Schools: what to do when a pupil shows signs of an eating disorder

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What should your school do when a pupil shows signs of an eating disorder or of disordered eating?

The more serious it seems, the more decisive and rapid you should be. At the ‘serious’ end, I would place any behaviours that might be part of a diagnosable eating disorder, plus any of the more extreme behaviours of disordered eating.

Low levels of disordered eating are very common among pupils, and may not warrant individual treatment. The school will have to use some common sense when deciding when to raise the alarm. When in doubt, let the experts decide.

* Link: Schools, this is how you spot an eating disorder *

If you suspect that a pupil could have an eating disorder, then I recommend you call the parents within 24 hours.

With older pupils you may choose to talk with them ahead of notifying their parents.

What to say to a pupil showing signs of an eating problem

Tell the pupil that you have concerns, describing one or two particular behaviours you have observed. Say you care for their wellbeing and that you are about to inform their parents. Give them a chance to tell you what’s going on, but make sure they understand that you cannot give them confidentiality in this matter. Resist giving any kind of advice, as they may twist it around and this will make treatment harder.

You don’t need to say you suspect an eating disorder, as this may put you out of your depth when the pupil assures you they are fine. A pupil may not recognise that they have a problem, may think they’ll solve it alone, may be ashamed, or may be scared of treatment. Don't be swayed by a pupil's pleas that they'll be fine. The most delightful young people can lie outrageously when they are in the grip of an eating disorder.

What to do when a pupil discloses problems with eating

If a pupil tells a staff member about a problem with their eating, your stance should be empathetic as well as action-driven. Show your concern for their wellbeing.

A pupil might open up about minor difficulties with eating, without admitting to a much bigger problem. Because eating disorders are secretive, this is an area where you should err on the side of safety and let experts assess what action is or isn’t required.

Explain that as difficulties with eating can be dangerous, confidentiality doesn’t apply. Explain that you will talk to the parents so that the pupil gets access to an expert, and it is this expert who will work out what type of the help the pupil does or does not need to be safe and happy.

I suggest that at this stage you just use the term ‘difficulties with eating’ or ‘difficulties with your body confidence’, with pupils who are not themselves using words like anorexia or bulimia. It’s just as true and it means you don’t get into an argument about diagnosis.

What to say to a pupil who reports concerns about a peer

Sometimes the alert is raised by a fellow pupil, and it’s OK if they wish to do this anonymously. Record what they disclose and then consult the designated member of staff for eating disorders. Thank the pupil for their input, which is potentially life-saving. Reassure them that experts are at hand to assess and treat.

What to say to parents (within 24 hours)

Why 24 hours? Because with some eating disorders, the downward journey is fast, with every day bringing more restrictions and a more entrenched attitude. Also, you don’t know what this pupil’s medical risk is — you can't tell from how they look. The sooner an eating disorder is treated, the more effective and lasting treatment is.

Don't assume that parents, surely, already know. They probably don't have experience of eating disorders the way you do. And the behaviours at home may still be normal. Early on in an eating disorder, youngsters often bin food in school while still eating as usual at home.

A school may also spot signs of relapse before the parents do. For instance they may notice that a pupils looks thinner after the summer break. By flagging up concerns they can help a minor setback from becoming a full-blown relapse.

It is a shock for parents to first learn that their child might have an eating disorder. Some could be paralysed and in denial. This is a time to build trust and mutual consideration, as you will need to work as a team. Seek to treat parents with empathy. You may also need to impart a minimum of information along these lines:

• we don’t know if it’s an eating disorder but if it is, then early treatment makes a huge difference – eating disorders are treatable (this gives hope while parents are in a state of shock)
• specialists will assess whether it’s ‘just a phase’ of disordered eating, or whether it’s an eating disorder (parents may be scared that by consulting specialists they are making a mountain out of a molehill and could cause their child to get worse — this is not the case)
• either way, specialists will advise both parents and school on the next steps

You may also want to point parents to this website you're on (anorexiafamily.com) as there is a lot of help for parents here.

How to get the pupil assessed by specialists (urgently)

If a pupil is showing signs of an eating disorder, they should be assessed by a specialised eating disorders service without delay. Neither the school nor the parents should ‘wait and see’.

In England, the specialists to call are the community-based eating disorder service for children and young people (CEDS). They can take referrals from parents or from school staff. GPs will also do referrals, of course, but this adds to the waiting time, and sometimes families get held back by inexpert advice.

In the rest of the UK and in other countries with a national health service there may be a requirement for parents to go through a GP/family doctor, who should promptly refer to eating-disorder specialists (in the UK, Australia, New Zealand, this is within child and adolescent mental health services (CAMHS)). Usually a school nurse is allowed to refer a child directly to CAMHS.

GPs will be involved throughout a child’s treatment, in collaboration with the specialists.

What to do if parents don’t want their child to see a clinician

Some parents may not agree with you that their child should consult specialists or even their GP.

I suggest you nurture a respectful relationship with these parents, as at this stage you don’t know if they’re paralysed by fear or if they have a greater understanding of the situation than you have.

For instance, some parents have already used the health service for their child’s eating disorder. They may have been disappointed by the standard or they may have developed plenty of their own expertise, and gone on to treat their child with minimal professional input. As long as the child is medically stable and making progress, this is perfectly fine.

Occasionally you may come across parents who, for whatever reason, are not taking action, while you suspect their child may have an untreated eating disorder. In this case I recommend you contact the health service experts and take your lead from them. Remember that in many places a school nurse has the power to make a referral.

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