Learning briefing: Thematic review – Eating disorders and childhood obesity

1. Learning Journey: What did we do?

We undertook a review to evaluate the recognition and response of multi-agency partners in relation to eating disorders and obesity. Examination of the current system of support available for children, young people and their families and carers in Devon took place. This included eating disorder and obesity support from primary care through to inpatient services, third sector and local support services. The partnership wanted to further question whether there were any demographic factors and explore to what extent we were able to identify and address potential childhood trauma as an influencing factor.

How did we do that?

• A review of research available including relevant Local Child Safeguarding Practice Reviews conducted by other partnerships nationwide.
• A multi-agency tabletop file audit exercise of four young people who have been in touch with services for childhood obesity (in Quality Assurance Delivery Group meeting).
• A review of training already on offer and the take up and impact of the training.
• A review of data available; locally and nationally.
• A practitioner survey to consider key lines of enquiry.
• Three Appreciative Inquiry Practitioner Meetings held to explore the journeys of families with young people who have been seen and treated by services for an eating disorder.
• Senior Leaders’ interviews of key agency.

2. What good practice did we find?

• Families told us that when they were linked in with specialist eating disorder services, they felt supported, informed and connected with the help on offer.
• There was some exemplary practice of using neurodiverse interests to help a young person to take control of their treatment and recovery.
• Parent, carers and young people report that when a young person requires specialist intervention for eating disorder, those services are accessible and respond immediately, although occasional delay was noted through a referral pathway.
• Some families told us that their schools were “amazing” once the eating disorder was identified.
• The feedback from parents and carers about specialist services was overwhelmingly excellent.

3. What else did we find?

• In several families, schools and parents were unable to pick up on deterioration in presentation through young people wearing baggy clothes or because healthy eating is not culturally prioritized.
• During lockdowns, young people were able to hide their eating disorders more easily.
• Parents said that GPs generally worked well with them despite not having expertise in eating disorders but were worried about the lack of knowledge amongst the GP population.
• There was worry from young people and families around transition to adult services.
• Families told us that there is a need for services to treat young people as a whole person, considering their mental health, wellbeing and physical health.
• A carer told us that it is really tough achieving change for young people who are overeating and that they did not get as much advice and information as they would have liked.
• There was no judgement felt by the parents of a young person with an eating disorder, but this was not the same experience for parents of a child with obesity.
• Young people told us that they felt a lack of support in hospital when they were there for an eating disorder – hospital staff seemed to play “good cop/bad cop.  Parents views were generally different; hospital stay was very helpful, supportive with methods used being necessary to keep their young people alive.
• A young person experiencing adversity in childhood, directly contributing to their illness wanted this to have been noticed by the worker. The young person wondered how often practitioners ask questions about the situations of adolescents and if they instead view adolescents as more resilient.
• Young people told us that they believe there is not enough support for mental health and that they think parents/adults need educating about eating disorders and obesity.
• In Devon, whilst it is true that eating disorders were on a steady rise before the pandemic, we have since seen a significant increase directly related to it.
• Nationally obesity levels among younger children rose significantly after lockdown. Data from NHS Digital show that almost one in seven children start primary school obese and more than a quarter are obese by the time they finish primary school.
• Practitioners told us that the barriers to accessing support included overstretched practitioners or services lacking capacity, long waiting lists, lack of GP appointments, not enough specialist support.
• There is very little access to training in these subject areas.

4. What can we learn?

• CAMHS consultants say approximately 40% of young people presenting with eating disorders have or are likely to be neurodiverse or be on the neurodiversity assessment pathway.
• Rushed mealtimes at school, a lack of conducive environments for meals, detentions clashing with mealtimes and restrictive food types offered impacted negatively for some young people.
• Universal and targeted services, at an early intervention level, are lacking capacity, especially to advise and consult schools to build confidence in identification and action.
• There are difficult transitions from child to adult and lack of clarity and planning for accessing services once an adult, how can your service improve on this?
• Some services were not keeping families up to date on plans for accessing appointments after the initial acute intervention and treatment.
• Practitioners have a general understanding of eating disorders but there is a lack of knowledge about other types of emerging disordered eating, for example avoidant/restrictive food intake disorder.
• Practitioners within the specialist pathway are confident about identification of eating disorders but some practitioners in other areas are not.
• We sometimes do not view the young person holistically (mental health and physical health) and instead we focus on one aspect for too long.
• We need to work effectively with neglect, in particular assessing parental capacity to sustain change. Food deprivation can lead to food insecurity and hoarding, of relevance to obesity.
• There has been an impact due to the lack of physical activity undertaken by children and young people during lockdown.
• Primary care services may focus on one parent/carer, generally the mother, as main carer with not enough value placed on the voice of the other parents/carers, in this case fathers, while specialist services saw the fathers as significant to their child’s care and wellbeing.
• There needs to be improved multi-agency clarity around roles and responsibilities within a package of care for young people with eating disorders and mental health/neurodiversity presentations.
• Visiting practitioners were described as taking young people out for meals and not necessarily role modelling healthy eating choices, instead defaulting to popular fast-food outlets.  Are senior practitioners aware that they are doing this? Should these things be considered in a young person’s plan?
• The disruption of the National Child Measurement Programme and a lack of line of sight during lockdowns has meant a lack of early identification in potential childhood obesity resulting in an increase in post Covid-19 pandemic referrals.
• When referrals were made into specialist services, such as dieticians, this sometimes resulted in primary care provision being discontinued. A ‘hand off’ approach occurred as opposed to working together to provide a holistic package of care.
• When young people were not brought to medical appointments the ‘was not bought’ process was not always followed in regard to information sharing and the ‘what next?’ was uncertain in professional response.
• We are not always seeking the voice of the child and considering the lived experience of young people within a family context. This was particularly identified where childhood obesity was a feature and focus was on the weight of the child rather than the possible causal factors.
• The medicalisation of a young person’s weight can allow practitioners to become distracted from the underlying causal factors and therefore safeguarding concerns are not always identified.

5. What are the recommendations?

• Greater understanding of the relationship between neurodiversity and eating disorders, disordered eating and obesity. Approximately 40% of young people presenting with eating disorders have underlying neurodiversity issues.
• Expand availability and quality of supervision for practitioners to increase professional curiosity, challenge and confidence.
• Training programme within Devon Safeguarding Children Partnership to be supported by eating disorder specialist service pathway.
• Consider the need for increased capacity in primary health services to support ‘team around the family’ meetings, where advice can be given, and confidence can be built.
• When young people are not brought to medical appointments the ‘was not bought’ process should be followed and there should be more consideration around ‘what next?’ and escalation processes.
• Consider a review of individual agency’s processes to maximise opportunities to engage with families around childhood obesity.
• Seek the voice of child/young person and lived experience and be more professionally curious about causal factors.
• Organise for specialist services to deliver eating disorders awareness raising and training sessions across the partnership workforce and consider ‘spotting the signs’ type awareness/resources for parents/carers.
• Provide training and education opportunities for multi-agency practitioners in identifying and managing childhood obesity.
• Develop interventions to facilitate a co-ordinated transition from paediatric to adult health services for adolescents with eating disorders.
• Devon Safeguarding Children Partnership/Southwest Child Protection Procedures to produce a page on safeguarding responses to obesity and eating disorders.
• Develop local child weight management pathways to ensure appropriate referrals and consistency of care.
• Develop clear protocols for the involvement of education settings in managing childhood obesity.
• Undertake a review of data recording systems so data extraction is available for childhood obesity.
• In order to provide effective oversight, managers should themselves have sufficient underpinning knowledge about obesity and eating disorders, risk of harm and vulnerability and understand the assessment, planning and management processes and be able to distinguish both good and insufficient practice.
• To discuss with Public Health Devon, opportunities for informing and educating parents about childhood obesity.
• Develop a Safeguarding Analysis Tool and resources to identify and intervene with childhood obesity.

6. What can you do?

• Read and share the Review and Briefing with colleagues and discuss the learning in team meetings, supervision and 1-2-1s.
• Attend relational and restorative support training and cascade to colleagues. Read further information about Restorative Practice and visit our training page.
• Identify areas for your own and your settings’ learning and improvement.

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