ࡱ> @ bjbjFF ",,VHVHVHVHH\ vnBI:|I|I|I|IWJWJWJuuuuuuu$wRyxu]WJWJ]]u|I|Iuaaa]F|I|Iua]uaap|7r|I6I BVH`;quu0 vMqXza@Xz$7r7r8Xzor0WJ)P(aQTTW WJWJWJuud#%D#Ga@% FUTURE DIRECTIONS FOR THE CARE, MANAGEMENT, AND TREATMENT FOR SERVICE USERS WITH EATING DISORDERS IN NEW ZEALAND A submission on behalf of members of the Paediatric Society of New Zealand and the New Zealand Faculty of Child and Adolescent Psychiatrists to the Mental Health Division of the Ministry of Health June 13, 2007 Introduction The organisations represented by the document The Paediatric Society of New Zealand is an independent society of health professionals throughout New Zealand, who are committed in their daily work to the delivery of health care services to children and young people. The Society includes almost all practising paediatricians in New Zealand, and also includes paediatric surgeons, general practitioners, paediatric dentists, child health nurses, midwives, allied health professionals (such as dietitians, physiotherapists, occupational therapists, speech language therapists, play specialists and pharmacists), child mental health professionals from several disciplines and social workers. The current membership of the Society is 402. The New Zealand Faculty of Child and Adolescent Psychiatrists is an independent society of health professionals who deliver mental health services to children and adolescents in New Zealand. The society comprises primarily of psychiatric consultants, as well as some psychiatric registrars. It has a membership of approximately 50 people. The authors Dr Hiran Thabrew is a psychiatric registrar, employed at Capital and Coast District Health Board, and is currently completing his final year of dual fellowship training in paediatrics and child and adolescent psychiatry. He has worked with children and adolescents with eating disorders at the Regional Rangatahi Adolescent Inpatient Service and in a liaison capacity at Wellington Hospital. He has also worked as a paediatric registrar in the Clinical Services division at the Ministry of Health. Dr Anganette Hall is an adolescent physician who is employed by Hutt Valley District Health Board. She has completed extensive training in the diagnosis and management of eating disorders at the Hospital for Sick Children Toronto, where she worked on their 13 bed inpatient unit and was involved in the day treatment and outpatient treatment programmes under the supervision of Dr Debra Katzman. She has also visited eating disorder services in Sydney (Westmead Childrens Hospital) and Melbourne (Royal Childrens Hospital) and currently consults to the Central Regional Eating Disorder Service at Johnsonville, Wellington. Dr Hall has also worked as a paediatric registrar in the Clinical Services division at the Ministry of Health. Discussion and timeframe We received the consultation draft of Future Directions via the New Zealand Paediatric Society on Tuesday the 5th of June. Following a telephone discussion, we made a request for comments from members of both the Paediatric Society and the New Zealand Faculty of Child and Adolescent Psychiatrists via email. We subsequently drafted this submission and circulated it to the same professional groups for review between the 11th and 12th of June. The final version was dispatched to the Ministry of Health on Wednesday the 13th of June. Due to the limited timeframe, all points of view may not have been adequately reflected by this submission. General Comments about the document Positive comments We acknowledge the efforts of the Ministry of Health to rectify the issues of variable service delivery, inconsistent access to services, and bed and workforce shortages that undermine current efforts to provide service users with a smooth and flexible package of care from onset to recovery from their illness experience. As gathered by the Ministry, and evident at an operational level, a review of eating disorder services in New Zealand is well overdue. Scope of the document We note that Future Directions aims to cover a broad set of aims as outlined in section 4 of the document including: A summary of current eating disorder services A summary of the collaboration between these agencies A discussion of staffing issues and workforce development The development of a whole systems approach to the management of eating disorders Guidelines for delivering eating disorder services Plans for ongoing consultation and service development We also note that the document is intended to sit alongside the Eating Disorder Service Specification on the Nationwide Service Framework Library, which will be developed by DHBs in collaboration with the Ministry of Health. We therefore assume that Future Directions is not an evidence-based guideline for clinical practice akin to the National Institute of Clinical Excellence (NICE) guidelines published in the UK in 2004(17). However, as the policies and overarching principles outlined in this document pertain to the day to day care of children and adolescents, we wish to comment on certain omissions and plans that are relevant to the service users with whom we are involved. Scope of this Submission As we both work with children and adolescents, we shall try to limit ourselves to comments on this age group. We shall divide the main body of our submission into the following sections: I Children and Adolescents/Young People (Issues we would like to see better addressed by the document) II Current Service Provision III Workforce Issues IV Other Comments about the Document I Children and Adolescents/Young People Description of the conditions As mentioned in Future Directions, eating disorders are defined by DSM-IV TR as syndromes of abnormal food behaviour, weight management and body image that lead to social and occupational impairment. Three categories of eating disorder are defined by DSM, namely Anorexia Nervosa (AN), Bulimia Nervosa (BN) and EDNOS (Eating Disorder-Not Otherwise Specified). The exact origin and nature of eating disorders remains unknown. They are best conceptualized as psychological disorders with medical manifestations and complications. Pure forms of eating disorders are rare. Psychiatric co-morbidities are common and include affective disorders (50%), anxiety disorders (especially social phobia and OCD) (30-65%), substance abuse (12-21% with AN, 9-55% with BN), and personality disorders (20-80%)(21). A lack of consideration of the true complexity of eating disorders will lead to the development of health care systems that do not truly meet the needs of people with these conditions. Systems for the identification of psychiatric co-morbidities do not appear to be adequately addressed in Future Directions. Eating disorders are serious and lethal. Crow and Nyman (6) reported a long term mortality rate of 10% in AN. Death occurs secondary to physical (usually cardiac) complications of malnutrition as well as due to suicide. Herzog (13) showed that the suicide rate was 58 times greater in eating disordered women than in those without an eating disorder. Sullivan (25) conducted a meta-analysis of 42 studies on patient mortality and found that 54% died from complications of eating disorders, 27% died from suicide and 19% died from other/unknown causes. The mortality rate increases with the duration of symptoms. The APA (2) quoted a mortality rate of 5% at 5 years and 20% a 20 years after diagnosis. All patients should be screened for the risk of suicide. Future Directions does not adequately describe how this will be facilitated, especially by level 1 services. Ninety percent of eating disorders develop before the age of 25 years, and the peak age for onset is 13-14 years. There is some evidence that the age of onset of eating disorders is declining, and it is not uncommon for services to see people as young as 8 years of age. Eating disorders are generally reported to have a prevalence of 0.5% in adolescents, and this makes them the third most common chronic disease of adolescence following obesity and asthma. In this age group, these disorders are ten times as common as insulin-dependent diabetes mellitus, and more likely to be debilitating to individuals. However, DHBs often fail to provide adequate treatment and monitoring for these service users. What is different about children and adolescents with eating disorders? 1. More than half of children and adolescents with eating disorders do not meet the criteria for AN or BN while still experiencing the same medical and psychological consequences of these disorders and requiring the same careful attention as those who do. (1). Although perceived as less dangerous, EDNOS (which is what most of these will be classified as having) in young people should not be managed in the same way as in adults. Serious sequelae, especially cardiovascular compromise, can occur unnoticed. Even those who look and feel deceptively well with normal ECGs may have cardiac irregularities, variations in pulse and blood pressure, and be at risk of sudden death (2). A statement by the adolescent medical committee of the Canadian Psychiatric Society (4) recommended that adolescents who restrict food intake, vomit, purge of binge in any combination with or without severe weight loss require treatment even if they do not meet strict criteria for eating disorders. In general, EDNOS should be managed in a manner similar to the major eating disorder that it most resembles. 2. Children and adolescents are prone to unique medical complications of eating disorders including growth retardation (that is potentially reversible before the closure of epiphyses), pubertal delay or arrest, and impaired acquisition of peak bone mass during the second decade of life (increasing the risk of osteoporosis in adulthood). Skilled medical management is essential to both assess and manage these situations (4). Due to the reversibility of such complications, most clinicians would argue that younger people need more intense and aggressive treatment than adults. A position statement by the Society for Adolescent Medicine (21) stated that because of the potentially irreversible effects of an eating disorder on physical and emotional growth and development in adolescents, the high mortality and the evidence suggesting improved outcome with early treatment, the threshold for intervention in adolescents should be lower than in adults. 3. Younger people are more likely to require admission. Some studies indicate admission rates of up to 80% for this age group. The RANZCP guidelines for the treatment of eating disorders (20) state that for non-severe AN, outpatient treatment may be preferable. As mentioned above, the definition of severity is not straightforward in young people and so this recommendation may have to be rationalized. The American Academy of Pediatrics (1) recommended that Children and adolescents have the best prognosis if treated rapidly and aggressively (an approach that may not be as effective in adults with a more protracted course). Hospitalization which allows for adequate weight gain in addition to medical stabilization and the establishment of safe and healthy eating habits improves the prognosis in children and adolescents. 4. Younger people are more likely to recover fully and to have good results with intensive treatment. A full and early course of treatment is cost-effective for treating eating disorders. Halmi (11) showed that readmissions of eating disorder patients increased steadily as the length of stay in eating disorder units became briefer and the weight at discharge was lower. Halmi and Licino (12) showed that patients with AN who reach 98% ideal body weight (IBW) were less likely to relapse than those who achieved only 83% IBW. Baran (3) showed that patients who achieved 96% IBW over 116 days in hospital had only a 7% rate of rehospitalisation and 19% rate of persistent anorexic symptoms compared with those who achieved only 76% IBW and had a 62% rate of rehospitalisation and 57% rate of persistent anorexic symptoms. Garfinkel (7) showed that half of people followed up for 5-10 years recover fully, 25% recover partially, and 25% remain ill or die. Studies of people with BN also show that the recovery rate is better when treatment commences sooner (80% if commenced within 5 yrs of onset, vs 20% if commenced at 15yrs after onset). 5. Evidence based research supports the use of family-based treatment for children and adolescents with AN. Although family involvement is mentioned in the document, the central position of the family within the treatment team, and necessity for provision for this to occur, has not been adequately stated. Modern staged family-based programmes such as the Maudsley Model empower parents to take over responsibility for meals from the child and to gradually give this back to them as they recover (rather than defer this responsibility to the treating team in a traditional manner). Educating the parents in this way ensures a smoother transition home and better long term care and family functioning (16). Problems with delivery of care for children and adolescents with eating disorders These issues have been succinctly described in section 8 of Future Directions, ie. Shortage of specialist eating disorder expertise in child and adolescent mental health services (CAMHS) Lack of eating disorder expertise in paediatric wards Difficulties in establishing a multi-disciplinary team across health (CAMHS, paediatrics, dietetics, primary care) on a case-by-case basis Lack of process for specialist eating disorder supervision of teams We agree with all of these statements and list some other issues of concern below. Admission to hospital Criteria for the admission of children and adolescents to hospital have been described by the RANZCP (20), Canadian Psychiatric Society (4) and American Academy of Pediatrics (1). As mentioned above, strict criteria may not be as applicable in young people as they are in adults. The evidence would suggest that a lower threshold for admission is more appropriate in this age group. In New Zealand, inpatient treatment is provided in a variety of settings, including psychiatric wards, paediatric wards and adult medical wards. An example of this state of affairs is that at the moment in Wellington, there are 6 children and adolescents receiving inpatient treatment, 2 at the Regional Rangatahi Adolescent Inpatient Service, 2 on the Wellington hospital paediatric ward, and 2 on the Hutt hospital adult medical ward. As mentioned above, there is variability in the level of staff confidence in different units (especially paediatric wards) to manage children and adolescents with eating disorders. This often relates to the frequency with which staff deal with such conditions. Regardless of the setting (which will be discussed further in the next section of this submission), it is important that young people receive a similar standard of care with similar components of their management (medical stabilization, nutritional rehabilitation and a family based-approach). We would advocate that facilities for the inpatient treatment of children and adolescents with eating disorders should be specifically developed for this age group, should have developmentally appropriate services that are focused on family therapy and behavioural management, and should have access to adequate medical support and investigations. Adult-focused eating disorder programmes do not adequately cater for these patients as they usually have different goals and treatment objectives (ie. not focused on intensive early intervention), waiting lists, different perceptions of need for inpatient admission, slower response to lack of weight gain and less than optimal family involvement. Admission to adult units can have a negative impact on young people as association with people with more chronic forms of the disorders can lead to new learned illness behaviours and demoralization. The optimal duration in hospital has not been established. As mentioned above, the evidence supports prolonged initial admission and discharge above 90% of IBW. Currently , anecdotal evidence would suggest that there is significant variation in the length of stay of young people with eating disorders of similar severity. Part of this discrepancy is due to the difficulty of accessing inpatient beds when needed. Part of it is due to philosophical differences between paediatric wards (which are used to brief admissions lasting from hours to weeks) and psychiatric wards (which are used to long admissions lasting from days to months). Most programmes, including those at the Royal Childrens Hospital, Melbourne and the Hospital for Sick Children, Toronto have moved toward this approach. It would be good to see this trend reflected in service planning within Future Directions. Short term management The American Academy of Pediatrics (1) states that medical stabilization and nutritional rehabilitation are the most crucial determinants of short term and intermediate term outcome in the treatment of children and adolescents with eating disorders. Currently, these are being provided by primary practitioners, paediatricians and child and adolescent psychiatrists and dieticians using variable protocols. Although there is neither an internationally accepted definition of medical stability nor a universally applied nutritional rehabilitation guideline, it would be good to establish some local consensus on what standards people should use. These would have to be age-appropriate and developed by clinicians with expertise in paediatric physiology and nutrition. Adolescent physicians and paediatric dieticians have valuable knowledge to contribute to this process. Longer term management Long term management of eating disorders involves ongoing supervision of meals, weight monitoring and often long term psychotherapy. Psychotherapy for young people with AN has been shown to work better in a family-oriented fashion than an individual fashion. This is because family dynamics often contribute to or maintain the condition. Family therapy involves parental education about the disorder, strengthening of the parental subsystem and reorganization of member roles so that young people can proceed with arrested developmental tasks. The Maudsley model is an evidence based progamme of family therapy from the UK that takes a number of months to complete. Individual psychotherapy is primarily of a cognitive-behavioural modality (CBT) and involves education about the disorder, problem solving around meals and communication strategies to avoid arguments about food and weight. CBT is the best treatment for BN. Other forms of psychotherapy such as psychodynamic psychotherapy and interpersonal therapy may also be utilized for the treatment of eating disorders. Service development should take into account the integral part of psychotherapy in the management of young people with eating disorders, and ensure that treatment pathways are not merely mapped onto a medical framework. Discharge and follow-up Children and adolescents discharged from inpatient treatment will require intensive outpatient management. The Society for Adolescent Medicine (21) recommends that a smooth transition from inpatient to outpatient care can be facilitated by an interdisciplinary team that provides continuity of care in a comprehensive, coordinated and developmentally oriented manner. The recommendation for an identified person to take responsibility for this transition is appreciated. Where possible and when consented to, day programme attendance that involves not only meal supervision and therapeutic activity, but also educational or vocational rehabilitation should be provided to young people. Involuntary treatment People with the most severe eating disorders are often the least likely to seek help and will often refuse treatment, even if their condition is life threatening. It is not uncommon for children and adolescents to be managed under the Mental Health Act (or equivalent legislation) in the most countries including New Zealand, the UK, Australia and Canada. Involuntary admission has not been associated with worse outcomes, and is usually associated with the severity of their illness at that time. Most of the deaths from eating disorders occur either in the first 2 years or after 15 years of suffering. It is important to realize that what is considered early on in the history of an eating disorder is a dangerous time and can be fatal if not treated accordingly. The criteria for use of the Mental Health Act in New Zealand are clear and include the presence of a mental disorder as well as danger to either oneself or another person. The evidence presented on page 13 of the document (under secondary care) suggests that involuntary treatment is associated with worse long term outcome and that brief admissions may be associated with lower mortality. The major confounder in both of these conclusions is the severity of illness. We would advocate the removal of this paragraph, or its clarification. Nasogastric feeding The position statement from the Society for Adolescent Medicine (21) states that short term nasogastric feeding may be necessary in those hospitalized with severe malnutrition. Most inpatient treatment facilities worldwide employ nasogastric feeding in this manner. Some do not. Nasogastric feeding should occur as part of a plan of nutritional rehabilitation, and it requires the availability of facilities to undertake post-citation x-rays as well as trained nursing staff. Future Directions should recommend the provision and maintenance of skill sets required to undertake nasogastric feeding to all units where children and adolescents will be admitted. Transition to adult services The New Zealand Mental Health Survey identified the median age of onset for eating disorders to be 17 years old (this statistic may not be entirely accurate as the study only included people over the age of 16 years). Many adolescents who develop eating disorders will need to transition from paediatric and child and adolescent psychiatry services to adult medical and mental health services. Despite this fact, pathways for transition of care have not been addressed by Future Directions. Services to mothers with eating disorders Child and adolescent psychiatrists and paediatricians work with families more often than adult specialists. It is therefore of concern to us that no comment has been made about the needs of mothers with eating disorders. Although they are considered as adults and managed using a more individual framework according to current practice and plans outlined in the document, their disorders can have a significant impact on the physical and emotional health of their children. The clinical experience of child protection coordinators is that working with parents with eating disorder is complex and that their illness can at times endanger the safety of children but almost always has a significant developmental impact either directly in relation to nutrition and the role of food in the family or indirectly in terms of the ability of the parent to acknowledge or attend to the developmental needs of the child. The international literature in relation to the impact on children of growing up in a household where a parent has an eating disorder is growing and is increasingly concerning. Measures to ensure the welfare of these children and to screen them for eating disorders and other mental disorders could be recommended by Future Directions. The document could be improved by: A statement in relation to comprehensive assessment of the roles of the client A statement in relation to child and adult services working together, where a parent has an eating disorder, to support safe parenting A statement regarding the importance of the safety and welfare of the Child A definition of family to include children of the client with eating disorder Primary prevention and early detection A Cochrane review of 8 studies into primary prevention of eating disorders (18) revealed insufficient evidence to recommend any particular programme. The RANZCP guidelines indicate some promise from programmes designed to boost self esteem. Both the NICE guidelines (17) and the policy statement from the American Academy of Pediatrics (1) include suggestions for screening questions that would help primary practitioners to detect eating disorders. Future Directions acknowledges the role of primary practitioners in screening for eating disorders. Primary prevention will be an important area for ongoing research by the Eating Disorder Network and other agencies. We accept the lack of evidence to encourage its initiation at the current time. Cultural differences We acknowledge the Ministrys commitment to reduce inequalities and improve the physical and mental health of Maori and Pacific peoples. The New Zealand Mental Health Survey result published in the document indicates that eating disorders are more prevalent in Maori and Pacific people than in New Zealand Europeans. However, there is a lack of information about the age of onset and type of eating disorders, and relevant environmental factors that affect children and adolescents from these cultures. Further research into this are would be helpful to ensure that services are designed in a culturally appropriate manner. II Current Service Provision Epidemiological limitations The statistics available to us indicate the prevalence of eating disorders in New Zealand, but not the incidence of these conditions. Within an ideal early intervention service, most of the service provision and expenditure for children and adolescents who develop eating disorders would be anticipated to be directed toward new service users. Without data to inform us of how many children and adolescents, what ages, what locations and which cultural groups need these services, service planning can only occur in a non-targeted fashion. Admittedly, even with this information, future trends may vary. However, an audit of current clients may be a valuable part of the Future Directions planning process. Comment on sections I-IV of the document It would be useful in part 7 of the document to distinguish between primary care services, adult community mental health services, child and adolescent community mental health services, outpatient adult medical services, outpatient paediatric services, inpatient adult psychiatric services, inpatient adolescent psychiatric services, inpatient paediatric services, as well as private adult and adolescent eating disorder services. All of these groups provide overlapping but different services. The paragraph on public services in part 7 incorrectly states that paediatric service users may be either admitted to a medical ward or onto a combined (with other specialties) paediatric ward, while adolescent service users come under the child and youth or adult (general) mental health services within a DHB. This is not always the case. Adolescents may be admitted to general paediatric wards and adult medical wards at times. They may also be admitted, when available, to specialist adolescent psychiatric facilities. One such adolescent psychiatric facility has been significantly omitted from the description of the central region. The Regional Rangatahi Adolescent Inpatient Service (RRAIS) is a 13 bed inpatient psychiatric facility that exclusively serves adolescents aged 12-19 years and is run by Capital and Coast DHB. Although it is neither a dedicated unit for the treatment of adolescents with eating disorders, nor does it have beds that are dedicated to the treatment of these service users, it usually houses 2-3 clients with eating disorders (usually anorexia nervosa) at any given time. Adolescents admitted to RRAIS go through a formal staged, family- based programme of recovery that is based on the Maudsley Model of care. Lengths of stay are usually between 3-6 months. RRAIS provides a regional (tertiary inpatient) service to a number of other DHBs including Gisborne, Hawkes Bay, Palmerston North, and Hutt Valley DHBs, and employees from these DHBs often visit for new or updated training in working with clients with eating disorders. Families are kept involved in treatment by attendance at weekly meetings in person or via videoconference, and overnight accommodation in a whanau room and whanau flat are available to aid those with transportation problems. The staff at RRAIS includes a psychiatric consultant with extensive expertise in the management of eating disorders, nursing staff who have been trained in overseas inpatient programmes, psychologists, social workers and occupational therapists with experience of adolescents with eating disorders. There is also access to medical monitoring facilities and investigations. In addition, the unit houses a day programme and school facilities that enable adolescents with eating disorders to transition more successfully back into their communities following discharge. The list on page 19 (part 9) refers to a number of service providers. Presumably CAMHS and Child, Adolescent and Family Mental Health Services are the same type of service. Pacific Mental Health Services (there is one in Wellington) have been excluded, as have outpatient adult medical services. In addition to RRAIS, the Wellington/Hutt region possesses one of the few adolescent physicians in the country (Dr Hall) who has specialist training in the area of eating disorders. Dr Hall runs an outpatient clinic for adolescents with eating disorders at Hutt hospital and consults with inpatients at both Hutt hospital and Wellington hospital, as well as the Central Regional Eating Disorder Service. Special mention should be made of adolescent physicians within paediatric services. The role of consultation-liaison services (ie. child and adolescent psychiatry teams situated within hospitals and working with young people with psychological problems in paediatric and medical setting) has not been adequately covered in Future Directions. These services exist in a number of centres and are vital to the management of children and adolescents with eating disorders. Consultation liaison services bridge the gap between paediatric and psychiatric services and enable treatment to proceed in a person-centred, rather than service-specific manner. Resources to cover liaison with both primary health (0.7 FTEs for the 0-19 year age group/100,000 population) and general hospital (0.5 FTEs for the 0-19 year age group/100,000 population) have been committed in the MOH document Blueprint for Mental Health Services: How Thing Need to Be and should be considered during the development of future eating disorders services. The paragraph on tertiary specialist eating disorder services states that with consideration to population size and geography, the sector (Eating Disorder meeting 2007) agreed that sufficient population, resources and expertise exist to support two centres in New Zealand that will be supported by the primary and secondary eating disorder services. The location of the centres was decided based upon existing tertiary services, workforces and facilities. The centres are based in Auckland and Christchurch. These centres will provide inpatient care for the highest level of eating disorder complexity alongside their own DHB service. It would be interesting to know the data upon which this very important decision has been made. The authors of this submission are uncertain about the structure and complexity of adult eating disorder services. However, given the omission of RRAIS and access to a specialist adolescent physician from the description of child and adolescent services within the central region, and given RRAISs current provision of tertiary eating disorder beds and expertise for the lower North Island, it may make more sense to have THREE specialist eating disorder centres for children and adolescents; one in Auckland, one in Wellington and one in Christchurch. The decision between two extremes of care ie. centrally-mediated services (with tertiary centre ideals) and locally organized services (with inadequate control and potentially variable quality) is a difficult one to make, and one of the reasons for creating this document. Many clinicians have experienced difficulties in engaging with young people with eating disorders and their families when they have been removed to tertiary units and later returned to their care. We envisage that the ideal situation would involve an expert team working with local secondary care services that could deliver care as close as possible to the homes of children and adolescents. This problem is not unique to the field of eating disorders. It has been contemplated and relatively successfully achieved with illnesses such as childhood cancer. Despite the cross-specialty issues involved in the treatment of eating disorders, there are probably lessons that can be learnt from such effective models of care, and we would recommend that these are investigated by the authors of the document. A Paediatric Society publication entitled Sustainable Nationwide Services for Children and Young People 2006(26) may also be of value as it considers the issues pertaining to the delivery of health services for children and adolescents in New Zealand. We would recommend that the nine principles espoused by this document are given serious consideration. Flow diagram 1 outlines the generalized pathway of care for eating disorder service users. Despite mention of private service providers such as Ashburn Clinic in the text of the document, they are not included in this flowchart. Comments in Appendix 1 about the lack of provision of mandated care under the Mental Health Act and nasogastric feeding within the central region do not reflect current practice. Service users with severe eating disorders are often admitted to RRAIS under the Mental Health Act, and most are discharged under community treatment orders. Nasogastric feeding is occasionally employed by experienced nursing staff. III Workforce Issues Who is currently involved in managing eating disorders and what do they do? As already mentioned, a variety of clinicians are involved with children and young people with eating disorders, both in the community and on inpatient units. Paediatricians are specialists trained in caring for children. They have expertise in monitoring growth and the physical health of young people. They are also trained in pubertal staging and are familiar with interpreting medical investigations. Paediatricians have a role in the detection of eating disorders, education and primary prevention via health professionals and schools, and advocacy with organizations. They also have a role in treating the medical symptoms and complications of eating disorders. Adolescent physicians are paediatricians who have undertaken extra training in adolescent health. They are familiar with health, developmental and social issues that affect adolescents and often work with young people with eating disorders on adolescent inpatient units and in outpatient clinics. Child and adolescent psychiatrists are mental health specialists who have training in the diagnosis and treatment of mental disorders including eating disorders. They can prescribe psychotropic medication and undertake psychotherapies including family therapy. Some child and adolescent psychiatrists do not work with people with eating disorders, those who do have varying levels of experience. Child and adolescent psychiatrists are familiar with the identification of psychiatric co-morbidities and risk assessment. Some child and adolescent psychiatrists work in a consultation-liaison capacity within hospitals, and assist paediatric teams to plan and care for young people with eating disorders. They may also engage with the person and their family to commence or continue psychotherapy while they are an inpatient. Paediatric dieticians are health professionals who have been trained in the nutritional management of young people. Many work in hospitals and run outpatient clinics. Some are based in the community and work with primary physicians. Paediatric mental health nurses receive varying levels of training in working with young people with eating disorders. Those that work on tertiary units and adolescent units may be very familiar with the overall and day to day management of eating disorders, including the placement of nasogastric tubes. Child and adolescent mental health therapists include psychologists, social workers and occupational therapists. They may work within eating disorder services, other inpatient facilities, or community clinics. They may have varying levels of expertise in the development and delivery of psychologically based therapeutic programmes. Paediatric nurses are familiar with the physical management of children and have limited experience in managing young people with eating disorders. They are usually familiar with the management of nasogastric feeding. General practitioners are at the frontline for identifying and treating young people with eating disorders, but may have variable experience in managing these conditions. With government-sanctioned primary mental health services being located within PHOs, it will be important that GPs receive adequate support and direction from allied health professionals and secondary and tertiary institutions. School-based professionals including school counselors, school nurses and librarian are also at the frontline for identifying and treating young people with eating disorders, because they may witness changes in the shape and weight of pupils, identify students who are accessing resources about weight loss, and see students when they present with symptoms of hypoglycaemia or malnutrition. Comments on the workforce as referred to in the document The Society of Adolescent Medicine (21) stated that Interdisciplinary treatment of established eating disorders can be time consuming, relatively prolonged and extremely costly. Lack of care or insufficient treatment can result in chronicity with major medical complications, social and psychiatric morbidity and even death. The RANZCP guidelines (20) stated that although the treatment of eating disorders remains within the preserve of psychiatry, multidisciplinary treatment is ideal and should include a specialist in physical medicine, a dietician, nurses and other allied health specialists (such as psychologists, physiotherapists, and occupational therapists). The American Academy of Pediatrics (1) suggested a significant role for paediatricians and adolescent physicians in the diagnosis and management of eating disorders, however, it has to be noted that the practice of the former group is different to that in New Zealand (US paediatricians provide level 1 and level 2/3 services, whereas New Zealand paediatricians only provide level 2/3 services). Within New Zealand, GPs generally have a poor knowledge of eating disorders (A Hall, National Survey of GPs, unpublished research at MOH, 2003). During this survey, 40% self-identified significant knowledge deficits in assessment and management of eating disorders. Also, interestingly few had interest in further training on the subject. Most undertook only 15 minute appointments despite the fact that the establishment of a therapeutic alliance with eating disorder clients is time-consuming, and that medical monitoring and explanations are often lengthy processes. Paediatricians also identified significant areas of knowledge deficit in a similar survey (A Hall 2003). There are few adolescent physicians in New Zealand. However, they would be a valuable resource for the treatment of eating disorders and the planning of service delivery. Mental health providers are generally not trained in the specific area of child and adolescent growth and development. However, psychiatrists that work with young people with eating disorders are usually familiar with such management or have access to medical colleagues who are knowledgeable in such matters. There was virtually no mention of consultation-liaison psychiatrists in Future Directions. These practitioners play a valuable role in enabling the care of young people with complex psychiatric conditions on medical wards, and should be included in service planning strategies. Recommendation for an alternative model of specialist knowledge Having mentioned the option of THREE specialist centres for eating disorders in New Zealand as opposed to two, it may be more appropriate to create THREE SPECIALIST TEAMS for the care of children and adolescents with eating disorders. The use of a TEAM structure would allow flexibility in the types of expertise to match that available geographically, and not limit experts to inpatient eating disorder facilities. We would suggest the minimum involvement of a child and adolescent psychiatrist, adolescent physician or paediatrician, general practitioner, dietician, psychiatric nurse and a mental health therapist on each team. Most of the activities generated for the Specialist Eating Disorders Network could be undertaken by such teams, and they could meet regularly to share and update knowledge, plan research and education strategies, and discuss national issues and trends. They could also be involved in two other projects of significance: 1) the creation or absorption of a set of nationally accepted guidelines for clinical management and 2) the creation of a confidential client database to inform future service planning and delivery. Audit of planned processes and quality measurement via performance indicators would also be worthwhile endeavours with which they may become involved. Psychodynamics As mentioned in the document, psychodynamics play an important part in the management of eating disorders. The fragmented nature of the persons sense of self is often projected onto those around them. They may also be reflected in the provision of services to people with eating disorders. Strong countertransferences are encountered when working with adolescents and can lead to staff burnout. It is critical for team members to communicate with families and with each other on a regular basis to manage their feelings and to avoid becoming the objects of a splitting defense. In addition to extrinsic (financial and geographical) barriers to treatment, patients and families often demonstrate ambivalence or resistance to diagnosis and treatment, and this threatens active engagement in the recovery process. This document is a valuable means of bridging the skills and efforts of many clinicians who treat young people with eating disorders. It is important that everyone feels heard and no one feels left out during the consultation process. IV Other Comments about the Document It would be more useful if the information in the section on International comparisons (within part 6) were presented in the form of a table with comparative data. A breakdown between adult and child/adolescent statistics would have been interesting, as well as a comparison of the mean age of onset of eating disorders between countries and over time. The variability of information presented in these paragraphs would suggest difficulty in accessing such information. A clearer description of timeframes pertaining to the execution of recommendations from the document would also be appreciated. Recommendations Please review the data included in Future Directions on current service provision to children and adolescents. There seem to be some significant omissions in the description of current systems. There is adequate evidence to recommend intensive and early intervention for children and adolescents who develop eating disorders, so that individual prognosis can be improved and so that medical and psychiatric complications of the disorder can be avoided. Please consider a division of the main sections of this document into 1) adult and 2) child/adolescent services, so that the difference between the needs of younger and adult populations are adequately reflected, and so the specific needs of each population can be taken into account when planning future services. Please ensure that service planning is undertaken in accordance with existing MOH strategies such as the Blueprint for Mental Health and Youth Health: A Guide to Action, and the Paediatric Society document Sustainable Nationwide Services for Children and Young People. Please also ensure that it maintains the operational standards recommended by the consensus statements such as those produced by the Royal Australian and New Zealand College of Psychiatry, the American Academy of Pediatrics, the Society for Adolescent Medicine and the National Institute of Clinical Excellence. Please ensure that services for children and adolescents, though flexible in structure, are reasonably uniform in quality. We would recommend that the ideal service for this age group is one that includes: Early detection and community management Management by services as close to home as possible with expert supervision Intensive medical stabilization if necessary and nutritional rehabilitation Family- based therapeutic programmes Support of educational needs Educational and vocational rehabilitation Smooth transitions based upon client need and severity of illness, not service limitations Access to psychotherapeutic support at all stages of treatment Planned transition to adult care As credible as the plan to create two specialist centres may be, we would advocate for THREE specialist teams of child and adolescent experts, which may or may not be directly associated with inpatient facilities. We would appreciate further consultation with paediatricians, adolescent physicians and child and adolescent psychiatrists before the document is finalized Dr Hiran Thabrew Dr Anganette Hall Paediatric and Psychiatric Registrar Consultant Adolescent Physician Capital and Coast DHB Hutt Valley DHB References American Academy of Pediatrics. Policy Statement: Identifying and Treating Eating Disorders. Pediatrics 2003: 111(1):204-211. American Psychiatric Association Practice Guidelines for the Treatment of Patients with Eating Disorders 3rd Edition  HYPERLINK "http://www.psych.org" www.psych.org 2006 Baran et al. Low Discharge Weight and Outcome in Anorexia Nervosa. American J of Psych. 1995:152;1070-1072 Canadian Pediatric Society, Adolescent Medicine Committee. Eating Disorders in Adolescents: Principles of Diagnosis and Treatment. Pediatrics and Child Health 1988:3(3);189-192 Commerford M et al. Guidelines for Discharging Eating Disorder Inpatients. Eating Disorders 1997:6; 69-74. Crow & Nyman. The Cost Effectiveness of Eating Disorder Treatment. Int J Eating Disorders 2004: 35;155-160 Garfinkel, PE. & Dorian, BD. Factors that may Influence Future Approaches to the Treatment of Eating Disorders, Journal of Eating and Weight Disorders 1997: 2; 1-16 Crisp et al. Long-term Mortality in Anorexia Nervosa: A 20 Year Follow-up of the St Georges and Aberdeen Cohorts. British J of Psych. 1992:161;104-107 Crow S & Nyman JA. The cost-effectiveness of anorexia nervosa treatment. Int J Eating Disorders 2004:35; 155-160. Fisher et al. Eating Disorders in Adolescents: A Background Paper. Journal of Adolescent Health 1995;16:420-437 Halmi, K et al. The Changing Epidemiology of Hospitalized Eating Disorder Patients. Paper presented at Academy of Eating Disorders Conference, NY, May 4 7, 2000. Halmi, K & Licino, E. Outcome: Hospital Program for Eating Disorders. In CME Syllabus and Proceedings Summary, 142nd Annual Meeting of American Psychiatric Association, Washington, DC. Herzog D et al. Mortality in Eating Disorders: A Descriptive study. Int J Eating Disorders 2000:28;20-26 Katzman, D. Medical Complications in Adolescents with Anorexia Nervosa: A Review of the Literature. Int J Eating Disorders 2005:37; S52-S59. Kreipe et al. Treatment and outcome of adolescents with anorexia nervosa. Adolescent Medicine: State of the Art Reviews 1992:3(3);529-540 Lock J & Le Grange D. Family-based treatment of Eating Disorders. Int J Eating Disorders 2005:37; S64-S67. National Institute for Clinical Excellence (NICE). Clinical Guideline 9: Core interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Disorders 2004.  HYPERLINK "http://www.nice.org.uk" www.nice.org.uk Pratt, BM & Woolfenden, SR. Interventions for Preventing Eating Disorders in Children and Adolescents. Cochrane Database of Systemic Reviews 2002: Issue 2, Art No. CD002891 Rome,E. Children and Adolescents with Eating Disorders: The State of the Art. Pediatrics 2003:111(1) Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for the Treatment of Anorexia Nervosa. Australian and New Zealand Journal of Psychiatry 2004:38;659-670 Society of Adolescent Medicine. Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine. Journal of Adolescent Health 2003; 33: 496-503. Sokol et al. Review of clinical Research in Child and Adolescent Eating Disorders. Primary Psychiatry 2005:12(4);52-58 Steiner, H & Lock, J. Anorexia Nervosa and Bulimia Nervosa in Children and Adolescents: A Review of the Past 10 Years. J Am Acad Child Adoelsc Psychiatry 1998:37(4);352-359 Strober et al. The Long-Term Course of Severe Anorexia Nervosa in Adolescents: Survival Analysis of Recovery, Relapse, and Outcome Predictors voer 10 15 years in a Prospective Study. Int J Eating Disorders 1997:22(4); 339-360 Sullivan, PF. Mortality in Anorexia Nervosa. American Journal of Psychiatry 1995: 152(7),10731074. Paediatric Society of New Zealand Sustainable Tertiary Services for Children and Young People November 2006.  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The Paediatric Society believes all children and youth should, by right, attain optimal physical, mental and social health and wellbeing.  By working as a coordinated national network of health professionals the Society dedicates its efforts and resources to making official submissions to both Government and Non-Government organisations on issues that will impact on the health and wellbeing of children and young people.

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