Eating with an anorexic child

War broke out on the day Rina Ranalli and her husband told their 12-year-old anorexic daughter the strict new house rules: three meals and three snacks a day.

Initially, their bright and previously sweet-natured girl cried, screamed insults and raged. She threw things. Punched holes in the wall. And she pretended to eat while plotting ways to hide the food. But when the seventh-grader realized her parents had her trapped — they would sit with her 24/7 if they had to — she ventured down the only available path. She began eating.

Chicago's Ranalli family was using the little-known Maudsley Approach, a grueling but evidence-based treatment for adolescents suffering from the eating disorder anorexia nervosa. The approach, also called "family-based therapy," flips conventional treatment on its head.

Often parents are advised to put their starving child in therapy or residential treatment, distance themselves to preserve the teen's independence, and wait for the day the child decides to resume eating.

But under Maudsley, parents immediately start the daunting task of "re-feeding" their malnourished child. Once weight is restored — and, theoretically, rational thinking returns because the brain has some nourishment — parents step back, and control over eating is gradually returned to the child. The final phase of treatment is the initial step in traditional therapy; it addresses the underlying psychological issues that may have caused the disorder.

Critics of the approach say forcing adolescents to relinquish their power over food can exacerbate underlying control issues. They question whether Maudsley teaches children how to eat intuitively. And they wonder whether parents are equipped for the harrowing and relentless task of getting a child to finally eat.

But Maudsley has something other remedies for anorexia do not: A small body of clinical evidence suggesting that most adolescent patients respond favorably after relatively few treatment sessions. For parents, it's a glimmer of hope for a serious illness still lacking a gold-standard treatment.

"If you just Google 'eating disorder' and 'anorexia' you feel like you've been handed a death sentence," said Ranalli, whose already slender daughter (whom they didn't want named) lost 16 pounds in six weeks. "You cry a lot. Maudsley reassures you that it's not your fault and empowered us; we were part of the solution."

Anorexia is unusual in that sufferers often see the illness as an ally. They have a morbid fear of fatness and think about food obsessively; they may cook extravagant meals for others or longingly gaze at food in the grocery store. But they don't eat.

Social isolation is common. When 26-year-old Emily Troscianko made the decision to eat more after living with her anorexia for 10 years, "it felt like I was bidding goodbye to my closet, most loyal friend," wrote Troscianko, the author of the Psychology Today blog "The Hunger Artist."

The disorder runs in families and is associated with perfectionism, said Dr. Walter Kaye, the director of the eating disorder treatment and research program at the University of California, San Diego.

"Those with anorexia tend to pay precise attention to detail. They want to do things right. They're achievement oriented and have advantages in engineering, medicine and academics," said Kaye, whose research focuses on the brain and eating behavior. "Perhaps the illness is caused by an excessive load of traits, puberty and hormones, environment or stress. We're still trying to figure it all out."

Eating disorders are difficult to treat in part because they're hard to study. They're still relatively rare — affecting an estimated 2 percent of U.S. women and 1 percent of men — and it's not easy recruiting research subjects, who rarely want to be treated in the first place.

Just five randomized, controlled studies have examined the treatment of anorexia in adolescents, according to Dr. Daniel Le Grange, director of the eating disorders center at the University of Chicago Medical Center. Four of the five published studies include family-based therapy, or the Maudsley Approach.

Though the studies are small, they indicate that early treatment with Maudsley boosts a child's chance of getting a handle on the illness. Maudsley has also been found to be effective for those who don't yet have full-blown anorexia but are teetering on the edge.

"A weight gain of 3 to 4 pounds in the first month of treatment gives an 80 percent certainty of good outcome," said Le Grange, a professor of psychiatry and behavioral neuroscience who helped develop the approach at London's Maudsley Hospital and brought the treatment to the U.S.

The success rate drops considerably for children who don't quickly gain weight during treatment. But Le Grange argues that given Maudsley's promising results — and limited comparative data — the family-based treatment should be the first-line intervention instead of an alternative for adolescents who qualify for outpatient care.

"To be really honest with families we should say: 'We only have one treatment. There is a fair amount of evidence and it's what you should start with,"' Le Grange said. "If clinicians are not willing to do that, then we have to agree we're just improvising."

After Ranalli's daughter was diagnosed in February of 2009, the family spent seven months using more traditional methods, including a therapist and nutritionist. "It was painfully slow," said Ranalli. "So much is left back to the adolescent, waiting for them to come along."

Maudsley generally involves 20 sessions over a six- to 12-month period. No one shoulders the blame, and families learn to separate the illness from the child. It's not that the child won't eat; it's that the illness has taken over and won't let them.

"The disease is calling the shots, starving her, making her depressed, obsessive, unable to sleep and compulsively exercise, so parents do need to take control," said Jane Cawley co-founder of the support group Maudsley Parents. "It seems awful and strange — like you're making your kid suffer — but the whole goal was to get her back in charge of her life."

Family meals are a crucial component of the process. The first takes place with a therapist present to help coach. After that, families are in charge of feeding their child an astonishingly high number of calories a day — often twice what a healthy person would need — to get the weight back on.

Rather than emotional pleas, parents are asked to use empathetic but firm declarative statements, such as "I'm no longer going to let you starve,' 'This is your medicine' and 'I won't give up,' said Dr. Katharine Loeb, an associate professor in the school of psychology at Fairleigh Dickinson University. She is also director of the eating and weight disorders program at the Mount Sinai School of Medicine.

During this challenging first phase, normal life stops until the sufferer eats. Parents may quit jobs, take leaves, cancel all social engagements. It's lonely and exhausting for everyone.

"It's a matter of wills," said Ranalli, who ate lunch with her daughter at school to make sure the girl wasn't throwing the food away. "As a parent you are stating, 'I'm not leaving, I'm not caving, I'm not negotiating. We are not leaving this table until you eat.'

"God, we went through a lot," she added. "But you'd do the same in a heartbeat if your child had cancer."

For 18-year-old Nate Schnur of Wheaton, Ill., who was diagnosed with anorexia in August of 2009 — a week before he was to leave for college — the family meal was a watershed moment. During the lunch, a therapist told him he wouldn't be able to exercise until his weight was restored. Schnur, who worked out compulsively, began to cry.

"The exercise component was Nathan's form of bulimia," said Schnur's mother, Jacqui. "Taking that away from him was our way of 're-feeding' him in a sense."

The morning after his first family meal, Schnur said he woke up, "freaked out for half an hour" and then ate pancakes. He gained 30 pounds in three weeks — eating mostly fast food — and is in the final phase of Maudsley.

"I didn't want to worry anymore; I just wanted to enjoy my food," said Schnur, who is headed to Loyola University in the fall. "I was always thinking about how much I could eat or not. But once I started eating, I really noticed how my mind didn't focus on food and working out."

Some critics of Maudsley question the long-term effectiveness of such a controlling approach, especially with teens. "Taking food completely out of their control could give message they can't be trusted or can't trust themselves, which might be problematic long term," said Jennifer Schurman, a counselor at the Awakening Center in Chicago who specializes in eating disorders.

And Maudsley isn't the answer for everyone. It's virtually impossible if parents don't agree on the approach. Families who use it often say they need more guidance, support and resources, especially in a single-parent household.

And even when there's success, as with the Ranalli family, making peace with food is an ongoing process.

"I still have body issues," the Ranallis' daughter said while sipping a light coffee Frappuccino at a Chicago Starbucks. "But the thing that has really changed is that I like food again."

RESOURCES

Maudsley Parents: Provides Information on eating disorders and family-based treatment. Includes a list of treatment providers and centers. Visit maudsleyparents.org

F.E.A.S.T.: Families Empowered and Supporting Treatment of Eating Disorders is an evidence-based support group for parents and caregivers. Features a forum called "Around the Dinner Table." Visit feast-ed.org

The University of Chicago Eating Disorder Program: Directed by Maudsley pioneer Dr. Daniel Le Grange, the program is one of the few sites in Illinois that utilizes family-based treatment for anorexia and bulimia. Visit eatingdisorders.uchicago.edu

The Training Institute for Child and Adolescent Eating Disorders: Trains and certifies therapists in family-based therapy. The site has information on training workshops for clinicians and an up-to-date list of certified therapists for parents. Visit train2treat4ed.com

Books: Family-based therapy books include "Help Your Teenager Beat an Eating Disorder" by James Lock and Daniel Le Grange and "Eating With Your Anorexic" by Laura Collins.