At Maudsley Parents, we often receive questions from worried parents. In our new column, we turn to leading eating disorder experts for answers. Do you have a question you'd like answered in a future column? Please write us experts@maudsleyparents.org
My daughter is 15. I think she is at a healthy weight. However, she does display disordered eating such as going a whole school day without eating and then eating steadily from after school until bedtime. She is somewhat restrictive in her habits and what foods she is comfortable eating.
We are in therapy and the Maudsley method was suggested. We have had two sessions but are having trouble doing our part at home. I am not sure if this method is required or appropriate, as she does not really need to gain weight, but certainly needs help with her relationship with food and her body image.
As expected, she is balking at having us say when and what to eat.
Can you comment whether the Maudsley approach is best or should we be looking at other types of therapy (for her or us as a family).
Katharine Loeb, PhD responds:
You are asking exactly the right question; since your daughter’s troubling behavior around eating and mindset about her body do not reflect the classic diagnosable eating disorders (anorexia nervosa, bulimia nervosa) for which the Maudsley method has been explicitly tested, is this the right approach for your family? The answer is that aspects of family-based treatment could be very helpful for your adolescent, but the specific strategies need to match her symptoms. Parenthetically, you say that she is not underweight, but if she has lost weight via unhealthy dieting practices (while still remaining within a normal range), she may regain some in response to your efforts. Regardless, her restrictive dietary practices - in terms of types of food she is willing to eat and frequency of eating - can carry some negative health implications in their own right, as well as put her at risk for worsening eating disorder symptoms. In addition, severe dietary restriction typically does not alleviate shape and weight concerns in the long run, but instead can potentiate disturbance in body image. Finally, her restriction appears to be leading to a feast-famine pattern wherein she starves herself during the day and then eats throughout the evening – possibly amounts and patterns that may constitute binge eating. Binge eating in turn can heighten shape and weight concerns and prompt further conviction to diet severely. Your daughter can benefit from your help in stopping this vicious cycle. A first step is to provide the scaffolding for your daughter to return to healthier eating habits by setting clear expectations for regular meals and snacks and the consumption of a wide range of foods. You can help manage her temptation to skip meals by providing supportive supervision as well as support in re-introducing anxiety-provoking foods. This can be accomplished more collaboratively than with a child in the throes of severe anorexia nervosa, where the illness is highly influential and extremely irrational. A point for you and your daughter to keep in mind is that she is probably consuming more calories than she intends to in the evening, and you will help her redistribute these in a manner that will protect her from eating episodes during which she feels out of control (such as what may be occurring at night). These strategies are consistent with cognitive behavioral therapy (CBT) as well, but parents assuming some of the responsibility for implementation of treatment techniques reflects the Maudsley framework. If your daughter’s body image issues persist to a concerning level following stabilization of her eating habits for a reasonable period of time, you could also consider CBT to address any residual shape and weight concerns.
My daughter is 12 and has anorexia. Using the Maudsley FBT approach, she is starting to gain back weight. She is very anxious about the weight gain and is complaining of feeling fat, not fitting into clothes, etc. Is there advice on how to address her anxiety as she gains weight? My fear is that she will regress into some of the disturbing negative behaviors she exhibited when we first began re-feeding.
Katharine Loeb, PhD responds:
First, congratulations on accomplishing some weight restoration as a family. Your questions are excellent – how can you manage your daughter’s corresponding anxiety about her weight and shape as you persist in your refeeding efforts? And more importantly, will heightening her anxiety inadvertently set your progress back by increasing resistance? I will address these in reverse. While it may seem that you are making the situation worse by potentiating her shape and weight concerns, you are not. As a field, we have not been able to successfully convince patients with anorexia nervosa to eat by working on body image first; conversely, food is medicine, and weight gain to a point of the body returning to normal functioning (physiologically, and especially hormonally) provides the best chance for the cognitive distress to lessen. While there are no good research data to support this, my clinical experience is that the time from weight restoration to this psychological relief is positively correlated with duration of illness. If you use your daughter’s anxiety to guide your efforts at nutritional rehabilitation, she is unlikely to gain weight and be able to put this pernicious illness behind her. In response to your first question, the best way to respond to her anxiety is with empathy and an emphasis on the distinction between the anorexia nervosa and herself. For example, you might say, “I’m sorry that the illness is torturing you like this, making you feel bad about my helping you become healthy again. Telling you you’re fat is one of anorexia nervosa’s tricks to try to get you to stop eating again, but I am here to make sure it doesn’t win. Soon you will not feel like this anymore.”
Katharine Loeb, PhD
Dr. Loeb is Associate Professor of Psychology at Fairleigh Dickinson University, Director of Research at the Eating and Weight Disorders Program at Mount Sinai School of Medicine, and serves as Clinical Advisor to Maudsley Parents.
My daughter is in the refeeding process, and is doing very well. She’s gained about half the weight she lost. Her treatment provider, who specializes in the Maudsley approach, says she will probably have to gain all her lost weight back, plus a few pounds.
How do we determine how much she will need to gain? She was never fat by any standard, but she was near the top of the healthy range for the height/weight charts. But right now she is happy with her body, she is back within the healthy weight range as defined by all of the height/weight charts, and she is having menstrual cramps, though has not started menstruating yet.
Does she really need to gain all of the weight back plus some, in order to not relapse? I'm afraid that by pushing her to be at the top of her weight range again, she is actually MORE likely to relapse, or else have other body hatred issues.
Angela Celio Doyle, PhD responds:
First, here’s a little background on what to take into account when considering a goal weight range. First is the adolescent’s previous percentiles on growth charts prior to the onset of the eating disorder. If you have access to the growth charts that your child’s pediatrician would have logged at their annual visits, get a copy of these to bring to your treatment team. If your child has always been in the 45th percentile for BMI, for instance, and then dropped to the 10th percentile, you can be fairly confident that your child should return to the 45th percentile.
Second, if your adolescent is a female, the weight at which she is able to regularly menstruate is a very helpful indicator (which is why treatment teams aren’t fond of the use of oral contraceptives since they “mask” this sign of health with an artificially-induced period).
Finally, parental body types can be useful to consider. If both parents have always been a bit stockier or quite slender throughout their lives, then this might suggest a body type to expect for their adolescent.
So, to more specifically answer your question, I would suggest looking at the history of your adolescent’s weight and BMI percentiles over the years with your therapist and your physician. Has she always been in the upper range of healthy weights? Or had it increased just prior to the eating disorder? I would rely on the general trend of her percentiles pre-eating disorder. Once her period returns, that does not signify an end to weight restoration, as she will probably need to put on a bit more weight to sustain her period on a regular basis. Finally, you are wise to look to signs of body satisfaction – this, along with less rigid views towards eating, increased cooperation with provided meals, and overall reduction in eating disordered thinking all mark progress towards a healthy weight.
A couple of other things to consider: it is important to aim for a range rather than a specific number. Also, this range can cause some difficulty with some adolescents in that they will aim for the lowest number in the range and not want to go above, especially if specific goal weight ranges are discussed too early on in treatment. This is something to discuss with your Maudsley therapist. Second, because adolescents are in the midst of growing, goal weight ranges are a “moving target”. With each passing year (and with any height increases), the goal weight range will shift upwards. Again, another reason to resist speaking about specific goal weight ranges too early in treatment, since it might change during treatment!
My 14 year old daughter has told me an 11 year old from our church is bulimic and anorexic. The child has loss a considerable amount of weight in three weeks and my daughter found her throwing up in the bathroom at the restaurant today.
How do I tell the parent's that there is a problem? My daughter is upset and wants to help.
Angela Celio Doyle, PhD responds:
This can be an awkward situation to address, but one that I would not shy away from. Before talking to the parents, I would ask yourself “Do I know all of the facts?” and “Is there an alternative explanation for this?”. Ultimately, I would guess your answer to these questions would be “No” and “Possibly”, respectively. With these things in mind, I would privately approach the 11-year old’s parents and mention what your daughter observed, acknowledging that you did not witness it yourself. However, you can mention that you noticed so-and-so has lost weight, so you did not want to ignore what might be seen as a possible eating disorder. Just describing what you have seen/heard is enough.
Be prepared that the parents may be very grateful for your concern (and may even assure you that they were looking into professional help) or, worst case scenario, they may be offended or angry that you approached them. Perhaps there is a medical illness that you are unaware of or perhaps the daughter has an eating disorder but the parents are unwilling to face that possibility at this point in time. In either case, you will have alerted them to what was observed, which is laudable.
Angela Celio Doyle, PhD
Dr. Celio Doyle is a Clinical Associate at the University of Chicago Eating Disorders Program and serves as Clinical Advisor to Maudsley Parents.
My daughter has been struggling with Anorexia for 3 years and has been in both acute care and long term residential programs on an ongoing basis. She developed the illness at age 13 and is now 16. Although she received treatment early on and has been in some reputable programs, the illness has progressed and has quite a hold on her. She has come close to death.
It seems that from the research compiled that Maudsley has been most successful with adolescents who are not yet entrenched in the illness. Are there success stories related to individuals who are further along in this disorder? Given the duration and severity of my daughter’s illness, would it be recommended to pursue this approach and if so, do you have any recommendations for clinicians who are formally trained who are in the NYC/Dutchess/Westchester county area?
Kara Fitzpatrick, PhD responds:
We always want to intervene as early as possible when someone has anorexia nervosa. In fact, the research suggests that family-based treatment is most effective when patients are under 18 and have a short duration of illness. That being said, we know that this approach has been successful with some young adults and those who have been ill for longer periods of time. Indeed, in my experience, this approach has worked well when residential, acute care and other intensive programs have not been successful. In part, this is because return to health happens in the home and in the very environment that your daughter needs to learn to thrive in.
Obviously, as with any illness, the longer the course, the more likely that the illness has begun to interfere with areas other than simply food/eating/shape and weight. The longer AN is present, the more likely that adolescents will be moved off of their normal “developmental curve” – in other words the illness can begin to interfere with social and friendship development, learning independence skills and being able to manage more challenging emotions without returning to restriction and eating disordered behaviors. This is again another reason why an approach that works to keep your daughter in her environment can be useful, as it allows her to work on social development and independence skills in addition to just changing eating patterns. Ultimately, full recovery from AN happens when food, shape and weight concerns are replaced with normal, healthy relationships and the home environment is often the best place to allow this simultaneous progression.
You can find a listing of therapists trained in family-based treatment here.
Our daughter has anorexia nervosa and exercises excessively (mostly with running, but also some weights). How much and what type of exercise/fitness is she permitted during the initial phase? Does everything stop?
Kara Fitzpatrick, PhD responds:
The focus of this approach is actually on parent empowerment and parental decision making around healthy and non-eating disordered behaviors, so this is a challenging question to answer, as we would encourage these decisions to be made by parents in conjunction with their treatment team. One challenge in treating eating disorders is that there is overlap between eating disordered behaviors and things we would consider to be normal and healthy, such as exercise. This often makes parents feel disempowered, because most of us understand that exercise is one ingredient in a healthy lifestyle. The problem is that, in the face of AN, exercise is really only healthy when the body is able to repair itself and has reached a state of nourishment that supports basic bodily processing and when exercise can occur with adequate caloric intake.
Generally speaking, we never encourage exercise when someone is of very low weight and/or medically unstable. The amount and type of exercise that you permit is most often based on how well your daughter is eating her meals, the level of struggle in these behaviors, the course of weight gain and what has been typical and normal for her before the eating disorder onset. If your daughter is able to eat meals with relatively little struggle and is making adequate weight gain, it may be time to consider allowing in more exercise. If these are still a struggle and your daughter is hiding, sneaking or engaging in excessive exercise, it may be that this is an appropriate target for change in treatment. Most families find that return to exercise is a slow process. For example, it might start with gentle yoga or stretching, progressing to walks or return to school (Note: as much as we may think that school is largely sedentary, in my experience return to school requires far more calories than most people realize!). For some families, return to activity involves a return to supervised or team sports activities that are more structured or are time limited. Ultimately, the goal should be a return to a whole range of healthy behaviors, including exercise.
My 16 year old daughter has made great progress in recovering from anorexia since the summer. She has gained weight, eats healthy amounts of food, and has stabilized. However, she is very rigid regarding what she eats. She has been seeing two treatment professionals. Until recently this was effective, but it is now causing conflict.
I feel she has hit a plateau, not medically in danger but unable to be flexible with food. For example she eats the same breakfast and lunch every day with a little variety at dinner. Eating out is stressful and she avoids it with friends by not going or goes but doesn’t eat. One professional favors challenging her to try new food gradually but after one attempt she has since refused. The other thinks the focus should be on why she is so controlling and not to push anything new.
I am concerned that these food preferences and eating behaviors, although not life threatening, may become more difficult to change the longer they go on. However if I push for change it causes arguing and no change anyway. What is the priority at this time and what do you think is the next step toward recovery?
Kara Fitzpatrick, PhD responds:
As a parent, you can clearly see the boundaries that anorexia nervosa has drawn for your daughter and the way it is keeping her from normal, healthy behaviors such as eating flexibly and socially and so should be concerned. And you are also right in recognizing that the longer we allow rigid patterns to remain in place, the harder they are to break. Typically such rigidity occurs when there are significant food fears and it may be that your daughter has learned to eat a limited number of foods that keep her “out of danger” but do not require her to eat foods that she may perceive as fattening. Although I say this somewhat tongue in cheek, I believe that normalized eating really occurs when we can go on vacation and find something to eat, no matter where we are, or go to a friend’s wedding with greater focus on the ceremony than on what is being served!
So how do you go about encouraging flexibility? First, encouraging flexibility does not mean just trying something once and deciding you do not like it. Remember when your child was a baby and you gave her different baby foods? She probably had some she liked the first time and others that you had to present a number of times before she would take them without struggle. It is the same at this phase of treatment, where you might find that you need to present more challenging foods several times. Remember that this will be a challenge, as you are asking your daughter to face significant food fears, but this also will help both you and her widen the range of healthy behaviors that support full recovery.
Kara Fitzpatrick, PhD
Dr. Fitzpatrick is a psychologist working with Eating Disorders at Stanford University/Lucile Packard Children's Hospital and serves as clinical advisor to Maudsley Parents. She is widely trained in a variety of models for treatment and performs research in applied clinical treatments for adolescents and neuropsychological factors associated with eating disorders.
My daughter is 15 years old and was diagnosed with anorexia about two months ago. We had been trying to allow her to refeed herself, and it was not working. We are now beginning to use a Maudsley-based approach. My question in the refeeding process is should we limit the amount of time allowed for her to eat a meal? She eats very slowly, and it can take over an hour for her to consume all of her required food. It seems like by the time she finishes with one meal, it is time for the next.
Katharine Loeb, PhD responds:
I admire that you are immediately trying to find the right approach for your family, and that if eating on her own was not effective for your daughter, you are attempting alternatives such as the Maudsley method. Allow me to say at the outset that while the overarching “mission statement” of Maudsley is clear and definitive - that parents are initially in charge of their child’s nutritional rehabilitation process until the disorder begins to wane – the details of implemtation can really vary by family, and a particular strategy that works for one child may not be useful for or applicable to another. Procedures around meal duration are a good example of this variability. Some parents find that sustaining a meal as long as necessary to fully accomplish the planned food consumption sends a strong message to the eating disorder that nothing will deter their mission of health. Often, as weight is gained and the illness recedes, excessive time spent on meals will become more aversive to the adolescent as s/he re-engages with other interests and activities. For example, as the healthy part of your daughter emerges, she may rather complete a meal sooner and go out with friends than sit at the kitchen table all day. Alternatively, other parents find that imposing a time limit on meals, rather than allowing their duration to shrink naturalistically, yields better functioning for their child. This is especially true when the meal is extended as a function of compulsions or rituals around food or eating (e.g., cutting food into very small pieces, pacing bites at certain intervals). Such rituals represent eating disorder behaviors that parents should tackle along with the “refeeding” process. Empathic but firm messages to your child such as, “I know the eating disorder is making it so uncomfortable for you to eat this way, and that is why we’re here to help you – so you’re not alone in this. If we allow the illness to have any influence over how you eat, we are not doing our job as parents to protect you from this terrible disorder.” A time limit often works best in combination with something to look forward to at the end of the meal, such as a pleasurable or distracting activity.
My 11 year old daughter has just been diagnosed with anorexia nervosa. We have an appointment at a clinic next week. Until then, I am doing research of my own to find ways to help her! I know she has to eat maximum calories in small amounts at first to gain her weight back.
I have been reading the recipes on your website & they look delicious, but I have a question. I am a personal trainer and we are a very active and fit family. I have always emphasized eating healthy meals and snacks in our household, but I never forbidden my children to eat “kid food” (ice cream, cookies and chips). They eat it everyday! I do not have an eating disorder, but feel like I cannot eat the meals with all the fat and cream. Even if I only have a little, she will see that I'm not eating the amount I expect her to eat. I don't need to gain weight, but I know she does. How do I handle this?
Katharine Loeb, PhD responds:
I’m sorry to hear about your daughter’s recent diagnosis. It sounds as though you are doing your best to get her the help she needs, and trying to think preemptively about potential obstacles, including her perceptions of your own eating habits relative to what you will be asking her to consume. Having a family culture that emphasizes a combination of physical fitness and flexible eating is positive and in no way incompatible with the Maudsley method. Moreover, the quantity and quality of food required for nutritional rehabilitation in the context of anorexia nervosa does not need to generalize to well family members, including yourself. While parental modeling of the healthy consumption of a range of foods, including desserts and snacks, in reasonable ratios, is good to implement as part of an overall family plan, family-based treatment for an eating disorder is a unique process that emphasizes food as medicine for the ill child. What is appropriate for your daughter to eat will likely be unnecessary for others in your home. If the anorexia nervosa tries to debate with you about “fairness” or “double standards,” please do not be distracted or thwarted by this! A firm but empathic response such as “I know the illness is looking for any excuse to gain the upper hand, but we love you and won’t let you be sick,” will get you farther than a point-by-point argument.
My 14 year old daughter was just diagnosed with anorexia last week. She was immediately admitted to the hospital for a week due to fluctuations in blood pressure. She was put on a nasal feeding tube, which dispenses nourishment 8 hrs. a night. She was fed 3 meals a day at the hospital, always in the presence of a nurse. She complied with the protocol while at the hospital. We just came home a few days, but every meal is a struggle at home. We were told not to present a threatening atmosphere, but each attempt at meals is met with a barrage of verbal abuse from her (we'd been told to anticipate this), and I can already notice her eating a little less at each meal. We try to keep conversation light during meal times, and I go to her school every day for lunch in a private room (she despises this!). The verbal assaults would wear the Pope down, but we try to act as if this behavior has no affect. We were told to separate out the "disease talking" and "our daughter talking." Since we've been home she has complained of terrible heartburn, always attributing this to the reason she can't eat, although she complied adequately at the hospital. We've given her Prilosec at home per doctor's orders, but it doesn't seem to help. Bottom line: she is extremely reticent to comply with eating the required meals as prescribed. My husband and I wanted to see if there was any tactic we could try to get her to eat. We have a follow up with the doctor next week, and if things don't turn around, we are braced for yet another hospitalization.
Katharine Loeb, PhD responds:
I want to start by commending you on several fronts. First, you mobilized quickly to begin getting your daughter the help she needs and sound determined to see her recovery through. Second, even if what you are currently facing and what lies ahead seems daunting, you are presenting a calm and committed front to your daughter, already sending a message that you will not be deterred or frightened by the eating disorder in the process of restoring her to health. You are also separating the illness from your daughter, which will make it easier for you to take action that is met with extreme conflict, knowing that it is the anorexia nervosa, not your daughter, pushing back. Third, you are already implementing specific and effective strategies such as supervised meals, even if she protests. This combination of attitude and strategy will serve you very well in the face of this significant challenge.
I would also like to normalize your experiences thus far. Most of the patients we see in family-based treatment for anorexia nervosa are, by definition, resistant to the idea of nutritional rehabilitation. The cardinal feature of this disorder is fear of weight gain. This fear can manifest in all the ways you describe, and typically is exacerbated by active attempts at refeeding. In other words, your daughter’s response to your efforts indicates that you are doing something right, not wrong. Not only can you be personally assured of this, but you can also be comforted knowing that the healthy part of your daughter – even if it significantly occluded by the anorexia nervosa at this point – does not want you to back down. I know this from my professional perspective as a clinician and researcher, and, most importantly, directly from adolescents who have thanked me and their parents in later phases of treatment for not giving up early on when the illness made them emotionally dysregulated, irrational, or unpleasant.
To sustain the Maudsley framework and work effectively within it, the help and support of a practitioner trained in or supportive of the approach will undoubtedly be very useful to you, and I hope one is available in your area. Maintaining a judicious blend of firmness and empathy with your daughter will also be key, as will presenting an extremely united front with your husband around issues of refeeding so the illness has no room to negotiate. Parents are often surprised at how effective these pieces of advice are when implemented, but they reflect exactly how an inpatient staff operates. Moreover, you have an important incremental advantage over a professional staff in that you love your daughter and are more motivated than anyone to see her well again. Your daughter’s complaints of heartburn may be objective, subjective, an excuse of the eating disorder, or a combination thereof, but should not distract you from your efforts, especially if she was able to eat in the hospital and is cleared by her physician for a range of foods. Please think of every meal and snack as a unique opportunity to reverse the illness by a measurable degree, and feed your daughter the most densely caloric and nutritious foods as possible to meet her level of starvation and medical complications. Hopefully, with professional assistance in expanding on what you are doing already, another hospitalization can be avoided.
Katharine Loeb, PhD
Dr. Loeb is Associate Professor of Psychology at Fairleigh Dickinson University, Director of Research at the Eating and Weight Disorders Program at Mount Sinai School of Medicine, and serves as Clinical Advisor to Maudsley Parents.
My 12-year old daughter was diagnosed with anorexia in late January. She was immediately admitted into the hospital, and from there to a family-based eating disorders program. After spending 3 weeks as an inpatient, we were able to bring her home. She has really done very well at home as we have continued our appointments initially on a weekly basis, and now on a bi-weekly basis. She has been able to maintain her weight, add back "normal" 12-year-old activities, and we are really very proud of her. Here is our problem: she continues to be bound to a schedule of eating her meals and snacks throughout the day, which is making it difficult for the rest of our family to be flexible, have more freedom, and enjoy the wonderful progress she has made. In addition, she is continuing to have difficulty being willing to try different foods at different times. I love my daughter, would do anything for her, and want to support her, but it is SO hard sometimes. I'm so tired of always having to worry about what might set her off and I'm anxious to get back to the more fun-loving times we used to be able to have that didn't revolve around what to eat and when. Is this a typical recovery? Do I just need to continue to be patient? Are there any other suggestions or advice you can give me? Is it ok for us to be firm with her about our expectations and point out how hard this is for the rest of us, too? Your advice would be greatly appreciated.
Kara Fitzpatrick, PhD responds:
It is wonderful to hear that your daughter and your family have made such excellent progress. Setting up routines for normal, healthy intake help most families tackle the initial stages of renourishment efforts. Unfortunately, these routines and structures can sometimes take on a life of their own and prevent full adjustment to flexible eating and a view of food as something to enjoy, rather than something to plan. As a family-based practitioner, I often work flexibility into therapy to assist families with exactly the concerns you present here. Truly “normal” eating requires a measure of flexibility both around timing as well as around types of foods that we eat. To that end, I really enjoy implementing “planned flexibility” tasks in treatment. For example, if a family had difficulty eating out due to rigid eating patterns, we might make such an outing the focus of a therapy session, though such discussion as: giving plenty of warning time, allowing the patient to choose the restaurant and going over the menu carefully to pick a meal that is agreed upon by parents and patients. When this is successful, we might focus on greater flexibility such as providing less time of warning before an outing, not choosing meals prior to going, choosing new restaurants or allowing other family members to choose where a meal might occur. These can be made fun and can also address expected areas of difficulty, such as vacations, leaving for college or holiday meals. Areas for implementation may be large (such as eating at restaurants) but may also be somewhat smaller, such as creating flexiblity around the time of a meal or even placement of a meal (at the dinner table, but in a different chair) or food type (waffles instead of oatmeal). Planned flexibility “experiments” can be excellent for engaging siblings they are often are quite expressive about ways that they see the eating disorder continuing to have a hold on the individual and/or other family members and likely can provide models for what normal flexible eating habits look like.
My daughter is 16. She was anorexic at 13, but we found a therapist who she liked and was comfortable with. During this period, she gained all her weight in a span of 6 months. As a reward, we traveled overseas for a 6 week visit with family, where she gained several pounds. Upon our return, she immediately began exercising to lose the weight. I watched her as her foods became less and less, and more restrictive to peanut butter, ice cream, chocolate, coffee, and tea. She has purged after binging several time over the past 3 months. It was the purging that brought the relapse to my attention.
I want to my daughter eat and get well, but I am wondering about scales. It is my feeling that it should be removed from the home, particularly since she is not underweight. My daughter weighs herself religiously and it seems to me that to make the home a safe environment, the scale needs to be removed. What is the your view about scales?
Kara Fitzpatrick, PhD responds:
It is wonderful that you noticed and are concerned about setting up a safe environment for your daughter. Relapse often makes us take a second look at our environment and safety nets in addressing eating disordered behavior and it sounds as though you are doing just that. It sounds as though your daughter is using her scale to provide reassurance and feedback that her eating disordered strategies are working and that she has set a narrow range of acceptable weight for herself. To that end, having a scale that she can use for continuous feedback is likely supporting her eating disordered behaviors and I want to empower you to take the steps you feel are necessary to assist your daughter in her recovery – including removing the scale.
However, I do not mean to imply that it is not important for your daughter to get feedback on her weight. This is a common misconception in eating disorder treatment, as many physicians and treating professionals do not reveal weights to patients. Within a family-based approach, knowing one’s weight and having exposure to this information is an important part of treatment, for several reasons. First, anorexia always over-estimates how many calories are being consumed and how rapid weight gain will be. Providing feedback on actual weight gain provides on-going “evidence” that the anorexic thoughts are inaccurate and not tied to actual weight gain. In addition, providing on-going feedback about weight changes helps patients and families monitor and adjust their efforts as necessary – whether it is adding more calories because of the resumption of regular athletic activity or the slowing of weight gain without caloric change as one reaches an ideal body weight. Not knowing weights seems a bit like going to a shooting range without a target to provide feedback! How do you know if your shots are hitting their intended target in the absence of feedback. This feedback becomes particularly important with increased independence where we expect that individuals will be able to manage their weight and shape on their own. This is particularly true in the case of relapse, as your daughter struggles to resume “normal” eating patterns and abandon maladaptive strategies to lose weight (or keep her weight at its current level). What is most useful are standard weights, with time between weigh-ins to avoid focus on minute shifts in weight over the course of the day. In our clinic, we have weekly weigh-ins prior to the onset of sessions and this information is shared with the family to track progress, monitor the impact of strategies and activities in the interim between sessions. Weights are also charted and monitored to look at a trend, rather than focusing on individual weight values.
Relapse is challenging and often those with eating disorders develop new symptoms or eating disordered strategies during relapse that require new skills on the part of their families. At the same time, you and your family have been successful in addressing these skills and challenges previously, so you have a wealth of resources and knowledge to draw upon in facing the challenges ahead.
My 15 year old daughter has been receiving intensive outpatient treatment at an eating disorder clinic for seven months. My husband and I have also been going for 7 months (family counseling, family support groups, etc), as well as monitoring her eating, and helping her stick to an eating plan. She has gone from 95 lbs to 115 lbs. which is an acceptable weight for her. The clinic has been "stepping her down" from 3 days, to 2 days to 1 day of treatment, as she has gained her weight. Now that her weight is acceptable, they are talking about exiting her from the program.
My daughter is scared to death to leave. She feels that the clinic is a safe place and she cries whenever she thinks about leaving. Her mental state is still very impaired. She has started bingeing and seems to have very little control and she also purges. She constantly talks about how fat she is, and how she hates herself and she is just filled with self loathing and disgust. I am so worried about her, and don't see how the clinic can think she is ready to leave. I know that the eating disorder recovery is more than maintaining an acceptable weight. I want her to get better psychologically too. What can I do?
Kara Fitzpatrick, PhD responds:
Reasons for release from residential and inpatient treatment programs vary, but ultimately the goals of learning to eat and maintain healthy behaviors in everyday life are critical behaviors that must occur for one to be recovered. The transition from any “safe” environment to an environment in which one has been filled with eating disorder thoughts and behaviors is always challenging. Skills learned in her intensive program may be hard to “generalize” or use quickly and easily at home, school and in everyday life. That is one way that parents can help: creating an environment that does not allow the eating disorder to take control.
There are several critical areas where you, as parents, can help your daughter continue this eating disorder fight. The first is to continue to assist her by monitoring meals and making certain that she is eating regular, nutritious meals that assist her in keeping her weight-restored status. Parental monitoring of intake, even when your child is weight restored, can be critical to keeping weight gains and assisting your daughter in eating flexibly and normally in the home. The second is to create an environment in which binge eating and purging behaviors are not acceptable. Families may need to have a higher level of vigilance around binge eating behaviors, interrupt binges, and even take more drastic steps such as removing binge trigger foods or managing meals. Methods to prevent purging can include monitoring after meals and preventing the use of unsupervised bathroom time. These are only a few strategies families might use, or need to use, to help with adjustment in the home, school and other settings. The goals are to provide an environment where your daughter’s anorexia is not in charge and slowly transition toward greater independence. She has obviously thrived in an environment that provides a high level of support and your family can work toward mimicking these aspects at home.
Of course, recovery can and should continue outside of intensive treatment settings. We encourage you and your family to discuss appropriate referrals with your daughter’s current treatment team to find outpatient providers who can assist you with continued adjustment. Finding a family-based therapy provider to assist your family with maintaining nourishment either alone or in conjunction with an individual therapist who might continue to provide your daughter with the support she needs to overcome her eating disorder. Finally, remember that recovery occurs over time and the effects of renourishment efforts on behavior and cognitions typically lag well behind actual weight gain. By helping your daughter remain stable in her weight, you will help her continued psychological as well as physical recovery.
I have a student in my class who was recently diagnosed with anorexia, and as I have never known anyone struggling with this issue, I want to make sure that I am helping do what I can.
The student is constantly ‘moving’ in an effort to burn calories. The student jogs from point to point in the classroom and school; does squats when picking up items from floor; does leg lifts while sitting at desk. If I redirect the behavior, am I causing more anxiety? If I say nothing, am I enabling unhealthy behaviors to continue? What do you recommend?
Kara Fitzpatrick, PhD responds:
As a teacher, you have identified some significant eating disordered behaviors that clearly interfere with this student’s ability to learn, but more significantly, to recover. Compulsive exercise and increased restlessness and hyperactivity are components of anorexia. Many individuals with this disorder feel that they need to move continuously to burn calories, but it is also important to understand that the brain responds to malnourishment by increasing a sense of restlessness and agitation.
As a first step, I would bring these concerns to the attention of the parents to make certain they understand the extent of these behaviors. Often family members are unaware of the extent of exercise and activity away from home and the disorder itself would make it unlikely that your student could accurately estimate their level of activity. Helping parents and others involved in the care of the student understand the behaviors you see in the classroom will assist those involved in the student’s care know where they might best make adjustments to guide your student toward recovery.
In treatment, we help teach families how to put reasonable expectations for safe and healthy behaviors in place at home and ways to enforce these to help keep anorexic behaviors “in check” until the individual can manage these on their own. Although individuals with anorexia are typically wonderfully capable, bright and motivated individuals, within the realm of food, eating and shape/weight, it is useful to think of them as regressed or unable to make appropriate decisions about their care. Often, having rules for behavior can help the anorexic individual because this allows them to respond to outside rules, not just the rules set by the eating disorder. In addition, setting rules and clear expectations for behavior can relieve some of the stress placed on the individual by the eating disorder. That said, it is important to set limits on disruptive and inappropriate behaviors in the classroom. Letting the student know that you have expectations for sitting in their seat, remaining still and walking, not running, between destinations would likely be reasonable expectations for your classroom.
Kara Fitzpatrick, PhD
Dr. Fitzpatrick is a psychologist working with Eating Disorders at Stanford University/Lucile Packard Children's Hospital and serves as clinical advisor to Maudsley Parents. She is widely trained in a variety of models for treatment and performs research in applied clinical treatments for adolescents and neuropsychological factors associated with eating disorders.
My
partner's daughter is 12 and was admitted to the hospital with anorexia
nervosa. Both her mother (my partner) and father are in shock but coping with
the immediate crisis. The parents separated more than a year and a half ago and
the two girls spend one week at each parent's home. I have been reading about
the Maudsley approach but it seems to be geared towards a traditional nuclear
family. Am I missing something? Or is there another approach that is geared
specifically towards families that are more complicated?
Renee Hoste, PhD responds:
Evidence is accumulating to suggest that the Maudsley approach can be effective for those with a nontraditional family structure. A recent study from the University of Chicago showed that single-parent families were just as effective as two-parent families in helping their children recover from bulimia nervosa. Anecdotally, we have found that many families with separated, divorced, or remarried parents can join together to help their child recover from his or her eating disorder. Logistically it is certainly more challenging when two households are involved, but as long as all parents can be on the same page, at least temporarily, families seem to be able to make this work. If conflict between parents prevents sessions from being optimally productive, the therapist can meet separately with each parent or set of parents. The goal is to ensure that even if the child is spending time in two different households, the expectations for eating will be the same regardless of where she is. If parents are truly unable to work together to guide their child through the recovery process, it may be preferable for the child to stay with just one parent or set of parents during the first phase of treatment.
The Maudsley approach does not take a rigid view of what constitutes a family. As we wrote in a recent article:
"Another term worth mentioning in relation to the Maudsley approach is 'family'. In the context of this treatment approach, as in many other settings, 'family' is not merely dictated by biology or law. The family engaging in Maudsley treatment can be composed of parents, step-parents, long-term significant others, siblings, grandparents, aunts, uncles, etc. Each week, the therapist will want to meet with everyone who lives with the individual with the eating disorder. Also, the therapist might want to meet with people who are involved in caring for/feeding the individual, but who do not live with the individual with the eating disorder. For instance, if grandparents care for the child/adolescent after school, or if there are no siblings and support is needed from close friends, it could be important for these other individuals to join a few sessions to learn more about the Maudsley approach. All caregivers are enlisted to be on 'the same page' with one another in the way that the disorder is viewed and treated, and siblings play an important role as well as supportive peers."
Getting everyone on the same page when they aren't under the same roof might pose some special challenges, but bear in mind that even in two-parent families there can be disagreements and conflict. Remembering the common ground--surely, all parents love their children and want the best for them, no matter what their disagreements--is a good start. Working with a good therapist can help caregivers figure out how to work together and make the most of each individual’s strengths to get the job done. This is true for traditional as well as less traditional families.
My
13 year old daughter with anorexia nervosa was recently discharged from the
hospital. She is medically stable, but not at her target weight.On her doctor’s advice, we are aiming
for her to eat 3000 calories a day. This is difficult because she is a
vegetarian (started at the onset of the eating disorder) and so she needs to
consume large quantities of food to get that many calories. Of course, this is
not an easy task.She has just
returned to school after a 2.5 month absence and because of the routine/timing
of the school day we have found that a smaller calorie meal is about all she
has time to consume at lunch (it is a supervised lunch). This leaves a large
amount of calories to be consumed in the later part of the day.What about using products like a high
protein/high calorie powder? Is this an OK thing or a bad thing? Any other
suggestions?
Renee Hoste, PhD responds:
Using protein supplements is something that we often encourage parents to do, and many families have found them very helpful. It is difficult to get in the necessary amount of calories each day and protein supplements can add calories without adding a great deal of volume.
As far as the short lunch period, it may be helpful to consult with school administrators to determine whether they can allow your daughter extra time at lunch. If that is not possible, then it will be important to ensure that she is eating a high-calorie meal at lunch and having snacks during the school day. On that note, I would strongly encourage you to consider stopping the vegetarian diet, at least temporarily. It is not at all unusual for the onset of vegetarianism to occur close to the onset of an eating disorder. I do not mean to suggest that vegetarianism is akin to having an eating disorder, nor that vegetarianism causes an eating disorder, but it is not uncommon for a child who has developed or is on her way to developing an eating disorder to use vegetarianism as a way to avoid “scary” foods. Once a person has fully recovered, he or she can make the decision to become vegetarian without the eating disorder clouding his or her judgment.
Renee Hoste, PhD
Dr. Hoste is an Instructor of Psychiatry at the University of Chicago's Eating Disorder Program and serves as Clinical Advisor to Maudsley Parents. Read more about Dr. Hoste here.
We’ve
just started therapy. It’s been two sessions so far, and my daughter says she
hates the therapist and doesn’t want to go back. Because of this, my husband
and I feel very unsure we are doing the right thing. We are getting her to eat
a little more but she is so angry with us. We wonder if it would be better to
find a therapist she connects with? Right now she doesn’t even talk in
sessions.
Angela Celio Doyle, PhD responds:
Do not be surprised to hear your adolescent say she does not like her therapist, particularly if your child has anorexia or is restricting her diet and you are in the early stage of treatment. This may feel strange at first, because with most other therapeutic relationships you would expect to have a very positive relationship with your therapist. However, the early stage of recovery can be extremely hard for kids. Maudsley therapists expect your adolescent to do exactly what the eating disorder fears the most (eat and gain weight!). So it’s no real surprise if your child expresses negative feelings about therapy or therapists or about parents who insist they eat--no matter how competent and compassionate the therapist is, or how loving the parents are. It just feels really bad to have to eat, but this is necessary for recovery.
For unaware parents, an adolescent’s dislike of the therapist can be a quite effective way of derailing treatment – you might imagine your child saying, “But Mom, I HATE Dr. Smith. I can’t talk to her. I want to have a different therapist…(one who will not make me gain weight!).” Many parents find it useful to respond sympathetically to their child when they say things like this, but to remain steadfast in their commitment to the treatment and therapist with whom they are working. You might consider the bad feelings that your daughter expresses a little glimpse of the anorexic thoughts she’s living with. If you’re making headway with behavior change, that’s great news. It’s the first step toward recovery. A good therapist will work with your family to build on that progress and help engage your daughter as she begins to recover. With lots of positive support from parents and therapist during the tough times, most kids begin to see things from a different perspective as they start to feel better.
Angela Celio Doyle, PhD
Dr. Celio Doyle is a Clinical Associate at the University of Chicago Eating Disorders Program and serves as Clinical Advisor to Maudsley Parents.
How do I use the Maudsley method with my daughter who refuses to go to a therapist, talk to us, or admit a problem (she restricts and has been caught purging), adamantly refusing to any interaction with us until we “lay off”?
Joy Jacobs, JD, PhD responds:
This is a challenging situation and all too common when attempting to treat an eating disorder. The magic of the Maudsley approach is that its effectiveness does not depend on getting your daughter to “buy in” to treatment. You can start to take steps to help her recover even if the eating disorder is still in control. How do you do this? This might require that you as a parent take a strong stand—for example, setting a contingency system of privileges and consequences that is determined by her compliance with the eating and post-meal supervision plan that your devise for her. This will take a great deal of consistency and determination on your part, but if you can hang in there you will maximize your chances of seeing positive results.
In the period of late January through March 2009, our daughter lost 20 pounds through intense exercise and starvation. Her therapy with a nutritionist/therapist began soon after we realized what was happening (early April). She also sees a adolescent medical doctor who specializes in eating disorders. Since then, she has gained back 9 pounds and is now medically stable and in the low range of her target weight. Her period has also resumed. We have been buying her all of the things that she wants such as soy milk, protein drinks, cinnamon covered almonds, banana chips, and vegetable chips. She is obsessed with eating alone and refuses to eat at family mealtime. She picks at things all day and rarely will put something on a plate. She also says she does like to eat anything that I (her Mom) make. While she is in a better place in a very short period of time and her medical doctor is pleased with her progress, her eating quirks only seem to be getting worse. While I have tried to be compassionate and helpful, there are times when I absolutely lose control of my temper and tell her awful this thing is that she is doing to herself and her family. I know that this is not productive, but the frustration level builds and then explodes, especially when she refuses to eat with the family. How can we get her to eat with us? Please help. Her therapist does not seem to be offering concrete ideas for intervention.
Joy Jacobs, JD, PhD responds:
Your frustration at this point is understandable. Oftentimes, the path to recovery from an eating disorder is an endurance contest for family members (analogous to a marathon rather than a sprint). The good news is that your daughter’s weight is headed in the right direction. Nevertheless, she may still be quite underweight and the behaviors you describe may be reflective of significant eating disorder ideation. Most likely, your daughter’s need to eat specific foods and to eat them alone is part of the eating disorder and should be discussed as such in therapy session. If your daughter refuses to eat with you when asked, you may need to take a more directive approach—requiring that she eat meals with the rest of the family, in the same way as you may require that homework be completed, chores done, etc. If you take this route, be prepared for a great deal of initial resistance. Remind your daughter that you love her and will be supportive at meal time. Your goal is not to critique or judge but to restore her to full health. Try to be patient and lean on friends and family members for support. Ideally, your therapist is equipped to support your decisions and to help you map out a game plan for implementing these changes. Best of luck!
Our 15 year old has been out of hospital for about a month and is being treated using the Maudsley method. We are currently refeeding her.
She went to a therapist the week before she went into hospital and she really liked her. She hates the current therapists and feels she is getting no support for the awful feelings she is going through. Her dad and I believe in the Maudsley method and believe the psychologists when they say she will get better when she is refed. However, belief is one thing and the feeling that our little girl is suffering and we are not helping her is quite another. I suppose I'm asking is there anything we can do to provide more overt support to her while she is being refed? I don't want to undermine the treatment or go backwards because I'm feeling helpless but I'd hate to think that there was something we could have been doing to more actively assist in psychologically supporting her through this really difficult period.
Joy Jacobs, JD, PhD responds:
Clearly you are sensing your daughter’s feelings of isolation as the refeeding progresses. As you point out, moving forward with refeeding in some way requires that you ignore the demands of the eating disorder (and the suffering your daughter experiences from not being able to comply with the demands of the eating disorder). It can be tempting to modify the goals of refeeding when you see that your child is suffering. Refeeding is a tough process, not only for the individual with anorexia but for the entire family. It can be hard as a parent to stay focused with refeeding when you witness the misery that your child is experiencing psychologically. I would encourage you first to remind yourself (multiple times daily, if needed) that although your child appears to be suffering now, a chronic eating disorder would most likely bring with it a great deal more suffering. Your daughter’s current distress is hopefully in lieu of future, greater suffering.
That said, what concrete things would help her weather this process? First, let your daughter know that you are sympathetic to her feelings. This can go a long way toward alleviating feelings of resentment and isolation. Ask your daughter what things you could do that would help her to feel more comfortable during this process; explain that aspects related to refeeding are off limits but that other accommodations are possible. In addition, how about rallying siblings and close friends to invite your daughter to do favorite activities (movies, crafts, etc)? This may help to improve your daughter’s mood and provide an outlet for sharing with others and feeling more supported.
My
15-year-old daughter has recently developed anorexia. She has been
limiting herself to 500 calories a day. She has seen our family
practitioner and we have an appointment with a therapist scheduled.
I've
been reading about the Maudsley approach, and I have one question.
Since my daughter has expressed that she is sometimes tempted to make
herself vomit when she feels she has eaten too much, how is that dealt
with during the refeeding stage in the Maudsley approach? What happens
if she panics when she sees the scale going up not down? Right now,
she says the only thing stopping her from vomiting is the fear that
she'll erode her esophagus.
Kara Fitzpatrick, PhD responds:
As parents it can feel very disempowering to think that we might ask our child to trade one set of symptoms (restriction) for another (purging). Within the Maudsley model, parents are in charge of re-nourishment efforts, including assisting their child in controlling purging or other “compensatory” behaviors, such as over-exercise. Just as with all re-nourishment efforts, parents can intervene when the eating disorder takes hold through various strategies, such as monitoring after meals and providing distractions that are incompatible with purging behaviors. Siblings can also help play a role in soothing your child after a meal.
Confronting the fear that comes with increased intake is a vital part of helping your child overcome this illness and parents are in an excellent position to provide this support and modeling. Therapists can help the family realize important skills and strategies that play the family’s strengths. One thing that is important to recognize is that panic is often something the anorexia will do when it loses control. Staying calm and consistent will help. That is one critical reason that parents are such strong “change agents” in therapy: they are not frightened or panicked by the anorexia and can provide an environment that helps confront the illness when their child cannot do so on her own.
My
19-year-old daughter has anorexia. After a hospital stay, we followed
up at home and she is now at a healthy weight. She lives at home and
attends community college. She will eat what my wife and I put in front
of her and she will eat at restaurants. The problem is that she refuses
to take ownership of eating by herself, i.e. preparing her own food.
She simply won't eat on her own. Any suggestions?
Kara Fitzpatrick, PhD responds:
It can be a challenge when anorexia becomes complacent in our re-feeding efforts and prevents our children from feeling comfortable and confident in taking over their own re-nourishment efforts. First, it might be helpful to recognize that your child may be feeling very “stuck” and afraid of these next steps – taking back control may mean facing her own concerns about whether or not she will gain or lose weight. Many individuals feel comfortable with parental control: they see that you will not let them binge or gain weight too rapidly, but they fear what will happen when it is up to them! Second, work with your therapist to begin to identify ways in which she might have supported independence. These may be “baby steps” toward her taking control, such as choosing the restaurant you are eating at, choosing her own beverage at meal times or plating her own food. Work toward mutual goals and identify areas in which having regained independence will foster feelings of confidence and adjustment in your daughter. Reinforce those changes and continue to find ways to support increased independence – around food as well as around other independence goals, such as friendships and academics. Remember that re-nourishment efforts are key, but so is continuing to develop into an independent, healthy young adult!
My 14-year-old daughter has dropped 15 pounds and has been diagnosed with anorexia. Her doctor and her therapist are encouraging us to make her eat, but she is so depressed and we see a lot of OCD behavior. Isn’t it important to address those concerns and treat them first? It seems to me that these are the real underlying problems.
Kara Fitzpatrick, PhD responds:
It can be compelling to want to chase what seems to be underlying anorexia, because that often feels as though we will resolve both if we focus on the “root cause.” Unfortunately, while anorexia is often associated with comorbid mood and anxiety disorders, nothing is more important than re-nourishment efforts. First, in a place of malnourishment and self-starvation, learning is impaired and individuals may not be able to benefit from standard therapeutic interventions. In addition, many of these symptoms are also caused or exacerbated by malnourishment, making it critical to regain to a healthy weight before focusing on these other areas. With luck, many of these symptoms will remit with re-nourishment efforts! Once your child is re-nourished and can maintain an ideal body weight, other symptoms can be assessed and treated as necessary. Remember, your daughter cannot make healthy choices for herself and her body at this stage and your efforts have to be directed toward eliminating self-starvation before you can all turn your focus toward other challenges.
We are refeeding my 16-year-old daughter and she has recovered some of her lost weight. She has experienced a lotof bloating and distention, along with constipation. It makes it very hard for her to eat enough. She constantly says she “feels fat.” What can we do?
Kara Fitzpatrick, PhD responds:
Delayed gastric emptying is a frequent challenge in the early stages of renourishment efforts. Because the body has slowed in its responses food moves through the bowel more slowly and many individuals experience constipation, bloating and abdominal discomfort. This can lead to feelings of early fullness, just when you want your child to be eating even more! There are several things you might to do ease this distress: First, have your medical team evaluate for gastro-intestinal difficulties, just to be safe. They may prescribe a mild laxative to help if your child has gone too long without a bowel movement. Do not do this on your own, however, as it can be dangerous. While there, check in with them to discuss whether your child may require more fluids than she is getting right now and whether this might assist with constipation. You can also apply warm compresses after meals to ease immediate discomfort. Do not, however, be tempted to cut back on meals or portions! In fact, this can exacerbate difficulties, as the body will resort to starvation mode, slowing the system further. Rather, know that this will pass and the shift toward more normal GI functioning can provide a wonderful early marker of the ways in which your child’s body is beginning to re-nourish and re-gain health.
Kara Fitzpatrick, PhD
Dr. Fitzpatrick is a psychologist working with Eating Disorders at Stanford University/Lucile Packard Children's Hospital. She is widely trained in a variety of models for treatment and performs research in applied clinical treatments for adolescents and neuropsychological factors associated with eating disorders.
My daughter is 20 and has anorexia nervosa. So far, counseling hasn't helped. She was too sick and depressed to stay at college so we brought her home. We'd like to try family-based treatment and she says she doesn't want to go to a treatment center. Is she too old for this to work?
Angela Celio Doyle, PhD responds:
There is no clear
first-line treatment for adults with anorexia at this point in time.However, there is initial support for
the Maudsley approach with college-aged individuals.The National Institute of Mental Health highlights three important components in treatment
of adults:
weight restoration
treating the psychological issues related
to the eating disorder
reducing or eliminating the behaviors or
thoughts related to the eating disorder, along with relapse prevention
The Maudsley approach for young adults
fits these criteria and is based on the premise that parents continue to play a
major role in their child’s life even when their child is a young adult; this
role might involve emotional support and guidance or it could be financial (i.e., parents pay for college).This situation provides an opportunity for parents to help
their child recover, although careful attention needs to be paid to their
healthy psychosocial development as an increasingly independent young adults.
In a recent case series at The
University of Chicago, a small number of young adults were provided the
Maudsley approach with some modifications based on their age.The results were positive, overall,
with the majority of the patients recovering and returning to school at
short-term follow-up.Additionally,
the patients and their families reported positive feelings towards the
treatment approach.(1) Because this form of the Maudsley
approach is still being developed and refined, your best bet would be to seek
out treatment with a trained and experienced Maudsley therapist who would be willing to adapt the treatment to an older
individual.Additional research using
randomized controlled trials will need to be done to determine whether this
approach is the best treatment for young adults, however.For one family’s experience with the
Maudsley approach with their young adult daughter, click here.
We're just starting out and it's so hard to get my daughter to eat! Is it alright to hide butter in her food and that kind of thing?
Angela Celio Doyle, PhD responds:
We don’t recommend lying or hiding foods and it is important
to keep all foods in your daughter’s diet as you are refeeding her.In the early part of treatment, you can
expect that your daughter will resist some of the foods that you are feeding
her, particularly feared foods like butter, oil, sweets, or other high calorie
foods.But these are the very
foods that will help your child to return to health.The idea is not to hide the food, but rather to prepare food
so that it contains the nutrition that your daughter needs at this critical
time.This may mean replacing skim
milk with whole milk, adding butter to pasta sauces or sandwiches, or using
coconut milk when making smoothies.The additional calories are more important than sticking exactly to the
recipe as it’s written or appeasing the eating disorder by avoiding these
helpful foods.
If your child asks you what is in the food
she is eating, do not feel compelled to discuss this with her.Healthy kids do not demand to know
exactly what is in the foods that they are eating, and thinking of this can
help to remind you that it is the eating disorder that is driving your
daughter’s questions.Some parents
will respond by saying, “this food has what your body needs right now,” rather
than getting into details of the ingredients or otherwise being pulled into a
debate about the food.Being
consistent with this response and remaining calm during your child’s
questioning will help. Helpful high-calorie recipes can be found on this
website by clicking here.
Angela Celio Doyle, PhD
Dr. Celio Doyle is a Clinical Associate at the University of Chicago Eating Disorders Program and serves as Clinical Advisor to Maudsley Parents.
My daughter is twelve years old and I'm worried about her eating. She's cut out a lot of her old favorite foods and lately avoids eating with the family whenever she can. I can tell that she's very worried when she does eat with us, and she gets angry that we "make" her. Maybe I'm overly anxious, but things just don't seem right.
Joy Jacobs, JD, PhD responds:
Parents often have a “sixth sense” about how their kids are doing. Your intuition is telling you that something is amiss with your daughter. As a parent, you must trust your intuition. If in doubt, reflect on all the times your hunches about your child have been right on in the past. The behavior changes you are describing have raised your suspicions and it sounds like the early attempts you have made to address your concerns have only increased your sense that something is amiss with your daughter’s eating.
I recommend that you gather more information before you decide exactly how to address the changes in your daughter’s eating behavior. Cutting out favorite foods is often the first step on a “diet” and an initial step toward an eating disordered path for many kids. Have you discussed your concerns with your daughter? If not, try to approach her in a supportive, concerned way…such as, “I have noticed that you no longer enjoy foods that you used to love so much (and give examples here). What has changed?” I recommend avoiding using words like “eating disorder” or “disordered eating, ” as these words could feel threatening to your daughter and make it more difficult to gain the understanding you are looking for. Just use this conversation to express your caring and desire to understand your daughter better and move forward with that in mind.
As an initial step, I would recommend family meals as much as is possible. Make presence at family meals non-negotiable. As you may know, family meals are associated with a variety of positive outcomes in children’s behavior, including improved grades, family communication, and reduced rates of delinquency and mental illness. Eating in secret is a classic eating disorder symptom and attempted intervention on this level may also give you a better understanding of the nature of your daughter’s problem and the reasons behind it. You could approach the subject with your daughter in the following way, “We miss you at family meals. It is important for us to eat together as a family. This is a special time when we can talk about our day and things that are essential to keeping our family running smoothly. You are an important member of our family and we need you to join us.” You may face some initial resistance but I encourage you to persist. This process may bring forth much of the information that you have been searching for.
If this process does uncover an eating problem in your daughter, you will be your daughter’s greatest asset in the recovery process. Let us know how it goes.
What is the Maudsley meal plan? Can I get a copy so I know what to feed my daughter?
Renee Hoste, PhD responds:
There is no specific Maudsley meal plan – the only meal plan is the one you come up with. Parents are not given a diet plan outlining a certain number of proteins or fats that their child must eat. We encourage parents to rely on the knowledge they already have about food and nutrition when deciding what to feed their starving child. Most parents know how to feed their kids, and until the eating disorder came along, you had a healthy and well-fed child. You may have other healthy and well-fed children at home. Use the knowledge you have as a parent to decide what your child needs to eat in order to gain weight. A Maudsley therapist can guide you in these decisions and offer suggestions, but the therapist will not dictate what your child should be eating. The therapist leaves that up to the parents, as you are the experts on your own family. Just remember that kids in recovery can need a surprising amount of food to reverse malnutrition. Although each family is different, many parents find that energy dense foods such as milkshakes are very helpful (as opposed to trying to achieve weight gain through sheer volume of food). Helpful high-calorie recipes can be found on this website by clicking here.
Renee Hoste, PhD
Dr. Hoste is an Instructor of Psychiatry at the University of Chicago's Eating Disorder Program and serves as Clinical Advisor to Maudsley Parents. Read more about Dr. Hoste here.
