The first tasks on the journey to recovery, and how parents support their child step by step
This is a section from Chapter 6 of 'Anorexia and other eating disorders – how to help your child eat well and be well'
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. In an initial phase you will need to take responsibility for these because a person in the grip of an eating disorder cannot do these things for themselves. This is what this chapter is about. The subsequent chapters give you more of the much-needed ‘how-tos’. Then in Chapter 10 we move on to tasks that bring your child back to autonomy, normal life and eventually a full recovery.
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 that our children fight us at this first stage. That they accuse us of making things worse, that they don’t see they have a problem, that they hate us, that their behaviour is so out of character. It’s normal that we’re at a loss for what to do next, and frightened that whatever we do will make them 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.
[Jumping to another section of the chapter…]
Food and love
As we saw in Chapter 4, food is the main component in the treatment of an eating disorder. It provides much-needed fuel for the brain and the rest of the body. There is also healing through the regular exposure to normal eating without purging. Yet for a while, regular eating is the most scary, horrible, anxiety-inducing thing you could ask your child to do. That’s where love comes in. A parent’s love is a healing force. Your child will not have to walk through hell alone because you’re going to be right by their side. sticking with them no matter what. It may not look like it right now, but you are building a relationship that will sustain your child’s recovery and support their wellbeing for years to come.
Remove choices: Magic Plate
You won’t find ‘Magic Plate’ in a treatment manual – it’s a term parent have coined to describe how the required food ‘magically’ appears on the table, without your child having had any involvement 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 for ever – 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 levels of freedom and choice. And you look forward to the day she can safely be making 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 confused, conflicted and guilty about eating what they need. It can protect them from a bullying eating-disorder voice.
With Magic Plate you don’t ask your child to choose between two types of biscuit, and you don’t check whether they’d prefer cheddar or brie in the sandwich – that will come later.
Say you present your child with a choice of two biscuits. This is what might be going on in her head:
- She tries to guess which has the fewer calories. The thought of getting it wrong is highly stressful. Her eating-disorder voice won’t allow her to take any risks. In the end, she’s so focused on calorie avoidance that she eats neither of the biscuits, and also turns down her milk.
- She knows which biscuit has the fewer calories, and it happens to be her all-time favourite. What luck! But just as she begins to feel some pleasure, the principle of self-denial kicks in. The eating-disorder voice reminds her she’s unworthy, and punishes her for enjoying food.
You don’t engage in discussions about quantities being greater or smaller than yesterday’s or different from what the hospital used to serve. You make sure that food cannot be hidden or purged.
Magic Plate can sound rather inflexible, so I suggest you are flexible in how you use it! For instance if your child is sobbing because the strawberry yoghurt with all the ‘bits’ in it is horrendous, but they’d easily eat the apricot version, it’s your wise decision what to do about it. With our daughter, in a first stage we learned not to swap any foods because she’d then find something wrong with the alternative and there would be more conflict.
You will learn from experience quite how rigid or adjustable you want your Magic Plate to be. If you accept a swap, or if you accept that a plate is not finished (we’ll come to that later) then the art is to keep your stance as a wise, caring parent – not a browbeaten one.
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’s different degrees of consultation and collaboration that may or may not work for you. For instance some youngsters manage early on to choose between two foods. In a minute I’ll say more on children who benefit from planning meals with their parent or from knowing ahead of time what’s for lunch.
People with ARFID usually benefit from more involvement and joint problem-solving – it helps that they are not terrified of weight gain.
Your guide throughout is, ‘what works best’. Your child’s age has very little to do with it.
Take for instance, our children’s common desire to take over the kitchen. My daughter’s hypervigilance was through the roof when she watched us cooking. We had to insist she leave or we’d never have managed to produce nutritious meals. Conversely I am thinking of a girl who ate a lot better when she’d helped chop vegetables. When her parents used oil she might voice some concerns 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.
Look out for changes too: after a few weeks some youngsters surprise their parents by requesting an old high-calorie favourite. Some suddenly ask, ‘How about an Italian theme tomorrow?’ In this case, you would be holding back progress if you insisted on being completely ‘in charge’. Occasionally, even early on in treatment, young people surprise us with a motivation to push themselves to get well (or to become free from the interference of annoying adults). [ii] 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 prompted to eat an extra blueberry – it’s likely that any attempts to collaborate will fail. Everyone gets exhausted and hopeless, and the illness gets 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 you probably need to join the majority of parents who have turned the illness around with the ‘Magic Plate’ approach. If that’s not working for you either, your clinicians should give you more help.
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:
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.
[Jumping to another section of the chapter…]
Meals in school
Once your son or daughter is not struggling so much with food at home, and assuming they’re physically and emotionally safe to return to school part-time or full-time, you’ll need to set up meal support at school. Otherwise it’s extremely unlikely that they will truthfully manage lunch and snacks. If they miss lunch, or bin everything except the carrots, they will suffer because of the big gaps in time. These reinforce the eating disorder mindset (low blood sugars… the brain sensing that the famine continues). I’ve spoken to parents who gave all the required daily calories at home, but until they set up meal support for the school hours, their child stayed stuck. While gaps make you and I ‘hangry’, for our children it’s a lot more serious.
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 for meals in school:
- 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 in order 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: your child will need a private room, with the plate and table in view of the camera. Hands must not go out of view below the table.
- 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. It’s understandable she should want to look normal, to fit in, and have people treat her with respect. And also be persistent: supervision, for a limited time, is non-negotiable.
More on school in this chapter, and more on this website:
- 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
[Jumping to the end of the chapter…]
Conclusion: parents take charge
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 particular things, you are their surrogate wise person. 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?
- Hiding food and lying
- Eating rituals
- Exercising, moving and standing
- Purging and bathroom visits
- Post-meal anxiety
- Running away
- Self-harm and suicidality
- Being cold
- Compulsive behaviours
- Body-checking and fat talk
- Protection from the internet
- Baking, recipes and images of food
- Protect your child from triggers
- Your self-care
- Planning how you will start treatment
- Conclusion: parents take the lead
You can also hear me cover the main questions parents ask in my Bitesize audios.
[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.