It still happens all the time.  I go to see a family in the hospital (and they can be from anywhere) and as I take their history, the parents begin their recitation of what brought their son or daughter to this juncture in the first place.

It often starts subtly: increased alone time as a result of less interest in social activities, more time spent on homework and “fitness” or sport.  Eating “healthy”.  Who can argue with eating healthy and homework?  Then the vegetarianism.  Again, who can really argue with that?

Next you go clothes shopping for school and discover you have to buy a size or two smaller than last year.  You voice your concern.  They laugh it off, “Mom, please… don’t be crazy… I’m just fine.”  Then one day you accidentally walk into the shower room and you can’t believe your eyes: the flesh has melted away.  Your formerly normal sized (small sized? big sized?) child is now a waif and arguing vociferously with you as you try to institute more food.  Maybe they complain about stomach pains.  You take them to the pediatrician or family doctor.  Yup.  The weight is down.  The doctor has a “heart to heart” talk with them about health and the need for good food and tells you to back off.  “I’ll check you again in a month.” A month!?

This is surely my pet peeve:  “I’ll see you in a month.”  Worlds can change in the life of a child in four weeks.  But not to be an “alarmist”, and not to worsen the arguments which have now begun in earnest over food, you bite your tongue and doubt your parenting.

Two weeks later you can’t stand it any more and call the doctor back.  You get the nurse who listens kindly and then schedules your child with the clinic dietician and/or therapist… or maybe recommends the one across town.  You go along too, but they won’t really include you in the conversation. It’s private. The professionals need to connect with the patient, establish rapport, etc. You start eating vicariously, as you see little appreciable effect of these sessions over the next two weeks and you are seriously stressed.

By now it’s time for that doctor’s appointment.  The doctor sees that the weight is now up half a pound (though down 25 pounds over all).  “See,” she says. “We’ve stopped the weight loss.  Let’s give it another few weeks to turn around.”  More meetings with the dietician are scheduled, but the next night you hear the sounds of exercising through the floorboards. You call your own mother. You call your best friend. You go on the Web.  You read three books. They just really freak you out and now you call the doctor’s office every couple of days because you can see yet more visible weight loss. The dietician has her making smoothies out of rice milk, protein powder, fat free yogurt, chia seeds, flax seeds and Splenda, but all to no avail.

Now you get serious about the Web, and that’s where we come in. You schedule an appointment for an eating disorder evaluation even though you dread being told that treatment might be needed that would interfere with school and soccer. Your spouse thought you were crazy at first, but now you are both really worried. And starting to feel guilty.

But you never make it to my appointment because your child has a fainting spell in school and the ambulance takes them to the hospital where they call me.  You are horrified. Why did we wait? Why?

So doctors, nurse practitioners, dieticians, therapists: please!  If your counsel is to be one of waiting, never go more than a week without seeing a child back who is losing weight and whose parents are concerned.  Where there’s smoke, there’s often fire and parents are the best early warning system we have. Set a weight gain goal.  At Kartini Clinic we would use a rate of 2-3 lbs gain per week.  Do not tolerate weight loss or even failure to gain weight.  Sign a written contract: if, after all your advice has been given, the child cannot meet that weight gain goal, send them for evaluation for more intense intervention. What is the point to waiting?  If someone recommends more intensive treatment than you think is warranted, you can always advise the parents to say no.  But be prepared to meet that weight gain goal as an outpatient or the next conversation may well be in the hospital.  There is literally no reason for children to present as medically unstable who have seen a professional for their eating disorder and had a plan in place.  

A written plan among adults can save a child.