Eating disorders policy and guidance for schools

Please help make this eating disorders policy for schools as useful as possible, so that schools know how to partner up with us to help our children recover.

This is a draft and I’d love your comments by 31 October 2017.

Click HERE for the Word document: everyone can edit and comment directly on it.

You might, for instance, add things relevant to schools in other countries – for the moment here I’ve just put in references to the UK system.

Once it’s all polished up I will make this policy freely available to any school worldwide.

  • Leave a reply at the end of a page to share your thoughts with everyone
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The (draft) policy

Please adapt this document for your school. The policy statements are in this font.

Annoyingly the fonts may not show up if you’re reading from your mobile phone

And in this font, I provide you with guidance. I am a parent and the author of a book for parents which is widely recommended in the NHS. I know from many parents’ accounts how wonderful a school can be in their child’s recovery. I know from schools how proud they can be of the part they played. Conversely, I know of schools who have not made any adaptations to a student’s needs, and the illness became chronic.

You have a precious role to play as your actions will help young people recover instead of becoming chronic sufferers. The rewards for the school are high as these students are often keen to please, bright, and conscientious.

The field is constantly evolving, and this document will help you get up to speed. Some of the information in published and online sources is not up to date and could be harmful.


This model policy was produced in 2017 by Eva Musby, parent and author of

‘Anorexia and other eating disorders – How to help your child eat well and be well’.

Contact:  http://anorexiafamily.com

Please get in touch to flag up any errors or omissions.


Summary

High schools and primary schools are likely to have students who are suffering from an eating disorder. All eating disorders are serious illnesses which requires urgent, specialised treatment with intense parental input. The school has a crucial contribution to make in supporting treatment. It also has a role in reducing risks and in early detection. This document suggests that you designate at least one member of staff to learn the essentials, to shape this policy, and to be a central point of contact for parents, clinicians and other school staff.


Our school’s stance towards eating disorders

We recognise that eating disorders are serious illnesses, that there is a strong likelihood that a number of our students are affected at any time, and that the school has a crucial role to play in detection and treatment.

Eating disorders are serious

Eating disorders can be life-threatening, because of malnutrition and of the high suicide risk. A person with an eating disorder is 4 to 7 times more likely to commit suicide than someone without an eating disorder. At the very least an eating disorder affects a student’s ability to concentrate and engage with school work and with peers.

How common are eating disorders?

Eating disorders are most likely to begin during secondary school. Among 100 high school students, around 8 suffer from an eating disorder. One of these may have anorexia and at least three may have bulimia. For children under the age 13, figures indicate that the main eating disorder is anorexia, affecting 3 in every 100,000 children. However the figures in primary schools may be much higher when you include disorders similar – and just as serious as – anorexia. At a guess, expect one in every few hundred children.

This policy will indirectly help the many teenagers in your school who may be suffering from ‘disordered eating’. Around 55% of girls and 30% of boys are estimated to skip meals, binge, use diet pills or laxatives, and vomit.

We will help prevent the condition from becoming a chronic illness by collaborating with parents and clinicians.

Early intervention and treatment give young people the best chance of recovery. Without it, a proportion of sufferers continue to suffer during their adult years, with the illness affecting both quality and duration of life. By making a student’s treatment a priority we can also prevent irreversible health effects.

To the best of our abilities we want to:

  • support students who are undergoing treatment, in partnership with the family and treatment providers
  • detect signs of an eating disorder so that a student can get treatment as soon as possible
  • play our part in reducing the risk of students developing an eating disorder

The rest of this document describes how this is done.

eating disorder policy for schools

Causation, and a zero-blame approach

We recognise an eating disorder is an illness, not a choice. It affects both sexes, irrespective of social class and of environment. We intend to have a respectful and compassionate stance towards the student, siblings and parents.

What causes an eating disorder?

Forget anything you’ve heard about people developing an eating disorder as a way of coping with emotions, asserting control or autonomy, or even being about vanity. Causation is so complex that the best experts are still investigating. What we do know now is that the causes as well as the maintaining factors of the illness have a lot more to do with biology than previously thought.

Twin studies show that a major part of the risk of developing an eating disorder is genetic. Genome work is flagging up metabolic abnormalities. There are biological factors that cause or maintain the illness. Anorexia usually begins – and is perpetuated – by negative energy balance (expending more energy than is consumed). Most of us, when we aren’t getting enough food, get urgent brain signals to eat. With anorexia the opposite happens. While the general state of the person is one of anxiety, restricting food brings on calm.

Eating disorders are not contagious! A student won’t get an eating disorder just because their friend has one.

Genes and environment interact in complex ways. It’s unlikely that you can get an eating disorder just because you’ve had a trauma, been bullied, exposed to images of skinny models or to dieting tips. But these things may contribute to the overall risk, and they certainly make recovery harder.

One thing we have known for decades now is that parents don’t cause eating disorders (sadly the internet is slow to catch up). Parents are the main assets in a young person’s treatment.

Understanding the different eating disorders

We will treat all types of eating disorders seriously. We are aware that harmful effects on the body and mind may not be visible.

What are the main eating disorders like?

The main eating disorders likely to affect students in your school are binge-eating disorder, bulimia, anorexia or variations of these.

All types carry major risks to health and deserve your attention as they are all dangerous, utterly miserable and can become chronic. The illness can morph from one type to the other and a student may show a confusing mixture of the signs listed below.

Is this section below too long or is it useful? Will schools read it or be turned off? I could make it very brief and supply a link to this info on my website.

Binge-eating disorder

People suffering from binge-eating disorder live with highly distressing negative thoughts about themselves, placing them at risk of suicide, and at the very least, making it hard to concentrate on school work.

They have episodes (at least once a week on average) of eating unusually large amounts of food in a very short while. During this time they have no control over their eating and may be in a trance-like state. After a binge they are distressed, ashamed, and full of self-loathing. Some may then go for hours or days with little or no food, battling hunger, recruiting extreme willpower, planning weight loss in great detail. If so, they may be malnourished, with medical risks just as serious as those of an underweight person.

In spite of all their efforts, soon they are compelled to binge again. Some secretly plan their binge in great detail.

At home, if the secret is out, there may be a lot of tension as the person consumes the family’s food reserves at a great rate. Shopping for food may drain the family budget.

People with binge-eating disorder often have a higher body weight than average, or it may yo-yo as they try and control their weight.

According to NICE, the recommended treatment is CBT-ED, a cognitive-behavioural therapy developed for eating disorders.

Part of the treatment involves the person having regular meals as this breaks the cycle of hunger and binge. This is hard for the person if they are beating themselves up about a binge. The school may therefore have a role in ensuring that the student can eat meals and snacks.

Bulimia nervosa

Bulimia is like binge-eating disorder, but in addition the person tries to compensate for their binges with some form of purging: vomiting, taking laxatives or diuretics, fasting, or excessive exercise.

In addition to the suicide risk, there is a significant risk of sudden death from the imbalance in electrolytes caused by vomiting or from large quantities of laxatives or diuretics. The person may look fine even though they are at serious risk and need regular medical checks.

They may think about food all day long, beating themselves up for their last binge, and exhausting themselves with punishing fasts or exercise.

Their body weight is usually average.

The NICE guideline for treating bulimia recommends a specialised form of family therapy (FT-BN). This places parents in charge of regular meals and normalising behaviours. It takes a lot of effort, consistency and courage for someone to end the habit of vomiting and to eat what they need.

The NICE guideline gives a second option for treatment: cognitive-behaviour therapy for eating disorders (CBT-ED). Just like with binge-eating disorder, the student will be required to normalise their behaviours even though this raises their anxiety, and they may need support to manage this.

Whichever treatment is in place, the school may need to give some level of supervision to ensure that meals and snacks are eaten, as any missed meals may trigger biological mechanisms that lead to bingeing later. The school may also need to supervise that the student cannot use toilets for an hour or two after a meal.

Anorexia nervosa

There are two types of anorexia: restricting anorexia and binge-purge anorexia. The risks to health come from a low body weight, from insufficient nutrition or fluids, from electrolyte imbalances, and suicidality.

Laypeople tend to associate anorexia with emaciated bodies. In fact there may be students in the school who look average, but whose thoughts are obsessively circling around food and exercise. The person may have a sense of an anorexic presence bullying them to restrict at all costs, praising them for their efforts or abusing them when they eat or relax. It may be an incessant voice in their head. This gets in the way of concentration on school or friends.

All the same, students with anorexia can be highly performing in school – the model student. Biological mechanisms kick in with anorexia, which seem to give the person energy, drive and even bouts of happiness. Feeling empty, without food, is calming and reassuring. . They may be insensitive to hunger, and at other times be torn between extreme hunger and internal rules. The student is likely to be at his or her worst when going through treatment, as it is horrific for them to eat and gain weight.

The drive to exercise may be enormous. In primary-school-age children it may be particularly evident as a restless, anxious state, where stillness is near-impossible. An exercise compulsion may also be part of the self-punishing nature of anorexia, and often it is a deliberate strategy to lose weight.

While weight and nutrition are low, and sometimes even after these have been restored, the person may suffer from depression, anxiety and obsessive-compulsive disorder (OCD). There may be self-harm and suicidality. These conditions share some of the risk factors for an eating disorder and may have developed before the eating disorder, or they may only be a problem while the person is malnourished.

As long as they can restrict without anyone intervening, people with anorexia may go for weeks or months of being on a high, appearing happy and energetic, even though they are effectively starving. Without treatment, people with anorexia will become underweight, and the more they lose weight, the more brain function is affected. Thinking becomes increasingly distorted, and eating becomes more horrific. There are more and more eating or exercising ‘rules’. Breaking a rule feels dangerous (note the overlap with OCD) and the person has a compulsion to compensate or atone for food, rest and anything that is enjoyable.

Many (but not all) people with anorexia also suffer from body dysmorphia: their brain sends them distorted signals that they are horribly fat. This may vary depending on their level of stress at any moment.

Many (but not all) people with anorexia have a great fear of gaining weight. Yet there cannot be recovery without weight-restoration.

In addition, the brain processes responsible for anorexia also create anosognosia in a number of sufferers: the person does not believe they are ill, or cannot recognise that their situation is serious. Whereas ‘denial’ is a psychological defence mechanism, with anorexia there can truly be a disconnect between what others see and what the person perceives.

At times, the person may have motivation to get better, but eating is so horrible that they cannot keep it up without support.

With the binge-purge type of anorexia, hunger occasionally drives the person to eat an amount which to their mind is enormous, though it may or may not be. After this the self-starvation and exercise is ramped up.

The NICE treatment recommended first and foremost for anorexia is anorexia-focused family therapy (FT-AN). This treatment requires parents to take charge of nutrition, weight gain and normalising behaviours. The young person gets a lot of support and the treatment works even when they have little motivation to beat the illness. If the experts have good reasons not to deliver FT-AN, there are two possible individual therapies, where it will be the sufferer’s task to achieve the same aims.

Either way, without support from the school it may not be safe for someone with anorexia to attend. They will often need some level of supervision or support to eat meals and snacks, and possibly to stop exercising or vomiting.

The eating disorders that are ‘nearly’ something else

When someone shows most – but not all—of the symptoms used to diagnose anorexia, bulimia or binge-eating disorder, they get the ARFID classification: avoidant/restrictive food intake disorder. Or sometimes the diagnosis is OSFED – other specified feeding or eating disorder or UFED – unspecified feeding or eating disorder.

There are many young people with an ARFID diagnosis who would most probably tick all the boxes for anorexia if their parents were not so well-informed and skilled at getting them to eat.

The treatment for ARFID , OSFED or UFED needs to be the same (and taken just as seriously) as for the most similar illness, whether anorexia, bulimia or binge-eating disorder.

Diabulimia

Diabulimia is not an official diagnosis but seems to be common among people with Type 1 diabetes (who need to inject insulin). They regularly restrict their insulin dose to lose weight or to compensate for bingeing. They suffer from the physical and mental risks associated with an eating disorder, plus those associated with untreated diabetes. There are many highly dangerous health effects including organ damage and a shortened life.

Orthorexia

Orthorexia is not an official diagnosis but can be as crippling as any eating disorder. Often it is a gateway to anorexia. Those affected have taken ‘healthy’ or ‘clean’ or ‘orthodox’ eating to heart to such an extent that there are very few foods they eat. They suffer from malnutrition and perhaps also weight loss. Medical risks are high. Their mental state is affected, so it can be hard to get them to re-introduce balanced eating.

Drunkorexia

Again, not a diagnosis, but a behaviour often linked to eating disorders. This is where people restrict food intake so that they can drink without consuming extra calories. They also do this to become drunk more quickly.

Muscle dysmorphia / Bigorexia / Reverse anorexia

These terms describe a compulsion to build muscle. It is not uncommon among body-builders and there is a link with eating disorders. Even though they may consume plenty of calories, those affected can be in danger from malnutrition because they are following an unbalanced diet designed for muscle-building. The person spends many hours in the gym at the expense of other activities. Their body image is distorted – they are ashamed of their looks and are obsessed about the need for ever-bigger muscles. Some people say they’ve beaten anorexia by getting into body-building, but bigorexia is just as much of a trap.

Early detection of eating disorders

If we suspect a student has an eating disorder, we will call the parents within one day, with the aim of the student seeing a specialist in the health service within one week. Depending on the student’s age we will initially talk with the student to tell them we are planning to meet their parents.

Don’t be swayed by a student’s denial that they have an eating disorder. People may not recognise that they have a problem, may think they’ll solve it alone, may be ashamed. Or it may be that they are scared of treatment.

We appreciate that this may be a great shock to the parents. We will strive to build a supportive relationship so that the student can get expert help fast. If in spite of our best efforts the parents were unwilling to get their child referred for treatment, we will contact the health service experts ourselves and take our lead from them.

The sooner an eating disorder is treated, the more effective and lasting treatment is. It is important for the school to flag up any worries as sometimes the eating disorder is not yet visible at home. In the initial phase the student may be binning food in school while still eating normally at home.

Parents could be paralysed and in denial when you first notify them of your concerns. This is a time to build trust and mutual consideration, as you will need to work as a team. As soon as you have the health service on board, specialists will be able to say if the student really does have an eating disorder, and will be able to give the parents education and support. You could also refer parents to the sources of information and support listed at the end of this document.

Eating disorders need specialist treatment. In England, the specialists to call are the community-based eating disorder service for children and young people (CEDS). They can take referrals from school staff and there is no requirement to go through a GP first. In the rest of the UK there may be eating-disorder specialists within CAMHS.

Don’t imagine that the eating disorder ‘will pass’, that it’s just ‘a phase’ or that the school can, on its own, beat an eating disorder. On the other hand, you may come across parents who have already used the health service to treat their child, been disappointed by the standard, and gone on to treat their child with minimal medical input. As long as the child is medically stable and making progress, this is perfectly fine.

If a friend of the student suspects an eating disorder, staff should record what they say in detail and pass the information on to a designated member of staff.

And if a student wants to confide to a staff member that they have an eating disorder, remember to warn them that confidentiality doesn’t apply when people are in danger. This means that parents have to be notified, as any eating disorder comes with high risks.

Signs that a student may have an eating disorder

We will make key members of staff aware of the main signs to watch out for – in particular, any staff overseeing school lunch or in charge of physical education or home economics. In this way we can contribute to early diagnosis and treatment, and we may flag up relapses.

Some of the signs below don’t mean much on their own, and some would describe the behaviour of many ordinary young people. Nobody expects you to diagnose these complex illnesses, but you may bring important pieces to the jigsaw, especially with behaviours that are not happening at home. Many young people begin restricting in school while still eating well at home. Conversely, some people show their worst behaviours at home, maintaining a show of normality in public.

Again, is this section below too long for schools? Or is it useful?

What’s going on in a student’s mind?

While you can’t see what’s going on in someone’s mind, you may remember the signs better once you understand the misery of an eating disorder.

Your student is probably thinking of food and of their body shape every minute of the day. They’re busy agonising over the food they’ve eaten, convinced it was too much and that their belly is enormous. They may have a voice in their head that’s shouting at them that they are weak and greedy and fat. They’re counting and re-counting calories. They’re forming rules in order to eat less next time, or exercise or purge more. They may be plotting how to get away with more restriction, or more bingeing, or more exercising. If they’ve been restricting they are desperately hungry and weak and it is hard to concentrate on work. They look on enviously at others tucking into chocolate bars (while feeling virtuous that they can resist anything). They may truly believe that they do not need food. After eating they may feel sick and anxious.

School provides some welcome relief from the incessant controlling voice in their head, and it can, for a few hours, restore self-esteem and a sense of self. But when lessons are hard, when there’s exam pressure or conflicts with peers, school adds to the stress of the illness. Stress reinforces the urge to restrict, binge or purge, so school can be part of a vicious cycle.

Behaviour around food

  • The student is leaving food uneaten, slipping it into the bin or pockets
  • The student brings lovely food in for others without eating any of it
  • On a school trip, or when someone brings in celebration food, the student eats nothing or very little
  • The student has become vegetarian or vegan, or is avoiding gluten or fats or some other major food group. Or they always eat the same small number of things.
  • The student does a lot of baking or cooking and is very skilful at it. They may have a hobby or job related to food. (This is why it’s useful to have well-informed home economics staff.)
  • The student nibbles very slowly (they’re making the food last because they’re hungry)
  • The student dissects the food, leaving some parts for later, or leaving aside anything oily or calorie-dense. They wipe their fingers to remove any traces of fat.
  • The student takes a very long time to complete a meal (possibly because eating is hard and scary)
  • The student has signed up to so many lunchtime activities that there is little opportunity to eat
  • The student is drinking large amounts of water or zero-calorie drinks (for those who vomit, it’s to help vomit; for those who restrict, it’s to ward off hunger)
  • The student is often chewing gum (anorexia: this is to hold off hunger; vomiting: to help disguise the smell – they may use mint sweets too)
  • The student is hardly drinking at all (because fluids are just as scary as food)
  • The student is anxiously taking a very long time to make food choices at the servery, possibly also looking up calories on their phone
  • Students who are prone to binge eating may eat large amounts fast and may justify this with accounts of how much they’ve exercised or how little they ate before. At other times they may eat very little.
  • Students who vomit are likely to visit the toilet after eating. You may hear flushing multiple times. The vomiting itself may be silent, or the person may run taps or play music to cover the noise. You may detect a smell of vomit in the bathroom or find a lot of perfume has been sprayed. Sometimes people vomit into bags that they later try to hide.
  • For those who binge-eat: large quantities of food may disappear; the person surreptitiously eats many helpings and tries to eat these in secret.

Behaviours around exercise

  • The student has signed up for many exercise classes
  • The student is moving a lot, takes extra-long routes to get from A to B, does not sit back in the seat, uses any opportunity to stand instead of sit

Behaviour around mood

  • This may be a model student – bright, studious, smart, helpful, getting consistently high grades, engaging in school life. They may have many friends and appear happy. (Meanwhile at home parents may be seeing anxiety, tears, suicidality, panic attacks, obsessionality, body-checking, difficulty sleeping. It depends if school is providing a welcome distraction from the eating-disordered thoughts, or is an extra source of stress)
  • At the opposite end there are eating-disorder sufferers who are wild and impulsive. They have rapid mood swings and engage in high-risk behaviours (around drink, drugs, sex, self-harm). This is less likely in those with restricting anorexia and more likely with people who binge and purge.
  • Eating disorders are often found in people on the autistic spectrum
  • The student seems pre-occupied, listless, anxious or depressed
  • A normally calm student gets irritable and has mood swings (think of how you are when you’ve not eaten for a while)
  • The student studies obsessively for long hours
  • The student’s thinking is inflexible, rigid, black-and-white (common in anorexia)
  • The student comes to life when discussing diet, exercise, obesity and body shapes
  • The student has poor self-esteem, is very critical of himself or herself, suffers from guilt, shame and self-disgust. May be suicidal.
  • The student is certain they are fat
  • The student doesn’t engage with others and turns down social events (this may be to avoid eating in public, or it may be about self-hate and the take-over of obsessive thoughts)

Physical signs

  • The student has boundless energy and seems on a high (especially with anorexia, while untreated)
  • The student looks weak, tired, lethargic and may be dizzy or even faint (because they may not have eaten for many hours)
  • The student wears more than others because they are cold (this is the starving body diverting resources to essential functions)
  • Some feel the cold but wear very little because they believe that being cold will burn more calories.
  • Hands are cold
  • The student wears baggy clothes to hide weight loss
  • The student is not growing like their peers (malnutrition)
  • The student is losing weight
  • Hands look bony, the mouth and eyes look tight over the skull (a sign of being underweight)
  • Hair is thinning, falling out, lifeleless
  • Fine furry down (lanugo) cover the body – visible on arms, face and the back of the neck (a sign of an undernourished body trying to stay warm)
  • The skin is very dry (especially for those who are restricting fluids)
  • The person is underweight, normal weight or high weight: do not rule out any of the eating disorders purely on the basis of weight
  • The person’s weight fluctuates fast (periods of restriction alternate with periods of eating large amounts)
  • The student is body-checking: you may see them feeling their belly, or feeling for the girth of their wrist or arm
  • In a room with mirrors, the student’s eyes are often drawn to his or her tummy
  • Any signs of self-harm (cuts on the arms) or of OCD (obsessive-compulsive behaviours like long hand-washing) would add to the possibility of an eating disorder
  • Often ill (e.g. colds) as the immune system cannot cope with malnutrition

Physical signs that might indicate vomiting

  • A swollen or puffy face (swollen glands between the ear and jaw line)
  • There are red marks, scars or callouses on the knuckles or the back of the hand (though some are capable of hands-free vomiting)
  • The person keeps their nails short (to not scratch inside their mouth)
  • The skin is dry and blotchy
  • There are mouth sores
  • Tooth damage: the teeth may look grey or ragged
  • Redness around the eyes (or a lot of makeup to conceal it) because of burst blood vessels
  • A sore throat

Treatment and the impact on the student’s studies

We understand that studies may have to take a back seat in order to prioritise treatment.

Treatment for an eating disorder involves doing what is most feared: eating what needs to be eaten, re-gaining weight, abstaining from purging and from over-exercise, eating regularly even when one has just had a binge.

It is a bit like asking someone who is scared of heights to take a bungee jump several times a day.

The first line of treatment for anorexia and bulimia is family-based, which means that the majority of your students’ parents will be guided by mental health services to take charge of treatment. The parents will be making sure that their child eats for weight restoration and normalises behaviours. At times there will be major resistance from the young person at home. Occasionally the person will be in crisis and homework will be the last thing on anybody’s mind.

Some students will be getting individual therapy instead of a family-based approach. In this case they will be battling their own demons, doing their best to find the willpower to eat (or avoid purging, bingeing or exercising) according to a plan agreed with their therapist.

It is hard for students to concentrate on their studies when they are going through all this, often with nobody but their family in the know. They may be very ashamed of how the illness makes them behave, and insist on secrecy. At school they often continue to be model students – high-achieving and well-loved by teachers and peers.

Teamwork

Eating disorders are serious medical conditions that require expert treatment. We will take our lead from the parents and from the health service.

One of the roles of specialist eating disorder services is to liaise with schools to provide general information, as well as to discuss the management of an individual’s care. You can ask them to train staff members.

We value teamwork with parents. We appreciate they are experts on their child. We recognise that much of the time they are the main providers of treatment, and have developed expertise on the illness. We are conscious that they may be under tremendous stress and need empathy.

Parents are very grateful for supportive school staff. Parents are going through an intense time. They fear for their child, they may have put work, play and sleep on hold, their life is all about clinical appointments and supporting meals, and the delightful student you see in school may be behaving like a possessed alien at home. In addition, parents will be surrounded by people who don’t understand them. Your non-judgemental, supportive stance will be a breath of fresh air. The staff at reception can make a difference. Think cups of tea, kindness and perhaps hugs.

A central point of contact in the school

The school has designated members of staff who are the go-to people for information and action on eating disorders. They set up or attend meetings with parents and clinicians and keep records.

They liaise with other members of staff and monitor that agreed actions are carried out.

All other teaching staff have basic awareness – enough to recognise the more obvious signs and to then consult the designated members of staff.

Part of the designated staff’s remit is teaching other members of staff how to detect an eating disorder as early as possible and to make them aware of the policy.

The designated staff will be building their knowledge through interaction with clinicians, parents and students. These notes contain much of the education required.

There is no need for designated staff to have nursing or counselling skills. What matters is that they be good at communicating, that they be non-judgemental and efficient. While school nurses and educational psychologists may be well placed to help a student access services, they are unlikely to have the level of specialisation needed to deliver direct care. The school should not do any weight checks unless by agreement with the care team.

With eating disorders, it is best that you don’t engage in counselling (unless, of course, the parents tell you differently). The student should already have a specialised team and that is enough. The danger, if you are tempted to counsel a student, is that they will not tell you the whole truth about their behaviours, so you will have an incomplete picture of what’s going on. They may draw you to pronounce on issues of weight, body shape or calories. They will then use innocent remarks you made to fight their treatment team. What you can do is treat the student with kindness and non-judgement, make them feel valued and remind them they’re wonderful and courageous. And that they have a great life ahead of them.

We will work out with parents how they can quickly and easily communicate news or requests to the designated staff members. The Head is also available for meetings should this be helpful.

It can be particularly helpful for parents to have direct access to catering staff. This is because they may need information about food without delay.

Once a student is receiving treatment, other members will only be informed of the illness on a need-to-know basis. We will do our best to respect the student and parents’ wishes in this respect.

Students who cannot attend school or need extra support with studies

We appreciate that students may need time in hospital, while for others there could be a phase of treatment at home, during which attending school would be counter-productive.

For these students we will take advice from the parents and the clinical staff. If they tell us it will help the student to continue studying, we will do our utmost to provide learning materials or arrange visits from teachers. If on the other hand the student needs to concentrate on their health and put studies on hold, we will support that too.

If the student needs a phased return to school, we will support that.

Flexibility in order to meet the student’s needs

We will help reduce unnecessary stresses on the student. For instance we may allow them to hand in homework late and we may stretch deadlines. We may arrange for them to have a teacher they are relaxed with rather than one that they feel anxious about. We may change the class group they are in so that they are with friends.

The student is likely to be in a near-constant state of anxiety and alarm. This leaves little room for extra stressors in school. When the person can’t cope with stress they resort to eating disorder behaviours, or some may tip into self-harm, suicidal ideation or even suicide attempts.

It is not helpful for a student to have extra stress about homework or assignment deadlines when they are also under having meltdowns at home because they are made to eat or prevented from bingeing, vomiting or exercising. The student may be torn by a strong need to please teachers, so they may need to be reassured that a piece of work can wait.

You can help a person’s recovery by being flexible around some of the rules that normally apply. This will not be for ever, so don’t worry about the ‘slippery slope’ argument. Students with an eating disorder are often conscientious and anything but ‘soft’ on themselves, and they’re unlikely to brag about the accommodations you made for them.

Relax about the student’s academic progress. Health is the priority (a First at Oxford is no use to someone with a chronic eating disorder). And many of your students will catch up after time off – they have the abilities and personality type. Many people who have suffered from anorexia are high achievers.

The stress of achieving top marks gets in the way of recovery. The drive to do everything to the highest standard contributes to the risk of an eating disorder. In treatment, the student may be learning to be less of a perfectionist. It is not helpful when teachers cheer the student on to be the best. Getting a C, for someone who is used to getting an A in every subject, is a good thing.

With careers counselling, be aware that someone with an eating disorder (especially anorexia) may be drawn towards hard, prestigious, high-status subjects (medicine, dentistry). It may take some work to discover what they actually like.

We will be flexible about students’ punctuality at classes, if meals or therapy appointments are causing delays.

The student is likely to have weekly appointments – sometimes more – during school hours. A therapy session can be distressing, causing further delays. It’s also common for young people to come in late for school because breakfast has been hard. The treatment priority is to manage the whole breakfast, not to be punctual.

Supporting meals in school

We will do what we can to enable students to eat as required while they’re in school.

Food is central to treatment. A student cannot recover unless they recover a healthy weight and unless they eat regularly. In school they will usually need a morning snack, lunch, and possibly an afternoon snack if they aren’t going straight home. Regular eating is crucial for those who would otherwise binge and/or purge. For those who restrict, it isn’t enough for parents to feed a whole day’s calories at breakfast and after school, because the eating disorder tends to get activated when there’s more than 3 or 4 hours without food.

When schools provide the right level of support around meals, the student can resume normal life sooner – and normal life is part of recovery. Without school support, students may need to stay at home for a long time. Or if they go to school and don’t eat what’s required, the eating disorder is likely to get worse.

There are different levels of support required from the school at different times. The parents and clinicians will work this out with you.

Level 1: the student stays away from school

The student may stay at home (or in hospital) because of their medical condition, or because eating is so hard that they need intense support. The student may or may not benefit from contact with the school. Sometimes, studying provides a welcome distraction, and sometimes it’s just too much.

Level 2: the parents feed their child at school

The student can attend school as long as the parent help them to eat – in a private room or in the car park. A meal may take longer than a normal break time so you may need to agree with the student that they may leave class early or join the next class late.

Level 3: the school gives one-on-one meal supervision

The student may be able to get through a meal without prompts or encouragement, but left to their own devices they would skip meals or reduce quantities and would become very ill again. Your support is to provide some one-on-one supervision. Have a well-informed member of staff sit with them at each meal or snack. Do this in a room where there is some degree of calm and privacy, and let the student choose if they’d like some friends to join them too. When you’re sitting with a student, your role is simply to check that the student is eating what they’re supposed to eat, and to notify parents if not. You are not expected to do the very skilful task of getting them to eat. All the same, you are providing precious help simply by being there, observing that food is eaten.

It is worth checking with parents or clinicians (and possibly with the student) what to say and what not to say. In general, you should be attentive enough to see if any food is being hidden, while adopting a non-judgemental and kind stance. You don’t want to be so kind that the student feels humiliated or patronised, and at the same time do bear in mind that for the student, getting through this food may take tremendous courage. Think of eating as a heroic act. You should not comment on the food (you never know what difficult thoughts can be triggered by innocent comments like ‘That looks nice’ or ‘Is that an cheese sandwich?’). Some students may enjoy engaging in light chat, others prefer silence.

If the student stops eating, you may ask, ‘Are you able to continue?’ If the answer is no, don’t signal any disapproval. Make an agreement with the parents what you say or do next. Agree with them how quickly they want to be notified. Some may want to come to the school right away help their child finish the meal.

If a student has previously been undernourished, expect packed lunches and snacks to contain a lot more food than normal, and be careful not to comment. Fast weight gain increases the chances of full recovery. The body needs a lot of calories to repair, and metabolism may not return to normal for many months. These quantities of food might seem excessive to you, but the student’s needs at this stage are very special. Besides, they may be extremely hungry and ready to eat more.

Note that at some stages of the illness a student may try to secretly bin some of the contents of their lunchbox as soon as they get into school. You can provide support by having someone at reception take the lunchbox directly from the parents.

Level 4: the school keeps an eye on the student in the dining hall

You provide low-level supervision. This works when the student can eat with ease and is unlikely to restrict on quantities. They are in a phase of treatment where they are practising autonomy and normality, while parents and school continue to provide a safety net. The person doing the supervision could be whoever normally oversees the students in the dining room. It could be one or two of the catering staff, who keep an eye on the choices the student makes at the servery. These details need to be worked out with the parents. What matters is that the student knows they are being monitored and that their parents will be notified if they don’t eat as expected.

With an eating disorder, it can be very hard to stand at a self-service and make fast choices. In their panic a person may choose just a side salad. In that case, see if you can give the parents the week’s menu ahead of time so that they can help their child plan. For students who cannot yet bear to serve themselves a normal-size portion, it helps when the parents notify catering staff of their child’s choice, so that the staff can dish up a sensible amount.

Occasionally parents may ask you to discreetly monitor their child’s food intake. This is when they suspect that that their child has an eating disorder or is in relapse. Their child may be telling them they had a full hot meal, when they only had an apple. If you keep computer records of students’ purchases in the dining hall, offer these to the parents.

The parents will let you know what level of support is needed at any time.

Support around other eating-disorder behaviours

We will attend to over-exercising according to the requests of parents or clinicians

Exercise is often as much part of an eating disorder as food. A person may be exercising excessively, secretly, and be unable to find any peace until they have satisfied an ever-increasing, self-imposed quota. Exercise is anything but ‘healthy’. The smiley student you see in class may have woken an hour early to secretly get through a regime of squats and sit-ups, or may have gone for a run, even though they have a heart condition.

There is a stage in treatment where rapid weight gain is a priority, and some forms of exercise would be ‘wasting’ calories.

Often someone with an eating disorder is obsessively using exercise to regulate their weight or change their body shape. It’s a source of intense misery – they may be exhausted and weak, yet only feel relieved once they’ve gone through an exercise routine. They need help to break the pattern of compulsive exercising. In treatment they practice other ways of dealing with thoughts and feelings, and may experiment with new forms of exercise (that are fun, sociable or relaxing).

For all these reasons, at some phases of treatment the parents or clinicians may ask you to keep a student away from exercise classes. Do suggest any school clubs that the student may enjoy that are not about exercise, such as art or music.

We will do what we can to keep students safe from vomiting or bingeing.

Parents may ask you to supervise that their child doesn’t go to the toilet after a snack or lunch, and may also have specific requests to help their child avoid bingeing or other eating disorder behaviours. Such measures are only needed for a while until a particular habit is broken and the student moves onto another phase of treatment.

If the student needs to be protected from accessing harmful websites, we will do what we can to block access.

Check that your school’s internet system is blocking access to sites that encourage eating disorders or give tips for self-harm or suicide. In addition, recovery is difficult when a student is obsessively consulting dieting or ‘fitness’ websites. The parents may have blocked internet access from their child’s phone, and may ask for your collaboration in keeping their child supervised while on the school’s internet.

If the student has been the victim of bullying, we will consult with them and with parents to make them feel safe.

Sometimes an eating disorder begins with a diet triggered by name-calling or bullying. Whether or not you classify an incident as bullying, if it is making the student regularly feel unsafe, the eating disorder will be hard to shift.

We will not comment on the student’s weight gain, and on the other hand we will flag up weight loss.

While a student is in treatment it’s important they regain weight fast. They may need to reach a weight that is significantly higher than a previous weight. Under a certain weight (which will differ for each individual), hormonal and brain processes cannot get fully back to normal. The parents and clinicians will be working on a weight that corresponds to full recovery of the body and of mental processes. The young person will most likely want to remain much thinner, partly because of the illness and partly because of our society’s poorly-informed bias towards thinness. Any well-meaning comment you make on a student’s increasing weight could jeopardise treatment.

On the other hand it is helpful if you flag up weight loss to the parents as it may highlight a blip in treatment or a relapse. It may be obvious to you that a student has lost weight (especially after a holiday), but sometimes parents don’t see gradual weight loss. Sometimes parents are confused because their child appears to be doing really well, talks the right talk, and yet is cheating the scales.

School trips

We will plan with parents how to make school trips successful.

The parents may need extra information about the trip in order to assess whether to allow their child to go. A poorly planned school trip could result in weight loss and a worsening of symptoms. On the other hand, a successful school trip is part of the good life, and that’s part of recovery.

Find out from the parents what support the student will need (especially at mealtimes), and what signs would indicate that the student needs more help. The parents should be ready to take their child home quickly if he or she is deteriorating.

Sometimes a family will need advance information, such as what types of meals are served, whether served or self-service. The student may need to bring some supplies of their own food in case they can’t cope with the food on offer.

School trip eating disorder anorexia flow chart

Prevention

We will not engage in eating-disorder prevention or body image initiatives unless there is research evidence that they are safe and effective. We are aware that well-intentioned talks on the dangers of eating disorders can backfire, with vulnerable students using the information like a ‘how-to-manual.

There are only a small number of validated prevention programs, and they tend to target one specific risk factor for eating disorders: dissatisfaction with body shape and weight. We are not sure how effective they are for eating-disorder prevention, but they could benefit the many young people today who don’t have an eating disorder but are distressed by a poor body image.

Having ‘awareness-raising’ talks from a recovered person may seem like a great idea but it’s very risky. The person may inadvertently be giving out ‘how-to’ tips, creating a sense of competition (‘I must eat even less’) and they may also have outdated theories of causation and of treatment.

We will not comment on people’s weight or shape. We want to create an ethos of body acceptance.

Your school may be under pressure to address an ‘obesity epidemic’. Please don’t give out anti-obesity messages: for the majority of your students they may do more harm than good, and for the many students affected by an eating disorder, they are disastrous. Note that you are likely to have more students suffering from an eating disorder than from real obesity.

Our society has a ‘thin’ bias, and many people in large bodies are at a weight that is biologically correct for them. Note also that to keep growing ‘up’, young people will have phases of growing ‘out’. And that weight needs to keep increasing – a constant weight, in a young person, is the equivalent of an adult’s weight loss. Girls need body fat to have periods. Being too thin is often more dangerous than being too fat.

If a student is at risk because of obesity, it is for their doctor to express concern and take action, not for the school.

To my knowledge there is no scientific evidence that obesity goes down when schools deliver health promotion messages. On the other hand there are many young people who began a diet – which set off an eating disorder – as a direct result of a health promotion class.

For the majority of your students (who are not vulnerable to an eating disorder), anti-obesity messages can cause harm because, contrary to popular belief, weight-loss diets are most likely to result in longer-term weight gain. This leads to yo-yo dieting and disordered, unbalanced, unrelaxed eating.

Weight stigma is a problem in our society. Scientists are still struggling to understand the causes of obesity – it is not as simple as ‘calories in, calories out’. Yet people with large bodies are judged and ridiculed, as though they lacked moral fibre. The school can strive to be a judgement-free place where the whole person is valued.

We will not encourage fasting.

There are accounts of schools leading a fast to fundraise or to raise awareness of poverty in other parts of the world. This is highly dangerous, as it could be the starting point for an eating disorder in a vulnerable individual. For those in treatment or who are well but need to guard against relapse, it is harmful as they should be eating every 3 or 4 hours and guarding against negative energy balance.

For all your other students, be aware a fast may be used as an occasion to lose weight, and will most likely lead to over-eating soon after. A fast gives the wrong message about the role of nutrition. For anyone with an eating disorder, it’s important to have a dispensation from religious fasts on medical grounds. 

We will take care to have a food-neutral stance. In other words we do not refer to any foods as good or bad, clean, healthy or unhealthy, junk or naughty. Food in the dining room will not be labelled as ‘healthy’ and during lessons we will strive to use neutral language.

All foods serve a purpose, whether for nutrition, pleasure or social events. You can refer to food as providing energy and nutrients, feeding a hard-working brain, satiating hunger, stabilising blood sugar levels, being satisfying or delicious, and being central to social interactions and celebrations. Students are likely to be exposed to many ‘rules’ about food, and the effect will range from unhappiness (for those who can’t stick to the rules) to malnutrition (for those who follow the rules too rigorously). For those struggling with an eating disorder, recovery means freedom from food rules, finding satisfaction in a wide variety of foods, and becoming attuned to the needs met by various foods. To be clear, at times the ‘healthiest’ choice for someone may be a portion of chips.

Do not ask students to keep a food or exercise diary, or to keep a log of calorie or fat intake. Do not ask them to read food labels. For someone with an eating disorder, this reinforces an obsessive attention to misguided food rules. It could trigger an eating disorder or relapse. For those without an eating disorder it could be the start of yo-yo dieting or of a restrictive diet.

You could bring this awareness to the staffroom. Often when I have lunch in a school staffroom I hear staff members discussing their weight-loss diets, and describing the doughnuts on the table as ‘naughty’.

Animal welfare

Don’t expose students to emotional sessions around the horrors of the meat industry. For those currently affected by an eating disorder, becoming vegetarian or vegan is a strategy to eat less and increase rigidity around food, thereby delaying their recovery. An eating disorder can also begin when someone loses weight because they’ve cut out meat without introducing alternatives.

Balance these risks against the unknown benefits: among the meat-eaters who are not vulnerable to an eating disorder, how many might eat less factory-farmed meat as a result of watching a gruelling documentary? I care a lot about animal welfare, and here is a more responsible way forward: have the school source its food from ethical providers.

Our attitude to exercise is devoid of value-judgements. We recognise that exercise is a human need, a source of wellbeing and that it serves a social purpose. We do not endorse any messages that exercise be used to change one’s body shape or weight or to compensate for eating.

Remember that with eating disorders, exercise is often just as much a problem as food.

We will not weigh students or comment on their weight.

In some parts of the world, schools are trying to fight obesity by weighing students and alerting parents. This is very risky and there is no scientific evidence that it is useful.

Education among students

We will make all students aware of eating disorders and encourage reporting.

Be careful not to inadvertently give dieting or exercising tips. The main message is this:

  • A number of students here will be suffering from an eating disorder.
  • They need expert diagnosis and treatment as early as possible because eating disorders can seriously affect one’s life. So please speak to a teacher if you suspect that you, or a peer, suffer from an eating disorder. Possible signs are hiding food, avoiding meals, major bingeing, rigidity and obsession around food, calories, body shape and exercise. Don’t worry if you’re not sure – it’s for the specialists to diagnose and to work out what to do next.
  • Eating disorders are nobody’s fault. Much of the causation is genetic. Think of them like any other illness. People who are battling the illness are glad for the parts of their life that are normal, so if you’re their friend, keep interacting as before.
  • If one of your peers is in treatment for an eating disorder and you see signs that they are deteriorating or relapsing, please report to a teacher (or to their parents, if you know them).
  • We will use your information without revealing your name. You may also tell your friend that you are concerned and are about to report your concerns to a teacher or to the parents, and if you do that, don’t be dissuaded by their assurances that they are fine or that they can get better without help.
  • If you think you have an eating disorder, we very much want to help, and hope you will talk to a teacher. Mr/Mrs [designated staff member] has special knowledge on the subject. Note that because eating disorders are very dangerous and early treatment is best, we are unlikely to assure you confidentiality. Instead, we will help you get sympathetic help.

We will support students who are upset about a friend who has an eating disorder.

Awareness-raising among staff

We will give all staff basic information to help them detect an eating disorder and know how to proceed.

  • All staff should be given the same basic awareness as the students are given. They should know of this policy and guidance. They should understand the main prevention points, in particular around how they talk of nutrition and body shape.
    They should know who the designated member of staff is and should make this person aware of any concerns without delay.
  • The staff members who are most likely to observe behaviours around food or exercise should take the time to read the guidance notes on signs that a student may have an eating disorder.

Boarding schools

Students in boarding schools often need to go home for the first phase of treatment. After that staff will need to support meals and promote normal behaviours in a way that is similar to what parents do. This requires skills and knowledge beyond the scope of this policy.

A boarding school may detect an eating disorder in the same way that a parent would. I suggest you read materials designed for parents.

Further guidance

NICE guideline for the recognition and treatment of eating disorders: https://www.nice.org.uk/guidance/ng69 I wrote a summary relating to under-18s here: http://anorexiafamily.com/nice-guidelines-adolescent-eating-disorder-ng69

FEAST: an international community of parents, with a team of specialist advisers. The site is rich in up to date, evidence-based information and advice. A good site for staff to learn. Do refer parents to it: http://www.feast-ed.org

Eva Musby: my book, videos and website are frequently recommended to parents by NHS specialists. Do point parents to them and use them yourself to learn more about the treatment of an eating disorder: http://anorexiafamily.com

Lock, Le Grange: ‘Help your teenager beat an eating disorder’: this book describes treatment within the family. Most of your students will be getting treatment along those lines.

BEAT: http://www.b-eat.co.uk

ABC: Anorexia and Bulimia Care http://www.anorexiabulimiacare.org.uk

For an insight into what binge-eating disorder is like for the sufferer, listen to this: http://tabithafarrar.com/podcast/ryan-sheldon-guy-binge-eating-disorder

For an accurate video on eating disorders, watch documentary on http://www.parents-to-parents.org

For well-presented information for schools, see http://www.foodforthought.org.au/

If you wish to research validated prevention programmes, look for the work of Michael Levine, Carolyn Becker and Eric Stice and check out http://media.2and2.com.au.s3.amazonaws.com/headspace/pdf/Initiate/Initiate_Prevention%20and%20Early%20Intervention.pdf.

For more on the statistics quoted in this document, see http://anorexiafamily.com/suicide-eating-disorders-statistics/

 

12 Replies to “Eating disorders policy and guidance for schools”

  1. It needs an index and summary section. Very detailed, but may need to be simplified in places. Introduction should buy into people or staff who are sceptical, biased or judgemental.
    Some graphics or undisclosed photos may be included.
    Thanks for taking the time and effort.

    1. Eva,
      Thank you so much for all that you do for us all. You are a warrior and we’re very grateful to you. Some points from me:

      1. Your reference to neutral language may need explaining; perhaps give examples of appropriate language, e.g. ‘balanced meal’ rather than ‘healthy/unhealthy diet’

      2. The details surrounding the different types of ED may be a bit wordy; better might be some form of graphic labelling symptoms, rather than lots of text.

      3. Same detail for behaviours and physical signs as point 2 – use of graphics perhaps?

      4. Like the levels of intervention but concerned one-to-one meal supervision from school staff may be too much of an ask (our school has been prickly in this regard re staff resources required to enable this).

      5. The School Trips graphic is brilliant (in fact, I’ve utilised it myself for a school trip).

      1. Louise and Nihan, thank you so much!
        I like your suggestions to reduce the number of words.
        Louise, about your Number 4, I am pretty sure the the one-to-one meal supervision needs to stay in. It’s so useful, and some schools manage it — no idea if they’re a majority or the exception.

  2. Wow this is long and comprehensive. For me the key is supervised lunches and if a student doesnt eat, they cannot continue in lessons. Access to a counsellor immediately could be good. Call the parents. Life stops until you eat should be the message imho. My sons school adopted this attitude and had huge success. My daughters school sisnt supervise lunches, didnt care if pupils didnt eat, were more bothered that they behaved nicely and achieved results. Life stops until you eat.

  3. Eva Musby, I think I love you ?. This will be a fantastic asset in the battle against eating disorders. My daughter ‘s anorexia crept in after the healthy eating programme at school when she was 12. Although I don’t blame the school this policy will greatly increase awareness within teaching staff
    Kind regards and thank you
    Angela

    1. Awww! Yes, my understanding is that these health promotion initiatives have got many of our kids to start restricting. My guess is most schools will not have any idea what could possibly be wrong with “health promotion”.

  4. Eva,
    I think perhaps add some quotes from sufferers who have been supported by school staff and a teacher’s point of view? These would also help to break up the text.

    I was indebted to my child’s school who gave us every support, and which most importantly included lunchtime supervision. This was managed through one of the school’s welfare officers sitting and eating her own packed lunch with my daughter while she ate hers – in a room well away from being observed by other pupils. This enabled my daughter to remain at school and maintain vital links with her friends.

    A huge thank you for all that you are doing to raise awareness. Your website and book have been invaluable!

    1. Thanks for the encouragement to add quotes. It makes everything longer but yes, it might bring things to life.
      What you’ve just written would make an excellent quote. If it’s OK with you I’ll put that in? As “A parent”?

      Anyone who can help, can we gather a few quotes from schools?

  5. This could make such a difference, I feel that something similar should be sent a to all GPs, maybe the parents you are in touch with, could become ED policy champions and try and ensure local schools, CAMHS and GP practices receive copies. I wonder if Early Detection and Signs of ED, should be more towards the start the policy?? With information regarding the particular ED further down in the policy? Thanks Eva for bringing this into the public domain.

    1. It’s a lovely, simple, and very practical suggestion: that parents all over the world can bring education to local schools and doctors with the support of an up-to-date document. All your comments are going to help shape this into that kind of document, thanks!

  6. Hi Eva,
    What a fantastic resource this will be and how very detailed. I did wonder if it might be appropriate to have separate templates for primaries and secondaries as the staff involved are so much more involved with and closer to the children at primary than those at secondary. From our own experience, once the primary staff recognised the problem (which bacame obvious to them on a school residential trip) they were all on board and were able to form a spy network. The dinner ladies reported selling a sandwich and the playground assistants reported seeing it being offered to friends or the janitor finding it in the bin. Parental lunchtime feeding was therefore facilitated and easy. The school nurse made the referral the doctor had refused to do. Secondary, on the other hand, is a very different beast not least because of the scale and complexity involved. No one member of staff has contact throughout the day and pupil behaviours around food are more difficult to confirm. We also experienced PE teachers being awkward when we asked for exercise to be restricted because our child “didn’t look” as if they had AN! I think a policy such as this would help greatly in getting all staff within the school to behave “as one” I.e. Once an ED has been recognised and diagnosed, all staff would be committed to playing their part in any interactions with the child in a constructive way. I agree with earlier comments that the policy is very long and detailed but there is nothing in there which I’d like to see you drop. Therefore I think an index (as already suggested) together with summary would be very beneficial. One further point again harps back to our experience in Scotland where your treatment depends on where you live. This was a few years ago and I hope things have improved since, but you mentioned that in Scotland, there MAY be someone with specialist knowledge in CAMHS. Sadly, that wasn’t the case for us, where out-dated practises and thought streams were initially employed. I know we weren’t alone with this, so if there is still not immediate access to up-to-date specialists, it may be worth recognising this in some way in the section where you talk about what parents are dealing with. Sometimes they are having to fight the system as well as the illness (although I’d like to think that’s not the case any more)….

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