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.
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 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.