleges from throughout the United
Kingdom were approached. Twenty-one institutions par-
ticipated in the study, including state, private, single
sex, co-educational, high achieving and low achieving
schools. Participating schools advertised the online
questionnaires to their students.
Pupils were eligible for inclusion if they were aged
between 11 and 19 and they currently attended a partici-
pating institution. A total of 511 pupils took part in the
study.
Survey administration
The study consisted of an anonymous self-report online
questionnaire, which took between 10 and 30 min to
complete. Participation was voluntary and no incentives
were offered for participation. The data were collected
between February and April 2010.
The questionnaires were hosted on a nonpassword
protected survey website. Computers were prepared in
advance of students’ arriving at their school’s IT rooms.
The questionnaires consisted of the information sheet
and 13 questionnaire items which appeared on separate
screens. Only questions relating to the participant’s age
and gender were compulsory. There was no randomisa-
tion of items.
There was no technical method of preventing multiple
entries from students but multiple entries would have
been unlikely as students completed the questionnaires
under supervision and were not provided with the web
address.
Analysis
The questionnaire generated both quantitative and qual-
itative data. The quantitative data were responses to
multiple choice questions. These data were summed and
the raw number of responses calculated for each item
was recorded as well as a percentage. When not all par-
ticipants recorded a response to a question, the percent-
ages were calculated according to the number of
respondents to the specific question.
Much of the data the questionnaire 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 (Flick, 1998; May-
ring, 2004; Weber, 1990).
A comprehensive coding system was developed by
analysing responses and classifying them into catego-
ries. A second researcher independently coded the data
using the coding system, blind to the original coding
decisions with an inter-rater reliability of 94% (1185 of
1261 coding decision were identical). Where there was
discrepancy between the two coders (n = 74), this was
generally the result of one researcher placing a response
in more categories than the other researcher. The eight
instances where the researchers did not agree on the pri-
mary category for a response were easily resolved.
Results
Demographic information
A total of 511 pupils aged 11–19 years (M = 15.4 years,
SD = 2.3) have participated. Participants came from
state schools (n = 420), independent schools (n = 74)
and home schools (n = 17). Independent schools were
slightly over-represented and female students were sub-
stantially over-represented (see Table 1). An estimated
1300 pupils were invited to participate in the study with
a response rate of 39%.
A large proportion of participants [38% (n = 195)]
endorsed either currently having an ED or having recov-
ered from one, 49% (n = 96) of these had never received a
diagnosis. Of the participants, 53% (n = 269) had a
friend who had suffered from an ED. Of the participants,
23% (n = 115) had not had an ED themselves and did
not have a friend who had ever suffered from one.
Pupils’ experiences and recommendations
Results from the closed questions are summarised in
Table 2, and free text responses are summarised in
Table 3. In this section, the two forms of data are drawn
together under the general themes that were identified.
Three themes emerged from the content analysis of
the free text responses. These were as follows:
1Picking up the signs: improving education for staff and
students.
2Encouraging disclosure and providing support.
3Management and integration: promoting recovery in
school.
Picking up the signs: improving education for staff
and students
Most pupils in this sample [79% (n = 361)] were confi-
dent that they would recognise ED symptoms, 56%
(n = 257) had recognised the signs in the past. Of the
30% of pupils who had been taught about ED at school,
82% (n = 124) felt the training could have been
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
2 Pooky Knightsmith et al. Child Adolesc Ment Health 2013; *(*): **–**

3. improved. The most common recommendation from
pupils was that both staff and pupils would benefit from
improved ED education. Of the pupils, 16% (n = 46)
made some reference to staff having little or no knowl-
edge about ED.
Teachers don’t have a clue about stuff like eating disorders.
(Male, 14)
Of the respondents, 59% (n = 185) suggested that
raising pupil awareness of ED would be helpful, both in
terms of reducing the associated stigma and in giving
young people the confidence to pick up warning signs in
friends and to respond appropriately.
People would bully less if they really understood. (Female, 12)
How do I know if my friend’s got an eating disorder, and what
should I do if she has? (Female, 14)
Encouraging disclosures and providing support
Only 7% (n = 33) of pupils said they would talk to a tea-
cher if they were concerned a friend might have an ED.
By far, the most prevalent reasons for not talking to a
teacher were that teachers either would not take it seri-
ously, over-react or fail to treat the matter in confidence.
They’d probably just laugh or say I was making it up for atten-
tion or something. (Female, 12)
There was also concern about the perceived stigma
associated with ED both from teachers:
My friend would go crazy if I told a teacher, cos once they
know they treat you like a right freak. (Female 12)
and peers:
What if I told a teacher, and they blabbed and everyone found
out? No one would want to talk to her and she’d get bullied.
(Female, 13)
The thing that most concerned pupils was the issue of
confidentiality. Of the pupils, 55% (n = 278) mentioned
trust or confidentiality as an issue, most often saying
that they would ‘not share concerns with a teacher
because they were worried that a teacher would inform
parents’.
Teachers go blabbing to parents before you can blink. (Male,
15)
Table 1. Demographics of current study vs national school averages
Independent school pupils State school pupils Girls Boys
National average 9% (n = 3,504,665) 91% (n = 3,182,130) 50% (n = 1,735,865) 50% (n = 1,735,865)
This study 15% (n = 74) 85% (n = 420) 72% (n = 370) 28% (n = 141)
Figures from Clarke (2012).
Table 2. Summary of pupil responses to eating disorders (ED) experience survey – closed questions
Are you able to spot the
signs of an ED
Yes – I have in
the past
Yes – I know the
signs
Unsure No
458 respondents 257 (56%) 104 (23%) 64 (14%) 33 (7%)
Has your school ever
taught you about ED
and was it helpful?
Taught –
helpful
Taught – not
helpful
Not taught Unsure
499 respondents 27 (5%) 124 (25%) 332 (67%) 16 (3%)
If you were worried that a
friend might be
suffering from an ED,
what would you do?
Try to help if
my friend
approached me
Approach my
friend and
offer help
Talk to a
teacher
Let a teacher
know
anonymously
Talk to an adult
out of school
Wait and see
505 respondents 137 (27%) 263 (52%) 33 (7%) 15 (3%) 29 (6%) 28 (6%)
If you told a teacher that
you were concerned
about a friend, what
would you want them to do?
Talk to
my friend
Help me help
my friend
Tell my
friend’s
parents
Get help
from a
counsellor or
doctor
Listen
479 respondents 122 (25%) 216 (45%) 11 (2%) 78 (16%) 52 (11%)
If you told a teacher that
you were concerned
about a friend, what do
you think they would
actually do?
Talk to
my friend
Help me help
my friend
Tell my
friend’s
parents
Get help
from a
counsellor
or doctor
Listen
474 respondents 106 (22%) 24 (5%) 229 (48%) 50 (11%) 65 (14%)
How would you most like
to raise concerns about a
friend with a teacher?
Face to face On the phone Text/SMS/IM Email/in
writing
461 respondents 337 (73%) 5 (1%) 17 (4%) 102 (22%)
If you were suffering
from an ED do you think
your school would be a
safe and supportive
place to recover?
Strongly agree Agree Neutral Disagree Strongly
disagree
504 respondents 12 (2%) 41 (8%) 81 (16%) 133 (26%) 237 (47%)
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12027 My teacher saved my life 3

4. Reports suggested that communication with parents
was not always handled well:
Her Mum came storming in saying I’d been spreading
rumours about her. They could at least of warned me they
were gonna ring her. (Female, 16)
In well managed situations, parental involvement
proved very positive:
We agreed what to tell her mum and she came straight to
school. Within an hour of me telling my teacher, we were all
sitting down together. We all cried. It was kind of weird but by
the end of the meeting I was really glad I’d said something.
(Male, 15)
If they were to tell a teacher, 73% (n = 337) of pupils
would prefer to discuss ED concerns face to face, far
exceeding the number of pupils who would prefer to
communicate in writing/email (22%; n = 102), on the
phone, or by text (5%; n = 22). Being able to raise con-
cerns about friends is also important:
We thought she was going to die and maybe it was our fault. If
someone had talked to us then we might have known how to
support our friend. (Female, 16)
The ability to receive support from nonteaching school
staff, such as counsellors was perceived as helpful:
Someone who we could talk to would be good. Not a teacher –
you don’t want to go and learn maths off someone who you’ve
just been talking to about all your deepest worries. A counsel-
lor would be better. (Male, 14)
Several examples of good practice were reported by
students:
You can make an appointment to see a teacher. No one knows
you’re going [it was a secure online appointment booking sys-
tem] and you know it’s just your time with them. (Female, 14).
Every half term, we all get a ten minute private meeting with
our form tutor. Normally I didn’t have much to say but this
time I did and I was glad I could say it in private to my form
tutor. (Male, 15)
Forty-nine pupils outlined highly positive situations,
which demonstrated the important role school staff can
play in supporting pupils with ED.
I had an amazing teacher who really cared and noticed the
signs. She helped me through a lot. (Female, 16)
Four pupils stated that they did not think they would
be alive today if it had not been for the support of specific
teachers.
She knew I needed help and she offered it. I was in a really bad
place. I don’t think it’s going too far if I say that my teacher
saved my life. (Female, 16)
Management and integration: promoting recovery
in school
Whereas the first three themes focused more clearly on
picking up signs and symptoms of ED, pupils also raised
issues of managing those with ED in the school setting,
particularly for those who had had to take some time
away because of the illness.
Only 1 in 10 (n = 53) pupils considered their school
would provide a supportive environment for someone
recovering from an ED. Difficulties arose in bullying from
other students as well as staff being unsure as how best
to manage the return to school.
Table3.Summaryofpupilresponsestoeatingdisorders(ED)experiencesurvey–freetext
Howschoolcould
helpstudents
understandED
Educate
peers
Better
services
inschool
Increase
openness
aboutED
Educate
teachers
Beless
judgemental
Teacherstake
morecaring
approach
Schoolcannot
help
Improveaccess
toservicesinschool
Betterresources
351respondents185(59%)68(22%)22(7%)19(14%)18(7%)16(6%)10(4%)9(3%)4(1%)
Howschoolcould
bettersupport
duringrecovery
Reduce
stigma
Tailored
support
Accessto
professional
support
NothingSupportgroupsConfidentialityPeermentorsPromoteschool
services
342respondents133(43%)72(23%)46(15%)27(9%)25(8%)20(6%)12(4%)7(2%)
Howschoolhas
helped
Referralto
professional
Supportive
staff
Contacted
parents
Flexible
schooling
On-goingsupport
169respondents67(22%)63(20%)19(6%)10(3%)10(3%)
Negativeschool
experiences
Staffdidnot
notice
PunishmentFailedto
consult
student
Pooraccessto
professional
help
Broke
confidentiality
JudgementalLackof
knowledge
Problemswith
theservices
Negativeexperience
notexpandedupon
321respondents89(27%)31(10%)31(10%)27(8%)21(6%)12(4%)10(3%)8(2%)92(28%)
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
4 Pooky Knightsmith et al. Child Adolesc Ment Health 2013; *(*): **–**

5. If you’re different in any way you get bullied and that includes
the anorexics. (Female, 12)
They were trying to be nice but I was being treated like a freak
and a weirdo. (Female, 13)
Just let me forget. Give me detentions and too much home-
work. I just want to be a normal kid now. (Male, 16)
One incident in which a pupil committed suicide fol-
lowing a failed attempt at reintegration into school fol-
lowing a period of absence due to an ED was outlined.
Maybe he was always going to kill himself, but I think that if
someone at school had done more, maybe he’d still be here.
(Male, 19)
In contrast, several pupils who had recovered from ED
outlined how important their school was in providing a
supportive environment.
My school was great. Our home would always be the place
where I’d been ill, but school wasn’t like that. I could start
again as the new me, it was like an escape. (Female, 17)
The most often used words to describe the ideal
approach from teachers were honest (n = 71), open
(n = 19), nonjudgemental (n = 23) and approachable
(n = 29).
Discussion
This study is the first to investigate pupils’ experiences
of ED in UK schools. Pupils shared a wide range of expe-
riences and many constructive recommendations about
how schools could offer better support in future. A nota-
ble strength of this study was the inclusion of male par-
ticipants, as previous research in this area has been
largely confined to females (Mond & Arrighi, 2011). A
limitation of this study is that it exclusively included
pupil responses. Future studies which include school
staff or parent responses could further our understand-
ing.
Participant characteristics and data quality
The prevalence of self-reported ED in this study was high
(38%) and females were over-represented. This preva-
lence is similar to other studies with self-selecting sam-
ples: Mond et al. (2007) report 29% with past or current
BN. Most likely these figures demonstrate a sampling
bias towards eating disordered participants and/or a
tendency for participants to overstate their levels of ED
psychopathology. Teachers, parents and pupils were
aware that the aim of the research was to gain a better
understanding of pupils’ experiences of ED, meaning
that those with particular experiences may have been
especially drawn to participating.
Whilst the sample is unlikely to be representative of
the general UK school population where ED prevalence
is estimated at less than 3% (Machado et al., 2007), the
self-selected sample was in a particularly strong position
to share insight into the experiences of pupils with ED.
The responses generated were relevant, specific and
included detailed descriptions of personal experiences
across a range of scenarios.
Pupil experiences
ED education. Less than a third of participants had
been taught about ED. The majority of pupils said they
would like to learn more about ED but felt that their
teachers needed to be trained as well. Given the limited
knowledge about ED demonstrated by some teachers in
existing studies (O’Dea & Abraham, 2001), these con-
cerns are likely to reflect genuine training needs of sec-
ondary school staff. Pupils felt that training for both
pupils and teachers should focus on raising awareness
of ED, reducing the stigma associated with them and
making sure that pupils were aware of what services
were available to help them if they or a friend had an ED.
The perceived lack of knowledge and awareness about
ED is in line with previous study showing that adoles-
cents have poor mental health literacy in this area (Mond
et al., 2007). In principle, proposed benefits of improved
mental health literacy could be: (a) prevention, (b) inter-
vention and (c) detection or improved help-seeking for
ED. Expected benefits of psycho-education for the pre-
vention of ED have not been found (Stice, Shaw, & Marti,
2007). There are also mixed findings regarding the effi-
cacy of mental health literacy interventions for adult
women with ED in improving symptoms and help-seek-
ing (Hay et al., 2007, 2011). The fact that those with ED
report especially poor knowledge about the most helpful
avenues for treatment (Mond et al., 2010) underlines the
importance of improving mental health literacy in those
in a position to detect problems early in schools – peers
and teachers – and to give them the tools to provide accu-
rate support and advice to those students who are show-
ing signs of a problem.
Further study needs to go into identifying exactly what
a successful ED education programme for staff and
pupils should look like, and study will need to be per-
formed to ensure that teachers have a thorough under-
standing of ED and are able to answer pupils’ questions
and foster an environment of mutual respect between
pupils, including those with ED. Although many psycho-
education programmes have demonstrated significant
improvements in pupil and staff knowledge about ED
(Franko et al., 2005; Killen et al., 1993; McVey, Gusella,
Tweed, & Ferrari, 2008), it is not known whether these
changes translate into greater student help-seeking and
improved perceptions of the supportiveness of the school
environment. Previous reports on the role of school staff
in the identification of ED in schools have highlighted
the importance of staff training in this area as well as
addressing teachers’ own attitudes towards weight,
shape and eating that may influence their ability to be
positive role models within the classroom (Paxton,
Schutz, Wertheim, & Muir, 1999; Piran, 2004).
Barriers to disclosure. Pupils were highly concerned
about the issue of confidentiality. Many said that they
would not talk to a teacher about ED concerns because
they were worried that a teacher would break their confi-
dence and inform parents. This is in line with previous
research reporting that only 2% adolescents would con-
sider approaching a teacher in the first instance when
concerned about an individual with bulimia (Mond
et al., 2007).
This is a very difficult issue to address, as teachers are
not legally allowed to keep matters confidential if a
child’s welfare is at risk. Added to that is the fact that a
minor cannot easily be referred for treatment without
parental consent. Serious thought needs to be given to
how this situation can best be managed so the contact
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12027 My teacher saved my life 5

6. between pupils, parents and school is more positive.
Good communication appears to be central to this issue,
both in terms of pupils understanding why parental
involvement is essential, and so that staff and parents
can work together with students and their friends to find
a solution.
There were several examples of good practice where
parental contact was undertaken collaboratively. Where
parents are to be informed, this should be discussed
with the pupil concerned first. Where possible, their con-
sent should be sought and the pupil and teacher should
be in agreement about what the parent will be told. Ide-
ally, the pupil, parent and teacher should then meet as
soon as possible so that they can work together as a
team.
Another reason why pupils would not share ED con-
cerns was the logistical problem of being able to speak
privately to a teacher. Some schools used strategies for
getting around this common problem such as allowing
pupils to book private appointments with a teacher or
scheduling regular one to ones with form tutors for all
pupils. Pupils spoke positively of these initiatives, which
could be adapted for use in other schools.
A further barrier to disclosure was the perceived
stigma surrounding ED – both from teachers and stu-
dents. This concern is likely to be valid as stigma associ-
ated with eating disordered behaviour has been
demonstrated in previous studies (Bowers, Manion, Pa-
padopoulos, & Gauvreau, 2012; Crisafulli, Thompson-
Brenner, Franko, Eddy, & Herzog, 2010; Mond, Robert-
son-Smith, & Vitere, 2006) and suggests a need for
improved mental health literacy of both students and
staff.
Creating a supportive environment. A supportive envi-
ronment can result in a far better long-term prognosis
for young people with an ED (Wade, Wilksch, & Lee,
2012) and the school can play an important role in work-
ing with families to support young people receiving/who
have received treatment. Whilst some pupils felt strongly
that their school provided a supportive environment for
pupils recovering from an ED, the majority did not. The
key issue highlighted by pupils was that ED led to bully-
ing, teasing or being treated differently both by pupils
and staff. This is in line with previous research suggest-
ing that although 69% of teachers reported noticing
weight-related teasing in the classroom, only 32% had
attempted to address the issue (Piran, 2004). It is vital
that teachers are aware that weight-related teasing is
not benign, and that ED sufferers may be particularly
vulnerable to these forms of teasing. Ideally, schools
should employ zero tolerance policies – both for pupils
and teachers and attempt to eradicate any teasing or
bullying on the basis of shape or weight.
That said, it is worth bearing in mind that pupils also
highlighted their dislike of being treated with kid gloves
during recovery. The overriding feeling was one of want-
ing to get back to normal. This is something that should
be discussed with each individual recovering from an ED
but the assumption should not be that pupils need out-
wardly special treatment. Improvements in both staff
and student knowledge about ED should be helpful in
building confidence to support those recovering from
these conditions without being overly protective and
inadvertently acting as a barrier to integration into nor-
mal school life.
Implications and core recommendations
Pupils can be an excellent source of early disclosures
about ED in their peers, and schools have the potential
to provide a supportive environment for those recover-
ing. This study indicates that in neither instance is this
potential consistently being realised. Improved educa-
tion and training about ED for both teachers and pupils
was implicated as the key means by which progress may
be made. This training could draw on the best practice
and positive experiences outlined during the current
research. Training for teachers, in addition to focusing
on recognition of ED in pupils, needs to include develop-
ment of skills on how to communicate concerns and how
to manage difficult situations around ED as they arise.
Much progress has been made in recent years in under-
standing the needs of parents of young people with ED
(Murphy et al., 2004; Perkins, Winn, Murray, Murphy,
& Schmidt, 2004; Kyriacou, Treasure, & Schmidt,
2008a, 2008b; Winn et al., 2007) and internet-, DVD-
and book-based interventions have been developed
training parents with relevant skills for supporting their
child with an ED effectively on their journey to recovery
(Goddard et al., 2011; Grover et al., 2011). Training for
teachers could be developed along similar lines and such
work is currently in progress (Eating Disorders Pocket-
book, Knightsmith, 2013).
Acknowledgements
The authors would like to thank the young people who partici-
pated in the study, and the school staff and parents who sup-
ported.
This study 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
salary support from the NIHR [Mental Health Biomedical
Research Centre] at South London and Maudsley NHS Founda-
tion Trust and King’s College London. The views expressed
herein are not necessarily those of the NHS, the NIHR or Depart-
ment of Health.
References
Bowers, H., Manion, I., Papadopoulos, D., & Gauvreau, E.
(2012). Stigma in school-based mental health: Perceptions of
young people and service providers. Child and Adolescent
Mental Health. (in press).
Clarke, A. (2012). Schools, pupils, and their characteristics
(2012). Department for Education accessed online: http://
dera.ioe.ac.uk/14745/1/sfr10-2012.pdf.
Crisafulli, M.A., Thompson-Brenner, H., Franko, D.L., Eddy,
K.T., & Herzog, D.B. (2010). Stigmatization of anorexia nerv-
osa: Characteristics and response to intervention. Journal of
Social and Clinical Psychology, 29, 756–770.
Currin, L., Schmidt, U., Treasure, J., & Jick, H. (2005). Time
trends in eating disorder incidence. British Journal of Psychi-
atry, 186, 132–135.
Flick, U. (1998). An introduction to qualitative research. Lon-
don: Sage, 192.
Franko, D.L., Mintz, L.B., Villapiano, M., Green, T.C., Mainelli,
D., Folensbee, L., & Budman, S.H. (2005). Food, mood, and
attitude: Reducing risk for eating disorders in college women.
Health Psychology, 24, 567–578.
Goddard, E., Macdonald, P., Sepulveda, A.R., Naumann, U.,
Landau, S., Schmidt, U., & Treasure, J. (2011). Cognitive
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
6 Pooky Knightsmith et al. Child Adolesc Ment Health 2013; *(*): **–**

7. interpersonal maintenance model of eating disorders: Inter-
vention for carers. British Journal of Psychiatry, 199, 225–
31.
Grover, M., Naumann, U., Mohammad-Dar, L., Glennon, D.,
Ringwood, S., Eisler, I., … & Schmidt, U. (2011). A random-
ized controlled trial of an Internet-based cognitive-behaviour-
al skills package for carers of people with anorexia nervosa.
Psychological Medicine, 20, 1–11.
Haines, J., Neumark-Sztainer, D., & Thiel, L. (2007). Address-
ing weight-related issues in an elementary school: What do
students, parents, and school staff recommend? Eating Disor-
ders, 15, 5–21.
Hay, P., Mond, J., Buttner, P., Paxton, S., Rodgers, B., Quirk,
F., & Kancijanic, D. (2011). Targeted prevention in bulimic
eating disorders: Randomized controlled trials of a mental
health literacy and self-help intervention. In P. Hay (Ed.), New
insights into the prevention and treatment of bulimia nervosa
(pp. 69–84). Rijeka, Croatia: InTech.
Hay, P., Mond, J., Paxton, S., Rodgers, B., Darby, A., & Owen,
C. (2007). What are the effects of providing evidence-based
information on eating disorders and their treatments? A ran-
domized controlled trial in a symptomatic community sam-
ple. Early Intervention in Psychiatry, 1, 316–324.
Killen, J.D., Taylor, C.B., Hammer, L.D., Litt, I., Wilson, D.M.,
Rich, T., & Varady, A. (1993). An attempt to modify unhealth-
ful eating attitudes and weight regulation practices of young
adolescent girls. International Journal of Eating Disorders, 13,
369–384.
Knightsmith, P. (2013). Eating disorders pocketbook. Hamp-
shire: Teachers’ Pocketbooks.
Kyriacou, O., Treasure, J., & Schmidt, U. (2008a). Understand-
ing how parents cope with living with someone with anorexia
nervosa: Modelling the factors that are associated with carer
distress. International Journal of Eating Disorders, 41, 233–
242.
Kyriacou, O., Treasure, J., & Schmidt, U. (2008b). Expressed
emotion in eating disorders assessed via self-report: An
examination of factors associated with expressed emotion in
carers of people with anorexia nervosa in comparison to con-
trol families. International Journal of Eating Disorders, 41,
37–46.
Machado, P.P.P., Machado, B.C., Goncßalves, S., & Hoek,
H.W. (2007). The prevalence of eating disorders not other-
wise specified. International Journal of Eating Disorders,
40, 212–217.
Mayring, P. (2004). Qualitative content analysis. In U. Flick, E.
von Kardoff & I. Steinke (Eds.), A companion to qualitative
research (p. 2). London: Sage.
McVey, G., Gusella, J., Tweed, S., & Ferrari, M. (2008). A con-
trolled evaluation of web-based training for teachers and
public health practitioners on the prevention of eating disor-
ders. Eating Disorders, 17, 1–26.
McVey, G.L., Lieberman, M., Voorberg, N., Wardrope, D., &
Blackmore, E. (2003). School-based peer support groups: A
new approach to the prevention of disordered eating. Eating
Disorders, 11, 169–185.
Mond, J.M., & Arrighi, A. (2011). Gender differences in percep-
tions of the severity and prevalence of eating disorders. Early
Intervention in Psychiatry, 5, 41–49.
Mond, J.M., Hay, P.J., Paxton, S.J., Rodgers, B., Darby, A., Nill-
son, J., … & Owen, C. (2010). Eating disorders “mental health
literacy” in low risk, high risk and symptomatic women:
Implications for health promotion programs. Eating Disor-
ders, 18, 267–285.
Mond, J.M., Hay, P., Rodgers, B., & Owen, C. (2008). Mental
health literacy and eating disorders: What do women with
bulimic eating disorders think and know about bulimia nerv-
osa and its treatment? Journal of Mental Health, 17, 565–
575.
Mond, J.M., Marks, P., Hay, P.J., Rodgers, B., Kelly, C., & Owen,
C. (2007). Mental health literacy and eating-disordered
behavior: Beliefs of adolescent girls concerning the treatment
of and treatment-seeking for bulimia nervosa. Journal of
Youth and Adolescence, 36, 753–762.
Mond, J.M., Robertson-Smith, G., & Vitere, A. (2006). Stigma
and eating disorders: Is there evidence of negative attitudes
towards individuals suffering from anorexia nervosa? pp.
519–532.
Murphy, R., Frost, S., Webster, P., & Schmidt, U. (2004). An
evaluation of web-based information. International Journal of
Eating Disorders, 35, 145–154.
Neumark-Sztainer, D. (1996). School-based programs for pre-
venting eating disturbances. Journal of School Health, 66,
64–71.
Neumark-Sztainer, D., Story, M., & Coller, T. (1999). Percep-
tions of secondary school staff toward the implementation of
school-based activities to prevent weight-related disorders: A
needs assessment. American Journal of Health Promotion, 13,
153–156.
O’Dea, J.A., & Abraham, S. (2001). Knowledge, beliefs, atti-
tudes, and behaviors related to weight control, eating disor-
ders, and body image in Australian trainee home economics
and physical education teachers. Journal of Nutrition Educa-
tion and Behavior, 33, 332–340.
Paxton, S.J., Schutz, H.K., Wertheim, E.H., & Muir, S.L. (1999).
Friendship clique and peer influences on body image con-
cerns, dietary restraint, extreme weight-loss behaviors, and
binge eating in adolescent girls. Journal of Abnormal Psychol-
ogy, 108, 255–266.
Perkins, S., Winn, S., Murray, J., Murphy, R., & Schmidt, U.
(2004). A qualitative study of the experience of caring for a
person with bulimia nervosa. Part 1: The emotional impact of
caring. International Journal of Eating Disorders, 36, 256–
268.
Piran, N. (2004). Prevention series. Teachers: On “being” (rather
than “doing”) prevention. Eating Disorders: The Journal of
Treatment and Prevention, 12, 1–9.
Price, J.A., Desmond, S.M., Price, J.H., & Mossing, A. (1990).
School counselors’ knowledge of eating disorders. Adoles-
cence, 25, 945–957.
Sharpe, H., Damazer, K., Treasure, J., & Schmidt, U. (in press).
What are adolescents experiences of body dissatisfaction and
dieting, and what do they recommend for prevention? A quali-
tative study. Eating and Weight Disorders.
Shaw, H., Stice, E., & Becker, C.B. (2009). Preventing eating
disorders. Child and Adolescent Psychiatric Clinics of North
America, 18, 199–207.
Stice, E., Shaw, H., & Marti, C.N. (2007). A meta-analytic review
of eating disorder prevention programs: Encouraging find-
ings. Annual Review of Clinical Psychology, 3, 207–231.
Swanson, S.A., Crow, S.J., Le Grange, D., Swendsen, J., & Meri-
kangas, K.R. (2011). Prevalence and correlates of eating dis-
orders in adolescents: Results from the national comorbidity
survey replication adolescent supplement. Archives of Gen-
eral Psychiatry, 68, 714–723.
Treasure, J., Claudino, A.M., & Zucker, N. (2010). Eating disor-
ders. The Lancet, 375, 583–593.
Wade, T.D., Wilksch, S.M., & Lee, C. (2012). A longitudinal
investigation of the impact of disordered eating on young
women’s quality of life. Health Psychology, 31, 352–359.
Weber, R.P. (1990). Content classification and interpretation.
Basic content analysis (2nd edn). Thousand Oaks, CA: Sage,
15–16.
Winn, S., Perkins, S., Walwyn, R., Schmidt, U., Eisler, I., Trea-
sure, J., … & Yi, I. (2007). Predictors of mental health prob-
lems and negative caregiving experiences in carers of
adolescents with bulimia nervosa. International Journal of
Eating Disorders, 40, 171–178.
Yager, Z. & O’Dea, J.A. (2005). The role of teachers and other
educators in the prevention of eating disorders and child
obesity: What are the issues? Eating Disorders, 13, 261–278.
Accepted for publication: 7 February 2013
© 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12027 My teacher saved my life 7