Treatment of Eating Disorders in Young People

I used to work in a CAMHS eating disorder service with a team of nurses and family therapists. I learnt a lot during my time there and I thought I would share some of it with you.

NOTE: This information should not substitute accessing treatment. Each case is unique and requires specialist intervention.

Diagnosis:

Anorexia Nervosa:

Persistent restriction of dietary intake leading to significant low weight (in context of what is expected for age, height and gender).
Either an intense fear of weight gain/becoming fat or persistent behaviour that interferes with gain.
Disturbed experience of weight/shape, undue influence of weight/shape on self-evaluation or lack recognition of the seriousness of their low weight

Complications of AN

Bulimia Nervosa:

Recurrent binges: eating an unusually large amount of food in a discrete period of time and a sense of lack of control over eating during the episode.
Recurrent inappropriate compensatory behaviour or purging in order to prevent weight gain.
Binge/purge both occur on average at least once a week for 3 months.
Undue influence of weight/shape on self-evaluation.

Complications of BN

To be diagnosed with an eating disorder the young person needed to have both the cognitive and behavioural elements of the condition and the they would needed to rule out other possible causes, such as autism or anxiety.

Treatment approach:

At the time, we used the New Maudsley Method, which was developed by Janet Treasure. You can find her book (written for parents) here. This approach involved supporting the parents in refeeding their child. Parents were educated about eating disorders (including all the tips and tricks sufferers will resort to), how to put in place boundaries regarding mealtimes and how to address any maintaining factors such as family dynamics. We stressed that the parents were experts on their own families and supported them in finding their own solutions where possible.

This would be done using family therapy sessions, preferably with the whole family attending, and sometimes also parent groups. In family therapy sessions we would sometimes ask them to bring in lunch so that we could observe how they interacted at meal times and give some helpful observations.

Managing meals:

We advised families to eat together at the table. Everyone should have the same meal and the young person should be given an appropriate portion size for their age. Usually parents know how to feed their child, as they have been doing so for many years before the eating disorder, and therefore don’t require input from a dietician.

We occasionally gave them a worksheet to help them plan their meals.

Meal planner

If the young person has been eating less than 500 calories a day for an extended period then they may be at risk of refeeding syndrome, which is a potentially fatal condition. They would therefore need to gradually increase their intake by 200 calories a day.

It should be made clear that the young person is expected to finish everything on their plate and will not be allowed to leave the table until they have done so.

If the young person tries to negotiate then parents should try to avoid being dragged into an argument and instead must continue to state simple encouragements like ‘I understand it is difficult and you need to finish what’s on your plate’. It will often seem monotonous and can take hours but it is really important to stick with it. Parents will need to work together and make sure they are being consistent even when the young person tries to split them.

Supporting a young person to eat when the eating disorder is telling them not to is very stressful and it may feel cruel at times. It is important to remember that you are saving your child’s life and you are fighting against the eating disorder, not them. When they tell you they hate you or lie to you, it’s generally the influence of the eating disorder. They are acting out of sheer desperation.

Parents should take their child to the GP regularly so their physical health can be monitored. They will generally need weekly weigh-ins, blood pressure monitored (sitting and standing) and blood tests.

It’s important to note that BMI is not an accurate measure in under 18 year olds as they are still developing. We therefore used a measure called Weight for Height, which compares the young person’s weight and height against the normal distribution of other young people of the same age and gender.

Risk managment:

We also provided parents with a rough guide for managing risks:

ED Risk Management

Parenting styles:

Janet Treasure identified six of the most common parenting styles (see below). Ideally parents should aim for the St Bernard emotional response and the Dolphin behavioural response, so that they can calmly guide and support their young person.

PARENT CARING STYLES

Individual therapy:

Once the young person had gained enough weight that they were no longer cognitively impaired, we could also offer one-to-one sessions. I would generally start with Motivational Interviewing, to help motivate the young person towards making changes regarding their eating. More details of this method can be found here.

Once the young person is showing signs of being motivated towards change, we can then start doing some sessions of CBT to help them challenge some of the eating disorder thoughts. We would also then start doing behavioural experiments where we test out some of their assumptions. Details of these approaches can be found here.

Grading foods:

We would start to gradually introduce foods that the young person has cut out. This may involve grading the foods:

GRADING FOODS

I often used the tree of life project with young people towards the end of their treatment, to help them develop a sense of identity separate from the eating disorder. Occasionally they were also taught new skills like poi and juggling so that the focus wasn’t entirely on their eating and they could start rebuilding interests and hobbies. A lot of these activities are also great ways of practising mindfulness.

I remember being surprised that the treatment model involved refeeding before individual therapy. It seemed backwards to expect someone to eat before changing their distorted thoughts. It seemed cruel but it was necessary as often people who are very underweight don’t have the cognitive ability to engage in therapy and are at such a dangerous weight that restoration needs to be prioritised. There’s no time for talking therapies if they’re on the verge of being admitted to hospital.

I’ve seen many cases of eating disorders and I know that generally this method is very effective and it has been supported by research. On a few occasions the young person became too unwell and need to either be admitted to an inpatient unit or a day service, where they were supported to eat or provided with group sessions like art therapy, self-esteem work, etc.

Resources:

Books:

Skills-based Learning for Caring for a Loved One with an ED: New Maudsley Method: Janet Treasure, Grainne Smith, Anna Crane

Help your Teenager Beat an Eating Disorder by James Lock and Daniel Le Grange

Anorexia and Bulimia in the Family by Grainne Smith
Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers by Janet Treasure.

Can I tell you about Eating Disorders: A guide for family, friends and professionals. By Bryan Lask and Lucy Watson

Websites:

www.eas-ed.co.uk
Website run by the parents of some of our recovered patients

http://instagram.com/facerecovery#
Instagram account run by some of our recovered patients

www.maudsleyparents.org

www.b-eat.co.uk

www.feast-ed.org