New Treatment Options for Children with Eating Disorders
By Mary K. Stein, Managing Editor
Although most very young children seriously ill with eating disorders have usually been treated in traditional eating disorders units, clinicians have learned that these patients have special needs that might not be met in programs originally designed for adolescents and young adults. As a result, a number of inpatient programs designed just for children have emerged in the past few years. The following are only a few of the growing number of programs specially designed to treat children.
Rhodes Farm: The First Unit Just for Children
In 1991, Rhodes Farm, near London, became the first treatment unit designed specially for the treatment of children with eating disorders. At the 32-place unit, family involvement is paramount, and patients are not admitted when their parents do not agree to attend regularly scheduled family meetings with Medical Director and founder Dr. Dee Dawson, or staff nurses. Parents are asked to attend sessions every two weeks or weekly sessions when necessary.
At Rhodes Farm, re-feeding is also a priority. Following the primary objective to restore the child's health, the staff places its first emphasis on restoring weight and health. According to the staff, very few children refuse to eat and, when this happens, nasogastric tube feeding may be ordered. Appropriate therapy can then follow. The nutrition program is designed so that the weekly weight gain target is 1 kg (2.2 lb).
Once weight is restored, the children can eat a wide variety of "normal" foods, including chicken burgers, pizza, and chocolate. The goal is to send children home without fear of food and to help them give up antisocial eating behaviors and rituals.
All young patients also undergo individualized treatment based on medical, psychiatric, psychological, psychosocial and nutritional assessment. The treatment team includes a primary care physician, a child psychiatrist, a child psychologist, a master's level therapist who leads individual and group sessions, and a registered dietitian. Registered nurses, a mental health technician, and practical nurses are on duty around the clock. A family therapist provides individualized family therapy, and an education coordinator is also on hand. The coordinator arranges with the girl's regular school to continue her classes while she is away from home.
Remuda Ranch: Addressing the Special Needs of Young Children
In May, Remuda Ranch in Wickenburg, AZ, opened a treatment unit exclusively for young children. It is the first non-institutional treatment center in the country that is specifically designed for young children with eating disorders. Marian Eberly, RN, LCSW, vice president of patient care services, developed the program in response to increasing calls for treatment for girls from 9 to 12 years of age. Before this, treating pre-teens usually involved children from rural areas who had no other access to treatment.
Several factors unique to young children become important to successful treatment, according to Eberly. The first is the challenge of separating the child from the family for treatment. The Remuda program involves the family to a greater degree than many other programs specifically designed for children, she said. Since the minimum treatment stay is 60 days, there were initial concerns about possible separation trauma. However, families are invited to visit several times during the treatment, and stay near the Ranch. All parental visits are optional. The first visit is from 1 to 3 days. At the first visit, parents meet with members of the treatment team. Psychological testing is provided and they have a chance to establish rapport with the treatment team. Parents are encouraged to contact the staff at any time. At each visit, parents are involved in a progressive structured program, with assignments. Visitation is limited because of family dynamics and enmeshment issues that might interfere with treatment.
A second challenge in designing the program was taking into consideration the fact that a child is at a different developmental stage than an adolescent or young adult. For example, children under 13 years of age are more likely to be more concrete thinkers, not abstract thinkers like older children and young adults, according to Marian Eberly. A third factor is the high incidence of obsessive-compulsive disorder seen in the younger patients.
Physiologic factors also become important. Children lose weight more quickly and develop medical problems more quickly than adolescents. Thus, when a child is admitted, clinicians need to act rapidly to begin re-feeding these young patients. "When we see them for the first time, the medical treatment tends to be a frontline effort," Eberly said. One positive factor is that younger children also tend to be more compliant and are easier to re-feed than older patients, she added. Young children are also less resistant to treatment than adolescents, and most improve more quickly than the more resistant teens.
"We are building on a progressive program with the parents as well as the child," Eberly said. "Our goal with parents is to help them build their confidence so they can take their child home, knowing they now have the skills to care for their child and a better understanding of the disorder," she said. Parents may be exacerbating the disorder, and the staff explains the causality of eating disorders and work to reduce the shame and guilt parents may be experiencing.
Most treatment centers offer a variety of activities and special therapies for the young patient. The children's program at Remuda Ranch was designed around the developmental needs of younger patients and includes strong experiential programs. The program includes equine therapy, where patients ride and care for their own horses, art therapy, body image therapy, creative movement, leisure activities, and experiential nutrition classes.
Children's Hospital, Omaha: A Multi-faceted Treatment Team
Children's Hospital and Creighton University School of Medicine, Omaha, NE, have developed a new eating disorders program designed for children and teens under 20 years of age. This program offers inpatient, day hospital, and outpatient services for youngsters with eating disorders and problems, including anorexia nervosa, bulimia nervosa, binge eating disorder, compulsive overeating, and feeding disorders.
The program is headed by Mae Sokol, MD, a child and adolescent psychiatrist. Dr. Sokol was the first to describe infection-triggered anorexia nervosa (pediatric neuropsychiatric disorder associated with streptococcus, or PANDAS) (see EDR, Sept.-Oct. 2001). She heads a multidisciplinary team, which uses a biopsychosocial approach to treatment. Each patient's treatment team includes a child and adolescent psychiatrist, pediatrician and a social worker. A clinical psychologist, dietitians, physical and activity therapists, a teacher, and a chaplain round out the treatment team.
The Children's Hospital Eating Disorders Program focuses not only on rapid control of symptoms and re-feeding but also on enhancing development to prevent the effects of eating disorders later in life. Since malnourishment interferes with development of muscle mass and normal growth of brain cells, treatment is designed to help patients develop healthier lifestyles and to understand the issues underlying their symptoms. First, the numerous physical and nutritional complications of the eating disorder are assessed and treated. Once the child is in a healthy nutritional state and active eating disorder symptoms are under control, psychological treatment can begin.
The partial hospitalization program offers an intermediate level of support and intervention for patients who need more support than outpatient services provide, but whose symptoms are less serious than those requiring inpatient hospitalization. In this program, patients do not stay overnight. An outpatient program is available for individuals who do not need full-time hospitalization. A diagnosis is established based on psychiatric, medical, nutritional, psychological, family, fitness and nursing assessments. The goal of outpatient consultation and treatment is to help reduce the frequency and severity of eating disorders symptoms. Treatment is coordinated with the referring clinician at all points from admission throughout treatment and in discharge planning.
Kartini Clinic: Working Closely with a Local Hospital
In Portland, OR, The Kartini Clinic offers treatment for children as young as 6 years of age. The Clinic's program for young children involves initial treatment at the Legacy Emanuel Children's Hospital in Portland. Once admitted, all patients are placed on telemetry, and most are fed orally. Only a few require nasogastric tube feeding. Family therapy is a mandatory part of the service, and family therapists meet with parents and patients weekly. Parents may stay with their child as much as they want, and siblings may visit, when this is cleared by the doctors. Friends and relatives may not visit.
After the child's weight has stabilized, he or she is admitted to one of two day treatment programs. The first program, the Legacy Emanuel Day Treatment Unit, is a partial hospitalization unit designed for children with restricting form of anorexia nervosa only. To be admitted, a patient must be medically stable and must be able to eat solid food. The program is held five days a week, and children go home at night and on weekends.
The day treatment program also consists of group therapy, child psychiatric evaluation, and family therapy. Activities include massage therapy, weekly art therapy , yoga/movement, nutrition class, dance, physical therapy, occupational therapy and educational classes.
The second day program, the Kartini Clinic Day Treatment Unit, uses a multi-modal approach to treating children as young as 6 who have binge-purge anorexia nervosa, bulimia nervosa, and related disorders. All care is provided at the Kartini Clinic. Physicians monitor patients throughout the week and weekly nutrition group sessions for parents and their children.
Outpatients see the medical doctor once a week, the family therapist/educator once a week for nutrition and family issues, and group therapy sessions are held once a week. An outpatient program is also available for obese children. Some children may be followed individually by psychiatric nurse practitioners or by a masters' level therapist. As the patient improves and the disease goes into remission, the number of visits is reduced substantially.
The Goal: Returning the Child to Normal Childhood
All programs work to help children return home healthier and with new skills and parental support. Marian Eberly of Remuda Ranch added, "If we pay attention and value the activities that we do with the children, we have a renewed sense that we need to value the simple things. The key is to be very intuitive and to find what matters to these children and to communicate with them. We need to find what helps to restore their joy," she said.