Children and Young People with an Eating Disorder – CARE PATHWAY
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Table of Contents
FLOW DIAGRAM
2
This document shows the pathway.
INFORMATION REQUIRED WHEN MAKING A REFERRAL
3
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
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5
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CAMHS EATING DISORDER ASSESSMENT FORM
6
Used by local CAMHS teams.
TRANSITION PLANNING FOR 16 & 17 YEAR OLDS
16
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.
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
FLOW DIAGRAM
Concerned that a
young person may
have an eating
disorder
Telephone to
discuss with
CAMHS
team
Referral to CAMHS
CACAMHS
Meets referral criteria and includes specific
additional referral information
Urgent Choice appt
Discharge or Sign
post to appropriate
service
NO
NO
Return to referrer with
advice & offer of telephone
consultation
Choice appointment
Formal Eating
Disorder
YES
Partnership
appointment
Case Holder
Appointed
Low Risk
Medium Risk
Physical
Medical
Checks
High Risk
(Increase in
Treatment freq
Discharge
Individual
Therapy
Family
Therapy
Medical
monitoring
Urgent Referral
Required
Review
Transition
Planning
Specialist
Treatment
Paediatric/
Adult Ward
Riverside
If over 18
or 17.5
years
Patient Information
What to expect
Discharge
From
Service
NICE
GUIDELINES
Adult Mental
Health Team
STEPS
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
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
Urea & Electrolytes
Anaemia, low white cell count, ferritin
Hypokalaemia from vomiting/Diuretic use
Hyponatraemia from water loading
Abnormal renal function, raised urea
Liver Function Tests
Total protein, albumin
Calcium, magnesium, Hypophosphataemia
Potassium
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.
2.
Dehydration with ongoing fluid refusal
Evidence of physiological instability as indicated by;
cold, blue peripheries
low volume pulses, especially in the foot
bradycardia (bpm<40)
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
3.
4.
5.
6.
hypothermia
dizziness, fainting episodes
postural hypotension. Postural drop >10 mmHg, Bp <90/50
Abnormal Electrolytes; hypokalaemia, abnormal renal function, low
magnesium, low phosphate
Cardiac dysrhythmias
Comorbid disease complications e.g. diabetes
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
Nutrition
Circulation
EXAMINATION
MODERATE RISK
<15
<3
<0.5kg
BMI
BMI Centiles
Weight loss/week
Purpuric Rash
Systolic Bp
Diastolic Bp
Postural Drop
Pulse Rate
Extremities
<90mmHg
<60mmHg
>10mmHg
<50bpm
Musculoskeletal
Squat Test
Sit Test
Temperature
Investigations
FBC, U&E, Mg, PO4, Ca,
LFT, Albumin, Bicarb,
Creatinine Kinase,
Glucose
ECG
Created 2011
Reviewed November 2012
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Unable to get up
without
Using arms for
balance
Unable to sit up
without using arms
as leverage
<35deg C
Concern if outside
normal limits
Rate<50
HIGH RISK
<13
<2
<1.0kg
+
<80mmHg
<50mmHg
>20mmHg
<40bpm
Dark Blue/Cold
Unable to get up
without using
arms as
leverage
Unable to sit up
at all
<34.5 deg C
K<2.5
Na< 130
PO4<0.5
Rate<40
Prolonged QT
Interval
Children and Young People with an Eating Disorder – CARE PATHWAY
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 NERVOSA
A. 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 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
1. 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.
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
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
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
GUIDELINES FOR THE ASSESSMENT OF EATING DISORDERS
PEOPLE PRESENT:
1. CURRENT CONCERNS:
2. COURSE:
3. PRECIPITATING/ MAINTAINING FACTORS:
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
4. WEIGHT AND WEIGHT HISTORY
(CURRENT, PREMORBID, LOWEST, HIGHEST)
5. BODY IMAGE
6. MENSTRUAL HISTORY
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
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
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
Purging behaviours
Exercise
Other
8. FAMILY HISTORY
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
9. PERSONAL HISTORY:
a Pregnancy and Development
b Education
c
Social/Peer Relationships
d Medical History
e Psychiatric History
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
10.
PERSONALITY
11. MENTAL STATE EXAMINATION
a Appearance and Behaviour
b Speech
c
Mood
d Thoughts
e Perceptions
f
Insight
g Motivation to Change
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
12 PHYSICAL EXAMINATION
General Appearance
Ear Temperature
Cardiovascular Examination
Pulse:
Lying
BP:
Lying
Standing
Standing
Symptoms
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
xv.
xvi.
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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
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
Tests (tick if done)
U&Es
FBC
TFT
LFT
Calcium
Phosphate
Magnesium
Glucose
ECG
Bone Density Scan
Pelvic ultrasound
Other
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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
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
13 SUMMARY AND DIAGNOSIS
14 MANAGEMENT PLAN
Medical Review
Individual Therapy
Family Therapy
Physical Investigations
Referral to other services:
15 INFORMATION GIVEN:
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
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:
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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.
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
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
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
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
Created 2011
Reviewed November 2012
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Children and Young People with an Eating Disorder – CARE PATHWAY
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/
Created 2011
Reviewed November 2012
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