Practical steps to help your child beat the eating disorder: magic plate and other tools for the first phase of treatment

The first tasks on the journey to recovery, and how parents support their child step by step

A few extracts from Chapter 6 of 'Anorexia and other eating disorders – how to help your child eat well and be well'. This is a BIG chapter with a lot of practical guidance.

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Helping a child with an eating disorder ought to be pretty intuitive. You just want your child to eat, right? You want them to stop bingeing or purging or over-exercising, and to regain lost weight. These are indeed the first tasks of treatment, and what the next few chapters are about.

Every day you have decisions to make: what to allow, what to prevent, what to try next. I’m going to tell you what worked for us and for other parents, and what experienced therapists recommend.

It’s normal for our children to resist us at this first stage. They may accuse us of making things worse, claim they don't have a problem, express hatred towards us, or behave in ways that seem out of character. It’s normal that we’re at a loss for what to do next, and frightened that we’ll make things worse. For every step you take, even when you encounter resistance, you are moving forward. If right now the journey I propose seems impossible to you, hang in there. Even a single tool, if it works for you, can make all the difference

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Take the lead on the things your child cannot manage

If your child could eat when their mind tells them they’re a glutton, if they could finish their plate when they’re in a state of terror, if they could rest when their in-ternal critic shouts they’re lazy, if they could fix the eating disorder for themselves, then they wouldn’t have an eating disorder.

The strength of a family-based approach is that we parents actively support our children to manage tasks which they perceive as impossible, even wrong. Our own confidence grows: experts talk of increasing parents’ ‘self-efficacy’.

Supporting our children to do hard things is normal of us. We did it when we took our little ones for injections. Now we require our children to eat and we persist with kindness as we prompt them to take one bite after the other.

I didn’t ‘get it’ until another parent asked me if we were ‘encouraging’ our son to eat or ‘requiring’ him to eat. None of the professionals had made the point that eating was non-negotiable.”

I know you’ll be nervous about your child’s reaction to you ‘taking control’. So choose your language. Daniel Le Grange, co-author of the FBT manual, wrote to me:

“I take a very deliberate stance not to talk about ‘parents in charge’ or ‘parents taking control’. It creates the impression of setting up an adversarial stance ‘against’ the adolescent and doesn’t sound supportive and empathic toward the adolescent.”

Likewise, the experts at Maudsley child and adolescent services use language of care, like ‘taking responsibility’ or ‘taking the lead’. You are a wise and loving parent ‘stepping in’ to take care of your child to whatever extent they need it. As your child gains some freedom from the illness, there will be fewer aspect you need to oversee – indeed later in treatment you will actively work towards promoting their autonomy (Chapter 10).

Your child may need to hear all this because of course they value their inde-pendence, freedom and… ‘I’m not a baby!’ This phase is not forever. And even now, your child can keep age-appropriate autonomy over aspects that don’t interfere with treatment.

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Food and love

For a while, regular eating is the most scary, horrible, anxiety-inducing thing you could ask your child to do. Your love makes it possible for them to manage. And when their mind is awash with self-loathing, your love is a force for healing.

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Remove choices: the Magic Plate method

You won’t find ‘Magic Plate’ in a treatment manual – it comes from parents exchanging tips on forums. It refers to the required food ‘magically’ appearing on the table: your child hasn’t been involved in the menu, the shopping, the cooking, or the quantities. Six times a day (some prefer to make it five times), you ask your child to sit down and you support them to eat what is on that plate.

Further down I’ll talk about more collaborative approaches. But the likelihood is that your child needs something like Magic Plate at the start.

You could start by informing your child in a clear and loving manner that for a while – this won’t be forever – you and your partner will make the decisions relating to food and health. For any other aspect of her life, you will gladly see her keeping age-appropriate freedoms and choices. And you look forward to the day she can safely make her own food choices again.

Magic Plate helps you give clear instructions on what you expect your son or daughter to manage. They may fight it, but privately they’re likely to feel less con-fused, conflicted and guilty about eating what they need. It can protect them from a bullying eating disorder voice.

Does your child become paralysed or combative when you offer a choice of two biscuits? That’s probably because:

• She worries about which one has the most calories. Her eating disorder voice won’t allow her to take any risks. In the end, she’s so focused on calo-rie avoidance that she eats neither of the biscuits, and also turns down her milk.
• She knows which biscuit has the fewest calories, and it happens to be her all-time favourite. What luck! But just as she begins to feel some pleasure, self-denial kicks in. Her internal critic reminds her she’s unworthy and punishes her for enjoying food.

This is why Magic Plate is helpful in a first phase: when your child isn’t able to make decisions, their mind quietens. It’s not all ‘magic’: they’ll still argue about portion sizes or ingredients, or try to hide food in their pockets, but you’ll get the skills to manage those difficulties.

You will learn from experience quite how rigid or adjustable you want your Magic Plate to be. Don’t let anyone’s advice turn you into a dogmatic, inflexible, authoritarian parent. Keep your ability to problem-solve, and keep your stance as a wise, caring parent – not a browbeaten one.

Your child is sobbing because ‘the bits’ in the strawberry yoghurt make it horrendous? She says she’ll have the apricot flavour? Use your wisdom and experience to decide. Some parents successfully swap foods of similar nutritional value. A relaxed, ‘Sure, that’s a fine choice too’ will do. With our daughter, for a while we had to stick to what we’d served: if we agreed to her alternative, she’d find something wrong with it and there would be more conflict. In this situation you might say, ‘Hmm, I’ll remember for another time that you’d like X. For now I’d like you to stay with what I’ve served.’

Magic Plate is, of course, a temporary strategy. Gradually you will be on the lookout for areas in which your child can wisely engage in teamwork.

Tips for effective collaboration… or not

Magic Plate is at one end of a spectrum of collaboration. At the extreme opposite end you’re allowing your malnourished child to nibble on steamed kale alone in their room. (If that’s what you’ve been doing, I am guessing it’s because you thought, ‘At least he’s eating something’. You knew this was not a solution but nobody had given you effective tools to risk anything else.) [i]

Along the spectrum, there are different degrees of consultation and collaboration that may or may not work for you. Your child’s age has very little to do with it. Some young people can competently choose between 5 snacks. Some parents report their child eats well if they’ve been collaborated in meal planning. Other youngsters only make progress with a strict ‘Magic Plate’.

Note that with ARFID treatment, young people must be involved, choosing the level of difficulty they’re willing to challenge themselves with. No Magic Plate for them. It helps that they are not terrified of weight gain.

If you think that everything is a manipulation by ‘ED’ you might miss something important. For instance, some youngsters – especially autistic youngsters, and especially while anxiety runs high – genuinely suffer when they hear other people chewing and swallowing.[i] Maybe your child really can eat more easily when you sit together in the living room, away from the family table, with music playing.

Your guide throughout is, ‘what works best’. Consider our children’s common desire to take over the kitchen. My daughter’s hypervigilance was through the roof when she watched us cooking. If we hadn’t insisted she leave, we’d never have managed to produce nutritious meals. Conversely, I am thinking of a girl who ate a lot better when she helped chop vegetables. When her parents used oil she sometimes voiced her concern but quickly accepted that it was OK. Among autistic youngsters, there are some who can only eat when they’ve been involved in planning, cooking or serving.

As your child progresses, you may find they’re able to collaborate in some areas. Some youngsters surprise their parents by requesting an old high-calorie favourite. Out of the blue, they ask, ‘How about an Italian theme tomorrow?’ Occasionally, even early on in treatment, young people surprise us with a push to move on. We don’t want to get in the way of that, as long as it’s working. In Chapter 14 I say more on motivational conversations that may or may not be useful.

If your child is very caught up in the eating disorder – they don’t believe they have a problem, they tremble when faced with an ‘extra’ blueberry – it’s likely that any attempts to collaborate will fail. Everyone gets exhausted and hopeless, and the illness becomes entrenched.

If you have good reasons to believe your child can drive some aspects of their recovery, you can agree to try something ‘and then we’ll review’ (within a day, not weeks, because eating disorders can spiral down fast). Be there to monitor – don’t allow yourself to get disempowered from your caring role.

We are talking about collaboration here – joint problem-solving towards the aim of recovery. You remain a wise and caring parent. If your child cannot tolerate your prompts, if they become extra distressed, if they fight you, if they end up with less food than is required, then join the majority of parents, who have turned the illness around with ‘Magic Plate’. If that’s not working for you either, request more help from your clinicians

Planning meals with your child?

Some parents – a minority – report that things go badly when they are making the decisions (as in Magic Plate) and that it’s more effective to plan meals with their child. They find that after an agreement is made, their child eats with minimal difficulty.

Further down I’ll talk about meal plans from clinicians. For now, if you are planning meals with your child, you might find these cautionary words helpful:

• If your child’s choices are insufficient, the tools in this book should help you persist in prompting for more (‘Your plan to have toast for breakfast sounds good. What else? …. Yes, you will need more… OK, well, I propose two scrambled eggs… Now see the butter you spread on your toast, that’s a good start, and at the same time you need more for a normal amount… How about you start spreading, and I guide you?’)
• If you keep having to compromise with too few calories, too little variety, and if you can’t make a Magic Plate approach work either, then you need more help from your clinicians.
• Micro-managing food is an eating disorder behaviour, so try and move away from details – make the plan a broad-brush one.
• Weighing and measuring precise amounts is also disordered. Ideally, you will serve your child. If they really want to serve themselves, they have to accept your guidance or corrections.
• If you are already stuck in a rut with precise quantities, then try to move on (‘Your breakfast bowl has had exactly six almonds for a while. Let’s get to the point you can casually throw in a handful. Too difficult? OK let’s practice one more almond each day this week.’)
• Don’t plan more than a day or two ahead, so you can grab opportunities that might speed up progress. Our children can surprise us with sudden leaps in courage, and you don’t want any meal plan to hold that back.
• Once an agreement is made there should be no more negotiation. Otherwise why go through the hard work of planning?

Advance information: what’s for lunch?

Some youngsters find a meal easier with advance information.[iii] Presumably they use the time to self-soothe. My daughter was the opposite: any prior knowledge made her anxiety and resistance shoot up. She’d ask what we were planning for dinner, and we’d say, ‘It’s better you find out when we serve it.’ Soon, she relaxed into acceptance. We discovered that she could rise to extreme challenges if they were sprung on her without warning. The anxiety would rise in the moment and we might get an earful, but this was nothing compared to all the anorexic distress that swirled round her head if she knew what was coming.

You will learn from experience what best suits your child.

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Meals in school

Once you expect your child to eat in school, you’ll need to set up meal support. Without it, it’s extremely unlikely that they will truthfully manage lunch and snacks. I know parents who gave all the required daily calories at home, but until they set up meal support for school hours, their child stayed stuck. Long gaps don’t just make our children ‘hangry’: they seem to activate the eating disorder.

Until a young person finds eating easy again, it’s likely that only their parents (or experts from an eating disorder service) have the skills to make meals succeed.

Your child may need to progress through these levels of support:

• You meet her in the school car park, or in a room the school allocates to you. She may come home for lunch.
• She is now used to eating, so she gets one-on-one supervision from a member of staff in a separate room, possibly with some friends of her choosing. Staff give immediate feedback to parents: did she eat everything or not? They are not expected to cajole her into eating.
• The risk of her cheating is now low, so she eats in the dining room, knowing that staff are keeping a discreet eye on her, and that they will report any problems back to the parents. And that you are monitoring her weight. Note that choosing food from a cafeteria can be overwhelming, so the night before, together you could consult the menu online. Sometimes there’s an agreement that a staff member will check on the person’s tray at checkout.

For some parents it’s just not feasible to put life on hold for weeks to feed snack and lunch in school. Here are ideas that parents have used:

• Get friends, family or professionals trained up to do some of those meals.
• Support by video call, with the plate and table in view of the camera. Hands must not go out of view below the table. Often, our children are secretive, so they need a private room. But a mother told me she supported lunches on video call while her daughter sat with a bunch of friends. Everyone chatted happily among themselves and with the mother.
• Shorter hours in school: keep your child home, or take them to work with you, until they’ve had their morning snack.
• If you can support lunch but not the morning snack, and if the gap is less than four hours, and if breakfast and lunch are large, you might avoid the pitfall of eating disorder ‘hanger’.

If your child hates having to meet you for lunch or having staff involved, give her empathy and show regret that, for now, there is no other solution. It’s understandable she should want to look normal, to fit in, and have people treat her with respect. Also, be persistent: supervision, for a limited time, is non-negotiable. My daughter’s anorexia when, age 15, she started restricting school lunches. So I am inclined to recommend that throughout their schooling, even when recovered, children eat in the dining room where staff can keep a relaxed eye on them – or do spot checks. If your child is going to backslide or relapse, it’s most likely to begin out of your view, with missed school meals. But as always, you’re the expert on your child.

More on school in this chapter, and more on this website [click]:

• A list of issues for parents to discuss with the school
• How to tell the school of your child's eating-disorder needs: template for a 504 plan
• Is your school supporting lunch? It must
• School trip or summer camp: a helpful flow chart
• What to say when you discover your child binned food at school
• School portal to eating, exercise & body issues

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Conclusion: parents take the lead

Parents, never doubt that your child needs you to take the lead at this stage of his or her recovery. They may appear capable because they can still solve quadratic equations, but this illness transforms part of their brain, robbing them of the ability to do a whole lot of things safely and wisely. For those things, you are their surrogate wise person. You’re lending them your wisdom. You’ll carry them until their body and mind learn that normal behaviours are indeed normal and safe. Then gradually you will give your child practice at taking care of themselves until they have age-appropriate autonomy. You will have the delight of seeing your wonderful child fly with their own wings. We are so lucky that out of all the terrible mental illnesses, eating disorders are perfectly treatable. Here’s one young person’s account, which I think says it all:

“Before, I’d say, ‘Mom, Dad, I’ll just eat more, I really will. I don’t need any more help.’ And they’d say, ‘Oh, good, glad to hear that.’ And they’d believe me. Now, I say that same thing, and they don’t believe me. They know they need to help. And knowing that they don’t take my ‘bullshit’ is SUCH a relief. It makes me KNOW that this will end. Knowing that I can’t convince my parents that I can do it on my own makes me know that I will be able to do it with them – and it all will end … thank goodness.”

In this chapter:

• Take the lead on the things your child cannot manage
• Will this treatment not ruin our relationship?
• Food and love
• Give your child ammunition against the eating-disorder voice
• Hear how your child speaks in code
• Remove choices: the magic plate method
• Tips for effective collaboration… or not
• Advance information: what’s for lunch?
• ‘You’re making me fat!’
• What if my child doesn’t eat?
• How long should we persist with a meal?
• How much food? Which foods?
• Target body weight
• Weighing your child: open or blind?
• Bodychecking and fat talk
• Hiding food and lying
• Eating rituals
• Exercising, moving and standing
• School
• Bedtime
• Purging and bathroom visits
• Bingeing
• Post-meal anxiety
• Running away
• Self-harm and suicidality
• Being cold
• Compulsive behaviours
• Clothes
• Protection from the internet
• Baking, recipes and images of food
• Protect your child from triggers
• Your self-care
• Plan how you will start treatment
• Conclusion: parents take the lead

Where to next:

* Back to Table of Contents *

* Chapter 7: How do you get your child to eat? (The bungee jumping analogy)

You can also hear me cover the many questions parents ask in my searchable Bitesize audio collection.

Endnotes [click]

[i] I am unhappy about how commonly parents are told they’re ‘colluding’ with the eating disorder or ‘enabling’ it. It’s blaming and fails to recognise that the parent needs more effective tools and support.

[ii] For an example of a son who responded well to jointly devised ‘contracts’ and a system of rewards, read Bev Mattock’s Please Eat

[iii] For instance recovered youngsters praise meal plans on youtu.be/pPSLdUUlTWE