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Feeding an ED child through puberty.

I have noticed an influx of parents with kids in the 9-14 age range lately. I have also noticed a ton of posts on all of the FB support groups from parents of kids in this age range who are being told to back off on calories and supervision because the child has reached "weight restoration". I feel compelled to address this.

As the mother of a daughter who began her decent into anorexia at 9 and was diagnosed at 10.5, I have walked this walk and am now 9 years out on the other side. My daughter has been in a solid recovery now for many years. I have talked with hundreds if not thousands of families over the last decade and have seen that the kids who are fed high calories and high fats and are monitored for a long period of time have the best outcomes. Kids in this age range are entering into (or already should be in) the time of their lives of the MOST growth and changes since infancy. In the next decade of their lives they must morph into young men and women. To do this takes a MASSIVE amount of energy for the average kid, let alone a kid diagnosed with the Metabo-psychiatric illness of an eating disorder. The average non ED girl will gain 40 to 50 pounds during this time and grow ten inches. For boys it is 50-60 pounds and 12 inches.

For those new to this realm, a large study came out in this past year called the "ANGI" (anorexia nervosa genetics initiative). The results found a specific genome-wide locus for anorexia. They also discovered metabolic connections. What this shows is what all of us who have walked this path know already: eating disorders are highly genetic and our loved ones bodies' metabolisms are warped and do not right themselves for a very long time. This is especially complicated when you have a child who is supposed to be growing exponentially and going through puberty.

My daughter was around 4 feet 7 inches and 66 pounds when she was officially diagnosed and at her lowest weight. She developed severe OCD with rituals surrounding movement, a severe exercise compulsion, auditory and visual hallucinations of "the darkness", anxiety, panic attacks, depression. She showed me what dress to bury her in and said the only way "the voice" would go away was if she was dead. All of these things are common place in the younger kids with EDs. Yet many in the medical field are not current in their understanding of this illness and of these side effects of malnutrition on the young child's brain chemistry. My daughter was diagnosed with "psychosis and possible early onset schizophrenia and anorexia" in the beginning. She had Anorexia. ALL of these other things disappeared with tons of weight gain and time. Of course sometimes kids DO have preexisting co-morbids of anxiety or OCD etc. but it is really difficult to tell what is what until the child has been refed back to a high enough weight and the brain has had time for full nutritional rehabilitation.

In the beginning of refeeding, my daughter's caloric needs kept going up. This is hypermetabolism and a normal part of eating disorder refeeding. She was initially able to gain in the mid 2000s, but then stalled out and needed 3000, 3500, 4500, 5000, and then 6000 A DAY. This was from the ages of around 11 to 14. We battled 9 inches in height, full puberty, and an over doubling of initial body weight. ONLY when her body had quit growing in height and had gone through puberty were we able to SLOWLY back off on the caloric intake. If my little teeny ten year old kid could eat 6000 calories a day, yours can eat whatever their body needs too. Dr. Peebles from CHOP recommends 4000 cals a day for a minimum of four years.

Learn from our mistakes. In the beginning when my daughter got up to a solid weight and had a tummy and cheeks at 11, we thought "oh no. We are going to over do this. We should back down a bit" and BAM did that bite us in the butt. Her body dropped 7 pounds in one week by us dropping her calories down and allowing her to eat lunch on her own at school. These kids can lose weight on a dime- another aspect of their malfunctioning metabolism. And of course she was not eating lunch. She was pretending to eat and dumping her thermos of creamy cheesy noodles into the garbage in the morning when she got off of the bus. We went back to the 6000 calories and supervised eating and we stayed there for the next several years. Us parents and our kids work too hard for that gain to see losses.

Only when she was able to eat on her own outside of what was required, take seconds, reliably eat when not with us etc. and had finished hardcore growth and puberty were we able to back down. This was from 14 to 15 for my daughter. Every kid will be different as they all are on their own timeline for puberty. Boys go through it a bit later than girls on the average.

So people always ask me "But what about the growth charts? The doctor says that he/she is weight restored and does not need to keep gaining at this rate." Brutal honesty here- I am happy we had no growth charts for my daughter as we never had any magic numbers to strive for. We literally just fed her until the ED was at bay and kept going for all of those years. I personally think that "target weights" should be thrown out the window in this age range because their weight is a moving target and will be for years. And frankly we have really no idea what each individual person is "supposed" to weigh or how tall exactly they are going to be as an adult. I am five feet eight inches and my husband maybe five feet ten inches. My three kids are five eight, five four, and six feet 2 inches. I just met a woman the other day who has a son who is 6 feet 10 inches tall and his parents are under six feet. They have no idea where his height came from. Genetics and environment are crazy things.

When my daughter was in ninth grade and growth stopped she was a bit round in the butt, thighs, face etc. and the brutal truth was that I was freaked out. I was worried we were making her "too big". I wanted to back off aggressively on her calories. My husband talked sense into me at that time. He said that we were already in the process of SLOWLY backing off on her calories/fats and that her body would adjust and morph and find a set point where it wanted to be. He was completely right. Within about 6 months her weight did not change but her body redistributed weight and she morphed into a woman's body. This was also the year that official recovery happened. She was able to eat on her own outside of meals and we were able to let her plate her own meals fully and not require empty plates etc. This was also when her brain completely righted itself and she was finally able on her own to totally battle and shut down any ED thoughts. She has told me since that this was the time that she felt she was truly able to make the decision to be done with ED. She was in control and not the eating disorder.

Don't back down.

Stay the course.

Feed them through growth and puberty.

Trust that process.

Do not focus on weight ranges and goal weights and BMIs.

Focus on behaviors.

Focus on the LONG GAME.

Throw out the timelines and stages.

I will not sugar coat it- this takes YEARS and it is hard. But ultimately it is worth it. My daughter is now 8 hours away in her sophomore year of college thriving. She has a girlfriend of 14 months, is studying to be a sex therapist. She is recording her second album (singer songwriter), and she KNOWS that we saved her life and she is incredibly grateful for all that we did. She is my hero- the bravest person I know.
Persistent, consistent vigilance!
Wow, what a bumpy ride! Lessons learned. We should be really aiming for adult weight and size as that is where our children should finish their growth. 

Before our ED years, I read a book about teenage growth written by a vet(!), who compared the body development of respective species. In short, why do homo sapiens have sudden brain growth at 2 significant stages: first few months and puberty. The infancy stage is self-explanatory. The head of a newborn is small enough to pass through the mother's body, and then quickly catches up for the baby brain to get ready for all that learning. The puberty stage remains a bit of a mistery but the brain volume increases inside the skull during puberty. And puberty is pretty much unique to our species. 

It is also a period of rapid learning. Learning at school or learning bad habits, that is. 

This just illustrates what a giant nutrition task we have as parents! I am inclined to believe that our (myself really) not keeping up in step might have triggered EDs. So for us now a growth spurt equals feed, feed, feed. We don't want any slip ups. 
Mum's Kitchen

14-y-o "healthy living" led to AN in 2017 and WR at 16. Current muscle dysmorphia.
The human brain is not fully developed until around the age of 24-25. The last part to fully develop is part of the frontal cortex which is responsible for risk assessment and decision making. The brain needs extra nutrition for the entire stage of puberty. 

My son is 16. He is weight restored and requires 8000-9000 calories a day to maintain his growth curve. He will require this amount for many years. Your kids need more than you think. 
KLB exactly. And that is a lot of food for sure! 
Persistent, consistent vigilance!
Most parents of teenage boys complain they are eating them out of house and home - they eat an enormous amount for that gain, and there is no doubt teen girls need to eat a lot for puberty, which is generally shorter and earlier than for boys but as you have pointed out @mamabear accounts for a substantial weight gain in normal healthy kids. When feeding for ED's we are adding on top of this. 
D diagnosed restrictive AN June 2010 age 13. Initially weight restored 2012. Relapse and continuously edging towards recovery. Treatment: multiple hospitalisations and individual and family therapy.
Great post. MamaBear.  Thanks.

MKR, to this: "The head of a newborn is small enough to pass through the mother's body, and then quickly catches up for the baby brain to get ready for all that learning," I would add that the newborn head presents some challenges.  One theory to explain why human babies are born "prematurely" in comparison to our ape friends is that the head needs to be able to get through the birth canal.  Our bigger brains result in bigger heads.  If our babies stayed in utero long enough to be able to do all the advanced stuff a newborn ape can do (e.g., hang on to its mom's back), their heads would be too big for birthing.  So the solution (albeit imperfect) is that our babies are born early and finish up this initial growth outside the womb.  xx

"We are angels of hope, of healing, and of light. Darkness flees from us." -YP