Eating Disorders in Schools; Prevention, Early Identification

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Summary of Eating Disorders in Schools; Prevention, Early Identification

Eating Disorders in Schools: Prevention, Early Identification and Response nedc.com.au Second Edition Eating Disorders in Schools: Prevention, Early Identification and Response Second Edition © 2016. This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or within your organisation. Apart from any use permitted under the Copyright Act 1968, all other rights are reserved. The National Eating Disorders Collaboration | www.nedc.com.au 3 Eating Disorders in Schools: Prevention, Early Identification and Response Contents INTRODUCTION ........................................................................................................5 General information about Eating Disorders ................................................5 Eating disorders in Australia ..........................................................................5 Eating disorders and mortality rates .............................................................6 Eating disorders and suicide .........................................................................6 Eating disorders and adolescents .................................................................6 Eating disorders and obesity .........................................................................7 The long term health consequences of eating disorders ..............................7 The financial consequences of eating disorders ...........................................7 Common misconceptions about eating disorders ........................................9 HOW TO PROMOTE HEALTH AND WELLBEING WITHIN YOUR SCHOOL ..........12 Make time for eating disorder prevention programs ...................................13 Use a whole school approach ....................................................................13 Understand the different prevention strategies for eating disorders ...........14 Know how to make your prevention program effective ..............................16 Know what material to cover in your prevention program ..........................17 Provide developmentally appropriate teachings at every year level ...........17 Make sure your program is evidence based ...............................................18 Create a positive classroom environment ...................................................18 Communicate appropriately about eating disorders ...................................18 How to get through to young people ..........................................................19 Communicating with families ......................................................................19 Do no harm ..................................................................................................20 Eating Disorders in Schools: Prevention, Early Identification and Response 4 Understand the relationship between eating disorders and obesity ...........20 Obesity and eating disorders: a shared approach ......................................21 The boomerang effect .................................................................................21 HOW TO RECOGNISE AND RESPOND TO EATING DISORDERS ........................23 How to recognise when a student may have, or be developing, an eating disorder .......................................................................................................23 Understand who is most at risk...................................................................23 High risk groups that you may be in contact with as a teacher ..................25 Eating disorders in males ............................................................................25 Recognise the warning signs ......................................................................27 What to do if you suspect a student has an eating disorder .......................28 HOW TO SUPPORT A STUDENT RECOVERING FROM AN EATING DISORDER 34 Remember recovery is possible ..................................................................34 Understand the recovery process ...............................................................34 Understand the stages of change ...............................................................35 Remember who the person is .....................................................................36 Be patient ....................................................................................................37 Communicate ..............................................................................................37 Be positive ...................................................................................................37 Develop a care plan for supporting the student’s recovery .......................37 WHERE TO LEARN MORE ABOUT EATING DISORDERS .....................................38 Where to go for more information ...............................................................38 Where to go for professional development .................................................38 Where to find resources ..............................................................................38 Resources for rural schools .........................................................................38 Where to find help .......................................................................................38 REFERENCES ..........................................................................................................39 Key References ...........................................................................................39 Other useful references ...............................................................................42 Online resources referred to in this resource ..............................................43 The National Eating Disorders Collaboration | www.nedc.com.au 5 INTRODUCTION General information about Eating Disorders Eating disorders are serious mental illnesses that are associated with significant physical complications. Eating disorders not only involve considerable psychological impairment and distress, but they are also associated with major wide-ranging and serious medical complications, which can affect every major organ in the body. Eating disorders are frequently associated with other psychological disorders such as depression, anxiety, substance abuse and personality disorders. A person with an eating disorder may experience long term impairment to social and functional roles and the impact may include psychiatric and behavioural effects, medical complications, social isolation, disability and an increased risk of death. The mortality rate for people with eating disorders is the highest of all psychiatric illnesses, and over 12 times higher than that for people without eating disorders. While estimates of the incidence of eating disorders vary between countries and studies, there is agreement that eating disorders, disordered eating and body image issues have increased worldwide over the last 30 years. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists all the Feeding and Eating disorders that are diagnosed by psychologists. Of these there are four specified eating disorders; Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder and Other Specified Feeding and Eating Disorder (OSFED). Fact sheets about disordered eating, body image and each of the eating disorders are available at: www.nedc.com.au/fact-sheets. Eating disorders in Australia Eating disorders have a significant and underestimated impact on Australian society. • Eating disorders are estimated to affect approximately 9% of the population • Anorexia Nervosa and Bulimia Nervosa affect between 2% and 4% of the population • Approximately 15% of Australian women experience an eating disorders during their lifetime • About one in 20 Australians has an eating disorder and this rate is increasing Research conducted with young people in 2010 on behalf of the NEDC indicated that: • Most young people know at least one other young person who they think might have a eating disorder Introduction | Eating Disorders in Schools: Prevention, Early Identification and Response 6 • 84.3% of respondents said they know one person who may have an eating disorder • 62.8% said they know up to five people who may have an eating disorder These figures do not take into account the frequent under-reporting and under-treatment of eating disorders. Eating disorders and mortality rates All eating disorders come with severe medical complications and increased mortality rates. • The risk of premature death for women with Anorexia Nervosa is 6-12 times higher than the general population • The risk of premature death for women with Anorexia Nervosa is ‘much higher’ than other psychiatric disorders • For females with Anorexia Nervosa and diabetes, there is a 15.7-fold increase in mortality rates when compared with females with diabetes alone Eating disorders and suicide The risk of premature death in people with eating disorders relates in part to medical complications associated with the disorder; however suicide has also been identified as a major cause of death in people with eating disorders. In fact, 1 in 5 individuals with Anorexia Nervosa who die prematurely have committed suicide. Research on suicide in people with Bulimia Nervosa and OSFED is less available; however rates of suicide in Bulimia Nervosa and OSFED are higher than in the general population. Eating disorders and adolescents Eating disorders can occur in people of all ages; however adolescents and young people are increasingly at risk. • Eating disorders represent the third most common chronic illness for young females • Eating disorders represent the second leading cause of mental disorder disability for young females • Adolescents with diabetes may have a 2.4-fold higher risk of developing an eating disorder • Adolescent girls who diet at a severe level are 18 times more likely to develop an eating disorder within 6 months - this risk increases to a 1 in 5 chance over 12 months Studies of body dissatisfaction in adolescence have found varying but consistently high levels: • 70% of adolescent girls have body dissatisfaction • Body dissatisfaction is identified in the Mission Australia Youth Survey (2013) as one of the top ranked issues of concern for young people Introduction | The National Eating Disorders Collaboration | www.nedc.com.au 7 Eating disorders and obesity Obesity and eating disorders may be viewed as occurring at the same end of a spectrum with healthy beliefs, attitudes, and behaviours at one end, and problematic beliefs, attitudes, and behaviours at the other end. Among the variety of weight- and eating-related problems, there are some separate and some overlapping protective, risk and maintaining factors. • Obesity in adolescents has increased by 75% in the past three decades • The development of co-morbid obesity with eating disorder behaviours has increased at a faster rate than that of either obesity or eating disorders alone • Adolescent girls with obesity have high rates of disordered eating • One in five people with obesity also present with disordered eating, mainly in the form of binge eating, but also evident in episodes of strict dieting and purging The long term health consequences of eating disorders The consequences of an eating disorder are not limited to acute episodes of illness but may also be long term. Only 46% of patients fully recover from Anorexia Nervosa while 20% remain chronically ill for the long term. Binge Eating Disorder is more common than Anorexia Nervosa or Bulimia Nervosa and is at least as chronic and stable as these disorders. The financial consequences of eating disorders The cost of care for a person with an eating disorder is substantial. Eating disorders are the 12th leading cause of mental health hospitalisation costs within Australia. The expense of treatment of an episode of Anorexia Nervosa has been reported to come second only to the cost of cardiac artery bypass surgery in the private hospital sector in Australia. Bulimia Nervosa and Anorexia Nervosa are the 8th and 10th leading causes, respectively, of burden of disease and injury in females aged 15 to 24 in Australia. This is measured by disability- adjusted life years. Introduction | Eating Disorders in Schools: Prevention, Early Identification and Response 8 The National Eating Disorders Collaboration | www.nedc.com.au 9 Common misconceptions about eating disorders To read more about the following misconceptions, where they come from and why they are not true visit: www.nedc.com.au/myths-about-eating-disorders. Myth: Eating disorders are a lifestyle choice, not a serious illness There is a generally low level of mental health literacy in the community which affects community responses to eating disorders and leads to underestimation of the seriousness of these illnesses. The truth is that eating disorders are serious mental illnesses; they are not a lifestyle choice or a diet gone ‘too far’ and people can’t ‘just stop’ their eating disorder. People with eating disorders require treatment for both mental and physical health addressing the underlying psychological issues and the impact on physical health. Myth: Eating disorders are a cry for attention or a person ‘going through a phase’ Research conducted with young people in 2010 on behalf of the NEDC indicated that 51.3% of 12-17 year olds agreed that a person with an eating disorder should ‘snap out of it, there are more important things in life to worry about’. However, an eating disorder is not a phase and it will not be resolved without treatment and support. People with eating disorders are not seeking attention. In fact, due to the nature of these illnesses a person with an eating disorder may go to great lengths to hide, disguise or deny their behaviour, or may not recognise that there is anything wrong. Myth: Eating disorders are about vanity The association between body dissatisfaction and eating disorders can lead people to mistakenly believe that eating disorders are about vanity. In truth, no one can be blamed for developing an eating disorder. There are genetic and personality vulnerabilities as well as social and environmental triggers. Eating disorders are not just about food or weight, vanity, will power or control. They are fuelled by distress, anxiety, stress and cultural pressures. Eating disorders are serious and potentially life threatening mental illnesses, in which a person experiences severe disturbances in eating and exercise behaviours because of distortions in thoughts and emotions, especially those relating to body image or feelings of self-worth. Myth: Families, particularly parents, are to blame for eating disorders A common misconception is that family members can cause eating disorders through their interactions with a person at risk. While there are environmental triggers which may impact on the development and maintenance of an eating disorder, there is no evidence that a particular parenting style causes eating disorders. Clinical guidelines for best practice in managing eating disorders encourage the inclusion of families at each stage of treatment for adolescents, from the initial assessment to providing recovery support. The impact of an eating disorder is not only felt by the individual, but often by that person’s entire family or circle of support. Introduction | Introduction | Eating Disorders in Schools: Prevention, Early Identification and Response 10 Myth: Dieting is a normal part of life According to research conducted with young people in 2010 on behalf of the NEDC, young people recognise that eating disorders are potentially harmful; however they also accept body ‘obsession’ and dieting as normal parts of growing up. While moderate changes in diet and exercise have been shown to be safe, significant mental and physical consequences may occur with extreme or unhealthy dieting practices. Eating disorders almost invariably occur in people who have engaged in dieting or disordered eating. Dieting is also associated with other health concerns including depression, anxiety, nutritional and metabolic problems, and contrary to expectation, with an increase in weight. Myth: Eating disorders only affect white, middle class females, particularly adolescent girls Adolescent females are one group with a high risk of eating disorders. However, eating disorders are not limited to any one group of people and the prevalence of eating disorders in specific high risk groups should not distract the community from the importance of recognising eating disorders in other populations. People from all age groups and cultural or socioeconomic backgrounds experience eating disorders. Eating disorders affect both men and women. Introduction | The National Eating Disorders Collaboration | www.nedc.com.au 11 Introduction MYTH BUSTED Eating disorders myths Snapshot Dieting is a normal part of life s a part Families, particularly parents, are to blame for eating disorders Eating disorders almost invariably occur in people who have engaged in dieting or disordered eating. Dieting is also associated with other health concerns including depression, anxiety, nutritional and metabolic problems, and, contrary to expectation, with an increase in weight. Eating disorders only affect white, middle class females, particularly adolescent girls Eating disorders can affect anyone. They occur across all cultural and socio-economic backgrounds, amongst people of all ages, from children to the elderly and in both men and women. There is no evidence that a particular parenting style causes eating disorders. Although a person’s genetics may predispose them to developing an eating disorder this is certainly not the fault of their family. To find out more visit Busted Eating disorders are not serious; they are a lifestyle choice or about vanity. Eating disorders are serious and potentially life threatening mental illnesses. A person with an eating disorder experiences severe disturbances in their behaviour around eating, exercising and related self harm because of distortions in their thoughts and emotions. Truth Myth Eating disorders are a cry for attention or a person ‘going through a phase’ Due to the nature of an eating disorder a person may go to great lengths to hide behaviour, or may not recognise that there is anything wrong. Eating disorders are not a phase and will not be resolved without treatment and support. Myth Truth Myth Myth Truth Truth Truth Myth nedc.com.au/myths Eating Disorders in Schools: Prevention, Early Identification and Response 12 HOW TO PROMOTE HEALTH AND WELLBEING WITHIN YOUR SCHOOL The Melbourne Declaration on Educational Goals for Young Australians sets out nationwide objectives for Australian schools that all Australian Education Ministers have agreed to. According to this declaration ‘schools play a vital role in promoting the intellectual, physical, social, emotional, moral, spiritual and aesthetic development and wellbeing of young Australians’. One of the Educational Goals outlined in the declaration is that ‘all young Australians … have a sense of self-worth, self-awareness and personal identity that enables them to manage their emotional, mental, spiritual and physical wellbeing’. Hence, mental and physical health education is critical within all Australian schools and teachers play an important role in promoting health and wellbeing within the school environment. Education about body image, disordered eating, the risks of dieting and eating disorders is an important aspect of all school health and wellbeing programs. Having the correct information and education about eating disorders can help prevent an eating disorder from developing, ease the suffering of a person in the early stages of an eating disorder, and reduce the stigma and misconceptions that surround eating disorders. Efforts to promote positive body image and healthy lifestyle choices should be integrated into every school’s teaching program as a general practice with the aim of proactively helping to prevent eating disorders from arising rather than simply responding reactively to existing issues. People who are identified and treated early in the course of an eating disorder have a significantly better chance of recovery when compared with those who have been living with an eating disorder longer; this is particularly relevant for young people. However, the median duration of treatment delay is extraordinarily long (10 years for those meeting criteria for bulimia nervosa and 15 years for those meeting criteria for anorexia nervosa). This suggests that people with eating disorders experience significant barriers to seeking help. One principal barrier has been identified as the stigma that exists around eating disorders. To reduce the stigma associated with eating disorders, there needs to be a shift in the attitudes and knowledge of the general community about eating disorders. In Australia there has been a growth in mental health awareness and active efforts by government, media and the wider community to reduce stigma and improve mental health literacy. Teachers are in a powerful position to help with these efforts. For early intervention to occur, young people and those in their circle of support, need to be able to recognise and respond to signs of distress, reduced functioning, and other indicators that present early in the development of an eating disorder. A person who has, or is at risk of developing an eating disorder can often feel high levels of shame, ambivalence and denial. As a result of this, that person may need guidance and support from those around them to take the first steps towards preventing or treating an eating disorder. It is therefore very important that schools work to deepen their level of understanding about eating disorders. How to promote health and wellbeing within your school | The National Eating Disorders Collaboration | www.nedc.com.au 13 Make time for eating disorder prevention programs Evaluation of the national mental health initiative ‘MindMatters’ has found that mental health education is competing for time within a crowded curriculum. Time for planning, lesson development and the provision of appropriate support after learning are all required to ensure that eating disorders prevention messages are safe and effective. The Australian Curriculum for Health and Physical Education (HPE) developed by the Australian Curriculum, Assessment and Reporting Authority (ACARA) is available at http://www.australiancurriculum. edu.au/health-and-physical-education/rationale. This document will help schools to approach the teaching of topics relating to health and wellbeing in a nationally consistent way. However, education about body image, disordered eating, the risks of dieting and eating disorders should not be limited to HPE programs. These topics can also be integrated into welfare programs conducted during roll call/form class/home room, peer support, pastoral care sessions or school camps. There are also opportunities for teachers to incorporate relevant information into other subject areas. For example, discussions about diet and exercise can be included in studies of Biology, body image awareness and media literacy education can be integrated into studies of English and The Arts, and opportunities to explore the influence of different societies and cultures on body image and healthy lifestyles may arise during History and Geography lessons. Use a whole school approach Each school should set out a clear policy with regards to what strategies they will employ for the prevention, early intervention and management of eating disorders. This policy should include initial response procedures such as the appropriate channels for teachers to report mental health disclosures through, who is responsible for informing the parents if this is appropriate, how to maintain adequate levels of confidentiality, how to deal with rumours, how to encourage the student and their family to seek help and a professional diagnosis (it is not the schools place to diagnose or treat eating disorders) and how to support a student recovering from an eating disorder (see ‘Developing a care plan for supporting a student’s recovery’ under HOW TO SUPPORT A STUDENT RECOVERING FROM AN EATING DISORDER ). For case study examples and detailed guidelines of the types of policies a school might consider implementing visit www.nedc.com.au/for-schools (to access CEED & EDV, 2004). Checklist for a whole of school approach (adapted from The National Advisory Group, 2009) Policy • Include a statement in the school mission about providing a body image friendly environment and celebrating diversity • Prohibit appearance-related teasing, including cyber-bullying in school policy • Ensure no weighing, measuring or anthropometric assessment of students in any context • Provide an opportunity for all students to engage in regular physical activity in a noncompetitive, nonweight-loss focused, safe and secure environment • Provide a balance of food options from all food groups in the canteen • Display public material/posters including a wide diversity of body shapes, sizes and ethnicity Workforce Development • Train all relevant teaching staff in the early identification and referral of students with serious body image concerns and eating disorders How to promote health and wellbeing within your school |