Make it Possible For Your Child to Eat
Many parents are desperate for answers to the life-or-death question, “How can we get our anorexic child to eat?”. For some, whose children can only bear a limited range of foods or are locked into a rigid meal plan, the pressing question is, “How can we help our child to eat normally?” With my own daughter I was frustrated with the lack of answers, so once she was well I compiled strategies in a book for parents of children and teenagers, based on the small amount of published research, on our experience and on the know-how of other parents, of recovered people and of therapists.
The ability to get our children to eat is crucial, because both nutrition and the formation of new habits get their brain working normally again.
Whatever our child’s age we all have a lot in common, so you should be able to adapt at least some of the following tips to suit your situation.
Are You Nudging or Taking Charge?
First, be clear about your role. How determined should you be to get your son or daughter to eat – and to eat well? Should you be a gentle guide who assists when your child is willing to receive your help? Or should you assume control and persist in spite of extreme resistance? For many treatment providers, the answer depends on the patient’s age. Yet surely it depends on how the illness is affecting the person: has it removed their willingness to eat? And even when a person is generally willing, does their resolve abandon them at mealtimes?
For people suffering from anorexia aged 18 or under, the best evidence is that parents should initially take charge of their child’s eating, after which the youngster is assisted to regain an age-appropriate level of autonomy. This is the essence of family-based treatment (FBT is also called ‘The Maudsley Method’).
Therapists guide parents to:
- prevent behaviors driven by the eating-disorder (such as purging, exercising or bingeing)
- get their children to eat what they need at regular intervals
- rapidly bring them up to a healthy weight if they are underweight.
With this treatment we are not waiting for our children to engage with the process and we don’t need them to have motivation. We are carrying them to good health whether they like it or not. If we can’t do it (because no single approach works for everyone) then hospitalization will bring them back to safety, after which we will be in charge again.
Youngsters suffering from bulimia are more likely to have motivation and the ability to engage with treatment. Family-based treatment for bulimia offers more teamwork than for anorexia, but parents remain mostly in charge.
For young adults with anorexia (age 17-25), family-based treatment is currently being adapted so that parents are hands-on but there is some level of buy-in from the patient.
Traditionally, over-18s suffering from any eating disorder are expected to engage in individual therapy and to take responsibility for their treatment. There is no research to indicate what contribution parents should make. In general parents are either not involved, or are offered skills to give gentle support (as in ‘The New Maudsley Approach’), nudging their loved one towards safety.
This is fine if gentle guidance is all it takes for your child to eat, and during the later phases of treatment it’s appropriate to be increasingly hands-off. But in the early stages, restrictive eating disorders put up a tremendous fight when there’s food on the plate. Which means if all you plan to do is ‘nudge’, you may back off at the very moment your barefoot child needs to be carried over the burning sands. Some parents see that their son or daughter is too consumed by the eating disorder to engage with treatment. Rather than wait for admission to an inpatient unit they attempt to take charge of food just as they would with a teenager.
Whether you take charge or just guide, you can do so with a supportive, compassionate, non-punitive approach, which you can adapt to age and circumstances. This is what I’ll talk about here.
It’s Not That our Children Won’t Eat, it’s That They Can’t
To be effective you need to try and understand your child’s internal world. You should assume he or she finds it near-impossible to eat because eating – even just the thought of eating – doesn’t ‘just’ create a feeling of disgust, it doesn’t ‘just’ create discomfort in the belly, it actually triggers fear. You might reason there’s nothing to fear about food but then you don’t have a brain disorder that responds to food with a flood of anxiety-producing chemicals, and that responds to hunger with feel-good hormones. Given that anorexia creates a state of near-constant anxiety, it makes sense that a sufferer should avoid eating with all their might, even if it means fighting you, lying, and giving up on everything they used to value.
Fear is not just abstract for some people with an eating disorder. Sometimes they have an internal bully, a critical voice which feels as real as a hijacker holding a gun to their head: if they collaborate with efforts to eat, they will pay dearly for it. If we keep this image in mind we are more likely to be compassionate towards our children and not take their hostile reactions personally, and indeed family therapists teach us to separate the child from the eating disorder.
With our compassionate support, our children’s fear levels tend to be lower. But we don’t wait for that to happen. We put food on the table and support them to eat in spite of how horrible it is for them.
Compassion is the Guiding Principle
Family-based treatment doesn’t tell us how to get food into our children. It gives us one important principle, though: we should aim to give unconditional acceptance. That means we try not to judge, blame, or criticize our children even when we hate their behavior. With parents who are very hostile and critical, outcomes are poor. It doesn’t mean we parents have to be perfect – every single one of us has bad days and our children still recover.
The Main Tools to Help Your Child to Eat
How have you helped your children cope with injections? How did you support them to go to school when anxiety gave them a ‘sore tummy’? And how would you like to be supported if you had to take a bungee jump?
The same principles apply when you’re helping your child to eat in spite of fear. I’ll outline a few here:
- You can remove wiggle-room and indecision, making eating a non-negotiable requirement (many children later reveal what a relief it was that their parents took the decision to eat away from them).
- You can make all the food-related decisions: you plan, shop and cook without your child and plate up the food you require him or her to eat.
- You can show calm confidence, compassion, patience, non-judgement – and as it takes practice to manage that even some of the time, fake it till you make it.
- You can exude competence and know-how so that your child trusts you.
- You can be unrelentingly persistent, determined and focused.
- You can put across hope and a vision of good things to come.
- You can give eating prompts over and over again: end most of your sentences with “Have a bite now”, “Please eat the potatoes now”, or “Keep going”. This is one of the few strategies for which we have some evidence.
- You and your partner can work as a team and show you’re united on what and how much your child must eat.
- You can validate your child’s unpleasant feelings as perfectly normal, harmless and short-lasting.
- You can address your child’s resistance (hostility, hysterics, tears) with compassionate communication. It’s common for our children to react to anything we say, but silent empathy can work wonders.
- You can offer distractions (before, during and after the meal) in the form of games, movies, non-food-related chat, and friends.
- You can track subtle signs of what’s going on for your child in order to steer each moment as skillfully as you can: this will help you guess when it’s useful to keep encouraging, to wait, to comment on progress, or be silent.
- You can step back after a meal and review what support you need to keep going.
There are also a whole lot of things we parents learn to stop doing while we’re supporting a meal.
- Most of us find that while food is on the plate it’s best to avoid using logical arguments or lecturing on nutrition. We refuse to discuss calories, quantities, weights.
- We avoid giving choices or serving alternative foods until our children are more able to cope with decision-making.
- Some of us find it helps our children to know in advance what will be served, and some of us find the exact opposite.
- We avoid making deals that we’ll have to backtrack on next time.
- We avoid shouting and blaming, and we excuse ourselves and leave the room before we lose control.
- When we think our child can’t eat any more, we try one more thing.
- We don’t let our fear or our child’s fear stop us from supporting our child to eat.
In case the above is too abstract, let me give you a flavor of what I mean with some examples. If my form of words doesn’t work for you, don’t give up – either you need more context to understand how to shape your responses, or you need more tools, and there’s lots more on my website, in my book, and in parents’ forums (I like FEAST and EDPS).
Your child: “I’m not eating this.”
You: “I understand. That’s a really normal reaction. I’m going to help you. Please start.”
Your child: “I’m too fat. You’re making me fat.”
You: “That must be such a horrible thought. No wonder you’re feeling so rotten with a thought like that. I’m sorry about what you’re going through. Would you make a start please.”
Your child: “I’ve been sitting all day. I don’t need all these calories.”
You: “Trust me. What’s on your plate is what you need to be well and feel good. Go ahead darling.”
Your child: “I’m not hungry.”
You: “I can see that makes it hard. You know food is the medicine you need right now? Please start.”
Your child: “Did you put cream in this? / How many calories is this?”
You: “For now, sweetheart, I’d like you to leave food stuff to me and Dad.”
Your child: “Do I have to eat this?”
You: “Yes, love. Let me tell you this crazy thing the dog did this morning.”
Your child: “I hate you!” [Tips half of the plate onto the floor, gets up]
You: “Please don’t do that – I find it so boring to clean up. I’m guessing you’re doing that because this is really hard for you, right? Scary? Hmmm. That’s a really normal feeling. It will pass. I’ll get you a new plate, and meanwhile why don’t you fire up the TV?”
Your child: “If I eat this, then next time you’ll be putting a whole pot of cream in.”
You: “What matters is right now. I’m guessing it’s really hard for you right now?”
Your child: [tears]
You: “May I give you a hug? No? OK, so I just want you to know it’s normal this is hard. It will pass. It will get easier. I love you. I have learned loads about eating disorders and we’re doing all the right things for you to get your happiness back. Now have a bite. So I was telling you about the dog…”
Any of the responses above could lead to food being eaten. After a while your child might need just one reminder that eating is required. But at the early stages most of us need to be persistent. Accept that resistance is a sign you’re doing exactly what’s needed to carry your child out of the eating-disorder whirlpool.
Normal Life on Hold
In order to support our child to eat one meal after another (and perhaps to stop exercising, purging, or self-harm), most of us have to make changes to our life for a few weeks or months. The risk with this is that we end up with so many unmet needs that we lose touch with our inner power and our compassion. If we’re going to support meals, we parents must make it a priority to source practical and emotional support for ourselves.
Our child’s normal life can be on hold too for a few weeks or months. When my daughter was well enough to go to school but weight gain was a priority, breakfast was non-negotiable. This meant that sometimes she was late to school and sometimes she didn’t make it at all because I wouldn’t let her go on an empty stomach.
Have a Plan B
Think ahead what you will do when in spite of your best efforts, your child doesn’t eat some or all of the meal. This will give you the courage to refeed boldly and fast. Have what some parents call a ‘Plan B’.
I outline a whole range of Plan B options in this video:
Depending on risks, on what you need to achieve, and on your resources, your Plan B might be about:
- medical safety: you’ll insist on rest and you’ll cancel activities; you’ll take your child to the hospital.
- getting the required calories in: you’ll provide an alternative food or an energy drink; you’ll make up for lost calories at the next meal.
- showing the eating disorder that resistance from now on is pointless because you are consistent in requiring 100% nutrition: some parents use reward and punishment, some are ready to stay at the table for many hours, while some (including myself) persist with steadfast compassion; if this doesn’t work you need to move to another Plan B item.
- marking the end of the meal while maintaining your position of trustworthy, compassionate leader or guide.
Regarding this last point, here are ways it might work for you:
- you find a way to end the meal without blame and without looking defeated
- you have someone ready to take over before completely losing your temper and making things harder for next time
- if most of the food is eaten or if this meal is about tackling a fear food (more than about nutrition), you choose to end on success and an acknowledgment of the courage it took.
I hope this gets you started and that you experience successes you can build on. Give yourself kindness for the heroic work you are doing, take stock of the support you need, and ready yourself for the next meal.
We parents are very good at guilt, so if the tips outlined in this brief article don’t work for you and you blame yourself, I have two suggestions for you.
First, you could recognize that for some people at a particular phase of the illness, treatment requires an entire specialized team. If your child is being fed in the hospital right now, use the time to recover your energy and learn as much as you can, so you can take over again when your child is better.
Next, you could learn more. This article only provides an overview of what is at times an extremely difficult job. An FBT/Maudsley therapist will guide you through a family meal during your second session. If you get multi-family therapy there will be meals too. To get more learning and support, make use of these additional sources:
- Your clinicians (additional mealtime coaching helped us turn the illness around).
- Parents’ forums, in particular the FEAST forum, and the FEAST or EDPS or IEDFS Facebook groups. Read their resource files or discover a diverse range of approaches by following conversations. (Remember that while parents are understandably passionate about the precise thing that worked for them, there is no single validated way of feeding your child).
- My book ‘Anorexia and other eating disorders: how to help your child eat well and be well’ goes into a lot more depth, with chapters on helping your child to eat, on exposure and desensitization, on compassionate communication, with many tips, examples and scenarios.
- ‘Help your teenager beat an eating disorder’ by Lock and Le Grange, who developed and continue to research and improve Family-Based Treatment (FBT/Maudsley) takes parents through the approach. Their ‘Treatment manual for anorexia nervosa’ is a must for clinicians.
About The Author:
This article was written by Eva Musby, a respected author on eating disorders, whose daughter suffered from anorexia.