Handbook of Eating Disorders - part 10 pptx

428 DASHA NICHOLLS AND RACHEL BRYANT-WAUGH understandable to everyone, whatever its nature. This includes agreeing a format, iden- tifying shared and (non-shared) aims and expectations, and identifying how progress in treatment can be reviewed. The management plan needs to build in physical monitoring, and responsibility for this clarified, together with how the information will be fed back to parents, young person and all others involved in treatment? Agreeing boundaries and responsibilities includes agreeing responsibility for care with parents, including responsibility for food provision, reporting concerns, ensuring attendance, etc. Informed decision making requires information. Since we ask children and parents to be involved in the decision-making process, we provide information at every stage— information about onset, course, prognosis, and outcome; information about physical as- pects, behavioural aspects and emotional aspects; contact addresses, and a reading list; and encourage questions. This process of information sharing has a number of functions: it demystifies the diagnosis, and can provide a framework for understanding the development and the maintenance of the eating disorder. But perhaps, more importantly, it allows parents and young people to make informed decisions regarding treatment in a way that attempts to minimise the escalation of issues around power and control. Once a formulation, a framework for management, goals and expectations, boundaries and responsibilities, have been clarified and agreed, therapeutic work can continue in a number of formats. In the younger age group it is our expectation that intervention will involve those with parental responsibility. Family Work The nature of family work has changed considerably over the years, as have assumptions about the role of the family in aetiology of eating difficulties. Family work is the first line treatment for anorexia nervosa (with or without binge–purges) in younger patients. Con- trolled studies have demonstrated maximum utility in those with relatively short duration of illness (less than three years’ duration), living within a family context (Russell et al., 1987). In this framework, the young person has some identity within the family other than her illness. The treatment developed for the treatment trials has recently been published in manual form (Lock et al., 2000) and will enable specific questions regarding the effi- cacy of this treatment approach in different patient subpopulations to be addressed. For example, the approach may be useful for some patients with bulimia nervosa and other eating problems, but may not be sufficient alone. The manual has the obvious benefit of making an effective treatment more widely accessible. Based on an outpatient model of treatment, the therapy adopts a systemic approach that emphasises parental responsibility and authority in response to their child’s crisis. These structural family therapy principles rest squarely on the work of Minuchin and colleagues (1978), who pioneered much of the work in this area. The other key concept in this form of therapy is the ‘externalisation’ of the illness (White, 1989)—a technique which enables detachment from the problem, and allows relationships to the problem (anorexia) to be the subject of scrutiny rather than the more intrusive exploration of relationships between people. ‘Conjoint family therapy’, when all family members are present, is not always ideal, and alternatives should be considered if parents are highly critical of their child, or intrafamilial abuse is suspected.Parental counselling uses the same principles as family work, but without CHILDREN AND YOUNG ADOLESCENTS 429 the young person present, and has been shown to be just as effective as conjoint family therapy (Eisler et al., 2000). Some parents find this easier if they have their own difficulties, and worry that they may be impinging on treatment, or are severely burdened with guilt. An alternative form of therapeutic work is in a family group context, otherwise known as multi-family therapy (Scholz & Asen, 2001). Involving the whole family allows family strengths and resources to be utilised, while connecting parents to other parents helps to overcome the feeling of isolation. Individual Work Individual therapy can have many formats, e.g. CBT, psychodynamic, play therapy, but younger patients can find individual therapy extremely difficult, particularly those with more concrete cognitive styles. Therapist style needs to be flexible and developmentally appropriate and parental support for the therapy is crucial. The nutritional state of the child, as well as cognitive and emotional development stages, are important in assessing suitability. The focus of work may be to encourage the child to address issues more directly with her parents by rehearsing with the therapist. Other specific indications for individual work include treatment for concurrent depression, obsessive-compulsive disorder or specific anxieties such as fear of swallowing or choking. Here, age appropriate cognitive-behaviour therapy (CBT) would be the treatment of choice (Christie, 2000). Group Work Group work with young people and with parents can be task focused or not. Group therapy is an established part of most treatment programmes for adolescents with eating disorders, the focus usually being on the development of self-esteem. Groups for younger children are less well established. The provision of unstructured time for children to explore peer relationships and to develop freedom of expression can be infinitely more accessible and acceptable to the child than individual therapy, in which a child can feel persecuted. A parents’ group can address issues such as coping with rejection, and provides an opportunity for parents to share their knowledge and their skills, and to learn from and support each other (Nicholls & Magagna, 1997). As one parent in our group commented ‘(anorexia nervosa) as an illness makes you feel as if your parenting is not good enough, but also that your common sense isn’t common sense. It challenges you to understand something completely different and your normal responses are no longer valid.’ Physical Intervention The paucity of work in the area of physical interventions in young patients makes it hard to give clear evidence-based guidelines for intervention. There are no randomised trials of nutritional supplementation, nor for psychopharmacology in this age group. The use of hormonal treatments has not been systematically evaluated, but may be worth considering in severe chronic anorexia nervosa in consultation with appropriate specialists, the young person and her family. Thresholds for hospitalisation may be somewhat lower in younger 430 DASHA NICHOLLS AND RACHEL BRYANT-WAUGH patients, although the Society of Adolescent Medicine guidelines for admission to hospital may be somewhat over-inclusive (Fisher et al., 1995). For example, arrested growth and development would be expected in pubertal children with anorexia nervosa, and whether inpatient admission improves or worsens the prognosis is an issue much in debate. Arrested growth would, however, suggest the need for specialised care from both a physical and therapeutic point of view. Thresholds for nasogastric feeding vary in the younger patient. On occasions when this is necessary, appropriate dietetic advice and a feeding rate suited to the age and nutritional status of the child is sought. The most important aspect of treatment interventions of this kind is the careful consideration of issues relating to consent for both the child and parents. Manley et al. (2001) offer a framework for considering ethical decision making in the care of young people with eating disorders, intended as guidance when difficult decisions regarding care, such as those outlined above, need to be addressed. The task for the clinician is to return the child to her appropriate developmental track, physically and psychologically. In this context, provision of information about normal phys- ical development, feedback about progress and growth potential and ongoing monitoring of physical health and pubertal development, whether through growth assessment, pelvic ultrasound scanning or other forms of physical assessment, are in themselves interventions and can be powerful therapeutic tools. Working with the Wider System Points for consideration in working with a complex network of professionals, as is often the case for specialist services, include agreement about communication, both written and verbal, within the network and within the family, and about sharing information. The poten- tial for disagreement and misunderstanding is high and views can easily become polarised if communication breaks down. For similar reasons, consideration of how the team will respond to crises, expectations regarding availability, clarifying and documenting policies and procedures, identifying statutory roles and responsibilities, staff support, teaching and training all merit specific attention. It can be helpful to identify a central point of contact as well as a system for feedback and review of treatment, which may be independent of, but include, the therapist and wider system or referrer and is documented. Consent for the young person and his or her parents is complex and the precise legal issues will differ from country to country. Some issues merit highlighting. The first is the difference between giving and withholding consent. A young person may not have the capacity, either on the basis of age or mental state, to give consent, while being within his or her rights to withhold consent (refuse). A second and related issue is that consent and competence are specific. A young person is not ‘competent or not’, but rather ‘competent to make decision x’. This means that each specific decision for which consent is required needs to be considered from the young person’s point of view, and his or her opinion sought. This concept is incorporated in the working principles we have described thus far. For those occasions where agreement cannot be achieved, local policies regarding child protection and legal responsibilities are important to clarify. We started this section saying that management was context dependent, provided consid- eration was given to the issues outlined. A number of elements are, in our view, essential. Treatment of young people with eating disorders works best when it is collaborative, and CHILDREN AND YOUNG ADOLESCENTS 431 based on a comprehensive, multidisciplinary assessment. Treatment should be appropriate to level of complexity. As the study by Ben-Tovim et al. (2001) has demonstrated, not all patients need intensive psychotherapy. Treatment should be responsive to the developmen- tal need and degree of autonomy of the child within the family—family therapy may be appropriate for a 20 year old, and not be viable in a 13 year old. Treatments need to be flexible enough to be responsive to the child’s immediate and wider context, i.e. treatment should fit the patient. The treating team needs clear policies and guidelines, enabling them to respond to medical and psychiatric urgency when needed. And finally, approaches need to be reviewed, developed and evaluated. Our treatments are evolving, and we must be ready and prepared to adapt to changing situations. REFERENCES Arnow, B., Sanders,M.J. & Steiner, H.(1999) Premenarcheal versus postmenarcheal anorexia nervosa: A comparative study. Clin. Child Psychol. Psychiat., 4, 403–414. Bachrach, L.K., Katzman, D.K., Litt, I.F., Guido, D. & Marcus, R. 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(2000) Children into DSM IV don’t go: A comparison of classi- fication systems for eating disorders in childhood and early adolescence. Int. J. Eat. Disord., 28, 317–324. Nicholls, D., Christie, D., Randall, L. & Lask, B. (2001) Selective eating: Symptom, disorder or normal variant? Clin. Child Psychol. Psychiat. 6, 257–270. Nicholls, D., de Bruyn, R. & Gordon, I. (1999) Physical assessment and complications. In B. Lask & R. Bryant-Waugh (Eds), Childhood Onset Eating Disorders (2nd edn). Hove, East Sussex: Earlbaum. Nicholls, D. & Magagna, J. (1997) A group for the parents of children with eating disorders. Clin. Child Psychol. Psychiat., 2, 565–578. Nussbaum, M., Shenker, I.R., Baird, D. & Saravay, S. (1985) Follow-up investigation in patients with anorexia nervosa. J. Pediat., 106, 835–840. Russell, G.F., Szmukler, G.I., Dare, C. & Eisler, I. (1987) An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch. Gen. Psychiat., 44, 1047–1056. Russell, G.F.M. (1985) Pre-menarchal anorexia nervosa and its sequelae. J. Psychiat. Res., 19, 363–369. CHILDREN AND YOUNG ADOLESCENTS 433 Russell, J. & Gross, G. (2000) Anorexia nervosa and body mass index. Am. J. Psychiat., 157, 2060. Scholz, M. & Asen, E. (2001) Multiple family therapy with eating disordered adolescents: Concepts and preliminary results. Eur. Eat. Disord. Rev., 9, 33–42. Shafran, R., Bryant-Waugh, R., Lask, B. & Arscott, K. (1995) Obsessive-compulsive symptoms in children with eating disorders: A preliminary investigation. Eat. Disord. J. Treat. Prevent., 3, 304–310. Singer, L.T., Ambuel, B., Wade, S. & Jaffe, A.C. (1992) Cognitive-behavioral treatment of health- impairing food phobias in children. J. Am. Acad. Child Adolesc. Psychiat., 31, 847–852. Steiner, H., Mazer, C. & Litt, I.F. (1990) Compliance and outcome in anorexia nervosa. West J. Med., 153, 133–139. Steinhausen, H.C. (1997) Outcome of anorexia nervosa in the younger patient. J. Child Psychol. Psychiat., 38, 271–276. Strober, M., Freeman, R. & Morrell, W. (1997) The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10–15 years in a prospective study. Int. J. Eat. Disord., 22, 339–360. Tanner, J.M. & Whitehouse, R.H. (1966) Standards from birth to maturity for height, weight, height velocity and weight velocity: British Children 1965. Part 2. Arch. Dis. Child., 41, 613–635. Treasure, J. & Thompson, P. (1988) Anorexia nervosa in childhood. Br. Med. J., 40, 362–369. Walford, G. & McCune, N. (1991) Long-term outcome in early onset anorexia nervosa. Br. J. Psychol., 159, 383–389. Ward, A., Brown, N. and Treasure, J. (1997) Persistent osteopenia after recovery from anorexia nervosa. Int. J. Eat. Disord., 22, 71–75. Watkins, E., Bryant Waugh, R., Cooper, P. & Lask, B. (2000) The nosology of childhood onset eating disorders. Anonymous. White, M. (1989) The externalising of the problem and the re-authoring of lives and relationships. Dulwich Centre Newsletter 3–20. Williams, S. (2000) Body Mass Index reference curves derived from a New Zealand birth cohort. N.Z. Med. J., 113, 308–311. CHAPTER 27 From Prevention to Health Promotion Runi Børresen Organization for Health and Social Affairs, Buskerud County, Norway and Jan H. Rosenvinge Department of Psychology, University of Tromsø, Tromsø, Norway SUMMARY r Paradoxically eating disorders are not the issue in the primary prevention of eating dis- orders r Disease prevention should be integrated in a health promotion perspective r Health promotion includes both schools, and a supportive environment to enable teachers, parents and other adults to be good role models r Empowerment in health promotion means learning personal skills to cope with stress in order to be able to take charge over one’s own life r Preventive programmes should take on a longitudinal and multicomponent approach r The Internet may become an important arena for doing preventive work r Prevention programmes should be evaluated using a variety of research methods r Health promotion may highlight difficult, conflicting political priorities in the develop- ment of society. INTRODUCTION: WHY IS PRIMARY PREVENTION IMPORTANT? Is primary prevention in general, and of eating disorders in particular, a nice, but unrealistic wish? The drive to diminish human suffering and prevent a fatal outcome of eating disorders is laudable. However, over time, professional opinions have oscillated between unrealistic optimism and fatalism. In this chapter we review what can be learned from the past, and describe a new model of prevention work in eating disorders. This is a middle way in a spirit of realistic optimism. Handbook of Eating Disorders. Edited by J. Treasure, U. Schmidt and E. van Furth. C  2003 John Wiley & Sons, Ltd. 436 RUNI BØRRESEN AND JAN H. ROSENVINGE THE DIETING CULTURE Many children, and girls in particular, believe that thinness is important to attractiveness, academic and social success, and a happy life in general. Even small children believe that fat is undesirable (Richardsen et al., 1961; Smolak & Levine, 1996). For instance, girls prefer thin rather than fat dolls (Dyrenforth et al., 1980), and 50% of girls aged 7–13 years want to lose weight despite the fact that only 4% actually are overweight (Davis & Furnham, 1986). Moreover, among girls aged 11–16, years, 15–20% may display weight and shape preoccu- pation as well as strict dieting (e.g. Cooper & Goodyer, 1997; Gresko & Rosenvinge, 1998). Thinness is an important component of how attractive and desirable a woman is perceived to be (Smith et al., 1990; Tiggerman & Rothblum, 1988) and physical attractiveness is more strongly associated with opposite-sex popularity for women than for men (Feingold, 1990, 1991). Excessive dieting disturbs school performance and interpersonal relations, affects general mental and physical health (Rosenvinge & Gresko, 1997; Smolak & Levine, 1996), and may increase the risk for developing eating disorders (Patton, 1999). Moreover, body dissatisfaction and dieting as well as diagnosable eating disorders seem to occur among still younger age groups (Bryant-Waugh & Lask, 1995). THE RECEPTOR: INDIVIDUAL VULNERABILITY Numerous studies report on factors that may explain the inclination to diet. Some of these studies focus on the impact of mass media, family and friends. For instance, media con- vey salient or hidden messages to girls about what they should look like (Andersen & DiDomenico, 1992; Waller & Shaw, 1994). This points to the negative impact of an in- creasingly aggressive media culture, viewing children as consumers. Moreover, the strong correspondence between dietary restraint of 10-year-old girls and their mothers’ dieting behaviour (Hill et al., 1990) becomes important because 60–80% of mothers may be on a diet (Edlund, 1997; Maloney et al., 1989). Also, almost 60% of girls aged 14 years reported that they had a friend who used to diet, and four times more girls than boys may have a friend who would like them more if they were thinner (Edlund, 1997). The question then, is how primary prevention can address and counteract negative external influences from poor human role models as well as from dysfunctional advertising. On the other hand, social influence, whether it comes from significant others or from mass media, needs a ‘receptor’. Hence, other studies explaining the inclination to diet focus on psychological factors like body dissatisfaction, interoceptive awareness, concurrent psychological stress, poor self- esteem, and the vicious circle between dieting, poor self-esteem, and general distress (Hsu, 1990; Polivy & Herman, 1993; Rosenvinge, 1994; Rosenvinge et al., 1999; Striegel-Moore et al., 1986). The question then, is how to conduct primary prevention in a manner that diminishes these kind of psychological factors. Models of understanding using ‘external–internal’ or ‘continuous–discontinuous’ dichotomies may represent oversimplifications. For instance, the inclination to diet may not stem from sociocultural pressures per se, and commercials with a slimness message may affect only those individuals who for some reason are vulnerable to this kind of message. A social-cognitive model (Fairburn & Wilson, 1993) may offer a framework bridging the dichotomies. Hence, sociocultural messages of thinness as the key to success, popularity and the resolving of psychological problems may be introjected and incorporated in the FROM PREVENTION TO HEALTH PROMOTION 437 cognitive-affective schemata of individuals who are vulnerable because they are looking for solutions to personal problems. Such a model also predicts that watching other people dieting becomes a model learning effect only if the behaviour is viewed as attractive and performed by significant others. Thus, cognitive schemata and negative model learning may be important targets for primary prevention. Normal developmental transitions are a risk period for developing eating problems and eating disorders. For boys, physical maturation brings them closer to the masculine ideal, but it takes the girls further away. Thus, boys gain weight due to an increase of muscle-and- skeleton mass, while girls gain weight due to an increase in body fat. For girls, particularly among those who mature earlier or later than their peers (Killen et al., 1992, 1994), physical changes may elicit body dissatisfaction and an inclination to lose weight. Furthermore, normal development may imply psychological changes in roles and responsibilities, and those who cope with such challenges in a more dysfunctional way may come to believe that to resolve problems is to improve on their appearance by reducing the size of the body by losing weight (Smolak & Levine, 1996; Striegel-Moore, 1993). Hence, information about normal physical changes in order to prepare adolescents for developmental challenges may be another important arena for primary prevention. An unknown number of children and adolescents on a diet actually develop diagnosable eating disorders. This low predictive value of risk factor studies to date inhibits creative thinking about prevention. To some extent, there has been too narrow a focus on preventing anorexia nervosa, bulimia and binge eating. To widen the perspective, one should focus on individual suffering regardless of whether one develops an eating disorder or not. Eating problems which never reach the criteria for anorexia nervosa, bulimia nervosa or binge eating disorder are associated with a lot of suffering and problems which reduce the quality of life. A further widening of perspectives may include a shift of paradigm of prevention, i.e. from disease prevention to health promotion (Rosenvinge & Børresen, 1999). PRIMARY PREVENTION: PAST EXPERIENCES AND FUTURE CHALLENGES History is the best teacher. Primary prevention and health promotion do work. The history of preventive medicine is a history of resourcefulness—of how new insights are translated into new standards of practice which have radically improved the standard of living. This, however, requires efficient models and the continuous revision of models according to theoretical innovations, practical experience and empirical research. Traditionally, preven- tive work has been guided by the disease prevention paradigm and with the KAP model (knowledge–attitude–practice) as the guiding principle for practical work. According to this model, if you provide people with knowledge about the hazards of a given illness or disease this will lead them to change their attitude, values or self image and will stop unhealthy behaviours. For instance, there is a tacit assumption that information about eating disorders and the unveiling of ‘false’ cultural ideals may bring about ‘insight’, and hence, attitudinal change and a reduction in dieting. This theoretical model of attitude and behaviour change does not take into account the complex relationship between attitudes and behaviours, and how to influence people’s choices. Moreover, this KAP model has not been supported by emprical research (see Rosenvinge & Børresen, 1999, for a review). The KAP model has generally been abandoned within other domains, such as the prevention of suicide, and [...]... Because of lack of time and knowledge, general practitioners often find it difficult to take on the treatment of their eating- disordered patients However, recently a number of studies have addressed the issue of how specialist treatments for eating disorders, in particular for bulimic type disorders, can be adapted for primary care, e.g by delivering brief formats of CBT (Waller et al., 1996) or use of psycho-educational... r Thyroid function r Electrocardiogram Improving Communication with Eating- Disordered Patients Patients with eating disorders often hesitate about disclosing their behaviours, thoughts and feelings, and general practitioners should view this as part of the problem of having an eating disorder Eating disorders often have the function of avoiding or resolving underlying problems (Gilchrist et al., 1998)... treatment and referral pathways of common mental disorders in primary care, including eating disorders This could lead to an improvement of primary care-based interventions if it is posssible to overcome the barriers of lack of time and skills Referrals to other specialists is not always successful The Dutch survey of 108 patients with an eating disorder revealed that of the 93 patients who visited... professionals and teachers have been visiting schools and youth organisations to target children and adolescents with programmes in order to prevent eating disorders The most usual approach has been that the school arrange a day where the focus is eating disorders In other words, the pupils listen to various topics related to eating disorders, and maybe watch a video of the development of eating disorders. .. shape content of popular male and female magazines: A dose-response relationship to the incidence of eating disorders? International Journal of Eating Disorders, 11, 283–287 Bandura, A (1977) Social Learning Theory Englewood-Cliffs, NJ: Prentice Hall Bronfenbrenner, U (1979) The Ecology of Human Development Experiments by Nature and Design Cambridge, MA.: Harvard University Press Bryant-Waugh, R & Lask,... Sundgot-Borgen, J & Gresko, R.B (1999) The prevalence and psychological correlates of anorexia nervosa, bulimia nervosa and binge eating among 15-year-old students: A controlled epidemiological study European Eating Disorders Review, 7, 382–391 Rosenvinge, J.H & Børresen, R (1999) Prevention of eating disorders: Time to change programmes or paradigms? Current update and future recommendations European Eating. .. for eating disorders is important However, in bulimia nervosa specialist treatment can be adapted for primary care by delivering brief formats of CVBT or manual-based self-help guides INTRODUCTION Given the severe physical, psychological, social and financial consequences of eating disorders for patients and their families—and the considerable potential for chronicity— secondary prevention of these disorders. .. diagnosis of anorexia nervosa (an incidence of 8.1 per 100 000 persons/year) and 85 patients a first diagnosis of bulimia nervosa (an incidence of 11.5 per 100 000 persons/year) during the period of 1985 to1989 These figures were higher than those found in earlier research These findings show that special and ongoing training of general practitioners can improve their ability to diagnose eating disorders. .. specialists for treatment of secondary complications of their eating disorder According to Whitehouse et al (1992), hidden cases of bulimia, or partial syndromes, are relatively common in primary care, but many of these patients remain undetected, even when the help of specialists is sought for what are likely to be secondary complications of the eating disorder In Austria, only 12% of the patients with... therefore surprising that this model is still widespread within the field of eating disorders It is possible that people working on prevention in eating disorders rather than being driven by empirical research, have been too focused on the hazards of eating disorders, and driven by good will and by the wish to act The pitfalls of this way of working is individual burnout and disappointment when no visible . Child., 67, 103 105 . Christie, D. (2000) Cognitive-behavioural techniques for children with eating disorders. In B. Lask & R. Bryant-Waugh (Eds), Anorexia Nervosa and Related Eating Disorders. H. Rosenvinge Department of Psychology, University of Tromsø, Tromsø, Norway SUMMARY r Paradoxically eating disorders are not the issue in the primary prevention of eating dis- orders r Disease. and of eating disorders in particular, a nice, but unrealistic wish? The drive to diminish human suffering and prevent a fatal outcome of eating disorders is laudable. However, over time, professional