In this article, Dr Dee Dawson raises the issues around treating children with eating disorders as inpatients or outpatients. She also discusses the problems of monitoring the health of anorexics and restoring children to their correct weights.
The inpatient-outpatient debate on children suffering from anorexia
For many years, there has been an ongoing debate among professionals treating children with eating disorders as to the relative merits of inpatient and outpatient treatments. Inpatient units stick to their belief that their methods are preferable, while clinicians, who have no inpatient beds, can always quote statistics to show inpatient care is rarely necessary.
In my mind, there is no debate. Outpatient treatment is always preferable. No clinician should be rushing to take a child away from its parents, siblings, friends and school. To take a sick child away from home and put them into a hospital is clearly traumatic and should be avoided if possible. Furthermore, most of the children who suffer from eating disorders are academic high-achievers, and the fear of falling behind their peers adds to the problems of these highly competitive children.
From time to time, a clinician sees a child with an eating disorder so severe that the child’s life is in danger and requires immediate admission. Happily, these cases are rare and most children can initially be treated on an outpatient programme.
Outpatient treatments for juveniles with eating disorders
The length of outpatient treatment is dependent on how advanced the illness is when the child is first referred, and how well the child responds. In turn, how well the child responds depends on the skill and experience of the team the child is referred to, and the amount of support the parents can give.
There are surprisingly few clinicians experienced in treating eating disorders and many child and adolescent mental health service do not have a multidisciplinary team to help very sick children. Children with eating disorders often need individual therapy, their families often need family therapy, and, in every case, the family needs counselling and dietary advice.
Monitoring the health needs of children with the disorder
Apart from psychiatric support, the child’s physical health needs to be monitored. A child who is losing weight, or is at very low weight, can drop their heart rate and blood pressure very suddenly to life-threatening low levels. Patients need monitoring regularly. Unfortunately, many of the psychiatrists treating these children seem to think that weighing is all that is necessary.
Even the weighing is not always done sensibly. The success or failure of a treatment programme, at least initially, is determined by weight gain or weight loss. It is therefore vital that these weights are accurate. This means that children should be weighed in their underwear, and checks made to see that they are not hiding weights in their underclothes or under their arms.
Parents need to be warned to supervise their children for at least two hours before their appointment to see that they do no drink water to increase their weight.
Inpatient treatment for children with eating disorders
Outpatient treatment should only continue if consistent weight gains are being made.
Too often a week of weight gain is followed by a week of losing and at the end of six months or a year no progress has been mad at all.
Children should have their weight and height recorded as a weight/height ratio not as a body mass index (BMI), which is only useful for adults. Most clinicians treating children with eating disorders agree that a child should be hospitalised when their weight/height ratio is 65-70% or below.
Children who are vomiting regularly need to have their blood potassium levels monitored regularly and should be hospitalised if the vomiting cannot be brought under control. Vomiting can cause sudden death even in children whose weight is within normal limits.
Despite a recent report finding a rise in young children suffering from anorexia, most specialised units have empty beds. However, with the NHS under enormous pressure to save money, it is becoming increasingly difficult for clinicians to obtain funding for inpatient treatment.
Restoring weight levels in children with the disorder
Over the twenty years that I have been treating children with eating disorders, I have seen many children whose outpatient treatment has extended into months and years, although no progress was being made. Outpatient treatment must restore weight and periods. It cannot be deemed treatment if it simply stabilises a child at a dangerously low weight.
We need to question the efficacy of continuing an outpatient programme which doesn’t seem to be working. Despite the obvious drawbacks of admitting a child to hospital, eating disorders can be extremely damaging and sometimes difficult decisions have to be made.
If a good unit weight gain is guaranteed and at a safe weight there is much more chance that the child will think more rationally. Do not accept a treatment that is not at least restoring your child’s physical health. Whilst treating the psychological issues of an eating disorder is often difficult, restoring weight is easy and a vital first step.
Be prepared to question decisions you do not agree with, doctors do not always get things right and they should not mind listening to what you want to say. You owe it to your child to see he or she is given the best possible chance to put their illness behind them and start enjoying life.