1. Eating Disorders Family Psychoeducation Part 3
Provider should give brief overview of levels of care for all families, which will include this slide and slides 4-9, since families may encounter several treatment settings during the course of recovery. Focus most discussion on level(s) of care most pertinent to family currently.
Presented by: Seattle Children’s Hospital, Psychiatry and Behavioral Medicine
Contributors: Cynthia Flynn, PhD
Taryn Park, MD
Angela Werfelmann Wood, MPS, LMHC, ATR
Sarah Wu, PhD

2. What We’ll Be Talking About Today
Eating disorder treatment options
A few key points about treating eating disorders
Tips and common questions about continuing recovery at home

3. Levels of Care for ED Treatment
Medical Admission
Hospital-Based Inpatient Psychiatric Treatment
Residential Treatment
Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
Outpatient Treatment

4. Outpatient Eating Disorder Treatment
Caregivers prepare meals, manage meal times and provide meal support
Psychotherapy (weekly)
Adolescent Medicine (initially weekly)
Nutrition (initially weekly)

5. Outpatient Eating Disorder Treatment
Recovery begins with getting your child back to a healthy weight and normalizing eating behavior
Treatment may draw from many types of therapy approaches
Family-Based Treatment (FBT)
Cognitive-Behavioral Therapy (CBT)
Acceptance and Commitment Therapy (ACT)
Dialectical Behavioral Therapy (DBT)
Outpatient treatment is best for patients with:
no or little prior outpatient treatment
no serious medical complications
Providers should give overview of MH therapies. Highlight differences between family-based and individually-based therapies but note that most individually-based therapies for children/adolescents will also have family components. Choosing which therapy is right for you is usually based on recommendations from your current team and what feels like a good fit for patient and family. Note that whichever patient/family does, it is very strongly recommended that patients have family support as it is associated with greater recovery success.

6. IOP = about 4-6 hours per day, includes 1-2 meals
Intensive Outpatient (IOP) / Partial Hospitalization (PHP)
IOP = about 4-6 hours per day, includes 1-2 meals
PHP = about 8-10 hours per day, includes most or all meals
Both IOP and PHP offer group and individual eating disorder therapy, and use similar therapy approaches as outpatient (may vary by treatment center)
May offer family therapy
IOP/PHP treatment is best for patients:
when outpatient treatment is not successful or doesn’t meet patient and family needs
when meal support/supervision is hard to provide
with no serious medical complications
Provider should note that treatment centers vary in terms of what they offer and what therapeutic modalities they use. Caregivers should be advised to ask question about this when they contact treatment centers to establish care.

7. Residential Treatment
Care is provided 24 hours a day in a non-medical setting; may provide minimal medical monitoring
Residential treatment offers group, individual eating disorder therapy, and uses similar therapy approaches as outpatient and IOP/PHP (may vary by treatment center)
May offer family therapy
Residential treatment is best for patients:
with no serious medical complications
when other treatment programs have not been successful and more intensive treatment is needed to recover
Provider should note that treatment centers vary in terms of what they offer and what therapeutic modalities they use. Caregivers should be advised to ask question about this when they contact treatment centers to establish care.

8. Hospital Inpatient Psychiatric Treatment
Care is provided 24 hours a day on an inpatient psychiatric unit
Shorter length of stay than residential treatment
Focuses on re-feeding and medical stabilization
Provides medical monitoring
Setting includes patients with a variety of needs (‘mixed-milieu’); program offers individual eating disorder therapy and general group therapy
Meal support training for caregivers
Inpatient psychiatric treatment is best for patients:
with medical complications
with acute refeeding needs
when families prefer shorter stay and mixed-milieu setting
This slide specifically describe the SCH PBMU program. If families are considering other inpatient psychiatric facilities, they should be advised to ask questions about medical monitoring, therapeutic modality and types of therapy offered and whether meal support training is offered. Providers should explain that PBMU is a ‘mixed-milieu’ setting, meaning that there will be patients there for a variety of reasons and that patients with eating disorder will be participating in general group activities. This is different from eating disorder residential facilities that provide only eating disorder treatment.

9. Inpatient Medical Admission
Care is provided 24 hours a day on medical and/or psychiatric unit
Primary goal is medical stabilization
Therapy for eating disorder is available, including education about treatment and meal support training
Medical admission is needed for patients:
with serious medical complications such as low heart rate (bradycardia), extreme changes in pulse or blood pressure (orthostasis), electrolyte imbalance
When eating disorder poses serious medical risk such as refusing to eat or drink, extreme purging
Most other hospital likely have less programming for eating disordered patients admitted to medicine; this slide refers to services offered her at SCH only. Providers should note that at SCH patients on eating disorder pathway may be treated on medical floor, PBMU or both while medical patients.

10. Key Points about Treatment
Improving nutrition is a necessary part of treatment; food is medicine
Family support is important to recovery
You will need a multidisciplinary team (Adolescent Medicine, Nutrition and Mental Health)
Type of treatment depends on your and your family’s needs
Be prepared for long term treatment (6-12 months at least)
Weight gain is a sign that your body is healthier but not the only goal of treatment
During recovery, other eating disorder symptoms (behavior, thinking, mood) can worsen even while physical symptoms improve

11. Tips for Supporting Recovery at Home
Don’t enter into negotiations about food
Do set clear and consistent rules and consequences
Don’t label foods as good or bad; don’t purchase diet or low fat foods
Do show enjoyment in food and flexibility in eating; demonstrate food choices that are consistent with normal eating for your family.
Don’t have siblings provide any coaching
Do plan some family time that is not about the eating disorder
Don’t allow teasing about weight or appearance
Do express appreciation of qualities other than physical appearance
Don’t comment on weight or appearance even if it seems positive
Do appreciate cooperation with recovery process and praise other accomplishments
Don’t comment on your own diet, plans to diet, or your own or other’s weight or appearance
Do model healthy eating and positive attitudes toward food; do remove scales at home
Don’t give up and don’t worry about having to do everything perfectly
Do remember that recovery is a process and will take time and patience; practice self-care
Provider should highlight that this is for family members supporting recovery.

12. What if my child won’t eat?
Common Questions about Continuing Recovery at Home
What if my child won’t eat?
Should we replace foods (with something my child prefers) during meals?
Should we use food supplements, such as Boost, if meals aren’t completed?
How much flexibility do we have to make changes?
How do we decide how much food to provide?
Should we be keeping track of calorie intake?
Should we measure food portions?
Provider should encourage discussion about these common concerns of caregivers, and provide answers below. Note that consulting a dietitian about these questions, before and after leaving the hospital can be helpful. Family’s therapist also can help trouble-shoot after discharge. Be sure to empower caregivers where appropriate. Leave time for additional questions.
If patient refuses food, stay calm, remind child of expectation for 100% completion, sit closer to child, remind that you care about them and completion is necessary for health. If continues to refuse, caregivers can end meal at pre-agreed-time. Be consistent and follow through on natural, logical consequences such as restrictions on physical activity restrictions to compensate for inadequate energy in.
No, caregivers should not offer food replacements. Work to plan meals that patient has previously been able to tolerate and do not negotiate during meals.
Ideally food supplements should not be used at home, but this decision depends on current health issues. Advise caregivers to consult their outpatient Adolescent Medicine provider and/or dietitian.
Caregivers should be empowered to feed their child as they think appropriate but advise them to utilize recommendations from their Adolescent Medicine provider and/or dietitian. Caregivers also should expect to maintain structured meal and snack times; key to normalizing hunger/satiety cues and boosting metabolism. Note that if patient has been inpatient, the inpatient dietitian will review discharge meal planning recommendations for home before discharge, which will also address this question.
Questions 5,6 and 7 are related. Caregivers should not count calories or measure foods. They should use more normal estimates such as a portion size equaling the size of a fist. Dietitians have other helpful ways to estimate portions. Also, remind parents that they have been feeding their child successfully for many years with success so they also can depend of their own experience.