First Do No Harm

I'm eager for some input from my fellow therapists. Yesterday I saw my youngest patient to date, a seven year old. I suppose this isn't breaking news - I've been hearing and reading more about eating disorders in children, and I've attended presentations given by specialized treatment facilities for patients younger than 10. I've also treated several 11 year olds and currently have a 9 year old on my caseload. Still, I found it a bit unsettling to sit across the room from a young girl so tiny her feet dangled over the edge of my easy chair, never reaching the floor. I wondered if I am up to the challenge of helping someone so young. I am determined to intervene slowly and carefully, and above all, to do no harm.

In the interests of protecting the confidentiality of this little girl and her parents I do not want to describe the situation in too much detail; and in fact I have not yet gathered enough information to have a clear picture. But so far I can say there is anxiety about eating and distortion regarding body image. There is a strong fear of fatness, both re: becoming fat herself and being near others she sees as far. Although there has been no weight loss there has been failure to gain such that she has dropped from the 50th percentile to the 25th over the past year. There were no feeding difficulties as an infant or toddler. She describes herself as a very "picky" eater and parents confirm she has eliminated many foods she was eating a year ago.

I would welcome input from anyone experienced with treating children this young. Obviously her parents are important allies in the process; they are clearly invested and capable. Should the primary focus be with parents, supporting them and empowering them to help her? Should we keep her out of the process entirely? Would a family focus be best? Or are there indications for individual therapy as well?

I will welcome your thoughts. Until next time, Gail

Comments

[JMC]

I'm not a therapist so I wouldn't presume to offer advice. I confess that I'm a bit puzzled by your asking if you should keep the child "out of the process entirely". In Family-Based Therapy for AN the entire family meets with the therapist. Empowering parents to help their children is not done "behind their backs". Once physical health is re-established returning independence and establishing a healthy identity is addressed--thoughtout all phases the family meets together. Treatment Manual for Anorexia Nervosa: A Family-Based Approach by James Lock, Daniel le Grange, W. Stewart Agras, & Christopher Dare is a good resource for clinicians.

[Jessica Setnick]

I have enjoyed reading your blog, and am happy to share my thoughts upon reading your latest entry.

This child barely qualifies for diagnosis as an eating disorder, so the guidelines for a feeding disorder may be equally appropriate - ie the parents are the ones providing the food, and the interaction at meal times may have a big effect on the meal time behavior.

Is it possible for you to participate in a meal with this child and family? Can they bring lunch to your office during your lunchtime and make it into a session? Or for them to videotape a family meal or two? There may be much more to see when they are actually around food. Ellyn Satter's books are an excellent resource for child feeding guidelines.

Although it is crucially important for you to bond with the child and to hear her point of view about all this without the parents present, it will be great to compare her behavior with and without her parents.

What is the child's explanation for the changes in eating habits? If you can get the child to talk with you about the individual items she no longer eats and why not, a dietitian can review these with the child (and family) and clear up any misconceptions. Certainly facts will not magically resolve the eating issues, but I have worked with many children who have made up, believed, and acted upon completely bogus nutrition information because they simply misconstrued something that in fact was correct. For example, an 8 year old who would not eat any sugar... She stopped eating potatoes when she saw 3 grams of sugar on the nutrition facts label on a bag of potatoes. Other kids are so obsessed with having a "healthy" diet that at least while you work on the other issues, the dietitian can engage them in eating more to be "healthy." The obsessive qualities of the diet ideally will dissipate eventually, but short-term (and maybe even long-term in severe cases) it's better to be obsessed with eating a dietitian-made meal plan than to be obsessed with eating nothing. Additionally, and I mean no offense, a child with an abnormal preoccupation with eating may engage more with a dietitian during a conversation about food and reveal significant information that will not come out in therapy. Of course you will have communication lines open with the dietitian so that she can refer these nuggets back to you.

Finally, in my experience, the youngest children with these problems seem to have the most experience with trauma and the most need for psychiatry and/or inpatient care. The fact that she is fearful to be around people she views as fat suggests something psychiatric, such as OCD or thought disorder if she is thinking that she can become fat via physical contact. It remains to be seen whether she will progress as an outpatient, but there is usually so much to pick apart that often the child's health begins to deteriorate and hospitalization may be necessary. I would discourage the slow and steady approach as a matter of fact, if you start to see a physical decline, and encourage you to stay in very close touch with the pediatrician. She may need weekly weight and vitals checks if her nutrition is not adequate and does not improve.

It is very tempting to look at the fact that it took one year before the parents brought the child in for care and wonder what else is falling through the cracks. Either way, they certainly need counseling as well, since they are all going through this, and we wouldn't want the patient to be the only one getting support.

Best wishes,
They are lucky to have you.

Jessica Setnick, MS, RD
Author of The Eating Disorders Clinical Pocket Guide