Are you the parent of an adult child with an eating disorder? Run, don't walk to this blog post by one of my favorite blogs, F*ck Feelings.

Actually, I'll save you the bother of clicking and just post the whole thing in its entirety below (the question from the parent is in italics. Everything else is from the blogger/psychiatrist):

People like to turn to an authority when they’re helpless, and if that helplessness only applied to 911-like situations, there would be no problem. For problems that don’t involve theft or fire but sadness and family, however, authority is useless; sure, doctors like me can give advice, but until medical schools start borrowing from Hogwarts’ curriculum, the best resources you have are your own. The sooner you realize that, the sooner you’ll learn to draw on your own authority to come up with the best possible management plan and execute it with confidence. You are your own best first responder.


I need to find a doctor who will tell my daughter she needs to take her medication. She’s always had a problem with depression, and she did well in high school when she took antidepressants. Now, however, she’s 24 and very reactive to however she’s feeling, whether it’s not getting out of bed, or not working, or feeling dizzy and deciding it’s the medication and stopping it. My husband and I can’t get her to stick with anything, and she won’t listen to us in any case, so our goal is to get you, or some professional, to tell her what she needs to do.



Whenever parents want a doctor to tell their kid what to do, you can be pretty sure they’ve lost faith in themselves and overestimated the power of communication/a medical degree.

And no, it doesn’t matter how old the kid is or how many Harvard degrees the doctor has; the doctor doesn’t have more power than the parents, no matter how powerless the parents feel.

In your case, I don’t know whether your daughter can be induced to take her medication, but I do know that she’s not going to be persuaded by the authority of a doctor at the age of 24 if her own experience and your words haven’t done it by now.

The probable reason for her unresponsiveness, by the way, isn’t stubbornness or a lack of respect, but a lack of control over her own impulsivity (probably enhanced by depression). In other words, it’s not clear she can make herself take medication regularly, even if she sincerely believes she needs it. At some point, other impulses take over, like the impulse to stay in bed indefinitely.

Fortunately, even though persuasion is probably useless, you have other tools that a mere doctor can’t touch. You can access them if you believe you know what your daughter needs, regardless of what she has to say about it.

For instance, if you believe that she needs to get up early and follow a daily activity regimen, then let her know that’s what you’ll pay for. If she says she’s too blah, tell her you know it’s hard, but she needs to try, and that she might be able to do it if she puts together a schedule and asks friends to help her keep it.

If she argues that she can’t do it until she feels better, tell her that you don’t know when she’ll feel better, so she’d better start trying to keep busy now, and maybe that will help her feel better later. Your tone should say that you believe what you believe, and there’s no point in arguing.

If she tells you that you don’t know what she needs, tell her that you’re the mother and you have a good idea what she needs. Don’t ask a doctor to be the authority– get whatever information you need from the doctor, and then assume you’re the authority. At 4 or 24, your kid needs to hear the same thing; you’re the mommy, that’s why. End of discussion.

If your incentives don’t work, don’t blame her or yourself, because, again, you don’t know whether she’s too sick to have the control she needs. By putting a priority on self-control, however, you provide her with a blueprint for moving forward that is not reactive to negative feelings or thoughts or painful side-effects.

You’re urging her to embrace goals that arise from her values and that she can stick with, regardless of how she feels or how much she accomplishes. Knowing medicine isn’t as important as knowing your daughter and what’s best for her. If she won’t listen to me, you can, and I’m telling you you’re the most qualified professional for the task.

STATEMENT:
“I’d like to think my daughter could respond to persuasion from someone she respects, but I suspect it’s not true. I’ll push her towards doing as much as she can, regardless of how she feels, and hope that incentives for good habits will take over where persuasion has failed.”

Excuse me while I go clone this guy millions of times over so that a) he can be all of our doctor and b) so that we can have him as our very own Psychiatrist Pocket Pal^TM.

It's nice to think about preventing eating disorders.  I'm not saying we can't do it or we shouldn't try.  But I'm wondering how teaching kids about "loving your body" and the dangers of eating disorders is actually going to help.

In a recent Huffington Post article, therapist Judith Brisman writes:

•Talk about eating disorders and how dangerous they are. Talk about it in the same way you talk about lung cancer and smoking -- or death and drunk driving. It's that dangerous. It can't be ignored.


•Help your kids pay attention to their inner life. What are they feeling inside when they turn to the third batch of cookies, or when they are skipping breakfast and lunch? Be genuinely curious about their fears, thoughts and worries about their body. And educate them! They may not know that skipping breakfast and lunch disrupts metabolism.

•Help your kids be responsible for what they are eating. Allow them snacks. For example, it's okay to eat cake -- but how many times a day? And what should portion size look like? Talk, be curious, instruct and pay attention. Kids need to know that if they get too skinny or become anorexic, they won't be able to be in the school play or on the hockey team. Kids should be as scared of anorexia, binge eating and bulimia as they are of smoking and drunk driving. They also should know that there are many things that can be done to help if they worry they are in trouble with food.

I don't think that these things are bad.  Open lines of communication between parent and child are very important.  And I do think that kids should be taught about eating disorders the same way they are taught about smoking, drunk driving and cancer.

My question is this: do we know that this will actually prevent eating disorders?

I'm guessing that most people who develop an eating disorder today probably know what one is.  I knew eating disorders were dangerous before I got sick, and it didn't really stop me.  One, I thought it would never happen to me. Two, I didn't realize I had anorexia until I was already stuck. 

I wish more kids (and adults!) were taught about the dangers of dieting and that "healthy eating" can go too far.  I want more people to know about exercise--too much and not enough.  I can believe that these things might help.

But explaining to someone how dangerous eating disorders are isn't going to prevent someone from getting sick.  It's like telling someone that cancer can kill you and expecting that this will make cancer rates go down.  It's a nice thought, but that's not how cancer works.  And that's not how eating disorders work, either.

Eating disorders are baffling and scary, and it's probably nice to think that if we just don't complain about our butts and if we tell little Susie and Sammy that EDs can kill, then surely they won't be stupid enough to get sick.  After all, my mother once told me (in all seriousness) that she never thought I would develop an eating disorder because I was smarter than that.  As in, I knew it was dangerous so why would I "dabble" in anorexia?

Because I didn't know I was dabbling in anorexia when I first got sick.  I just wanted to eat "better."  I was actually trying not to get anorexia.  It happened all the same because an eating disorder isn't a choice.  It's not logical.  It's an illness. 

So Dr. H (and her fantabulous Keurig!) loves metaphors.  Yet another reason we get along really well.  We were discussing my upcoming move, and she said:

"Your parents have really been like your training wheels, providing extra support and stability for you. And this move is kind of like taking off those training wheels. It's both scary and exciting."

It's 100% true.

I didn't have my dad take the training wheels off my bike until just before my 8th birthday.  He took them off once before, when I was about 5 or 6.  I remember starting to coast down our steep-ish driveway, gradually picking up speed on my training wheel-free bike.  I went to try and brake at the bottom, and I couldn't.  The brakes work, I just panicked.  And so I kept on coasting down the lawn and finally into the swing set.

I survived this escapade with only a few bruises, but I also had my dad put my training wheels back on my bike.  It was too soon, I was too scared, and I just couldn't do it.

It took until my friends were always racing around on their bikes to push me into taking those damn training wheels off.  As it turns out, my biking skills were just fine.  It was my confidence that needed some nudging.

And now, too, that is the case.  I know how to eat.  I'm not an idiot.  I do, however, have trouble believing that I can do it, that I can get better.  I'm not trying to convince myself that everything is fine, and I have nothing to worry about.  It's just that my self-doubts have often gotten the better of me in the past.  Maybe I did need those literal training wheels for several extra years.  I know I definitely needed these more metaphorical training wheels for the past 1.5+ years.

I also know that keeping these training wheels on for longer isn't going to make me any more ready to strike out on my own.  You can't really learn how to ride a bike until you take off those training wheels. 

There are safeguards, certainly.  I'm not moving to the moon.  I have a plan, I have a therapist, I have a lot on the line.  I'm motivated.  It's exciting and terrifying, all at once.

Last month, I wrote about the death of anti-anorexia activist Isabelle Caro. This morning, I learned that her mother Marie had committed suicide over the death of her child. Grief, guilt, and despair are painful, if normal, responses to loss.  I'm not faulting her mother for these seemingly intolerable feelings.  What I am wondering is how our habit of subtly blaming the parents for their child's eating disorder contributed to Marie's death.

In basically all of the news stories on Isabelle's death, there were comments about her mother, who was portrayed as a sort of Cruella de Ville of anorexigenic mothers.  An AOL story today said that:

Isabelle often spoke about her mother's phobia about Isabelle growing up and gaining weight, as well as her mother's depression. She had a lonely, difficult childhood as a result and had been anorexic since the age of 13. She wrote a 2008 memoir titled "The Little Girl Who Didn't Want to Get Fat."

This story also noted that Marie was especially devastated after a particularly critical article was posted about her in the wake of Isabelle's death.

Was Marie a perfect mother? Nope.
Did she cause her daughter's eating disorder? Nope.

A susceptibility to anorexia was part of Marie's genetic legacy that she bequeathed to Isabelle. Did she comment on her daughter's weight and size? I don't know. Even if she did, that couldn't cause Isabelle's anorexia.

Writes Dr. Julie O'Toole of the Kartini Clinic in a comment on her blog:

Even the most neurotic, dysfunctional, abusive parenting will not cause AN, much less what you have described above. AN is a brain disorder. Such parenting might, however, cause severe disordered eating, a neurotic obsession with appearance, or misplaced values.

In my years of practice I have had two mothers who actively tried to give their daughters anorexia nervosa. Why? Because they were mentally ill themselves. It is called Munchausen-by-proxy, and of course it didn't work. You can't give someone anorexia nervosa, even if you want to, and certainly not inadvertently.

It is likely that Marie was never told she could help her daughter recover, imperfections and all.  She clearly loved her daughter.  And if Marie herself had a subclinical eating disorder (I have no evidence that she did), it could have contributed to her alleged fears of Isabelle's gaining weight.

I remember discussing contributing factors with my mom in therapy.  At first, I believed that all of the unhelpful things she did were a direct cause of my eating disorder.  Anorexia was a rebellion!  A way of getting back!  A way of control!  Now I realize that these unhelpful things were a) inadvertent (how was she to know that getting good grades could be a bad omen?) and b) totally unrelated to my eating disorder.

Marie's death shows that the blame game is deadly--not just for sufferers, but also for loved ones.

I've never really gotten in touch with my inner child, but TNT is having me work on getting in touch with my inner parent.

The fact is, I'm not that good at parenting myself.  It's not that I didn't have good parents--I did.  My problem is that I never learned how to treat myself any way but harshly.  Call it the remnants of being a ruthless perfectionist, but much of my inner dialog is scolding and criticizing myself.  This frequently horrifies people, but it's rather true.

Along with the perfectionism comes black-and-white thinking.  I would seesaw between taking huge amounts of time to make the bed "perfectly" to not bothering to make it at all because it wouldn't look right anyway.  I've been known to procrastinate on doing anxiety-provoking things (like making phone calls) that nonetheless need to be done immediately.  It's all an opportunity for me to harp on myself and my carelessness, my procrastination, my anxiety, my willingness to pay a fine in lieu of making a simple phone call.

I babysat throughout 8th grade and then high school for the same family.  The two girls were more like my little sisters than the two kids I watched for a few hours every week (the oldest is now in college, which makes me feel practically ancient!).  I had to prod them into brushing their teeth at night, into washing their hands, and then read them to sleep.  They pulled some crazy stunts, as kids are wont to do.  I remember one incident where the youngest girl spent over 20 minutes "washing the soap" because it was dirty.  But I didn't yell at them or scold them.  I just kept encouraging and occasionally (metaphorically) strong-arming them into doing what needed to be done.

Although I have mixed feelings about whether I want my own children, I do know that I have parenting skills. I do okay with other people.

But with myself?  That's a different story.

For me, it helps to imagine what I would tell Aria to do.  If skipping a meal or snack would make her sick, then I would insist she eat.  It would be nice if she volunteered, or if she grew a pair of thumbs and opened the damn can herself, but if she doesn't, I would make sure she ate.  I need to learn how to do that with myself.  Be gentle but firm.

As for the criticizing bit, that's a whole 'nother story.  When I was talking to TNT yesterday, she said "Gosh, you are really hard on yourself."  And I was all "Ya think?"  People have always told me to be gentle with myself, but it's not something I've yet figured out how to do.  It's like all I can see is people who are doing more, who are more successful than me, and I feel that I "should" be doing all that and then some.  I've never learned how to give myself props, that reassuring pat on the back that I've done a really good job.  I can do that on occasion--I've finished a story recently and loved how it turned out--but not consistently enough to make any sort of difference in my day-to-day life.

That's one of the things I still need to work on, those "adult skills" that I never quite picked up.

What are some of the ways in which you have learned to be a good parent to yourself?

Today, I had the great fortune of reading two great pieces from Australia on eating disorders.

The first is an article titled Anorexia's Lifelong Legacy from the Sydney Morning-Herald, about how eating disorder diagnoses are missed in many boys, simply because pediatricians aren't looking for them, and don't think that males get eating disorders. Because proper, quick diagnosis has a large impact on disease outcome, these kinds of stories are very important. Besides covering this timely and important topic, the article did so in a scientifically accurate way. Some of my favorite quotes:

"When kids are starved, their brains shrink, they're more likely to get depressed and anxious, their thinking slows down and memory falters," Madden says. "This affects their relationships with their friends. The effects can be reversed with re-feeding, but not always."

These serious complications can be prevented if children at risk are picked up early. "If children get the right treatment early, 70 to 80 per cent get well in 12 months and 90 per cent are better in five years. This is much better than in adults where the recovery rate at five years is less than 50 per cent," Madden says.

And

Whether an eating disorder can take hold and thrive seems to rest in the balance of risk and protective factors that a person experiences. In the last few decades, the increasing number of risk factors experienced by children - such as stress, anxiety, dieting, body image worries, and exposure to media images and messages that equate fat loss with happiness - may be creating an unhealthy tipping point.

And

The media comes under fire, not as the cause of eating disorders, but as a potent "enabler" of fat phobia, body discontent and restrictive eating in young people...Kohn agrees that children are being influenced by anti-obesity messages. "Vulnerable children hear them in the wrong way and take them to the extreme. Then a physiological mechanism kicks in, reinforcing the behaviour. Eating less and losing weight dampens down the serotonergic mechanism in our brain that processes emotional responses. This makes the children feel better, calmer, less reactive. Their behaviour improves and they get positive feedback, locking in the dieting behaviour."

I wish more articles on anorexia were like this, chock-full of the latest research and entirely lacking in sensationalism and parent- and sufferer-blaming.

The other good read from Down Under is the book "My Kid is Back: Empowering Parents to Beat Anorexia Nervosa" by June Alexander. The book arrived in the mail on Monday, and I've been steadily chipping away at it ever since. As the title suggests, it is more intended for parents than sufferers, and contains the stories of several families who have helped their children conquer their eating disorder. Filled with wisdom and hope, it will be a great read for people needing encouragement along this long journey of recovery. It officially arrives for sale in the US in September, and you can pre-order your copy from Amazon.

Enjoy your Down Under reads- I know I am! Now, about that duck-billed platypus...

Much of my first several years in therapy for my eating disorder was spent looking at how my family was messed up. The assumption from every professional that I talked to was twofold: first, that my family was, in fact, messed up and two, that the messed-up-ness preceded the eating disorder.

My family has issues. What family doesn't? But those issues tend to be amplified when you have a child with a life-threatening illness that few can understand and even fewer can treat.

A recent study in the International Journal of Eating Disorders compared family functioning and maternal distress amongst those with anorexia, those with Type I diabetes, and healthy controls. Why diabetes?

"Specifically, both AN and IDDM (Insulin-Dependent Diabetes Mellitus) represent chronic illnesses involving self-care activities that are crucial to the physical health and psychological well-being of the adolescent. Both conditions involve complex changes in lifestyle in the form of changes in the amount and time of food consumption and exercise, and complicated medical regimens. If left untreated, both problems can have serious physical sequelae, placing an extraordinary burden on the adolescent and family members."

The purpose of the study, the authors say, was to challenge the assumption that family dysfunction not only causes AN, but also predates the onset of illness.

"The inclination to see family dysfunction at the root of AN has made it possible to neglect an alternative hypothesis, the possibility that AN may cause family distress. Research suggests that caring for someone with an eating disorder carries a significant burden, taking a toll on the health and well-being of the caregivers."

Although the authors did find some differences between the two groups (diabetes and AN), they also found quite a bit of similarity.

"When compared with mothers of daughters with IDDM, families of girls with AN experienced greater family conflict, reduced parental alliance, and increased feelings of depression. However, once the emotional impact of the illness on the mothers was statistically controlled, group differences were no longer significant."

Part of this may be attributed to the culture of blame that surrounds eating disorders, the authors hypothesize, as well as the fact that many of the people with AN in the study had been recently diagnosed or had relapsed; those with diabetes were simply receiving ongoing care.

But the last sentence of the study really says it all: "With a change in our understanding of the distress found within families of AN, our view of these families can be transformed from being part of the problem to being part of the solution."

I still feel guilty about all of the needless suffering my parents went through in the 6.5 years between my diagnosis and the start of effective treatment. I do know it wasn't my fault- I'm getting a teensy bit better at that.

But a diagnosis of an eating disorder in a child is often confusing and (when you start reading) kind of depressing. Don't get me wrong- an eating disorder is a life threatening illness. But there is also hope, and that's what we all need to cling to as the world gets tipped upside down and shaken like a snow globe.

Laura Collins says it best (from her forum Around the Dinner Table). It's what I wish someone would have told MY parents when I was first diagnosed:

It is not her fault. She is not choosing to do this, to feel this way, to think the way she is. It is a disease - a brain disorder.

It is not your fault. You did not cause it and probably could not have predicted it (unless you were an eating disorder specialist). It was a genetic predisposition that got set off by something (probably malnutrition or energy imbalance due to exercise).

It is fully treatable. With quick and assertive intervention, full nutrition, a lot of emotional and practical support, and time (many months) your daughter can not only recover her health she can be protected from eating disorder in future.

You will get a wide variety of clinical advice. Much of it will be mutually-exclusive. Some of it will be absolutely wrong. The world of eating disorder treatment is undergoing a massive change and that means you have to seek and secure the best care possible. Do not depend on clinicians to tell you what other clinicians offer.

The best evidence for effective treatment of adolescents living at home is "Family-Based" or "Maudsley" treatment. It is not widely available. Some old-school clinicians even advise against it. Research this approach, as others have said, and make up your own mind. It is worth travelling further to get the right treatment for your family than staying close to home and getting inadequate care.

You will be okay. Your daughter and your family can beat this. Do not believe anyone who tells you this is hopeless or that you should sit back and wait or watch - they are wrong.

Immoral parenting.

Interesting subject, no?

Now that there is so much parenting advice out there, if you don't do all 50 million things, then you're basically screwed.

Thankfully (for both my and any as yet unconceived children of mine), I am not a parent. I'm a mommy to my kitty, but that doesn't involve nighttime feedings, diaper changes, or pregnancy, so it's not quite the same.

Given the subject of my blog, I'm most concerned about how parents are judged on how they feed their children. I went to McDonald's, ordered a Happy Meal (Chicken Nuggets every time), drank juice at will, ate cookies regularly, had some sort of sweet almost every day, etc, etc. Today, this would make my mom a bad parent.

"Shame on you! You don't make your children exercise! You let them eat fast food! You let them drink juice! And pop!*"

Yet I never turned into an unhealthy person because of it. My health only seriously declined when I did the opposite of those things. As for my brother, well, let's just not go there. But his problems weren't related to what my mom fed us, either.

There was a commercial on for one of those cash advance companies and their ploy this time was, "You want to see super plays at Little League, not supersized fries."

I have nothing against Little League. I also have nothing against fries. They're trying to make a mom or dad feel guilty that they feed their children fries so they pay this huuuuuuuuuuuge fee to have time to get a "nutritious" meal and make it to a baseball game. In the long run, a fry is a fry. They're not immoral, nor are the people who eat them. I love fries, especially if you toss them in that powdered ranch dressing mix. I'm a fairly moral person. I don't cheat or steal. I always wear a seat belt. I at least try to be courteous. I meet deadlines. These were not things I learned from abstaining from fries for almost 7 years.

Not feeding your children- that's immoral. Or only feeding your children celery sticks. The line between immoral and harmful is vague. However, if you happen to have DNA that puts your children outside of the charts, you're hurting your child, and if you don't put them on a strict diet and exercise plan, you're destroying their health for the future.

People say the US has all of this horrible health. Yet infant mortality is low, we have a long life expectancy, deaths from infectious diseases are on the decline. Most people who die of heart disease have low cholesterol, and weight really isn't correlated either. Countries in Africa where food supplies are low and/or unstable, that's where you see problems. Having too little food is always always worse than having too much. So many products ::cough cough Alli cough cough:: are targeted at the 'overweight,' who actually have the lowest death rates. And if you're the parent of an 'overweight' child, you must have done something wrong.

The old saying is that "You are what you eat." So if carrot sticks are held up as this sort of Gold Standard of foods (or broccoli, or blueberries, or whatever) on both a nutritional and moral level, if you don't eat tons and tons of them, you're not only unhealthy, but you're a bad person. I don't vet this. Hitler was a vegetarian.

So let's have separation of church and state, body and business, and food and morality.

POST-NOTE: You're telling me Dr. Sanjay Gupta of CNN is a freakin' brain surgeon! Ha! Check out this chilling California ad campaign. It makes me sick!

*Where pop=soda. It's a Michigan thing. I ordered pop when I was in Atlanta and they gave me fries. I'm still scratching my head at that one.

I debated long and hard on my drive home from work over whether or not to write a post on this. But the more I thought about it, the more this particular story seems to highlight so much of our society's screwed up views on food, weight, and the role of parents.

I read a news article on my lunch break at work about an obese boy who social workers in the UK were attempting to remove from his home. Why? His mom wouldn't stop feeding him junk food, and wouldn't lock the fridge. They said that his weight and feeding habits were signs of parental neglect.

This baffles me, especially since the mother sought the advice of health professionals at the start of the year to help her son. Sure doesn't sound like neglect to me. The article also doesn't disclose whether the boy had any underlying metabolic disorders, citing privacy concerns. Which is all well and good, except they disclose damn near everything else, and any innate illness would make a big difference. I don't think you get a 200 lb eight-year-old who just likes potato chips a little too much. You just don't. There's something else going on there, something that sounds a lot like Prader-Willi Syndrome.

But at the end of the day, what really gets to me is that his mother is blamed for his situation. And what gets me thinking even more is both the difference and similarities with parents and anorexia. Say an 8 year old kid presents with anorexia. Would the parents be hauled into court for neglect? I can almost guarantee not. Society is, in my opinion, much more tolerant of low weights than of high ones. An 8-year-old with anorexia is in just as much mental and physical danger as an 8-year-old who weighs 200 pounds. But the whole obesity epidemic hype has gone a little bit too far. Does this boy have a weight problem? Absolutely. But I highly doubt that a little overeating and too much time in front of the telly could do something that drastic.

On the other hand, the parents of the hypothetical eight-year-old with anorexia will probably have their parenting skills called into question, too. "How could you let your kid DO this?" they might ask. You very well might ask that of the parents of a child with cancer. "How could you let this happen?"

There are skilled parents, and there are not-so-skilled parents. Even the children of skilled parents- like me- fall ill with diseases for which we know little about. This boy's mom is single, and suffers from depression. When I was young, my mom suffered from depression too. It makes parenting a whole hell of a lot harder- when I'm depressed I can hardly remember to feed my cat, let alone comprehend how to care for a child. Parents are people. They come with their own issues. Mothers aren't made saints when they pop their first child out from the womb.

I'm glad the boy is getting help. I hope his mother does, too, so they can all grow up to be happy and healthy.