Artwork by an adolescent patient undergoing multi-family therapy for anorexia nervosa, depicting their feelings of being caught between family (red) and the pull of the eating disorder (black).
Despite commonly-held misconceptions, eating disorders – in which the central anxiety or difficulty centres around food and eating – are neither a lifestyle choice nor a ‘normal adolescent phase’. Eating disorders are complex mental health illnesses which can have severe medical and psychosocial consequences, and can even be fatal.
The adolescent population (aged 10 to 19 years) is particularly at risk for this mental health illness; eating disorders are highly prevalent and represent the third most common chronic illness amongst this age group.
The four main types of eating disorders include anorexia nervosa (AN), bulimia nervosa (BN), avoidant restrictive food intake disorder (ARFID) and binge eating disorder (BED).
International data shows a continuing rise in the prevalence of eating disorders, particularly in children and adolescents1. Similar trends have also been seen locally, with KK Women’s and Children’s Hospital (KKH) seeing a steady increase in number of new referrals for suspected eating disorder. The hospital saw more than 70 new cases of suspected eating disorders in 2016 compared with 12 new cases in 2008.
Common signs and symptoms of eating disorders in adolescents:
- Rapid weight loss or poor weight gain
- Insufficient food intake for weight gain
- Secondary amenorrhoea
- Excessive exercise
- Vomiting or laxative abuse
What to do if an eating disorder is supected in a child under 16 years:
- The child should be promptly referred to the Adolescent Medicine Service at KKH for further assessment.
- While waiting for an outpatient appointment at KKH, the family can be advised to start the child on three main meals and three snacks daily, and the child should be excused from physical activity.
- If the child displays signs of medical instablity such as bradycardia, hypotension, electrolyte abnormalities or dehydration, they should be urgently referred to Children's Emergency at KKH.
TREATING THE CHILD AND FAMILY
The successful treatment of eating disorders in young people requires closely integrated medical and mental health management, as well as engaging the family in education and treatment. To meet these specialised needs, KKH has developed a family-focused Eating Disorders Programme with the aim of providing patients the best evidence-based treatment while empowering families to help their child in recovery within the home, school and community.
The programme is led by a multidisciplinary team of adolescent medicine physicians, specialist nurses, clinical psychologists, dietitians, medical social workers and psychiatrists, and comprises both inpatient and outpatient management.
Malnutrition is a frequent side effect of eating disorders, with associated medical complications such as bradycardia (an abnormally slow heart rate). The inpatient programme aims to medically stabilise these patients, and enable them to continue their journey to recovery at home, which is the best place for recovery.
The patient is admitted to the hospital and started on a safe and effective rapid refeeding protocol developed by dietitians. They are also closely monitored for refeeding syndrome – shifts in fluids and electrolytes resulting from refeeding, which may cause serious clinical complications if not promptly managed.
Patients with significant social issues which may be impeding recovery are provided medical social assistance, as well as psychiatric management if there are concerns about co-morbid mood disorders or safety issues. Nursing-led guidelines are also in place to supervise patients during meal times, helping them to practice healthy eating patterns, and to manage challenging behaviours such as hiding food or secretly exercising in bed.
The average duration of hospital stay for a child with malnutrition is 10 to 14 days. To provide holistic care to patients and enhance their wellbeing during this time, they are encouraged to participate in activities such as art and craft by Activity Therapists and classes run by the non-profit organisation, Club Rainbow.
Once the child is medically stable and eligible to move into the outpatient phase of treatment, parents are encouraged to practice meal supervision before the child is discharged, to empower them to help the child transition smoothly into the home environment and continue the journey to recovery.
At KKH, Family-Based Treatment (FBT) is the first line of outpatient management for children and adolescents with eating disorders. This specialised intensive outpatient treatment empowers caregivers to take the lead in restoring their child’s weight and normalising their eating patterns through helping them learn how to disrupt dysfunctional behaviours that are leading to (or maintaining) low weight, such as severe dieting and exercise.
The treatment is led by clinical psychologists, and includes continued medical monitoring of the patient, as well as multidisciplinary management by the Eating Disorders Programme team, tailored around factors impeding each individual patient’s recovery.
Case Study: Family-centred Care for a Teen with Anorexia
Twelve-year-old Jamie (not her real name) was admitted to KKH due to bradycardia as a result of losing 12 kg over a period of six months. She was referred to the Eating Disorders Programme and diagnosed with anorexia nervosa. Inpatient care was commenced comprising refeeding with close medical monitoring.
Jamie achieved medical stability after two weeks of inpatient care, and was discharged from hospital to commence outpatient FBT. However, her initial weight gain was poor and her case was examined by the KKH team to identify possible barriers to treatment. The team identifi ed a number of barriers including; lack of consistency between her parents' response to the illness, difficulties in parents separating their child from the illness leading to high levels of conflict within the family, and difficulties managing their child’s anxiety.
To rectify the issues, Jamie’s family members were enrolled in MFT sessions, which focused on increasing communication and unity between her parents, and helping them to develop more helpful responses to her illness. The intensity of FBT was also increased
and Jamie was further prescribed psychotropic medication to manage her anxiety and depressive symptoms.
Gradually, over two months, Jamie and her family began to adapt their behaviours and perceptions in response to FBT and MFT. This resulted in marked improvements in parental management of Jamie’s illness and subsequent improvements in her weight gain.
Following improvements in Jamie’s weight gain and eating disorder behaviours, a combination of individual and FBT was provided to increase Jamie’s autonomy around eating and address her residual anxiety symptoms. With support from her family, Jamie has returned to school and is responding well to follow-on treatment.
While the majority of patients respond positively to FBT, a proportion of patients – such as those with severe, refractory eating disorders – do not show expected improvements in eating disorder symptoms. To boost intervention for this group of patients, KKH is piloting possible adjunctive treatments such as Multi-Family Therapy (MFT), an intensive group intervention which focuses on working with families to help their child recover from their eating disorder.
MFT combines group therapy, family therapy and psychological education with creative, supportive activities and interventions. There are exercises for the whole group, as well as separate exercises just for the patients, siblings and parents.
By bringing together families who are all struggling with the same illness, MFT can help to create solidarity, reduce the sense of isolation and hopelessness, and diminish stigmatisation. Group intervention also allows families to learn from each other, thus facilitating new ways of thinking about habits and behaviours, leading to positive improvements.
MFT has shown good results in leading child and adolescent eating disorder programmes in the United Kingdom, United States and Australia. Following the first successful pilot of locally adapted MFT for anorexia nervosa in 2016, which showed promising clinical improvements in local patients, the team is working towards the integration of MFT and FBT to boost the effectiveness of family-based care for children and adolescents with eating disorders.
Research is also ongoing to better understand predictors of treatment and local adaptions needed for our population.
REACHING INTO THE COMMUNITY
The KKH team regularly engages with schools and community healthcare partners to encourage the early detection of children and adolescents with eating disorders and facilitate timely referral to specialised services.
In January 2017, the KKH team collaborated with students from CHIJ Secondary in a student-led initiative, where the students hand-made keepsakes and wrote notes of encouragement to improve the well-being of adolescents battling eating disorders.
An interactive educational session was also held at the school, led by
Dr Elaine Chew, Consultant, General Paediatric and Adolescent Medicine Service, KKH.
Dr Siobhan Kelly, Principal Psychologist, Psychology Service, KK Women’s and Children’s Hospital
Dr Siobhan Kelly is a principal psychologist specialising in child and adolescent eating disorders, and works closely with the adolescent medicine and psychiatry teams at KKH to provide integrated care. Dr Kelly underwent further specialist training in child and adolescent Family- Based Treatment (FBT) from the Training Institute for Child and Adolescent Eating Disorders, USA.
Dr Elaine Chew, Consultant, General Paediatrics and Adolescent Medicine Service, Department of Paediatrics, KK Women’s and Children’s Hospital
A keen researcher, Dr Elaine Chew specialises in the management of adolescents with complex health issues, obesity and eating disorders. In 2016, Dr Chew completed further specialist training in adolescent medicine at The Children's Hospital at Westmead in Sydney, Australia.
Ms Lee Kim Nai, Nurse Clinician, General Paediatrics and Adolescent Medicine Service, Department of Paediatrics, KK Women’s and Children’s Hospital
With more than 22 years of experience, Ms Lee Kim Nai provides nursing care and management for adolescents with eating disorders. In 2008, Ms Lee underwent a Health Manpower Development Programme attachment with the Division of Adolescent Medicine at the Hospital for Sick Children in Toronto, Canada.
- Halmi AH. Anorexia nervosa: an increasing problem in children and adolescents. Dialogues Clin Neurosci 2009; 11(1).