Tips for CYP feeding or eating disorders
Who is this for?
These tips have been developed for professionals working across health care; from primary and universal care, to hospital general paediatric services through to specialist Child and Young People Mental Health Services (CYPMHS).
Treatment of feeding or eating disorders is a collaborative process; with the child or young person and their family/carers, not treatment of the family and carers. In this, the fourth of our five tip sheets, we provide top tips on what to do for children and young people with feeding or eating disorders. This is not a therapy manual or therapy guide, it’s tips and help to guide you on the journey.
Collaboration is key. In the early phase of treatment this may be especially challenging. The child or young person may have distortions in their thinking regarding their weight or shape, may be very wary of seeking help, or may doubt their own capacity to make changes.
Early intervention is key, and earlier access to eating disorder multidisciplinary expertise leads to better outcomes.
Treatment and care
Onset of eating disorders can be linked to coping with uncertainty: the young person can feel as if they are gaining an element of control
Normal emotional responses to eating can get reversed in some of the disorders but not all
- 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
The illness may be masked by apparent clear thinking outside of the eating disorder issue
- 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
Resumption of adequate food intake is a key first step in treatment of anorexia nervosa
Establishing regular eating is key for successful outcome of the bulimia nervosa treatment
Avoidant/Restrictive Food Intake Disorder-ARFID- understand what is driving, maintaining the eating disturbance to inform future treatment
- 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
What do young people want in their treatment?
- 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
Family therapy focused on anorexia nervosa (FT-AN) is the best evidenced treatment for anorexia nervosa
Family therapy focused on bulimia nervosa (FT-BN) and/or FT-BN cognitive behavioural therapy (CBT) is best evidenced-based treatment for bulimia nervosa
NICE guidance recommends
- 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
Family therapy for children and young people with anorexia nervosa (AN)
- 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
Bulimia nervosa-focused family therapy (FT-BN) for children and young people with bulimia nervosa (BN)
- 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
- 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
If FT-BN is unacceptable or ineffective, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- 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
Binge eating disorder (BED) treatment
- 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.
Anxiety and depression often occur with eating disorders and may need additional treatment
- Young people who also have mood or anxiety problems may require medication as per the relevant NICE guidelines
Make reasonable and appropriate adaptations for autistic children and young people, and those with learning disability
- 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
What helps to engage a young person in treatment?
- Each young person will have different factors that help them work towards recovery. These ‘motivators of recovery’ may include:
- wanting to feel better physically
- return to leisure activities
- get back to school
- spend more time with friends and many more
Be aware, young people also have a range of thoughts, feelings or behaviours that may be experienced as obstacles to recovery
- The therapist needs to understand them in order to help the young person with these difficulties
Key psychological factors to be addressed in treatments
- 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’
Managed transitions are critical for good care
- particularly between services
- and across services separated by age bands
Use treatment outcome measurement tools
- 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
Medical emergencies can arise in eating disorders. Use the national guidance on Medical Emergencies in Eating Disorders (MEED)
- In 2022, Medical Emergencies in Eating Disorders (MEEDs) replaced Junior MARSIPAN-Management of Really Sick Patients under 18 with Anorexia Nervosa
Medication in eating disorders and vitamin supplements
- 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
Service Delivery and Models of Care
- 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
Wider system levers, drivers and policy
- 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, HEE, RCPsych
- 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.
Centile Charts and BMI
Medical Emergencies in Eating Disorders (MEED)
- 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)
NHSEI, NICE, NCCMH
- 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
Parliamentary Health Services Ombudsman Report 2017 Eating Disorders
Other useful resources
- 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
- 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.
- 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.
- 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
- 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
- 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.
- NICE guideline (NG69) 2017. Eating Disorders; recognition and treatments.
- Nicholls D, Becker A. Food for Thought: Bringing Eating Disorders out of the shadows. BJPsych 2019 Jul 26:1-2.
- 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)
- 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)
- 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)
Children and Young People - MindEd resources
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.
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.
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.
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.
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.
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.
All ages - NHS HEE TEL Resources
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.
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.
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.
These tips have been curated, drawn and adapted from a range of existing learning, including MindEd, NHSei, NICE, MMEEDs guidance, NHS HEE elfh/BEAT/RCPsych resources. Extracts from the MMEEDs are included with permission courtesy of the MMEEDs team.
The content has been edited by Dr Mima Simic (MindEd CYP Eating Disorder Editor and Dr Raphael Kelvin MindEd Consortium Clinical Lead) with close support of the inner expert group of Prof Ivan Eisler, Dr Dasha Nicholls, Dr Rachel Bryant Waugh and Dr Simon Chapman
A wider expert reference groups include BEAT (Kathrina Dixon-Ward, Martha Williams, Brooke Sharp), Dr Elaine Lockhart (RCPsych Child and Adolescent Faculty Executive chair), Gemma Trainor (MindEd Consortium RCN lead rep), Prof Ulrike Schmidt (Professor SLAM/KCL and MindEd Editor) Dr Lisa Shostack (MindEd Consortium BPS Lead Rep).
This document provides general information and discussions about health and related subjects. The information and other content provided in this document, or in any linked materials, are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment.
If you or any other person has a medical concern, you should consult with your healthcare provider or seek other professional medical treatment. Never disregard professional medical advice or delay in seeking it because of something that you have read in this document or in any linked materials. If you think you may have an emergency, call an appropriate source of help and support such as your doctor or emergency services immediately.
MindEd is created by a group of organisations and is funded by NHS England, the Department of Health and Social Care and the Department for Education.
© 2023 NHS England, MindEd Programme