When I lived in Shanghai, China had no specialized eating disorder services available.  The English-language newspaper carried a distressing story about the availability of an "innovative" treatment for anorexia at the local hospital that consisted of implanting electrodes in the brain.  The only reasonable option for Western patients with severe anorexia nervosa was inpatient eating disorder programs in Australia, the U.S., orEurope. 

Eating disorders pose a unique challenge to international schools.  These schools often provide the only support system for the expatriate families who have literally moved away from every resource to which they would normally turn for assistance.  In these communities, there may be no specialized eating disorder resources available in the student's native language, or indeed at all.

A survey of eating disordered behaviors at one international school in Shanghai showed rates of eating disordered behavior among all students grades 7-12 comparable to US rates - between 7% and 13%.  Expatriate childrenexperiencing the mental stresses of transitions and culture shock may even be at increased risk for mental illnesses, including eating disorders. 

Eating disorders must be addressed from both a medical and a mental health perspective for full recovery to occur.  The soonerone gets help, the greater the likelihood of recovery.  Without early intervention, eating disorders may become chronic, or even fatal.

It is therefore important for international schools to be take measures to prevent the development of eating disorders, to be prepared to intervene quickly when they emerge, and to have resources available to help support their students and families facing eating disorders

Recommendations for International Schools   

The International School may have to play a more leading and active role in identification and treatment of eating disorders than a school in the home country.  The National Association of Anorexia Nervosa and Associated Disorders (ANAD) and the National Eating Disorders Association (NEDA) have published guidelines for schools in dealing with Eating Disorders.  Their recommendations (modified slightly for the specific context) are especially relevant for International Schools. 

Prevention

• Provide an environment that promotes and models healthy behaviors.  The school cafeteria should provide nutritious food and unhealthy foods should be removed from vending machines.

• Provide a curriculum that promotes healthy flexible eating and size acceptance; discourages dieting or counting of calories; sends no anti-obesity messages; and raises awareness about eating disorders.

• Set a policy for students to report harassment based on weight or appearance.  Never weigh children in public,tell them their BMI or tell them to lose weight.

Intervention

• Get up to date on evidence-based treatments.  Train faculty in identifying eating disorders and early intervention. Train staff to sensitively address students showing warning signs.  Designate a person or team to guide interventions. 

• Identify both local and international resources to which to refer students with eating disorders.

• If the school suspects an eating disorder in a student, inform the parents early.  Denial is often encountered when eating disorder behavior is confronted.  Be sensitive to the parents' feelings and concerns, which may include shame, blame, and confidentiality.  The goal is for the parents to acknowledge the problem and accept the school as a partner in the treatment.

• Once referrals to medical and mental health resources are provided, the student should receive supportive counseling and medical monitoring.  Communicate with any outside team members that are providing treatment.  Discuss with the parents who will monitor the child (the school or an outside provider) and how, and clarify the communication lines among the school, parents, and treatment providers.  It may be appropriate for the school nurse to conduct periodic assessments and follow-up such as weight, pulse, and blood pressure checks.

• Even if the family minimizes the severity of the eating disorder, show concern for the student's safety and protect the school from liability.  Seek guidance from a treatment team on whether the studentmay participatein sports, field trips, and the like.  Limits on strenuous activities may be appropriate forchildren with eating disorders.

The treatment team and school should work with the family to ensure that the full medical, psychological, and academic needs of a student in recovery are addressed. The student may need a reduced course load, time off for appointments or bed rest, extra snacks, meal monitoring, release from health and PE classes, or other accommodations.  In some cases, students may need a leave of absence to attend an inpatient treatment program.  In these cases the school may be able to provide lessons to the child in treatment.  Children returning from residential treatment may need help reintegrating into school and getting caught up on work.