War broke out on the day Rina Ranalli and her husband told their 12-year-old anorexic daughter the strict new house rules: three meals and three snacks a day.
Initially, their bright and previously sweet-natured girl cried, screamed insults and raged. She threw things. Punched holes in the wall. And she pretended to eat while plotting ways to hide the food. But when the seventh-grader realized her parents had her trapped — they would sit with her 24/7 if they had to — she ventured down the only available path. She began eating.
Chicago's Ranalli family was using the little-known Maudsley Approach, a grueling but evidence-based treatment for adolescents suffering from the eating disorder anorexia nervosa. The approach, also called "family-based therapy," flips conventional treatment on its head.
Often parents are advised to put their starving child in therapy or residential treatment, distance themselves to preserve the teen's independence and wait for the day the child decides to resume eating.
But under Maudsley, parents immediately start the daunting task of "re-feeding" their malnourished child. Once weight is restored — and, theoretically, rational thinking returns because the brain has some nourishment — parents step back, and control over eating is gradually returned to the child. The final phase of treatment is the initial step in traditional therapy; it addresses the underlying psychological issues that may have caused the disorder.
Critics of the approach say forcing adolescents to relinquish their power over food can exacerbate underlying control issues. They question whether Maudsley teaches children how to eat intuitively. And they wonder whether parents are equipped for the harrowing and relentless task of getting a child to finally eat.
But Maudsley has something other remedies for anorexia do not: A modest body of clinical evidence suggesting that most adolescent patients respond favorably after relatively few treatment sessions. For parents, it's a glimmer of hope for a serious illness still lacking a gold-standard treatment.
"If you just Google 'eating disorder' and 'anorexia,' you feel like you've been handed a death sentence," said Ranalli, whose already slender daughter (whom they didn't want named) lost 16 pounds in six weeks. "You cry a lot. Maudsley reassures you that it's not your fault and empowered us; we were part of the solution."
Anorexia is unusual in that sufferers often see the illness as an ally. They have a morbid fear of fatness and think about food obsessively; they may cook extravagant meals for others or longingly gaze at food in the grocery. But they don't eat.
Social isolation is common. When Emily Troscianko, 26, made the decision to eat more after living with her anorexia for 10 years, "it felt like I was bidding goodbye to my closest, most loyal friend," wrote Troscianko, the author of the Psychology Today blog "A Hunger Artist."
The disorder runs in families and is associated with perfectionism, said Dr. Walter Kaye, the director of the eating disorder treatment and research program at the University of California, San Diego.
"Those with anorexia tend to pay precise attention to detail. They want to do things right. They're achievement-oriented and have advantages in engineering, medicine and academics," said Kaye, whose research focuses on the brain and eating behavior. "Perhaps the illness is caused by an excessive load of traits, puberty and hormones, environment or stress. We're still trying to figure it all out."
Eating disorders are difficult to treat in part because they're hard to study. They're still relatively rare — affecting an estimated 2 percent of U.S. women and 1 percent of men — and it's not easy recruiting research subjects, who rarely want to be treated in the first place.
Just five randomized, controlled studies have examined the treatment of anorexia in adolescents, according to Daniel Le Grange, director of the eating disorders program at the University of Chicago Medical Center. Four of the five published studies include family-based therapy, or the Maudsley Approach.
Though the studies are small, they indicate that early treatment with Maudsley boosts a child's chance of getting a handle on the illness. Maudsley has also been found to be effective for those who don't yet have full-blown anorexia but are teetering on the edge.
"A weight gain of 3 to 4 pounds in the first month of treatment gives an 80 percent certainty of good outcome," said Le Grange, a professor of psychiatry and behavioral neuroscience who helped develop the approach at London's Maudsley Hospital and brought the treatment to the U.S.
The success rate drops considerably for children who don't quickly gain weight during treatment. But Le Grange argues that given Maudsley's promising results — and limited comparative data — the family-based treatment should be the first-line intervention instead of an alternative for adolescents who qualify for outpatient care.
"To be really honest with families, we should say: 'We only have one treatment. There is a fair amount of evidence, and it's what you should start with,'" Le Grange said. "If clinicians are not willing to do that, then we have to agree we're just improvising."
After Ranalli's daughter was diagnosed in February 2008, the family spent seven months using more traditional methods, including a therapist and nutritionist. "It was painfully slow," Ranalli said. "So much is left back to the adolescent, waiting for them to come along."
Eating With an Anorexic Child
Under the Maudsley Approach, family members take responsibility for forcing patients to eat, even if it means being with them 24/7.
We've upgraded our reader commenting system. Learn more about the new features.
The Baltimore Sun encourages civil dialogue related to our stories; you must register and log-in to our site in order to participate. We reserve the right to remove any user and to delete comments that violate our Terms of Service. By commenting, you agree to these terms. Please flag inappropriate comments.