Tips for CYP feeding or eating disorders

• The restriction of eating gives a temporary impression of being in control, but this leads to ill health, so it is maladaptive
• For some children and young people these behaviours as well as bingeing and other compensatory behaviours are an attempt at managing emotions arising from uncertainty or any other difficult feelings
• Many of the behaviours typical of feeding or eating disorders can bring a sense of relief or safety in the short term, but can then take on a life of their own, superseding the original ‘benefits’ for the person
• When the illness takes over, a young person loses control over the illness behaviours
• However, each of the seven main feeding and eating disorders has its own psychology and course
• For example, in anorexia nervosa the negative spiral of eating disorder behaviours is accelerated by the impact of starvation and deficient body nutrition on the brainA rigidity can set in. It can seem like an ‘addiction’ and relationships can suffer. For example, avoidance of eating together or distress responses around food, all impact family relationships

• People with anorexia nervosa feel more agitated after eating and calmer when they don’t eat
• People who binge experience the calming when binging, but distress returns afterwards

• Be aware that mental capacity (in terms of the Mental Capacity Act) may be intact for other issues, BUT thinking and hence mental capacity may be severely impaired for the eating disorder related issues

• For example, when the eating disturbances are related to particular thoughts/cognitions might differ from treatment when it is sensations/sensory experiences linked to food and are driving the food avoidance

• Everyone involved in their care to communicate with each other, respecting appropriate agreements for confidentiality and information sharing
• To be listened to, their views to be heard and wishes taken into account
• Treatment to be based on the possibility of recovery
• Professionals and family/carers not to give up on them
• Access to skilled professionals in the community, who have expertise in feeding or eating disorders and understand wider mental health issues (mood, anxiety, etc.) and how this interacts with food and eating
• Treatment to be collaborative with young people and families involved in setting up their care plan and treatment goals
• If the young person needs inpatient treatment, for their community team to remain involved in their care throughout and help seamless transition back home
• Possibility of self-referral to dedicated community eating disorder services or other appropriate services
• Advice and support available for their family and carers own mental health and wellbeing needs

• That the child or young person’s family is an integral part of the treatment
• That family strengths are mobilised, building collaboration towards finding solutions together
• For older young people, that family involvement is subject to appropriate consents being in place

• Usually consists of 18-20 sessions over a one-year period
• Aims to help parents/carers support young person’s meals in initial phases of treatment Later the young person regains their age-appropriate autonomy in eating
  • The therapist should make it clear that ensuring the patient's health and safety must come first, and that AN is too serious a disorder not to be urgently treated
  • The therapist should support the family to feel safe and secure in the collaborative agreement on how to manage eating disorder behaviour

• Typically consist of 18 to 20 sessions over 6 months
• A good therapeutic relationship with the person and their family members or carers is key and supports collaboration of effort between family members and the young person
• Do not blame the person, their family members or carers
• Provide information about:
  • regulating body weight
  • dieting
  • the adverse effects of attempting to control weight with self-induced vomiting, laxatives or other compensatory behaviours
  • the ineffectiveness of vomiting or abusing laxatives as a strategy to lose weight

• Which typically consists of 18 sessions over 6 months, may include additional sessions with parents or carers

• Needs to target the main factors underlying and maintaining the eating disturbance – these may vary between individuals
• The primary treatment modality will be a form of psychological intervention aimed at changing eating behaviour
• Most promising psychological interventions include adapted cognitive behavioural approaches, behavioural techniques, and adapted family-based interventions for eating disorders
• Alongside the appropriate psychological intervention, treatment also needs to include medical and dietetic monitoring and management
• ARFID treatment therefore requires multi-disciplinary, multi-modal input

• Treatment for BED focuses on regular eating with reduction of binge eating. This may prevent further weight gain but does not necessarily result in weight loss.
• NICE guidance recommends guided self-help as step 1 in treatment
• If self-help is ineffective, CBT and medication can both be considered.

• Young people who also have mood or anxiety problems may require medication as per the relevant NICE guidelines

• Reasonable and appropriate adaptations are required for those with vulnerabilities and additional needs
• This includes autistic children and young people, those children and young people with learning disability, and in line with equality, diversity and inclusion principles

• Each young person will have different factors that help them work towards recovery. These ‘motivators of recovery’ may include:
  1. wanting to feel better physically
  2. return to leisure activities
  3. get back to school
  4. spend more time with friends and many more 

• The therapist needs to understand them in order to help the young person with these difficulties

• Stabilise physical state, address acute nutritional deficits, engage, and provide knowledge-psychoeducation
• Explain the nature of the condition
• Highlight its impact on the brain, body and mind
• Work to help everyone to see the child or young person as separate from the condition

• Address young person’s need to feel safe, feel in control, and their emotional management strategies that can include eating disordered behaviours to cope with anxiety and distress
• Be mindful that denial is common and may be linked to shame, guilt or even terror of consequences of making changes. Find ways to overcome this collaboratively
• Address impacts of the condition on relationships
• Help the young person to manage eating and eating habits that have become the core of their daily living in a way that is outside the normal population range
• Keep in mind that interventions or management should be based on holistic person-centred formulation, not a single issue like weight or ‘diagnosis’

• particularly between services
• and across services separated by age bands

• Review treatment progress regularly
• Use standard symptom scales, impairment scales, patient and family feedback on progress and agreed goals of intervention
• Use appropriate standard outcome measures such as the EDE-Q for AN and BN, the PARDI-AR-Q, for ARFID.
• Intervention goals should be regularly reviewed

• In 2022, Medical Emergencies in Eating Disorders (MEEDs) replaced Junior MARSIPAN-Management of Really Sick Patients under 18 with Anorexia Nervosa

• When prescribing for children and young people with an eating disorder, professionals need to consider the impact of malnutrition and purging or related behaviours on the effectiveness of medication
• Medication can play a useful adjunctive role in the management of eating disorders for a range of reasons, especially for comorbid disorders like depression and/or anxiety disorder
• However, medication should not be used in isolation, but as part of a holistic management plan
• In severe adolescent anorexia nervosa, Olanzapine has been used, especially early in treatment, to help with extreme anxiety, making it easier to adhere to the meal plan. Use the lowest dose possible because of the risk of physical complications.
• Consider the risk of the side-effects in physically compromised young people
• ECG monitoring needs to be offered to young people with an eating disorder where medication can compromise cardiac function, for example, those with bradycardia below 40 bpm, hypokalaemia or a prolonged QT interval
• Young people with inadequate diet leading to malnutrition should be encouraged to take an age-appropriate oral multivitamin and multi mineral supplement until their diet meets daily dietary reference values
• Oral or transdermal oestrogen therapy should NOT be routinely offered to treat low bone mineral density in children or young people with AN, the focus instead should be on assisting the return of age-appropriate eating habits and weight gain through psychological interventions

• Effective liaison and coordinated care are critical
• In cases of emergency, the eating disorder service should be contacted to provide support within 24 hours
• If a number of services are involved simultaneously then clear communication and a shared care plan needs to be in place outlining responsibility of each service to deliver their part of the care plan
• Care needs to be multidisciplinary and coordinated. An eating disorder service team is likely to include clinical psychologists, dietitians, family therapists, nurses, paediatricians, psychiatrists and administrators

• A ‘public health approach’ to eating disorders is recommended in all aspects of data collection, training, academic funding and service delivery
• Eating disorders should be a central consideration to public health policy on obesity and mental health
• General rebalancing of provision, from a focus on inpatient services to expansion of community-based services to access treatment earlier, and closer to home
• Comprehensive person-centred holistic care plans (NICE QS 1) should be in place
• Dedicated, community-based eating-disorder services have been shown to improve outcomes and cost-effectiveness
• Services have best outcomes when they are based on continuous improvement- drawing on best evidence, open to participation of experts by experience, and learning from outcomes
• Avoid commissioning for severity in isolation as it mitigates against necessary early intervention in eating disorders
• Prevention programmes are more effective if they are multi-session, interactive and delivered to young people at high-risk of developing an eating disorder
• For eating disorder care (this does not preclude need for admission for physical care needs) clinicians should keep in mind that there is no evidence that inpatient treatment has any advantages over providing treatment in the community.

• BEAT Tips Poster
• BEAT leaftlet: Seeking treatment for an eating disorder? The first step is a GP appointment.
• BEAT carers booklet: Eating disorders: a guide for friends and family
• Type 1 diabetes with an eating disorder: more information
• BEAT elearning for nurses (for all ages, not child and young person specific - Each of the 3 sessions will take around 30 to 60 minutes to complete and includes additional learning resources for those looking to further increase their knowledge. To access the elearning in the elfh Hub directly, please visit the links below.
  • Screening and Assessments
  • The Impact of Starvation
  • Sensitive Communication

RCPCH BMI Centile Charts  

Junior Marsipan App for median BMI

Body mass index cut offs to define thinness in children and adolescents: international survey

• Medical Emergencies in Eating Disorders (MEED). Guidance on recognition and management. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Annexe 1: Summary sheets for assessing and managing patients with severe eating disorders. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Medical Emergencies in Eating Disorders. Annexe 2: What our National Survey found about local implementation of MARSIPAN recommendations. RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)
  • Guidance on Recognising and Managing Medical Emergencies in Eating Disorders. Annexe 3: Type 1 diabetes and eating disorders (TIDE). RCPsych College Report CR233, May 2022. (Replacing MARSIPAN and Junior MARSIPAN)

• Eating Disorders: Recognition and Treatment NICE Guideline (NG69) 2020
• Access and Waiting Time Standard for Children and Young People with an Eating Disorder: Commissioning Guide, particularly in relation to managing transitions between services 2015
• Eating Disorders Quality Standard (QS175) 2018
• NHS England children and young people’s eating disorders programme 2019

• Ignoring the alarms: How NHS eating disorder services are failing patients. Presented to Parliament pursuant to Section 14(4) of the Health Service Commissioners Act 1993, Ordered by the House of Commons to be printed on 6 December 2017.

• Eating Disorders from the Inside Out: Laura Hill at TEDxColumbus

From MindEd session Eating Disorders: Further Information for Professionals:

• Talk ED
• Beat (beating eating disorders)
• Eva Musby youtube videos for parents/carers with young people with anorexia nervosa 
• Faculty of Eating Disorders Royal College of Psychiatrists
• F.E.A.S.T. (Families Empowered and Supporting Treatment of Eating Disorders)
• National Institute for Health and Care Excellence guidance for Eating disorders: recognition and treatment

1. Bould H, De Stavola B, Lewis G, Micali N. Do disordered eating behaviours in girls vary by school characteristics? A UK cohort study. Eur Child Adolesc Psychiatry 2018; 27: 1473–81.
2. Byford S, Petkova H, Stuart R, Nicholls D, Simic M, Ford T, Macdonald G, Gowers S, Roberts S, Barrett B, Kelly J, Kelly G, Livingstone N, Joshi K, Smith H, Eisler I. Alternative community-based models of care for young people with anorexia nervosa: the CostED national surveillance study. Southampton (UK): NIHR Journals Library; 2019.
3. House J, Schmidt U, Craig M et al. Comparison of specialist and non-specialist care pathways for adolescents with anorexia nervosa and related eating disorders. Int J Eat Disord 2012;45:949-956
4. McClelland, J., Simic, M., Schmidt, U., Koskina, A., & Stewart, C. (2020). Defining and predicting service utilisation in young adulthood following childhood treatment of an eating disorder. BJPsych Open, 6(3), E37
5. Neale J, Pais SMA, Nicholls D, Chapman S, Hudson LD. What Are the Effects of Restrictive Eating Disorders on Growth and Puberty and Are Effects Permanent? A Systematic Review and Meta-Analysis.J Adolesc Health. 2019 Nov 23. doi: 10.1016/j.jadohealth.2019.08.032.
6. NICE guideline (NG69) 2017. Eating Disorders; recognition and treatments. 
7. Nicholls D, Becker A. Food for Thought: Bringing Eating Disorders out of the shadows. BJPsych 2019 Jul 26:1-2.
8. Petkova H, Ford T, Nicholls D, Stuart R, Livingstone N, Kelly G, Simic M, Eisler I, Gowers S, Macdonald G, Barrett B, Byford S. Incidence of anorexia nervosa in young people in the UK and Ireland: a national surveillance study. BMJ Open 2019; BMJ Open 2019 Oct 22;9(10)
9. Simic, M., Stewart, C.S., Konstantellou, A. et al. From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (part 1)—treatment course and outcomes. J Eat Disord 10, 27 (2022) 
10. Stewart, C.S., Baudinet, J., Munuve, A. et al. From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (Part 2): 7-year follow-up. J Eat Disord 10, 14 (2022)

1) Eating Disorders in Young People

Description: For General Health CYP Entry Level Audience (5-18 yrs)

This session gives an overview of the nature, aetiology and risk factors linked to eating disorders. Also covered are the diagnostic elements that allow us to distinguish between eating disorders and other conditions affecting the eating behaviour of young people.

Author(s):

Dasha Nicholls 

2) Eating Disorders; Anorexia and Bulimia

Description: For Specialist Mental Health CYP Health Entry Level Audience (5-18 yrs)

This session is aimed at more experienced/specialist users and outlines the diagnostic criteria and non-specific risk factors for eating disorders that most often start in childhood and adolescence. The eating disorders most frequently seen by mental health professionals, for example, anorexia nervosa, are explained in more detail. Treatment interventions and treatment outcomes for anorexia nervosa and bulimia nervosa will be discussed, with particular emphasis given to the key family therapy interventions for anorexia nervosa.

Author(s):

Mima Simic 

3) Feeding Difficulties

Description: For wider general health audience (0-5 yrs olds)

This session describes the normal developmental progress of children from birth to five; from breast/bottle to eating independently and the difficulties encountered by parents during this developmental process.

Author(s):

Judy More 

4) Eating Disorders

Description: For Families/parents/carers, Universal Audience (about CYP 5-18 yrs)

This session gives parents basic information and advice about the eating disorders: anorexia nervosa, bulimia nervosa, binge eating and similar behaviour, that do not usually meet threshold criteria. It is not intended to address childhood obesity or infant eating difficulties. 

Author(s):

Brian Jacobs  
Mima Simic 

5) Eating Disorders (CT): Families and Professionals

Description: Specialist CYP mental health entry level (5-18 yrs)

This session describes Community Eating Disorder Services for Children and Young people (CEDS-CYP) and the importance of accessing the right support for these disorders early. It explains the physical risks and psychological aspects of eating disorders and the multi-disciplinary nature of CEDS-CYP. It highlights the importance of engaging the young person in treatment and the role of the family in this. The session also outlines psychological and medical treatments, the need to attend to the often co-occurring psychiatric conditions and the use of medication. 

Authors:

Mima Simic,

Rachel Bryant-Waugh

6) Eating Disorders (CT): Further Information for Professionals

Description: Specialist CYP mental health entry level (5-18 yrs)

This session will provide a background to Community Eating Disorder Services for Children and Young People (CEDS-CYP) and the assessment and treatment of eating disorders. It will cover psychological treatments, appropriate use of medication and co-occurring conditions. 

Authors:

Mima Simic,

Rachel Bryant-Waugh

Eating disorders training for health and care staff

This suite of training was developed in response to the Parliamentary and Health Service Ombudsman (PHSO) investigation into avoidable deaths from eating disorders, as outlined in recommendations from the report titled Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients(PHSO, 2017).

It is designed to ensure that health and care staff are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. It is the result of collaboration between eating disorder charity Beat and Health Education England with key partners.

Eating disorders training for medical students and foundation doctors

This eating disorders training is designed for medical students and foundation doctors. The two sessions will take around 20-30 minutes to complete and includes additional learning resources for those looking to further increase their knowledge. The sessions also provide good preparation for those who go on to participate in medical simulation training on eating disorders.

• Signs, Symptoms and Causes
• Practical Requirements

Eating disorders training for nurses

This eating disorders training is designed for the nursing workforce. Each of the 3 sessions will take around 30 to 60 minutes to complete and includes additional learning resources for those looking to further increase their knowledge.

• Screening and Assessments
• The Impact of Starvation
• Sensitive Communication

Eating disorders training for GPs and Primary care workforce

This eating disorders learning package is designed for GPs and other Primary Care clinicians. The two sessions will take around 30-40 minutes each to complete and includes additional learning resources for those looking to further increase their knowledge. 

• GPs and Primary Care: Understanding Eating Disorders
• GPs and Primary Care: Assessing for Eating Disorders

Medical Monitoring in Eating Disorders learning for all healthcare staff who are involved in the physical assessment and monitoring of eating disorders

The eating disorders learning package for Medical Monitoring is designed for primary care teams, eating disorder teams or other teams who are monitoring the physical parameters of a person with an eating disorder. The session will take around 30 minutes to complete and includes additional learning resources for those looking to further increase their knowledge.

• Medical Monitoring in Eating Disorders