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Children and Young People with an Eating Disorder – CARE PATHWAY

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Table of Contents

FLOW DIAGRAM

This document shows the pathway.

INFORMATION REQUIRED WHEN MAKING A REFERRAL

When making a referral to your local CAMHS team please

complete this form as well as the SPE forms. This will allow

us to better assess urgency.

DSM-IV CRITERIA FOR ANOREXIA NERVOSA

DSM-IV CRITERIA FOR BULIMIA NERVOSA

DSM-IV CRITERIA FOR EATING DISORDER NOT OTHERWISE SPECIFIED

CAMHS EATING DISORDER ASSESSMENT FORM

Used by local CAMHS teams.

TRANSITION PLANNING FOR 16 & 17 YEAR OLDS

Highlights the possible routes for 16 & 17 year olds.

WHAT YOU CAN EXPECT FROM YOUR CAMHS TEAM

Information for patients, which includes previous patients

experiences and a helpful website.

FLOW DIAGRAM

INFORMATION REQUIRED WHEN MAKING A REFERRAL

1. Eating Disorder Symptoms

- calorie restriction and preoccupation with food

- distorted body image

- fear of fatness

- excessive exercise

- purging

2. Duration of Symptoms and history of weight loss

3. Any recognised Co-Morbidity

- OCD

- depression

- Aspergers

- Anxiety

- self-harm

4. Current Weight, Height and BMI – (historical if possible)

5. Menstrual history - LMP

6. Sitting and Standing Bp and Pulse

7. Past Medical History

8. Medication History

9. Family Structure

10. Current diet and eating pattern

We would also recommend the following blood tests

Full Blood Count / Anaemia, low white cell count, ferritin
Urea & Electrolytes / Hypokalaemia from vomiting/Diuretic use
Hyponatraemia from water loading
Abnormal renal function, raised urea
Liver Function Tests / Total protein, albumin
Calcium, magnesium,
Potassium / Hypophosphataemia
Glucose / Hypoglycaemia

Children and Adolescents Requiring Acute Medical Admission

Occasionally Children and Adolescents may present with an extremely low BMI after a prolonged period of starvation and/or have biochemical disturbance after vomiting/dehydration. Below are the recommended indications for an acute Medical Admission;

1.Dehydration with ongoing fluid refusal

2.Evidence of physiological instability as indicated by;

-cold, blue peripheries

-low volume pulses, especially in the foot

-bradycardia (bpm<40)

-hypothermia

-dizziness, fainting episodes

-postural hypotension. Postural drop >10 mmHg, Bp <90/50

3.Abnormal Electrolytes; hypokalaemia, abnormal renal function, low magnesium, low phosphate

4.Cardiac dysrhythmias

5.Comorbid disease complications e.g. diabetes

6.Acute complications of starvation

-pancreatitis

-seizures

-cardiac failure

BMI alone is not an indication for admission to a medical bed.

Risk Indices of Physical Deterioration

SYSTEM / EXAMINATION / MODERATE RISK / HIGH RISK
Nutrition / BMI / <15 / <13
BMI Centiles / <3 / <2
Weight loss/week / <0.5kg / <1.0kg
Purpuric Rash / +
Circulation / Systolic Bp / <90mmHg / <80mmHg
Diastolic Bp / <60mmHg / <50mmHg
Postural Drop / >10mmHg / >20mmHg
Pulse Rate / <50bpm / <40bpm
Extremities / Dark Blue/Cold
Musculoskeletal
Squat Test / Unable to get up without
Using arms for balance / Unable to get up without using arms as leverage
Sit Test / Unable to sit up without using arms as leverage / Unable to sit up at all
Temperature / <35deg C / <34.5 deg C
Investigations / FBC, U&E, Mg, PO4, Ca, LFT, Albumin, Bicarb, Creatinine Kinase, Glucose / Concern if outside normal limits / K<2.5
Na< 130
PO4<0.5
ECG / Rate<50 / Rate<40
Prolonged QT
Interval

DSM-IV CRITERIA FOR ANOREXIA NERVOSA

Refusal to maintain body weight at or above minimally normal weight for age and height (less than 85% normal or BMI less than 17.5).
Intense fear of gaining weight or becoming fat, even though underweight.
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
In postmenarcheal females, amenorrhoea i.e. the absence of at least 3 consecutive menstrual cycles.

Specify Type

Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behaviour
Binge-eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas)

DSM-IV CRITERIA FOR BULIMIA NERVOSA

Recurrent episodes of binge eating characterised by
Eating, in a discrete period of time an amount of food that is definitely larger than most people would eat in similar period.
Sense of lack of control over eating during the episode.
Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, excessive exercise.
Self-evaluation unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa

Specify Type
Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.

DSM-IV CRITERIA FOR EATING DISORDER NOT OTHERWISE SPECIFIED

For females, all the criteria for Anorexia Nervosa are met except that the individual has regular menses.
All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual’s current weight is in the normal range.
All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.
The regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amounts of food (e.g. self-induced vomiting after the consumption of 2 cookies).
Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
Binge eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of Bulimia Nervosa.

CAMHS EATING DISORDER ASSESSMENT FORM

Name:

DOB:

Age:

Address:

School:

Year:

GP:

Referrer:

Date of Referral:

Weight at assessment
(kg)
Height
(kg)
BMI
BMI centile for age
Weight for Height
Age at menarche
Date of last period
Estimated weight loss prior to assessment

GUIDELINES FOR THE ASSESSMENT OF EATING DISORDERS

PEOPLE PRESENT:

CURRENT CONCERNS:

COURSE:

PRECIPITATING/ MAINTAINING FACTORS:

WEIGHT AND WEIGHT HISTORY

(CURRENT, PREMORBID, LOWEST, HIGHEST)

5.BODY IMAGE

MENSTRUAL HISTORY

CURRENT EATING BEHAVIOUR

Diet/Nutrition

(foods will/won’t eat, vegetarian/vegan, preferences, religion, allergies/intolerances, calorie counting, max calorie intake allowed

Typical daily food intake:

Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack:

Eating pattern

Purging behaviours

Exercise

Other

FAMILY HISTORY

PERSONAL HISTORY:

aPregnancy and Development

bEducation

cSocial/Peer Relationships

dMedical History

ePsychiatric History

10.PERSONALITY

MENTAL STATE EXAMINATION

aAppearance and Behaviour

bSpeech

cMood

dThoughts

ePerceptions

fInsight

gMotivation to Change

12PHYSICAL EXAMINATION

General Appearance

Ear Temperature

Cardiovascular Examination

Pulse:LyingBP:Lying

StandingStanding

Symptoms

Weakness/fatigue
Dizziness/faintness
Impaired concentration
Frequent sore throats
Non-focal abdo pain
Diarrhoea
Constipation
Muscle pain/cramps/weakness
Bone pain
Shortness of breath
Palpitations
Chest pain
Amenhorroea
Cold intolerance
Cold extremities
Hair loss

Tests (tick if done)

U&Es

FBC

TFT

LFT

Calcium

Phosphate

Magnesium

Glucose

ECG 

Bone Density Scan

Pelvic ultrasound

Other

Consider inpatient treatment if:

Weight  75% ideal body weight

BMI  2nd centile

Rapid weight loss

Food refusal

Out patient treatment failure

Signs of dehydration

Pulse  50 bpm or  110 bpm

Orthostatic changes 20 mm Hg or 20 bpm

Squat test positive

Hypolkalaemia  3.0

Electrolyte imbalance, low alb, low gluc

Hypophosphataemia

ECG abnormality

Suicidal

Poor motivation to recover

Comorbid psychiatric disorder requiring

admission

Severe family problems

Supervision required

Other environmental stressor

13SUMMARY AND DIAGNOSIS

14MANAGEMENT PLAN

Medical Review

Individual Therapy

Family Therapy

Physical Investigations

Referral to other services:

15INFORMATION GIVEN:

TRANSITION PLANNING FOR 16 & 17 YEAR OLDS

The needs of the young person are paramount, there is an agreed care pathway for 16 and 17 year olds, which stipulates:

The main principles underpinning this pathway are:

The service provided should be based on that which best meets the needs of the young person
The young person (and their carer(s), if appropriate), should be involved in the choice of service(s)
Effective communication and relationships are at the heart of robust care pathways, particularly at points of change or transition of services
CAMHS and AMHS should provide advice, support and signposting to for the provision of services to 16 and 17 year olds
Where AMH/CAMHS identify a need for a joint assessment or joint working, both services will actively participate in the process.
Although referrers should be provided with guidance on effective referring for this cohort, a referral to any mental health service should enable access to all options in the care pathway, both at the point of referral, and at any subsequent point in the care pathway

*A Care Pathway for young people aged 16 and 17 in need of specialist mental health services, 2007

AWP, UBH and NBT. (hyper link to 16-17yr old care pathway)

Some Young People may well attend University or choose to be discharged to the care of their own General Practitioner. The same above communication and care planning principles should apply.

WHAT YOU CAN EXPECT FROM YOUR CAMHS TEAM

Family involvement can make a difference in helping a child or adolescent recover from an eating disorder. Involving the family acknowledges that children and young people live within the context of a family rather than in isolation. We aim to include the family as a resource in treatment.

Initially we will offer assessment appointments to establish the severity and type of eating disorder. The treatment offered will be dependent on the outcome of these appointments. In most cases we would seek to offer the following.

Individual Therapy, for the young person.
Monitoring of physical health.
Family therapy.
Review appointments.

Some families feel desperate when attempting to find professional help for their child. They are trying to figure out the health care system related to eating disorders and secure what services are available. This search is often fraught with fear, helplessness, guilt, self-blame, and ambivalence. By offering the above approach we seek to support the young person becoming well again in order to fully engage with their life, hopefully achieving their full potential.

Our experience has shown that a young person’s family is a key resource to them becoming well again. We are not seeking to attach any blame to the family; our goal is to fully utilize the strengths within each unique family as an aide to their child’s recovery.

*This approach is based on current evidenced based research and any clinician will be happy to discuss this further with you at any of your appointments.

Patient Comments on the initial appointments.

“Initial engagement was a bit overwhelming and very frightening at times”,

“Questions always fully answered”

“Good information on what the service can provide”

Patient comments on family therapy

“Being observed at first for the family sessions seemed confusing and left me feeling scared. This was probably because (child) was very ill at the time. Subsequently things became more stable”

“it was helpful and it did change how we interacted as a family which was one of the triggers for xx’s illness”

Patient comments on Individual Therapy

“The psychologist sessions went well for my daughter – it helped her to open up”

“They helped me recognise that I had a problem eating and then helped me find solutions”

“The best sessions for her (daughter) were with the dietician and she felt she could really open up and ask questions about various foods, carbohydrates etc a lot of her fears were put aside after these sessions. And she was able to gain a much more balanced approach to food and sport. It would have been more helpful if a dietician had been available earlier on”

General Comments

“Listened to, my feelings mattered”

“I felt very much understood and supported from beginning to the end, it was wonderful knowing that I could phone for advice and help, whenever I needed it. Staff were all very approachable”.

“All staff were really lovely and very supportive of xxxx and us as parents always came away feeling we could fight another day”

“We were incredibly impressed by the amount of attention and the with seriousness with which they took us, feel that that they really listen to us – and accept what we are saying”

“Feel that the service is giving us what we need. Xx has been absolutely brilliant, huge amount of support – whenever we needed it – made it clear that they were taking it very seriously which is great in itself. Always been there when we have needed them if phoned up either got straight through or phoned back that day. Always felt backed up and supported. Would have felt that if we had had another crisis we could have contacted them and someone would have been there to talk to”

“You may not see an instant cure but if we hadn’t have had CAMHS…..marriage probably would have broken up and there is the consequences of that if you look at the impact of families falling apart – really was a life saver and I think eventually they will get better but you can’t say well it is that specific treatment”

“blame - I have read enough now to know that they may never know what the cause is and triggers – because you go in thinking they are going to look at me an say it is something I’ve done and that is part of the assessment – need reassurance that it may be nothing you’ve done and not to blame yourself – don’t beat yourself and feel guilty, which won’t stop us feeling it, but the affirmation that they don’t know because they don’t would help”

“Would help if faith issues were taken into account – counselling tweaked to accommodate this. Ask the right questions – taking faith into account. How they might best deal with the problem from their perspective and use this therapeutically. e.g. marriage counselling with evangelical Christians – divorce wrong so warrants a different conversation – or requirement to forgive in context of sexual abuse - finding out from someone’s faith perspective how it would be possible to deal with their problem”

Drafted By a Clinician & Patient May 2011

Useful web sites

Created 2011

Reviewed November 2012