FUTURE DIRECTIONS FOR THE CARE,

MANAGEMENT, AND TREATMENT FOR SERVICE

USERS WITH EATING DISORDERS IN
NEW ZEALAND
A submission on beha! o! membe"s o! #he $ae%ia#"i& So&ie#' o!
Ne( Zeaan% an% #he Ne( Zeaan% Fa&u#' o! Chi% an%
A%oes&en# $s'&hia#"is#s #o #he Men#a Hea#h Di)ision o! #he
Minis#"' o! Hea#h
*une +,, -../
In#"o%u&#ion
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
!"#.
The New Zealand $aculty of %hild and &dolescent Psychiatrists is an independent society
of health professionals who deliver mental health services to children and adolescents in
New Zealand. The society comprises primarily of psychiatric consultants, as well as
some psychiatric registrars. 't has a membership of appro(imately )" people.
The authors
*r +iran Thabrew is a psychiatric registrar, employed at %apital and %oast *istrict
+ealth ,oard, and is currently completing his final year of dual fellowship training in
paediatrics and child and adolescent psychiatry. +e has worked with children and
adolescents with eating disorders at the -egional -angatahi &dolescent 'npatient Service
and in a liaison capacity at .ellington +ospital. +e has also worked as a paediatric
registrar in the %linical Services division at the /inistry of +ealth.
*r &nganette +all is an adolescent physician who is employed by +utt 0alley *istrict
+ealth ,oard. She has completed e(tensive training in the diagnosis and management of
eating disorders at the +ospital for Sick %hildren Toronto, where she worked on their 12
bed inpatient unit and was involved in the day treatment and outpatient treatment
programmes under the supervision of *r *ebra 3at4man. She has also visited eating
disorder services in Sydney (.estmead %hildren5s +ospital and /elbourne (-oyal
%hildren5s +ospital and currently consults to the %entral -egional 6ating *isorder
Service at 7ohnsonville, .ellington. *r +all has also worked as a paediatric registrar in
the %linical Services division at the /inistry of +ealth.
*iscussion and timeframe
.e received the consultation draft of 8$uture *irections9: via the New Zealand
Paediatric Society on Tuesday the )
th
of 7une. $ollowing a telephone discussion, we
made a re;uest for comments from members of both the Paediatric Society and the New
Zealand $aculty of %hild and &dolescent Psychiatrists via email. .e subse;uently
drafted this submission and circulated it to the same professional groups for review
between the 11
th
and 1#
th
of 7une. The final version was dispatched to the /inistry of
+ealth on .ednesday the 12
th
of 7une. *ue to the limited timeframe, all points of view
may not have been ade;uately reflected by this submission.
Gene"a Commen#s abou# #he %o&umen#
Positive comments
.e acknowledge the efforts of the /inistry of +ealth to rectify the issues of variable
service delivery, inconsistent access to services, and bed and workforce shortages that
undermine current efforts to provide service users with a smooth and fle(ible package of
care from onset to recovery from their illness e(perience. &s gathered by the /inistry,
and evident at an operational level, a review of eating disorder services in New Zealand is
well overdue.
Scope of the document
.e note that 8$uture *irections9: aims to cover a broad set of aims as outlined in
section ! of the document including<
= & summary of current eating disorder services
= & summary of the collaboration between these agencies
= & discussion of staffing issues and workforce development
= The development of a whole systems approach to the management of eating
disorders
= >uidelines for delivering eating disorder services
= Plans for ongoing consultation and service development
.e also note that the document is intended to sit alongside the 6ating *isorder Service
Specification on the Nationwide Service $ramework ?ibrary, which will be developed by
*+,s in collaboration with the /inistry of +ealth. .e therefore assume that 8$uture
*irections: is not an evidence=based guideline for clinical practice akin to the National
'nstitute of %linical 6(cellence (N'%6 guidelines published in the @3 in #""!(1A.
+owever, 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
&s we both work with children and adolescents, we shall try to limit ourselves to
comments on this age group. .e shall divide the main body of our submission into the
following sections<
' %hildren and &dolescentsBCoung People ('ssues we would like to see better
addressed by the document
'' %urrent Service Provision
''' .orkforce 'ssues
'0 Dther %omments about the *ocument
I Chi%"en an% A%oes&en#s01oun2 $eo3e
*escription of the conditions
&s mentioned in 8$uture *irections9:, eating disorders are defined by *S/='0 T- 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
*S/, namely &nore(ia Nervosa (&N, ,ulimia Nervosa (,N and 6*NDS (6ating
*isorder=Not Dtherwise Specified. The e(act origin and nature of eating disorders
remains unknown. They are best conceptuali4ed as psychological disorders with medical
manifestations and complications.
Pure forms of eating disorders are rare. Psychiatric co=morbidities are common and
include affective disorders ()"E, an(iety disorders (especially social phobia and D%*
(2"=F)E, substance abuse (1#=#1E with &N, G=))E with ,N, and personality disorders
(#"=H"E(#1. & lack of consideration of the true comple(ity of eating disorders will lead
to the development of health care systems that do not truly meet the needs of people with
these conditions. S's#ems !o" #he i%en#i!i&a#ion o! 3s'&hia#"i& &o4mo"bi%i#ies %o no#
a33ea" #o be a%e5ua#e' a%%"esse% in 6Fu#u"e Di"e&#ions78
6ating disorders are serious and lethal. %row and Nyman (F reported a long term
mortality rate of 1"E in &N. *eath occurs secondary to physical (usually cardiac
complications of malnutrition as well as due to suicide. +er4og (12 showed that the
suicide rate was )H times greater in eating disordered women than in those without an
eating disorder. Sullivan (#) conducted a meta=analysis of !# studies on patient
mortality and found that )!E died from complications of eating disorders, #AE died from
suicide and 1GE died from otherBunknown causes. The mortality rate increases with the
duration of symptoms. The &P& (# ;uoted a mortality rate of )E at ) years and #"E a
#" years after diagnosis. A 3a#ien#s shou% be s&"eene% !o" #he "is9 o! sui&i%e.
8$uture *irections: does not ade;uately describe how this will be facilitated, especially
by level 1 services.
Ninety percent of eating disorders develop before the age of #) years, and the peak age
for onset is 12=1! 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 H years of age.
6ating disorders are generally reported to have a prevalence of ".)E in adolescents, and
this makes them the third most common chronic disease of adolescence following obesity
and asthma8 In #his a2e 2"ou3, #hese %iso"%e"s a"e #en #imes as &ommon as insuin4
%e3en%en# %iabe#es mei#us, an% mo"e i9e' #o be %ebii#a#in2 #o in%i)i%uas8
Ho(e)e", DH:s o!#en !ai #o 3"o)i%e a%e5ua#e #"ea#men# an% moni#o"in2 !o" #hese
se")i&e use"s.
.hat is different about children and adolescents with eating disordersI
1. Mo"e #han ha! o! &hi%"en an% a%oes&en#s (i#h ea#in2 %iso"%e"s %o no# mee# #he
&"i#e"ia !o" AN o" :N (hie s#i e;3e"ien&in2 #he same me%i&a an% 3s'&hoo2i&a
&onse5uen&es o! #hese %iso"%e"s an% "e5ui"in2 #he same &a"e!u a##en#ion as #hose
(ho %o. (1. &lthough perceived as less dangerous, 6*NDS (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 se;uelae, especially cardiovascular compromise, can occur
unnoticed. 6ven those who look and feel deceptively well with normal 6%>5s may have
cardiac irregularities, variations in pulse and blood pressure, and be at risk of sudden
death (#. & statement by the adolescent medical committee of the %anadian Psychiatric
Society (! 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. 'n general, 6*NDS should be
managed in a manner similar to the maJor eating disorder that it most resembles.
#. Chi%"en an% a%oes&en#s a"e 3"one #o uni5ue me%i&a &om3i&a#ions o! ea#in2
%iso"%e"s including growth retardation (that is potentially reversible before the closure of
epiphyses, pubertal delay or arrest, and impaired ac;uisition 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 (!. *ue to
the reversibility of such complications, most clinicians would argue that younger people
need more intense and aggressive treatment than adults. & position statement by the
Society for &dolescent /edicine (#1 stated that 8because 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.
2. 1oun2e" 3eo3e a"e mo"e i9e' #o "e5ui"e a%mission. Some studies indicate
admission rates of up to H"E for this age group. The -&NZ%P guidelines for the
treatment of eating disorders (#" state that for non=severe &N, outpatient treatment may
be preferable. &s mentioned above, the definition of severity is not straightforward in
young people and so this recommendation may have to be rationali4ed. The &merican
&cademy 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). ospitali!ation which allows for adequate weight
gain in addition to medical stabili!ation and the establishment of safe and healthy eating
habits improves the prognosis in children and adolescents.

!. Counger people are more likely to recover fully and to have good results with
intensive treatment. A !u an% ea"' &ou"se o! #"ea#men# is &os#4e!!e&#i)e !o" #"ea#in2
ea#in2 %iso"%e"s. +almi (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. +almi and ?icino (1# showed that patients with &N who
reach GHE ideal body weight (',. were less likely to relapse than those who achieved
only H2E ',.. ,aran (2 showed that patients who achieved GFE ',. over 11F days in
hospital had only a AE rate of rehospitalisation and 1GE rate of persistent anore(ic
symptoms compared with those who achieved only AFE ',. and had a F#E rate of
rehospitalisation and )AE rate of persistent anore(ic symptoms. >arfinkel (A showed
that half of people followed up for )=1" years recover fully, #)E recover partially, and
#)E remain ill or die. Studies of people with ,N also show that the recovery rate is
better when treatment commences sooner (H"E if commenced within ) yrs of onset, vs
#"E if commenced at 1)yrs after onset.
). E)i%en&e base% "esea"&h su33o"#s #he use o! !ami'4base% #"ea#men# !o" &hi%"en
an% a%oes&en#s (i#h AN. &lthough 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 ade;uately stated. /odern staged family=based
programmes such as the 8/audsley /odel: 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. 6ducating the
parents in this way ensures a smoother transition home and better long term care and
family functioning (1F.
Problems with delivery of care for children and adolescents with eating disorders
These issues have been succinctly described in section H of 8$uture *irections9:, ie.
= Shortage of specialist eating disorder e(pertise in child and adolescent mental
health services (%&/+S
= ?ack of eating disorder e(pertise in paediatric wards
= *ifficulties in establishing a multi=disciplinary team across health (%&/+S,
paediatrics, dietetics, primary care on a case=by=case basis
= ?ack of process for specialist eating disorder supervision of teams
.e agree with all of these statements and list some other issues of concern below.
&dmission to hospital
%riteria for the admission of children and adolescents to hospital have been described by
the -&NZ%P (#", %anadian Psychiatric Society (! and &merican &cademy of
Pediatrics (1. &s 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.
'n New Zealand, inpatient treatment is provided in a variety of settings, including
psychiatric wards, paediatric wards and adult medical wards. &n e(ample of this state of
affairs is that at the moment in .ellington, there are F children and adolescents receiving
inpatient treatment, # at the -egional -angatahi &dolescent 'npatient Service, # on the
.ellington hospital paediatric ward, and # on the +utt hospital adult medical ward. &s
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 fre;uency with which staff deal with such conditions.
-egardless of the setting (which will be discussed further in the ne(t section of this
submission, it is important that young people receive a similar standard of care with
similar components of their management (medical stabili4ation, nutritional rehabilitation
and a family based=approach. .e 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
ade;uate medical support and investigations.
&dult=focused eating disorder programmes do not ade;uately 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.
&dmission 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 demorali4ation.
The optimal duration in hospital has not been established. &s mentioned above, the
evidence supports prolonged initial admission and discharge above G"E of ',..
%urrently , 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. /ost programmes, including those at the -oyal
%hildren5s +ospital, /elbourne and the +ospital for Sick %hildren, Toronto have moved
toward this approach. I# (ou% be 2oo% #o see #his #"en% "e!e&#e% in se")i&e 3annin2
(i#hin 6Fu#u"e Di"e&#ions<7.
Short term management
The &merican &cademy of Pediatrics (1 states that medical stabili4ation 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. %urrently,
these are being provided by primary practitioners, paediatricians and child and adolescent
psychiatrists and dieticians using variable protocols. &lthough 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 e(pertise in paediatric physiology and nutrition. &dolescent
physicians and paediatric dieticians have valuable knowledge to contribute to this
process.
?onger term management
?ong term management of eating disorders involves ongoing supervision of meals,
weight monitoring and often long term psychotherapy. Psychotherapy for young people
with &N 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.
$amily therapy involves parental education about the disorder, strengthening of the
parental subsystem and reorgani4ation of member roles so that young people can proceed
with arrested developmental tasks. The 8/audsley model: is an evidence based
progamme of family therapy from the @3 that takes a number of months to complete.
'ndividual psychotherapy is primarily of a cognitive=behavioural modality (%,T and
involves education about the disorder, problem solving around meals and communication
strategies to avoid arguments about food and weight. %,T is the best treatment for ,N.
Dther forms of psychotherapy such as psychodynamic psychotherapy and interpersonal
therapy may also be utili4ed 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.

*ischarge and follow=up
%hildren and adolescents discharged from inpatient treatment will re;uire intensive
outpatient management. The Society for &dolescent /edicine (#1 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 8identified person:
to take responsibility for this transition is appreciated. .here 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.
'nvoluntary 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. 't is not uncommon
for children and adolescents to be managed under the /ental +ealth &ct (or e;uivalent
legislation in the most countries including New Zealand, the @3, &ustralia and %anada.
'nvoluntary admission has not been associated with worse outcomes, and is usually
associated with the severity of their illness at that time. /ost of the deaths from eating
disorders occur either in the first # years or after 1) years of suffering. 't is important to
reali4e that what is considered Kearly on5 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
/ental +ealth &ct in New Zealand are clear and include the presence of a mental
disorder as well as danger to either oneself or another person. The e)i%en&e 3"esen#e%
on 3a2e +, o! #he %o&umen# =un%e" >se&on%a"' &a"e?@ su22es#s #ha# in)oun#a"'
#"ea#men# is asso&ia#e% (i#h (o"se on2 #e"m ou#&ome an% #ha# b"ie! a%missions ma'
be asso&ia#e% (i#h o(e" mo"#ai#'8 The maAo" &on!oun%e" in bo#h o! #hese
&on&usions is #he se)e"i#' o! iness8 We (ou% a%)o&a#e #he "emo)a o! #his
3a"a2"a3h, o" i#s &a"i!i&a#ion.
Nasogastric feeding
The position statement from the Society for &dolescent /edicine (#1 states that short
term nasogastric feeding may be necessary in those hospitali!ed with severe
malnutrition. /ost 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 re;uires the availability of facilities to undertake post=
citation (=rays as well as trained nursing staff. 6Fu#u"e Di"e&#ions<7 shou%
"e&ommen% #he 3"o)ision an% main#enan&e o! s9i se#s "e5ui"e% #o un%e"#a9e
naso2as#"i& !ee%in2 #o a uni#s (he"e &hi%"en an% a%oes&en#s (i be a%mi##e%.
Transition to adult services
The New Zealand /ental +ealth Survey identified the median age of onset for eating
disorders to be 1A years old (this statistic may not be entirely accurate as the study only
included people over the age of 1F years. /any adolescents who develop eating
disorders will need to transition from paediatric and child and adolescent psychiatry
services to adult medical and mental health services. Des3i#e #his !a&#, 3a#h(a's !o"
#"ansi#ion o! &a"e ha)e no# been a%%"esse% b' 6Fu#u"e Di"e&#ions<7.
Services to mothers with eating disorders
%hild and adolescent psychiatrists and paediatricians work with families more often than
adult specialists. 't is therefore of concern to us that no comment has been made about
the needs of mothers with eating disorders. &lthough 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 e(perience of child protection
coordinators is that working with parents with eating disorder is comple( 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.
Measu"es #o ensu"e #he (e!a"e o! #hese &hi%"en an% #o s&"een #hem !o" ea#in2
%iso"%e"s an% o#he" men#a %iso"%e"s &ou% be "e&ommen%e% b' 6Fu#u"e
Di"e&#ions<7. The document could be improved by<
= & statement in relation to comprehensive assessment of the roles of the client
= & statement in relation to child and adult services working together, where a
parent has an eating disorder, to support safe parenting
= & statement regarding the importance of the safety and welfare of the %hild
= & definition of family to include children of the client with eating disorder
Primary prevention and early detection
& %ochrane review of H studies into primary prevention of eating disorders (1H revealed
insufficient evidence to recommend any particular programme. The -&NZ%P guidelines
indicate some promise from programmes designed to boost self esteem. ,oth the N'%6
guidelines (1A and the policy statement from the &merican &cademy of Pediatrics (1
include suggestions for screening ;uestions that would help primary practitioners to
detect eating disorders. 8$uture *irections9: acknowledges the role of primary
practitioners in screening for eating disorders. Primary prevention will be an important
area for ongoing research by the 6ating *isorder Network and other agencies. .e accept
the lack of evidence to encourage its initiation at the current time.

%ultural differences
.e acknowledge the /inistry5s commitment to reduce ine;ualities and improve the
physical and mental health of /aori and Pacific peoples. The New Zealand /ental
+ealth Survey result published in the document indicates that eating disorders are more
prevalent in /aori and Pacific people than in New Zealand 6uropeans. +owever, 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. $urther
research into this are would be helpful to ensure that services are designed in a culturally
appropriate manner.
II Cu""en# Se")i&e $"o)ision
6pidemiological limitations
The statistics available to us indicate the prevalence of eating disorders in New Zealand,
but not the incidence of these conditions. .ithin an ideal early intervention service, most
of the service provision and e(penditure for children and adolescents who develop eating
disorders would be anticipated to be directed toward 8new: service users. .ithout data
to inform us of how many children and adolescents, what ages, what locations and which
cultural groups need these services, service planning can only occur in a non=targeted
fashion. &dmittedly, even with this information, future trends may vary. +owever, an
audit of current clients may be a valuable part of the 8$uture *irections9: planning
process.
%omment on sections '='0 of the document
't would be useful in part A 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. &ll of these
groups provide overlapping but different services.
The paragraph on public services in part A 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 *+,. This is not always the case. &dolescents
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.
Dne such adolescent psychiatric facility has been significantly omitted from the
description of the central region. The -egional -angatahi &dolescent 'npatient Service
(--&'S is a 12 bed inpatient psychiatric facility that e(clusively serves adolescents aged
1#=1G years and is run by %apital and %oast *+,. &lthough 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 clients with eating
disorders (usually anore(ia nervosa at any given time. &dolescents admitted to --&'S
go through a formal staged, family= based programme of recovery that is based on the
/audsley /odel of care. ?engths of stay are usually between 2=F months. --&'S
provides a regional (tertiary inpatient service to a number of other *+,s including
>isborne, +awkes ,ay, Palmerston North, and +utt 0alley *+,s, and employees from
these *+,s often visit for new or updated training in working with clients with eating
disorders. $amilies 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 --&'S
includes a psychiatric consultant with e(tensive e(pertise in the management of eating
disorders, nursing staff who have been trained in overseas inpatient programmes,
psychologists, social workers and occupational therapists with e(perience of adolescents
with eating disorders. There is also access to medical monitoring facilities and
investigations. 'n 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 1G (part G refers to a number of service providers. Presumably %&/+S
and %hild, &dolescent and $amily /ental +ealth Services are the same type of service.
Pacific /ental +ealth Services (there is one in .ellington have been e(cluded, as have
outpatient adult medical services. 'n addition to --&'S, the .ellingtonB+utt region
possesses one of the few adolescent physicians in the country (*r +all who has
specialist training in the area of eating disorders. *r +all runs an outpatient clinic for
adolescents with eating disorders at +utt hospital and consults with inpatients at both
+utt hospital and .ellington hospital, as well as the %entral -egional 6ating *isorder
Service. S3e&ia men#ion shou% be ma%e o! a%oes&en# 3h'si&ians (i#hin 3ae%ia#"i&
se")i&es.
The "oe o! &onsu#a#ion4iaison se")i&es =ie8 &hi% an% a%oes&en# 3s'&hia#"' #eams
si#ua#e% (i#hin hos3i#as an% (o"9in2 (i#h 'oun2 3eo3e (i#h 3s'&hoo2i&a
3"obems in 3ae%ia#"i& an% me%i&a se##in2@ has no# been a%e5ua#e' &o)e"e% in
6Fu#u"e Di"e&#ions<7. These services e(ist in a number of centres and are vital to the
management of children and adolescents with eating disorders. %onsultation liaison
services bridge the gap between paediatric and psychiatric services and enable treatment
to proceed in a person=centred, rather than service=specific manner. -esources to cover
liaison with both primary health (".A $T6s for the "=1G year age groupB1"","""
population and general hospital (".) $T6s for the "=1G year age groupB1"","""
population have been committed in the /D+ document 8,lueprint for /ental +ealth
Services< +ow Thing Need to ,e: and should be considered during the development of
future eating disorders services.
The paragraph on tertiary specialist eating disorder services states that 8with
consideration to population si!e and geography, the sector ("ating #isorder meeting
$%%&) agreed that sufficient population, resources and e'pertise e'ist to support two
centres in (ew )ealand that will be supported by the primary and secondary eating
disorder services. *he location of the centres was decided based upon e'isting tertiary
services, workforces and facilities. *he centres are based in +uckland and Christchurch.
*hese centres will provide inpatient care for the highest level of eating disorder
comple'ity alongside their own #, service.: 't 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 comple(ity of adult eating disorder services.
+owever, given the omission of --&'S and access to a specialist adolescent physician
from the description of child and adolescent services within the central region, and given
--&'S5s current provision of tertiary eating disorder beds and e(pertise for the lower
North 'sland, i# ma' ma9e mo"e sense #o ha)e THREE s3e&iais# ea#in2 %iso"%e"
&en#"es !o" &hi%"en an% a%oes&en#sB one in Au&9an%, one in Wein2#on an% one in
Ch"is#&hu"&h.
The decision between two e(tremes of care L ie. centrally=mediated services (with
tertiary centre ideals and locally organi4ed services (with inade;uate control and
potentially variable ;uality L is a difficult one to make, and one of the reasons for
creating this document. /any clinicians have e(perienced 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. .e envisage that the ideal situation would
involve an e(pert 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 uni;ue
to the field of eating disorders. 't has been contemplated and relatively successfully
achieved with illnesses such as childhood cancer. *espite 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.
& Paediatric Society publication entitled 8Sustainable Nationwide Services for %hildren
and Coung People #""F:(#F may also be of value as it considers the issues pertaining to
the delivery of health services for children and adolescents in New Zealand. .e would
recommend that the nine principles espoused by this document are given serious
consideration.
$low diagram 1 outlines the generali4ed pathway of care for eating disorder service users.
*espite mention of private service providers such as &shburn %linic in the te(t of the
document, they are not included in this flowchart.
%omments in &ppendi( 1 about the lack of provision of mandated care under the /ental
+ealth &ct and nasogastric feeding within the central region do not reflect current
practice. Service users with severe eating disorders are often admitted to --&'S under
the /ental +ealth &ct, and most are discharged under community treatment orders.
Nasogastric feeding is occasionally employed by e(perienced nursing staff.
III Wo"9!o"&e Issues
.ho is currently involved in managing eating disorders and what do they doI
&s 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 e(pertise 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
organi4ations. They also have a role in treating the medical symptoms and
complications of eating disorders.
= &dolescent physicians are paediatricians who have undertaken e(tra 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.
= %hild 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
e(perience. %hild 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. /any 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.
= %hild 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 e(pertise in the development and delivery of psychologically based
therapeutic programmes.
= Paediatric nurses are familiar with the physical management of children and have
limited e(perience in managing young people with eating disorders. They are
usually familiar with the management of nasogastric feeding.
= >eneral practitioners are at the frontline for identifying and treating young people
with eating disorders, but may have variable e(perience in managing these
conditions. .ith government=sanctioned primary mental health services being
located within P+D5s, it will be important that >P5s receive ade;uate 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.
%omments on the workforce as referred to in the document
The Society of &dolescent /edicine (#1 stated that -nterdisciplinary treatment of
established eating disorders can be time consuming, relatively prolonged and e'tremely
costly. .ack of care or insufficient treatment can result in chronicity with ma/or medical
complications, social and psychiatric morbidity and even death. The -&NZ%P
guidelines (#" 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 &merican
&cademy 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 (@S
paediatricians provide level 1 and level #B2 services, whereas New Zealand paediatricians
only provide level #B2 services.
.ithin New Zealand, >P5s generally have a poor knowledge of eating disorders (& +all,
National Survey of >P5s, unpublished research at /D+, #""2. *uring this survey, !"E
self=identified significant knowledge deficits in assessment and management of eating
disorders. &lso, interestingly few had interest in further training on the subJect. /ost
undertook only 1) minute appointments despite the fact that the establishment of a
therapeutic alliance with eating disorder clients is time=consuming, and that medical
monitoring and e(planations are often lengthy processes. Paediatricians also identified
significant areas of knowledge deficit in a similar survey (& +all #""2. There are few
adolescent physicians in New Zealand. +owever, they would be a valuable resource for
the treatment of eating disorders and the planning of service delivery.
/ental health providers are generally not trained in the specific area of child and
adolescent growth and development. +owever, 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 8$uture *irections9:. These
practitioners play a valuable role in enabling the care of young people with comple(
psychiatric conditions on medical wards, and should be included in service planning
strategies.
-ecommendation for an alternative model of specialist knowledge
+aving mentioned the option of T+-66 specialist centres for eating disorders in New
Zealand as opposed to two, i# ma' be mo"e a33"o3"ia#e #o &"ea#e THREE
S$ECIALIST TEAMS !o" #he &a"e o! &hi%"en an% a%oes&en#s (i#h ea#in2
%iso"%e"s. The use of a T6&/ structure would allow fle(ibility in the types of e(pertise
to match that available geographically, and not limit e(perts to inpatient eating disorder
facilities. We (ou% su22es# #he minimum in)o)emen# o! a &hi% an% a%oes&en#
3s'&hia#"is#, a%oes&en# 3h'si&ian o" 3ae%ia#"i&ian, 2ene"a 3"a&#i#ione", %ie#i&ian,
3s'&hia#"i& nu"se an% a men#a hea#h #he"a3is# on ea&h #eam. /ost of the activities
generated for the Specialist 6ating *isorders 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 # the creation of a confidential client
database to inform future service planning and delivery. &udit of planned processes and
;uality measurement via performance indicators would also be worthwhile endeavours
with which they may become involved.
Psychodynamics
&s mentioned in the document, psychodynamics play an important part in the
management of eating disorders. The fragmented nature of the person5s 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. 't 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 8splitting: defense. 'n addition to
e(trinsic (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. 't is important that everyone feels heard and no one feels left out during the
consultation process.
IV O#he" Commen#s abou# #he Do&umen#
't would be more useful if the information in the section on -nternational comparisons
(within part F were presented in the form of a table with comparative data. & breakdown
between adult and childBadolescent 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.
& clearer description of timeframes pertaining to the e(ecution of recommendations from
the document would also be appreciated.
Re&ommen%a#ions
+8 $ease "e)ie( #he %a#a in&u%e% in 6Fu#u"e Di"e&#ions<7 on &u""en# se")i&e
3"o)ision #o &hi%"en an% a%oes&en#s8 The"e seem #o be some si2ni!i&an#
omissions in #he %es&"i3#ion o! &u""en# s's#ems8
-8 The"e is a%e5ua#e e)i%en&e #o "e&ommen% in#ensi)e an% ea"' in#e")en#ion
!o" &hi%"en an% a%oes&en#s (ho %e)eo3 ea#in2 %iso"%e"s, so #ha# in%i)i%ua
3"o2nosis &an be im3"o)e% an% so #ha# me%i&a an% 3s'&hia#"i& &om3i&a#ions
o! #he %iso"%e" &an be a)oi%e%8 $ease &onsi%e" a %i)ision o! #he main
se&#ions o! #his %o&umen# in#o +@ a%u# an% -@ &hi%0a%oes&en# se")i&es, so
#ha# #he %i!!e"en&e be#(een #he nee%s o! 'oun2e" an% a%u# 3o3ua#ions a"e
a%e5ua#e' "e!e&#e%, an% so #he s3e&i!i& nee%s o! ea&h 3o3ua#ion &an be
#a9en in#o a&&oun# (hen 3annin2 !u#u"e se")i&es8
,8 $ease ensu"e #ha# se")i&e 3annin2 is un%e"#a9en in a&&o"%an&e (i#h e;is#in2
MOH s#"a#e2ies su&h as #he :ue3"in# !o" Men#a Hea#h an% 1ou#h Hea#hC
A Gui%e #o A&#ion, an% #he $ae%ia#"i& So&ie#' %o&umen# Sus#ainabe
Na#ion(i%e Se")i&es !o" Chi%"en an% 1oun2 $eo3e8 $ease aso ensu"e #ha#
i# main#ains #he o3e"a#iona s#an%a"%s "e&ommen%e% b' #he &onsensus
s#a#emen#s su&h as #hose 3"o%u&e% b' #he Ro'a Aus#"aian an% Ne( Zeaan%
Coe2e o! $s'&hia#"', #he Ame"i&an A&a%em' o! $e%ia#"i&s, #he So&ie#' !o"
A%oes&en# Me%i&ine an% #he Na#iona Ins#i#u#e o! Cini&a E;&een&e8
D8 $ease ensu"e #ha# se")i&es !o" &hi%"en an% a%oes&en#s, #hou2h !e;ibe in
s#"u&#u"e, a"e "easonab' uni!o"m in 5uai#'8 We (ou% "e&ommen% #ha# #he
i%ea se")i&e !o" #his a2e 2"ou3 is one #ha# in&u%esC
= Ea"' %e#e&#ion an% &ommuni#' mana2emen#
= Mana2emen# b' se")i&es as &ose #o home as 3ossibe (i#h e;3e"# su3e")ision
= In#ensi)e me%i&a s#abiiEa#ion i! ne&essa"' an% nu#"i#iona "ehabii#a#ion
= Fami'4 base% #he"a3eu#i& 3"o2"ammes
= Su33o"# o! e%u&a#iona nee%s
= E%u&a#iona an% )o&a#iona "ehabii#a#ion
= Smoo#h #"ansi#ions base% u3on &ien# nee% an% se)e"i#' o! iness, no# se")i&e
imi#a#ions
= A&&ess #o 3s'&ho#he"a3eu#i& su33o"# a# a s#a2es o! #"ea#men#
= $anne% #"ansi#ion #o a%u# &a"e
F8 As &"e%ibe as #he 3an #o &"ea#e #(o s3e&iais# &en#"es ma' be, (e (ou%
a%)o&a#e !o" THREE s3e&iais# #eams o! &hi% an% a%oes&en# e;3e"#s, (hi&h
ma' o" ma' no# be %i"e&#' asso&ia#e% (i#h in3a#ien# !a&ii#ies8
G8 We (ou% a33"e&ia#e !u"#he" &onsu#a#ion (i#h 3ae%ia#"i&ians, a%oes&en#
3h'si&ians an% &hi% an% a%oes&en# 3s'&hia#"is#s be!o"e #he %o&umen# is
!inaiEe%
D" Hi"an Thab"e( D" An2ane##e Ha
$ae%ia#"i& an% $s'&hia#"i& Re2is#"a" Consu#an# A%oes&en# $h'si&ian
Ca3i#a an% Coas# DH: Hu## Vae' DH:
Re!e"en&es
1. &merican &cademy of Pediatrics. Policy Statement< 'dentifying and Treating
6ating *isorders. Pediatrics #""2< 111(1<#"!=#11.
#. &merican Psychiatric &ssociation Practice >uidelines for the Treatment of
Patients with 6ating *isorders 2
rd
6dition www.psych.org #""F
2. ,aran et al. ?ow *ischarge .eight and Dutcome in &nore(ia Nervosa.
&merican 7 of Psych. 1GG)<1)#M1"A"=1"A#
!. %anadian Pediatric Society, &dolescent /edicine %ommittee. 6ating *isorders in
&dolescents< Principles of *iagnosis and Treatment. Pediatrics and %hild +ealth
1GHH<2(2M1HG=1G#
). %ommerford / et al. >uidelines for *ischarging 6ating *isorder 'npatients.
6ating *isorders 1GGA<FM FG=A!.
F. %row N Nyman. The %ost 6ffectiveness of 6ating *isorder Treatment. 'nt 7
6ating *isorders #""!< 2)M1))=1F"
A. >arfinkel, P6. N *orian, ,*. $actors that may 'nfluence $uture &pproaches to
the Treatment of 6ating *isorders, 7ournal of 6ating and .eight *isorders 1GGA<
#M 1=1F
H. %risp et al. ?ong=term /ortality in &nore(ia Nervosa< & #" Cear $ollow=up of
the St >eorge5s and &berdeen %ohorts. ,ritish 7 of Psych. 1GG#<1F1M1"!=1"A
G. %row S N Nyman 7&. The cost=effectiveness of anore(ia nervosa treatment. 'nt 7
6ating *isorders #""!<2)M 1))=1F".
1". $isher et al. 6ating *isorders in &dolescents< & ,ackground Paper. 7ournal of
&dolescent +ealth 1GG)M1F<!#"=!2A
11. +almi, 3 et al. The %hanging 6pidemiology of +ospitali4ed 6ating *isorder
Patients. Paper presented at &cademy of 6ating *isorders %onference, NC, /ay
! L A, #""".
1#. +almi, 3 N ?icino, 6. Dutcome< +ospital Program for 6ating *isorders. 'n
%/6 Syllabus and Proceedings Summary, 1!#
nd
&nnual /eeting of &merican
Psychiatric &ssociation, .ashington, *%.
12. +er4og * et al. /ortality in 6ating *isorders< & *escriptive study. 'nt 7 6ating
*isorders #"""<#HM#"=#F
1!. 3at4man, *. /edical %omplications in &dolescents with &nore(ia Nervosa< &
-eview of the ?iterature. 'nt 7 6ating *isorders #"")<2AM S)#=S)G.
1). 3reipe et al. Treatment and outcome of adolescents with anore(ia nervosa.
&dolescent /edicine< State of the &rt -eviews 1GG#<2(2M)#G=)!"
1F. ?ock 7 N ?e >range *. $amily=based treatment of 6ating *isorders. 'nt 7 6ating
*isorders #"")<2AM SF!=SFA.
1A. National 'nstitute for %linical 6(cellence (N'%6. %linical >uideline G< %ore
interventions in the Treatment and /anagement of &nore(ia Nervosa, ,ulimia
Nervosa and -elated *isorders #""!. www.nice.org.uk
1H. Pratt, ,/ N .oolfenden, S-. 'nterventions for Preventing 6ating *isorders in
%hildren and &dolescents. %ochrane *atabase of Systemic -eviews #""#< 'ssue
#, &rt No. %*""#HG1
1G. -ome,6. %hildren and &dolescents with 6ating *isorders< The State of the &rt.
Pediatrics #""2<111(1
#". -oyal &ustralian and New Zealand %ollege of Psychiatrists %linical Practice
>uidelines for the Treatment of &nore(ia Nervosa. &ustralian and New Zealand
7ournal of Psychiatry #""!<2HMF)G=FA"
#1. Society of &dolescent /edicine. 6ating *isorders in &dolescents< Position Paper
of the Society for &dolescent /edicine. 7ournal of &dolescent +ealth #""2M 22<
!GF=)"2.
##. Sokol et al. -eview of clinical -esearch in %hild and &dolescent 6ating
*isorders. Primary Psychiatry #"")<1#(!M)#=)H
#2. Steiner, + N ?ock, 7. &nore(ia Nervosa and ,ulimia Nervosa in %hildren and
&dolescents< & -eview of the Past 1" Cears. 7 &m &cad %hild &doelsc
Psychiatry 1GGH<2A(!M2)#=2)G
#!. Strober et al. The ?ong=Term %ourse of Severe &nore(ia Nervosa in &dolescents<
Survival &nalysis of -ecovery, -elapse, and Dutcome Predictors voer 1" L 1)
years in a Prospective Study. 'nt 7 6ating *isorders 1GGA<##(!M 22G=2F"
#). Sullivan, P$. /ortality in &nore(ia Nervosa. &merican 7ournal of Psychiatry
1GG)< 1)#(A,1"A2L1"A!.
#F. Paediatric Society of New Zealand Sustainable Tertiary Services for %hildren and
Coung People November #""F.
http<BBwww.paediatrics.org.n4BdocumentsB#""FE#"documents
E#"deniseBSustainableE#"nationwideE#"servicesE#"1!E#"11E#""FE#"$inal
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