With the start of every autumn term, we in Camhs eating disorders services wait for the flurry of new referrals to roll in. They typically say something like: “Parents hadn’t noticed how thin their child had got until they saw them in their swimming costume over the summer.”
Because of the effects of undereating on motivation and meta-cognition, our first priority is always physical rehabilitation. Psychological therapy is unlikely to be successful until the chronic and acute effects of starvation are reduced.
We recommend to families that they feed their child six times a day: three meals and three snacks, and that, for each of these, the child is supervised or supported. Children and adolescents need to learn to eat regularly and sufficiently in their homes, their schools and their communities. Inpatient units are a last resort for those who are the most seriously ill, and it is best for young people to stay in their own communities if at all possible.
Battle against guilt
So, where does that leave schools? Generally, a morning snack and lunch need to be eaten in school by our patients, and they will in all likelihood need supervision and possibly support to eat it. The battle of an eating disorder is a battle against the guilt of eating. Having supervision and support means the young person doesn’t feel they have a choice to eat, and so the guilt is reduced.
Once regular eating is established, we are (generally) on an upward trajectory to recovery. Although some young people may need psychological therapy to break disordered patterns of thinking about food, a significant number find that the psychological hold the disease has over them fades away, once they are nutritionally rehabilitated.
In the eating-disorders world, we talk a lot about “meal plans”, by which we mean a set amount and usually type of food that the young person has to eat that day. We do this to take away the negotiation and arguments about food. To have a meal plan provides clarity, and reduces anxiety.
We very much see the meal plan as the medicine. Many anorexic patients feel full very quickly, because they are not used to having enough food in their stomachs, and because gastric emptying can be delayed. Therefore, most need to eat little and often. If they can’t eat at school, they can’t recover.
Lies and avoidance
Young people with eating disorders often have an incredibly high drive to avoid food generally, or to avoid specific foods (carbs, for example) or amounts of food (for example, they might eat half a sandwich).
The eating disorder is like an addiction, and it will drive them to lie about food intake. We say to parents that, if you haven’t seen them eat it, they probably haven’t. Some of our patients will drop food on the floor. Others will stuff it up their sleeves or into their pockets, cough it out into a tissue, or cut it up and smear it over the plate to avoid eating it.
When they are in school, lots of our patients will need the presence of a kind adult in a quiet room at lunchtime in order to be able to eat. No particular skill or expertise is required from the adult: usually the supervision alone gives them the necessary push they need to eat.
My team, the Royal Free London NHS Trust, works across five boroughs. On our patch, we have some of the schools that regularly top the league tables, and we have areas of extreme social deprivation.
Lunch in the car
While we don’t have the wherewithal to monitor statistics, it seems we pick up proportionally more patients from the selective and girls’ schools than any others. Yet what is offered in terms of support by schools to pupils with eating disorders varies widely, with no obvious pattern in terms of school type.
One well-known, high-achieving local school, regularly featuring high in league tables, will not offer any supervision or support at mealtime for young people. Indeed, they will not even provide a room for the pupil to have a supported lunch with their parents. We have had many patients there over the years, and some have had to go and sit in the local pub each day – or even eat in the car – so that their parent can support them to eat.
Other schools are able to offer much more. Often pupils with eating disorders will eat supervised or supported by the school nurse/head of year/class teacher, away from their friends and the canteen. Usually that member of staff will regularly report back to the parents about what the young person has eaten.
Sometimes canteens are primed to provide a particular food (saving some back, if necessary) for our eating-disorders patients. Some teachers are prepared to do distant supervision: seemingly wandering around the canteen, but really keeping an eye on the young person as they eat with a group of peers in the canteen. Some schools form a group of pupils with eating disorders, although that is rarely helpful, as the young people will often trigger each other to eat less.
Can I just say thank you to these teachers and schools? You make a huge difference in helping these pupils recover from a serious mental-health condition.
A manipulative disorder
My top tips to these schools would be:
- Remember that an eating disorder can be a manipulative disorder, even in the most compliant child. If you don’t watch, they may not be able to resist the temptation to stuff their sandwich in a pocket.
- Please think about appropriate conversation, and avoid anything about dieting, your own eating habits or body dissatisfaction. Someone with an eating disorder, however thin, would likely think that you are choosing that topic because you think they are fat.
Some schools have family-style lunches, where teachers eat with the pupils and there is a group responsibility for conversation and clearing up. I can only think this would be a good thing in terms of avoiding, noticing and treating eating disorders. Obviously, it raises logistical issues for teachers, who may want a well-earned break away from the children. But, in terms of placing eating in a social and cultural context, it is undoubtedly a positive thing.
An eating disorder is a complex psychological and physical health condition, potentially with long-term consequences, and has the highest rate of mortality of any mental disorder.
A sobering thought. And another example where the two over-stretched organisations, health and education, have to stretch even further to accommodate young people, and to help them to flourish.
Dr Tara Porter is a clinical psychologist at the Royal Free London NHS Trust and Anna Freud National Centre for Children and Families, as well as Tes' mental health columnist. She tweets as @drtjap. The views expressed are her own