Eating Disorders in Complex Adolescents

Transcript

• 00:00OK. So whenever I'm giving
• 00:03a talk on this topic,
• 00:04I always start with this image. For
• 00:07any folks that are in mental health,
• 00:09whether working in clinic based settings
• 00:11and your own practice in our school systems,
• 00:14you've probably encountered these
• 00:16silos that that come up often with
• 00:18complex presentations in adolescents
• 00:20and to I think Wendy's point in
• 00:22younger youth as well of treatments
• 00:25being quite siloed for one another.
• 00:27And I think that we've seen
• 00:29it really that epitomized
• 00:31in eating disorder care which I'll
• 00:33talk more about down the line is
• 00:35how it's become kind of such a
• 00:37niche area that it's often something
• 00:38that a lot of providers, unless it's
• 00:41been a specialty area of training,
• 00:43maybe have have some tentativeness
• 00:45with with approaching and managing.
• 00:47And so we're hoping and talking about
• 00:50these complex adolescents where
• 00:51this is often one component of a multi
• 00:54component presentation thinking about
• 00:56how best to navigate when you have
• 00:59a patient or a student or anyone
• 01:01raising some of these concerns and
• 01:03what's the right way to go?
• 01:05Because I think right now,
• 01:06again,
• 01:07with the siloed nature of care and
• 01:08such an uptick in cases as many
• 01:11of you have probably encountered,
• 01:12referrals to eating disorder
• 01:14specialists are often quite lengthy
• 01:17in terms of the wait list.
• 01:20So why has this become so siloed?
• 01:22I wish I had a a very clear straightforward
• 01:25addressable answer for everybody today,
• 01:26but it really has for some reason
• 01:28eating disorders have become
• 01:29this niche area and mental health
• 01:31training as well as medical training.
• 01:32So when I talk with my colleagues
• 01:34in the pediatric hospital in
• 01:36adolescent medicine for this,
• 01:37they talk about that,
• 01:38that same experience of that it's
• 01:40kind of you do eating disorders or you don't,
• 01:43which has really led to again,
• 01:45despite the fact that we often see
• 01:48co-occurring depression, anxiety,
• 01:49Um,
• 01:50other self injurious behaviors and number
• 01:52of concerning kind of presentations,
• 01:54it becomes this,
• 01:55this separate thing that we treat.
• 01:59So before going into a lot of those complex
• 02:02comorbidities and thinking about today,
• 02:04we're really talking about meeting the
• 02:06needs of of adolescents and I want to hit
• 02:08on some really important factors related
• 02:10to identity that are misrepresented when
• 02:13we're thinking about eating disorder
• 02:15treatment as well and assessment.
• 02:17So I invite everyone here just to think
• 02:19about what image comes to mind when you
• 02:21hear the term eating disorder and I show
• 02:23here the images that, when you Google
• 02:24it, are the first ones that come up and
• 02:27and yes these are presentations
• 02:30of adolescent and young adults, white
• 02:32females that are experiencing low weight.
• 02:35But there's this very clear idea
• 02:37of when you say eating disorder,
• 02:39what it looks like.
• 02:40And now I don't think that this
• 02:41is limited to eating disorder.
• 02:42I think to the point in both Michael
• 02:44and Youngsun's talk of hitting on
• 02:47of some of the different groups
• 02:49that are kind of unduly affected
• 02:51by depression and suicidality,
• 02:54we often have a misrepresentation.
• 02:57So in reality we know that feeding
• 02:59and eating disorders are complex
• 03:01and heterogeneous presentations
• 03:02that a lot of times couldn't be more
• 03:05different from one another.
• 03:06Now despite we lump all eating
• 03:09disorders into this one camp,
• 03:11a lot of times the co-occurring
• 03:13concerns and the presentations and
• 03:15what we're addressing therapeutically
• 03:16are more overlapping with non-eating
• 03:19disorder presentations and we'll hit
• 03:20on some of that of when we're thinking
• 03:23about what to keep an eye out for.
• 03:26So I pop up here the DSM or diagnostic
• 03:28manual's definition of eating and
• 03:30feeding disorders to just hit on
• 03:33how broad it ends up being and what
• 03:35we're having to consider and or what
• 03:37we're thinking about with feeding
• 03:39and eating disorders.
• 03:40So in essence to meet criteria,
• 03:42a persistence disturbance in eating
• 03:45or eating related behaviors that results
• 03:47in an altered consumption of food and
• 03:50significantly impairs functioning,
• 03:51either physical or psychosocial.
• 03:53So in essence if it's clinically significant and
• 03:56it has to do with food,
• 03:57then it it fits in that camp.
• 03:59So you can imagine the variety of what
• 04:02that means and what that looks like.
• 04:05Hitting some on then to that point
• 04:07of the diversity that we actually
• 04:09see an eating disorder presentations
• 04:10based on a number of aspects of
• 04:13identity and again that image
• 04:15that often comes to mind,
• 04:16these are some prevalence rates that
• 04:18have been put forward by both the
• 04:21National Eating Disorder Association as
• 04:24well as the association for or the ANAD.
• 04:30So we actually see that BIPOC
• 04:32individuals are significantly less
• 04:34likely than their white counterparts
• 04:36to have been asked by a provider
• 04:38about eating disorder symptoms.
• 04:40This is even in the context of when
• 04:42self reporting eating disorder concerns.
• 04:44So raising this to think about the
• 04:46students that you may be working with
• 04:48in some of just the data that we have
• 04:50of how some of these things can be
• 04:52missed in different systems of care.
• 04:55BIPOC individuals are half as
• 04:57likely to be diagnosed or receive
• 04:59treatment when experiencing clinically
• 05:02significant eating disorder concerns.
• 05:04Black individuals and Black youth
• 05:06are significantly less likely to
• 05:08be diagnosed with a presentation
• 05:10of restricting like anorexia,
• 05:12but may but experience the condition
• 05:13as a result for a longer period of time
• 05:16and develop more likely to develop than
• 05:19what we call a protracted presentation.
• 05:21And in reality,
• 05:23Black teenagers are 50% more likely
• 05:25to exhibit compensatory behaviors or
• 05:28bulimic behaviors of purging, excessive
• 05:31exercise, in addition to the binge behaviors.
• 05:34Similarly,
• 05:35we see that being more present in
• 05:38Hispanic and Latinx youth.
• 05:40We see actually Asian college
• 05:42students reporting higher rates
• 05:44of restriction as well as higher
• 05:47rates of body dissatisfaction.
• 05:51To a point that I will, I could give
• 05:53money talks on this and I know Ashley
• 05:55Rutherford will be hitting on considerations
• 05:57in gender dysphoria this afternoon,
• 05:59but this is something I think for anyone
• 06:02working with adolescents in school
• 06:03systems or clinical settings to be
• 06:05aware of is the clinically significant
• 06:07concerns of disordered eating in both
• 06:09sexual and gender minority individuals.
• 06:12And this is going to be very broad
• 06:15strokes overview but we see in gay
• 06:17men and gay adolescents or self
• 06:20reporting gay adolescents seven times
• 06:22more likely to report binge eating and
• 06:2512 times as likely to report purging.
• 06:28Significantly more likely to engage
• 06:31in any compensatory behaviors,
• 06:33to the point of an important distinction
• 06:35that would be happy to answer questions
• 06:37about our talk more about the distinction
• 06:39of being a sexual and gender minority.
• 06:41But in transgender individuals,
• 06:43we see eating disorders four times
• 06:46higher than their cisgender classmates.
• 06:48One in three individuals, this is again
• 06:51based on prevalence studies,
• 06:52reporting using disordered eating as
• 06:54a way to modify their body without
• 06:57hormones is just some research that
• 06:59we've been replicating within our
• 07:01gender program and we see gender
• 07:04dysphoria and body dissatisfaction
• 07:06often key links in disordered eating.
• 07:09And this is again true for not just
• 07:12our binary trans masculine and
• 07:14trans feminine individuals,
• 07:15but also for non binary individuals.
• 07:20To build on the last talk of our
• 07:21high risk presentations that we often
• 07:23have to think of these co-occurring
• 07:25concerns that it will then carry
• 07:27over into the afternoon specifically
• 07:29in gender minority youth.
• 07:32This is a kind of just a highlight
• 07:34why we can't treat these things
• 07:36separately. In some prevalence work
• 07:39that has looked at comorbidities
• 07:41of eating disorders with suicide,
• 07:44suicidal ideation and suicide
• 07:46attempts actually, in individuals who
• 07:48identify as trans both
• 07:49binary and non binary, research showed
• 07:52that for those youth who identify as
• 07:54both trans and having a history of
• 07:57an eating disorder being 20 times
• 07:59based on the odds ratios to have
• 08:01attempted suicide in the past year.
• 08:04Then two really important
• 08:06comparison groups,
• 08:06both cisgender females with an
• 08:08eating disorder who are already
• 08:10at higher risk for suicide,
• 08:11as well as trans individuals
• 08:13without an eating disorder.
• 08:15And to the point of the last talk,
• 08:16that is also a very high risk population.
• 08:19We also see that about 3/4 of trans
• 08:22youth with an eating disorder
• 08:25endorse either suicide attempts,
• 08:27suicidal ideation or engaging in non
• 08:29suicidal self injury within the last year.
• 08:31So again,
• 08:32this is to highlight in the purpose
• 08:33of our our talk today why we have
• 08:36to think about these high risk
• 08:37adolescents very holistically and
• 08:39and of these complex interacting
• 08:41kind of presentations that they're
• 08:45experiencing as well.
• 08:47I'm hitting on some other things,
• 08:49just considerations that we do see
• 08:51higher rates of disordered eating
• 08:52concerns in individuals with physical
• 08:54disabilities and individuals with autism
• 08:57and other forms of neurodiversity,
• 08:58including ADHD,
• 09:00as well as
• 09:03in individuals with ASD traits.
• 09:08And again building on the points that I
• 09:10think Wendy had raised up that we can't,
• 09:12even though we often think about adolescence,
• 09:13young adult with eating disorders,
• 09:15thinking about those risk
• 09:16factors at a younger age.
• 09:18In some prevalence work that has been
• 09:20done in the school systems over 40% of
• 09:231st to 3rd grade girls in the sample,
• 09:25in a nationally representative sample,
• 09:27reporting wanting to be thinner.
• 09:30Over 80% of 10 year old children reported a
• 09:33fear of being fat or fat being a bad thing.
• 09:36Close to half of 9 to 11 year olds
• 09:38in the sample reporting sometimes
• 09:40are very often on diets.
• 09:42Now what I highlight here is this is
• 09:44the self report of a 9 to 11 year old.
• 09:46So what that diet entails is not
• 09:48clear and may not actually be the
• 09:51behaviors of severe restriction,
• 09:52but that we're thinking about that
• 09:54cognitive mindset of I need to lose weight
• 09:56or there's something wrong with my body.
• 09:58We see a high prevalence of adolescent
• 10:01girls engaging in compensatory
• 10:03behaviors and and maladaptive dieting
• 10:06behaviors.
• 10:07And in college samples,
• 10:10over 90% of women reporting attempting
• 10:12to control their weight due to
• 10:15dissatisfaction with body and dieting.
• 10:18So an important piece to consider here
• 10:20with all these risk factors though and
• 10:22what we'll get back to in terms of
• 10:24again what populations are affected is
• 10:26actually when we're looking at truly
• 10:29what's income encompassed by that
• 10:31the diagnosis of an eating disorder.
• 10:33And yes,
• 10:33there are those specifically
• 10:35related to severe restriction,
• 10:36but actually less than 6% of
• 10:38individuals with eating disorders are
• 10:40actually in the underweight zone.
• 10:41So that clinically significant impairment
• 10:43on life that that is associated
• 10:46with having an eating disorder.
• 10:48Less than 6% of individuals who meet
• 10:50criteria for other types of eating disorders,
• 10:53whether bulimia,
• 10:54binge eating,
• 10:55other presentations that we'll
• 10:57talk about are actually look like
• 10:59what society has decided in eating
• 11:02disorder looks like.
• 11:03And so yeah despite what all the
• 11:05all this data shows us,
• 11:07there's a swag stereotype that exists
• 11:09and thinking about the students and
• 11:11patients that you work with and
• 11:13some of what can lead to hesitancy
• 11:15of endorsing some of these behaviors
• 11:17is that to have an eating disorder
• 11:19you, it's a skinny white affluent
• 11:21girl when we know that as a result,
• 11:24a number of our current treatment
• 11:26models are based on samples and this
• 11:29population sample of affluent, young adult,
• 11:31cisgender, neurotypical, white women.
• 11:32A big part of this that that will
• 11:35hit on briefly is also because
• 11:36of some of the models of care and
• 11:38often self pay models to accessing
• 11:41eating disorder treatment.
• 11:43And the swag stereotype that we see
• 11:46even what what what's illustrated?
• 11:48So to head on broadly and I'll be
• 11:50mindful time to go through quickly
• 11:52to hit more on kind of treatment
• 11:54approaches that could be used in
• 11:55the school systems more robustly.
• 11:57But thinking about the diagnosis
• 11:59that are
• 12:00encompassed in that eating and
• 12:02feeding disorder presentation.
• 12:04So we have pica, rumination disorder,
• 12:07avoidant and restrictive
• 12:08food intake disorder,
• 12:09I'll hit on each of these,
• 12:10this is something called ARFID
• 12:12that I'm sure folks are hearing
• 12:14more and more about, anorexia,
• 12:16bulimia and then binge eating disorder.
• 12:19The really tough part,
• 12:21especially in from a developmental
• 12:23lens with adolescence is based
• 12:25on DSM criteria classification
• 12:27to meet one of these diagnosis
• 12:29is mutually exclusive.
• 12:30And so for anybody who works with
• 12:33children or adolescents to and to.
• 12:34I think a really important point
• 12:36that Dr. Bloch had raised in the
• 12:38last study of how sometimes our
• 12:39models of care for both assessment
• 12:41and treatment for youth are
• 12:42based on adult models of things,
• 12:45it's not uncommon that we see more of either
• 12:49sub threshold presentations that
• 12:50are still clinically significant
• 12:52or things that kind of blend a few
• 12:54of these boxes and so then we end
• 12:56up with this catch all term of the
• 12:59other specified feeding and eating
• 13:01disorder when it is probably more
• 13:04accurate to have to dually identify
• 13:06the clinical conceptualization
• 13:08of multiple diagnoses.
• 13:11So I used this infographic as a as
• 13:13opposed to having to just walk you all
• 13:16through the specific DSM diagnoses.
• 13:19But to hit on broadly what we're
• 13:21thinking of with these different
• 13:22presentations and the conceptualization
• 13:24and to highlight why they're so
• 13:27actually distinctly different
• 13:28despite being lumped together,
• 13:30anorexia is what is more of
• 13:32that quintessential traditional
• 13:34idea of what an eating disorder is.
• 13:36So it's having significantly
• 13:38low weight or significantly low
• 13:40restriction that is associated with
• 13:42the unrealistic idea about body image
• 13:45and an intense fear of gaining weight.
• 13:47Now really important components here
• 13:49and thinking about what the students
• 13:51and patients that you're working with
• 13:52is even when you are seeing low weight
• 13:54to meet criteria for for anorexia,
• 13:56it is that intense fear of gaining
• 13:59weight and then the unrealistic idea
• 14:01of body image is something that we call
• 14:04kind of an overvaluation of weight and shape.
• 14:07So when you're thinking about
• 14:08kind of an adolescent or
• 14:10child or adult sense of self,
• 14:12their weight and body shape being one
• 14:14of the most important factors for that.
• 14:17And this is a really important piece
• 14:19to hit on because it is often what
• 14:21leads to kind of hesitancy to actually
• 14:23disclosing that that's happening
• 14:25or seeking treatment is when we
• 14:27all have things that are important
• 14:29to how we view ourselves as people.
• 14:31If if you're a provider in the school
• 14:33systems or clinical provider a lot
• 14:35of times you're work is a part of
• 14:37it and maybe being a parent or a
• 14:38daughter or a son or you know a
• 14:41a friend,
• 14:41a partner to somebody and maybe
• 14:43ways that we contribute to society.
• 14:45All these factors that impact how we
• 14:48evaluate ourselves and our judgment
• 14:50of ourself and youth and adult
• 14:52when experiencing anorexia is that
• 14:54there's such an over emphasis put
• 14:56on weight and shape that actually
• 14:58the getting better, the having to
• 15:00increase intake is almost telling
• 15:02all part of their brain that
• 15:04what they're doing is bad or wrong.
• 15:06So it really it's it's what we
• 15:08have to do to get better is almost
• 15:10antithetical to everything that
• 15:12their brain is telling them.
• 15:14Bulimia is, you know,
• 15:15it's interesting as I've had a
• 15:17colleague say that bulimia is a
• 15:20diagnosis of the past because now
• 15:22we're seeing much more of anorexia,
• 15:25binge purge type system,
• 15:26a lot of restrictions,
• 15:27significantly low weight.
• 15:28But with bulimia, it is a true binge episode.
• 15:31So a significantly large amount
• 15:33of food and an experience of loss
• 15:35of control couldn't have stopped
• 15:37self with then followed by some
• 15:39type of compensatory behavior.
• 15:40So over exercise, severe
• 15:42fasting after the fact,
• 15:44or of course, purging behaviors,
• 15:47use of laxatives, even diuretics.
• 15:50Binge eating disorder is in
• 15:52essence the bulimia without the
• 15:54without the purging behaviors.
• 15:56So we still are seeing that eating
• 15:58that significantly large amount
• 15:59of food. An important component
• 16:01here to identify for the
• 16:03clinical distress is the sense of
• 16:05loss of control. A patient wants
• 16:06you know,
• 16:07we talked about like the trains left
• 16:08the station, couldn't have stopped
• 16:10self if tried, and so there's feelings of
• 16:13guilt and disgust associated afterwards.
• 16:16Rumination disorder and Pica are
• 16:18those that we won't hit on these
• 16:20ones as much because these are more
• 16:22common in youth and adolescents with
• 16:27neurodevelopmental disabilities.
• 16:28So rumination is the regurgitation,
• 16:30it's not the purging, regurgitation
• 16:32into the mouth and re swallowing and
• 16:36then pica eating the non food objects.
• 16:39ARFID, or avoidant restrictive
• 16:41food intake disorder,
• 16:43this is one that we're seeing
• 16:44quite an uptake in the pandemic.
• 16:45And actually this really complicated
• 16:47blurred line between that and
• 16:49anorexia because what ARFID is
• 16:52is severe restriction, low weight,
• 16:54malnutrition, malnutrition in youth/
• 16:55adolescents for reasons that don't
• 16:57have to do with that point I was
• 17:00saying of an overvaluation of weight
• 17:01and shape or fear of gaining weight.
• 17:04So we often see it due to a fear
• 17:06of or an avoidance of
• 17:08negative consequences.
• 17:09So,
• 17:09for example,
• 17:10we've seen quite a number of youth
• 17:12with GI complicated GI histories
• 17:13that will then avoid eating
• 17:15because there's a fear of pain.
• 17:17Or we often see, because of food sensitivity,
• 17:19the textures of things,
• 17:21severe restriction or kind of an
• 17:24unawareness of their own hunger cues.
• 17:26The challenging part here is when
• 17:28these were developed, ARFID, anorexia,
• 17:30considered quite separate.
• 17:31But if you imagined all those points,
• 17:33I was saying of how especially
• 17:35young youth and adolescents are
• 17:37at such high risk for these,
• 17:38um,
• 17:39disordered eating concerns based
• 17:40on societal kind of body image on
• 17:43things that can be thrown at them.
• 17:45You may have an adolescence who
• 17:47it started as this avoidance and
• 17:49restricting more indicative of
• 17:50ARFID though we also have body
• 17:52image concerns that are very
• 17:54understandable and adolescent so.
• 17:56So this is where some of those diagnostic
• 17:58lines become quite blurred.
• 18:02And so often we think about here,
• 18:04I would say we, we like to try to
• 18:06pull these things apart and say
• 18:08that there's those presentations
• 18:10of restriction like anorexia,
• 18:11anxiety, pain sensory, ARFID, pica,
• 18:14dysregulation, loss of control,
• 18:16bulimia, binge eating.
• 18:18But really there's this overlap,
• 18:19they really are more of these Venn diagrams,
• 18:21which again can make things like
• 18:24accessing appropriate assessment
• 18:25and treatment quite tricky.
• 18:29I share these rates because I know
• 18:31we're hitting a lot on today with
• 18:33the uptick during the pandemic.
• 18:34These are actually the most recently
• 18:36published rates by NIMH from
• 18:38their National Comorbidity survey
• 18:39and the Adolescent Supplement.
• 18:41So this was from about 20 years ago
• 18:43and we have seen a significant increase
• 18:45during the pandemic that I'll hit on.
• 18:47But you see even at that time and prior to
• 18:50the current kind of crisis that we're in,
• 18:53you see what you saw by the time of 18,
• 18:55close to 4% of females and 1.5%
• 18:58of males meeting criteria
• 19:00for an eating disorder.
• 19:02Now during the pandemic,
• 19:04just like any of the concerns
• 19:05that we're talking about today,
• 19:07it has just kind of significantly
• 19:10been exacerbated.
• 19:11So there's this,
• 19:12I remember this editorial that came
• 19:14out in May of 2020 and it was the
• 19:16COVID-19 and the implications for eating
• 19:18disorders and it kind of anticipated
• 19:20that we were going to see an uptick,
• 19:21but completely underestimated kind
• 19:23of what has actually happened. And the
• 19:27first publication pertinent to the
• 19:29children and adolescents that we're
• 19:31talking about a very severe cases
• 19:33that highlighted the increase
• 19:34in the most severe cases,
• 19:36so these are going to be youth
• 19:38who are hospitalized medically
• 19:39for the complications associated
• 19:41with restrictive eating,
• 19:42so issues with vitals, what's going on
• 19:44with the heart and you know that that
• 19:46they have to be in the hospital to be
• 19:48weight restored and stabilized,
• 19:50we saw published in July of 2021 from a
• 19:54hospital in Michigan that just noting
• 19:56the difference in admission rates
• 19:58and it being significantly higher
• 20:00that now in the last year we've seen
• 20:03replicated throughout the country
• 20:04as well as in Europe,
• 20:06and I'll hit on some of the data
• 20:08that we've actually seen at the
• 20:10children's hospital in New Haven.
• 20:12When we think about what's
• 20:14exacerbated those prevalence rates,
• 20:15it really was the pandemic created a
• 20:17perfect storm for eating disorders to grow,
• 20:20both those related to restriction as
• 20:21well as those with loss of control.
• 20:23So there's this greater susceptibility
• 20:25to illness just associated with
• 20:27being in the pandemic.
• 20:29The presentation of,
• 20:30you know,
• 20:30much related to eating disorders in
• 20:32the camp of restricting being about
• 20:34control and what you're doing is
• 20:36taking away all control about the
• 20:38environment and really isolating
• 20:40somebody and really being socially connected
• 20:42are some of the most protective factors
• 20:45here. And then there's the amount
• 20:47of virtual interaction,
• 20:48only seeing your peers online,
• 20:50only seeing filtered images of your
• 20:52friends online and the dangers
• 20:54of social media on body image.
• 20:56So not only only getting to connect via
• 20:58zoom and having to see yourself on screen,
• 21:01but then everything that you
• 21:02see online through social media
• 21:04engendering a more negative body image.
• 21:06And so I'm I'm sure that folks had
• 21:08seen that the time of when the pieces
• 21:11coming out from the the Facebook and
• 21:12Instagram whistleblower of the
• 21:14algorithms that they actually identified
• 21:17that once youth and adolescents
• 21:19were starting to look at like
• 21:21any types of thing on Instagram
• 21:23related to to body image,
• 21:25even more positive body image,
• 21:27some of the algorithm could take
• 21:28them to pro Ana or pro anorexia
• 21:30sites because it increases the
• 21:32clicks of things and so that there
• 21:34really are a lot of these dangers
• 21:36to what could be vulnerability
• 21:38factors for the youth currently.
• 21:41When we're looking specifically, and
• 21:43for those of us that are in
• 21:45Connecticut, at what we've actually
• 21:46seen at Yale New Haven Children's
• 21:48Hospital to highlight this increase.
• 21:50So these are again youth hospitalized
• 21:52for the severe medical complications
• 21:54associated with restrictive eating.
• 21:56We did a medical record review
• 21:58of the three years prior to the
• 22:00start of the pandemic and had 48
• 22:02children hospitalized for those
• 22:04severe medical complications.
• 22:06And then in looking in just the first
• 22:08year and a half of the pandemic,
• 22:09we saw already 60.
• 22:11So we'll be looking again at the
• 22:13end of this calendar year for that
• 22:15full three-year period and of
• 22:17course not expecting just doubles,
• 22:19but to just show that in that time
• 22:20period we would expect it to more than
• 22:22double or maybe even triple to what
• 22:24we saw the three years before the pandemic.
• 22:28We also saw an increase
• 22:29in the length of stay.
• 22:30This was both due to lack of resource
• 22:33and available for disposition or
• 22:35for where to refer folks as well
• 22:37as what we saw of the increase
• 22:39in severity presentation.
• 22:40To the point that's been raised
• 22:42about how much more concern
• 22:44we're seeing in younger youth,
• 22:46a significantly higher number of youth
• 22:48under the age of 13 being hospitalized
• 22:51for the severe medical complication.
• 22:53Requiring medical, um, psychiatric medication,
• 22:56more patients
• 22:58requiring discharge to a higher
• 23:00level of care and again,
• 23:01what we've seen around the country.
• 23:04To hit on some of the severity and why,
• 23:07including in the talk today and thinking
• 23:08of how to provide more resources,
• 23:10eating disorders are among the
• 23:13deadliest mental illnesses,
• 23:15second only to opioid overdoses.
• 23:17Anorexia specifically has a
• 23:19relapse rate of approaching 50%.
• 23:21So even when technically
• 23:23going into remission,
• 23:25one in two individuals will relapse.
• 23:28The standardized mortality ratio,
• 23:30or what that means of somebody at
• 23:32an age with anorexia compared to
• 23:35somebody without is six times as
• 23:37likely to to have early mortality.
• 23:40This is a really important point to
• 23:42working with children and adolescents.
• 23:43It's about one in five individuals who,
• 23:46once meeting criteria for individual
• 23:48develop what we call a severe
• 23:49and protracted illness,
• 23:50which means it does never get
• 23:53better until the until death.
• 23:55We see a death about once every hour
• 23:57attributed to an eating disorder.
• 23:59And among individuals with anorexia,
• 24:02we do see those higher rates
• 24:03of suicide and of course,
• 24:05the medical complications
• 24:06associated with an early death.
• 24:11Eating disorders cost a great deal
• 24:13to both our hospital systems and,
• 24:15so this is again why we continue
• 24:17to think about other ways to both
• 24:19meet of course public health costs,
• 24:21but more so the individual need of
• 24:23our of our patients and students.
• 24:25Really important point here,
• 24:26again this isn't for those very severe
• 24:29restrictive presentations of anorexia,
• 24:31but about one in 10 individuals
• 24:33in their life meet criteria,
• 24:34clinical criteria for an eating disorder.
• 24:36This includes all those of the
• 24:39binge eating, bulimia,
• 24:40ARFID, so important to highlight
• 24:42to again the likelihood of a number
• 24:45of students or patients that you
• 24:47have that may be meeting criteria but
• 24:50not sharing. Our treatment
• 24:52approaches that I'll hit on where
• 24:54we're really working to build because
• 24:55we we haven't really hit on the
• 24:58most effective strategies yet.
• 24:59And unfortunately we don't have
• 25:01medications that actually are FDA
• 25:03approved or shown to be effective
• 25:05currently for addressing eating
• 25:07disorder concerns in adolescents.
• 25:08We do have some efficacy
• 25:10in adults. Often when we see
• 25:12medications being used and if any
• 25:14folks have questions on that,
• 25:15we fortunately have a number of
• 25:17psychiatrists here on our panel today, as
• 25:19treating those co-occurring conditions.
• 25:21So the co-occurring depression
• 25:23or anxiety or other concerns.
• 25:26So to the point of the high comorbidities,
• 25:28the high comorbidities again already
• 25:30hitting on the higher rates that
• 25:32we see in individuals with gender
• 25:34dysphoria as well as the higher
• 25:36rates of suicidal ideation.
• 25:37We do see greater negative long
• 25:39term effects when there are those
• 25:41associated comorbidities and why
• 25:43we want to treat the whole child.
• 25:45We see over half of adolescents with
• 25:48anorexia having some type of mood disorder.
• 25:51The challenge here is that it's
• 25:53the chicken or the egg question
• 25:55just because severe starvation
• 25:56can, of course,
• 25:59impact mood. We see about one in
• 26:02four individuals with anorexia meeting
• 26:04criteria for an anxiety disorder.
• 26:06One in four individuals have
• 26:09experiencing a substance abuse concern,
• 26:12most prevalent those associated
• 26:13with weight loss,
• 26:14including cocaine and amphetamines, and high
• 26:17rates of OCD in individuals with anorexia.
• 26:21One of an important distinction here
• 26:23is because there is often such an
• 26:25obsession related to food and body
• 26:27image, a co-occurrence of OCD is
• 26:29only considered truly a co-occurring
• 26:31disorder if the OCD symptoms occur
• 26:34outside of eating and weight concerns.
• 26:38I highlight here again also just to
• 26:40show that these complex adolescents
• 26:42and how all of these pieces come
• 26:44together that actually the NYSARC
• 26:46data set that looks, it's an adult
• 26:48data set that looks at a nationally
• 26:51representative sample across the
• 26:53country had, based on self report
• 26:55from adults who had had a lifetime
• 26:57diagnosis of eating disorder of an
• 26:59eating disorder showing how high,
• 27:01how high suicide attempt rates were.
• 27:03So especially in that anorexia
• 27:06binge purge type, so
• 27:07experiencing like a loss of
• 27:09control with eating and purging,
• 27:10but still having that very
• 27:11significantly low weight.
• 27:15And the reality is despite us
• 27:17really understanding this,
• 27:18we continue to be in a crisis of care
• 27:20in treating patients with anorexia.
• 27:22And this is true for adolescents.
• 27:23This is a wonderful, a wonderful
• 27:25read for anybody who has free time,
• 27:27just about a page and 1/2 paper
• 27:29that was in the journal JAMA
• 27:30Psychiatry last year that highlights
• 27:32kind of all the reasons for this.
• 27:34And why our team is really thinking
• 27:36again about meeting the complex
• 27:37needs of adolescence is how we've
• 27:39really developed into this siloed
• 27:41nature of care from funding sources
• 27:43to how clinical care is provided.
• 27:45And why we really have to think
• 27:47about innovative ways of addressing,
• 27:48especially through prevention efforts.
• 27:52So some of the common evidence based
• 27:54treatments for eating disorders and I
• 27:55I often like to say evidence informed
• 27:57just because even though and you know
• 27:59I think of course very highly of all
• 28:01these approaches, is our remission rates
• 28:03aren't where we would like them to be.
• 28:06So but these are the ones that we
• 28:08are often using to when somebody is
• 28:10engaged in eating disorder treatment
• 28:11I'll hit on some of the most the
• 28:13most common ones and the most
• 28:16frequently used. So in adolescents,
• 28:19so if you if you have any students
• 28:21or patients that you are seeing
• 28:22truly it is restricting and we need
• 28:25to focus on weight restoration,
• 28:27family based treatment is one of
• 28:29the most effective modalities
• 28:31for weight restoration.
• 28:33What this therapeutic approach
• 28:35entails and is in essence the idea
• 28:39that when somebody has entered into
• 28:41the eating disorder mindset right, and
• 28:43that they're that for an adolescent
• 28:45that isn't able to think as clearly
• 28:47because of the way that it really
• 28:49has kind of taken over thought
• 28:50processes and the way that that,
• 28:52because of that overvaluation of
• 28:54weight and shape is getting in
• 28:56the way of engaging in things like
• 28:58cognitive behavioral strategies.
• 28:59The idea from a developmental lens is
• 29:01that we have to turn over nurturing the
• 29:04the child or adolescent to the parent.
• 29:06So this,
• 29:06the first phase is the parents
• 29:08kind of have to completely take
• 29:10over the weight restoration phase.
• 29:12Then there's a second phase of
• 29:14really trying to transition back over
• 29:16control to eating to the adolescent
• 29:17and then thinking before launching
• 29:19of how to address some of those
• 29:21factors that may have contributed
• 29:23to the eating disorder in the 1st place.
• 29:26Now because of this FBT, or family
• 29:28based treatment, is the most
• 29:30effective for weight restoration,
• 29:32but it does not work for all families.
• 29:34And so this is one of the places that
• 29:36we're getting into with these complex
• 29:38adolescents is for anybody here and I
• 29:40know you know probably everybody here
• 29:41who works with children and adolescents,
• 29:43some of the rule outs for things
• 29:45like this are you know the more toxic
• 29:47or negative family dynamics or any
• 29:49issues in the family system that
• 29:51would get in the way of treatment.
• 29:53That parents have to be available to
• 29:55do refeeding at all the meals and be
• 29:57monitoring those things and if there
• 29:59are things like co-occurring suicidality
• 30:01or high risk behaviors that it's
• 30:03it's often a counter indicator for
• 30:05family based treatment alone, itself.
• 30:07So that makes, as we're seeing this
• 30:10uptick this uptick in very complex cases,
• 30:13often things that we can pull from
• 30:15for this approach,
• 30:16but can be difficult to only
• 30:18implement when we have to address
• 30:20these other high risk concerns.
• 30:22Some of the other strategies then
• 30:24that we think about as well are
• 30:27things pulling from for example
• 30:29cognitive behavior therapy.
• 30:30So what CBT for eating disorders
• 30:32looks at is in essence a multi stage
• 30:35approach of both kind of starting
• 30:38with where somebody is at right after,
• 30:41especially more so after that immediate
• 30:43weight restoration that we need some
• 30:45stabilization there because again
• 30:46if somebody is in such a place of
• 30:49starvation or malnutrition engaging
• 30:51in cognitive strategies
• 30:53to change thoughts is you know an
• 30:56untenable task in a lot of ways.
• 30:58So we have to have that immediate
• 31:00stabilization and then we're focusing
• 31:02on really what are the roots of
• 31:04what's kind of perpetuated the
• 31:06disordered eating behavior.
• 31:07So things related to body image
• 31:09and addressing those concerns, the
• 31:11dietary restraint,
• 31:12how do we just restructure our
• 31:14schedule in day to make sure getting
• 31:16enough, and then identifying events,
• 31:17moods and stressors and preparing
• 31:20to address for what could be
• 31:22more stressors moving forward.
• 31:25Another very interesting approach
• 31:26that people pull from is I'm
• 31:28sure folks here are familiar with
• 31:31dialectical behavior therapy.
• 31:32What radically open dialectical behavior
• 31:34therapy is actually almost the opposite,
• 31:37to the extent or another end
• 31:39of the spectrum.
• 31:40So with the idea of DBT being
• 31:42for presentations of severe
• 31:44emotional dysregulation,
• 31:46radically open DBT focuses on
• 31:49presentations of maladaptive over control.
• 31:52So you think about, and the idea with
• 31:54um,
• 31:54with individuals or youth with that,
• 31:57with something like anorexia are
• 31:59often very disconnected from
• 32:01others, socially isolating, feeling
• 32:03a distance that leads to
• 32:05the depression and anxiety,
• 32:06and really wanting to mask those feelings.
• 32:08And so,
• 32:08so much of what the approach here
• 32:10is about being able to engage
• 32:12in more open expression,
• 32:14becoming more socially connected,
• 32:15feeling safe and secure.
• 32:17So it really is focusing in some ways
• 32:20similar to other approaches of that
• 32:22social and interpersonal connectedness.
• 32:24I always like to bring this one into
• 32:26the talk as well because I think that
• 32:29it highlights even the the model
• 32:31here highlights why the pandemic
• 32:32was so damaging for eating disorders
• 32:35is we're saying being socially
• 32:36connected to others is so protective
• 32:39for eating disorders because you
• 32:41you know if you're so isolated and
• 32:43so focused on the eating disorder
• 32:44and the restricting the foods,
• 32:46itself that being connected
• 32:47with others is really protective
• 32:49against that and that was taken
• 32:51away during the pandemic and had
• 32:53to be for the sake of
• 32:54of isolation.
• 32:57And then there is an approach here
• 32:59thinking of some almost just pragmatic
• 33:01and having resources for folks
• 33:04here that are looking for you know,
• 33:06I'm seeing some some students or
• 33:07people that I work with some eating
• 33:09concerns that I would like to address.
• 33:11It's not needing to go to a specialty
• 33:14eating disorder facility or requiring
• 33:16that type of intervention, is the
• 33:18integrative modalities therapy.
• 33:20So in essence what the authors did here
• 33:22was take a number of the treatment
• 33:24approaches and create a buffet.
• 33:25So it's not a a structured protocol.
• 33:27Um, it is a manual but basically takes a
• 33:29lot of the evidence based interventions
• 33:31that we have for eating concerns and
• 33:34has resources both for clinicians to
• 33:37utilize different formats used for group,
• 33:39for parent work,
• 33:40for individual work that
• 33:42hits on the foundations of these
• 33:44different ones that I mentioned.
• 33:46So they take the foundations of
• 33:48family based treatment and doing
• 33:49some family work without having to
• 33:51do purely the family based treatment
• 33:53model, using acceptance and mindfulness
• 33:55based approaches, focusing on again
• 33:57because that dietary restraint that
• 33:59pack and happens, engaging in more
• 34:02regulative and appetite of eating.
• 34:04So that structure of how to
• 34:06reconfigure those cues to let you know
• 34:08when you're hungry and full and then
• 34:09really focusing on body acceptance.
• 34:11So,
• 34:12so this is a wonderful one that I
• 34:14think is a great resource for anybody
• 34:16working with students or patients
• 34:18in these age ranges because it does
• 34:20have the pieces that you can kind of
• 34:22pull from and you can download what
• 34:24why you can't download the whole
• 34:26manual online and it does have
• 34:28to be purchased they are,
• 34:29I do highlight that all of their
• 34:31worksheets and things are freely
• 34:32available online and they have
• 34:34available for folks to download.
• 34:38So before and, trying to be mindful of making
• 34:40time for discussion points or questions,
• 34:43I do want to hit on some of the
• 34:44things that are most effective here.
• 34:46And one we're thinking about what this
• 34:48uptick in concerns and what's actually
• 34:50most effective to caring for youth with
• 34:52these concerns is that early detection
• 34:54is the the most effective thing.
• 34:56So it is, unfortunately we've gotten
• 34:57to this place with the crisis and
• 34:59care that we're in of having to be so
• 35:01reactive that a lot of times people
• 35:03aren't able to access care until you
• 35:05are requiring going to the hospital.
• 35:06But really what we know, because
• 35:09how these presentations can become
• 35:11so severe and protracted, is early
• 35:13detection and addressing those things
• 35:15that can lead to those,
• 35:17those very severe presentations
• 35:18is going to be the most effective.
• 35:20And so there are some really
• 35:23wonderful prevention programs that
• 35:24are really aimed at this.
• 35:26So one thinking specifically to school
• 35:28systems but have been implemented in
• 35:31other settings are things known as
• 35:33the body project. So for folks who
• 35:37aren't familiar,
• 35:38it's what's called a cognitive
• 35:40dissonance based program.
• 35:41It was actually developed to be
• 35:43implemented in high schools with
• 35:45with high school girls and what it
• 35:48does is really engender or promote
• 35:50a positive body image and social
• 35:52connectedness with the idea of then
• 35:54being a preventative approach to
• 35:56developing disordered eating concerns.
• 35:58Now of course during the course of
• 35:59the pandemic when at home for all the
• 36:02reasons that our behavioral health
• 36:03concerns escalated in the 1st place
• 36:05was quite difficult to implement.
• 36:06So what the the approach does is really
• 36:09challenge unwanted body comments,
• 36:11focuses on improving body image
• 36:14and connects other,
• 36:15connects students and patients with
• 36:17others that are impacted by the
• 36:20complicated relationship of food
• 36:21and exercise and really focuses
• 36:23on that validation.
• 36:25Because again,
• 36:26eating disorders are such isolating
• 36:28presentations that really feeling
• 36:30connected to others and validated in a,
• 36:32is a way of being protected and commits
• 36:35to making positive change as a group.
• 36:37So for folks that that are interested
• 36:39just to provide one resource and
• 36:41know no conflicts of interest on my
• 36:43end to disclose just thinking more
• 36:45of resources that are available.
• 36:47They do have workshops and things
• 36:48online to both train individuals who
• 36:50are interested in running such groups
• 36:52or even providing to students and
• 36:54families and patients of, for some
• 36:56of their online resources as well
• 36:58that really focuses on again that
• 37:00way of engendering healthy body
• 37:02images and self esteem within the
• 37:04school systems and really addressing
• 37:06more of that prevention.
• 37:08As opposed to why do we react when somebody,
• 37:11when something develops so significantly
• 37:12to require being in the hospital.
• 37:14But these all these things that we
• 37:16know that are risk factors for getting
• 37:18to that point and really building
• 37:20more healthful both connections
• 37:22with others and healthful practices,
• 37:24learning those things early on in
• 37:27a validating environment. OK.
• 37:29And I will stop there
• 37:33and would be open to any questions that
• 37:36that have been raised by the group.
• 37:43So I unmuted Nicole.
• 37:46I don't know if you want to ask your
• 37:49question or you want me to ask it.
• 37:51Oh yeah, I can definitely do that.
• 37:55My biggest struggle is I work with younger
• 37:58adolescents and I can usually see risk
• 38:01factors for eating disorders and they're
• 38:04not meeting criteria for diagnosis.
• 38:06What would you suggest as the best treatment,
• 38:09especially if there's minimal parent
• 38:12engagement and their behaviors can be
• 38:16impacting the risk? For reference,
• 38:18I'm in a school based clinical setting.
• 38:22Nicole, it's a really great question and I
• 38:25think that this is a crux of some of our,
• 38:27I guess to highlight why I think
• 38:29preventative work is so much more important
• 38:31is there's this whole idea of like a
• 38:33clinical staging model of probably what
• 38:35you are seeing are the patients that
• 38:37if when intervention doesn't happen,
• 38:39we end up seeing those more, you know,
• 38:41severe presentations and that question
• 38:43comes up of why don't we intervene earlier.
• 38:46To that point,
• 38:47I completely hear what you're saying.
• 38:49We're then it's hard to often get parental
• 38:51engagement to get the appropriate resources.
• 38:52Right.
• 38:53Because if somebody's not meeting criteria
• 38:55for a diagnosis that we can put down
• 38:57all the, all of the things that can make
• 38:59it more of a challenge for providers.
• 39:01I think really what I what we know
• 39:04across eating disorder presentations,
• 39:07what are some of the underlying
• 39:09challenges with the exception of those
• 39:12that are more related to like food
• 39:14sensitivity and if it truly is like
• 39:17a fear avoidance of textures or
• 39:19or pain, is the the benefits of body
• 39:22acceptance.
• 39:23So this is true of whether somebody's
• 39:25experiencing more loss of control or
• 39:27purging behaviors or more restrictive
• 39:29eating is really engendering and
• 39:31focusing on those pieces.
• 39:32So that even though it's the
• 39:34interesting part of eating disorder
• 39:35treatment of when somebody has developed
• 39:37a very, very severe presentation,
• 39:39almost what we have to do to stabilize
• 39:41them is so opposite of what
• 39:44actually helps long term right is
• 39:45because it's so focused on on the food,
• 39:48just getting into enough calories.
• 39:49But when you have somebody with more
• 39:51of that sub threshold presentation
• 39:53or the subclinical and you can
• 39:55really focus more so on engendering
• 39:57that positive body image and if
• 39:59possible to be able to identify what
• 40:01are some of those things at home that
• 40:04actually might be doing the opposite
• 40:05in a strength based way for parents,
• 40:07right.
• 40:07If the child can identify things
• 40:09that do make them want to skip meals
• 40:11or you know really focusing on
• 40:13that communication of it to really
• 40:15promote as opposed to here is what
• 40:17parents are doing wrong, right.
• 40:18But rather here's what we just
• 40:20know would be the most helpful.
• 40:23Yeah, that's great.
• 40:24Thank you.
• 40:28So I'll ask a follow up question to Nicole's.
• 40:31I don't quite know how to ask the question.
• 40:33So Rebecca, try to make some sense of it.
• 40:37I guess I was just thinking in if I were
• 40:39in schools the thing I'd be really struggling,
• 40:42there are multiple things that
• 40:43I'd really struggle with in
• 40:45in sort of helping these kids,
• 40:47the first one is sort of thinking about
• 40:49group level, school level interventions
• 40:52versus individual interventions and just
• 40:55here are your thoughts more
• 40:57about that and then what,
• 40:59what should someone do if
• 41:01they actually see a kid
• 41:04sort of struggling
• 41:05in this school setting,
• 41:07like what's the appropriate
• 41:09place of teachers and
• 41:12and adults to intervene and have
• 41:15what's an effective way to
• 41:17actually think about intervening?
• 41:20Both really great questions.
• 41:21I think that to the point of
• 41:23the individual versus group,
• 41:25I think when resources are available
• 41:27for group and if it is kind of being
• 41:30more implemented in a school setting,
• 41:32that's always what I would
• 41:33go with because again,
• 41:34I think that there's that to the point of
• 41:36how these presentations can be so isolating,
• 41:39it's that really it can be very
• 41:41validating and supportive.
• 41:42Now the reason that I bring up
• 41:44in the schools that that does
• 41:46seem and feel safer is when there
• 41:48are really severe presentations
• 41:50sometimes that can be less helpful
• 41:52right at like the inpatient level
• 41:53or things like that where more of
• 41:55because people aren't really in
• 41:56that place often of being ready
• 41:58to make changes of sharing some of
• 42:00the ways to more engage in the
• 42:03more problematic eating behavior.
• 42:05So group at higher levels of care
• 42:07aren't always the most effective
• 42:08but in the school based setting when
• 42:10we're thinking more from preventative,
• 42:12sub threshold presentations,
• 42:14getting socially connected,
• 42:15normalizing that it makes sense
• 42:17that these students are feeling
• 42:19uncomfortable about their bodies in this way,
• 42:21trying to promote more healthful ways
• 42:23that actually and healthful ways
• 42:26of managing relationships with food,
• 42:27as well as thinking about promoting
• 42:29not focusing on food so much what
• 42:31are the other kind of things we're
• 42:33focusing on in life that makes life
• 42:35worth living is the most protective.
• 42:38When doing individual work
• 42:40though to that point I think ways
• 42:41to continue to just provide that
• 42:43validating environment is the most
• 42:45important thing of kind of normalizing
• 42:47why this makes so much sense that
• 42:49the youth is struggling with it and
• 42:51also you providing that validation
• 42:53and acceptance to try to make change
• 42:57to then challenge some of those more
• 42:59negative thoughts. I think to the
• 43:01point or the to the question about
• 43:03the resources though and where to go,
• 43:05one of the you know, a lot of times
• 43:07as part of kind of series of talks
• 43:09I often have to give a talk on why
• 43:11parents are often very much in
• 43:12denial of realizing how severe their
• 43:14their child's presentation is.
• 43:16So I raised this to your point Dr
• 43:18Bloch is I think that that's something
• 43:20for school providers to be mindful
• 43:22of is just that we we do see with
• 43:26presentation with eating disorder
• 43:27concerns more more frequently we
• 43:30see parents kind of being resistant
• 43:32to acknowledging the severity of it
• 43:34because so many of the behaviors
• 43:36start very healthfully.
• 43:38And then there's this this thin line
• 43:40of when it does become maladaptive
• 43:42and these are, because these are often
• 43:45students or children who present
• 43:46as very high achieving,
• 43:48they're a bit anxious maybe you
• 43:50know kind of have, do really well in
• 43:52school doing all the things right
• 43:54and seeing things start to go in
• 43:56this scary more negative direction
• 43:58parents are understandably avoidant of.
• 44:00So there's been some qualitative
• 44:02work with parents who have
• 44:03you know in the interviews they
• 44:04talk about like "we had to be at the
• 44:06point of having go to the hospital
• 44:07before I could even
• 44:08acknowledge what was going on."
• 44:10So I think for school providers
• 44:12that are noticing those things,
• 44:14trying to think about how to
• 44:15approach with parents in that very
• 44:17supportive way and just being mindful
• 44:19of the parent potentially being
• 44:21very resistant to this feedback.
• 44:23And so very much in a
• 44:24non judgmental observation of just
• 44:26what has been noticed at school.
• 44:27The student is isolating more.
• 44:29The student is sitting alone
• 44:30at lunch and not eating.
• 44:31Just providing the data without
• 44:33any judgment to it and then
• 44:35providing some of the
• 44:37um, the ideas for resources to the families.
• 44:40I think approaching the if,
• 44:43I think offering to the child if
• 44:44there are groups going on is always
• 44:46a valuable thing and things that
• 44:48can be more related to the social,
• 44:50the social connection.
• 44:51I think though,
• 44:53unless the child is actually
• 44:55raising the eating concerns,
• 44:56that can be a quite a challenging
• 44:58things to raise at school because
• 45:00it is something that really just
• 45:01as part of the presentation
• 45:03is kept so much more hidden.
• 45:07OK, last question because I
• 45:09don't want to stand between
• 45:11people and the and their lunch.
• 45:13I guess another thing,
• 45:14I may be projecting a little bit on
• 45:16to the people who work at schools,
• 45:18but another thing that would worry
• 45:21me about trying to implement some
• 45:23of these more school based group
• 45:26interventions is not having anything
• 45:28to do with the kids that you identify
• 45:31as having more severe problems
• 45:33if you did the interventions.
• 45:35And so I guess it's two parts.
• 45:36Could you really do the interventions
• 45:38if you don't have a good place
• 45:39to send kids who are struggling?
• 45:42And then are there any places that
• 45:45are good resources for families?
• 45:48It's a great question.
• 45:49So I guess highlighting to the point of
• 45:51unfortunately the place that we're in is,
• 45:53there is and this is why we're
• 45:55trying to do more work of making
• 45:58eating disorder care more robustly
• 46:00available because it has become
• 46:02these very siloed niche areas.
• 46:04Those specialty places often do
• 46:06have more significant wait lists.
• 46:08But I think to the point of seeing more
• 46:11subclinical or less severe presentations
• 46:13but still clinically notable of
• 46:15wanting to address making sure just
• 46:17connected to a mental health provider
• 46:19to address what's often the
• 46:21co-occurring concerns is very important
• 46:23that then can integrate some of the
• 46:25work related to to body image concerns.
• 46:28I think for if they are seeing more
• 46:31significant presentations but a
• 46:33lack of kind of access to an eating
• 46:35disorder specific facility,
• 46:37there is a program called equip EQUIP
• 46:42that is a telehealth resource that
• 46:46provides an interdisciplinary team.
• 46:49And virtually for families who
• 46:50aren't able to access it,
• 46:52again in person care is always preferred,
• 46:55but they they do integrate elements of
• 46:57family based treatment as well as with
• 46:59strategies from things like CBT or DBT.
• 47:01And I know for some of our families
• 47:04that haven't been able to access the
• 47:06appropriate kind of levels of care,
• 47:09it is a resource that we have
• 47:11used with some success.