Eating Disorders

Raising Children After Anorexia

How can your eating disorder and recovery affect your parenting, and vice versa?

Posted Mar 08, 2019

This is the second guest post by medic and mother Karen Photiou on the topic of anorexia and children, following on from her discussion of pregnancy and early motherhood by exploring the later phase when babies become children.

I have always wanted children—which is why I now have four of them. Emily and I have had several discussions about the dichotomy between her decision not to have children and mine to produce an entire brood, and we thought it might be helpful to share more of my experience of taking the other fork in this path of life, a little further down the road from pregnancy and the early months of motherhood.

The life-changing decision about whether or not to have children can raise an inordinate number of questions and concerns—even without a history of anorexia. The choice is very personal, and should be viewed as a positive one either way. I’m not going to try to sell the idea of motherhood or give parenting advice—I certainly don’t have all the answers and am, like most parents, simply muddling along as best I can. I fully expect my kids to turn around in 20 years time with a list of things I did wrong that messed them up, but I now know it’s not realistic to hold myself to superhuman standards any more. Here are some of the things I've learned so far about parenting after an eating disorder.

The responsibilities and the pleasures of parenthood

When my children were born, I put an enormous amount of pressure on myself to get everything right, sacrificed myself to fulfill their needs, and then blamed myself for everything that went wrong. But there are two principles it is important to remember here. The first is that you are only one influence on your children, and the second is that your life matters as much as theirs. It took me a very long time (and a fair bit of expensive therapy) to realise that I am not solely responsible for my children’s lives, and that I am important too.

Karen Photiou
Source: Karen Photiou

My boys are 11, 9, and 7, and my daughter is 2 years old. Before Emma was born I felt quite relieved to have boys—of course, boys can also struggle with mental illness and anorexia, but my female experience conferred a certain degree of separation. When I became mother to a daughter I was hit by an overwhelming sense of responsibility to ensure I did not allow my own issues to be transferred to her. In terms of modelling behaviour and attitude towards eating and body acceptance—well, let’s just say when Emma arrived I was light-years away from anything I would dream of being even remotely acceptable for her. Which raised the question, if it wasn’t acceptable for my daughter, why was it acceptable for me? And that was a bit of an eye-opener, and a huge motivation for recovery.

There is never a right time or ‘perfect moment’ to have children (although I would highly recommend being in stable recovery before doing so—see my pregnancy post for more on why). Trying to decide when to make this momentous leap into the unknown in a logical manner can lead to paralytic overthinking, particularly if you start to weigh-up practicalities like childcare, work, and financial costs (here’s a clue—you can never afford it). I had my children relatively young, partly because I was worried I would struggle to conceive, and partly because my circular overthinking and planning for every potential outcome in every sphere of my present and future life was driving me (and my husband) slowly insane. In hindsight, it was totally the wrong time—I was newly married, in my second year as a junior doctor, at the beginning of a seemingly never-ending run of postgraduate exams, working in a hospital 1 ½ hours from home, just about to move jobs/house/cities… but when Alex came along, none of that mattered. You can overthink all this to the nth degree, but until you have children you really have no idea how any of it will work out. Yet it does, and it will.

A lot of people I know with a history of anorexia, my past self included, crave solitude and peace. When you have children, time to yourself goes out of the window, and the thought of that can be a huge concern. I honestly don’t know how, but I don’t find the lack of time alone a problem any more. Maybe it’s because the relationship a mother has with her children is unlike any other, and their constant company doesn’t feel like a drain on the self—more a life-affirming presence (as cheesy as that sounds). My children bring me more joy than any other people in my life. I have never laughed so hard, felt so moved by love (almost to the point of pain), or experienced such extreme, intense and powerful emotions as I have since my children entered my life. The bond is indescribable—I feel more comfortable with my children than I do with anyone else, and enjoy no one else’s company the way I enjoy theirs. I can be completely and unashamedly myself—I can dance around the kitchen to the Spice Girls, tell silly jokes, sing at the top of my lungs…all in a completely safe space with people who love and accept me unconditionally, and who I love in return. They’re my crew. And, with that as an alternative, solitude has lost its appeal.

Of course, it’s not all sunshine and rainbows. Children are demanding, unpredictable (my husband likens it to living with a ticking bomb), noisy, messy, and bone-shatteringly exhausting (particularly in the early years of chronic sleep deprivation), and the thought of coping with all that in such depths of exhaustion can be a concern after anorexia….but most people do cope OK, one way or another. Worrying can take on a whole new level once children are in the picture, and I hope my experiences can do a little to alleviate some common concerns.

Perfectionistic tendencies are common companions to anorexia, but rather than such tendencies being a problem in parenthood, you may find, as I did, that having children is the ultimate antidote to unrealistic self-imposed standards and expectations, because you absolutely cannot, ever, get everything right, and you have no hope of controlling anything. Perfectionism is totally incompatible with parenthood. You will always get stuff wrong, and miss things, and not have a clue, and think you could have done better, and realise someone else is doing x y z…. Your home will always be a little bit chaotic. You will be late for things. You will arrive at work with a bag full of nappies and expressed breast milk rather than the one containing your lunch and stethoscope (or maybe that’s just me). But it doesn’t matter. I quickly learned that the only way for any of us to survive was by letting go of all that. The big example for me was with academic work: before having children I was obsessive, worked ridiculously hard, and had a complete inability to switch off, but that's impossible to maintain with children, and it's not an exaggeration to say they saved me from myself. It's incredibly grounding. I work much less than I did before, but what I am able to achieve is still more than good enough. And being forced to redirect the time I would have otherwise effectively wasted by adding it to the inordinate amount of time I already spent working has added several more wedges to the pie chart of my life.

Parent–child and child–parent influences

a) Genetics

One anxiety for people with a history of anorexia is that a child may ‘inherit’ an eating disorder. You can’t prevent your children from developing anorexia. The aetiology of the illness is multifactorial, including genetic and environmental factors and other influences we do not as yet understand, and genetic research on anorexia makes clear how difficult genome characterisation is for a condition this complex (Pinheiro et al., 2009; Duncan et al., 2017). There are certain things that can be done to create a healthy home environment, which I will go into a little later, but the genetic component is something one can do nothing about. And, if it does happen, as awful as it would be, it is important to remember that despite the awfulness, you would cope with it, just as you did with your own illness, and just as one does with the exhaustions of motherhood. It is also possible that your own hard-won insights could help it be less awful (in some ways) than it might otherwise have been—despite the associated misplaced guilt. Feelings of guilt are, after all, optional, unconstructive, and almost universal amongst every parent who has a child with an eating disorder, regardless of appropriateness. And we can all cope with more than we think.

b) Cooking, eating, and exercise

Another widespread concern after an eating disorder is feeding children appropriately when you’re acutely aware that eating well isn’t part of your skill-set. The amount of meal prep and planning involved in feeding a family of 6 is mind-boggling, and I certainly struggled early in recovery with feeling my entire day was spent planning, purchasing, preparing, or eating food (and clearing up the ridiculous amount of mess children produce at mealtimes). Again, they key here was to back off with the perfectionism and the pressure—you are not a failure if you don’t provide a constant stream of lovingly prepared, home-cooked organic meals for your beloved offspring to turn their little noses up at and chuck on the floor. Asking my husband to take over the cooking sometimes has been very helpful when it all feels a bit too much.My children would be the first to confirm my cooking is useless (or ‘rank’ according to my 11 year old—I was certainly never one of those anorexics who delighted in cooking for and feeding others), so I cut corners wherever I can (a special thank-you to Waitrose for their awesome range of ready meals). And they all seem to be fine.

Karen Photiou
Source: Karen Photiou

As an aside, watching children is wonderful lesson in normality in terms of behaviour around food and movement. The same goes for body acceptance: I can learn a lot from watching my daughter innocently run around the house naked and delight in poking her round little tummy in the bath. Small children don’t decide what to eat or how to move based on the effect it may have on their weight and shape. I most certainly don't think about it when I feed my children or take them to play in the park—and I'm pretty sure I can use my attitude to feeding the kids as a benchmark for non-disordered thinking about food.  When I start to overanalyse my recovery and notice myself justifying certain ways of eating or moving that I know deep down to be questionably motivated, looking at my children gives me a great frame of reference for ‘normality’ (as nebulous as that word can be in today’s disordered society). Applying to myself the principles I use to feed my children has been hugely helpful: I trust their bodies to take care of themselves, which helps me remember I can trust mine too. I wouldn’t dream of weighing them in the morning before deciding whether or not to ‘allow’ them to eat breakfast, or force them to go for a 10k run to ‘earn’ their lunch. The idea of titrating their intake to an arbitrarily pre-determined calorie allowance fortunately strikes me as completely ridiculous—so why would I do that to myself? 

c) Feeding disorders, fussy eating, and disordered eating

Little children can be notoriously fussy eaters. It is incredibly frustrating when the delicious meal you spent time and effort preparing is met with screaming, crying, throwing, spitting, demands for different food, or an exasperating combination of all of those things. Some mothers deal with the frustration of a picky eater occasionally, while others endure this scenario at every meal. All of my children have, at one time or another, driven me close to insanity with behaviour of this nature. As children grow, they develop preferences and test boundaries, and dinner table skirmishes can quickly degenerate into power struggles. I have found the best approach to picky eating is to remain calm and neutral and wait for the phase to pass—if children are generally healthy and growing well they will most likely be fine. Children usually outgrow selective eating and eventually consume a wider range of foods, but the interim period can be very challenging for all mothers—particularly those with a history of anorexia. Feeding children can he highly emotive, and refusal to eat can be felt as personal rejection. Food waste can be difficult to deal with and this type of behaviour can be uncomfortably reminiscent of our own struggles with food, but it is important to be mindful that strong emotional reactions to picky children can be as much about our own issues as anything else.

Children with fussy eating are annoying and wasteful; those with serious feeding disorders and failure to gain weight and thrive are quite another matter. My second baby was born prematurely, and had severe reflux that led to significant feeding difficulties, to the point where his paediatrician wanted to admit him to hospital for tube-feeding to improve his static growth. I found this very difficult to deal with: admitting you are unable to feed your child is heart-breaking and can feel like the ultimate failure as a mother. The experience with baby Tom still holds a significant amount of unresolved guilt and pain on my part, and I almost didn't add it here as it felt too personal to share. I suppose because part of me still wonders if my inability to feed him was due to my anorexia on some subconscious level, although I have been told on countless occasions that he had physical problems and this was not my fault. All my other children were fine, and my husband has patiently pointed out repeatedly that nobody could feed Tom (i.e. it wasn’t just me). Tom is now, thankfully, absolutely fine, and healthy, and well-nourished—so I should probably just let it go and put it down to another example of misplaced maternal guilt. But discussing these issues is important.

I didn’t like the evidence I found when I explored this issue further, but that is no reason to ignore it. Studies have shown that children of mothers with eating disorders are at an increased risk for feeding and eating problems compared to those of healthy controls (Zerwas et al., 2012). The early years are critical in shaping children's eating habits, and children’s daily feeding routines are most often determined by their mothers. Feeding-related decisions, such as what food to offer, when, and in what quantity are, unsurprisingly, more complicated and distressing when the mother has an eating disorder (Mazzeo et al., 2005). Mothers with past or present anorexia are less likely to use pressuring feeding strategies with their four-year-olds (i.e. to push them to eat, or to eat more) but more likely to report emotional overeating in their children (de Barse et al., 2015), and first-time mothers who have had an eating disorder in the first year postpartum have been shown to have more intrusive, more conflictual, and less positive interactions with their children during feeding (Stein et al., 1994). Mothers with active eating disorders may limit toddlers’ food intake and exploration, with worrying self-reports of their toddlers being aware of and imitating disordered behaviours (Sadeh-Sharvit et al., 2015). Primary-school aged children whose mothers have an eating disorder are more likely to have “health-conscious” eating habits (Easter et al., 2013), and by age thirteen children of mothers with a past or present eating disorder report higher levels of disordered eating than other children, while the mothers report more preoccupation with their children’s bodyweight (Allen et al, 2014). Mothers with past experience of an eating disorder have also been found to be less likely than healthy controls to restrict how much their children eat but more likely to restrict their children’s consumption of processed foods (Hoffman et al., 2012). And women with a past or present eating disorder also tend to follow a less regular feeding schedule and to use food for non-nutritional purposes (such as soothing or distraction) more frequently, for children aged 2 to 5, and to report more negative emotion in their children from age 5 (Agras et al., 1999). 

There are caveats to bear in mind about this research. Most of the studies are based on self-report; correlation is not causation; ‘recovery’ criteria for studies distinguishing between past and present eating-disorder experience may be questionable (i.e. genuine recovery may annul more of the negative effects than it seems to); and the underlying genetic component contributing to inter-generational patterns of disorder is largely unexplored. However, as a mother and a paediatrician who has had a child with a feeding disorder, I think it is important to be aware of this sort of uncomfortable information to allow us to identify behaviours in ourselves that may be problematic, and manage the inherent risk better. If you have unresolved issues that may be adversely influencing how you feed your children, talk to someone and ask for help. Your eating disorder is not your fault, but it is your responsibility to do something about it.

It is also important to recognise when picky eating becomes something more significant. Failure to grow (or weight loss), as with my son Tom, is a clear warning sign that this is more than simple fussiness. If picky eating is prolonged, severe, or affects a child’s emotional or medical wellbeing, the possibility of other underlying disorders or forms of ‘disordered eating’ should be considered. Avoidant/restrictive food intake disorder (ARFID) is a type of disordered eating where certain foods are limited based on appearance, smell, taste, texture, brand, presentation, or a past negative experience with the food. Children with autism also have a higher degree of selective eating, and food phobias can be at the root of specific food avoidances. And, although 95% develop between the ages of 12 and 25, eating disorders can and do affect younger children. Ifyou are concerned about your child’s eating it is important to explore the thoughts and attitudes behindit. Talk to your child to determine whether there are concerning underlying motivations related to dieting, weight, or shape. Even young children are exposed to society’s dieting mania through the media, attitudes and behaviours of parents or older siblings, and school programs that weigh children and issue “fat letters” to parents. Arbitrary reasons for picky eating like “I don’t like green foods” or “vegetables taste yucky” are less concerning than beliefs like “green foods are bad for you” or “I like vegetables because they make me skinny”. 

As children become older, socially acceptable restrictive diets, like vegetarianism or veganism or the ubiquitous ‘clean eating’ trend, can be simple experimentation, but can also be the start of something more sinister. My own anorexia was directly preceded by vegetarianism, which, with hindsight, was a convenient excuse for avoiding calorific family meals disguised as concern for animal welfare. Identifying the boundary between fussiness and incipient disorder can be difficult, but recognising the underlying reasons for dietary modifications, particularly any attempts to modify shape or weight, can be helpful in distinguishing the two. And maternal (or paternal) instinct should not be underrated—particularly amongst those of us who know first hand what we are looking for. If you are worried or have a ‘gut instinct’ that something is wrong, you should seek medical help and advice.

I know I am oversensitive to this kind of thing—and so do my kids. The best example of this was when my 11-year-old son announced that he had decided to become a “gluten-free raw vegan”... before following up with “Only joking, Mum—I wanted to see what face you’d make if I ever told you I was taking hard drugs.” So, although these are serious issues, a little shared humour can go a long way in defusing the underlying fears and anxieties, encouraging open discussion, and bringing the darkness into the light. 

Karen Photiou
Source: Karen Photiou

Doing your best 

My husband has been incredibly helpful and supportive in raising our children, and in establishing a healthy home environment in terms of attitudes to food and eating. If I am ever unsure about issues involved in feeding the children I tend to default to him, as I am very aware he is far better equipped to manage this type of thing appropriately. We try to make food neutral, and don’t talk about ‘good’ and ‘bad’ foods—but this is a tricky area and I’m sure I’m not doing it completely right. Nothing is banned, and I try to be as relaxed and hands-off with my children’s diet as possible, trusting them to self-regulate (within reason!). Not dieting yourself (in the conventional sense of the term) makes good sense (not least because calorie restriction doesn’t work). Restricting your children’s sugar intake probably makes sense (the evidence for how sugar can addictively interfere with everything from brain chemistry to metabolic responses is substantial, and growing), but the question then is how to make sure sugar doesn’t become a forbidden excitement or a submerged craving, and that having less of it doesn’t make them feel socially weird. Using the teeth explanation, and having sweet things as a family sometimes but not too often, seems like a good balance. Arguments are often made for the importance of not using sugar as a reward, so I suppose the periodic sugary things shouldn’t be emphasised as rare ‘treats’, but just treated matter-of-factly as ordinary things we sometimes have because they’re nice.

Another common anxiety involves not wanting to repeat the mistakes made by our own parents. My mother prided herself on being slim and ‘too busy to eat’, and made it very clear that ‘fatness’ or ‘laziness’ or simply being ordinary were not desirable characteristics in a child. Whilst I’m not saying her attitudes were causes of my anorexia, it is likely they were contributory to some degree. Although, having said that, I don’t know if things would have been different with a different maternal role model, and I know that she, like me, was simply doing her best. We can try to create a protective home environment but, although a lot of this is common sense, there are always grey areas and hindsight is a wonderful thing.

Although causality is tricky to establish, high-pressure environments and anorexia seem to be related, and giving a child the impression that one kind of achievement matters more than any other is bound to be dangerous. My mother’s over-valuation of intellectual achievement definitely played a role in my past obsession with academic work. I am acutely aware that, even without me saying anything, my external appearance as an academically successful, high-achieving professional woman exerts a certain amount of pressure on my children. But I suppose having awareness of the potentially damaging nature of this type of thing is protective in itself. And my husband (also a doctor) and I try consciously not to exert pressure on our children to pursue certain professional roles or value academic success above other kinds, which, so far at least, seems to be panning out OK.

Comments about appearance are difficult. Some people advise against telling girls they’re pretty or saying nice things about what they’re wearing, but I tend to think that if being complimented on how one looks is only one of many positive inputs, it's unlikely to do harm. Growing up having never been told that by one's own parents, and hearing other people's parents say it to them, must create some weirdness too.  I tell my daughter she is beautiful—because she is beautiful, and the word encompasses more than just aesthetics. I say the same to my sons. I also tell them all they are kind, compassionate, clever, caring, brave, hard-working… none of which holds more importance than any other. I try to make it clear I love them for who they are, not for what they look like (or what they achieve). Slimness is quite a different matter: it's an objective characteristic with questionable objective benefits and a whole lot of value-laden baggage, perhaps especially for females. I avoid making comments about size, shape and weight at all costs. But we cannot protect our children from the outside world, where they will invariably encounter adverse influences of this nature, and to attempt to do so would be counterproductive in terms of fostering resilience and self-reliance.

I don’t criticise or comment on my own body and do my best to model normal eating, which is another motivator to stay strong in my recovery. But, there is no need to hold yourself to superhuman standards of self-acceptance. If you can be happy with your body as it is, that’s wonderful, but you shouldn't feel you need to get to that point for your children's sake. Many children grow up with mothers with the most awful conceivable relationships to food and their bodies, and seem to be fine—they may even learn first-hand the futility and sadness of living like that, and so develop the tools to reject it for themselves with conviction. In respects like these it's impossible to make reliable predictions. It’s impossible to tell whether an influence will prompt a congruent action or a contrasting reaction—whether your children will copy you or rebel against you. So, I suppose my provisional conclusion would be to be as healthy, calm, and balanced as you can, but for yourself, not just for them. 

What about the question of whether and when and how to tell your children about your eating disorder? Well, if you don't talk to children they make up their own truths, which are usually more frightening.  I told my oldest sons about my anorexia at the beginning of my recovery (in very simple terms—describing it as an illness in which people are afraid of food) and explained a little about the genetics and the importance of talking about any worries or concerns. They took it all in their stride, before deciding it was hilarious that mummy was scared of pasta and chasing me around the house with a packet of spaghetti! 

Although I am yet to navigate the unchartered waters of adolescence with my own children, I am acutely aware there are new pressures faced by the iGeneration that I do not fully understand. I don’t know what effect hours of daily use of digital technology, social media, instagram, texting, messaging, snap-chatting, etc. will have on our children, but I do know I struggled enough growing up without added pressure conferred by massive quantities of media consumption. The best I can hope to do is support my children as we learn together, and trust that we will be able to deal with these challenges as and when they arise.

The last thing it was crucial for me to accept upon choosing to embark on this journey is that we cannot predict how things will work out and we cannot avoid risk. I am a mother of four and a paediatrician, and I still don’t feel like I know what I’m doing half the time. Children don’t come with a rule-book, and we will invariably make mistakes—both for ourselves and for them. There will always be risk, and to attempt to eliminate risk will invariably curtail freedom, which is perhaps the greatest risk of all. If you try too hard to protect your children from everything, you make them vulnerable outcasts, but how much protection is too much, or too little? We just have to take a balanced approach that we judge to be best at the time, and accept the outcome without self-blame or recrimination. So yes, having children may risk x y z…, but then again, the things you’re risking may never materialise. And, if they do, we are all able to tolerate more than we think we can. All we can do is embrace the unpredictability of living, and trust ourselves to do the best we can. And remember that doing our best is good enough.

References

Agras, S., Hammer, L., & McNicholas, F. (1999). A prospective study of the influence of eating-disordered mothers on their children. International Journal of Eating Disorders, 25(3), 253e262. Paywall-protected journal record here.

Allen, K. L., Gibson, L. Y., McLean, N. J., Davis, E. A., & Byrne, S. M. (2014). Maternal and family factors and child eating pathology: Risk and protective relationships. Journal of Eating Disorders, 2(1), 11. Open-access full text here.

de Barse, L. M., Tharner, A., Micali, N., Jaddoe, V. V. W., Hofman, A., Verhulst, F. C., & Jansen, P. W. (2015). Does maternal history of eating disorders predict mothers' feeding practices and preschoolers' emotional eating? Appetite, 85, 1e7. Paywall-protected journal record here.

Duncan, L., Yilmaz, Z., Gaspar, H., Walters, R., Goldstein, J., Anttila, V., ... & Hinney, A. (2017). Significant locus and metabolic genetic correlations revealed in genome-wide association study of anorexia nervosa. American Journal of Psychiatry174(9), 850-858. Open-access full text here.

Easter, A., Naumann, U., Northstone, K., Schmidt, U., Treasure, J., & Micali, N. (2013). A longitudinal investigation of nutrition and dietary patterns in children of mothers with eating disorders. The Journal of Pediatrics, 163(1), 173e178. Paywall-protected journal record here.

Hoffman, E. R., Bentley, M. E., Hamer, R. M., Hodges, E. A., Ward, D. S., & Bulik, C. M. (2014). A comparison of infant and toddler feeding practices of mothers with and without histories of eating disorders. Maternal & Child Nutrition, 10(3), 360-372. Open-access full text here.

Mazzeo, S. E., Zucker, N. L., Gerke, C. K., Mitchell, K. S., & Bulik, C. M. (2005). Parenting concerns of women with histories of eating disorders. International Journal of Eating Disorders, 37, S77eS79. Direct PDF download here.

Pinheiro, A. P., Root, T., & Bulik, C. M. (2009). The genetics of anorexia nervosa: Current findings and future perspectives. International Journal of Child and Adolescent Health2(2), 153. Open-access full text here.

Sadeh-Sharvit, S., Levy-Shiff, R., Feldman, T., et al., (2015). Child feeding perceptions among mothers with eating disorders. Appetite95, 67–73. Direct PDF download here.

Stein, A., Woolley, H., Cooper, S. D., & Fairburn, C. G. (1994). An observational study of mothers with eating disorders and their infants. Journal of Child Psychology and Psychiatry, 35(4), 733e748. Paywall-protected journal record here.

Zerwas, S., Von Holle, A., Torgersen, L., Reichborn-Kjennerud, T., Stoltenberg, C., & Bulik, C. M. (2012). Maternal eating disorders and infant temperament: Findings from the Norwegian mother and child cohort study. International Journal of Eating Disorders, 45(4), 546e555. Open-access full text here.