Presentation at NEDA 2015 conference

Lauren and Katie presenting NEDA 2015

Katie and I had the honor of presenting in the Individual, Family, and Friends track at the National Eating Disorder Association Conference in San Diego yesterday.  The title of our talk was:  Family Based Nutrition Therapy:  Creating A Supportive Environment.  It was a chance to share the way we work to support families who are helping children with eating disorders.

Here are some of the key points of our talk:

FBT Insights from the Neonatal Kitten Nursery

Parents feed children in FBT Kitten CollageI recently began volunteering at the Best Friends Neonatal Kitten Nursery. Best Friends Los Angeles opened its neonatal kitten nursery in February 2013.  The nursery is staffed with a dedicated coordinator and supported by volunteers who sign up for two hour feeding shifts 24 hours a day to help the kittens grow and thrive.

If you were an abandoned kitten in the Los Angeles area, or even a kitten with a mother, you’d be lucky to make your way to the Best Friends Neonatal Kitten Nursery.

The most vulnerable animals in the Los Angeles shelters are newborn kittens, often abandoned at birth, or turned into shelters from accidental litters. Because the kittens cannot feed themselves, they will die without someone to bottle feed them.

In the mommy and me section of the nursery, mothers nurse their kittens. In the other sections, kittens are bottle-fed, tube-fed, or syringe-fed until they are able to eat gruel on their own. Kittens are weighed before and after each feeding. If their weights are not steadily going up, the interventions increase. They are very fragile at this age.

The other night, the nursery coordinator, Nicole, was tube-feeding some kittens who were ill. As she explained, they were feeling too sick to eat on their own. Although acknowledging that her tube feeding was making them angry, Nicole was resolute. No kitten would starve to death on her watch. Of course, I connected this back to my families working to re-feed their children with anorexia.

In the neonatal nursery, we don’t spend time thinking about why the kitten is not nursing or eating in the expected fashion. If they are sick, they are treated for that, but in the meantime, every kitten is fed around the clock and those who don’t have mothers are bottle fed, those who won’t nurse from their mothers (often when they are too congested) are tube-fed, and those who won’t eat gruel independently are syringe-fed.

How does this relate to parents doing Family Based Treatment (FBT) for Eating Disorders with children who have Anorexia?

Of course, parents do not literally force food down human children’s throats, but they do set up contingencies to require eating even if the child doesn’t feel well and even if they rail and resist and are angry about it.

This is the heart of FBT Phase 1. When children are not able to eat on their own (due to an eating disorder) parents are instructed to nourish their starving child back to health. Parents need to step in and help their children make steady weight gains until they are able to eat on their own. Parents need to be resolute and not worry about their children being angry at them. They also should not spend time exploring why their child is not eating.

For further information on parental direction over eating in FBT, check out this prior blog post.

 

Parental direction works, but don’t expect your kid to be happy about it: Research on The Family Meal in FBT

Slide1Parents charged with helping their children to recover in Family-Based Treatment often wonder 1) how to actually get their children to eat and 2) whether they will harm their children or the parent-child relationship by requiring them to eat. A recent study addressed these concerns by looking at the family meal.               

How do parents of adolescent patients with anorexia nervosa interact with their child at mealtimes? A study of parental strategies used in the family meal session of family-based treatment

Hannah J. White BSc (Hons), Emma Haycraft PhD,*, Sloane Madden MD, Paul Rhodes PhD, Jane Miskovic-Wheatley DCP/MSc, Andrew Wallis MFAMTher, Michael Kohn MD and Caroline Meyer PhD (Article first published online: 26 JUN 2014)

The above study in the International Journal of Eating Disorders looked at the family meal in Family-Based Treatment (FBT), the best-researched outpatient treatment for adolescent anorexia. In FBT, the family plays a central role in treatment. Parents take responsibility for weight restoration and interruption of eating disorder behaviors, and family meals are an essential part of this process. Typically the second session of Family-Based Treatment is a family meal in which the family brings a picnic meal to the therapist’s office. The goal of the session is for the therapist to empower the parents to get their child with anorexia to eat one bite more than the child was prepared to eat.

The strategies used during mealtimes by parents of adolescents with anorexia have not been previously documented. Some believe that the eating habits of these adolescents have regressed and that the adolescents should be viewed as younger children who need more feeding assistance from their parents. Thus, parental strategies used to encourage eating would be similar to the strategies used by parents of younger children with and without feeding problems, which have been studied: these parents have been noted to use both encouragement and pressure to eat. Little is known about the response of adolescents with anorexia to their parents’ attempts to get them to eat.

The purpose of this study was to examine the strategies used by parents and the results. The study included 21 families with children between the ages of 12 and 18 who were undergoing FBT for adolescent anorexia.

The main aims of the study were:

1)   to identify mealtime strategies used by parents during the family meal session of FBT.

2)   to explore the relationships between these strategies and parental ‘success’ in encouraging eating.

3)   to explore the relationships between these strategies and their results with the emotional tone of the mealtime.

While this research was conducted in an artificial setting – a therapist’s office and in the presence of the therapist – the findings should be applicable to family meals occurring in the home.

Specifically, the researchers found:

1)   parents used a variety of strategies to prompt the child to eat: direct eating prompts (e.g., “You’ve got to eat all your eggs” or “Pick it up and eat it”), non-direct eating prompts (e.g. “Keep going” or “Why don’t you eat some more pasta?”), physical prompts (e.g., pushing a plate of food towards the adolescent), autonomous comments (e.g., “Do you want another one?” or “Which one do you want?”) and information provision (e.g., “Your body needs the calcium” or “This will make your bones strong”).

2)   direct, non-direct, and physical prompts were more successful in getting adolescents to eat than providing information about the food or offering food-related choices to the adolescent.

3)   in general, the more the parents prompted the child to eat and the more successful they were, the more negative the adolescents became. It makes sense that attempts to encourage eating, which contradict the anorexic tendencies, would cause psychological distress and a more negative emotional tone.

The authors conclude “It is interesting that a behavioral focus on eating (i.e., verbal and physical prompting) was associated with parental success as opposed to other strategies such as offering choices to the adolescent or consequences. This indicates that parents implementing a direct focus on food may be central to eating behavior and supports the emphasis on behavioral change rather than insight which is central to FBT.”

Keeping in mind that this is only one small study, the results are consistent with my observations of family meals in my practice and reports from parents refeeding their adolescents:

  1. parents need to directly prompt or pressure their child with anorexia to eat.
  2. offering choices and providing information is generally less effective in getting children with anorexia to eat.
  3. the more the parents pressure the child and the more the child eats, the more negative and upset the child becomes.

This study highlights the paradox parents face in implementing FBT. When a child is in distress, the parental instinct is to try to soothe them. Intentionally upsetting the child runs counter to a parent’s nature. However, for children with anorexia, food is medicine. The best measure of the parent’s success in FBT is the amount of food consumed. Parents should expect that their child will have a negative reaction to both pressure to eat and the eating itself. This negativity is not a sign of failure, but a reaction to a treatment that is working.

While these interactions often lead to more short-term conflict and distress, parents must persist and weather the storm in order to support their child’s recovery.  Over time, this persistence will challenge the anorexia and encourage change and recovery.

 

Recognizing and Managing the Subtler Signs of Starvation in Children with EDs

This interaction on twitter caught my eye:

Signs of Anorexia

Watching cooking shows, collecting and reading recipes, and cooking for others (but not eating it oneself) are some of the earliest signs of anorexia that are often missed and misinterpreted by parents. 

In Keys’ landmark study “The Biology of Human Starvation” male volunteers were put on starvation diets.  According to Keys, food became “the principal topic of conversation, reading, and daydreams.”  The volunteers studied cookbooks and collected cooking utensils.  Three of them went on to become cooks even though they’d had no interest in cooking before the experiment.  When starving, people may obtain vicarious satisfaction from cooking and watching others eat.

In my own experience, I contracted severe food poisoning during my second pregnancy.  Unable to eat without severe consequences, my doctors instructed me to forgo solid food for a full week.  I remember clearly that I spent the week lying in bed (entertaining my toddler) and watching cooking shows.  It seemed nonsensical to me at the time, like an unusual form of self-torture.  But, now I know it was an attempt to vicariously soothe my intense hunger.

In her book Brave Girl Eating, Harriet Brown discusses how her daughter went through a “foodie” phase during the onset of her anorexia.  I have seen a similar profile in a number of my young clients.  Parents do not usually think these are signs of trouble and are more often impressed by their child’s sophistication.  Some of the less obvious early signs of starvation parents should watch for include:

  • Reading recipes
  • Blogging about food
  • Cooking food they do not eat
  • Watching cooking shows

Of course, not every child who shows a strong interest in cooking has or will develop anorexia, but it is something that should pique a parents’ interest.

My own daughter went through a phase where she was obsessed with cooking and watching cooking shows.  It so happened that she was not eating enough at this time, which coincided with the start of her adolescent growth spurt.  I did an early FBT-like intervention and she gained and grew; as she did, the obsession with cooking abated.  Was this merely a passing phase or anorexia averted?  I’ll never know, but I’m glad I intervened.  (More about that in future post.)

When a child with a diagnosis of anorexia shows these behaviors, I recommend that they be stopped.  In FBT, parents take charge of their child’s food and food environment.  Food is the child’s medicine and the number one priority.  For this reason, vicarious gratification of hunger should be removed.  Children with anorexia should not be watching cooking shows, reading recipes, or cooking.  I usually recommend that children do not participate in preparing their own food at all in Phase 1.  In Phase 2, children gradually get involved in food preparation again, but the usual rule I recommend is that if they make something, they must eat it.

FBT Meal Strategies Gleaned from Ziplining

Understanding and Responding to Your Youngster’s Fear: A Metaphor

FBT Meal Strategies Gleaned from Ziplining
The author on the zipline

I often explain to parents that for a youngster suffering from an eating disorder, a meal can feel dangerous – like jumping out of an airplane. A couple of years ago I had the opportunity to (almost) live out this metaphor on a family vacation. This experience led me to reflect on the experience of both the teen and their support team:

Recently our family went zip-lining for the first time. I was terrified. But as I was zip-lining, I paid close attention to how I felt and behaved and what helped me get through the experience.

Despite the excitement I had felt when we initially planned the activity, when I saw the length and height of the zip-lines, I had misgivings. I imagined that this is how many of my patients must feel before many meals. Imagine, though, that they face this fear up to six times daily!

During the zip-lining adventure, I felt most comfortable going after my children and before my husband. Even though once I was on the zip-line I was alone, rushing through the air at speeds of up to 50 miles per hour, so fast my eyelashes were blowing into my eyes – somehow taking the plunge in this order made me feel like I was snugly nestled between them.

The calm and assurance of the line attendants was comforting. They knew what they were doing. At every single end of each of the eight lines, I felt compelled to tell the attendant that secured or unstrapped me exactly how terrified I was. I was relieved when they joked and told me they knew I would be fine. I also felt supported when my kids received me at the end of each line and reminded me that the next one wouldn’t be any harder. Knowing that my kids and husband were there with me and that we were doing it together made this fear something I wasnt facing alone.

So, how does this apply to supporting a young person with an eating disorder?

Physical Placement of Support

During the zip-lining adventure, I felt most comfortable going after my children and before my husband. One of the basic premises of FBT is that the support of the family during mealtimes provides a supportive environment for recovery. Parents often find that sitting at the table on either side of their adolescent during mealtimes provides additional structure and support. It is an act of love to support a child through a meal when they are terrified.

Confidence

If the zip-line attendants had expressed hesitation or anxiety about what they were doing I probably would have refused to go. Calm and confident parents inspire trust in their children, making it easier for them to eat. Sometimes parents have to fake it until they do feel confident.

Validation

At every single end of each of the eight lines, I felt compelled to recount my terror to the attendant that secured or unstrapped me. I didn’t need to hear any response in particular. It just relieved me to express how scared I was and to know that the attendants heard me. When parents hear their child say he or she doesn’t want to eat, it is more helpful to simply hear it and stay calm than it is to get upset and try to argue or reason.

Reassurance

If the zip-line attendants had tried to reassure me by giving me detailed factual information about the strength of the lines and so on, my attempts to parse this information in my state of anxious activation might have only increased my anxiety. Parents can empathize with the fear and express confidence that their adolescent will be okay. “I know you are scared. I know you can do this.” Parents know their youngster and know whether joking will work. It is usually best to avoid getting into the content of the fear, such as how many calories are in the food, why they need fats in their diets, etc.

Togetherness

I also felt supported when my kids received me at the end of each line and reminded me that the next one wouldn’t be any harder. Knowing that my kids and husband were there with me, and that we were doing it together, made this fear something I wasn’t facing alone. The presence and support of parents and siblings and extended family during and after meals is critical.

 

At the end of my zip-lining experience, my nerves were spent and I felt exhausted. But, I was happy and proud I had faced my fear with the support of family. In the far more essential activity of eating, families can provide similar support to make fears bearable and provide an environment that allows teenagers with eating disorders to recover and flourish.

Parents usually get the best results when they are like the zip-line attendants: calm, empathizing with the fear, and never engaging the source of the fear (in this case, the eating disorder). Avoid getting pulled into the content of the eating disorder thoughts. When your adolescent says they are worried about the caloric content of food, think about what they are really expressing: their anxiety about eating. It is much better to empathize with how scared they are than to debate whether food is healthy for them (spoiler alert: it is).