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Children and Young People with an Eating Disorder – CARE PATHWAY

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Table of Contents

FLOW DIAGRAM 2This document shows the pathway.

INFORMATION REQUIRED WHEN MAKING A REFERRAL 3When making a referral to your local CAMHS team pleasecomplete this form as well as the SPE forms. This will allowus to better assess urgency.

DSM-IV CRITERIA FOR ANOREXIA NERVOSA 5DSM-IV CRITERIA FOR BULIMIA NERVOSA 5DSM-IV CRITERIA FOR EATING DISORDER NOT OTHERWISE SPECIFIED 5

CAMHS EATING DISORDER ASSESSMENT FORM 6Used by local CAMHS teams.

TRANSITION PLANNING FOR 16 & 17 YEAR OLDS 16Highlights the possible routes for 16 & 17 year olds.

WHAT YOU CAN EXPECT FROM YOUR CAMHS TEAM 17Information for patients, which includes previous patientsexperiences and a helpful website.

Created 2011 Reviewed November 2012

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FLOW DIAGRAM


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Concerned that a young person may

have an eating disorder

Referral to CAMHS

Meets referral criteria and includes specific additional referral information

Formal Eating DisorderNO YES

Partnership appointment

Discharge

Case HolderAppointed

Physical Medical Checks

Low Risk Medium Risk High Risk (Increase in

Treatment freq

Individual Therapy

Family Therapy

Medical monitoring

Urgent Referral Required

Transition Planning

Paediatric/Adult Ward

Riverside

STEPS

Adult Mental Health Team

If over 18 or 17.5 years

SpecialistTreatment

Review

Urgent Choice appt Choice appointment

Return to referrer with advice & offer of telephone consultation

NO

Telephone to discuss with CAMHS team

Discharge or Sign post to appropriate service

NICE GUIDELINES

Patient Information What to expect

DischargeFrom

Service


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 loss3. Any recognised Co-Morbidity

- OCD - depression- Aspergers- Anxiety- self-harm

4. Current Weight, Height and BMI – (historical if possible)5. Menstrual history - LMP6. Sitting and Standing Bp and Pulse7. Past Medical History8. Medication History9. Family Structure10. Current diet and eating pattern

We would also recommend the following blood tests

Full Blood Count Anaemia, low white cell count, ferritinUrea & Electrolytes Hypokalaemia from vomiting/Diuretic use

Hyponatraemia from water loadingAbnormal renal function, raised urea

Liver Function Tests Total protein, albuminCalcium, 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 refusal2. Evidence of physiological instability as indicated by;

- cold, blue peripheries- low volume pulses, especially in the foot- bradycardia (bpm<40)


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- 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 dysrhythmias5. Comorbid disease complications e.g. diabetes6. 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 RISKNutrition BMI <15 <13

BMI Centiles <3 <2Weight loss/week <0.5kg <1.0kgPurpuric Rash +

Circulation Systolic Bp <90mmHg <80mmHgDiastolic Bp <60mmHg <50mmHgPostural Drop >10mmHg >20mmHgPulse Rate <50bpm <40bpmExtremities Dark Blue/Cold

MusculoskeletalSquat Test

Unable to get up withoutUsing 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 CInvestigations FBC, U&E, Mg, PO4, Ca,

LFT, Albumin, Bicarb, Creatinine Kinase, Glucose

Concern if outside normal limits

K<2.5Na< 130PO4<0.5

ECG Rate<50 Rate<40Prolonged QTInterval


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DSM-IV CRITERIA FOR ANOREXIA NERVOSA

A. 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).

B. Intense fear of gaining weight or becoming fat, even though underweight.C. 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.

D. 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 NERVOSAA. 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.

B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, excessive exercise.

C. Self-evaluation unduly influenced by body shape and weight.D. The disturbance does not occur exclusively during episodes of anorexia nervosa

Specify TypePurging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemasNonpurging 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 SPECIFIED1. For females, all the criteria for Anorexia Nervosa are met except that the

individual has regular menses.2. 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.3. 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.

4. 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).

5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.6. Binge eating disorder: recurrent episodes of binge eating in the absence of the

regular use of inappropriate compensatory behaviours characteristic of Bulimia Nervosa.


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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


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GUIDELINES FOR THE ASSESSMENT OF EATING DISORDERS

PEOPLE PRESENT:

1. CURRENT CONCERNS:

2. COURSE:

3. PRECIPITATING/ MAINTAINING FACTORS:


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4. WEIGHT AND WEIGHT HISTORY(CURRENT, PREMORBID, LOWEST, HIGHEST)

5. BODY IMAGE

6. MENSTRUAL HISTORY


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7. 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


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Purging behaviours

Exercise

Other

8. FAMILY HISTORY


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9. PERSONAL HISTORY:

a Pregnancy and Development

b Education

c Social/Peer Relationships

d Medical History

e Psychiatric History


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10. PERSONALITY

11.MENTAL STATE EXAMINATION

a Appearance and Behaviour

b Speech

c Mood

d Thoughts

e Perceptions

f Insight

g Motivation to Change


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12 PHYSICAL EXAMINATION

General Appearance

Ear Temperature

Cardiovascular Examination

Pulse: Lying BP: Lying

Standing Standing

Symptoms

i. Weakness/fatigue ii. Dizziness/faintness iii. Impaired concentration iv. Frequent sore throats v. Non-focal abdo pain vi. Diarrhoea vii. Constipation viii. Muscle pain/cramps/weakness ix. Bone pain x. Shortness of breath xi. Palpitations xii. Chest pain xiii. Amenhorroea xiv. Cold intolerance xv. Cold extremities xvi. Hair loss


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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


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13 SUMMARY AND DIAGNOSIS

14 MANAGEMENT PLAN

Medical Review

Individual Therapy

Family Therapy

Physical Investigations

Referral to other services:

15 INFORMATION GIVEN:


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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, 2007AWP, 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.


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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


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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


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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

http://www.b-eat.co.uk/get-help/


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http://www.b-eat.co.uk/get-help/

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