International Journal of Psychiatry in Clinical Practice
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Should parents take charge of their child's eating disorder? Some preliminary findings and suggestions for future research David Wood, Paul Flower & Dora Black To cite this article: David Wood, Paul Flower & Dora Black (1998) Should parents take charge of their child's eating disorder? Some preliminary findings and suggestions for future research, International Journal of Psychiatry in Clinical Practice, 2:4, 295-301 To link to this article: http://dx.doi.org/10.3109/13651509809115377
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International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 295-301
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Should parents take charge of their child’s eating disorder? Some preliminary findings and suggestions for future research DAVID WOOD, PAUL FLOWER AND DORA BLACK
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Rhodes Farm Clinic, Mill Hill, London, UK
Correspondence Address Dr David Wood, MB, BS, MRCPsych, Rhodes Farm Clinic, The Ridgeway, London hW7 IRH, UK Tel: +44 (0) 181 906 0885 Fax: +44 (0) 181 906 3155
The treatment of children and young adolescents with anorexia newosa is facilitated, relative to the treatment of adult patients, by the possibility of enlisting parents as allies in gaining control over eating behaviour. Experience at Rhodes Farm Clinic suggests that the capacityfor parents to be firm with their child enhances weight maintenance following inpatient treatment. Our treatment approach is outlined, and illustrated with some clinical material. A pilot study of 59 cases (58females, I male) strongly confm that weight maintenance is positively associated with parental firmness, and also negatively associated with age on admission to the Clinic. (Int J Psych Clin Pract 1998; 2: 295 - 301)
Received 4 September 1997; revised 17 April 1998; accepted for publication 6 May 1998
INTRODUCTION ne of the features of anorexia nervosa that makes it so 0 difficult to treat that the condition involves a powerful set of defences against overwhelming anxieties is
that the patient feels unable to face. Although many patients want to get better and be able to get on with their lives, they are genuinely temfied of doing so. ‘Treatment’ is experienced as making them wdrse, because as the starvation is dealt with, they become more assailed by their anxieties. Thus often the first difficulty to be dealt with in treatment is that of engaging the patient. However, in contrast to the adult patient, the child is not solely responsible for her treatment and parents can be enlisted as powerful allies. This fact is exploited in the use made of family therapy in the treatment of anorexia. Many authors (Lask,’ for example) have pointed out that an important focus when treating children is helping the parents to regain control of the child‘s eating behaviour. The ease or difficulty of achieving this is in our experience a major factor in the recovery of the patient. We describe below a preliminary retrospective study that gives some support to the view that children whose parents are able to regain control will maintain their weight within a healthy range more easily.
THEORETICAL BACKGROUND Our experience of nearly 400 cases referred to our inpatient
treatment programme is of a wide variation in parents’ capacity to take charge of their child’s eating, ranging from a wish to be firm accompanied by considerable uncertainty as to whether it is the right thing to do, to an almost total helplessness. Although one might think it obvious that parents need to take charge when their child is unable to eat, we continue to be struck by the frequency with which parents report being given advice from professionals to ‘let her decide how much she should eat’. We do not know how many patients in this situation go on to regulate their calorie intake adequately and gain weight, but we suspect that it is not many. This advice seems to arise out of a mistaken idea that the anorexic child feels that she* is not being given enough freedom. The problem is more that the child is temfied of freedom and autonomy because of a fear that her impulses, appetites and urges will get out of control to a dangerous degree. She lacks a sense of sufficient internal controls to help her regulate these appetites in a way that feels comfortable to her. What the patient needs is not less control but more, but in a way that she can utilize to develop her own controls through a process of internalization. Following the work of Minuchin and Selvini-Palazzoli (two of the major figures in the development of family
*In this paper, use will be made of the female pronoun, as the majority of patients are female. However, the same principles apply in the case of male patients unless otherwise stated in the text.
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the rap^),^-^ the role of the family in the treatment of anorexia nervosa has been a subject of much interest. But the fact that family therapy has resulted in successful treatment of the condition does not necessarily imply a family aetiology. As Dare and Eisler6 have pointed out, much research supports the patient’s view that the eating problem is a personal issue, and there is little evidence that families of such patients are particularly unusual. However, the clinical impression remains that families can have much to offer in helping the patient recover, and research evidence has confirmed the value of a family Our clinical experience has been that successful recovery of a healthy weight in children and adolescents is fundamentally linked to the process of parents regaining control of the patient’s eating behaviour. The processes by which experiences of ‘external reality’ become internalized have been conceptualized in increasingly sophisticated ways since Freud first described the notion of the superego as a consequence of “identification with the parental a g e n ~ y ”Of . ~ particular significance have been the concepts - ’ ~ RIGS of internal working rnodels,’o-’2farnily s c r i p t ~ ’ ~ and (Representations of Interactions that have become Generalised).” All these ideas centre on the postulate that the human subject’s experience of interactions over time results in the development of internal models of interaction that play a significant part in the construction of the The way each individual responds to impulses, wishes and desires is determined, at least in part, by her internal representation of the ways in which various important figures have dealt with them. Anorexic patients, in our experience, frequently describe (once one has managed to move away from the topics of food or fatness) their anxieties about what they see as their selfishness. They appear to feel that their needs and desires will be too much for the significant others in their lives. Whilst one side of their fear has to do with the intensity of their feelings, the other has to do with the perceived fragility of the person from whom something is being asked. Parents are perceived as being unable to cope with demands-“it will be too much for them”, “they can’t cope with me”. The task of helping parents to regain control is aimed not only at making sure that the life-endangering physical situation is rectified, but at transforming the patient’s perception of parents into one in which the ‘external’parents are seen as being able to cope with anything that the adolescent can throw at them. If the real parents can be redefined in this way, then the internal representation of a fragile parent can be modified, allowing the patient to feel able to manage the intense feelings that previously threatened to overwhelm her.
the setting of a large family home and has been described in detail elsewhere.2’*22It does not come under the National Health Service. Calorie intake is controlled so that patients gain a steady kilogram in weight per week. The atmosphere is more that of a small boarding school than of a hospital; patients are not confined to bed, attend the in-house school for a normal academic day, and are encouraged to participate in a wide range of activities (including exercise). Individual, group and family psychotherapy are essential elements of the programme. When an adolescent loses weight to the point of requiring inpatient treatment (in our view, when the weight-for-height ratio* falls below SO%), it is usually the case that parents are at their wits’ end, exhausted and terrified. The prospect of someone else taking over the responsibility of keeping their child alive is a huge relief. At the same time, most parents feel tremendous guilt that they are not able to feed their child (one of the most basic tasks of parenting, and therefore the reason why the apparent refusal to eat strikes straight at the heart of parental selfesteem) and the idea that someone else can, makes them feel even worse. Thus to begin with, parents are often very concerned with questions such as “What has caused this?”-which can usually be translated as “DO you think we are to blame?”. We have found it helpful to take this issue up carefully with parents, neither by colluding in the blaming nor by a false reassurance that it has nothing to do with them, but by a genuine and respectful enquiry into what they think they might have done, or not done, that has resulted in their child’s illness. An acknowledgement of the helplessness that everyone has felt, including the patient, can be the start of an exploration into why it has been so difficult to find a way of gaining control over the anorexic behaviour. In order to facilitate the process of parents regaining control, we have developed a programme of gradual reintegration into the family. To begin with, all responsibility for feeding their child is removed from parents in order to give them a chance to ‘recharge their batteries’, although they retain responsibility for the decision that their child remains in treatment. After four weeks, providing the patient has attained a minimum of 75% weight-for-height (i.e., is physically safe) we ask parents to take their child out for the day at a weekend (but not to return home). We provide a carrier bag containing all the food the patient needs for the day, including snacks, drinks and a packed lunch. The family brings their own picnic. We ask parents to ensure that their child eats every crumb.
/
DESCRIPTION OF THE TREATMENT PROGRAMME Rhodes Farm Clinic is a specialized residential treatment unit for children and young people with eating disorders in
*The weight-for-height scale is based on the ratio weightheight2, a widely used index of obsesity in adults. However, when used with children the ratio needs to be standardized for age.23 This is done by deriving a reference value of weight/height2,using the Tanner 50th centiles of height and weight for the child’s age and sex. The child’s weightheight2 is then expressed as a percentage of the reference value. This method of defining weight-for-height is validated by Cole” and unlike other methods it takes into account the age of the child.
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They are asked to set a time limit so that the meal does not go on all afternoon. If the patient is unable to eat, the parents are provided with the last-resort ‘safety net’ of bringing their child back to the clinic, where she has to eat whatever remains uneaten with a nurse. When patient and parents have successfully completed packed lunches on two consecutive weekends, they move on to the qext stage. They are asked to take their child out to a restaurant for a meal. This is more difficult, as the patient has to choose her meal from a menu, and she must choose a meal containing at least 1000 kcal. The same safety net is provided. Following two successful meals, progress is made to the third phase, a trial weekend at home. Parents are given as much advice as they need about a suitable menu for the weekend. Their child will be eating sufficient amounts of food in the clinic to achieve weight gain of 1 kg per week. Parents are asked to provide their usual family fare at home, but to ensure that their child eats sufficient to provide the same calorie intake as they would receive at the clinic. Again, should their child not manage to eat properly at home, then parents are asked to return them immediately to the clinic. We have found that at each stage one of three things can happen: 1. The- $sk is completed successfully; 2. The parents are unable to find a way of helping their child eat, and they return her to the clinic; 3. The patient returns to the clinic at the allotted time reporting that everything has gone well, but gradually over the next few days it emerges that in fact she did not eat, but parents decided that they did not wish to spoil their day, or weekend, or upset the patient, by returning early. Outcome 1 is obviously not problematic. Outcome 2 is regarded as a success, as it demonstrates that parents feel able to do something about the situation rather than feel helpless. Outcome 3 is worrying, and the situation is taken up in the next family meeting and explored in detail. Our experience has been that this programme is usually successful in enabling parents to begin to feel in control again. Parents often report that the safety net is invaluable in giving them something that they can do if all else fails. The programme also provides an important focus for family meetings. Rather than concentrate on the past and ‘what went wrong’, parents can focus on what needs to change in order for them to complete the tasks successfully. This in turn provides a framework for exploring various family issues that make it difficult to regain control.
DIFFERENT TYPES OF FAMILIES We have found it clinically useful to divide families into three groups: Group 1 Parents are extremely helpless and are unable to take control at all;
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Group 2 Parents are initially very anxious, but gain in confidence during the treatment programme and become quite firm in time; Group 3 Parents have lost control during their child’s illness but regain it almost immediately following admission, and maintain it.
CLINICAL EXAMPLES In order to illustrate these groupings, three clinical examples are provided. In order to protect confidentiality these cases are fictitious, but each contains elements amalgamated from a number of real cases. Group 1: Andrea A Andrea was referred following two previous admissions to another unit. Although on both occasions she had gained weight while in hospital, she had rapidly lost it again as soon as she was discharged. She had developed her anorexia at the age of 12 and was 14 by the time of referral to us. She was the youngest of four children; the others were 10,8 and 5 years older respectively. The two oldest had left home and married and the third, a daughter, was due to leave for university in a few months’ time. Although professing a satisfactory marriage, Andrea’s parents led virtually separate lives. Her father was a railway enthusiast who spent most weekends travelling the country in pursuit of his hobby. Her mother had not worked outside the home since the birth of her first child and rarely went out. She could not drive and was dependent upon her husband and adult children for transport. The pattern of Andrea’s previous admissions repeated itself with us. She ate with little difficulty whilst in the clinic but whenever she went home she was quite unable to eat sufficient to maintain her weight. Her father seemed uninterested and was unprepared to forego his hobby in order to help his wife manage Andrea’s eating. Mrs A declared herself to be completely helpless in the face of Andrea’s refusal. Although Andrea’s mother declared her first packed lunch a success (eaten only with her mother as her father had not arrived, although expected), Andrea told her friends, who then told a nurse, that in fact she had only eaten half of it. Her mother had apparently suggested that she should leave the rest if she could not manage to eat it and they would not tell the staff. Although Andrea had agreed with this at the time, when confronted with the story she readily confessed and spoke of her disappointment that her mother had not been firmer with her. This was discussed at the next family meeting but despite her mother insisting that she would not do the same thing again, the pattern was repeated. During family meetings Mrs A described her own extremely deprived childhood. She was born as the result of a ‘one-night stand and never knew her father. Her mother had rejected her repeatedly, eventually placing her into care at the age of 11, and she spent the rest of her childhood in children’s homes. She
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had determined that her own children would not suffer the same fate and thus found it impossible to exercise any form of discipline whatsoever, in case her children might ‘hate’ her. Mr A’s father had been in the army and the family had repeatedly moved around the country. Mr A had attended 13 schools. Both his parents had been remote figures and he could not remember ever feeling any warmth from either of them, He found it hard to understand what the problem was; as far as he was concerned Andrea was an extremely selfish child who enjoyed causing all this trouble. She should do as she was told and get on and eat. He viewed his wife as largely responsible as she “always gave in”, but did not see it as his place to try and help her. He thought therapy a waste of time and stopped coming. Despite much work little change occurred in the family relationships. Andrea always lost weight during trial weekends home (despite eating well in the clinic) and eventually social services were asked to accommodate her, with her parents’ consent. However, she again lost weight and had to be readmitted. She remains in hospital. Group 2: Beatrice B Beatrice (aged 14) was referred with a 9-month history of restriction of calorie intake. She had begun by not eating her school lunches, and progressed to eating only very small meals at home until, three weeks before admission, she was eating ‘nothing at all’. She had a weight-for-height ratio of just 65% on admission and was weak, cold and lethargic. Her blood pressure was 70/50 and her heart rate 50 beats per minute. She was the elder of two children, having a younger brother aged 9. She was born following a normal pregnancy during which her mother’s old nanny, to whom her mother was closely attached, had died. Mrs Bs own father had died when she was 3 years old, following which her mother had gone out to work, leaving her very much in the care of the nanny. Mrs B was aware how much her nanny’s death had affected her and thought this had an effect on Beatrice, leaving her an anxious baby. She had been a poor sleeper, and had been very clingy as a toddler. It also emerged, during family meetings, that Mr B had a history of anxious attachments in his family. He had been sent to boarding school at the age of 8 but had always worried about his parents. He remembered once at the age of 14 getting angry with his father who had promptly burst into tears. He had vowed never ever to upset him again. Mr and Mrs B were able to acknowledge that their own life experiences had left them wanting their own children to have as much say in the family as possible. All decisions were taken ‘democratically’, with the children having an equal vote from a very young age. This included major decisions such as moving house, etc. They gradually came to accept that this put a heavy burden of responsibility on their children and began to take more responsibility themselves for decision-making. Initially Beatrice refused to finish her packed lunch with
her parents, who regretfully and tearfully brought her back to the clinic. They questioned the wisdom of “being so hard on her” and tried to persuade nursing staff to let her leave what was uneaten as it was “obviously” too much for her. The nurse pointed out that Beatrice was regularly eating the same amount during the week in the clinic without apparent difficulty. The following week Mr and Mrs B were again very anxious and Beatrice again did not finish her meal, saymg she felt sick. She was returned to the clinic but this time her parents left immediately, clearly rather cross with her. The following week Beatrice again refused to finish her lunch but this time her father lost his temper with her. Beatrice finished her meal. The restaurant meals went much better. Beatrice was clearly very anxious about having to choose her own meal but her father, in particular, was much more firm with her and she managed it successfully. Mrs B remained very anxious about Beatrice and very fearful of upsetting her, which she felt would end in her hating her mother. After a number of trial weekends at home Beatrice herself decided she would prefer to go to boarding school, which the family were able to afford. Her parents remained anxious about her, but she has maintained her weight and got on with her life away from home. Group 3: Chrissy C Chrissy (aged 15) was the elder of two daughters. On referral she had been ill for six months, and despite much hard work from her local child psychiatrist she had continued to lose weight until at 54% weight-for-height she had been admitted to a paediatric ward. She had continued to lose weight and was referred to us as an emergency. Her parents, understandably, were desperate. They felt they had tried everything they could but to no avail. Their daughter continued to fade away before their eyes and they were convinced she was going to die. They found it almost impossible to believe that their daughter ate her first meal for six weeks within 2 hours of arriving at the clinic. In family meetings, initially both parents were preoccupied with their sense of failure, which had been made worse by the apparent ease with which ‘the clinic’ had persuaded Chrissy to eat. It soon became apparent that both were, and almost certainly had been before Chrissy’s illness, extremely unsure of themselves as parents. Both had been married before, but both first marriages had foundered before children had been conceived. Following his second marriage Mr C had had a long period of phobic illness which continued until the onset of Chrissy’s eating problems, but which had subsided since. Both Mr and Mrs C valued family meetings and quickly became engaged in exploring their own family histories. Mr C described his anxious attachment to his own mother, who would frequently attempt to control her children by threatening to leave. On a number of occasions she had packed her bags and left, although she had always returned (this had left Mr C feeling that he had been “too m u c h for her). After talking about this in a family meeting, he
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obtained great relief from discussing it with his sister for the first time; she confirmed his experience and shared her own similar feelings. These revelations allowed both Mrs C and Chrissy to see Mr C in a different light; instead of seeing him as a rather weak incompetent man with a psychiatric illness they began to understand his anxiety as a consequence of his childhood uncertainty. Mrs C softened towards him, which in turn allowed Mr C to become less defensive and angry with his wife. They began to work together as an effective team, and whereas previously Chrissy had been able to get them arguing together with ease, she now met a united front. At the first packed lunch Chrissy put up a token struggle and refused to eat a biscuit. Mr and Mrs C brought her straight back to the clinic and left. The following week Chrissy ate with no difficulty, and she accomplished her meals likewise. On her first weekend at home she had a furious row with her father, who stood firm and insisted upon her eating. Subsequent weekends passed smoothly and Chrissy was discharged back home at the predicted time. It is important to note that she still struggled with concerns about her weight but she entered outpatient individual psychotherapy, and her family continued with family meetings for some six months, with steady improvement.
A PILOT STUDY
METHOD In order to test our hypothesis that the maintenance of weight following discharge is associated with a firmer style of parenting, we looked at data readily available in the clinic database. As part of our normal follow-up programme, parents are asked to telephone the clinic weekly with the patient's current weight. Thus we have weekly records of weights of all discharged patients. All patients admitted under one consultant (DW) and discharged between 21/3/96 (when data began to be entered on to the computer database) and 31/3/97 were entered into the study. Two members of staff (the medical director and a senior nurse) who knew the parents well during each patient's admission were asked to assign each patient to one of the three groups described above. Post-discharge weekly weights for each case were averaged to yield a mean postdischarge weight. This was subtracted from the patient's target weight to give 'mean weight loss' (MWL). A positive value therefore reflects weight loss and a negative one, weight gain. Relationships between MWL, age on admission (AA), weight-for-height ratio on admission (WHRa), length of illness before admission (LI), length of admission (LA), and parenting group were explored using analysis of variance (ANOVA) and linear regression. Weight-for-height ratio on discharge ( W R d ) was the same for all patients, as the criterion for discharge was a
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WHRd of 95%. All patients received weekly individual psychotherapy from the same therapist (DW), and all patients' families were seen once every two weeks for family therapy by the same therapist. Treatment variables thus correlate exactly with length of admission (LA). The numbers of trial weekends at home were not recorded but would roughly correlate with the length of admission.
RESULTS Fifty-nine cases were entered into the study. All were diagnosed on admission as suffering from anorexia nervosa according to the Great Ormond Street (GOS) Diagnostic C h e ~ k l i s t . ~Most ~ ' were admitted because of very low weight. Some with less extreme weight loss were admitted because of very rapid decline, or intractable vomiting. The mean values, standard deviations (SD) and ranges for LI, WHR", AA, LA and MWL are set out in Table 1. Means for MWL in each group are given in Table 2. ANOVA for all three groups showed that the MWL was significantly different between the groups, being greatest in Group 1 (see page 297 for Group definitions) and least in Group 3. However, pairwise analysis revealed no significant difference between Groups 1and 2, a moderately significant difference between Groups 2 and 3, and a highly significant difference between Groups 1 and 3 (Table 3). Because of the lack of difference between Groups 1 and 2, cases in those groups were amalgamated, leaving two groups, 'low' and 'high' firmness. Inclusion of the new groups as a dummy variable in a regression of MWL against AA showed both independent variables to be highly significant (Table 4). Parental group and age at admission were not significantly correlated (12 = 0.07). MWL was not significantly correlated with WHR" (? = 0.03), LI (12 = 0.01), or LA (12 = 0.01).
DISCUSSION The results of this pilot study must be treated with some considerable caution, mainly because the allocation of cases to the groups was not made by raters who were blind to outcome; both raters had some idea as to who was maintaining weight and who was not. Although the raters were asked to make their decisions only on the basis of their impression of parents during admission, they cannot, of course, be considered to be free of bias.
*As pointed out by Lask', the DSM-IV and ICD-10 diagnostic criteria do not adequately address the problems of diagnosing anorexia nervosa in children, particularly in prepubertal children in whom menstruation would not otherwise have been expected to have occurred. The GOS checklist is as follows: 1. Determined food avoidance; 2. Weight loss or failure to gain weight during the period of preadolescent growth (10-14 years) in the absence of any physical or other mental illness; 3. Any two or more of the following: (a) preoccupation with body weight, (b) preoccupation with energy intake, (c) distorted body image, (d) fear of fatness, (e) self-induced vomiting, (0 extensive exercising, (g) purging (laxative abuse).
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Table 1 Means, SD, and rangesfor length of illness, weight-for-height ratio on admission, age on admission, length of admission, and mean weight loss for each group (for abbreviations and Group definitions, see text)
Table 2 Mean weight loss: mean values and variance
F=5.137,P=0.0089
The decision to allocate cases to one of three groups was made on the basis of a clinical impression that parents could be described as belonging to that group. However, such a division of what is almost certainly a continuum of parental ‘firmness’ is clearly arbitrary. The results suggest that only two groups are useful-high and low firmness. If a robust way of assessing ‘firmness’ at the beginning of treatment can be developed, and further research confirms that firmness predicts outcome on a range of measures, then such an assessment will be useful in influencing the alloction of resources. It will also be useful in directing research into which therapeutic interventions have an effect on changing parental firmness in the desired direction.
CONCLUSION We have argued elsewhere2’ that, although recovery of a healthy weight is not the sole criterion of recovery from anorexia nervosa, it is an essential part of treatment for adolescents, who otherwise may become stunted, osteoporotic and infertile. Although our programme focuses on weight, treatment of the core psychopathology is not neglected. Insofar as anorexia nervosa is a solution to the problem of overwhelming anxiety, often precipitated by puberty and adolescence, and linked with a difficulty in
Table 3 Pairwise comparison between groups
Table 4 Regression of MWL against group, and age at admission
2z0.366*
developing internal working models of sufficiently robust parents, our programme provides a framework for addressing the problem by working hard to help parents regain control of eating behaviour as a preliminary step to the patient internalizing this control and modifying their internal working models accordingly.
Parents of children with eating disorders
Results from our pilot study have at present to be treated with some caution. However, they suggest that the model is worth exploring further. A prospective study is being planned which will attempt to formalize a measure of ‘parental firmness’, and investigate whether outcome is indeed related to this firmness and whether firmness can be influenced by treatment.
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ACKNOWLEDGEMENTS We are grateful to Dr Dee Dawson and Ms Kate Wellesley for their help in rating the cases, and to Mrs Caroline Cronin for typing the manuscript.
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REFERENCES 1. Lask B (1993) Management overview. In: Childhood onset anorexia nervosa and related eating disorders (ed B Lask, R Bryant-Waugh). Lawrence Erlbaum, Hove. 2. Minuchin S, Baker L, Rosman BL et a1 (1975) A conceptual model of psychosomatic illness in children. Arch Gen Psychiatry 32: 1031-8. 3. Minuchin S, Rosman BL, Baker L (1978) Psychosomaticfamilies: Anorexia nervosa in context. Harvard University Press, Cambridge, MA. 4. Selvini-PalazzoliM (1974) Self-starvation: From the intrapsychic to the transpersonal approach. Chaucer, London. 5. Selvini-Palazzoli M, Civillo S, Selvini M (1989) Family games: General models of psychotic processes in the family. Kamac, London. 6. Dare C, Eisler I (1995) Family therapy. In: Handbook of eating disorders: theory, treatment and research (ed Z Szmukler, C Dare, J Treasure). Wiley, Chichester. 7. Russell GFM, Szmukler G, Dare C, Eisler I (1987) An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 44: 1047-56. 8. Dare C, Eisler I, Russell GFM, Szmukler G (1990) Family therapy for anorexia nervosa: Implications from the results of a controlled trial of family and individual therapy. j Marital Family Ther 16: 39-57. 9. Freud S (1993) New introductory lectures on psycho-analysis (Standard Edition, Vol XXII, 3.) Hogarth Press, London. 10. Bowlby J (1969) Attachment and loss. Vol. 1. Attachment. Basic Books, New York. 11. Bowlby J (1973) Attachment and loss. Vol. 2. Separation: Anxiety and anger. Basic Books, New York. 12. Bowlby J (1980) Attachment and loss. Vol 3. Loss: Sadness and depression. Basic Books, New York.
13. Byng-Hall J (1985) The family script: A useful bridge between theory and practice. j Family Ther 7: 301-5. 14. Byng-Hall J (1986) Family scripts: A concept which can bridge child psychotherapy and family therapy thinking. j Child Psychother 12(2): 3- 13. 15. Byng-Hall J (1988) Scripts and legends in families and family therapy. Family Process 27: 167- 180. 16. Byng-Hall J (1995) Rewriting family scripts. Guilford Press, New York. 17. Stem D (1985) The interpersonal world of the infant. Basic Books, New York. 18. Stem D (1991) Maternal representations: A clinical and subjective phenomenological view. Infant Mental Health j 12: 174- 86. 19. Stem D (1994) One way to build a clinically relevant baby. Infant Mental Health j 15: 9-25. 20. Zeanah CH, Anders TF, Seifer R, Stem DN (1989) Implications of research on infant development for psychodynamic theory and practice.] Am Acad Child Adolesc Psychiatry 28: 657-68. 21. Black D, Dawson D, Wood D (1995) The Rhodes Farm Project a unique residential treatment setting for early onset anorexia patients. ACPP Rev Newsletter 17(2): 87-96. 22. Black D (1996) Aspects of eating disorders. (ACPP Occasional Papers No. 12, Psychosomatic Problems in Children), Association for Child Psychology and Psychiatry, London, UK. 23. Cole TJ (1979) A method of assessing age-standardised weightfor-height in children seen cross-sectionally. Ann Human Biol 6: 249 - 68. 24. Bryant-Waugh R, Kaminski Z (1993) Eating disorders in children: an overview. In: Childhood onset anorexia nervosa and related eating disorders (ed B Lask, R Bryant-Waugh) Lawrence Erlbaum, Hove.
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Should parents take charge of their child's eating disorder? Some preliminary findings and suggestions for future research David Wood, Paul Flower & Dora Black To cite this article: David Wood, Paul Flower & Dora Black (1998) Should parents take charge of their child's eating disorder? Some preliminary findings and suggestions for future research, International Journal of Psychiatry in Clinical Practice, 2:4, 295-301 To link to this article: http://dx.doi.org/10.3109/13651509809115377
Published online: 12 Jul 2009.
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International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 295-301
295
Should parents take charge of their child’s eating disorder? Some preliminary findings and suggestions for future research DAVID WOOD, PAUL FLOWER AND DORA BLACK
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Rhodes Farm Clinic, Mill Hill, London, UK
Correspondence Address Dr David Wood, MB, BS, MRCPsych, Rhodes Farm Clinic, The Ridgeway, London hW7 IRH, UK Tel: +44 (0) 181 906 0885 Fax: +44 (0) 181 906 3155
The treatment of children and young adolescents with anorexia newosa is facilitated, relative to the treatment of adult patients, by the possibility of enlisting parents as allies in gaining control over eating behaviour. Experience at Rhodes Farm Clinic suggests that the capacityfor parents to be firm with their child enhances weight maintenance following inpatient treatment. Our treatment approach is outlined, and illustrated with some clinical material. A pilot study of 59 cases (58females, I male) strongly confm that weight maintenance is positively associated with parental firmness, and also negatively associated with age on admission to the Clinic. (Int J Psych Clin Pract 1998; 2: 295 - 301)
Received 4 September 1997; revised 17 April 1998; accepted for publication 6 May 1998
INTRODUCTION ne of the features of anorexia nervosa that makes it so 0 difficult to treat that the condition involves a powerful set of defences against overwhelming anxieties is
that the patient feels unable to face. Although many patients want to get better and be able to get on with their lives, they are genuinely temfied of doing so. ‘Treatment’ is experienced as making them wdrse, because as the starvation is dealt with, they become more assailed by their anxieties. Thus often the first difficulty to be dealt with in treatment is that of engaging the patient. However, in contrast to the adult patient, the child is not solely responsible for her treatment and parents can be enlisted as powerful allies. This fact is exploited in the use made of family therapy in the treatment of anorexia. Many authors (Lask,’ for example) have pointed out that an important focus when treating children is helping the parents to regain control of the child‘s eating behaviour. The ease or difficulty of achieving this is in our experience a major factor in the recovery of the patient. We describe below a preliminary retrospective study that gives some support to the view that children whose parents are able to regain control will maintain their weight within a healthy range more easily.
THEORETICAL BACKGROUND Our experience of nearly 400 cases referred to our inpatient
treatment programme is of a wide variation in parents’ capacity to take charge of their child’s eating, ranging from a wish to be firm accompanied by considerable uncertainty as to whether it is the right thing to do, to an almost total helplessness. Although one might think it obvious that parents need to take charge when their child is unable to eat, we continue to be struck by the frequency with which parents report being given advice from professionals to ‘let her decide how much she should eat’. We do not know how many patients in this situation go on to regulate their calorie intake adequately and gain weight, but we suspect that it is not many. This advice seems to arise out of a mistaken idea that the anorexic child feels that she* is not being given enough freedom. The problem is more that the child is temfied of freedom and autonomy because of a fear that her impulses, appetites and urges will get out of control to a dangerous degree. She lacks a sense of sufficient internal controls to help her regulate these appetites in a way that feels comfortable to her. What the patient needs is not less control but more, but in a way that she can utilize to develop her own controls through a process of internalization. Following the work of Minuchin and Selvini-Palazzoli (two of the major figures in the development of family
*In this paper, use will be made of the female pronoun, as the majority of patients are female. However, the same principles apply in the case of male patients unless otherwise stated in the text.
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the rap^),^-^ the role of the family in the treatment of anorexia nervosa has been a subject of much interest. But the fact that family therapy has resulted in successful treatment of the condition does not necessarily imply a family aetiology. As Dare and Eisler6 have pointed out, much research supports the patient’s view that the eating problem is a personal issue, and there is little evidence that families of such patients are particularly unusual. However, the clinical impression remains that families can have much to offer in helping the patient recover, and research evidence has confirmed the value of a family Our clinical experience has been that successful recovery of a healthy weight in children and adolescents is fundamentally linked to the process of parents regaining control of the patient’s eating behaviour. The processes by which experiences of ‘external reality’ become internalized have been conceptualized in increasingly sophisticated ways since Freud first described the notion of the superego as a consequence of “identification with the parental a g e n ~ y ”Of . ~ particular significance have been the concepts - ’ ~ RIGS of internal working rnodels,’o-’2farnily s c r i p t ~ ’ ~ and (Representations of Interactions that have become Generalised).” All these ideas centre on the postulate that the human subject’s experience of interactions over time results in the development of internal models of interaction that play a significant part in the construction of the The way each individual responds to impulses, wishes and desires is determined, at least in part, by her internal representation of the ways in which various important figures have dealt with them. Anorexic patients, in our experience, frequently describe (once one has managed to move away from the topics of food or fatness) their anxieties about what they see as their selfishness. They appear to feel that their needs and desires will be too much for the significant others in their lives. Whilst one side of their fear has to do with the intensity of their feelings, the other has to do with the perceived fragility of the person from whom something is being asked. Parents are perceived as being unable to cope with demands-“it will be too much for them”, “they can’t cope with me”. The task of helping parents to regain control is aimed not only at making sure that the life-endangering physical situation is rectified, but at transforming the patient’s perception of parents into one in which the ‘external’parents are seen as being able to cope with anything that the adolescent can throw at them. If the real parents can be redefined in this way, then the internal representation of a fragile parent can be modified, allowing the patient to feel able to manage the intense feelings that previously threatened to overwhelm her.
the setting of a large family home and has been described in detail elsewhere.2’*22It does not come under the National Health Service. Calorie intake is controlled so that patients gain a steady kilogram in weight per week. The atmosphere is more that of a small boarding school than of a hospital; patients are not confined to bed, attend the in-house school for a normal academic day, and are encouraged to participate in a wide range of activities (including exercise). Individual, group and family psychotherapy are essential elements of the programme. When an adolescent loses weight to the point of requiring inpatient treatment (in our view, when the weight-for-height ratio* falls below SO%), it is usually the case that parents are at their wits’ end, exhausted and terrified. The prospect of someone else taking over the responsibility of keeping their child alive is a huge relief. At the same time, most parents feel tremendous guilt that they are not able to feed their child (one of the most basic tasks of parenting, and therefore the reason why the apparent refusal to eat strikes straight at the heart of parental selfesteem) and the idea that someone else can, makes them feel even worse. Thus to begin with, parents are often very concerned with questions such as “What has caused this?”-which can usually be translated as “DO you think we are to blame?”. We have found it helpful to take this issue up carefully with parents, neither by colluding in the blaming nor by a false reassurance that it has nothing to do with them, but by a genuine and respectful enquiry into what they think they might have done, or not done, that has resulted in their child’s illness. An acknowledgement of the helplessness that everyone has felt, including the patient, can be the start of an exploration into why it has been so difficult to find a way of gaining control over the anorexic behaviour. In order to facilitate the process of parents regaining control, we have developed a programme of gradual reintegration into the family. To begin with, all responsibility for feeding their child is removed from parents in order to give them a chance to ‘recharge their batteries’, although they retain responsibility for the decision that their child remains in treatment. After four weeks, providing the patient has attained a minimum of 75% weight-for-height (i.e., is physically safe) we ask parents to take their child out for the day at a weekend (but not to return home). We provide a carrier bag containing all the food the patient needs for the day, including snacks, drinks and a packed lunch. The family brings their own picnic. We ask parents to ensure that their child eats every crumb.
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DESCRIPTION OF THE TREATMENT PROGRAMME Rhodes Farm Clinic is a specialized residential treatment unit for children and young people with eating disorders in
*The weight-for-height scale is based on the ratio weightheight2, a widely used index of obsesity in adults. However, when used with children the ratio needs to be standardized for age.23 This is done by deriving a reference value of weight/height2,using the Tanner 50th centiles of height and weight for the child’s age and sex. The child’s weightheight2 is then expressed as a percentage of the reference value. This method of defining weight-for-height is validated by Cole” and unlike other methods it takes into account the age of the child.
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They are asked to set a time limit so that the meal does not go on all afternoon. If the patient is unable to eat, the parents are provided with the last-resort ‘safety net’ of bringing their child back to the clinic, where she has to eat whatever remains uneaten with a nurse. When patient and parents have successfully completed packed lunches on two consecutive weekends, they move on to the qext stage. They are asked to take their child out to a restaurant for a meal. This is more difficult, as the patient has to choose her meal from a menu, and she must choose a meal containing at least 1000 kcal. The same safety net is provided. Following two successful meals, progress is made to the third phase, a trial weekend at home. Parents are given as much advice as they need about a suitable menu for the weekend. Their child will be eating sufficient amounts of food in the clinic to achieve weight gain of 1 kg per week. Parents are asked to provide their usual family fare at home, but to ensure that their child eats sufficient to provide the same calorie intake as they would receive at the clinic. Again, should their child not manage to eat properly at home, then parents are asked to return them immediately to the clinic. We have found that at each stage one of three things can happen: 1. The- $sk is completed successfully; 2. The parents are unable to find a way of helping their child eat, and they return her to the clinic; 3. The patient returns to the clinic at the allotted time reporting that everything has gone well, but gradually over the next few days it emerges that in fact she did not eat, but parents decided that they did not wish to spoil their day, or weekend, or upset the patient, by returning early. Outcome 1 is obviously not problematic. Outcome 2 is regarded as a success, as it demonstrates that parents feel able to do something about the situation rather than feel helpless. Outcome 3 is worrying, and the situation is taken up in the next family meeting and explored in detail. Our experience has been that this programme is usually successful in enabling parents to begin to feel in control again. Parents often report that the safety net is invaluable in giving them something that they can do if all else fails. The programme also provides an important focus for family meetings. Rather than concentrate on the past and ‘what went wrong’, parents can focus on what needs to change in order for them to complete the tasks successfully. This in turn provides a framework for exploring various family issues that make it difficult to regain control.
DIFFERENT TYPES OF FAMILIES We have found it clinically useful to divide families into three groups: Group 1 Parents are extremely helpless and are unable to take control at all;
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Group 2 Parents are initially very anxious, but gain in confidence during the treatment programme and become quite firm in time; Group 3 Parents have lost control during their child’s illness but regain it almost immediately following admission, and maintain it.
CLINICAL EXAMPLES In order to illustrate these groupings, three clinical examples are provided. In order to protect confidentiality these cases are fictitious, but each contains elements amalgamated from a number of real cases. Group 1: Andrea A Andrea was referred following two previous admissions to another unit. Although on both occasions she had gained weight while in hospital, she had rapidly lost it again as soon as she was discharged. She had developed her anorexia at the age of 12 and was 14 by the time of referral to us. She was the youngest of four children; the others were 10,8 and 5 years older respectively. The two oldest had left home and married and the third, a daughter, was due to leave for university in a few months’ time. Although professing a satisfactory marriage, Andrea’s parents led virtually separate lives. Her father was a railway enthusiast who spent most weekends travelling the country in pursuit of his hobby. Her mother had not worked outside the home since the birth of her first child and rarely went out. She could not drive and was dependent upon her husband and adult children for transport. The pattern of Andrea’s previous admissions repeated itself with us. She ate with little difficulty whilst in the clinic but whenever she went home she was quite unable to eat sufficient to maintain her weight. Her father seemed uninterested and was unprepared to forego his hobby in order to help his wife manage Andrea’s eating. Mrs A declared herself to be completely helpless in the face of Andrea’s refusal. Although Andrea’s mother declared her first packed lunch a success (eaten only with her mother as her father had not arrived, although expected), Andrea told her friends, who then told a nurse, that in fact she had only eaten half of it. Her mother had apparently suggested that she should leave the rest if she could not manage to eat it and they would not tell the staff. Although Andrea had agreed with this at the time, when confronted with the story she readily confessed and spoke of her disappointment that her mother had not been firmer with her. This was discussed at the next family meeting but despite her mother insisting that she would not do the same thing again, the pattern was repeated. During family meetings Mrs A described her own extremely deprived childhood. She was born as the result of a ‘one-night stand and never knew her father. Her mother had rejected her repeatedly, eventually placing her into care at the age of 11, and she spent the rest of her childhood in children’s homes. She
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had determined that her own children would not suffer the same fate and thus found it impossible to exercise any form of discipline whatsoever, in case her children might ‘hate’ her. Mr A’s father had been in the army and the family had repeatedly moved around the country. Mr A had attended 13 schools. Both his parents had been remote figures and he could not remember ever feeling any warmth from either of them, He found it hard to understand what the problem was; as far as he was concerned Andrea was an extremely selfish child who enjoyed causing all this trouble. She should do as she was told and get on and eat. He viewed his wife as largely responsible as she “always gave in”, but did not see it as his place to try and help her. He thought therapy a waste of time and stopped coming. Despite much work little change occurred in the family relationships. Andrea always lost weight during trial weekends home (despite eating well in the clinic) and eventually social services were asked to accommodate her, with her parents’ consent. However, she again lost weight and had to be readmitted. She remains in hospital. Group 2: Beatrice B Beatrice (aged 14) was referred with a 9-month history of restriction of calorie intake. She had begun by not eating her school lunches, and progressed to eating only very small meals at home until, three weeks before admission, she was eating ‘nothing at all’. She had a weight-for-height ratio of just 65% on admission and was weak, cold and lethargic. Her blood pressure was 70/50 and her heart rate 50 beats per minute. She was the elder of two children, having a younger brother aged 9. She was born following a normal pregnancy during which her mother’s old nanny, to whom her mother was closely attached, had died. Mrs Bs own father had died when she was 3 years old, following which her mother had gone out to work, leaving her very much in the care of the nanny. Mrs B was aware how much her nanny’s death had affected her and thought this had an effect on Beatrice, leaving her an anxious baby. She had been a poor sleeper, and had been very clingy as a toddler. It also emerged, during family meetings, that Mr B had a history of anxious attachments in his family. He had been sent to boarding school at the age of 8 but had always worried about his parents. He remembered once at the age of 14 getting angry with his father who had promptly burst into tears. He had vowed never ever to upset him again. Mr and Mrs B were able to acknowledge that their own life experiences had left them wanting their own children to have as much say in the family as possible. All decisions were taken ‘democratically’, with the children having an equal vote from a very young age. This included major decisions such as moving house, etc. They gradually came to accept that this put a heavy burden of responsibility on their children and began to take more responsibility themselves for decision-making. Initially Beatrice refused to finish her packed lunch with
her parents, who regretfully and tearfully brought her back to the clinic. They questioned the wisdom of “being so hard on her” and tried to persuade nursing staff to let her leave what was uneaten as it was “obviously” too much for her. The nurse pointed out that Beatrice was regularly eating the same amount during the week in the clinic without apparent difficulty. The following week Mr and Mrs B were again very anxious and Beatrice again did not finish her meal, saymg she felt sick. She was returned to the clinic but this time her parents left immediately, clearly rather cross with her. The following week Beatrice again refused to finish her lunch but this time her father lost his temper with her. Beatrice finished her meal. The restaurant meals went much better. Beatrice was clearly very anxious about having to choose her own meal but her father, in particular, was much more firm with her and she managed it successfully. Mrs B remained very anxious about Beatrice and very fearful of upsetting her, which she felt would end in her hating her mother. After a number of trial weekends at home Beatrice herself decided she would prefer to go to boarding school, which the family were able to afford. Her parents remained anxious about her, but she has maintained her weight and got on with her life away from home. Group 3: Chrissy C Chrissy (aged 15) was the elder of two daughters. On referral she had been ill for six months, and despite much hard work from her local child psychiatrist she had continued to lose weight until at 54% weight-for-height she had been admitted to a paediatric ward. She had continued to lose weight and was referred to us as an emergency. Her parents, understandably, were desperate. They felt they had tried everything they could but to no avail. Their daughter continued to fade away before their eyes and they were convinced she was going to die. They found it almost impossible to believe that their daughter ate her first meal for six weeks within 2 hours of arriving at the clinic. In family meetings, initially both parents were preoccupied with their sense of failure, which had been made worse by the apparent ease with which ‘the clinic’ had persuaded Chrissy to eat. It soon became apparent that both were, and almost certainly had been before Chrissy’s illness, extremely unsure of themselves as parents. Both had been married before, but both first marriages had foundered before children had been conceived. Following his second marriage Mr C had had a long period of phobic illness which continued until the onset of Chrissy’s eating problems, but which had subsided since. Both Mr and Mrs C valued family meetings and quickly became engaged in exploring their own family histories. Mr C described his anxious attachment to his own mother, who would frequently attempt to control her children by threatening to leave. On a number of occasions she had packed her bags and left, although she had always returned (this had left Mr C feeling that he had been “too m u c h for her). After talking about this in a family meeting, he
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obtained great relief from discussing it with his sister for the first time; she confirmed his experience and shared her own similar feelings. These revelations allowed both Mrs C and Chrissy to see Mr C in a different light; instead of seeing him as a rather weak incompetent man with a psychiatric illness they began to understand his anxiety as a consequence of his childhood uncertainty. Mrs C softened towards him, which in turn allowed Mr C to become less defensive and angry with his wife. They began to work together as an effective team, and whereas previously Chrissy had been able to get them arguing together with ease, she now met a united front. At the first packed lunch Chrissy put up a token struggle and refused to eat a biscuit. Mr and Mrs C brought her straight back to the clinic and left. The following week Chrissy ate with no difficulty, and she accomplished her meals likewise. On her first weekend at home she had a furious row with her father, who stood firm and insisted upon her eating. Subsequent weekends passed smoothly and Chrissy was discharged back home at the predicted time. It is important to note that she still struggled with concerns about her weight but she entered outpatient individual psychotherapy, and her family continued with family meetings for some six months, with steady improvement.
A PILOT STUDY
METHOD In order to test our hypothesis that the maintenance of weight following discharge is associated with a firmer style of parenting, we looked at data readily available in the clinic database. As part of our normal follow-up programme, parents are asked to telephone the clinic weekly with the patient's current weight. Thus we have weekly records of weights of all discharged patients. All patients admitted under one consultant (DW) and discharged between 21/3/96 (when data began to be entered on to the computer database) and 31/3/97 were entered into the study. Two members of staff (the medical director and a senior nurse) who knew the parents well during each patient's admission were asked to assign each patient to one of the three groups described above. Post-discharge weekly weights for each case were averaged to yield a mean postdischarge weight. This was subtracted from the patient's target weight to give 'mean weight loss' (MWL). A positive value therefore reflects weight loss and a negative one, weight gain. Relationships between MWL, age on admission (AA), weight-for-height ratio on admission (WHRa), length of illness before admission (LI), length of admission (LA), and parenting group were explored using analysis of variance (ANOVA) and linear regression. Weight-for-height ratio on discharge ( W R d ) was the same for all patients, as the criterion for discharge was a
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WHRd of 95%. All patients received weekly individual psychotherapy from the same therapist (DW), and all patients' families were seen once every two weeks for family therapy by the same therapist. Treatment variables thus correlate exactly with length of admission (LA). The numbers of trial weekends at home were not recorded but would roughly correlate with the length of admission.
RESULTS Fifty-nine cases were entered into the study. All were diagnosed on admission as suffering from anorexia nervosa according to the Great Ormond Street (GOS) Diagnostic C h e ~ k l i s t . ~Most ~ ' were admitted because of very low weight. Some with less extreme weight loss were admitted because of very rapid decline, or intractable vomiting. The mean values, standard deviations (SD) and ranges for LI, WHR", AA, LA and MWL are set out in Table 1. Means for MWL in each group are given in Table 2. ANOVA for all three groups showed that the MWL was significantly different between the groups, being greatest in Group 1 (see page 297 for Group definitions) and least in Group 3. However, pairwise analysis revealed no significant difference between Groups 1and 2, a moderately significant difference between Groups 2 and 3, and a highly significant difference between Groups 1 and 3 (Table 3). Because of the lack of difference between Groups 1 and 2, cases in those groups were amalgamated, leaving two groups, 'low' and 'high' firmness. Inclusion of the new groups as a dummy variable in a regression of MWL against AA showed both independent variables to be highly significant (Table 4). Parental group and age at admission were not significantly correlated (12 = 0.07). MWL was not significantly correlated with WHR" (? = 0.03), LI (12 = 0.01), or LA (12 = 0.01).
DISCUSSION The results of this pilot study must be treated with some considerable caution, mainly because the allocation of cases to the groups was not made by raters who were blind to outcome; both raters had some idea as to who was maintaining weight and who was not. Although the raters were asked to make their decisions only on the basis of their impression of parents during admission, they cannot, of course, be considered to be free of bias.
*As pointed out by Lask', the DSM-IV and ICD-10 diagnostic criteria do not adequately address the problems of diagnosing anorexia nervosa in children, particularly in prepubertal children in whom menstruation would not otherwise have been expected to have occurred. The GOS checklist is as follows: 1. Determined food avoidance; 2. Weight loss or failure to gain weight during the period of preadolescent growth (10-14 years) in the absence of any physical or other mental illness; 3. Any two or more of the following: (a) preoccupation with body weight, (b) preoccupation with energy intake, (c) distorted body image, (d) fear of fatness, (e) self-induced vomiting, (0 extensive exercising, (g) purging (laxative abuse).
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Table 1 Means, SD, and rangesfor length of illness, weight-for-height ratio on admission, age on admission, length of admission, and mean weight loss for each group (for abbreviations and Group definitions, see text)
Table 2 Mean weight loss: mean values and variance
F=5.137,P=0.0089
The decision to allocate cases to one of three groups was made on the basis of a clinical impression that parents could be described as belonging to that group. However, such a division of what is almost certainly a continuum of parental ‘firmness’ is clearly arbitrary. The results suggest that only two groups are useful-high and low firmness. If a robust way of assessing ‘firmness’ at the beginning of treatment can be developed, and further research confirms that firmness predicts outcome on a range of measures, then such an assessment will be useful in influencing the alloction of resources. It will also be useful in directing research into which therapeutic interventions have an effect on changing parental firmness in the desired direction.
CONCLUSION We have argued elsewhere2’ that, although recovery of a healthy weight is not the sole criterion of recovery from anorexia nervosa, it is an essential part of treatment for adolescents, who otherwise may become stunted, osteoporotic and infertile. Although our programme focuses on weight, treatment of the core psychopathology is not neglected. Insofar as anorexia nervosa is a solution to the problem of overwhelming anxiety, often precipitated by puberty and adolescence, and linked with a difficulty in
Table 3 Pairwise comparison between groups
Table 4 Regression of MWL against group, and age at admission
2z0.366*
developing internal working models of sufficiently robust parents, our programme provides a framework for addressing the problem by working hard to help parents regain control of eating behaviour as a preliminary step to the patient internalizing this control and modifying their internal working models accordingly.
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Results from our pilot study have at present to be treated with some caution. However, they suggest that the model is worth exploring further. A prospective study is being planned which will attempt to formalize a measure of ‘parental firmness’, and investigate whether outcome is indeed related to this firmness and whether firmness can be influenced by treatment.
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ACKNOWLEDGEMENTS We are grateful to Dr Dee Dawson and Ms Kate Wellesley for their help in rating the cases, and to Mrs Caroline Cronin for typing the manuscript.
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