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INFORMATION FOR

YCSC Eating Disorder Care

August 01, 2023
  • 00:09Hello everyone. My name is Rebecca Cammady,
  • 00:11I'm a clinical psychologist and assistant
  • 00:13professor with the Yale Child Study Center.
  • 00:16And I'll be speaking in today's
  • 00:18webinar on eating disorder care
  • 00:19at the Child Study Center,
  • 00:21focusing quite a bit initially on kind of
  • 00:25the presentations of disordered eating
  • 00:26that we see across levels of care.
  • 00:29And then what the center has done to address
  • 00:32that and what kind of hopes for things are.
  • 00:35So whenever giving a talk on this topic,
  • 00:38I start with this image of the silos
  • 00:40of care and especially pediatric
  • 00:42eating disorder care with other
  • 00:44mental health comorbidities.
  • 00:46Unfortunately,
  • 00:46what's happened is receiving treatment
  • 00:49and the research and program
  • 00:51development that's often associated
  • 00:53with eating disorder care becomes
  • 00:56quite siloed from other child and
  • 00:58adolescent mental health services and
  • 01:00kind of thinking about those other
  • 01:03presentations that we often see.
  • 01:05Why is this the case that
  • 01:07it's become so siloed?
  • 01:09Eating disorders in the mental health,
  • 01:11medical,
  • 01:11social work kind of across different fields
  • 01:14have become a a niche area throughout
  • 01:17training and program development.
  • 01:19And despite we often see the significant
  • 01:22comorbidities that we often see,
  • 01:24we still see it kind of separated out
  • 01:27that makes providing the most kind of
  • 01:30holistic and cohesive care quite challenging.
  • 01:34So when thinking about how we
  • 01:36really have to move that forward,
  • 01:38I always invite folks to think about
  • 01:40what images come to mind when you hear
  • 01:42the term eating disorder and they think
  • 01:43that the system of what perpetuates
  • 01:45this more kind of siloed mentality of it.
  • 01:48When you Google search it,
  • 01:50the similar kind of images come up of slim,
  • 01:53white young adult females.
  • 01:55And in reality,
  • 01:56we know that feeding,
  • 01:58eating and weight disorders are
  • 02:00actually very complex heterogeneous
  • 02:02presentations that don't fit one mold.
  • 02:04So when we actually think about what
  • 02:07constitutes a feeding or eating disorder
  • 02:08based on the DSM or a manual that we
  • 02:11used to diagnose psychiatric diagnosis,
  • 02:13it's characterized by a persistent
  • 02:15disturbance of eating or eating
  • 02:17related behavior results in an
  • 02:19altered consumption of food and
  • 02:21that significantly impairs physical
  • 02:23health or psychosocial functioning.
  • 02:24So in essence,
  • 02:26it's disturbance with food that's
  • 02:28clinically significant impacts relationship
  • 02:29with food and how much we're eating
  • 02:31and then impacts are functioning.
  • 02:33And as you can imagine that that's
  • 02:35quite broad in the range of youth,
  • 02:37young adults who are requiring care
  • 02:39for these kind of presentations.
  • 02:44So I highlight here some of the issues
  • 02:46related to diversity in disordered
  • 02:48eating presentations that are often
  • 02:50kind of not conceptualized in a lot of
  • 02:53our more traditional models of care.
  • 02:55So we actually know that Bipoc youth and
  • 02:57young adults are less likely than their
  • 02:59white counterparts to be asked by doctors
  • 03:02about their eating disorder symptoms.
  • 03:04Even when they're self reporting
  • 03:06disordered eating symptoms,
  • 03:08Bipoc individuals are half as likely
  • 03:10to be diagnosed or receive treatment
  • 03:12than their counterparts with it,
  • 03:14the white counterparts with
  • 03:16an eating disorder.
  • 03:17Black individuals are less likely
  • 03:19to be diagnosed with anorexia,
  • 03:21but may experience the OR do experience
  • 03:23the condition for a longer period of time.
  • 03:26In some ways related to these difficulties
  • 03:29accessing the appropriate care,
  • 03:32black teenagers and adolescents
  • 03:34are more likely than white teeners
  • 03:37to exhibit binge purge eating.
  • 03:39Similarly,
  • 03:39Hispanic youth are more likely
  • 03:42to experience bulimia and nervosa
  • 03:44than their non Hispanic peers.
  • 03:46And we know that Asian Americans experience,
  • 03:49based on some nationally representative data,
  • 03:52higher rates of restriction
  • 03:53compared to their white peers,
  • 03:54as well as some higher levels
  • 03:57of body dissatisfaction.
  • 04:00We see diversity in presentations based
  • 04:04on gender and sexual minority identity.
  • 04:07So we see higher rates of binge
  • 04:09purging in gay men and adolescents,
  • 04:11as well as increased likelihood of
  • 04:14experiencing compensatory behavior.
  • 04:16So fasting, vomiting, using laxatives,
  • 04:19we see transgender college students
  • 04:22reporting higher experiences of
  • 04:24disordered eating as well as this
  • 04:27really important component among
  • 04:29individuals who identify as the gender
  • 04:31minority of the role that disordered
  • 04:33eating can play in a way of affirming
  • 04:36one's body as a gender affirming tool.
  • 04:39And that is where we see then often a
  • 04:42tie in with more gender dysphoria and
  • 04:45body dissatisfaction overlap and and
  • 04:47impact disordered eating in this population.
  • 04:53Among youth with eating disorders,
  • 04:55we see a particularly high
  • 04:58risk population among trans
  • 05:00and gender diverse adolescents,
  • 05:02so we know similarly.
  • 05:05Based on prevalence data and a
  • 05:07nationally representative sample
  • 05:09of young adult of adolescents,
  • 05:11we see that in trans use with
  • 05:13youth with eating disorders,
  • 05:15they're more than 20 times as likely
  • 05:17to have attempted suicide in the
  • 05:19past year than either cisgender
  • 05:21female with the history of an eating
  • 05:24disorder or trans use without a
  • 05:26history of an eating disorder.
  • 05:28And approximately 3/4 of trans use
  • 05:31with an eating disorder have endorsed
  • 05:34suicidal ideation or engaging in non
  • 05:36suicidal self injury in the past year.
  • 05:39So very high risk population.
  • 05:42We also see diversity in terms
  • 05:45of disabilities in individuals
  • 05:46with disordered eating.
  • 05:48So among with physical disabilities
  • 05:50and young girls being more likely
  • 05:52to develop disordered eating,
  • 05:54we see high rates of disordered
  • 05:56eating among individuals with
  • 05:58neurodiversity or on autism spectrum.
  • 06:01We see high rates of autism and a SD
  • 06:04traits among individuals with eating
  • 06:06disorders and high rates of EDHD as well.
  • 06:13And despite the fact that we
  • 06:14often think about these as
  • 06:15presentations affecting young adults,
  • 06:17we see much higher rates in
  • 06:19children than adolescents Now.
  • 06:20So in similarly some large national
  • 06:23survey data and looking at school age,
  • 06:25children see 42% of 1st to 3rd grade
  • 06:29girls with a desire to be thin or thinner.
  • 06:33Over 80% of 10 year old children in the
  • 06:36survey reporting a fear of being fat.
  • 06:39close to 50% of 9 to 11 year
  • 06:42olds reporting being on a diet
  • 06:44some of the time for themselves.
  • 06:47And we see 35 to 57% of adolescents
  • 06:50engaging in unhealth unhealthy disordered
  • 06:53eating behaviors to control their weight.
  • 06:56And over 90% of women,
  • 06:58once they reach college,
  • 06:59then trying to control their weight
  • 07:01through different dieting behaviors.
  • 07:03A really important piece too that I
  • 07:05want to highlight here as you here.
  • 07:07We're talking about just some of what
  • 07:08may be developing at a younger age.
  • 07:10But since the start of the pandemic,
  • 07:12we've seen actually much higher
  • 07:14rates of hospitalizations for
  • 07:16medical complications associated
  • 07:17with restrictive eating,
  • 07:19especially in the younger skew to
  • 07:21to being younger children who are
  • 07:23requiring the highest level of care.
  • 07:27So you know, important to consider despite
  • 07:29the fact that we have this this kind of
  • 07:32stereotyped idea of what it looks like
  • 07:34to have an eating disorder that less
  • 07:36than 6% of people with an eating disorder
  • 07:39are actually diagnosed as underweight.
  • 07:41Now this is with any clinically
  • 07:44significant eating disorder, so not just
  • 07:46anorexia where of course we do see much,
  • 07:48much higher rates of being underweight
  • 07:50given that's part of the diagnostic criteria.
  • 07:52We think about clinically
  • 07:54significant disordered eating that
  • 07:56impacts somebody's functioning.
  • 07:57We have this kind of as a society
  • 08:01misrepresented idea of what that looks like.
  • 08:05And yet there is a SWAG stereotype that
  • 08:07exists that we talked about in the field
  • 08:09of if you have an eating disorder,
  • 08:11you're skinny, white,
  • 08:13affluent girl when.
  • 08:14And it's very problematic of not
  • 08:16just societal views of it,
  • 08:18but that current treatment models are
  • 08:20based often on samples of affluent,
  • 08:22young adult, cisgender,
  • 08:24neurotypical white women,
  • 08:25when there's quite a range of presentations
  • 08:28of individuals who and youth who
  • 08:31can experience these presentations,
  • 08:32as Google Images shows us.
  • 08:37So as I was saying there,
  • 08:38there's a wide range of
  • 08:40disordered eating presentations.
  • 08:42Pika and rumination disorder are ones
  • 08:44that I'll talk about in a moment that
  • 08:47mostly affiliated or associated with
  • 08:49neurodevelopmental disabilities in
  • 08:51younger children avoidant restricted
  • 08:53food intake disorder and anorexia,
  • 08:55both resulting in lower weight bulimia
  • 08:57nervosa and binge eating disorder,
  • 08:59both associated with episodes
  • 09:01of binge eating and bulimia
  • 09:02with associated purge episodes.
  • 09:07The challenge here,
  • 09:08especially for children and adolescents,
  • 09:10is, as anybody who has kids of their
  • 09:12own or works of kids knows that things
  • 09:15don't often nicely kind of fit into one box.
  • 09:17And that happens with psychiatric
  • 09:19presentations as well.
  • 09:19We often see symptoms or elements of
  • 09:22different presentations that are what
  • 09:24we'd call trans diagnostic kind of
  • 09:26crossing in and out of these boxes
  • 09:28and to meet diagnosis for an eating
  • 09:30disorder based on our DSM criteria.
  • 09:32It's mutually exclusive.
  • 09:34So having experiences with of
  • 09:38symptoms of multiple presentations
  • 09:39results in a lump sum diagnosis
  • 09:41of something that we call Osfed or
  • 09:43other specified feeding and eating
  • 09:45disorder which is often what we
  • 09:47see with children and adolescents.
  • 09:52So here's a list of the types of
  • 09:54eating disorders those that will
  • 09:55be talking about requiring kind of
  • 09:57our our highest level of care are
  • 09:59most frequently anorexia nervosa,
  • 10:01which is going to be having an unrealistic
  • 10:03idea about body image and overvaluation
  • 10:05of how important that is, right.
  • 10:08It's one of the most fundamental
  • 10:10important things to to an adolescent
  • 10:12sense of self and this intense fear
  • 10:14of gaining weight that results
  • 10:16in significantly low body weight.
  • 10:18The Lumia Nervosa are episodes
  • 10:20of binge eating,
  • 10:22so eating significantly large amounts
  • 10:24of food with an experience of loss of
  • 10:26control in a short amount of time,
  • 10:28following by purging episodes or some
  • 10:30other type of compensatory behavior.
  • 10:33Sometimes excessive exercise,
  • 10:35fasting, use of laxatives,
  • 10:38binge eating disorder is bulimia without
  • 10:40the compensatory behaviors are perching.
  • 10:42So having those significant binge episodes,
  • 10:46larger amount of food than somebody
  • 10:48would typically eat in a short
  • 10:49amount of time and experiencing a
  • 10:51sense of loss of control and then
  • 10:53an associated feeling of disgust or
  • 10:56guilt with oneself after the fact.
  • 10:58Rumination disorder is an experience when
  • 11:01somebody swallows in the regurgitates
  • 11:04the food and the re swallows and and
  • 11:07pica is consuming non food objects.
  • 11:10These two,
  • 11:11as I mentioned are are often highly
  • 11:14cooccurring with a number of other
  • 11:18developmental presentations.
  • 11:19Avoidant and restrictive food
  • 11:21intake disorder is,
  • 11:22as I mentioned previously,
  • 11:24one of our other restrictive presentations.
  • 11:27Whereas anorexia is focused on a
  • 11:30body image concern or fed or another
  • 11:33name for avoidant and restrictive
  • 11:35food intake disorder is when a youth
  • 11:38or an adolescent or a young adult
  • 11:40forever is experiencing it severely
  • 11:43restricts what they're eating for
  • 11:45a non body image related reasons.
  • 11:47So sometimes it's a sensitivity
  • 11:50to to the experience of eating,
  • 11:52sometimes not being aware of hunger cues,
  • 11:55sometimes of a fear of pain,
  • 11:57right of if they've had some type of
  • 11:59medical complication that often leads
  • 12:00to then significantly low weight.
  • 12:05So with these different presentations,
  • 12:07we can lump them together into
  • 12:09these boxes that again don't quite
  • 12:11fit nicely away from one another,
  • 12:13but but do have some overlap.
  • 12:15We have these presentations of
  • 12:17restriction or overcontrol,
  • 12:18which is what we would
  • 12:19think about with anorexia,
  • 12:21this regulation and loss of control
  • 12:23with bulimia and binge eating
  • 12:24and those related to anxiety,
  • 12:26pain or sensory sensitivities.
  • 12:28This is where we put our food or the pika.
  • 12:31The challenge is that as we
  • 12:34conceptualize these things different,
  • 12:36what therapeutic treatment looks
  • 12:37like is going to be different,
  • 12:40but they don't fit nicely in those
  • 12:42boxes and and so that's really where
  • 12:44kind of providing the most effective
  • 12:46treatment can be a challenge.
  • 12:50So with regard to eating disorder prevalence,
  • 12:53unfortunately their data overall
  • 12:54is quite is a little outdated.
  • 12:56So this is from the nationally representative
  • 12:59prevalence data from NIMH looking at
  • 13:02the lifetime prevalence of eating
  • 13:04disorders by the time of reaching mature
  • 13:07adolescence from about 20 years ago.
  • 13:09And this was where we see close to
  • 13:124% of females and 1.5% of cisgender
  • 13:15males meeting criteria for an eating
  • 13:18disorder by the time that they turn 18.
  • 13:22This is as as is clear from the
  • 13:25dates of it you know very,
  • 13:27very much pre pandemic.
  • 13:28And so we already saw an increase
  • 13:30happening over those those years of kind
  • 13:32of the the early 2000s and 2000 tens
  • 13:35when we see continue to see increase on
  • 13:37body image pressures by society that
  • 13:40have been really exacerbated by the
  • 13:42pandemic and a very important piece
  • 13:44to hit on as we're thinking about
  • 13:46care for this patient population.
  • 13:48So beginning at the at the beginning
  • 13:51of the pandemic there was anticipation
  • 13:53of kind of the impact on eating
  • 13:56disorders that was significantly I
  • 13:58think underestimated what we would
  • 14:00actually see that the,
  • 14:02the first publication was now two years
  • 14:05ago of how medical admissions related
  • 14:07to restrictive eating disorders among
  • 14:09youth had increased significantly.
  • 14:11Looking at pre pandemic to during
  • 14:13the pandemic rates of youth requiring
  • 14:15medical hospitalization to be stabilized
  • 14:17and this has been replicated throughout
  • 14:20the country and throughout Europe
  • 14:21and at our own Children's Hospital
  • 14:24seeing that significant increase.
  • 14:27So what's exacerbated the prevalence
  • 14:29and severity,
  • 14:30There's a number of factors that
  • 14:32we can contribute to it,
  • 14:34a greater susceptibility to
  • 14:36illness during the pandemic,
  • 14:38psychological distress with a pandemic
  • 14:40happening and then the uncertainty
  • 14:42and social isolation that happens.
  • 14:44We do know especially things like
  • 14:46anorexia is a very isolating disease
  • 14:47and so social connection is one
  • 14:49of the most protective things.
  • 14:51And so taking, you know,
  • 14:52as was needed,
  • 14:53but taking kids away from one another
  • 14:56really increased kind of risk factor.
  • 14:58There was almost nothing but virtual
  • 15:00interaction staring at one another on
  • 15:02the screen and then a lot more time
  • 15:04spent on social media and the dangers
  • 15:06that we know associated with that,
  • 15:08with what youth are exposed to in terms
  • 15:10of content and unrealistic body image ideals.
  • 15:15So then thinking specifically at
  • 15:17our Children's Hospital at Yale,
  • 15:19what we saw in the couple of years before
  • 15:21the pandemic to the first year and a half,
  • 15:24we saw a significant increase where
  • 15:26even in half of the time we saw more
  • 15:29cases in that first year and a half
  • 15:31of the pandemic increasing from 48
  • 15:33cases the year and a half before the
  • 15:35pandemic or the three years before
  • 15:36the start of the pandemic to just
  • 15:38the first year and a half of 60.
  • 15:40So as you can imagine and and our team
  • 15:42still needed to comb through that data,
  • 15:45we see more than a double increase
  • 15:46anticipated of what we've seen
  • 15:48in the similar time frame.
  • 15:52So not only did we see an increase in
  • 15:54the number of patients hospitalized,
  • 15:56but an increase in the length of stay
  • 15:59because of the severity of cases
  • 16:00and the lack of appropriate kind of
  • 16:03referral options for post discharge
  • 16:04because of the crunch on the system,
  • 16:07a much higher number of youth
  • 16:10younger than the age of 13.
  • 16:11This is consistent with now some
  • 16:14recently published data that has come
  • 16:16out kind of more nationally as well
  • 16:18where we're continuing to see the the
  • 16:21average age of hospitalization for
  • 16:23restrictive eating concerns skewing
  • 16:25younger and younger which unfortunately
  • 16:27again are treatment care models.
  • 16:29Kind of historically as a nation
  • 16:31and as a society are not up to date
  • 16:34with see a greater number of youth
  • 16:37requiring medication intervention
  • 16:39for psychiatric concerns because of
  • 16:41the comorbidities and more patients
  • 16:43requiring A discharge to a higher
  • 16:45level of care.
  • 16:46And this is consistent with other
  • 16:48sites in Connecticut and then
  • 16:49country and world more broadly.
  • 16:53And so why are we worried, right,
  • 16:55We're seeing this increase and
  • 16:57we know of course that eating
  • 16:59disorders can be significant,
  • 17:00but really in terms of the severity,
  • 17:01it's worth taking note just
  • 17:03how severe they can be.
  • 17:04So eating disorders are among
  • 17:06the deadliest mental illnesses,
  • 17:08second only to opioid overdoses.
  • 17:11Relapse rate for anorexia,
  • 17:13once somebody has experienced
  • 17:15the disease approaches 50%.
  • 17:19The standardized mortality ratio of
  • 17:21somebody with anorexia is approximately 6,
  • 17:24which means to somebody else there,
  • 17:26same age, all other factors,
  • 17:28they're six times as likely
  • 17:30to have mortality of that age.
  • 17:33Approximately one in five
  • 17:35patients with anorexia develops
  • 17:36a severe and protracted illness,
  • 17:39which means we don't expect to
  • 17:42necessarily experience any remission.
  • 17:44And there is an estimated death
  • 17:46almost every hour each each year
  • 17:49attributed to eating disorders.
  • 17:52Among individuals with anorexia specifically,
  • 17:55we see 60% of the deaths attributed
  • 17:57to the medical complications
  • 17:59associated with it such as cardiac
  • 18:01arrest and sudden organ failure,
  • 18:04but as well as suicide.
  • 18:06And we know that's overall suicide
  • 18:07rates among individuals with eating
  • 18:09disorders are are quite high.
  • 18:12So not only is there the
  • 18:14individual health costs,
  • 18:15but we do see a significant
  • 18:17health costs in our our medical
  • 18:19and healthcare systems costing
  • 18:21about close to $65 billion.
  • 18:26Approximately 9% of people will
  • 18:28experience some type of eating
  • 18:30disorder in their lifetime.
  • 18:32I think it's important to note here,
  • 18:34this doesn't mean 9% people experiencing
  • 18:37anorexia could be a number of those
  • 18:39other presentations I mentioned.
  • 18:40But that does mean clinically
  • 18:42significant disordered eating where
  • 18:44it's impacting somebody's daily
  • 18:46life despite the prevalence and
  • 18:48and kind of robustness that we
  • 18:50see in society that therapeutic
  • 18:52interventions have modest results and
  • 18:54we actually don't have FDA approved
  • 18:56medications except for an adults with
  • 18:59binge eating disorder or bulimia.
  • 19:02We often we also see high comorbidities
  • 19:05in this patient population.
  • 19:06So despite you know that that we imagine
  • 19:09that these are the patients that need
  • 19:12the the most cohesive and and holistic
  • 19:15care because eating disorder care is
  • 19:17often siloed out as when we started the
  • 19:21presentation that it's difficult to to
  • 19:23receive treatment for both at the same
  • 19:26time and and having the psychiatric
  • 19:28comorbidities are associated with
  • 19:30greater negative longterm outcomes.
  • 19:32We see over half of adolescence with
  • 19:35anorexia display some type of mood disorder.
  • 19:38The challenge here is it it's
  • 19:40often hard to disentangle.
  • 19:41Is that a result of the severe
  • 19:44malnutrition or does the mood disorder
  • 19:46predate the the eating disorder?
  • 19:51One in four patients with
  • 19:53anorexia have an anxiety disorder.
  • 19:56We see one in four patients with anorexia
  • 19:58experiencing a substance use disorder.
  • 20:00Particularly cocaine and amphetamines are
  • 20:02quite high and a high rate of comorbidity
  • 20:06with OCD in individuals with anorexia.
  • 20:09An important distinction here is that
  • 20:11there are obsessive kind of tendencies
  • 20:14associated with severe restrictive eating,
  • 20:16and the cooccurrence of OCD requires
  • 20:18the obsessions to be outside just the
  • 20:21restrictive eating presentation themselves.
  • 20:26Hitting further on the the importance
  • 20:28of kind of conceptualizing that how high
  • 20:31risk this patient publishing can be.
  • 20:33In another nationally representative
  • 20:35study that looked at prevalence rates
  • 20:38among among adults with a diagnosis of
  • 20:40an eating disorder in their lifetime,
  • 20:42we saw elevated rates or we do see
  • 20:45elevated rates of a lifetime and a
  • 20:48suicide attempt that in individuals with
  • 20:50a subtype of anorexia being over 40%.
  • 20:52So despite the fact that we silo
  • 20:54out and and separate eating disorder
  • 20:56care from other psychiatric concerns,
  • 20:59it it doesn't work as a treatment
  • 21:01model because these things are so
  • 21:02often Co occurring and leads to to
  • 21:04poor care that can be delivered.
  • 21:08So I painted this picture of the
  • 21:11significance and severity of eating
  • 21:13disorder presentations and the
  • 21:14increase that we're continuing to see,
  • 21:16that we're continuing to see it
  • 21:18in younger and younger patients.
  • 21:20And the reality is despite all this,
  • 21:23our country continues to experience
  • 21:24what we consider a crisis in care,
  • 21:27in eating disorder care,
  • 21:28especially in anorexia.
  • 21:30And this is actually a paper from
  • 21:32about two years ago now that was
  • 21:33in some ways a call to action and
  • 21:36it's published in Gym Psychiatry,
  • 21:37the journal that highlights the
  • 21:40number of reasons for that.
  • 21:42So the major take home points is that
  • 21:44really we continue to experience a
  • 21:46crisis in care for patients with
  • 21:49eating disorders and and especially
  • 21:51anorexia that it's critical to
  • 21:53improve eating disorder care.
  • 21:55We continue to be in the systems
  • 21:57where we are more kids,
  • 21:59young adults requiring those higher
  • 22:02levels of stabilization because
  • 22:03there's not enough resources in
  • 22:06the community and at lower levels
  • 22:08of care that there's a need for
  • 22:10more funding for research because
  • 22:12eating disorders are significantly
  • 22:14underfunded research field and
  • 22:16the need to develop more effective
  • 22:19interventions because both are are
  • 22:21therapeutic and psychopharmological
  • 22:23or medication based interventions
  • 22:25do have modest success thus far.
  • 22:28But it's critical to improve training
  • 22:30as again where I'd started as it's
  • 22:32been such a niche area of our fields
  • 22:35that that's a much smaller percentage
  • 22:37of our mental health and medical
  • 22:39providers are trained in eating
  • 22:41disorder care than we actually need.
  • 22:43There need to be more resources for
  • 22:45treatment for patients and families.
  • 22:46There are often long wait lists
  • 22:49that allow the the disorder to to
  • 22:51exacerbate or get worse before
  • 22:54receiving care and we have to develop
  • 22:56higher standards of care which
  • 22:57just aren't available currently.
  • 23:01So highlighting the severity,
  • 23:03highlighting the need,
  • 23:05what are we doing about it at Yale,
  • 23:08what's been done to address
  • 23:09the problem is you know,
  • 23:11really acknowledging the reality
  • 23:12of of the severity and increase
  • 23:15of cases that we've seen.
  • 23:16I highlighted the,
  • 23:17you know what has happened with the
  • 23:19numbers overall in the pandemic.
  • 23:21I would say we're continuing to see that
  • 23:23escalation while while it ebbs and flows,
  • 23:25I know just recently we had five
  • 23:27patients in the Children's Hospital with
  • 23:29being hospitalized on the Pediatrics
  • 23:31floor for the medical complications
  • 23:33associated with restrictive eating.
  • 23:35So we don't see this
  • 23:37slowing down anytime soon.
  • 23:39What we've done to address that need
  • 23:42kind of given given the state of the
  • 23:44field and and those different issues
  • 23:46with resources that we have talked
  • 23:48about of just kind of as a a field
  • 23:50generally is trying to be creative
  • 23:52and innovative in the collaboration
  • 23:54with the Children's Hospital.
  • 23:56So collaborations with the
  • 23:58Pediatrics team for these youth
  • 24:00that are medically hospitalized.
  • 24:02So these patients are managed by our
  • 24:04consultation liaison team who serve or
  • 24:06youth that are medically hospitalized
  • 24:08requiring psychiatric supports.
  • 24:10There's weekly case rounds where
  • 24:11the youth with eating disorders
  • 24:13are rounded on by both the medical
  • 24:15and psychiatric team as well as
  • 24:17other members caring for them,
  • 24:19including nursing child life,
  • 24:23doing trainings, teaching didactics
  • 24:25with the Pediatrics team as well as
  • 24:27the consultation liaison team and
  • 24:29educating on eating disorder care.
  • 24:31And trying to revisit our clinical
  • 24:32pathway that we use to care for these
  • 24:34patients to try to keep it as up to date
  • 24:36as possible to provide the best care.
  • 24:40We've also done is the necessity
  • 24:41of providing bridging plans for
  • 24:43patients due to wait list there.
  • 24:44As I had kind of started to allude to,
  • 24:48there is a significant kind of dearth
  • 24:50of resources in the community for this
  • 24:52patient population that is in a lot
  • 24:54of ways you know largely connected
  • 24:55to that niche area that it's become.
  • 24:58So often we have patients that
  • 25:00once medically stabilized,
  • 25:01they're still not the right next
  • 25:03treatment for them immediately available.
  • 25:05And so we're having to create these
  • 25:07bridging plans to not unnecessarily
  • 25:08keep them in the hospital people
  • 25:10either without kind of access to
  • 25:13necessarily an eating disorder mill you.
  • 25:16We're working to create innovative
  • 25:18and responsive treatment care
  • 25:19models for complex patients.
  • 25:21So as I had you know already said
  • 25:23that the eating disorder very
  • 25:25infrequently happens in the vacuum.
  • 25:27And so we've more and more frequently
  • 25:29see youth coming in with those concerns,
  • 25:31but also having suicidality
  • 25:33or other mood concerns.
  • 25:34And because treatment models
  • 25:36are often very separate,
  • 25:37we have to think about how do we bridge
  • 25:39that and provide more appropriate care,
  • 25:43finding ways to provide training
  • 25:45education to clinicians within the Child
  • 25:48Study Center across levels of care.
  • 25:50And that who are often working with
  • 25:52these patients whether it be outpatient
  • 25:54or in home services who are also
  • 25:57coordinating with their medical teams.
  • 25:59And then thinking about the goals for eating
  • 26:01disorder care at the Child Study Center.
  • 26:02Building on this work
  • 26:04that's already been done,
  • 26:05we're working to build more robust
  • 26:07eating disorder care in partnership
  • 26:09between the Child Study Center and
  • 26:11Neil New Haven Children's Hospital.
  • 26:13This is something that in in kind of
  • 26:15moving those efforts forward has been
  • 26:17primarily led by the Child Study Center
  • 26:19and with mental health lead and with
  • 26:22the interdisciplinary partnership with
  • 26:24Pediatrics and nutrition with really
  • 26:27that goal again not to shy away from
  • 26:30those high risk complex presentations,
  • 26:33really another goal addressing the
  • 26:35limited community referral options.
  • 26:36So that can be done in a number of
  • 26:39ways through both increasing those
  • 26:41outpatient services affiliated
  • 26:42directly with Yale or through
  • 26:44community partnerships and trainings.
  • 26:46So again training of community providers
  • 26:49within the Yale system and developing
  • 26:51more of those bridging services,
  • 26:54trying to think about and other goals
  • 26:56of developing that streamline pathway
  • 26:58from those youth requiring that medical
  • 27:00inpatient stabilization to outpatient care.
  • 27:02So once somebody is brought into the system,
  • 27:05what are the steps to getting them back out
  • 27:08safely knowing that it's not, you know,
  • 27:10kind of one stop and then back out.
  • 27:12This includes that aim of utilizing
  • 27:14sites within the Yale New Haven
  • 27:17Children's Hospital Network,
  • 27:18including the initiative to begin to
  • 27:21utilize places like Bridgeport Hospital
  • 27:23for stabilization of these patients and
  • 27:25ensuring the most robust supports there
  • 27:27available that are needed to support
  • 27:29this patient population that has been
  • 27:31built up at our York Street campus.
  • 27:35Really another goal of maintaining that
  • 27:37mindset of the multiple systems level
  • 27:39approach that is needed in partnership with
  • 27:42colleagues throughout our departments.
  • 27:44So given such a complex high
  • 27:47risk patient population,
  • 27:49not just think about who is
  • 27:50directly caring for this patient,
  • 27:51but where will this patient be
  • 27:53going next And and really thinking
  • 27:56about helping it to be as fluid a
  • 27:58process for families as possible.
  • 28:01And this is where we start with the
  • 28:03need and the goal of prioritizing an
  • 28:05ambulatory program that can provide
  • 28:07that interdisciplinary support to
  • 28:08a patient and their family when
  • 28:11those concerns are emerging.
  • 28:14And then of course one of the other,
  • 28:16you know really,
  • 28:17really crucial and I would say
  • 28:19critical goals and priorities being
  • 28:21a prioritizing training of fellows
  • 28:23throughout the departments including
  • 28:25the child study center in Pediatrics.
  • 28:27To get away from this idea,
  • 28:28from it being a niche area of training
  • 28:31and really trying to focus on kind
  • 28:34of broadening the exposure for
  • 28:35trainees and professionals working
  • 28:37with this patient population,
  • 28:38this as it's critically needed for care.
  • 28:41And so well the the Child City
  • 28:43Center and Children's Hospital has
  • 28:45done a lot to to work through some
  • 28:47of these challenges and to be able to
  • 28:50address this continued increasing need.
  • 28:51There continues to be a lot of goals
  • 28:54for those next steps and and as you
  • 28:56know it's been highlighted throughout
  • 28:58the field is where we're continuing to
  • 29:00see the increase in need and trying
  • 29:03to evolve dynamically as a center
  • 29:06and a hospital system to meet that
  • 29:09need for this patient population.
  • 29:11And figuring out how to to to best
  • 29:14serve a patient population that does
  • 29:15pull on on resources quite a bit and
  • 29:17to be able to deliver the the best
  • 29:20care for that patient population.
  • 29:25Thank you very much for
  • 29:26for attending the webinar.
  • 29:27I hope that you know the note that I
  • 29:30really do want to end on is with the
  • 29:32hope of despite us seeing the dire
  • 29:34need in the field on the increase
  • 29:36in severity and presentations that
  • 29:37somewhere like the child study
  • 29:39center you know New Haven Children's
  • 29:41Hospital has the infrastructure and
  • 29:42the right sports in place to meet
  • 29:44that need and and the right vision
  • 29:47to continue to innovate and move
  • 29:49those move that process forward.
  • 29:52Thank you.