Our daughter has been recovering from anorexia for 21 months now. We have implemented family-based treatment and have had a great therapist to help us. Our daughter was weight restored very quickly (less than 3 months) but her brain has been much slower to heal. We do believe she has reached a healthy weight as we have taken her above where she was historically and she is menstruating regularly. She still has some body dysmorphia and when she recently lost 7 pounds was very upset and resistant to putting it back on.
Our biggest issue now seems to be her eating habits. What I think started out as eating disorder behaviors have either now become habits or they are still lingering ED behaviors. She scrapes her teeth on her fork, she avoids touching her lips to her fork or spoon, she sucks food off her spoon rather than letting it touch her lips, she wipes her fork on her napkin between courses, she drops food all over the place (sloppy eating).
Our therapist refuses to treat these behaviors since our daughter won't engage in therapy and doesn't see that these behaviors are a problem. She says they will either fade with time or our daughter will want to change. We have tried targeting these behaviors during meal times but it inevitably ends up ruining dinner for the entire family. What can we do?
Renee Hoste, PhD responds:
Congratulations on helping your daughter become weight restored so quickly! Unfortunately there can be a lag between the time someone is weight restored and the time his or her thinking returns to normal, which can be very frustrating for families. Research has found that this delay in cognitive improvement may take up to a year following a return to physical health, and a drop in weight after recovery could delay this further. Although it is possible that some of these lingering problematic behaviors may improve as her cognitive functioning continues to improve, you are right to be concerned about them. As with many behaviors, the longer they are allowed to go on, the more difficult they may be to change. In addition, the goal of treatment is to stamp out the eating disorder entirely, and allowing behaviors such as these to continue can leave the door open for ED behaviors to worsen or return. Thus, it is important for parents to help their children discontinue any ED-related rituals or behaviors. One way to do this is to make the behavior difficult to engage in. If she is scraping her teeth on her fork, consider serving her foods that do not require utensils. If she is wiping her fork on her napkin, you may want to avoid giving her napkins until she has finished the meal (you may also want to avoid tablecloths, placemats, long sleeves, or anything else that can be used in place of a napkin). If she is dropping food to avoid eating, the dropped food can be replaced on her plate. The goal is to continue to send the message to the anorexia that eating disordered behavior, in any form, will not be allowed to continue to disrupt your daughter’s life.
Renee Hoste, PhD
Dr. Hoste is Clinical Assistant Professor and Director of Clinical Services and Research for the University of Michigan’s Comprehensive Eating Disorders Program. She serves as Clinical Advisor to Maudsley Parents. Read more about Dr. Hoste here.