Eating disorders strike children at virtually all stages of development. Sometimes we think it’s most difficult when they strike a very young child, sometimes it seems the most difficult when a “child” is about to go off to college, or a student exchange program, or start a new school. Personally I think mid adolescence is one of the most difficult times for an eating disorder to strike a child.

Childhood and early adolescence are characterized by learning new skills, but also by reliance on parents and family members as role models. The younger child is more apt to listen to his or her parents, to expect rules and guidance. By late adolescence a stronger sense of self has been formed. Standing on the verge of young adulthood, youth are often more relaxed and secure about who they are and who “is telling them what to do”. They are often more able to take in advice from their parents, and even occasionally appreciate it.  But middle adolescence is very different.

See this excellent summary of the stages of normal adolescent development, adapted from the American Academy of Child and Adolescent Psychiatry’s Facts for Families guidelines. The stages described in the Facts for Families describe the “tendency to distance selves from parents” and a “continued drive for independence, and drive to make friends with greater reliance on them” (as opposed to parents).  These features of middle adolescence can make eating disorder treatment at that time a challenge. A mid-teen may ask “why are you telling me what to eat?”, “why do my parents have to supervise my food”, or “why do they have to control everything I do?”, followed by “you can’t make me! It’s my life!”. Everyone who has engaged in family-centered treatment, whether the programmatic Lock and Le Grange-style Maudsley/at home refeeding, or the Kartini style family-centered treatment in various settings, knows that parental supervision of mealtimes is an essential feature.  Mealtime supervision and parents in charge of food — formerly much disparaged by psychologists, psychiatrists and other mental health professionals — is not intended to be an invasion of privacy or an attempt at “infantilization”.  Rather, it is done to keep an eating disordered child safe. Children vary tremendously in their ability to understand the necessity for parental supervision of and participation in mealtimes.  In my experience, younger patients and much older ones are more accepting of this supervision than are those in middle adolescence (14-18 years) who are in the midst of their own struggle to achieve independence.  It is unfortunate when the eating disorder strikes in the middle of that struggle, throwing dust in everyone’s eyes, and obscuring the simple fact of the necessity for such supervision. Parents are often made to feel insecure about the recommendation for tight supervision of their child’s meals.  They are sometimes criticized for being “controlling” and “invasive”. This is wrong, unhelpful and entirely misplaced. At Kartini Clinic, supervision means “eating with”.  It does not mean staring at a child while they eat.  Meals in our program, in whatever setting, are eaten communally; our therapists eat on our meal plan alongside our patients. At home, patients eat with their parent or parents, who eat alongside them and on the meal plan. Once the meal has begun a parent does not leave the table for any reason, and dogs are not allowed to roam beneath their feet (for obvious reasons!).  During our program our therapists teach parents a few tricks of the trade, for example: when bringing plated food to the table for multiple family members, always bring the eating disordered child’s plate last. This ensures no unsupervised time for their food to linger on the table.  Another example: we no longer use napkins at the table, as they have often proven to be an opportunity to hide food.  In short, we do what it takes to keep our kids safe in as pleasant and commonplace an atmosphere as possible, whether that’s in the Kartini Day Treatment Unit or at home. Close supervision is remarkably hard to achieve.  It requires a self-confident, determined, loving parent.  It is not a job for friends or siblings.  Despite the fact that you (as the parent) may get pushback, even severe pushback, eventually our patients tell us that their parents’ commitment to supervising their meals made them feel safe. Charlotte Bevan, before her untimely death, and her collaborator, Mary Gutteridge, of C&M Films fame, left us a legacy of very excellent short films illustrating the challenges of mealtime supervision.  I urge everyone to view these film shorts and draw encouragement and humor from them.  Yes, humor; we need humor.  It’s a long road, a tough road, but we travel it for our children.