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Winter 2007/08 | Vol 11 No 2

Focus

Why weight?

Early treatment for eating disorders gives youth and families hope

By Avril Roberts

Adolescence is a time of gaining experiences that help us move from childhood to adulthood; however, it is also a time when disordered eating attitudes and behaviours can begin to emerge. The most common age of onset is between 14 and 25, but research suggests eating disorders are increasingly seen in children as young as 10.

Consider these alarming statistics: A 2001 study published in the Canadian Medical Association Journal found that of 1,739 Ontario schoolgirls aged 12 to 18, 27 per cent said they engaged in bingeing or purging; 23 per cent said they were dieting and 8 per cent reported self-induced vomiting. The study noted that disordered eating attitudes and behaviours increased gradually throughout adolescence. These startling findings are echoed across Canada.

The prevalence of disordered eating and eating disorders in young girls is troubling, because the behaviours, if continued unabated, can place youth at risk for full-scale anorexia or bulimia, which can become chronic, even life-threatening.

Dr. Leora Pinhas, psychiatric director of the Eating Disorders Program at the Hospital for Sick Children in Toronto, says that starvation affects an adolescent’s brain at a critical time, when the frontal lobes are developing. Children who are malnourished are also usually quite isolated because they avoid settings where there might be food. Their ability to focus and concentrate may be impaired. And most tragic, mortality rates for people with eating disorders sit between eight and 10 per cent, according to the American Psychiatric Association.

The prevalence of disordered eating and eating disorders in young girls is troubling, because the behaviours, if continued unabated, can place youth at risk for full-scale anorexia or bulimia, which can become chronic, even life-threatening.

Given these risks, early intervention is crucial. “If caught early, most of these disorders can reverse completely,” says Pinhas. Dr. Daniel le Grange, director of the Eating Disorders Program at the University of Chicago in Illinois, agrees: “It’s like cancer stage zero – If it’s treated aggressively early, cancer can be prevented from developing into later stages or becoming terminal. And disorders are easier to treat when they are short in duration. Eating disorders are no exception.”

However, detecting eating disorders in the early stages – generally within the first year of developing symptoms – can prove difficult. Pinhas says that secrecy and denial are barriers. And in a society that values thinness, “It’s hard to just eyeball whether it is OK or whether it is tipping into not being healthy,” says Pinhas. Preconceptions can also make eating disorders difficult to detect. “We see girls from different countries where we think girls are thinner than average anyway, so we might underestimate how ill they are.” Younger children don’t always use language that is food-, weight- or shape-focused, complaining instead of stomach upset or giving other reasons for not eating, which lead to investigating gastrointestinal or other causes.

Le Grange adds that families often don’t realize there is a problem: “It happens at the time adolescence starts, so parents will often say, ‘It’s just a phase. She’ll snap out of it.’”

Despite these challenges, treatment programs are hoping to catch youth early before the disorder becomes chronic. The treatment of choice for young clients is a family-based strategy, specifically, the Maudsley approach, developed in the 1980s to treat anorexia. “This outpatient treatment mobilizes parents to take on the role nurses would have if the adolescent were admitted to a specialist inpatient unit,” says le Grange. “Parents use their capacity and leverage over feeding their children to make sure they get the amount of food they should in order to regain weight. Once the weight is regained, psychosocial issues are addressed if they are part of the presentation.” The approach typically involves 15 to 20 treatments over six to 12 months.

The Maudsley approach has recently been validated in the first study in the United States to evaluate treatment for adolescents with bulimia. Led by le Grange and published in 2007 in the Archives of General Psychiatry, the study found that youth aged 12 to 19 with bulimia who received family-based treatment were less likely to continue bingeing and purging than youth who received supportive psychotherapy that explored issues underlying the disorder. The results held at six-month follow-up.

At the Outpatient Eating Disorder Clinic at Sick Kids in Toronto, which sees about 100 new clients a year, early treatment options include the Maudsley approach, multi-family group therapy based on Maudsley principles and a psychoeducational group for parents and kids. The clinic also offers separate support groups for parents and kids.

Children and adolescents under 18 with an eating disorder are accepted, whether or not they meet DSM-IV diagnostic criteria. “If a child has a problem that is affecting their functioning and it’s related to their eating, they are accepted,” says Pinhas, provided they have a doctor’s referral and after they undergo medical, psychological and nutritional assessments.

A pediatrician monitors the youth’s medical status. A psychiatrist is available if there are co-morbid disorders or if psychopharmacology is indicated. A dietitian works with parents to determine how much the youth needs to eat and develops a meal plan. A social worker provides family support or family therapy.

Pinhas describes the Maudsley approach and multi-family group therapy as problem-based. “If your child isn’t eating enough to keep herself safe, you should be worried. How are you going to help your child eat? What can you put into place in terms of how you manage your child to help change her mind about the eating disorder?”

In one of the early tasks, families are observed eating a meal, in order to reveal how the family works and provides support, encouragement and ideas. If parents negotiate too much around a child’s eating habits – ‘Just eat this carrot; it’s OK if you don’t eat anything else’ – one objective could be to help parents build perseverance and larger expectations about what their child needs to do, without being punitive or over-controlling.

The parents’ role is critical because “often kids are not our customers,” says Pinhas. “They may not be interested in changing this behaviour because it’s socially desirable. Parents are the ones who are concerned about their children, their eating, growth and long-term potential, so they’re highly motivated. Also, parents are the ones the children live with.”

Families first attend the psychoeducational group called Why Weight? based on a program developed at Southlake Regional Health Centre in Newmarket, Ontario. Up to eight families meet one evening a week for eight weeks to learn from one another what works and what doesn’t.

In 2008, Sick Kids plans to offer a transitions therapeutic group for youth who will be turning 18, preparing them to move into the adult health system, where the onus is on the individual, not the family, to seek and participate in treatment. The hospital also offers inpatient treatment for youth who are medically unstable and a day hospital program for those whose eating disorder is severe, chronic or complicated by comorbid issues.

Across the country in British Columbia, the Healthy Attitudes program also strives to veer youth off the path to a chronic eating disorder. The program offers one-on-one counselling, nutrition information and support to young people aged 13 to 24 with eating disorder symptoms, disordered eating or anxiety about food, weight or body image.

Begun as a pilot project in 1996 out of the South Community Health Office of the Vancouver Coastal Health Authority, Healthy Attitudes served 49 new clients in 2006 – 46 females, three males – and currently has 20 clients. The program accepts only young people who have not been in a hospital-based program or received extensive medical treatment. “We serve people who would not get accepted by tertiary care programs because their symptoms are not severe enough,” says counsellor Sonia Usmiani. Hospital eating disorders programs can have waiting lists of up to one year – a year that can make all the difference in a young girl’s recovery.

Referrals can come from anyone. For teenage girls, referrals from friends are common and youth can attend the program without parental consent. Following a telephone screening by the community health nurse, an intake meeting and a team assessment, a nurse, registered dietitian and counsellor are available one afternoon a week, with extended hours for counselling an additional afternoon every other week. A physician is on call. Clients must stay connected with their family doctor throughout treatment.

While youth may be ambivalent or resistant at first, Usmiani says, “Once they get a sense of what this is about, they’re usually very eager and compliant.”

Healthy Attitudes starts with the premise that eating disorders are anxiety-based. It teaches youth how to manage both the anxiety and the eating disorder. “We address the underlying issues that are interfering with that person’s happiness and we also address the beliefs, behaviours and feelings that are the eating disorder itself,” says Usmiani.

Clients can continue in the program for as long as their recovery takes. Once they leave, return visits, months later, are not uncommon. “There’s nothing linear about working with eating disorders,” says Usmiani. “Progress usually happens in phases. The youth can come and go and we stay with them wherever they are.” However, if disordered eating behaviours persist for a long time with no sign of improvement, the program will refer the client to a more suitable resource. The team also intervenes if a client is medically at risk.

Surveying the big picture of interventions for eating disorders, Merryl Bear, director of the National Eating Disorder Information Centre, says there is room for improvement: “Along the continuum of interventions, from health promotion through to treatment and clinical services, there are big gaps.” For example, there is a shortage of interdisciplinary treatment programs so that parents often have to patch together the services of a doctor, dietitian, psychotherapist and family therapist, partly at their own expense, while in the midst of a crisis with their child.

Training and awareness also fall short. “Many medical practitioners are ill-equipped to recognize, identify or manage patients with an eating disorder,” says Bear. And Pinhas notes, “Among mental health professionals, there is a stigma around eating disorders. They are perceived as being harder to treat and there is a myth that people don’t recover.”