Re-Nourishing your Anorexic Child During Covid-19

(Adapted from Eva Mumsby, Maudsleyparents.org, FBT principles, and many years of clinical experience)

Over the last few months, there has been a significant increase in anorexia in both children and teens. Social isolation has been positive in that it allows parents working at home to be available for meal and snack supervision. On the other hand, being socially isolated has had a significant impact on adolescent mental health. Some youth are reporting increased preoccupation with exercise and calorie counting and a lot more conflict at home.

Family Based Treatment (FBT) is the most evidenced based treatment for eating disorders in teens. In addition to FBT with a trained professional, it is important to schedule an appointment with your child’s pediatrician as soon as possible. Your pediatrician will likely want to follow you weekly for the first month and then appointments can be spread out once your child becomes more stable.

Recommend readings: 

Help Your Teenager Beat an Eating Disorder, by James Lock and Daniel Le Grange, which gives a thorough overview of eating disorders and the most current and comprehensive thoughts on FBT.

Survive FBT: Skills manual for Parents Undertaking Family Based Treatment (FBT) for child and adolescent Anorexia Nervosa, by Maria Ganci

WEBSITES:

maudsleyparents.org

F.E.A.S.T-around the tablehttps://www.feast-ed.org

Eva Mumbsby; anorexiafamily.com-great youtube clips

keltyeatingdisorders.ca- meal support videos

KEY POINTS:

Put yourself in your child's shoes

In order to be successful, you need to understand that eating can be extremely distressing for your child. It's not that your child won’t eat – it’s that they can’t eat; at least not without your help.

Because eating seems like such a simple task, it's hard to appreciate how much courage it takes for your child to eat. Especially in the early days, eating during anorexia recovery will cause tremendous anxiety before, during and after meals and snacks.

Your child’s mindset may temporarily worsen with increased expectations around eating. It is as if your child’s brain has been taken over by a “demon.” Many children have outbursts that are not at all like them. This is because increased fear around food places their nervous system in a state of fight, flight or freeze.

Many parents back off when they see how much anxiety re-feeding can cause. Continuing to insist on full nutrition in a compassionate and loving way will see your child through—if you don’t give up. Standing firm against eating-disordered behaviors while offering healthy support is the key to turning the situation around.

You are in charge

Since eating is so hard for your child, parents need to put themselves in charge. Most children later say what a relief it was.

Unfortunately, most teens are not motivated to recover and “don’t want to get better" while they’re in the strong hold of an eating disorder. Many parents have found that once their child is weight-restored, psychological recovery follows.

The brain is part of the physical body, and when it is malnourished, it doesn’t work properly. When it’s well-nourished over a period of time, rational thinking resumes. For some kids the change happens fast; for others, weeks or months of full nutrition must pass before cognitive and emotional responses improve. But it does happen.

The end goal of treatment is for kids to eat normally and happily on their own. Once your child is physically well and able to maintain a healthy weight, treatment focuses on returning control over eating to your recovering teen.

What and how much do I need to feed my child?

Anorexia can throw even the most confident parents off track, causing them to question themselves and second-guess their decisions, especially when it comes to feeding their child during the weight restoration phase of treatment. Remember- you have successfully managed to feed your child for years before anorexia, and probably still manage to feed your other children well. Have confidence in yourself.

Helpful Tips for Meal Support:

· Your child will need 3 meals and 3 snacks per day, with no more than 2-4 hours in-between. Bigger gaps activate the restricting or bingeing mindset. Remember- the food is the medicine.

· Plan for a parent/caregiver to eat every meal and snack with your child. Parents should decide what foods to serve, plate the food for their child, and expect it to all be finished. Remember- “the eating disorder lives in the last bite.”

· Don't give your child choices for quite a while: (e.g., 'What do you want for lunch? Want some more?') For some, though, a choice between A or B does work.

· Don’t be scared of what your child is scared of. Serve plenty of carbs, proteins, dairy, and fat. No low-fat/low-sugar/diet versions of foods (you’re aiming for balanced and ‘normal’).

· Feed for rapid weight recovery in the first 4 weeks. Children who gain 4-6 pounds in the first month tend to have a better prognosis. In order to reverse malnutrition, the amount of food your child will require to eat can be surprisingly large. Increase calories if weight gain is not rapid enough (please check with your pediatrician about re-feeding syndrome).

· Serve normal family meals without calorie-counting or measuring. Don’t be bullied into counting calories or weighing food (You can tell your child; ‘Trust me, I know what you need’). Favour home cooking, where your child cannot know calories. Consider blacking out nutrition labels. See Maudsleyparents.org for some great recipes.

· Don't offer reassurance on ingredients, calories, or having measured the food, (e.g., 'it's the same as yesterday' or 'you're not fat'). This usually reinforces the anxiety.

· Favour energy-dense foods (high nutrition in a small volume). You can boost the caloric value of foods by adding butter, cream, whole-fat milk, olive oil, whipped cream, etc. Some families also cut back on servings of plain fruits and vegetables during re-feeding because these foods add fiber, taking up a lot of room in the stomach (which can lead to feeling too full).

See great tips on F.E.A.S.T.

· Parents (not the child) should be in charge of grocery shopping and cooking to avoid negotiation with the eating disorder

· Keep your child preoccupied and out of the kitchen while you are preparing meals and snacks to reduce anxiety and avoid negotiations about what and how much to serve.

· Use positive distractions to quiet the bullying mind and change the mood when you can. Some families read aloud, watch movies, listen to music, or play games before, during, or after meals to reduce anxiety and stress for everyone.

· Some parents use leverage to encourage eating, removing phone, internet, TV etc. Others find that rewards or consequences increase resistance and that compassionate persistence works better.

· Your child will experience some uncomfortable fullness and stomach-aches. During starvation, the metabolism and digestive processes slow way down, and they must readjust when the child begins to eat again. Some families find that a warm heating pad over the stomach helps during and after meals.

· Here's a counter-intuitive lesson: many kids can't bear to receive a 'Well done!' or “Good job” at the end of a meal.

· Don't paint disaster scenarios. Your child needs you to be the bearer of hope, not someone who increases their state of fight, flight or freeze.

Work together (with your spouse, partner, or others in your network)

Parents/caregivers are a major resource in supporting their child’s recovery. There is no getting around it- parents simply need to be present. This can be a real challenge because it may involve changing routines, modifying work schedules or arranging a leave of absence to be available for meals and snacks. Teens who are acutely ill may not be able to manage lunch at school or snacks on their own. Even if this is difficult to arrange, being consistent will likely pay off.

Implementing the strategies outlined above can be difficult. The key to success is for all the adults in a recovering child’s life to deliver consistent messages, follow the same rules, and communicate fully.

Often parents come to the recovery process with different senses of timing, urgency, and normal responses to crisis. They must work together to get on the same page and explore any disagreements away from the recovering child. This may entail working through, or putting aside, any prior disagreements on discipline, lifestyle, and past events, all of which can and will be exploited by the illness to cause dissent.

Some parents have found the following helpful:

· Do not negotiate or consult with your child. This protects them from their internal bully.

· Present a united front.

· Troubleshoot and plan privately, not in front of the child.

· Use each adult’s strengths: one parent may be better at supervising mealtimes, another at cooking. One parent may be good at research, the other at communicating with clinicians.

· Prioritize your own relationship by taking time to talk and concentrate on each other.

· Keep siblings’ needs in mind in all decision

· Get away before showing aggression (fight) or blatantly giving up (flight)

· Never disagree with your partner in front of your son or daughter.

· Even if you've been told to 'externalise' the illness, don't use it to bash your child. When parents shout, 'I am sick of ED!' the young person hears, 'I am sick of you'.

· Remember, this is demanding and emotional work. You will need some time to take care of yourself.