Shephard Pratt
https://eatingdisorder.org



Maudsley trained therapist:

http://www.sarahbennettphd.com/

OP, you are ABSOLUTELY right to be concerned. Your step daughter is showing many symptoms of entrenched, full blown anorexia.

Listen to your gut. Get her to an eating disorder clinic.

The pediatrician's reaction is DANGEROUSLY OUTDATED. What is important in diagnosing an eating disorder is whether there has been a reduction in the child's historic weight percentile. If she's always been 75th%ile for weight, and is now 15th%ile for weight -- that's a BIG PROBLEM even though technically 15th percentile is not supposed to be underweight.

As the stepmom I agree you are in a very tough spot. But the earlier you can get your husband on board the better chances you have for turning this around. I'm sorry, so many of us have had to learn this the hard way -- the therapists and pediatricians often don't know best practices here and we need to educate ourselves.

(That said, just FYI I took my son to Shephard Pratt Eating Disorder Clinic and felt like they were competent. I know some people have had different experiences there though.)

Here is a video that your husband should watch:

https://vimeo.com/50460378

Whatever you do, keep the lines of communication open. You're never going to get help from the bio mom's family on this issue until it's too late. (I've seen it with my inlaws and their extended family.) Can you quietly/privately meet with a senior school official, and advisor or therapist? They might be able to educate DH without saying you brought it to their attention. They can try with bio mom but it doesn't seem like that will go anywhere. Kudos to you, op. You're not an alarmist.

Pp might have the right idea. But anorexia is sometimes an attempt to gain control, force feeding especially if not extremely underweight can have the opposite effect and I'd worry about relapse.

Anorexia is unlike other diseases.

Anonymous wrote:

Anonymous wrote:Get treatment soon. However, remember that YOU can't stop anorexia in its tracks. It is your DD's struggle. It is great you are being so supportive, but do realize you can't stop this for her. You sound like a super parent in recognizing behaviors. Your job is to provide tools for her to help herself.

I think I wasn't clear here. Of course, family therapy is needed and food is the medication here. All of your family has hard work in front of them. But the potentially anorexic child has to buy in.

This is a family problem, not one child's problem.

No, she really doesn't. If she loses too much weight or goes too long without eating, an anorexic child ends up in the hospital on a feeding tube. The hospital personnel won't care whether she wants the tube or not.

Your kid doesn't need to buy in to her cancer treatment or her diabetes treatment. You wouldn't provide your kid with the tools she needed to dig herself out of a suicidal depression. You would treat her no matter what she thought about it, and you'd check her into the hospital and make it happen if you couldn't get her to cooperate at home. Food is no different. Twelve-year-old children do not solve their own medical problems or decide whether or not they want to treat them.

It is usually counterproductive to try to reason with/educate someone with with anorexia until they are eating well and regularly and are weight restored. Anorexia is a psychiatric illness. Similar to major depression, stabilization--here refeeding and weight restoration--has to happen first.

No words of advice, OP, just words of praise for your willingness to step into a potentially lethal situation and try to help this child. It sounds like you are the only person right now who recognizes the problem and who is willing to help her. You are a wonderful example to step-mothers and mothers everywhere for not only recognizing the problem and acting on it, but also for having won your new daughter's trust and willingness to tackle this problem with you. Hugs and best wishes to you both. She is so lucky to have you on her side fighting for her to be healthy and well.

OP, what you are describing is a FULL BLOWN EATING DISORDER.

This is what PPs above mean when they say it can get very bad very quickly. She is already in a bad place.

It is time to stop talking with her and time to start acting. She should be "forced" to eat 3 meals and 3 snacks, prepared by you or other adult, every day. By forced I mean: can't do anything else until the meal/snack is eaten. Can't go to see a friend, school shopping, go for a walk, use the computer, nothing. Put the food in front of her, sit with her until she eats, do not allow her to visit bathroom for 30 minutes after meal.

You are not somehow giving in to weird obsessions by making her sit in a restaurant until she finishes a normal amount of food. You are insisting on intake of the amount of food needed to fuel a growing body, just as you would insist on intake of insulin if she needed it.

Don't discuss her weight, the way she looks, veganism, healthy foods vs nonhealthy foods, nutrition, etc. *She* is not having these conversations with you, her eating disorder is having these conversations with you. What you say to her are things like, "Veganism is a way of eating food, not a way of eating less food. I'm not going to discuss that with you." "You know I think you look lovely. I'm not going to discuss your weight/size with you." "I'm sorry you don't want to eat that, but food is required for good health."

She has developed an exercise fixation. Do not allow her to take the yoga class anymore.

But I get that you have relatively little control here. So your first steps, IMO, should be:

(1) stop discussing weight, looks, food, etc with her. Discussion only feeds the obsession.
(2) make her eat with you, to the extent you can. Try to insist on normal food, normal portions. Try to insist on breakfast, snacks, etc.
(3) consult with a specialist as the initial step to:
(4) get your DH on board. <----This will be the most important part.

Can you get him to read this?

https://feast-ed.site-ym.com/?page=WarningSigns

And tell him that anorexia has the highest mortality rate of any psychiatric illness.

Anonymous wrote:Get treatment soon. However, remember that YOU can't stop anorexia in its tracks. It is your DD's struggle. It is great you are being so supportive, but do realize you can't stop this for her. You sound like a super parent in recognizing behaviors. Your job is to provide tools for her to help herself.

I think I wasn't clear here. Of course, family therapy is needed and food is the medication here. All of your family has hard work in front of them. But the potentially anorexic child has to buy in.

This is a family problem, not one child's problem.

you sound very well intentioned and this is very complicated if you are the step mom.
former anorexic here.
honestly - pushing therapy and treatment centers etc. isn't going to work with this dynamic. she will likely just get worse and go more underground.
You don't have much control as the step mom which is why I'm giving you different advice than normal.
with this history and personality i would focus on what healthy food you can get into her as safe foods.

she's not going to want to gain weight. talk to her about nutrition. hard boiled eggs, orgain shakes etc. (they are vegan) even if she's eating little, get protein and vitamins into her and at least see if you can have her stabilize at this weight and not lose more.

wouldn't you rather have her eat two eggs than make pizza and have her refuse or pretend to be sick or not eat it? that's what I would try to do, work on giving her the tools to at least find foods that will work for where she's at.

Thanks everyone for the help. I really truly appreciate all the posts and appreciate that, like with many things, people are going to disagree about best approaches. I also understand that every situation is unique and every person is unique and that seeking advice from an online community isn't how our family is going to address the problem--I really was hoping to get practical suggestions for good professionals to go to. Because there are good therapists and not so good ones.

I'm "just" the step-mom here. And I seem to be the ONLY one who is concerned. So... either I'm an alarmist (could be!) or everyone else is clueless (could be!). But it makes everything about this situation way more complicated. Obviously. From the practical (if her bio mom doesn't "believe" in the problem or the solution, then she isn't helping to get her to a therapist nor doing any of the work at home to support) to the more esoteric stuff (DH getting upset that I'm telling him he's a bad parent). So ... yeah. But I'm alarmed enough that I have unilaterally decided (with DD's acknowledgement that she recognizes she has a problem) to take her to someone. I just wanted advice on where/who/starting advice.

Obviously, there was a high conflict divorce and bio parents don't effectively co-parent. I have no doubt that contributes to anxiety and other difficulties. Kid and parents were in therapy many years ago when DD was younger but both bio parents thought it was a waste of time. I ultimately agreed but I really think it was bc that particular therapist wasn't effective not b/c DD and the family couldn't have benefited from therapy. But I can't single-handedly change any of that. As for the specific problem of the anorexia...this is going to be long, which is why I didn't post it before. But for those who are interested....

She's always been athletic and built "normally" but has also been an earlier developer (breasts and period before her friends). Never chubby. Never skinny. She happened to have close friends all of whom were on the extremely scrawny side so she always complained of being "fat" even though she remotely wasn't. DH and DD always reported to me that there was A LOT of pressure from mom's side of the family re: weight. That at 2 years old, grandma would call DD fat. That mom was ALWAYS on a perpetual diet. That skipping meals was encouraged at that house. I couldn't do anything about any of that except establish different rules at my house where I focused on teaching good nutrition, positive body images, and eating to properly fuel bodies. I always packed her lunch for school and made sure it was good. Throughout elem school, DD would complain at our house that she felt like she was "starving" at her other house sometimes. Gave her secret money to buy school lunch on days she was with bio mom so she wouldn't feel that way. Yes. I realize how fucked up all this is. I was just doing the best I could do in the circumstances. But her weight/growth/strength remained normal. Back to her skinny lifelong friends...Some of these girls have started to mature and are now normalizing into more adult bodies except her best friend. Best friend was always called "a picky eater" by her parents. I've always thought it was way more than that. At birthday parties, I would watch best friend take a big plate of food, secretly take most of it and throw it away/put in her pockets/drop on floor/etc. and then lie to others that she'd eaten the whole thing. To me, that's not a picky eater. I told girl's mom and the woman has never really spoken to me since. Anyway, in elementary school, this best friend would do a lot of meal skipping etc and there have been "episodes" where my DD would tell me she was "trying" to do the same thing but 1.) thankfully she loved food and she was active so she said it seemed impossible to not eat and 2.) I would try to "scare her straight" by telling her how harmful/wrong that behavior was. These were very concerning to me (again, only me) but they really were "one-off" situations that didn't seem to go anywhere. And it's not like I had the power to not let her be friends with this person. In the mean time, as this is going on, DD has an older cousin who is diagnosed anorexic. DD saw her behavior during family events (not eating; compulsive exercise if forced to eat one bite; etc.) and her physical condition and was sad for her. I thought that was actually good for her to see but now my research tells me an anorexic family member is actually a warning factor.

So that's basic background. Now it's this summer. Like everyone else, DD is in a variety of camps and long trips away from home. And what little time is left is divided between 2 houses. On the few days I get to see her, she is looking much thinner than she's ever looked, but she was eating normally in front of me the few meals we did have together so I think maybe it's just natural change. Also, definitely still on the normal side of skinny. Not concerning. The only thing concerning to me was the change seemed to be happening very fast. But she was healthy and active. And behaving "normally" (in front of me). Then she goes away with bio mom for almost 3 weeks. When she comes back to go on vacation with us, she's even skinnier. Again, if someone saw her on the street you wouldn't be alarmed. But I am b/c it's a big change. And on vacation, the behavior is alarming.

She is refusing to eat anything before lunch time. Says it makes her feel nauseous. Ok. I don't usually love bfast either. But I get the sense that it's more than that. Then at lunches and dinners, the girl who loves food is ordering food but only eating like 3 bites of it. Continuously says she doesn't like it. Or there's something wrong with it. Etc. Again, lots of kids exhibit this picky behavior normally but this girl has always had the palate of Anthony Bordain. After 2 days of it, I confront her about it. She admits she isn't eating on purpose. That she's lost a lot of weight from not eating and so she wants to keep doing it. It's a long drawn out emotional scene about how fat she is. How she longs to be "perfect." It's clear from the convo that she does not see the truth about her body and sees fat where this is none. She also points out people who are heavier or the same and says they're perfect but she's a fatso. Simultaneously, she pointed out extremely skinny looking people and would idolize them. Family (including DH) has a 3 hour conversation about it all and it felt like real progress. But hours later, I catch her pinching a tiny bit of skin on her stomach and telling herself how fat she is. That kind of thing. Every day. Crying in the dressing room while she shop for school clothes. Obsessing over what others look like. Obsessing over herself. Also I am fighting with her at every meal to eat her food (and she was already ordering very small amounts). We had a week of "serious long talks" where she cries and says she understands and will do better but the behavior wouldn't change at all. Simultaneous to this, I take her to her first yoga class. It was a very positive, loving, amazing studio. She loved it and I thought maybe the positive self-love messages were helping. She wants to go every day. It's hot yoga. We go to the 60 min. Then she wants the 90 min. She gets anxious and angry if I say we should do some other activity. In class, I see her pushing herself like she's training for a marathon. We come back from vacation and she wants an unlimited class pass so she can go to yoga every day. She starts talking about what other activities she can drop so she can do this. DH thinks it's great because.... how can yoga be bad for you? But her behavior seems compulsive and almost obsessive. Hard to describe without taking up everyone's day but in a period of a week, I feel like she's developed an obsession. Then I find out she's dropped an elective in school that she LOVED in order to take gym class every day. Plus she's on an athletic team with 2 practices a week plus games. Anyway, so it's mostly 1.) Skipping meals; 2.) barely eating at meals; 3.) what appears to be an almost compulsive drive to exercise that has come out of the blue; 4.) body dismorphia and incredibly negative self-image. And the intensity of all this just kind of showing up on our vacation was overwhelming and concerning. I'm completely exhausted. And I am very worried that I'm watching behavior that, in a matter of months, will have her in the same place as her older cousin.

What's weird is that, at least during vacation, she was very open about it. I couldn't believe she would tell me what she was telling me. She told me she was thinking of going vegan b/c "that makes it ok to not eat most foods." To sit and fight with me at restaurants that she was only going to eat 1/4 of whatever it was that I had ordered for myself. She was constantly talking about her body in the worst terms possible. A lot of the behavior seemed... really manipulative or attention-seeking to me. I'm aware that many anorexics engage in much more secretive behavior (like her best friend throwing away food behind people's backs). I sometimes felt like saying we were going to sit in the restaurant until she ate a normal amount of food was just ... giving in to this weird manipulation. But to not give in would be to let her starve all day. So... it's a lose-lose proposition and I clearly need professional advice on how to appropriately respond to these circumstances. She just started 7th grade. She packed her own lunch--a handful of peanuts in a plastic bag. That was it. So, obviously I will need to supervise lunch packing but how do I know if she's going to eat it? So I start weighing her every day and then take things away from her/punish her if she drops below a certain amount? This all seems like insanity to me but I also have heard that this stuff can just grab hold of people and not let go. Like drug addiction. I mean... if she was doing "a little bit" of heroin, I don't think I would be overreacting.

Dad concerned in the moment of when she would say/do these things but just thinks saying things like "you look great. eat your food" is enough. And privately he tells me I'm way overreacting and that this is all "normal for her age." We returned from vacation and went to her pediatrician who basically rolled her eyes at me. Because she's still in the range of "normal" height/weight. Which is true. She was always in the high range and is now in the very low range, but sure. The chart says she's normal. But she WON'T be normal with another few months of this behavior. And more importantly all this negative self-image and terrible eating habits seems like it should be addressed. Dr. did the same thing Dad does. "Hey, kid. You need to eat good, healthy meals. You're not fat. OK?" And gives her a pat on the head. It's like... they want to wait until her skin turns sallow and her bones are protruding and she's too weak to do anything before anyone gets concerned??? But maybe I AM an alarmist. It hurts me to hear her say these terrible things to herself. I keep telling her that she would never let someone else say those kinds of things to a friend so why does she do that to herself? DD has agreed that she'd like to "talk to someone" and that the decisions she is making for herself are "bad." So I'd at least like to do that. But since neither mom nor dad will be really supporting this, and she's so young, I'd like to find a place near her school that she could get herself to instead of just heading home to do homework.

Thanks for listening. If you think I'm crazy, please tell me. Because mom, dad, grandparents, etc. all seem to think that my fears that in a few months/years time we could be looking at hospitalized stays etc are way overblown.

Maudley Approach

Look up EDPS on Facebook and ask to join.

Anonymous wrote:

Anonymous wrote:There have been some early flashes of behavior that concerned me, but I knew that DD loved to eat and always hoped that healthy desire to consume delicious foods would counter balance any stupid ideas she got in her head for a few days. I also know lots of girls 12-14 are really struggling with self-esteem, self-confidence, hormonal changes, social pressures, etc. All of a sudden, her behavior has taken a turn for the worse. Dad isn't concerned but I'm ready to send her to therapy before this kind of thinking and behavior gets engrained. ANY good recs for appropriate therapist/doctor/etc. in downtown metro DC area[u] would be greatly appreciated. Other parenting advice also appreciated. I have no idea how to handle/respond.

I say this as a father with experience, do not mess around with this. DD had better wake up. there is one in the immediate DC area called Renfro i believe. Other than that Shepard Pratt in MD is considered excellent and Reflections in Falls Church. Do not go for convenient and close over quality.

Eating disorders are not about social pressure per se, they are very complicated and become almost like drug addiction very quickly.

I'm guessing that very few people who have actually experienced SP's eating disorder unit would use a word like "excellent" to describe it. That place is a revolving door of ineffective, cookie cutter treatment.

OP, you should definitely check out the discussion forum Around The Dinner Table (aroundthedinnertable.org). You'll find lots of great advice there from parents who have been where you are.

OP all this advice being given is for if your child actually has anorexia -- obviously you need to get her evaluated!

Anonymous wrote:

Anonymous wrote:

Anonymous wrote: I also know lots of girls 12-14 are really struggling with self-esteem, self-confidence, hormonal changes, social pressures, etc. All of a sudden, her behavior has taken a turn for the worse. Dad isn't concerned but I'm ready to send her to therapy before this kind of thinking and behavior gets engrained. ANY good recs for appropriate therapist/doctor/etc. in downtown metro DC area[u] would be greatly appreciated. Other parenting advice also appreciated. I have no idea how to handle/respond.

This is the treatment for anorexia and you don't actually need a therapist to do it, although they might be able to help you get her to eat.

Feed her. Make sure she eats. 3 meals and 3 snacks per day. WATCH HER. Cancel ALL exercise and sports until she is eating normally again and has gained back any lost weight or is back where she should be on her growth curve.

It doesn't matter that she loves her sport and it is her whole life -- sports are for healthy people and she isn't healthy until she can eat enough to fuel her growth and activities.

The treatment is intensive and exhausting and you have to put your life on hold for a while but the alternative is devastating, and treatment by the family has the highest rate of success. Anorexia has the highest death rate of any mental illness. The earlier you can intervene the easier the treatment and the better your child's chance of recovery.

Yes, this is the essence of family-based therapy. While it sounds easy, it's really hard. Meals must be eaten where you can observe, no going to the bathroom after. Parents make/select all the food and put it on a plate (with a good idea of how many calories are on the plate in order to keep track of caloric intake), and the kid has to eat it before anything else is done--school, social activities, whatever. You can distract by playing games, watching TV, but the food must be eaten. Where a nutritionist can be extremely helpful is in determining how many calories the kid should be eating and how to get that many calories into the kid. Kids who have eating disorders need an astonishing number of calories to become weight restored--for some it is 4,000-5,000 calories a day. It takes a lot of planning and scheming to feed a (reluctant, if not outright hostile) kid that much food. At this stage, a therapist can also provide a lot of support, to the parent perhaps more than to the kid.

But yes, it's possible to undertake this without assistance (and in areas where there aren't good treatment options, parents often have to take this own by themselves). The discussion forums at Around The Dinner Table provide invaluable help with this.

http://www.feast-ed.org/?page=magicplate

Anonymous wrote:

Anonymous wrote: I also know lots of girls 12-14 are really struggling with self-esteem, self-confidence, hormonal changes, social pressures, etc. All of a sudden, her behavior has taken a turn for the worse. Dad isn't concerned but I'm ready to send her to therapy before this kind of thinking and behavior gets engrained. ANY good recs for appropriate therapist/doctor/etc. in downtown metro DC area[u] would be greatly appreciated. Other parenting advice also appreciated. I have no idea how to handle/respond.

This is the treatment for anorexia and you don't actually need a therapist to do it, although they might be able to help you get her to eat.

Feed her. Make sure she eats. 3 meals and 3 snacks per day. WATCH HER. Cancel ALL exercise and sports until she is eating normally again and has gained back any lost weight or is back where she should be on her growth curve.

It doesn't matter that she loves her sport and it is her whole life -- sports are for healthy people and she isn't healthy until she can eat enough to fuel her growth and activities.

The treatment is intensive and exhausting and you have to put your life on hold for a while but the alternative is devastating, and treatment by the family has the highest rate of success. Anorexia has the highest death rate of any mental illness. The earlier you can intervene the easier the treatment and the better your child's chance of recovery.

Yes, this is the essence of family-based therapy. While it sounds easy, it's really hard. Meals must be eaten where you can observe, no going to the bathroom after. Parents make/select all the food and put it on a plate (with a good idea of how many calories are on the plate in order to keep track of caloric intake), and the kid has to eat it before anything else is done--school, social activities, whatever. You can distract by playing games, watching TV, but the food must be eaten. Where a nutritionist can be extremely helpful is in determining how many calories the kid should be eating and how to get that many calories into the kid. Kids who have eating disorders need an astonishing number of calories to become weight restored--for some it is 4,000-5,000 calories a day. It takes a lot of planning and scheming to feed a (reluctant, if not outright hostile) kid that much food. At this stage, a therapist can also provide a lot of support, to the parent perhaps more than to the kid.

But yes, it's possible to undertake this without assistance (and in areas where there aren't good treatment options, parents often have to take this own by themselves). The discussion forums at Around The Dinner Table provide invaluable help with this.