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HRT0812 – Health Roundtable MHBG 2008. P E D A T. Paediatric Eating Disorders Advisory Team Demeter Child & Youth Mental Health Service. The Demeter Context. Demeter– growing population of 500 000 Projected population over next 5 years = 574 000) 0 – 19 years = 100 000

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P e d a t

HRT0812 – Health Roundtable MHBG 2008

P E D A T

Paediatric Eating Disorders

Advisory Team

Demeter Child & Youth Mental Health Service


The demeter context
The Demeter Context

  • Demeter– growing population of 500 000

    • Projected population over next 5 years = 574 000)

  • 0 – 19 years = 100 000

    • Projected over next 5 years = 109 500)

  • Education facilities :

    • 51 state primary schools

    • 15 state high schools

    • 3 special schools

    • 20 private primary and secondary schools


  • Our work context
    Our work context

    • 34 bed Paediatric Ward –

    • Paediatric Outpatient Department

    • 8 bed Child and Youth Mental Health Unit –

    • 3 community CYMHS teams –

    • CYMHS Consultation Liaison service



    The problem
    The problem…

    • Eating disorders - remain the most difficult and dangerous of psychiatric conditions to understand and treat

    • Treatment of eating disorders requires a coordinated, multidisciplinary, physical, psychological and other service interventions in, and across, a number of different health settings. (RANZCP, 2004; NICE, 2004)

    • “There is general consensus that a multiskilled and multidisciplinary approach is optimal…. (RANZP, 2004)

    • The numbers of presentations of eating disorders within the District was increasing

    • The age of presentations with eating disorders was decreasing


    The problem1
    The problem…

    • A typical young person’s journey :

      • Can begin with GP or private practitioner

      • Referred to paediatric and/or psychiatric outpatient care (often both)

      • Move to paediatric and/or psychiatric inpatient care (often both) and

      • Return to both paediatric and psychiatric outpatient care


    The problem2
    The problem…

    • These multiple treatment sites and their interfaces provide significant difficulty with:

      • Continuity of care

      • Holistic treatment planning

      • Fragmentation of service delivery

      • Poor skill level – low levels of clinician competence and confidence

      • Desire to reduce rates of re-admission (to both paediatric and psychiatric wards)

      • Early treatment drop-out

      • Lengthy episodes of care within the health system


    Solution found
    Solution found ?

    • No additional funding/resources were available

    • Initiative to develop a specialist advisory team rather than a specialist treating team to:

      • Provide expert consultation and advice

      • Facilitate sharing of knowledge and skills between treating clinicians and members of the advisory team

      • Facilitate the development of skills across clinical settings (paediatrics, cymhs and private practitioners)

    • Based on a collaborative approach between the departments of Paediatrics and Child & Youth Mental Health Services


    Advisory team members
    Advisory team members

    A group of expert health care professionals who utilised the best available evidence in assisting clinicians to plan and provide high quality care for those with eating disorders

    • Consultant Psychiatrist

    • Paediatrician

    • Dietician

    • Psychologist


    Pedat was born
    PEDAT was born…

    • Key objectives of the PEDAT –

      • provide expert assessment

      • advise on the identification, treatment, and management of the eating disorders Anorexia Nervosa, Bulimia Nevosa, Eating Disorders not otherwise specified, and related conditions

      • Provide specialist multidisciplinary care with an emphasis on improving and highlighting the importance of the ‘experience of care’ for young people and their carers


    Other pedat roles
    Other PEDAT roles:

    • Provide input as requested to case conferences across both community and inpatient settings

    • Liaise with other service providers in the primary care and private care sector

    • Educate, advise and support GP’s and schools

    • Advocate for resources/services for young persons with eating disorders


    • Maintain continuity of care with the treating team

    • Ensure ongoing monitoring, at various levels of intensity, of all children and adolescents experiencing eating disorders in our service

    • Provide coordinated care that was previously provided by paediatric outpatients



    The process1
    The process. . .

    • The key method of provision is a monthly half day ‘clinic’

    • Components:

      • direct consultation to young person and/or family and carer

        (as needed)

        - Paediatric review

        - Dietetic review

        - Psychiatric review

      • Case consultation to case manager

        (without f-f client contact)

      • Supervision and support of therapy

      • Option to provide all components, or some of


    The process2
    The process. . .

    • Advice and recommendations for the bio-psycho-social management of the young person are provided

    • The core treatment remains with the case manager and the respective CYMHS Consultant Psychiatrist

    • Recommendations made to the clinical team - must be fed back through the treating teams clinical case conference via the case manager


    The process an example
    The process. . . An example

    • Example of a consultation session:

      • Case presentation – history; symptoms; formulation; areas of concern or questions for the advisory team

      • Collaboration in determination of priorities and care plan ie. what components/format would best meet the identified needs of young person

      • Implementation of plan

      • Team re-group and discuss findings and recommendations with case manager, family and client; answer questions; and clinical documentation



    Paediatrician
    Paediatrician

    • Medical assessment

      • BP, PR, Temp

      • Ht, Wt.

      • General physical

    • Decide

      • Medically stable

      • Inpatient admission vs outpatient care

    • Designated bad guy


    The bearer of bad news
    The bearer of bad news

    • Diagnosis

      • You/Your child has an eating disorder

      • You/ your child might die

    • Treatment

      • Admission to GCH

      • NGT, blood tests, IV


    Dietitian
    Dietitian

    • Detailed diet history

      • How detailed?

    • Physical activity

      • How much

      • What type

    • Purging & binging

    • Food behaviours & interests

    • Quasi – scientific knowledge


    Food myths
    Food Myths

    • Can’t eat after 7pm

    • Allergic to meat/dairy etc

    • Fat = fat

    • Fat from the shower/water/washing up

    • I have a fast metabolism

    • I come from a skinny family


    Food myths1
    Food Myths

    • Vegetarians

      • “The poor animals”

    • Portion sizes

    • Misinterpretation of what ED is

    • Misinterpretation of what is normal eating


    Pedat as a team
    PEDAT as a team

    • Treatment of eating disorders extremely difficult in isolation

    • Pressure off treating therapist

      • Talking about food & medical

    • Extreme end of bell curve

      • early intervention of children & adolescents disordered eating


    Sequence
    Sequence

    • PEDAT GCH Robina PEDAT

    • GCH

      • Paediatrician on-call

      • Dietitian on-call

      • CL Team


    Common scenarios in gch
    Common scenarios in GCH

    • Once medically ‘out of danger’

      • “Mum the <insert clinician> is being mean to me, I want to go home”

      • Denial – ‘I wasn’t really sick in the first place’

      • Attempt to force parents to choose

        • Child and their love/affection

        • Rx of ED

        • Soln: parents choose not to choose

        • Warn parents in advance


    Recovery of normal function
    Recovery of Normal Function

    • Initial

      • Sometimes physically impossible to eat enough

      • NGT often only option

      • Role of TBK

        • Lean body mass

        • ED Vs Leukaemia

    • Long term

      • 90% of weight for height

      • Maintain for > 6 months


    Outcomes
    Outcomes

    • Acceptance by clinicians

    • Acceptance by Paediatricians and Psychiatrists

    • Direct clinical supervision for paediatric monitoring and dietetic services

    • Communication of consultation advice back to the treating clinical team

    • Improved supervision and confidence for case manager clinicians

    • Improved continuity of care

    • Improved consumer/carer experience (“one-stop shop”)

    • Continuity of care within the advisory team

    • Maintenance of a holistic approach to care


    Challenges
    Challenges

    • Referrals of clients from outside the service

    • Triage criteria – when demand exceeds available appointment times

    • Acute versus early intervention



    A helpful reflection from another
    A helpful reflection from another. . ..


    • Prof Susan Sawyer

      (Royal Children’s Healthy Eating Clinic)

      “I started the healthy eating clinic with the whole idea of it being an early intervention service, trying to be a site that young people and their families could come to before all of the severity of anorexia nervosa in its full hand came into being. I think it is really ironic that we spent the first six years of running this service absolutely at the hard end – we only ever saw the most extreme cases of anorexia nervosa. Now that we are so well known for the service that we run, the really good news now is that in the last few years we have started to see much more exactly the sorts of cases that I had established the clinic to see. We still see the hard end, but in addition we see a number of young people at really the right time to be seeing them.”

      (VicHealth, 2004)


    In summary
    In summary . . .

    • The formation of the PEDAT arose out of a need to better meet the needs of young people presenting to the health service with eating disorders

    • In the absence of resources to provide an appropriate (minimum) standard of care, it is our attempt to provide a multiskilled and multidisciplinary approach to children and adolescents experiencing the devastating effects of eating disorders


    In summary1
    In summary . . .

    • We have learnt an enormous amount, including :

      • the importance of expert case management;

      • of communication;

      • of holding the anxiety within the family;

      • and within the other health professionals;

      • the value of integration between inpatient and outpatient services

      • the delicate and complex nature of finding a balance between the medical, the nutritional, the psychological, the social ….

      • And the list could go on . . . . . .


    Pedat s future
    PEDAT’s future

    • Service enhancement – additional two specialist eating disorders clinicians

    • PEDAT provides a solid platform (specialist collaboration and team work ) for further service expansion

    • Estimated that 70% of clients will be managed through the Maudsley Model/CBT- E

    • Ongoing role of PEDAT for initial assessment by multidisciplinary team and ongoing monitoring of an estimated 30% of clients with eating disorders

    • Move towards balance between acute illness and early intervention

    • Increase capacity to assist with education and training

    • Merge with the state-wide initiatives

    • Further formal evaluation of service


    Acknowledgements
    Acknowledgements

    This initiative has been developed through the leadership, commitment and dedication of :

    Dr Doug Shelton, Paediatrician, Director of Child Community Health

    Dr Nigel Collings, Psychiatrist, Director of Child & Youth Mental Health Services

    Ms Jodie Watkins, Assistant Director of Psychology, Child & Youth Mental Health Services

    Ms Lyza Norton, Senior Paediatric Dietician


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