Re-training the brain and modifying behavior in eating disorder treatment

Ah the brain, it’s so complex; we are so complex!  What of our behavior is under our control?  What is amenable to cajoling, influence and even coercion? Does this change with age?  How is general willingness and ability to learn affected by a specific brain disorder, or can we generalize?

These issues quite frequently come to the fore during the treatment of food phobia, and even infrequently in the treatment of early onset anorexia nervosa.

Some percentage of our young food phobia patients are able to achieve “bite, chew, swallow” once we have them on the seemingly magical dose of 7.5 mg Olanzapine, have sufficiently re-fed their brains with nasogastric feeds, released them from the anxiety of being presented with food for a while, and have taught them that they have nothing to fear from us.  But some are not able to get there without a final “push”, and that push is the incentive/disincentive system whereby they win a visit from their parents only by eating their food.  

This incentive/disincentive system, somewhat inaccurately referred to as behavior modification (“behavior mod”, shorthand) is something we do with great reluctance.  It is supremely hard on parents, especially mothers, something we at Kartini Clinic can easily understand as most of us are parents and the majority of us are mothers.  Yet we do it when we need to, because it works.  And we are all about outcome.

In the rare case of childhood anorexia nervosa where the child is unable to face food even when adequately supported by nutrition, medication, team and family, we enlist this extra “push” by requiring them to eat in order for their parents to visit.  This is done on a meal by meal basis, so that the reward is immediate.  We have framed this for our young patients as “re-training the brain”— showing the brain “it’s hard, but I can do it.  I can do it for my mother.  I can do it for my father.  Watch me!”  But it can’t be done in a vacuum and almost never from day one.  There is a delicate balance between doing what you need to in order to move forward, to re-train behaviors, and punishment.  It can never be punishment.  All other incentives and motivators should be tried first, the child should not be in a malnourished state (in other words, use NG feeds to nutritionally restore the brain first if necessary), and the team should be familiar to them and comfortable with this intervention.  The team must also be prepared to do a great deal of hand-holding and comforting — of the parents.

Children respond to “re-training the brain” differently, according to temperament, but are unlikely to be the limiting factors in the success of this intervention.  The limitations are set by the ability to tolerate this intervention on the part of us, the parents.  

A child’s parents must first believe it can work, and second they must know that their child’s team is NOT interested in punishing their child, and finally this technique must never be done — and cannot be done — without parental sign-off and support.  It’s not unlike leaving a sobbing toddler at daycare every day, even when you know they are playing happily once you have been out of sight for ten minutes.  Painful.  Very painful.  But with some children it is necessary to help them realize they can stand on their own feet, that adults are in charge to keep them safe, that love never wavers, even when that love must do what is hard in the moment.