Friday 18 August 2017

"How to Weigh an Eating Disordered Child or Teen" Blog by Dr Julie O'Toole of the Kartini Clinic - why our CAMHS team did none of this

I'm on the US Portland-based Kartini Clinic mailing list. I have a huge admiration for them - they speak such sense. Today they sent me a link to a blog post entitled "How to Weigh an Eating Disordered Child or Teen" by Dr Julie O'Toole.

When my son, Ben, was being treated by CAMHS (the UK-based Child & Adolescent Mental Health Services) the weekly weighing session was always a huge problem. If Ben had put on weight then the entire therapy session would be spent fire-fighting his severe anxiety and panic. If he'd lost weight, then everything would run smoothly.

From reading various information on the Net and as a member of the Around The Dinner Table Forum for parents of young people with eating disorders, I had a gut feeling that my son should have been weighed differently. Dr O'Toole's blog post endorses my concerns - here are my comments on what she says:

"When we discharge a patient from Kartini Clinic back to their primary care provider, it is usually with the instructions for weekly blind weights for about a month, then, if stable, every two weeks, then monthly for about half a year." 

None of this happened with Ben despite his weight on discharge being the same as when he began treatment. Also, he was never weighed blind; he was always told his weight which caused big problems.

"Remember that weights are a source of extreme anxiety for children/youth with eating disorders and, to the extent that weight gain/stabilization is seen by families as the only “real” benchmark of progress, pressure on the patient to falsify it in order to please others will be strong. Nonetheless, weight restoration is critical, critical, critical in recovery —even though it's not everything."

With Ben there was no emphasis on weight restoration. Quite the reverse. He was told that he could choose a weight he felt happy with and that some young people choose to remain at a low weight. As I said above, his weight at the end of 26 months of treatment was the same as it was when he began eating disorder treatment.

"Any patient who has web access will be aware of multiple ways to falsify their weight; you need to safeguard them against this overwhelming temptation by weighing them in a predictable, unvarying way (see below)."

No checks were ever carried out and Ben was simply told to remove his shoes and jacket before standing on the scales.

"I would encourage you not to share a patient's weight with them, but rather to carry their anxiety about weight numbers for them (with their parents, of course). Don't make a big state secret out of it, just say something general like, "You're doing a good job, we're pretty stable," or "We're headed in the safe direction." 

CAMHS always shared Ben's weight with him and I believe it is one of the reasons why he lost weight under their care (before gaining it again as a result of our Contract, taking his weight back to where it was when he began treatment).

"Taking a weight is just like taking any other vital sign, which is what it is. Do it professionally, privately and kindly."

Yes, I agree, they did this.

"Always weigh the patient on the same scale. If you have multiple scales in your office, mark one discretely (fingernail polish works, just a dot)."

They did this too.

"Always weigh them in a gown with no underwear and with their back to the scale."

Never, never and never.

"Please do not weigh them in the hall."

Ben was weighed in a private room, so that was good.

"Educate your nurse or medical assistant to say nothing while taking a weight or afterward, and to write it down away from the patient; do not leave the chart in the room."

No, Ben was always made aware of his weight (see above). And the nurse would get out her cardboard BMI wheel to calculate his BMI. "Congratulations, you've just slipped into the healthy BMI range," they would say. Of course the eating disorder interpreted this as: "You've got fat!" and Ben would promptly lose weight again.

"Weigh the patient after a void. Check the specific gravity of the urine in order to assess for any degree of water-loading; if the urine specific gravity is 1.005 or less, ask them to void again before weighing them. If it remains that dilute, abort the weighing and have a talk with them and their parents about over-drinking prior to a weight being taken. Let the parents help them prevent this."

Never and never. 

"If you have concerns about your patient wearing weights, ask them not to bring any bags, purses, etc into the exam room while they change into a gown. Once they leave, discreetly check the wastebasket for discarded heavy items."



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