Workshop held at Eating Disorders Alpbach 2013, The 21 st International Conference, October 17-19, 2013

Workshop held at Eating Disorders Alpbach 2013, The 21 st International Conference, October 17-19, 2013

Working with children and adolescents suffering from eating disorders in Nordland County, Northern Norway Iris Anette Søderholm, psychologist irso@nlsh.no Kamilla Kvikstad Mathisen, child- and adolescent psychiatrist kkm@nlsh.no Unit for Eating Disorders Child and Adolescent Mental Health Department Nordland Hospital, Norway

Bodø Nordland Northern Norway Our aim and our challenges Nature, population and history as basis for our working model Our working model Clinical example Questions/discussion

Challenges and aim Long distances to patients and support services Travel by plane, car, train and boats/ferries, takes hours... Transport and communication a challenge in itself. Thinly spread population, 240 000 inhabitants in Nordland county, 52 000 inhabitants under 18 years of age. Cities: Bodø (39000), Mo i Rana (18000), Narvik (14000), Mosjøen (9500) + 7 smaller cities. Our aim: to give good specialized service to patients, no matter where they live.

O ce upo a ti e 1974 the first specialty mental health service for child and adolescents in Nordland, established in Bodø, 6 employees, psychologist as the head of department Pediatric department established same year Bodø served Nordland county, visited all 6 local hospitals every month. 1990 CAMHD at 7 locations in Nordland. Bodø important for supervision, education, the role as a other cli ic.

CAMHS in Nordland

National focus on Eating disorders ; the Parlia e t decided a Natio al pla for mental health 1999-6, with special focus on prevention and treatment of eating disorders. Inadequately developed treatment facilities in Norway and insufficient expertise in ED. Norwegian board of Health supervision published Guidelines for treatment of eating disorders, 2000.

Experience in Nordland In late 70s; two young sisters died of severe AN. Conflicts and splitting between systems, in the family and between clinicians/therapists. 80-90; 4-14 referrals to Bodø each year of patients with eating problems, mostly ED. Collaboration CAMHS and pediatric ward.

Experiences in Bodø 1999- acute ward for youth. Girl with severe AN, OCD and self harm. No specialized team or ward working with ED in Norway Establishment of a team working with the girl 2000- establishment of Unit for Eating Disorders in Bodø.

Establishment in new terrain Consultation and guidance to all local CAMHS in Nordland, teaching courses. Guidelines for collaboration with pediatric ward Inspiration from specialized Units in UK (Maudsley in London), Denmark (Copenhagen) and Sweden (Østersund, Lund) 2 year education program of ED

Aims for the working model All patients should get equal quality of treatment wherever they live. Raise local therapists knowledge of ED, being the persons with the closest relationship to the patient, her family and her community. Focus on family and network

Flexibility of the working model Flexibility is a key value as well as a necessity. The unit tries to adjust the treatment to the individual patients and their families. This means we have different elements of treatment within the working model.

Elements of treatment Collaboration with others Intensive Apartment Family Therapy Family work and therapy Parent therapy Individual therapy Eclectic approach Motivational approach Psychoeducation Somatic follow up Dietary plans to promote weight gain

Partners Family and extended family Schools Health nurses Therapists at local CAMHD General practitioners Dietitians/nutritionists at local hospitals Pediatric ward Medical ward at local hospitals for patients over 15 yrs of age Regional Centre for Eating Disorders, Tromsø, inpatient ward for youth. Regional Centre for Eating Disorders, Bodø, inpatient ward for adults.

Working with families «The psychosomatic family», or mobilizing family resources? Minuchins theories really put the importance of families «on the map» Later research indicates that families indeed are important in maintaining the eating disorder as well as in recovery Eating disorders have a major impact on family life

Intensive Apartment Family Treatment Many families have a long way to travel to get to therapy, this means traditional outpatient treatment is not always possible Other families need more intensive therapy than regular outpatient therapy can provide These families can come to the unit's apartment for 1-5 (10) days for intensive therapy 1-10 stays in the apartment

Working in the apartment Intensive treatment The focus is first on stabilizing somatic condition and working towards more normal eating routines Psychoeducation Family resources and challenges Individual resources and challenges Individual, family, sibling (or others) and parent sessions

Collaboration with the Pediatric ward Patients under 14 suffering from severe eating problems can be admitted to the Pediatric Ward for treatment Agreement with the Pediatric Ward in Bodø where the Unit's responsibilities include; If possible to meet the family and local helpers before admission Be a part of the team around the patient while admitted and after discharge (team meetings twice a week) Family sessions 3 times per week during admission Make sure the family has the right help after discharge

Referrals to Unit for Eating Disorders 2003-2012

Unit for Eating Disorders 50 45 40 35 30 25 20 15 10 5 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Referrals Current cases

Gender 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Girls Boys

Age 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 16-20 years 11-15 years 6-10 years

Diagnosis ICD-10 1% 9% 1% 1% 2% 1% 3% 3% 12% 1% 2003-2011 F50 Eating disorders F32 Depression F40 Phobia F42 OCD F43 Stress reaction F98 Feeding disorder F95 Tics Z03.2 Obs 66% No diagnosis 1999 Info missing F92 Conduct and emotions

Eating disorders diagnosis F50, 2003-2011 F 50.0 Anorexia nervosa 18% F50. 1 Atypical anorexia nervosa F50.2 Bulimia nervosa 1% 4% 3% 3% 15% 56% F50.3 Atypical bulimia nervosa F50.4 Overeating F50.8 Other ED F50.9 ED unspecified

Clinical example

Unit for Eating Disorders Working model which is based on challenging geography, collaboration between systems, making the local therapist good. The specialized Unit for ED as a supplement to the local therapist, not instead of. Focus on family and network. Strengthening of parental authority. Flexibility is a strength of the team, but can also make it vulnerable

Thank you for your attention!