FUTURE DIRECTIONS FOR THE CARE,
MANAGEMENT, AND TREATMENT FOR SERVICE
USERS WITH EATING DISORDERS IN
NEW ZEALAND
A submission on behalf of members of the Paediatric Society of
New Zealand and the New Zealand Faculty of Child and
Adolescent Psychiatrists to the Mental Health Division of the
Ministry of Health
June 13, 2007
Introduction
The organisations represented by the document
The Paediatric Society of New Zealand is an independent society of health professionals
throughout New Zealand, who are committed in their daily work to the delivery of health
care services to children and young people. The Society includes almost all practising
paediatricians in New Zealand, and also includes paediatric surgeons, general
practitioners, paediatric dentists, child health nurses, midwives, allied health
professionals (such as dietitians, physiotherapists, occupational therapists, speech
language therapists, play specialists and pharmacists), child mental health professionals
from several disciplines and social workers. The current membership of the Society is
402.
The New Zealand Faculty of Child and Adolescent Psychiatrists is an independent
society of health professionals who deliver mental health services to children and
adolescents in New Zealand. The society comprises primarily of psychiatric consultants,
as well as some psychiatric registrars. It has a membership of approximately 50 people.
The authors
Dr Hiran Thabrew is a psychiatric registrar, employed at Capital and Coast District
Health Board, and is currently completing his final year of dual fellowship training in
paediatrics and child and adolescent psychiatry. He has worked with children and
adolescents with eating disorders at the Regional Rangatahi Adolescent Inpatient Service
and in a liaison capacity at Wellington Hospital. He has also worked as a paediatric
registrar in the Clinical Services division at the Ministry of Health.
Dr Anganette Hall is an adolescent physician who is employed by Hutt Valley District
Health Board. She has completed extensive training in the diagnosis and management of
eating disorders at the Hospital for Sick Children Toronto, where she worked on their 13
bed inpatient unit and was involved in the day treatment and outpatient treatment
programmes under the supervision of Dr Debra Katzman. She has also visited eating
disorder services in Sydney (Westmead Children’s Hospital) and Melbourne (Royal
Children’s Hospital) and currently consults to the Central Regional Eating Disorder
Service at Johnsonville, Wellington. Dr Hall has also worked as a paediatric registrar in
the Clinical Services division at the Ministry of Health.
Discussion and timeframe
We received the consultation draft of “Future Directions…” via the New Zealand
Paediatric Society on Tuesday the 5th of June. Following a telephone discussion, we
made a request for comments from members of both the Paediatric Society and the New
Zealand Faculty of Child and Adolescent Psychiatrists via email. We subsequently
drafted this submission and circulated it to the same professional groups for review
between the 11th and 12th of June. The final version was dispatched to the Ministry of
Health on Wednesday the 13th of June. Due to the limited timeframe, all points of view
may not have been adequately reflected by this submission.
General Comments about the document
Positive comments
We acknowledge the efforts of the Ministry of Health to rectify the issues of variable
service delivery, inconsistent access to services, and bed and workforce shortages that
undermine current efforts to provide service users with a smooth and flexible package of
care from onset to recovery from their illness experience. As gathered by the Ministry,
and evident at an operational level, a review of eating disorder services in New Zealand is
well overdue.
Scope of the document
We note that “Future Directions…” aims to cover a broad set of aims as outlined in
section 4 of the document including:
- A summary of current eating disorder services
- A summary of the collaboration between these agencies
- A discussion of staffing issues and workforce development
- The development of a whole systems approach to the management of eating
disorders
- Guidelines for delivering eating disorder services
- Plans for ongoing consultation and service development
We also note that the document is intended to sit alongside the Eating Disorder Service
Specification on the Nationwide Service Framework Library, which will be developed by
DHBs in collaboration with the Ministry of Health. We therefore assume that “Future
Directions” is not an evidence-based guideline for clinical practice akin to the National
Institute of Clinical Excellence (NICE) guidelines published in the UK in 2004(17).
However, as the policies and overarching principles outlined in this document pertain to
the day to day care of children and adolescents, we wish to comment on certain omissions
and plans that are relevant to the service users with whom we are involved.
Scope of this Submission
As we both work with children and adolescents, we shall try to limit ourselves to
comments on this age group. We shall divide the main body of our submission into the
following sections:
I Children and Adolescents/Young People (Issues we would like to see better
addressed by the document)
II Current Service Provision
III Workforce Issues
IV Other Comments about the Document
I Children and Adolescents/Young People
Description of the conditions
As mentioned in “Future Directions…”, eating disorders are defined by DSM-IV TR as
syndromes of abnormal food behaviour, weight management and body image that lead to
social and occupational impairment. Three categories of eating disorder are defined by
DSM, namely Anorexia Nervosa (AN), Bulimia Nervosa (BN) and EDNOS (Eating
Disorder-Not Otherwise Specified). The exact origin and nature of eating disorders
remains unknown. They are best conceptualized as psychological disorders with medical
manifestations and complications.
Pure forms of eating disorders are rare. Psychiatric co-morbidities are common and
include affective disorders (50%), anxiety disorders (especially social phobia and OCD)
(30-65%), substance abuse (12-21% with AN, 9-55% with BN), and personality disorders
(20-80%)(21). A lack of consideration of the true complexity of eating disorders will lead
to the development of health care systems that do not truly meet the needs of people with
these conditions. Systems for the identification of psychiatric co-morbidities do not
appear to be adequately addressed in “Future Directions”.
Eating disorders are serious and lethal. Crow and Nyman (6) reported a long term
mortality rate of 10% in AN. Death occurs secondary to physical (usually cardiac)
complications of malnutrition as well as due to suicide. Herzog (13) showed that the
suicide rate was 58 times greater in eating disordered women than in those without an
eating disorder. Sullivan (25) conducted a meta-analysis of 42 studies on patient
mortality and found that 54% died from complications of eating disorders, 27% died from
suicide and 19% died from other/unknown causes. The mortality rate increases with the
duration of symptoms. The APA (2) quoted a mortality rate of 5% at 5 years and 20% a
20 years after diagnosis. All patients should be screened for the risk of suicide.
“Future Directions” does not adequately describe how this will be facilitated, especially
by level 1 services.
Ninety percent of eating disorders develop before the age of 25 years, and the peak age
for onset is 13-14 years. There is some evidence that the age of onset of eating disorders
is declining, and it is not uncommon for services to see people as young as 8 years of age.
Eating disorders are generally reported to have a prevalence of 0.5% in adolescents, and
this makes them the third most common chronic disease of adolescence following obesity
and asthma. In this age group, these disorders are ten times as common as insulindependent diabetes mellitus, and more likely to be debilitating to individuals.
However, DHBs often fail to provide adequate treatment and monitoring for these
service users.
What is different about children and adolescents with eating disorders?
1. More than half of children and adolescents with eating disorders do not meet the
criteria for AN or BN while still experiencing the same medical and psychological
consequences of these disorders and requiring the same careful attention as those
who do. (1). Although perceived as less dangerous, EDNOS (which is what most of
these will be classified as having) in young people should not be managed in the same
way as in adults. Serious sequelae, especially cardiovascular compromise, can occur
unnoticed. Even those who look and feel deceptively well with normal ECG’s may have
cardiac irregularities, variations in pulse and blood pressure, and be at risk of sudden
death (2). A statement by the adolescent medical committee of the Canadian Psychiatric
Society (4) recommended that “adolescents who restrict food intake, vomit, purge of
binge in any combination with or without severe weight loss require treatment even if
they do not meet strict criteria for eating disorders”. In general, EDNOS should be
managed in a manner similar to the major eating disorder that it most resembles.
2. Children and adolescents are prone to unique medical complications of eating
disorders including growth retardation (that is potentially reversible before the closure of
epiphyses), pubertal delay or arrest, and impaired acquisition of peak bone mass during
the second decade of life (increasing the risk of osteoporosis in adulthood). Skilled
medical management is essential to both assess and manage these situations (4). Due to
the reversibility of such complications, most clinicians would argue that younger people
need more intense and aggressive treatment than adults. A position statement by the
Society for Adolescent Medicine (21) stated that “because of the potentially irreversible
effects of an eating disorder on physical and emotional growth and development in
adolescents, the high mortality and the evidence suggesting improved outcome with early
treatment, the threshold for intervention in adolescents should be lower than in adults”.
3. Younger people are more likely to require admission. Some studies indicate
admission rates of up to 80% for this age group. The RANZCP guidelines for the
treatment of eating disorders (20) state that for non-severe AN, outpatient treatment may
be preferable. As mentioned above, the definition of severity is not straightforward in
young people and so this recommendation may have to be rationalized. The American
Academy of Pediatrics (1) recommended that “Children and adolescents have the best
prognosis if treated rapidly and aggressively (an approach that may not be as effective in
adults with a more protracted course). Hospitalization which allows for adequate weight
gain in addition to medical stabilization and the establishment of safe and healthy eating
habits improves the prognosis in children and adolescents.”
4. Younger people are more likely to recover fully and to have good results with
intensive treatment. A full and early course of treatment is cost-effective for treating
eating disorders. Halmi (11) showed that readmissions of eating disorder patients
increased steadily as the length of stay in eating disorder units became briefer and the
weight at discharge was lower. Halmi and Licino (12) showed that patients with AN who
reach 98% ideal body weight (IBW) were less likely to relapse than those who achieved
only 83% IBW. Baran (3) showed that patients who achieved 96% IBW over 116 days in
hospital had only a 7% rate of rehospitalisation and 19% rate of persistent anorexic
symptoms compared with those who achieved only 76% IBW and had a 62% rate of
rehospitalisation and 57% rate of persistent anorexic symptoms. Garfinkel (7) showed
that half of people followed up for 5-10 years recover fully, 25% recover partially, and
25% remain ill or die. Studies of people with BN also show that the recovery rate is
better when treatment commences sooner (80% if commenced within 5 yrs of onset, vs
20% if commenced at 15yrs after onset).
5. Evidence based research supports the use of family-based treatment for children
and adolescents with AN. Although family involvement is mentioned in the document,
the central position of the family within the treatment team, and necessity for provision
for this to occur, has not been adequately stated. Modern staged family-based
programmes such as the “Maudsley Model” empower parents to take over responsibility
for meals from the child and to gradually give this back to them as they recover (rather
than defer this responsibility to the treating team in a traditional manner). Educating the
parents in this way ensures a smoother transition home and better long term care and
family functioning (16).
Problems with delivery of care for children and adolescents with eating disorders
These issues have been succinctly described in section 8 of “Future Directions…”, ie.
- Shortage of specialist eating disorder expertise in child and adolescent mental
health services (CAMHS)
- Lack of eating disorder expertise in paediatric wards
- Difficulties in establishing a multi-disciplinary team across health (CAMHS,
paediatrics, dietetics, primary care) on a case-by-case basis
- Lack of process for specialist eating disorder supervision of teams
We agree with all of these statements and list some other issues of concern below.
Admission to hospital
Criteria for the admission of children and adolescents to hospital have been described by
the RANZCP (20), Canadian Psychiatric Society (4) and American Academy of
Pediatrics (1). As mentioned above, strict criteria may not be as applicable in young
people as they are in adults. The evidence would suggest that a lower threshold for
admission is more appropriate in this age group.
In New Zealand, inpatient treatment is provided in a variety of settings, including
psychiatric wards, paediatric wards and adult medical wards. An example of this state of
affairs is that at the moment in Wellington, there are 6 children and adolescents receiving
inpatient treatment, 2 at the Regional Rangatahi Adolescent Inpatient Service, 2 on the
Wellington hospital paediatric ward, and 2 on the Hutt hospital adult medical ward. As
mentioned above, there is variability in the level of staff confidence in different units
(especially paediatric wards) to manage children and adolescents with eating disorders.
This often relates to the frequency with which staff deal with such conditions.
Regardless of the setting (which will be discussed further in the next section of this
submission), it is important that young people receive a similar standard of care with
similar components of their management (medical stabilization, nutritional rehabilitation
and a family based-approach). We would advocate that facilities for the inpatient
treatment of children and adolescents with eating disorders should be specifically
developed for this age group, should have developmentally appropriate services that are
focused on family therapy and behavioural management, and should have access to
adequate medical support and investigations.
Adult-focused eating disorder programmes do not adequately cater for these patients as
they usually have different goals and treatment objectives (ie. not focused on intensive
early intervention), waiting lists, different perceptions of need for inpatient admission,
slower response to lack of weight gain and less than optimal family involvement.
Admission to adult units can have a negative impact on young people as association with
people with more chronic forms of the disorders can lead to new learned illness
behaviours and demoralization.
The optimal duration in hospital has not been established. As mentioned above, the
evidence supports prolonged initial admission and discharge above 90% of IBW.
Currently , anecdotal evidence would suggest that there is significant variation in the
length of stay of young people with eating disorders of similar severity. Part of this
discrepancy is due to the difficulty of accessing inpatient beds when needed. Part of it is
due to philosophical differences between paediatric wards (which are used to brief
admissions lasting from hours to weeks) and psychiatric wards (which are used to long
admissions lasting from days to months). Most programmes, including those at the Royal
Children’s Hospital, Melbourne and the Hospital for Sick Children, Toronto have moved
toward this approach. It would be good to see this trend reflected in service planning
within “Future Directions…”.
Short term management
The American Academy of Pediatrics (1) states that medical stabilization and nutritional
rehabilitation are the most crucial determinants of short term and intermediate term
outcome in the treatment of children and adolescents with eating disorders. Currently,
these are being provided by primary practitioners, paediatricians and child and adolescent
psychiatrists and dieticians using variable protocols. Although there is neither an
internationally accepted definition of medical stability nor a universally applied
nutritional rehabilitation guideline, it would be good to establish some local consensus on
what standards people should use. These would have to be age-appropriate and
developed by clinicians with expertise in paediatric physiology and nutrition. Adolescent
physicians and paediatric dieticians have valuable knowledge to contribute to this process.
Longer term management
Long term management of eating disorders involves ongoing supervision of meals,
weight monitoring and often long term psychotherapy. Psychotherapy for young people
with AN has been shown to work better in a family-oriented fashion than an individual
fashion. This is because family dynamics often contribute to or maintain the condition.
Family therapy involves parental education about the disorder, strengthening of the
parental subsystem and reorganization of member roles so that young people can proceed
with arrested developmental tasks. The “Maudsley model” is an evidence based
progamme of family therapy from the UK that takes a number of months to complete.
Individual psychotherapy is primarily of a cognitive-behavioural modality (CBT) and
involves education about the disorder, problem solving around meals and communication
strategies to avoid arguments about food and weight. CBT is the best treatment for BN.
Other forms of psychotherapy such as psychodynamic psychotherapy and interpersonal
therapy may also be utilized for the treatment of eating disorders. Service development
should take into account the integral part of psychotherapy in the management of young
people with eating disorders, and ensure that treatment pathways are not merely mapped
onto a medical framework.
Discharge and follow-up
Children and adolescents discharged from inpatient treatment will require intensive
outpatient management. The Society for Adolescent Medicine (21) recommends that “a
smooth transition from inpatient to outpatient care can be facilitated by an
interdisciplinary team that provides continuity of care in a comprehensive, coordinated
and developmentally oriented manner”. The recommendation for an “identified person”
to take responsibility for this transition is appreciated. Where possible and when
consented to, day programme attendance that involves not only meal supervision and
therapeutic activity, but also educational or vocational rehabilitation should be provided
to young people.
Involuntary treatment
People with the most severe eating disorders are often the least likely to seek help and
will often refuse treatment, even if their condition is life threatening. It is not uncommon
for children and adolescents to be managed under the Mental Health Act (or equivalent
legislation) in the most countries including New Zealand, the UK, Australia and Canada.
Involuntary admission has not been associated with worse outcomes, and is usually
associated with the severity of their illness at that time. Most of the deaths from eating
disorders occur either in the first 2 years or after 15 years of suffering. It is important to
realize that what is considered ‘early on’ in the history of an eating disorder is a
dangerous time and can be fatal if not treated accordingly. The criteria for use of the
Mental Health Act in New Zealand are clear and include the presence of a mental
disorder as well as danger to either oneself or another person. The evidence presented
on page 13 of the document (under ‘secondary care’) suggests that involuntary
treatment is associated with worse long term outcome and that brief admissions may
be associated with lower mortality. The major confounder in both of these
conclusions is the severity of illness. We would advocate the removal of this
paragraph, or its clarification.
Nasogastric feeding
The position statement from the Society for Adolescent Medicine (21) states that “short
term nasogastric feeding may be necessary in those hospitalized with severe
malnutrition”. Most inpatient treatment facilities worldwide employ nasogastric feeding
in this manner. Some do not. Nasogastric feeding should occur as part of a plan of
nutritional rehabilitation, and it requires the availability of facilities to undertake postcitation x-rays as well as trained nursing staff. “Future Directions…” should
recommend the provision and maintenance of skill sets required to undertake
nasogastric feeding to all units where children and adolescents will be admitted.
Transition to adult services
The New Zealand Mental Health Survey identified the median age of onset for eating
disorders to be 17 years old (this statistic may not be entirely accurate as the study only
included people over the age of 16 years). Many adolescents who develop eating
disorders will need to transition from paediatric and child and adolescent psychiatry
services to adult medical and mental health services. Despite this fact, pathways for
transition of care have not been addressed by “Future Directions…”.
Services to mothers with eating disorders
Child and adolescent psychiatrists and paediatricians work with families more often than
adult specialists. It is therefore of concern to us that no comment has been made about
the needs of mothers with eating disorders. Although they are considered as adults and
managed using a more individual framework according to current practice and plans
outlined in the document, their disorders can have a significant impact on the physical
and emotional health of their children. The clinical experience of child protection
coordinators is that working with parents with eating disorder is complex and that their
illness can at times endanger the safety of children but almost always has a significant
developmental impact either directly in relation to nutrition and the role of food in the
family or indirectly in terms of the ability of the parent to acknowledge or attend to the
developmental needs of the child. The international literature in relation to the impact on
children of growing up in a household where a parent has an eating disorder is growing
and is increasingly concerning.
Measures to ensure the welfare of these children and to screen them for eating
disorders and other mental disorders could be recommended by “Future
Directions…”. The document could be improved by:
- A statement in relation to comprehensive assessment of the roles of the client
- A statement in relation to child and adult services working together, where a
parent has an eating disorder, to support safe parenting
- A statement regarding the importance of the safety and welfare of the Child
- A definition of family to include children of the client with eating disorder
Primary prevention and early detection
A Cochrane review of 8 studies into primary prevention of eating disorders (18) revealed
insufficient evidence to recommend any particular programme. The RANZCP guidelines
indicate some promise from programmes designed to boost self esteem. Both the NICE
guidelines (17) and the policy statement from the American Academy of Pediatrics (1)
include suggestions for screening questions that would help primary practitioners to
detect eating disorders. “Future Directions…” acknowledges the role of primary
practitioners in screening for eating disorders. Primary prevention will be an important
area for ongoing research by the Eating Disorder Network and other agencies. We accept
the lack of evidence to encourage its initiation at the current time.
Cultural differences
We acknowledge the Ministry’s commitment to reduce inequalities and improve the
physical and mental health of Maori and Pacific peoples. The New Zealand Mental
Health Survey result published in the document indicates that eating disorders are more
prevalent in Maori and Pacific people than in New Zealand Europeans. However, there is
a lack of information about the age of onset and type of eating disorders, and relevant
environmental factors that affect children and adolescents from these cultures. Further
research into this are would be helpful to ensure that services are designed in a culturally
appropriate manner.
II Current Service Provision
Epidemiological limitations
The statistics available to us indicate the prevalence of eating disorders in New Zealand,
but not the incidence of these conditions. Within an ideal early intervention service, most
of the service provision and expenditure for children and adolescents who develop eating
disorders would be anticipated to be directed toward “new” service users. Without data
to inform us of how many children and adolescents, what ages, what locations and which
cultural groups need these services, service planning can only occur in a non-targeted
fashion. Admittedly, even with this information, future trends may vary. However, an
audit of current clients may be a valuable part of the “Future Directions…” planning
process.
Comment on sections I-IV of the document
It would be useful in part 7 of the document to distinguish between primary care services,
adult community mental health services, child and adolescent community mental health
services, outpatient adult medical services, outpatient paediatric services, inpatient adult
psychiatric services, inpatient adolescent psychiatric services, inpatient paediatric
services, as well as private adult and adolescent eating disorder services. All of these
groups provide overlapping but different services.
The paragraph on public services in part 7 incorrectly states that paediatric service users
may be either admitted to a medical ward or onto a combined (with other specialties)
paediatric ward, while adolescent service users come under the child and youth or adult
(general) mental health services within a DHB. This is not always the case. Adolescents
may be admitted to general paediatric wards and adult medical wards at times. They may
also be admitted, when available, to specialist adolescent psychiatric facilities.
One such adolescent psychiatric facility has been significantly omitted from the
description of the central region. The Regional Rangatahi Adolescent Inpatient Service
(RRAIS) is a 13 bed inpatient psychiatric facility that exclusively serves adolescents aged
12-19 years and is run by Capital and Coast DHB. Although it is neither a dedicated unit
for the treatment of adolescents with eating disorders, nor does it have beds that are
dedicated to the treatment of these service users, it usually houses 2-3 clients with eating
disorders (usually anorexia nervosa) at any given time. Adolescents admitted to RRAIS
go through a formal staged, family- based programme of recovery that is based on the
Maudsley Model of care. Lengths of stay are usually between 3-6 months. RRAIS
provides a regional (tertiary inpatient) service to a number of other DHBs including
Gisborne, Hawkes Bay, Palmerston North, and Hutt Valley DHBs, and employees from
these DHBs often visit for new or updated training in working with clients with eating
disorders. Families are kept involved in treatment by attendance at weekly meetings in
person or via videoconference, and overnight accommodation in a whanau room and
whanau flat are available to aid those with transportation problems. The staff at RRAIS
includes a psychiatric consultant with extensive expertise in the management of eating
disorders, nursing staff who have been trained in overseas inpatient programmes,
psychologists, social workers and occupational therapists with experience of adolescents
with eating disorders. There is also access to medical monitoring facilities and
investigations. In addition, the unit houses a day programme and school facilities that
enable adolescents with eating disorders to transition more successfully back into their
communities following discharge.
The list on page 19 (part 9) refers to a number of service providers. Presumably CAMHS
and Child, Adolescent and Family Mental Health Services are the same type of service.
Pacific Mental Health Services (there is one in Wellington) have been excluded, as have
outpatient adult medical services. In addition to RRAIS, the Wellington/Hutt region
possesses one of the few adolescent physicians in the country (Dr Hall) who has
specialist training in the area of eating disorders. Dr Hall runs an outpatient clinic for
adolescents with eating disorders at Hutt hospital and consults with inpatients at both
Hutt hospital and Wellington hospital, as well as the Central Regional Eating Disorder
Service. Special mention should be made of adolescent physicians within paediatric
services.
The role of consultation-liaison services (ie. child and adolescent psychiatry teams
situated within hospitals and working with young people with psychological
problems in paediatric and medical setting) has not been adequately covered in
“Future Directions…”. These services exist in a number of centres and are vital to the
management of children and adolescents with eating disorders. Consultation liaison
services bridge the gap between paediatric and psychiatric services and enable treatment
to proceed in a person-centred, rather than service-specific manner. Resources to cover
liaison with both primary health (0.7 FTEs for the 0-19 year age group/100,000
population) and general hospital (0.5 FTEs for the 0-19 year age group/100,000
population) have been committed in the MOH document “Blueprint for Mental Health
Services: How Thing Need to Be” and should be considered during the development of
future eating disorders services.
The paragraph on tertiary specialist eating disorder services states that “with
consideration to population size and geography, the sector (Eating Disorder meeting
2007) agreed that sufficient population, resources and expertise exist to support two
centres in New Zealand that will be supported by the primary and secondary eating
disorder services. The location of the centres was decided based upon existing tertiary
services, workforces and facilities. The centres are based in Auckland and Christchurch.
These centres will provide inpatient care for the highest level of eating disorder
complexity alongside their own DHB service.” It would be interesting to know the data
upon which this very important decision has been made. The authors of this submission
are uncertain about the structure and complexity of adult eating disorder services.
However, given the omission of RRAIS and access to a specialist adolescent physician
from the description of child and adolescent services within the central region, and given
RRAIS’s current provision of tertiary eating disorder beds and expertise for the lower
North Island, it may make more sense to have THREE specialist eating disorder
centres for children and adolescents; one in Auckland, one in Wellington and one in
Christchurch.
The decision between two extremes of care – ie. centrally-mediated services (with
tertiary centre ideals) and locally organized services (with inadequate control and
potentially variable quality) – is a difficult one to make, and one of the reasons for
creating this document. Many clinicians have experienced difficulties in engaging with
young people with eating disorders and their families when they have been removed to
tertiary units and later returned to their care. We envisage that the ideal situation would
involve an expert team working with local secondary care services that could deliver care
as close as possible to the homes of children and adolescents. This problem is not unique
to the field of eating disorders. It has been contemplated and relatively successfully
achieved with illnesses such as childhood cancer. Despite the cross-specialty issues
involved in the treatment of eating disorders, there are probably lessons that can be learnt
from such effective models of care, and we would recommend that these are investigated
by the authors of the document.
A Paediatric Society publication entitled “Sustainable Nationwide Services for Children
and Young People 2006”(26) may also be of value as it considers the issues pertaining to
the delivery of health services for children and adolescents in New Zealand. We would
recommend that the nine principles espoused by this document are given serious
consideration.
Flow diagram 1 outlines the generalized pathway of care for eating disorder service users.
Despite mention of private service providers such as Ashburn Clinic in the text of the
document, they are not included in this flowchart.
Comments in Appendix 1 about the lack of provision of mandated care under the Mental
Health Act and nasogastric feeding within the central region do not reflect current
practice. Service users with severe eating disorders are often admitted to RRAIS under
the Mental Health Act, and most are discharged under community treatment orders.
Nasogastric feeding is occasionally employed by experienced nursing staff.
III Workforce Issues
Who is currently involved in managing eating disorders and what do they do?
As already mentioned, a variety of clinicians are involved with children and young
people with eating disorders, both in the community and on inpatient units.
- Paediatricians are specialists trained in caring for children. They have expertise
in monitoring growth and the physical health of young people. They are also
trained in pubertal staging and are familiar with interpreting medical
investigations. Paediatricians have a role in the detection of eating disorders,
education and primary prevention via health professionals and schools, and
advocacy with organizations. They also have a role in treating the medical
symptoms and complications of eating disorders.
- Adolescent physicians are paediatricians who have undertaken extra training in
adolescent health. They are familiar with health, developmental and social issues
that affect adolescents and often work with young people with eating disorders on
adolescent inpatient units and in outpatient clinics.
- Child and adolescent psychiatrists are mental health specialists who have training
in the diagnosis and treatment of mental disorders including eating disorders.
They can prescribe psychotropic medication and undertake psychotherapies
including family therapy. Some child and adolescent psychiatrists do not work
with people with eating disorders, those who do have varying levels of experience.
Child and adolescent psychiatrists are familiar with the identification of
psychiatric co-morbidities and risk assessment. Some child and adolescent
psychiatrists work in a consultation-liaison capacity within hospitals, and assist
paediatric teams to plan and care for young people with eating disorders. They
may also engage with the person and their family to commence or continue
psychotherapy while they are an inpatient.
- Paediatric dieticians are health professionals who have been trained in the
nutritional management of young people. Many work in hospitals and run
outpatient clinics. Some are based in the community and work with primary
physicians.
- Paediatric mental health nurses receive varying levels of training in working with
young people with eating disorders. Those that work on tertiary units and
adolescent units may be very familiar with the overall and day to day
management of eating disorders, including the placement of nasogastric tubes.
- Child and adolescent mental health therapists include psychologists, social
workers and occupational therapists. They may work within eating disorder
services, other inpatient facilities, or community clinics. They may have varying
levels of expertise in the development and delivery of psychologically based
therapeutic programmes.
- Paediatric nurses are familiar with the physical management of children and have
limited experience in managing young people with eating disorders. They are
usually familiar with the management of nasogastric feeding.
-
-
General practitioners are at the frontline for identifying and treating young people
with eating disorders, but may have variable experience in managing these
conditions. With government-sanctioned primary mental health services being
located within PHO’s, it will be important that GP’s receive adequate support and
direction from allied health professionals and secondary and tertiary institutions.
School-based professionals including school counselors, school nurses and
librarian are also at the frontline for identifying and treating young people with
eating disorders, because they may witness changes in the shape and weight of
pupils, identify students who are accessing resources about weight loss, and see
students when they present with symptoms of hypoglycaemia or malnutrition.
Comments on the workforce as referred to in the document
The Society of Adolescent Medicine (21) stated that “Interdisciplinary treatment of
established eating disorders can be time consuming, relatively prolonged and extremely
costly. Lack of care or insufficient treatment can result in chronicity with major medical
complications, social and psychiatric morbidity and even death”. The RANZCP
guidelines (20) stated that “ although the treatment of eating disorders remains within
the preserve of psychiatry, multidisciplinary treatment is ideal and should include a
specialist in physical medicine, a dietician, nurses and other allied health specialists
(such as psychologists, physiotherapists, and occupational therapists)”. The American
Academy of Pediatrics (1) suggested a significant role for paediatricians and adolescent
physicians in the diagnosis and management of eating disorders, however, it has to be
noted that the practice of the former group is different to that in New Zealand (US
paediatricians provide level 1 and level 2/3 services, whereas New Zealand paediatricians
only provide level 2/3 services).
Within New Zealand, GP’s generally have a poor knowledge of eating disorders (A Hall,
National Survey of GP’s, unpublished research at MOH, 2003). During this survey, 40%
self-identified significant knowledge deficits in assessment and management of eating
disorders. Also, interestingly few had interest in further training on the subject. Most
undertook only 15 minute appointments despite the fact that the establishment of a
therapeutic alliance with eating disorder clients is time-consuming, and that medical
monitoring and explanations are often lengthy processes. Paediatricians also identified
significant areas of knowledge deficit in a similar survey (A Hall 2003). There are few
adolescent physicians in New Zealand. However, they would be a valuable resource for
the treatment of eating disorders and the planning of service delivery.
Mental health providers are generally not trained in the specific area of child and
adolescent growth and development. However, psychiatrists that work with young
people with eating disorders are usually familiar with such management or have access to
medical colleagues who are knowledgeable in such matters. There was virtually no
mention of consultation-liaison psychiatrists in “Future Directions…”. These
practitioners play a valuable role in enabling the care of young people with complex
psychiatric conditions on medical wards, and should be included in service planning
strategies.
Recommendation for an alternative model of specialist knowledge
Having mentioned the option of THREE specialist centres for eating disorders in New
Zealand as opposed to two, it may be more appropriate to create THREE
SPECIALIST TEAMS for the care of children and adolescents with eating
disorders. The use of a TEAM structure would allow flexibility in the types of expertise
to match that available geographically, and not limit experts to inpatient eating disorder
facilities. We would suggest the minimum involvement of a child and adolescent
psychiatrist, adolescent physician or paediatrician, general practitioner, dietician,
psychiatric nurse and a mental health therapist on each team. Most of the activities
generated for the Specialist Eating Disorders Network could be undertaken by such teams,
and they could meet regularly to share and update knowledge, plan research and
education strategies, and discuss national issues and trends. They could also be involved
in two other projects of significance: 1) the creation or absorption of a set of nationally
accepted guidelines for clinical management and 2) the creation of a confidential client
database to inform future service planning and delivery. Audit of planned processes and
quality measurement via performance indicators would also be worthwhile endeavours
with which they may become involved.
Psychodynamics
As mentioned in the document, psychodynamics play an important part in the
management of eating disorders. The fragmented nature of the person’s sense of self is
often projected onto those around them. They may also be reflected in the provision of
services to people with eating disorders. Strong countertransferences are encountered
when working with adolescents and can lead to staff burnout. It is critical for team
members to communicate with families and with each other on a regular basis to manage
their feelings and to avoid becoming the objects of a “splitting” defense. In addition to
extrinsic (financial and geographical) barriers to treatment, patients and families often
demonstrate ambivalence or resistance to diagnosis and treatment, and this threatens
active engagement in the recovery process. This document is a valuable means of
bridging the skills and efforts of many clinicians who treat young people with eating
disorders. It is important that everyone feels heard and no one feels left out during the
consultation process.
IV Other Comments about the Document
It would be more useful if the information in the section on International comparisons
(within part 6) were presented in the form of a table with comparative data. A
breakdown between adult and child/adolescent statistics would have been interesting, as
well as a comparison of the mean age of onset of eating disorders between countries and
over time. The variability of information presented in these paragraphs would suggest
difficulty in accessing such information.
A clearer description of timeframes pertaining to the execution of recommendations from
the document would also be appreciated.
Recommendations
1. Please review the data included in “Future Directions…” on current service
provision to children and adolescents. There seem to be some significant
omissions in the description of current systems.
2. There is adequate evidence to recommend intensive and early intervention
for children and adolescents who develop eating disorders, so that individual
prognosis can be improved and so that medical and psychiatric
complications of the disorder can be avoided. Please consider a division of
the main sections of this document into 1) adult and 2) child/adolescent
services, so that the difference between the needs of younger and adult
populations are adequately reflected, and so the specific needs of each
population can be taken into account when planning future services.
3. Please ensure that service planning is undertaken in accordance with existing
MOH strategies such as the Blueprint for Mental Health and Youth Health:
A Guide to Action, and the Paediatric Society document Sustainable
Nationwide Services for Children and Young People. Please also ensure that
it maintains the operational standards recommended by the consensus
statements such as those produced by the Royal Australian and New Zealand
College of Psychiatry, the American Academy of Pediatrics, the Society for
Adolescent Medicine and the National Institute of Clinical Excellence.
4. Please ensure that services for children and adolescents, though flexible in
structure, are reasonably uniform in quality. We would recommend that the
ideal service for this age group is one that includes:
- Early detection and community management
- Management by services as close to home as possible with expert supervision
- Intensive medical stabilization if necessary and nutritional rehabilitation
- Family- based therapeutic programmes
- Support of educational needs
- Educational and vocational rehabilitation
- Smooth transitions based upon client need and severity of illness, not service
limitations
- Access to psychotherapeutic support at all stages of treatment
- Planned transition to adult care
5. As credible as the plan to create two specialist centres may be, we would
advocate for THREE specialist teams of child and adolescent experts, which
may or may not be directly associated with inpatient facilities.
6. We would appreciate further consultation with paediatricians, adolescent
physicians and child and adolescent psychiatrists before the document is
finalized
Dr Hiran Thabrew
Paediatric and Psychiatric Registrar
Capital and Coast DHB
Dr Anganette Hall
Consultant Adolescent Physician
Hutt Valley DHB
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