Abstract
Whilst empirical studies continue to demonstrate the efficacy of family-based therapy in the treatment of adolescent anorexia nervosa, less comprehensive evidence exists in guiding the treatment of pre-adolescent eating disorders, which are typically characterised by a greater variety of symptom presentation. We present the case of a pre-adolescent male who met criteria for selective eating who was treated into full remission with eating-disorder-focused family therapy. This family-based intervention deviated significantly from recently manualised family-based therapy interventions, and we suggest continued exploration of family therapy techniques in the treatment of pre-adolescent eating disorders.
Current research pertaining to the eating disorders indicates that early intervention is significantly correlated with favourable treatment outcome, reduced medical complications and mortality rates (Madden, Morris, Zurynski, Kohn, & Elliot, 2009). As a result, much research has focused on developing a therapeutic approach suitable for the treatment of adolescent eating disorders, given that adolescence is typically the most common age of onset of eating disorder symptomatology (Lock, 2011). However, in addition to adolescent presentations, recent research has documented an increase in the prevalence of pre-adolescent eating disorders, noting that presentations in this age group typically demonstrate greater vulnerability to medical risk (Madden et al., 2009).
A greater variety of symptom presentation in pre-adolescent eating disorders (including selective eating, food phobias, pervasive refusal syndrome, and food avoidant emotional disorder) (Bryant-Waugh & Lask, 1995; Cooper, Watkins, Bryant-Waugh, & Lask, 2002; Higgs, Goodyer, & Birch, 1989; Nicholls & Bryant-Waugh, 2008), in addition to relatively low incidence rates, has resulted in difficulties in ascertaining guidelines for best practice in this age group (Rhodes, Prunty, & Madden, 2009). Furthermore, the varying symptom profiles observed in such presentations have received relatively little empirical attention, despite one recent study documenting that food avoidant emotional disorder and selective eating account for more pre-adolescent presentations than anorexia nervosa (Cooper et al., 2002). With specific respect to selective eating, this is characterised by a pattern of food intake that is highly selective in terms of food variety (Lask & Bryant-Waugh, 2000), although this typically occurs in the context of normal weight and height (Nicholls, Christie, Randall, & Lask, 2001), and may not feature the dramatic medical complications characteristic of anorexia nervosa. Whilst some aspects of selective eating may be normative amongst toddlers, the persistence of selective eating into middle childhood is deemed less normative (Nicholls et al., 2001) and is usually marked by increasing rejection of previously consumed foods, and marked distress and reluctance around attempting new foods. However, the difficulties characteristic of selective eating are long standing, and may be associated with significant impairment to quality of life (including impinging upon friendships, social activities and familial relationships, in addition to experiencing expressed criticism and rejection) and the later development of clinical eating disordered symptomatology, inclusive of the attendant medical risk (Nicholls et al., 2001).
Thus far, treatment approaches to these children are preliminary in nature, although have generally fallen into either behavioural or cognitive behavioural treatment models (Bachmeyer, 2009; Nicholls et al., 2001). Whilst the extant literature is sparse, small-scale treatment studies have documented that cognitive behavioural models may attain moderate symptom alleviation, although symptoms may become more severe in 50% of cases (Nicholls et al., 2001), whereas behavioural treatment approaches based on positive and negative reinforcement appear largely ineffective (Calam, Waller, Cox, & Slade, 1997). An alternative approach to the treatment of selective eating advocates intervention within the context of the family (Calam, Waller, Cox, & Slade, 1997) given that “parental response to selective eating may influence the course of selective eating” (Nicholls et al., 2001, p. 267), although little evidence documents family-based treatment approaches.
Indeed, family therapists have demonstrated sustained interest in the treatment of eating disorders through a variety of theoretical lenses, including structural family therapy (Minuchin, Rosman, & Baker, 1978), Milan systemic family therapy (Selvini-Palazzoli, 1974), strategic family therapy (Madanes, 1981), and narrative family therapy (White, 1987). However, family therapy approaches to eating disorders have largely converged over the last decade due to the growing empirical support advocating the use of Maudsley Family Based Treatment (MFBT) as a first-line intervention for adolescent anorexia nervosa. This treatment model demonstrates strong empirical support, with symptom remission rates of between 70% and 90% sustained at 5-year follow-ups reported (Lock, Agras, Bryson, & Kraemer, 2005). This approach charges parents with the task of taking control of all anorexic behaviours in order to re-feed their child, whilst mobilising siblings to help support the patient during times of distress (Lock, Le Grange, Agras, & Dare, 2001). Ultimately, control is gradually restored to the adolescent patient following weight restoration and remission of eating disordered symptomatology (Lock et al., 2001). While there is some evidence that children with anorexia nervosa respond to family-based therapy (Lock et al., 2006) little is known as to the efficacy of MFBT in other pre-adolescent presentations such as food avoidant emotional disorder or selective eating, except that it may provide a starting point for treatment due to the shared short-term treatment goals of restoration of normal and varied eating (Rhodes et al., 2009). We present the case of a 9-year-old boy who presented for treatment of a longstanding history of selective eating.
Case details
Diego was a 9-year-old only child who lived with his biological parents, who were of European descent. Upon presentation Diego and his parents described selective eating for approximately 7 years (since age two), reporting a body mass index (BMI) of 15.4, which fell within the 32nd percentile. In describing his food intake, his parents stated that the only foods he ate were chips, chicken nuggets and plain bread, to the exclusion of all other foods presented. Diego also arranged these ‘safe foods’ in a particular manner, and typically ate in a structured order, consuming all of one food group (i.e. the chips) before he started with the next (i.e. the chicken nuggets). Furthermore, Diego reported that if his parents put a new food on the same plate as his safe foods, or if his safe food deviated in any way from his expectations (i.e. an oddly shaped chip), then he would not be able to eat any food off that plate and would request that his parents make a new plate. This is consistent with presentations of selective eating, and further clinical assessment did not reveal further obsessive or compulsive behaviours.
However, Diego reported a desire to gain weight and reported no fear of weight gain, which is increasingly common in male presentations of disordered eating (Darcy et al., in press). Further, he reported no body image disturbance, although Diego however did report a strong fear of vomiting upon trying new foods, and on several occasions had vomited following new foods without medical explanation. As a result of this wide scale food refusal, Diego reported a reduced quality of life relative to his peers, and frequently declined to attend social gatherings, parties and sporting events due to his concerns about the food provided, and further noted stunted growth in comparison to peers.
Accordingly, Diego’s parents reported concerted attempts over several years to normalise his eating, although they stated that this typically resulted in greater food refusal and family conflict. Subsequently, Diego’s parents reported accommodating his specific food requests after the effect that confronting them had on Diego’s mood and on their marital relationship. For instance, Diego’s parents reported that meal times inclusive of non-safe foods typically resulted in frequent and intense parental disagreement as to how to entice Diego into eating. At the time of assessment Diego ate separate meals to his parents, who ate a widely varied diet.
Treatment
Owing to the restrictive nature of Diego’s eating practices, his parent’s expressed desire to help bring about normal food variation and ensure weight gain as he became older, MFBT was chosen (Lock et al., 2001). Despite not meeting criteria for anorexia nervosa, the first phase of MFBT was employed because of its over focus on symptoms, non-blaming approach and capacity to help the parents to regain a sense of authority and confidence, while also providing support for Diego via externalising the problem. However, upon commencing the family meal at the second session of treatment Diego experienced severe emotional distress, and in 3 hours did not eat one bite of his meal, despite his parents doing what was considered to be an excellent job of providing united instructions in a calm, warm and supportive manner. The session was ultimately terminated without any food consumption, although Diego’s parents were charged with the task of replicating the same intensity around family meals at home, coupled with their united guidance for Diego. However, over the following week Diego was not able to eat any new foods, despite his parents making all food-based decisions, providing new foods at every meal (in addition to some safe foods) and supervising all meals with warm but firm guidance.
At this point MFBT was terminated, and a more generic family therapy approach was adopted. Whilst resistance is not uncommon upon commencing MFBT, the behavioural enactment undertaken during the family meal revealed that although Diego’s food refusal was underpinned by catastrophic interpretations regarding the consequences of eating: this centred around anxiety related to vomiting, further clarifying that weight or shape concerns were not a feature of his presentation. The disparities in Diego’s presentation compared with typical cases of anorexia nervosa indicated that Deigo’s food refusal would be better reformulated as a food-related anxiety disorder. This change allowed Diego’s anxiety (rather than the selective eating) to be externalized (White, 1984), which he labelled as ‘Beaster the Worry Wart’. Subsequently, the notion of a therapeutic paradox was quickly introduced, and under guidance from the treatment team, Diego’s parents commiserated with Diego and openly shared their great surprise in witnessing how strong Beaster was during the family meal session. The family explained to Diego that perhaps Beaster was too strong for him to challenge all by himself, stating that he should therefore not attempt any new foods. In further discussing their observed strength of Beaster, Diego’s parents decided that it was appropriate to “protect” him from playing sports in case Beaster “tried to bite Diego unexpectedly”, and so would not permit him to play any more sport until the treatment team “could figure out a way to tame Beaster”. This therapeutic paradox aimed to reverse the parental stance in relation to Diego’s food non-compliance, in the hope of thereby eliciting a paradoxical response from Diego. Finally, Diego’s parents agreed to do some detective work during the following week and spy on Beaster, looking for any clues to suggest that Diego may be ready to resume his fight against Beaster.
The following session, Diego arrived with a list of 10 new foods (including vegetables, salad and steak) which he had spontaneously attempted of his own volition, reporting that he liked many of the new foods he had tried. In addition, Diego reported that Beaster’s predictions around him vomiting had not come true, and that Beaster was therefore a liar. Diego’s parents devised a scheme to reward him for every five new foods he tried, and his courage in singlehandedly taking on Beaster was amplified in session. Following this session Diego continued to attempt many new foods over a period of 4 months (spanning nine sessions), reporting that Beaster continued to become “smaller and less scary looking”. Furthermore, Diego for the first time reported variety in the foods he was able to eat, and reported consistent weight gain, and at the end of treatment reported a BMI of 16.7, which fell within the 58th percentile.
Discussion
This case study documents a 9-year-old boy who was treated for a longstanding case of selective eating with family-based therapy. Subsequent to terminating MFBT, the treatment entailed more generic family therapy techniques including the use of a therapeutic paradox, which brought about symptom dissolution. This therapeutic paradox helped realign Diego’s relationship with his symptoms, allowing him to experience an intrinsically aversive outcome as a result of his food refusal. It is also likely that the removal of Diego’s parents from enforcing symptom alleviation helped realign the structure of the family around Diego’s symptoms, and a reversal in parental approach (in a direction opposite to that proposed by MBFT) to Diego’s food non-compliance thereby elicited a paradoxical response from Diego, who alleviated his own symptoms in a manner consistent with his non-compliance.
The approach utilised in this case runs contrary to the approach outlined in MFBT, in which parents are encouraged to take more direct control over symptom resolution. However, it is important to note that Diego did not meet diagnostic criteria for anorexia nervosa and as such did not report a fear of weight gain, therefore experiencing reduced symptom ego-syntonicity, which may have mediated the extent to which Diego’s parents were required to exert direct control over symptom reduction. Furthermore, Diego’s symptom profile was also deemed consistent with a food-related anxiety disorder, rather than an eating disorder per se, which may have further mediated the efficacy of MFBT in this case. This is consistent with recent evidence suggesting that selective eating may be inclusive of wide-scale anxiety-related psychopathology (Nicholls et al., 2001), such that treatment approaches focusing exclusively on disordered eating may not suffice in fully attending to all aspects of psychopathology. Nevertheless, the nature of symptom alleviation suggests that family therapy may be effective in the treatment of pre-adolescent presentations of disordered eating with methods beyond those outlined specifically in MFBT, supporting the notion of eating disorder focused family therapy as opposed to manualised MBFT (Eisler, 2011). This may hold particular relevance for the treatment of selective eating, given previous findings reporting that this may be optimally treated within the context of the family (Calam et al., 1997), despite direct parental pressure often resulting in symptom escalation (Galloway, Fiorito, Lee, & Birch, 2005).
This case also highlights the need for ongoing clinical judgement, hypothesising and therapy skills in undertaking eating-disorder-focused family therapy. Selective eating in particular may be inclusive of anxiety-related psychopathology that may not be evident upon initial assessment, which may mediate any disordered eating (Nicholls et al., 2001), further underscoring the necessity for ongoing assessment in this presentation. In this case Diego did not meet criteria for anorexia nervosa, although his symptom profile was not atypical of a young male with an eating disorder and, as such, MFBT was deemed a suitable first-line treatment. However, the functional assessment undertaken in the family meal confirmed that Diego’s fear of vomiting was of central importance and there were no hidden or undisclosed shape or weight concerns, and therefore constituted a variation in the anxiety and symptom profile typically seen in anorexia nervosa. This delineation is of central importance to the treatment endorsed, as charging parents with the task of re-feeding in cases where there is no fear of weight gain, reduced symptom ego-syntonicity, and an expressed desire to gain weight may in some cases lead to mixed results. We recommend the continued exploration of family therapy techniques in the treatment of eating disorders.