Eating Disorder FAQ
About Kartini Clinic
The Kartini Clinic For Disordered Eating, based in Portland, Oregon (USA), is one of the world’s leading facilities for the treatment of eating disorders in children, adolescents and young adults. Its unique treatment protocol includes:
- inpatient hospitalization for medical stabilization, if required;
- a day treatment program designed to restore your child’s weight; extinguish his/her eating disorder symptoms; design a relapse prevention plan; and train parents how to provide ongoing care centered around maintenance of Kartini’s unique meal plan.
- followup outpatient services to keep your child’s remission on track and to assist in transition to normal development
Kartini was founded by pediatrician Dr. Julie O’Toole, who continues as medical director, along with a true multidisciplinary team of physicians, psychiatric nurse practitioners, and licensed psychotherapists.
Kartini Clinic treats a wide range of eating disorders, including anorexia nervosa (both restricting and binge/purge subtypes), bulimia nervosa, EDNOS (eating disorder not otherwise specified), food phobia, selective eating and miscellaneous conditions that may lead to wasting and growth impairment.
Kartini Clinic has treated children as young as 4 years of age. It maintains two separate treatment groups, one for school-age children, up to age 17; the second for college-age young adults, 18-22, with occasional break-out groups for very young patients. At Kartini Clinic we enjoy treating all ages within our mandate, but are especially experienced with anorexia nervosa in the very young child (under 12) of either gender.
Yes. We treat boys and young men suffering from anorexia and other eating disorders.
Yes. As the symptoms and treatment objectives are very similar for boys and girls, they are treated within the same groupings, based on age. Within the groups, boys and girls may be given different therapeutic activities related to their specific interests.
The Kartini Clinic is a pediatric clinic and a outpatient mental health facility that operates under the professional licenses of its providers, anchored by two Board certified pediatricians, Dr Julie O’Toole and Dr. Naghmeh Moshtael.
- Dr. O’Toole, is board certified in pediatrics and has been in private pediatric practice for over 20 years. She is a member of the A.A.P. (American Academy of Pediatrics), AED (Academy for Eating Disorders), NEDA (National Eating Disorders Association), and EDAP (Eating Disorders Awareness and Prevention) and is a member of the advisory board to F.E.A.S.T. She also has a Master's degree in public health (international health).
- Dr. Moshtael, MD, is a board certified pediatrician, and fellow of the A.A.P. (American Academy of Pediatrics) and a member of A.E.D.(Academy for Eating Disorders). Dr. Moshtael completed her pediatric residency at Oregon Health Sciences University and served as Chief Resident there until joining Kartini Clinic full time in 2006. Dr Moshtael also holds a Master's degree in international studies and community health development.
Though many of its patients live in the Pacific Northwest, Kartini Clinic also serves patients from throughout the United States and abroad. In recent years we have treated young people from Alabama, New York, New Jersey, Florida, California, Tennessee, Idaho, Montana, Ohio, Virginia, Washington, North Carolina, South Carolina, Georgia, Hawaii, Alaska, Arizona, Israel, Japan and France.
- Janiece E. DeSocio, PhD, PMHNP, RN: Janiece is a licensed Psychiatric Mental Health Nurse Practitioner and is board certified as both a family psychiatric nurse practitioner and a clinical specialist in child/adolescent psychiatric mental health. At Kartini Clinic Janiece meets with patients and parents for psychiatric evaluations and consults with the team about medication management. She is coordinator of Kartini research activities and has published a textbook chapter on eating disorders and numerous articles on psychiatric issues facing children and adolescents. In addition to her work at Kartini Clinic, Janiece is Associate Dean of Graduate Education and Associate Professor for the College of Nursing at Seattle University.
- Jade Buchanan, LCSW: Jade is the Director of College Age Services and the Milieu Therapist for the College-Age Day Treatment Unit. She has been with Kartini Clinic since 2003.
- Jayotta J. Feimoefiafi, LCSW: Jayotta is a group and Day Treatment Unit milieu therapist at Kartini Clinic. She has a graduate degree from Portland State University and more than 12 years of experience as a therapist with children, young adults and families and has been with Kartini Clinic since 2003.
- Bart Walsh, LCSW: Bart provides Kartini Clinic’s patients with group relaxation therapy, hypnotherapy for anxiety and work with the unconscious. He is a licensed clinical social worker and has many years experience utilizing hypnotherapy with individuals, including children and adolescents.
- Pam Williams-Gifford: Pam is Kartini Clinic’s resident school teacher, overseeing academic programs for its patients in tight coordination with their teachers back home. Pam has 12 years experience as a classroom teacher. She received a B.A. in Art Education from SFSU and Waldorf Teacher Training from Rudolf Steiner College.
- Beth Sommers: Beth is Kartini Clinic’s medical assistant and patient advocate. She has a bachelor's of science in Physical Anthropology from Oregon State University and a nearly complete M.P.H. from Portland State University.
- Amy Stauffer: Amy is a milieu facilitator at Kartini Clinic. She earned a Psychology degree from Westminster College in Missouri.
- Jessica Stumpf, MA ATR: Jessica, a milieu therapist in Kartini Clinic’s Day Treatment Unit, specializes in the use of art therapy to help patients communicate thoughts and emotions, particularly relating to self image. Her work experience includes working with adult males at a forensic psychiatric hospital in Napa and locally with adolescents in residential drug and alcohol treatment. She received her Bachelor’s in Fine Arts from Regis University in CO. and a Master’s in Art Therapy Counseling from Marylhurst University in Oregon.
- Mandy Brice: Mandy is a milieu therapist's assistant in the Day Treatment Unit. She graduated from the University of Oregon with a B.A. in Sociology.
- Judy Potts MA/ABS: Judy is an Adjunct Milieu Therapist in the Day Treatment Program. She received a Bachelor's Degree in Social Psychology from Brandeis University, and a Master's Degree in Counseling from City University of Seattle. She has worked in the field of eating disorders for the past 10 years.
- Dena Wilder: Dena is Kartini Clinic’s movement therapist. She has a degree in recreational therapy from Arizona State University and is a certified yoga instructor. Dena also leads Sibling Group.
- Kathy Franz, LPC, CADCI. Kathy is a family therapist at Kartini Clinic. She earned her Bachelor of Science in Human Development and Family Sciences from Oregon State University and continued her education at Lewis & Clark College, earning her Master's of Arts in Counseling Psychology; Marriage and Family Therapy. She is an Oregon Board certified Licensed Professional Counselor and is Certified Alcohol and Drug Counselor I.
- Leslie Weisner, LMFT. Leslie, who joined Kartini Clinic in 1999, is a licensed family therapist with extensive experience in the field of eating disorders. In addition to serving as family therapist, Leslie leads our weekly parent group. She has a Master’s Degree in Marriage and Family Therapy from Southern Connecticut State University.
- Zanita Zody PhD. Zanita completed her PhD in Marriage and Family Therapy at Purdue University in Indiana and since doing so has worked almost exclusively with families and individuals experiencing eating disorders. Zanita has also worked on numerous eating disorder policy and prevention efforts in Indiana and Washington DC.
We aim for medical stability, quick and complete weight restoration, resumption of menses (in post pubertal girls), and remission of eating disorder symptoms and behaviors. Measurement of vitals (including weight) determines medical stability. Where there is any doubt about return to full hormonal functioning we may measure hormone levels or obtain a pelvic ultrasound (in females). In the Karitni Day Treatment Unit (KDTU) our professional staff is able to work intensively on remission of eating disorder symptoms such as restricting, hiding food, odd table behaviors, bingeing and/or purging. In the outpatient setting the patient is monitored by the doctors, the family therapists and the group leaders. At six-month follow-up, we may measure progress by re-administering an eating disorders evaluation tool, used during initial assessment, known as the REDS-C (Rating of Eating Disorder Severity in Children).
With experience of treating more than 1800 patients using Kartini family-centered Treatment we know it works very well for the vast majority of our patients. We know the cornerstone of our initial treatment for anorexia nervosa -- complete weight restoration -- is achieved in close to 100% of patients graduating from the KDTU program. And we also know that we achieve remission of significant disordered eating behaviors as well. And utilizing the KDTU program as a step-down intervention between the hospital and home has proven much more effective than hospitalization alone. In the years before we had a KDTU program the rate of re-admission to the hospital (within one year of discharge from KDTU) was about 40%, roughly on par with published studies. For those completing KDTU however, that rate fell to less than 8%. We are looking forward to sharing more complete findings with parents and the professional community as they become available.
Referral for residential treatment is considered for those children whose parents, for one reason or another, are not able to participate fully in family-centered treatment or who elect not to do so. It is also appropriate for those who require 24-hour care but are not medically unstable.
Which term we use depends on the eating disorder diagnosis in question. For example, in the case of food phobia we speak of “recovery”, even “cure”, as it has been our experience that once extinguished the food behaviors do not return. In the case of anorexia nervosa, however, we use the term “remission”, reflecting our belief that this condition is a chronic illness whose symptoms can be extinguished, but which can recur in times of stress. An important part of our treatment program is working with the patient and family to design an effective relapse prevention plan, giving the patient the tools necessary to react quickly to any re-appearance of symptoms. The goal is to teach our young patients and their families how actively to manage their lives-- not unlike teaching diabetics to eat carefully, stay active and use medication (insulin) so they can lead normal, productive lives despite their condition.
Kartini Clinic Treatment Approach
For the restrictive type of anorexia -- the most common form found in children and adolescents -- Kartini Clinic has developed a highly effective treatment protocol employing:
- a unique meal plan that reduces your child’s anxiety about eating and restores weight in a healthy and natural, family mealtime-oriented way;
- medication (where indicated) and
- therapeutic training for both patient and parents designed to quickly return patient to sustainable “ordered” eating
At Kartini Clinic, eating disorders are viewed as neurobiologically-based brain disorders. Some eating disorders are short lived when treated adequately (e.g. food phobia) while others may be chronic in nature (e.g. anorexia nervosa). All can be successfully treated so that they do not continue to have a negative impact on a child’s future, schooling, home life or growth and development. We treat patients in the knowledge that parents do not cause eating disorders, nor do children choose to have them. Adequate weight restoration and full medical stability are the “non-negotiable”, absolute prerequisites to restoring normal brain functioning--even before psychotherapies can be effective. We believe the family is key to effective treatment; we work closely with your family to learn to identify eating disorder symptoms, to deal with them effectively and to keep the disorder in remission. The ultimate goal is to guide your child back on the path to normal childhood or adolescent development.
At Kartini Clinic, our understanding of eating disorders differs in many ways from that of traditional treatment facilities -- and this understanding translates into a radically different approach to treatment. Unlike at many traditional treatment programs, Kartini Clinic providers are not invested in a time-consuming quest for “underlying issues” such as “family dysfunction” or “unconscious conflict” or “flights from maturity” to “blame” for your child’s eating disorder. We remain agnostic as to causes and will do so until the neurobiology is better defined. Nor do we ever wait for your child to “choose” to get better. We simply do not believe that an eating disorder (i.e. brain disorder) is a choice your child can make, or unmake. We focus, instead, on restoring your child’s body and mind to health in the quickest and most cost-effective way.
Another fundamental difference is how we view the family’s role. Traditional treatment providers tend to distance the family from the patient, and some, in their search for “underlying issues” go so far as to blame parents for their child’s illness. This is both cruel and counterproductive (not to mention false). At Kartini Clinic, we are certain that you could not have caused your child’s eating disorder. More to the point, we know successful treatment is unlikely to happen without you (parents). We believe that a successful outcome, long-term, is dependent on the sustained support and active participation of parents and siblings. That is why we cannot agree to treat your child without you. For adult patients (i.e. over 18), not living at home, some exceptions may be made with approval of the medical director.
Kartini Clinic’s eating disorder treatment plan has three components: in-patient hospitalization (if required), a day treatment program, and outpatient followup. Hospitalization, if required, could take as little as a day or two, and as long as several weeks, depending on how quickly your child can be stabilized medically. The Day Treatment program for school-age patients is eight weeks, while college-age treatment follows a 10-week treatment plan. Actual treatment times may vary depending on your child’s progress. Outpatient follow-up is generally recommended for at least six months following graduation from day treatment to provide a smooth transition between the clinic, home environment and school. Obviously, for families travelling for treatment, such an extended period of time in outpatient may not be possible. In such cases every effort is made to return the patient to their previous outpatient provider(s), if any, or to find adequate treatment alternatives in their area (unfortunately, however, this is not always possible).
Kartini Clinic is first and foremost a pediatric clinic run by doctors who want nothing more than to serve your child’s return to health and normal life. Our program is structured, but flexible enough to meet the needs of different diagnoses, ages and families. Our professional staff is firm, yet compassionate. We are respectful of each individual, empathetic to their pain and distress, flexible and adaptable when possible, yet always clear about the non-negotiable return to full weight restoration and function. And we are experts in treating children and their families. After all, its all we do.
Kartini Clinic has practiced a family-centered approach to treating eating disorders since its founding in 1998. In order to avoid confusion around the term “FBT”, we prefer to call what we do the Kartini Method of Family-based Treatment. The basics of our approach include parents being in charge of all meals and food preparation/supervision at home, family meals, and participation by parents in all medical appointments, family therapy sessions and parent group.
We use the American Academy of Pediatrics (AAP) guidelines that lay out criteria for hospitalization in eating disorder patients. For our core Day Treatment program we use our own protocols, developed and refined over the past decade. These guidelines are fully described in Dr O’Toole’s recently published clinical guide for physicians and parents, Give Food a Chance: A New View on Childhood Eating Disorders.
In the medical world, “evidence-based” means that the efficacy of a certain treatment has been proven useful in controlled research trials. The use of evidence-based interventions does mean that we do not also use our own clinical experience and judgment. Examples of evidence-based interventions which we use, where appropriate, would be prompt weight restoration, family-centered treatment, cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT).
Intake & Assessment
We invite you to call our intake coordinators at 503 249 8851 or email them at email@example.com. You may also send us an information request and we’ll respond promptly. Once you have had a chance to tell us about your child’s situation, we’ll schedule a medical assessment appointment with Dr. O’Toole or Dr. Moshtael, usually within a few days. In the meantime you will be asked to fill out a few forms and complete an in-depth medical and family history questionnaire.
The assessment appointment will take about two hours. Your child will be examined and interviewed by our doctor. She will also meet with you separately to review your family history and listen to your observations about your child. An evaluation will be made of your child’s medical condition as well as the nature and severity of his/her eating disorder and shared with you on the spot. Therapeutic options will be discussed first with the parents privately and then opened for discussion with your child present. One of our insurance experts will also meet with you to explain your insurance options.
Our doctor will do a complete examination including weight, height, blood pressure and temperature as well as a neurological examination, review any labs or notes from previous providers, administer the REDS-C (Rating of Eating Disorder Severity in Children) and have a discussion with your child that covers medical as well as psychological parameters.
Most children brought to us for evaluation will benefit from a combination of inpatient medical stabilization and day treatment. An occasional child or young adult, however, may be deemed stable enough to be followed in our outpatient clinic only. The appropriate level of treatment for your individual child will always be discussed with you first.
We will recommend immediate hospitalization if your child is medically unstable. We follow the guidelines established by the American Academy of Pediatrics (AAP) with some modification based on experience. For anorexia nervosa, the admission criteria are:
less than 75% Minimum Weight for Health (MWH)*, or ongoing weight loss despite intensive management
- Refusal to eat at all
- Heart rate < 50 per minute daytime; < 45 bpm nighttime
- Systolic pressure < 90
- Orthostatic changes in pulse (differential rise of > 35 bpm) or systolic blood pressure (differential drop of> 10 mm Hg)
- Syncope (fainting)
- Serum potassium concentration <3.2 mmol/L
- Serum chloride concentration <88 mmol/L
- Esophageal tears
- Cardiac arrhythmias including prolonged QTc
- Suicide Risk
- Intractable vomiting
- Failure to respond to outpatient treatment
We hospitalize all of our patients across the street from the Kartini Clinic, at Legacy Emanuel Children's Hospital, Oregon's premier hospital for pediatric medical care. We place our patients on the School-aged/Adolescent medical floor, not a psychiatric floor. We treat anorexia nervosa as a medical condition and believe strongly that psychiatric wards are not appropriate for children with such an illness.
While we rely on the excellent, hardworking nurses of Legacy Emanuel Children's Hospital (whom we have trained) to carry out our very specific treatment protocols, our patients never leave the supervision and care of Kartini Clinic physicians. Care of our patients is not assumed by staff “hospitalists”, though they remain on call to assist in the event of emergencies. Kartini Clinic physicians conduct hospital rounds on our patients 365 days a year. We also have full control over the food prepared for our patients in the hospital’s kitchen.
The hospital setting is peaceful and safe. We insist on measures to prevent purgeing (vomiting) or exercise. All of our patients have their own room and bathroom (which is locked), most of them are on telemetry (continuous wireless cardiac monitoring), all meals are supervised by a nurse. Once patients are on Phase III, they eat with the other eating-disorder patients in the common room, but always under supervision of a nurse.
Depending on your child’s medical stability at admission, he or she will be placed in one of several activity phases (the lowest phase being 24-hour “medical bed rest”). As your child begins re-feeding and gradually becomes more stable, he/she will move into higher activity phases, until stable enough to be released from the hospital and begin treatment in Kartini’s DTU. Typically, hospitalization might last one to three weeks, but this period is entirely dependent on the state of your child’s health. Sometimes only a day or two is required; in severely complicated cases, considerably more time than that.
A severely malnourished child needs to be re-fed with the greatest of care. We begin re-feeding immediately but slowly and we monitor blood values very carefully to prevent a rare but potentially fatal complication called re-feeding syndrome. The full-blown re-feeding syndrome can involve imbalances in a number of things (potassium, glucose, magnesium, liver enzymes, vitamins and fluids, etc.), but it is hypophosphatemia, or the sudden drop in levels of phosphorus, that can be extremely dangerous. We regularly check phosphorus levels throughout the initial phase of re-feeding.
Kartini parents are always a part of treatment. Although not initially present for the hospital meals, you will spend many hours at your child’s side, supporting him or her during this initial, distressing period of re-feeding. You will be able to meet with our doctors every morning on rounds. Each family will have at least one family session a week with a Kartini Clinic family therapist and Monday nights are “Parent Group”. Parent group is designed to let you share some of your distress and to give you more education about eating disorders and the many aspects of our treatment program.
Generally, no one visits during the hospital stay except parents and siblings. But grandparents and other family members can attend parent group if they are adults and you wish them to.
Day Treatment Unit - Medical Management
The Kartini Day Treatment Unit (KDTU) is the core intensive intervention once medical stabilization has been achieved. Patients are admitted either into the school-aged program or the young adult, college-aged program, according to age and team determination. The school-age group treats children and adolescents 6-17 years and the college-age group handles young adults, 18-22. Within these age groups we sometimes subdivide patients further into different milieus according to age and/or diagnosis. The groups are small -- usually only six to eight patients -- allowing our highly trained and experienced therapists to give abundant attention to the needs of each patient. The KDTU program runs eight weeks for school-age children and 10 weeks for college-age youth, although each child’s actual period of treatment may vary somewhat according their needs and progress. New patients can join the group at any time.
The programs are similar in that the initial goals of each are full weight restoration and extinction of eating disordered behaviors such as restricting, bingeing, purging, table rituals, etc. The focus of treatment for the young adults is independent living, while younger patients will have more age appropriate goals.
The school-age group meets five days a week: Monday and Wednesday are longer treatment days, from 8am to 6pm, and include all meals. On Tuesday, Thursday and Friday, the treatment day ends at 3:30 pm, following afternoon snack. Parents are responsible for preparing dinner at home (or in the Ronald McDonald House) on those three days, plus all meals on weekends.
Vitals are checked by the medical assistant during the week and reported to the doctor if necessary. Patients are weighed and a urine sample obtained. In addition, a medical management consultation is conducted each week, with parents and patient, to review progress, meals eaten and discuss medication.
In patients who are struggling with food or weight related anxiety we often prescribe a neuroleptic such as Zyprexa (olanzapine). The pros and cons of any and all medication will be discussed with you prior to administration. The goal of such medication is to “turn down the volume” of eating disordered thoughts and cognitions in order to help get the refeeding process established. Typically, we prescribe very low doses and over a relatively brief period of time -- usually less than six months.
A medical management consultation with our pediatrician is scheduled each week. We will discuss your child’s physical health, changes in medications and overall progress through the program with you.
We keep an eye on a long list of medical conditions that can arise from an eating disorder and malnutirtion, particularly those affectng the heart. We will order an EKG or other cardiac studies if required and may request blood tests to monitor any concerns the physicians might have during treatment.
At Kartini Clinic we do not practice any form of primary medical care, all general medical (non-eating disorder related) issues will be referred back to your child’s pediatrician. Specialist care (such as for diabetic children) can be continued with their outside provider through prior arrangement.
A medical management consultation with our pediatrician is scheduled each week. We will discuss your child’s physical health, changes in medications and overall progress through the program with you.
Doctors and therapists work closely day-to-day at Kartini Clinic, consulting each other constantly. In addition, every Tuesday we hold a general staff meeting in which we discuss the progress of each child under our care. We take a team approach, seeking input from all the therapists, doctors, therapist assistants and office personnel who work with your child throughout the week.
How long (and if) a child is in the hospital depends entirely on how sick they are when admitted. The KDTU program is a minimum of eight weeks (School-aged DTU) or ten weeks (college-aged DTU), although an occasional patient will need more time and a rare patient less time. It is individualized to their progress.
Day Treatment Unit - Therapies
The KDTU, the core of Kartini Clinic’s treatment program, employs a wide range of psychotherapeutic approaches within a group setting. After their medical check of vitals, patients join their group, or milieu. The group, of up to eight patients, is facilitated by one of several milieu therapists who will work throughout the day, using a variety of tools, to engage patients in themes revolving around eating disorders: body image, self-esteem, anger, food fears, emotional distress, etc. This work is complemented by specific interventions by experienced therapists in the fields of art therapy, assertive communication training, relaxation, yoga/movement, and hypnotherapy. Techniques of CBT, DBT and motivational interviewing are all utilized by our therapists.
CBT is used to modify beliefs, values, and cognitive processes that maintain counter-productive behaviors. We employ various CBT tools throughout the treatment day. For example, we might propose an exercise in which a patient draw a life-size outline of their body as they see themselves, and then, on the same paper, trace a second outline of their body as it really is. The difference in the two profiles is often striking and gives the therapist ample material to help the patient realize that they have distorted beliefs about their body.
DBT is a therapeutic approach that aims to change maladaptive behaviors through acquisition of certain skills. It has been shown to be effective in treatment of bulimia, binge-eating disorder and anorexia. The skills modules include core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills and distress tolerance. At Kartini Clinic, a DBT approach might be used in group or individual therapy to help a patient develop the resources to “ride out” an emotional wave without turning to disordered eating, or self-harm behaviors.
Academics are very important for our patients, many of whom are great students. A few hours each morning in the DTU are dedicated to study, with the assistance of our experienced resident teacher, Pam Williams-Gifford. Pam will coordinate with your child’s school to ensure that structured academic work continues while your child is undergoing treatment in the KDTU.
Kartini Clinic has found hypnotherapy to be an effective healing tool for many of our eating disorder patients. Our experienced hypnotherapist, Bart Walsh, uses various modes of hypnosis to help patients communicate with their unconscious mind. The unconscious mind has access to very deep levels of functioning, from the molecular to the psychological. Many powerful healing, corrective and strengthening resources lie at these deep levels. The aim of this therapy is to guide the patient, via the unconscious mind, to "switch off" his/her eating disorder. Our young patients learn to access these resources on their own so they can keep their eating disorder under control long after they are treated at Kartini Clinic.
We view eating disorders as chronic conditions. We can push symptoms into remission, permitting our patient to regain a normal life, but we believe that the patient retains a lifelong vulnerability for those symptoms to come back. As such, relapse prevention planning is a vital part of Kartini Clinic’s treatment protocol. Our therapists work with your child to identify and evaluate his or her own “triggers” -- events, situations, environments, etc. that are prone to trigger one’s own disordered eating thoughts and behaviors. From that, a plan is drawn up to effectively deal with such eventualities -- quickly -- rather than permit the disordered thoughts and behaviors to spiral into relapse. Family therapists and doctors will help parents understand what to watch for in order to catch a relapse before it becomes disabling.
In essence we think about discharge from the day of admission by preparing parents to gain and maintain control over their family’s food. Concrete discharge planning will depend on whether the family decides to be followed by us or not. If non-Kartini providers will be used to follow your child, please let us know who they are within a few weeks of admission to the KDTU so a realistic plan can be made.
At Kartini Clinic, parents are expected to take an active, involved, ultimately commanding role to manage their child’s treatment. During the time your child is at the clinic, our job is to empower you to be in charge. We will train you to take a lead role in helping your child eat in an ordered fashion, restore and then maintain weight and prevent any reappearing symptoms from turning into relapse.
Distress about gaining weight is normal. Kartini Clinic therapists are very experienced in managing such distress and will help you support your child through this period as well. But it is worth remembering that prompt and adequate weight restoration is essential for a lasting recovery.
Kartini Clinic’s Parents Group is designed to help families better understand the complexities of eating disorders and guide and support them through the treatment process. The group meets every Monday at 5 PM (just before pick up in the KDTU) for an hour. Parents, along with other carers in the family (grandparents, in-laws, etc) can attend these meetings. A Kartini Clinic therapist serves as facilitator for the group. Parents share their stories, recount their successes and difficulties over the previous week, vent their frustrations and fears, and learn from others in the group who have had similar experiences.
During treatment at Kartini you will have numerous consultations and contacts with Kartini’s professional staff. Each week you will have a medical management consultation with one of our pediatricians and a family therapy consultation, both of which provide opportunity for discussing progress of your child.
At Kartini Clinic, you are assigned a family therapist from the very first medical assessment appointment. Unlike in traditional treatment centers which often employ family therapists to “fix” your family, we start with the assumption that your family is just fine, though undoubtedly under severe distress because of your child’s eating disorder. Your family therapist will help your family members to better manage that distress so you can be as effective as possible to help your child. In particular, the family therapist will focus on helping you apply the Kartini meal plan and other elements of family based treatment to your family’s particular circumstances and dynamics. Should you identify severe family/parental issues during this time, an outside referral for couples counseling may be needed.
We are very sensitive to the havoc an eating disorder can wreak on siblings. Their family life has been disrupted, if not destabilized. Their relationship with the suffering brother or sister has been transformed or even cut off by the illness. Strong feelings of guilt, resentment and anger are common. Their homelife has been invaded by a disease they usually don’t understand. To try to help with these issues, our family therapist may include siblings during some sessions. Additionly, we have developed a Siblings Group, which meets monthly at the clinic. It is designed to help your other children better understand the illness, vent their often pent-up emotions, and learn ways they can support their sister or brother through the difficult healing process.
Weight Restoration, Modeled Eating & the Kartini Meal Plan
Clinical evidence shows that prompt, adequate weight restoration and control of brain nutrition is the only treatment intervention that will get a child into remission and keep them from a lifetime of suffering and disability. At Kartini, we begin restoring your child’s weight from the first day of treatment.
Establishing an appropriate body weight for your child is a balancing act that takes into account a lot of variables, some of which will come into play, or not, depending on the particular stage of your child’s development -- which is itself a moving target. We will assess Tanner Stage (pubertal stage), growth charts, pre-morbid weight (i.e. the weight of your child before the illness) and parental size and shape for each individual child. We do NOT base the goal weight on BMI charts. For a more detailed analysis of establishing weight goals please go to http://www.kartiniclinic.com/blog/determining-ideal-body-weight/
Once the initial re-feeding has been established, your child will be put on the Kartini meal plan, whether at the clinic or at home. Where needed to maintain weight gain, additional food may be added to meals, called “add-ons”. A daily activity level will be set as well. Your child will be weighed every treatment day. He or she is also required to submit a food journal (this may be done online too), completed by the parent, that details what your child ate during all meals away from the clinic. The food journal also details your child’s exercise or activity on non-clinic days. For more details about this important process you may choose to read Dr O’Toole’s guidebook for parents: Give Food A Chance
No. We generally put patients suffering from binge/purge symptoms on the same meal plan as restricting patients. Even if they have built up extra weight from binge/purge behaviors, we find that the body, over time, will find its natural level with the balanced nutrition provided in the meal plan.
Indeed, we weigh our patients in a way that prevents them from seeing the result. One’s weight is a number. It is neither good, nor bad. Yet for a person suffering from an eating disorder, that number carries terrible significance and produces enormous anxiety. We do not discuss weight with our patients during treatment.
Our therapists “model” ordered eating by eating with your child on clinic treatment days. While leading cheerful dinnertable conversations, the therapist will firmly correct any disordered eating behaviors, including various eating “rituals” your child may have developed -- slow eating, cutting food into bits, etc.
Early in the treatment program, you will be scheduled to dine with your child’s group at the DTU. You will be shown how to correctly measure portions -- vital for adherence to the meal plan --and then participate in the meal along with our patients. This is an important modeling exercise. You will see how the therapist corrects disordered eating behaviors -- a role you will take over when feeding your child outside the clinic. We require that parents continue to eat with their children as part of ongoing treatment.
If additional nutrition is required we use Benecalorie (mixed in with whole-milk yogurt), Boost Plus or Ensure. Boost Plus may also used in a compensatory manner, given to patients who cannot finish their meal in the required time (30 minutes for lunch, 40 minutes for dinner). Additionally, all patients take a multivitamin with D and most take extra zinc and calcium.
All patients at the Kartini Clinic follow a meal plan that is essential to our treatment approach. It is a balanced nutritional plan spread over three meals and a snack, and based on a Mediterranean regime of fresh vegetables and ingredients, olive oil, rice, pasta, meat and fish. However it can be adapted to a variety of ethnic and culturally diverse styles of cooking. The regime calls for lots of fruit, vegetables and whole milk dairy products. It excludes all low-fat foods as well as diet drinks and low-cal foods. Ingredients and portions are to be measured exactly, and 100% of the meal is to be eaten.
The meal plan is the blueprint for what we call ordered eating. Ordered eating is the cornerstone of both physical and psychological recovery from anorexia nervosa because it is as much about anxiety reduction as it is about adequate nutrition. It provides both a floor and a ceiling; the patients know that by following the mealplan they will be consuming no less than what their body requires--and, no more. When that becomes clear, anxiety about eating drops and it becomes easier to eat.
It is true that the Kartini meal plan has no desserts, although there are some sweet items on the menu such as fruit, flavored yogurt and jam. Snack foods -- chips, soft drinks, candy -- as well as cakes, cookies, etc are off the meal plan because they are considered “hyper-palatable”, that is, they have a tendency to stimulate one’s desire to eat them; they challenge you, physiologically, to “eat more than one.” For a person grappling with an eating disorder, such stimulation of the palate risks provoking bingeing behavior. By keeping all hyperpalatable foods off the menu we can effectively prevent a patient from swinging from restricting to binge/purge symptoms -- a significant risk in patients going through weight restoration.
Parents are to keep a food journal which they must submit the following clinic day (this may be done online). The journal details what was prepared and what was eaten, where and at what time. The journal will also indicate the nature and duration of any physical activity. As weight restoration is managed throughout treatment, the information in the food journal is vital to help clinicians follow and assess unexpected increases or decreases. The Food journal is merely a record of what is happening outside the clinic; it is the “check register” in our check book.
We recommend that patients stay on the meal plan up to a year. However, many patients find safety in the meal plan and prefer to integrate it into their lives long term.
Adaptation of the meal plan is not difficult, but you may undoubtedly need some help making it compatible with the needs of your other family members. Translating the meal plan to your particular home environment is one of the central roles of our family therapists. You will be meeting with your family therapist regularly throughout treatment.
At the start of treatment it is likely that exercise will be very limited, if not prohibited. Exercise burns calories, countering our urgent task of restoring weight. As your child becomes medically stable, increasing amounts of moderate exercise -- walking, biking, hiking, swimming -- will be permitted. Exercise that is solitary and repetitive will not be allowed. The goal, however, is to return each child to their own normal, happy level of activity.
Yes, we have had patients who keep kosher and we can accommodate them as long as paper plates and plastic utensils are acceptable to you and as long as you understand that other patients may mix meat and milk at the same table (your child will not be allowed to do so, however). A frank discussion with the doctor about what kosher means to your individual family will be best.
Generally, if your child’s vegetarianism developed during onset of the eating disorder, we will look at it as a part of the eating disorder. If the vegetarianism existed prior to onset, or if your family keeps a vegetarian diet, we will honor it. The meal plan permits a wide variety of protein foodstuffs: eggs, soybeans, lentils, nuts, fish, seafood.
For families in the Portland area, patients are “stepped down” to an outpatient program to bridge the transition from KDTU to their home environment. Coordinated outpatient care is an essential part of maintaining physical and psychological remission of eating disorder symptoms. The outpatient program generally lasts for about six months and will include several visits per week -- medical consultation, group, individual and/or family therapy -- depending on your child’s specific needs for outpatient support.
Outpatient services include medical appointments, as well as family, individual, and group therapies. We will strive to work with your primary care physician and/or other treatment providers to ensure adequate long-term care for your child’s illness.
The doctor will closely monitor your child’s weight goals. Weights may be shared with parents, if they like, but are never shared with patients nor talked about during doctor’s visits.
Any medication prescribed by us will be managed by us.
Because of state licensing laws, distance follow-up by phone or skype is only possible within the states of Oregon and Washington, or places outside the United States.
Contact Kartini Clinic providers immediately if you detect a reappearance of eating disorder symptoms. The sooner symptoms can be addressed the better the chances for preventing them from strengthening and spiraling into full relapse.
Alternatives to Kartini Clinic
Yes we can. However, recommendations are a challenge we take quite seriously. By recommending another facility or provider, we are saying to you we feel the care they provide is of a quality we would insist upon for our own children. To do this effectively, we'll need to speak with you on the phone and get some idea of the symptoms your child is experiencing, something of their history and some idea of the resources available to cover their care. Even then, we cannot guarantee we'll be able to suggest another facility. But we are willing to try. Please call our intake coordinators at 503 249 8851 for more information.
There are one or two nutritionists to whom we make referrals, when appropriate. This is another instance when its important to speak with one of our intake coordinators first, to make sure such a referral is the right step to take.
While your child is in treatment at the Kartini Clinic, we ask that patients take a holiday from their other eating disorder treatment providers, to eliminate the possibility of inconsistent or conflicting therapeutic interventions or advice. When time comes for discharge planning, the question of which community providers to use will be revisited, and at that time it may be decided that returning to your present therapist is the best option.
It is crucial to promptly restore young patients to good health, and it is by far preferable to do it the first time they enter treatment for an eating disorder. For treatment to fail because it is inconvenient, too time consuming or is perceived to be too costly can end up costing far more time, expense and inconvenience than effective treatment the first time would ever have required. With that in mind, rest assured that the staff of Kartini is very sensitive to economic pressures that parents are under, and treat your resources just as we would our own. But beware the lure of false economies when treating children for eating disorders. Successful treatment is the goal to keep in mind. When your child is returned to good health, you will count your resources as well invested.
Many patients suffering from an eating disorder may deny that they have a problem and will refuse even to visit a doctor. It is part of the nature of an eating disorder that it may actually make the sufferer feel good, pure and happy about not eating, no matter how much discomfort it is bringing to their body. They genuinely can’t see what everyone is fussing about. You may need to be strong and determined to get your child into treatment. However, once admitted to our program, the vast majority of children are relieved to be with us because they now feel safe and may have been unable to admit to their own worry about their (uncontrollable) behaviors.
This is a challenge for many of our families. Often, one parent will stay in Portland while the other will take over primary care for the other kids at home, jobs permitting. Others invite relatives or neighbors to help out at home. Or they split the job, which is actually beneficial in that both parents can be trained by us directly: one parent is trained during the first half of the treatment period, the other parent in the second half. For parents who need to take time off during treatment and who want to apply to their employer under the Family Medical Leave Act (FMLA) absence, our front office staff can assist you with the necessary paperwork.
Your child is not in charge of his or her treatment. You are. You are not choosing a summer camp, but a treatment program that can save your child’s life. Having said that, while we follow a treatment protocol that includes a meal plan , we routinely modify it according to the individual needs of each patient. Eating disordered patients each have different medical histories, likes and dislikes, different psychological profiles, different bodies, different ages, different family situations. We make the adjustments necessary to maximize the effectiveness of treatment for each child.
This is a common concern, but it is misplaced. Eating disorder behaviors are not learned from others, but are manifestations of the illness itself. In any case, the internet is filled with descriptions and accounts of such behaviors. At Kartini Clinic, we work to eliminate ALL eating disorder symptoms, however or wherever they appear.
Again, suicidal thoughts, or “ideation,” is not uncommon in eating disorders. Such is the internal suffering these individuals encounter. So yes, we can accept a patient having such thoughts and work to suppress these thoughts. However, if it becomes apparent that the patient poses an actual danger to himself or herself, i.e. is in fact suicidal, we would act immediately to place him or her in safe psychiatric hospitalization, and return them to the KDTU when the danger has passed.
Self-harm behaviors are not uncommon in adolescents They may predate onset of the eating disorder, or appear after onset, as a symptom. Either way, some children may engage in self-harm as a way to cope with emotional waves that wash over them. Dialectical Behavior Therapy (DBT) techniques may be used to teach the patient various skills to help them regulate their own emotions.
Parents of children over 18 may need to consider court procedures to establish legal guardianship. When a young adult’s parents take over medical decision-making responsibilities from them, it can be a life-saving intervention. Guardianship is painful for the parents, who, out of love and concern, must act decisively in the best interests of their child. They are making a very difficult decision and yet at the same time also make a powerful statement of determination to help their child, no matter what. Our intake coordinators can help guide you through the process of establishing guardianship. Please call 503 249 8851 and ask to speak to one of our coordinators.
No. Effective eating disorder cannot be conducted under such circumstances, and would need to wait until the patient were no longer suicidal.
If hospitalization is required, only parents and siblings are permitted in the hospital. During treatment in the KDTU, there are no limits on visitation or contact. Your child will be with you on evenings and weekends, and may be in contact with any family and friends he or she desires to see. However, many children suffering from eating disorders are depressed and withdrawn, so their desires to see others outside your immediate family will likely be limited until their symptoms begin to subside.
We require loose-fitting clothes, such as gym pants and sweatshirts, that cover the body. The reason is simple: individuals with eating disorders tend to be very sensitive about shape and size, in themselves as well as in others. Modest, loose-fitting dress is only sensible.
How to decide
There is no “safe” level for an eating disorder. They often begin gradually, imperceptibly, over a period of months, then gain speed and intensity without warning. The earlier treatment begins, the better. Your child will suffer less and the prognosis will improve if they are brought into remission as soon as possible. Bear in mind that we also have outpatient treatment programs, for those patients who are appropriate for this level of care. What we cannot do is treat someone who, in our professional opinion, requires day treatment at the outpatient level. That would be unethical and, more to the point, ineffective.
Would you wait until summer vacation to treat cancer, heart disease or diabetes? An eating disorder, once set into motion, can quickly spiral out of control. The resulting malnutrition can ravage your child’s body and brain. And it can kill. Treatment is required urgently. Please don’t allow other things - as important as they might seem at the time - to intrude upon medically necessary treatment. Nothing is as important as your child’s immediate health needs: not school (even college), sports, camp, cherished family vacations, etc.
We take school very seriously because it is often very important to our patients and families. The KDTU dedicated 2 hours every day to school work, under the guidance of our staff teacher who will coordinate efforts with your school. Of course, as with any medical treatment, there is a possibility your child will need to make up some work when he or she returns to class following treatment, although our experience has been that our patients are able to do very well and graduate on time. See Managing School Issues During Treatment.
But also take a moment to consider the other possibility: what might happen to your child’s scholastic future if he or she does NOT receive effective treatment? As the illness gains force, malnutrition will weaken your child and depression may set in; further, obsession with calories and weight risk taking over your child’s every waking hour; there may be no capacity left for concentration on normal things like school and your child’s scholastic future -- or any future -- becomes greatly compromised.
This can be a difficult situation for any parent, and it is not uncommon. Be that as it may, urgent medical conditions require urgent action. Our intake coordinators are more than happy to speak to your spouse (or ex-spouse, if they have joint custody) directly and take the time to explain to them the risks of inaction. Please call 503 249 8851 or give us a number to call them.
No. Unlike some residential programs, the Kartini Day Treatment model places the family at the center of the healing process. It simply will not work without you.
Kartini Clinic welcomes families of all faiths, including those without faiths. We base our treatment on evidence-based science and practices that have shown themselves to be effective for our more than 1800 patients of all faiths over the past decade.
Kartini Clinic has and will continue to make every effort to contract with insurance carriers who support evidence-based eating disorder treatment. But even if we are not contracted with your insurer on a permanent basis we can work with you to secure a Single Case Agreement (SCA). SCAs can often provide the same level of coverage as your regular policy.
Currently we are contracted with Regence BCBS or Oregon (and all out of state BCBS plans) and ODS. If you aren’t sure whether your insurer is contracted, call 503 249 8851 and ask for our intake coordinator.
We will contact your insurance company and request a summary of your eating disorder treatment benefits. We will provide you with a written summary of the information given to us by your insurer and provide you with an estimate of your out- of-pocket treatment costs.
We always recommend you verify any information given to you; insurance companies have been known to give inaccurate information to providers. As you ultimately will be responsible for any outstanding balances, it is essential you satisfy yourself that all benefit information is accurate and up-to-date.
This is a common problem. All insurance companies have financial relationships with certain providers (aka "preferred providers"). Unfortunately these financial relationships have little to do with the quality of care and everything to do with the cost of treatment. It will depend on you and your doctor to determine what is the right care for your child.
When choosing an appropriate eating disorder treatment program it is essential to remember that not all such programs are appropriate for children, regardless of what insurance carriers say. You should always insist on a program with specific expertise in treating children. You should also insist your child attend a facility that treats eating disorders exclusively, not simply as another diagnosis among many (e.g. so-called "dual diagnosis" clinics). Otherwise your child may be treated alongside those with addictions and severe behavioral issues. This is not an appropriate environment for a child or young adult with a serious medical condition.
Our business office can assist you and your primary care doctor to ensure that insurance carriers do not make inappropriate treatment recommendations for your child. Call us at 503 249 8851 and ask for our intake coordinator, who can help you to get the process started.
We will provide you with a written estimate based on the best available information about your insurance policy. Please bear in mind, virtually every insurance plan these days will require you to pay a substantial deductible and co-insurance, regardless of where you seek treatment.
We make every effort to work with families to meet the cost of treatment. In most instances we will ask for a partial deposit prior to the start of treatment, but our business office will do everything possible to find suitable financial arrangements. Please call our intake coordinator at 503 249 8851 if you have questions about payment.
Applications for financial assistance can also be made through the Kartini Foundation. You may find more information and obtain an application form here.
Money & Insurance issues
Your cost of treatment at Kartini Clinic will vary significantly depending on your insurance carrier and the specifics of your insurance plan. If you do not have insurance coverage and are contemplating paying for treatment yourself, our standard charges for self-pay clients are indicated below:
- Kartini Day Treatment Unit, $750 per day; a typical 8-week treatment period would be billed at $30,000.
- Outpatient Program, between $450 and $750 per week initially, then tapering off as fewer appointments are needed. Over the course of six months, outpatient service charges would fall in the range of $2800 to $4900.
These fees do not include particular medical tests, such as blood analysis, or psychiatric evaluations which may be required during treatment. Again, these are billed rates only; actual costs to you will vary based on insurance benefits.
Legacy Emanuel Hospital's fees for self-payers are in the range of $3,000 per day. For more information about costs associated with a hospital stay at Legacy Emanuel, or to determine if your insurance is accepted by Legacy, please contact their business office, at 503 413 2584. Please note that Kartini Clinic patients are admitted to Legacy Emanuel as medical -- not mental health -- admissions, and will therefore fall under your insurance policy's medical benefits.
Yes. All prospective families are given a benefits summary and a written estimate of treatment costs. Our intake and business office staff are at your disposal before, during and after you initial appointment to answer any questions you may have.
If your insurance does not have Kartini Clinic within its network of providers, your estimated out-of-pocket expenses will be requested at the start of each KDTU treatment week, or, if in outpatient, at each appointment. Please contact our business office if you require other payment arrangements.
We will contact your insurance company and request a summary of your eating disorder treatment benefits. We will provide you with a written summary of this information given to us by your insurer and provide you with an estimate of your out-of-pocket treatment costs. You should verify this information with your company as you ultimately will be responsible for any outstanding balances.
We accept most forms of insurance, and others may agree to “single case agreements”, based on their determination. We do our utmost to work with all insurance companies and employer sponsored plans. We are part of the Blue Cross/Blue Shield national network, as well as ODS, Pacific Source, Cigna Behavioral Health, Samaritan Health, and MHN/Healthnet, and MHN/Caremark PPO. Please contact our business office for changes to this list.
Even if Kartini Clinic is not contracted with your insurer on a permanent basis we can work with you to secure a Single Case Agreement (SCA). SCAs can often provide the same level of coverage as your regular policy.
This is a common problem. All insurance companies have financial relationships with certain providers (aka "preferred providers") that have little to do with the quality of care they provide. It is for you and your doctor to determine what is the right care for your child. When choosing an appropriate eating disorder treatment program it is essential to remember that not all such programs are appropriate for children, regardless of what insurance carriers say. You should always insist on a program with specific expertise in treating children. You should also insist your child attend a facility that treats eating disorders exclusively, not simply as another diagnosis among many (e.g. so-called "dual diagnosis" clinics). Otherwise your child may be treated alongside those with addictions and severe behavioral issues. This is not an appropriate environment for a child or young adult with a serious medical condition. We can assist you and/or your primary care doctor to ensure that insurance carriers do not make inappropriate treatment recommendations for your child. Call us at 503 249 8851 and ask for our intake coordinator, who can help you to get the process started.
The Patient Protection and Affordable Care Act (PPACA, aka ObamaCare), passed in 2010, represents a long overdue reform to mental health insurance benefits and has already secured vital insurance coverage for many of our families previously threatened with financial bankruptcy due to costs of treatment (and these were families who had insurance). Many of its provisions are to be phased in over the next several years. One immediate benefit of the reform, effective September 2010, was a requirement that insurance companies provide coverage to children with pre-existing illnesses. So even if your child has been suffering from an eating disorder for some time, they cannot be refused coverage. Oregon’s legislature has also eliminated enrollment periods, meaning you can sign up your child at any point in the calendar year.
Another helpful PPACA reform: adult children are now allowed to remain on their parents' health plan(s) to age 26 (previously 22). This removes the need to switch to sub-standard benefits (at least for eating disorder treatment) available through most student health or individual insurance plans.
Read this for more info on PPACA reforms.
The name of the game is persistence. Insurance companies are far more responsive if they know you are going to advocate relentlessly for your rights and those of your child. If you get your insurance through your employer, talk to your employer's benefits manager or HR person. Insurance carriers are often more responsive to employers (who pay the premiums). Most importantly, don't give up! We have seen many, many families successfully challenge insurance carriers to get the vitally needed eating disorder treatment their child needed.
Questions About Eating Disorders
Unfortunately, many pediatricians and family doctors are not trained to recognize the tell-tale signs of eating disorders, or else the training they received in medical school is now far out of date. We have produced a video, Spotting the Tiger, specifically to help family doctors understand and diagnose eating disorders.
Nothing, other than pass along your genes. Parents cannot cause eating disorders. Period.
It often looks that way, but an eating disorder is not something your child has chosen to have, nor could have chosen to have. It’s a medical illness, pure and simple.
A divorce, a pet’s death, a bully at school, or any number of distressing or traumatic events in a child’s life are commonly reported as contributing factors to the eating disorder. However it is important to not confuse this with proven “cause.” The cause of anorexia nervosa is entirely unknown. It is likely a genetic predisposition which is acted on by unknown environmental agents. Please remember that parents don’t cause eating disorders and children don’t choose to have them.
It is very common for eating disordered patients to be attracted to the world of cooking. But we believe it is dangerous to place a person with this illness or fragility in a food-related environment, as it could prove triggering. During childhood and adolescence, your child’s only job should be to eat what you prepare. No shopping, no cooking, no kitchen cleanup.
Give Food a Chance: A New View on Childhood Eating Disorders by Dr. Julie O’Toole, MD, MPH, Founder and Medical Director, Kartini Clinic for Disordered Eating.
Eating Disorders in Childhood and Adolescence, edited by Brian Lask & Rachel Bryant-Waugh
Online Eating Disorder resources:
FEAST -- Families Empowered and Supporting Treatment of Eating Disorders --an international non-profit association supporting parents and evidence based treatment for eating disorders.
Around the Dinner Table -- an online forum, run by FEAST, to help parents, particularly those working with family-based treatment models to re-feed their family member at home.
Academy for Eating Disorders (AED)
International Association of Eating Disorder Professionals (IAEDP)
Alliance for Eating Disorders Awareness
ANAD: National Association of Anorexia Nervosa and Associated Disorders
Binge Eating Disorder Association (BEDA)
The National Association for Males With Eating Disorders (NAMED)
National Eating Disorders Association (NEDA)
We suggest that you discuss this issue fully with your child and let him or her decide. Unless you have your child’s specific permission to do otherwise, please inform school officials on a need-to-know basis only about your child’s diagnosis.