School staff experiences of eating disorders - academic journal article
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School staff experiences of eating disorders - academic journal article

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Background: Eating disorders (ED) have a peak rate of onset in school-aged children. Little is known about ...

Background: Eating disorders (ED) have a peak rate of onset in school-aged children. Little is known about
teachers’ experiences of ED.

Method: A total of 826 school staff completed an online questionnaire exploring
their Eating Disorder experiences. Responses were analysed using content analysis principles.

Results: 74 per
cent of respondents’ schools had received no training on ED, 40% did not know how to follow up
pupils’ Eating Disorder concerns and 89% of respondents felt uncomfortable teaching pupils about ED.

Conclusions: School staff feel ill-equipped to support ED. Training in the recognition, support and teaching of
ED would be welcomed and could improve outcomes for young people.

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    School staff experiences of eating disorders - academic journal article School staff experiences of eating disorders - academic journal article Document Transcript

    • We don’t know how to help: an online survey of school staff Pooky Knightsmith, Janet Treasure & Ulrike Schmidt Division of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crepsigny Park, London, SE5 8AF, UK. E-mail: jodi.knightsmith@kcl.ac.uk Background: Eating disorders (ED) have a peak rate of onset in school-aged children. Little is known about teachers’ experiences of ED. Method: A total of 826 school staff completed an online questionnaire exploring their Eating Disorder experiences. Responses were analysed using content analysis principles. Results: 74 per cent of respondents’ schools had received no training on ED, 40% did not know how to follow up pupils’ Eating Disorder concerns and 89% of respondents felt uncomfortable teaching pupils about ED. Conclusions: School staff feel ill-equipped to support ED. Training in the recognition, support and teaching of ED would be welcomed and could improve outcomes for young people. Key Practitioner Message • Eating disorders have a peak onset in school-aged children • School staff can play an important role in recognising and supporting children and adolescents with eating disorders • School staff currently feel unable to adequately support children and adolescents with eating disorders. Training is not widely available and most schools have no policies or procedures in place for managing eating disorders • Reintegration of students who have been absent from school receiving eating disorder treatment poses a par- ticular challenge. Schools would welcome tailored support to ease the transition Keywords: Anorexia; bulimia; binge eating disorder; eating disorders; teacher; school Introduction Mental health issues are highly prevalent amongst ado- lescents with between 10% and 20% suffering from a diagnosable mental disorder (Kataoka, Zhang, & Wells, 2002; Green, McGinnity, Meltzer, Ford, & Goodman, 2005). It is well documented that children with mental health problems do less well in terms of academic and social development with lasting implications for later life (Farrington, Healey, & Knapp, 2004; Colman et al., 2009). Numerous education policy initiatives in the United Kingdom have sought to implement an enhanced role for schools in the mental health and well-being of their pupils, with a particular emphasis on the prevention of mental health difficulties. This includes ‘Every Child Matters’ (Department for Educa- tion and Skills, 2003), ‘National Healthy Schools’ (Department for Education and Employment, 1999) ‘Social and Emotional Aspects of Learning’ (Depart- ment for Children, Schools and Families, 2007) and the ‘Targeted Mental Health in Schools Project’ (Department for Children, Schools and Families, 2008). Of all of the mental disorders arising in adoles- cence, eating disorders (ED) have the highest rate of morbidity and mortality due to complications of the disorder and completed suicide (Rome et al., 2003). The peak onset of Eating Disorders is between the ages of 10 and 19 (Currin, Schmidt, Treasure, & &Jick, 2005) and recent statistics show a dramatic increase in hospital admissions for patients with ED of this age in England (Health and Social Care Information Cen- tre, 2012). When ED are treated early, outcomes can be very posi- tive with a good chance of full recovery (Treasure, Clau- dino, & Zucker, 2010). Therefore, Eating Disorder prevention and early intervention are key to ensuring successful long-term outcomes and school staff are in an excellent position to facilitate this process (McVey, Lieberman, Voorberg, Wardrope, & Blackmore, 2003; Shaw, Stice, & Becker, 2009), provided they have the appropriate knowledge and understanding (Knight- smith, Sharpe, Breen, Treasure, & Schmidt, in press). Unfortunately, training on Eating Disorders is often limited (Neumark-Sztainer, Story, & Coller, 1999; Piran, 2004) and ED and mental health, in general, are often not readily talked about in schools and seeking support can have a significant stigma attached (Bowers, Manion, Papadopoulos, & Gauvreau, 2012). The current study aimed to gain an understanding of UK school staff experiences of ED in school, including access to training to assess whether they are adequately equipped to support children at risk of, or currently suf- fering from, disordered eating. We also aimed to generate © 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health. Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA Child and Adolescent Mental Health Volume **, No. *, 2013, pp. **–** doi:10.1111/camh.12039
    • recommendations from school staff about how they could be best supported in helping young people with ED. Methods Design The study comprised an anonymous online questionnaire aimed at school staff in UK schools. A convenience sample of 1250 school staff were invited to participate. Institutional review board approval and informed consent procedures Ethical approval was obtained from King’s College London Research Ethics Committee (Ref PNM/09/10-110). Once they had logged into the questionnaire, participants were provided with detailed information about the study and were given the opportunity to contact the research team about the project. It was made clear to participants that by completing the survey, they were giving their consent to participate in the study. Survey content The survey explored school staff experiences of ED, including access to training and support. It also asked for recommenda- tions about how they could best be supported in helping young people with ED. The items included in the questionnaire are summarised in Tables 1 and 2. Development and pretesting The online survey was developed following consultation with teachers and pupils. Face validity was judged by a panel of school staff who met as a focus group to discuss the structure and content of items in the survey. The panel provided useful comments for wording and restructuring of items to improve the ease of understanding and completion, but reported no technical difficulties or problems with comprehension. The panel agreed that the survey had adequate content validity in that it contained a representative sample of items relevant to staff experiences of ED in school. 26 teachers completed the survey 10 days apart with kappa coefficients ranging from 0.78 to 0.88 for the closed questions outlined in Table 2. Recruitment process A database of school staff email addresses was obtained from a teacher training provider. All staff on the list had previously expressed interest in mental health training and came from a variety of primary, secondary and special schools from through- out the United Kingdom. Staff were eligible for inclusion if they were currently employed, or on a placement, with a UK mainstream or private school of any type. Survey administration The study consisted of an anonymous self-report online ques- tionnaire, which took between 10 and 30 min to complete. Com- pletion of the questionnaires was voluntary and no incentives were offered for participation. The data were collected between September 2010 and April 2011. The questionnaire was hosted on a survey website, which was not password protected. The questionnaires consisted of a cover page containing the information sheet and 19 question- naire items, each of which appeared on a screen alone. Only questions relating to the participant’s school type and role were compulsory. There was no randomisation of items. There was adaptive questioning such that, based on their previous answers, only relevant questions were presented. Participants were given the opportunity to review and amend their answers prior to submitting their responses. Response rates 1250 school staff were invited to participate and, of these, 826 (66%) chose to complete the questionnaire. Preventing multiple entries from the same individu- als Multiple responses from the same IP address (same computer) were prohibited to prevent multiple entries from the same indi- viduals. Table 1. Summary of Staff Responses to Eating Disorders (ED) Experience Survey – Closed Questions Does your school have an Eating Disorder policy? (774 respondents) No Yes – part of another policy Unsure Yes – specific policy 320 (41%) 208 (27%) 205 (26%) 41 (5%) Are Eating Disorder policies effective? (519 respondents) Effective Ineffective Very effective Very ineffective 317 (61%) 148 (29%) 42 (8%) 12 (2%) Has your school offered ED training? (791 respondents) No Yes 583 (74%) 208 (26%) Who attended the training? (147 respondents) 3 of fewer staff members Whole staff All pastoral staff All middle and senior managers 82 (56%) 43 (29%) 19 (13%) 3 (2%) Training delivery method (161 respondents) Seminar Lecture Written materials 107 (66%) 37 (23%) 17 (11%) If you have not received any training, do you think you would find training useful?(346 respondents) Very useful Quite useful Not very useful Not at all useful 160 (46%) 156 (45%) 30 (9%) 0 (0%) Are you aware of any current or past cases of Eating Disorders in your school? (530 respondents) Yes, directly involved Yes, not involved No 266 (50%) 181 (34%) 83 (16%) if a student is concerned a friend may have an ED Talk to any member of staff Never been discussed Concerns go to specific staff member Use anonymous service (e.g. SMS) 364 (47%) 287 (37%) 112 (14%) 18 (2%) Would you feel comfortable teaching students about Eating Disorders? (785 respondents) Very uncomfortable Uncomfortable Comfortable Very comfortable 419 (54%) 273 (35%) 84 (11%) 9 (1%) Has your school reintegrated students following absence due to ED? (487 respondents) Yes No 329 (68%) 158 (32%) Did staff/students receive any advice on how to support returning students? (317 respondents) Yes No 240 (76%) 77 (24%) All questions were optional. When not all participants recorded a response to a question, percentages were calculated according to the number of respondents to the specific question. © 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health. 2 Pooky Knightsmith, Janet Treasure, & Ulrike Schmidt Child Adolesc Ment Health 2013; *(*): **–**
    • Analysis The questionnaire generated quantitative and qualitative data. The quantitative data were responses to multiple questions. These data were summed and the raw number of responses cal- culated for each item was recorded as well as a percentage. All questions were optional. When not all participants recorded a response to a question, the percentages were calculated accord- ing to the number of respondents to the specific question. Much of the data generated were in the form of free text. These data were analysed using content analysis – a process by which the ‘many words of texts are classified into much fewer categories’ enabling analysis, examination and verification (Weber, 1990; Flick, 1998; Mayring, 2004). A categorisation system was developed by analysing responses and classifying them into categories with care being taken to ensure that the coding system was comprehensive whilst avoiding overlapping of categories. A second researcher independently applied the categories, blind to the original researcher’s decisions. An interrater reliability of 89% was achieved [(1808 of 2032 decisions were identical – Kappa = 0.471 (p < .001)]. Results Demographic information The 826 participants completed our questionnaire in a variety of roles and phases. They comprised members of school staff from 548 individual schools and colleges. Participants came from secondary (n = 531), primary (n = 116), special schools (n = 102) and further educa- tion colleges (n = 77). The majority of participants were teachers [35% (n = 286)] or middle leaders [24% (n = 196)]. 17 per cent (n = 137) of respondents were senior leaders, 15% (n = 127) were pastoral leaders and 10% (n = 80) were support staff including school nurses and teaching assistants. 84 per cent (n = 447/530) of respondents were aware of current or past cases of ED in their schools and 50% (266/530) had been directly involved with cases. School staff experiences and recommendations Full results are outlined in Tables 1 and 2 below. Table 1 outlines the quantitative results recorded from closed questions. Table 2 shows categorised results of free-text questions. Four topics were repeatedly referred to in the free text responses. These were: • Lack of clarity over how to support students with ED • Lack of ED training and policies available in schools • Staff feel uncomfortable teaching students about ED Table 2. Summary of Staff Responses to Eating Disorders (ED) Experience Survey – Free Text Benefits of ED training (142 respondents) Increased confidence supporting ED Learnt how to support sufferers Learnt Eating Disorder warning signs Sharing ideas/experiences with others Generally Useful 39 (27%) 31 (22%) 21 (15%) 15 (11%) 14 (10%) Learnt about referral processes Raised awareness of ED Not useful 12 (8%) 7 (5%) 3 (2%) What would have made training more useful? (96 respondents) Longer/more in-depth More staff attending Repeat, refresher or regular sessions Case studies Training was comprehensive 24 (25%) 17 (18%) 10 (10%) 10 (10%) 7 (7%) Practical support suggestions More relevant to specific student Better trainer/presentation Policy/referrals info Smaller groups 7 (7%) 6 (6%) 6 (6%) 5 (5%) 4 (4%) What you would do if you had Eating Disorder concerns about a student (782 respondents) I don’t know Refer to colleague/Follow policy Seek advice from colleagues Talk to the pupil Work with parents 316 (40%) 168 (21%) 146 (19%) 107 (14%) 25 (3%) External referral Monitor pupil 13 (2%) 7 (1%) Reasons some staff would feel uncomfortable teaching about Eating Disorders (546 respondents) Lack of knowledge It would lead to a rise in eating disorders Students already have a good understanding Worried about difficult questions/disclosures 312 (57%) 109 (20%) 64 (12%) 61 (11%) Experiences of communicating Eating Disorder concerns with parents (781 respondents) Denial/Refusal to communicate/cooperate Mixed reactions First contact difficult, but became supportive Anger – parent thinks it is an accusation of poor parenting 364 (47%) 287 (37%) 112 (14%) 18 (2%) Support that would be useful when reintegrating a student following absence due to an Eating Disorder (105 respondents) Information about the specific case Increased quantity/quality of training Involve more stakeholders All relevant staff to receive training/support Ongoing help & support from professionals 30 (29%) 25 (24%) 17 (16%) 13 (12%) 8 (8%) Prepare peers for pupil return Other 8 (8%) 4 (4%) All questions were optional. When not all participants recorded a response to a question, percentages were calculated according to the number of respondents to the specific question. © 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health. doi:10.1111/camh.12039 We don’t know how to help 3
    • • The reintegration of students following absence needs specific support Lack of clarity over how to support students with eating disorders Although the majority of participants had encountered a student with ED in their school, 40% (n = 316/782) of staff said they would not know how to follow up Eating Disorder concerns. “We don’t know how to help. No one has told us what to say or do and you’re always scared of saying the wrong thing and making it worse.” (Biology teacher) Lack of ED training and policies currently available in schools 41 per cent (n = 320) of respondents’ schools had no ref- erence to Eating Disorders in any policy. Only 5% (n = 41) of respondents’ schools had implemented spe- cific Eating Disorder policies, although the majority of participants considered Eating Disorder policies to be effective [61% (n = 317)]. “Having a policy in place has enabled us to clear up questions over how referrals should be made and to whom. We no longer have concerns about pupils slipping through the gaps.” (Head of pastoral care) “An ED policy would be highly effective as long as it was written as a practical document and gave clear guidance.” (Maths tea- cher) Of those who thought that Eating Disorder policies would prove ineffective [31% (n = 160)], many cited the difficulties of working with a policy designed by senior staff, but meant for implementation by teaching or sup- port staff: “It would just be another box ticking exercise done by the head teacher to please the inspectors. There wouldn’t be anything actually useful in it.” (Year 6 teacher) “What usually happens with these things is that the senior leadership team writes them and we’re all supposed to jump in line even though what they’ve put together is completely impractical and can’t be used for its intended purpose.” (Geog- raphy teacher). 74 per cent (n = 583) of respondents’ schools had provided no training on ED and of the 26% (n = 208) of respondents whose schools had provided training, in the majority of cases [56% (n = 82)], this training had been made available to three members of staff or fewer. Staff who had received training found it useful for a range of reasons, including increased confidence in supporting Eating Disorders [27% (n = 39)], a source of practical support ideas [22% (n = 31)] and an increased awareness of Eating Disorder warning signs [11% (n = 15)]. “Being able to share ideas was incredibly helpful. I went away feeling more confident that I could provide good support to pupils with EDs in the future.” (Head of PE) “Now I know what to look out for I think I’ll be able to spot the early warning signs and hopefully help move things on before the ED really takes grip.” (Head of Year 9) Some of those who had received training felt that it could be improved by being more in-depth [25% (n = 24)], available to more staff [18% (n = 17)] or repeated on a regular basis [10% (n = 10)]. “I was left with more questions than answers, I felt like I’d just started learning. It was useful but I’d have liked a lot longer. Refresher sessions would be useful too as it’s a huge amount to take in.” (Assistant Head) 91 per cent (n = 316) of staff who had not received training said that they would find ED training useful or very useful. “This doesn’t feel like the sort of thing you should be learning on the job – we should get proper training. After all, there’s so much potential to say or do something harmful completely by mistake.” (Learning support assistant). Staff feel uncomfortable teaching students about ED Majority of staff felt either very uncomfortable [54% (n = 419)] or uncomfortable [35% (n = 273)] teaching their students about ED. A wide range of reasons were given for this – the most repeated being a lack of knowl- edge [57% (n = 312)]: “It’s something I know so little about myself that it just wouldn’t be appropriate for me to lead a class on it.” (French teacher) Many teachers felt that it was inappropriate to teach students about ED because it may increase their preva- lence [20% (n = 109)]: “My understanding has always been that if you teach a pupil about ED, you give them the tools to develop that disorder themselves.” (Year 5 teacher) Others were worried about how they would answer students’ questions or deal with disclosures [11% (n = 61)]: “I could probably teach a basic lesson but I’d be clueless when it came to answering probing questions.” (Maths teacher) “I’d be worried in case one of my students talked about their ED in class. I wouldn’t know how to handle that situation.” (RE teacher) Some teachers simply believed that it was unneces- sary to teach students about Eating Disorders as they © 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health. 4 Pooky Knightsmith, Janet Treasure, & Ulrike Schmidt Child Adolesc Ment Health 2013; *(*): **–**
    • thought students already had a secure knowledge of the subject [12% (n = 64)] “What can I teach them that they haven’t already learnt from Heat magazine or The Sun? They’re walking encyclopaedias on this topic.” (Chemistry teacher) “If anything, they should be teaching us. One of my students did a project on anorexia recently, I learnt a lot from her.” (Year 10 form tutor) Around one third of respondents [37% (n = 287)] said that it had not been made clear to students what they should do, or whom they should tell if they were con- cerned about a friend’s eating behaviour. The reintegration of students following absence needs specific support The majority [68% (n = 329)] of respondents reported that their school had had to reintegrate a pupil into school following a period of absence caused by an Eating Disorder. 24 per cent (n = 77) reported receiving no sup- port or advice about how to support the returning stu- dent. “I will always feel guilty about it. We did our best to help her but we’d had no support, no training, and ultimately we didn’t rec- ognise that things weren’t going okay. She was more clever in her deceit this time, she hid the signs better and told us what she knew we wanted to hear. She seemed more or less okay. She died in her sleep.” (Deputy Head). 76 per cent (n = 240) of respondents’ schools did receive some form of training or advice; there were sev- eral suggestions about how this training could be devel- oped to be more effective. The most cited potential improvement was an increase in the quantity or quality of training [28% (n = 30)]. “She’d been out of school 6 months – a 30 min briefing prior to her return wasn’t enough.” (Head teacher) “We were provided with advice but it felt really generic and didn’t answer any of our school specific questions. Above all we were panicked about what to do at mealtimes.” (Form tutor) Several respondents highlighted the need for tailored training that prepared staff to deal with the specifics of the individual case [24% (n = 25)]: “Every case is different, we needed to know exactly how we could help her. Was she allowed to do PE? What should we say if she asked to join the gymnastics team again? Did it matter that she was spending hours on her homework? The training didn’t answer any of these questions. It would have been help- ful as a general session for staff but it didn’t prepare us for the difficult journey we had ahead of us trying to keep her in recov- ery.”(Head of pastoral care) Other respondents felt that the training should involve a broader range of people – including parents, pupils and the health provider as well as teachers [16% (n = 17)] “In the end we managed to help him fight his illness by working together with his parents, friends and counsellor – the training could have been a real opportunity to get us all in a room and figure out how we were going to do it. Instead it was just a missed opportunity and we learnt the hard way.” (Head of PE) Discussion This study was the first of its size and type to investigate school staff experiences of ED in the United Kingdom. Participants shared a wide range of experiences and also made recommendations about how school staff might be best supported in helping young people with Eating Dis- orders. The large volume of qualitative data available in the current study provided a high degree of insight into the issues explored. However, the results of the current study are based on a fairly basic content analysis – fur- ther studies could usefully expand upon the findings. Participant characteristics Participants were recruited from a database of UK school staff who had previously expressed an interest in mental health training. Therefore, there was a sam- pling bias, with the participants likely to have more experience of, or interest in, mental health issues than average. Whilst their views may not have been entirely representative, participants were in a particularly strong position to share insight into the experience of supporting pupils with ED. The responses generated were relevant, specific and included detailed descrip- tions of personal experiences across a range of scenar- ios. The sample represented a wide range of schools within the United Kingdom, with the majority of respondents from secondary schools. This bias towards secondary schools reflects the typical teenage onset of ED. Participants’ roles within schools were varied and included support staff, senior leaders and class teach- ers. The broad spectrum of roles represented lends weight to the representativeness of the current study. Eating Disorder prevalence Recent prevalence estimates in adolescents (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011; Machado, Machado, Goncßalves, & Hoek, 2007) suggest that ED affect every secondary school in the United King- dom. Therefore, it is of importance that staff are equipped to respond appropriately to pupils causing concern. Our findings indicated that this is not the case, as 40% of respondents said ‘I don’t know’ when asked what their next steps would be if they had Eating Disor- der concerns about a pupil. This is in line with earlier studies (Piran, 2004), but is worrying, given the vital role of early intervention in improving Eating Disorder out- comes (Treasure et al., 2010). Access to training Majority of staff in the current sample did not have any training about Eating Disorders and where training was © 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health. doi:10.1111/camh.12039 We don’t know how to help 5
    • provided it was often delivered to small numbers of staff, limiting its reach and impact. Lack of teacher knowledge and confidence has been cited in past studies as a major barrier to Eating Disor- der prevention and intervention (Price, Desmond, Price, & Mossing, 1990; Yager & O’Dea, 2005). Those staff who had attended training, cited an increase in Eating Disor- der knowledge and confidence as key benefits. Partici- pants specifically found that being briefed about Eating Disorder warning signs was helpful and welcomed prac- tical strategies that they could implement at school. Some suggested that training should be more in-depth, made more widely available and/or repeated on a regu- lar basis. However, pressures of time and resources available for continuing professional development and competing demands on school staff to develop their skills and expertise in a wide range of areas need to be consid- ered (Kennedy & McKay, 2011). Nearly all respondents who had not had access to ED training said that they would welcome it. Other studies from the United States and Canada have shown similar results (Neumark-Sztainer et al., 1999; Piran, 2004). School policies Very few schools had an Eating Disorder policy in place, either as a stand-alone policy or as part of another pol- icy. Several respondents highlighted that a lack of stan- dardised policies or procedures surrounding Eating Disorder referrals could lead to pupils ‘falling through the gaps’ with staff failing to address their concerns appropriately. School staff may find it helpful if clear referral pathways were set up within school with a named person being made responsible for mental health. Where school policies are implemented, respon- dents made it clear that these would be effective only if they were highly practical in nature and appropriately disseminated with briefing or training. Teaching students about ED In addition to a lack of confidence in following up Eating Disorder concerns, respondents were uneasy about the idea of teaching lessons about ED. Their concern was largely due to a lack of knowledge, which could be addressed easily through training. Many of the school staff we surveyed considered the teaching of ED inappro- priate for students, believing that it may lead to an increase in cases. There is evidence that some strategies for teaching about ED may increase body dissatisfaction or Eating Disorder symptoms (Yager, 2007; Carter, Stewart, Dunn, & Fairburn, 1997; O’Dea, 2000). How- ever, teaching students about ED within appropriate guidelines or as part of a positive body image programme should have more positive than negative outcomes (O’Dea, 2000). This is in line with UK government recom- mendations following a recent report, which suggested the need for mandatory body image and self-esteem les- sons for children at primary and secondary school (All Parliamentary Group on Body image, 2012). Teachers can play an important role in dispelling myths associated with weight loss and ED and empha- sise their severity as serious psychological disorders (O’Dea, 2000, 2005). It is also important that pupils are taught how to support a friend who may be causing them concern – in a parallel study many students said that they did not alert a member of staff about a friend’s dis- ordered eating simply because they did not know whom to tell and did not know whether the situation would be taken seriously (Knightsmith et al., in press). Student reintegration following illness A majority of respondents reported that their school had reintegrated a pupil into school following a period of absence caused by an Eating Disorder, but training and support around this issue were inconsistent. Relapse is common in people recovering from ED (Keel & Brown, 2010), and returning to school after a period of treat- ment can be daunting for all involved. Several partici- pants in this study suggested that they would like tailored help, which would inform them exactly how to support the student who was returning. It was also sug- gested that the school should work alongside parents and the healthcare provider to support the pupil as a team and that staff should be made aware of relapse indicators. The importance of clear lines of communica- tion with the student’s healthcare provider was high- lighted so that the school had someone to whom they could turn if they had concerns. Implications and core recommendations ED were encountered by a majority of school staff in the current sample. Despite this, many school staff reported that they were ill-equipped to support students at risk of, or suffering from, ED either in the early stages of the disor- der or during the recovery period. Many staff had received inadequatetrainingornoneatallandwouldwelcomemore in-depth, practical training tailored to the school environ- ment. However, such enthusiasm for training must be tempered with the need to fit within school curricula as well as time and budgetary constraints. The efficacy of a short (1 day or less), but highly focused, ED training pro- gramme aimed specifically at school staff would be worth exploring. Ideally, such a programme would specifically address the most common warning signs for ED, how to follow up on Eating Disorder concerns with students and parents and look at ways in which schools can support pupilsduringthe recovery period. Some participants in the current study encouraged the designation of a person responsible for ED (or per- haps all mental health issues) to whom all cases should be referred to prevent pupils falling through the gaps. Some schools may find the adoption of a specific Eating Disorder policy useful, providing it is highly practical in nature and implemented effectively. School staff felt uncomfortable teaching pupils about ED and expressed some valid concerns. It is clear from current research that it is possible to cause harm whilst teaching students about ED, which has resulted in guid- ance on what not to do (Yager, 2007). However, school staff can play an important role in dispelling myths pur- veyed by the media and educating young people that an Eating Disorder is a serious psychological illness. Future studies are needed to look at how school staff can most appropriately teach comprehensive practical guidance on this difficult subject. Acknowledgements This work was supported by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Scheme (RP-PG-0606-1043). Ulrike Schmidt receives © 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health. 6 Pooky Knightsmith, Janet Treasure, & Ulrike Schmidt Child Adolesc Ment Health 2013; *(*): **–**
    • salary support from the National Institute for Health Research (NIHR) [Mental Health Biomedical Research Centre] at South London and Maudsley NHS Foundation Trust and King’s Col- lege London. The views expressed herein are not necessarily those of the NHS, the NIHR or Department of Health. The authors would like to thank the young people who participated in the study, and the school staff and parents who supported. The authors have declared that they have no competing or potential conflicts of interest. References All Parliamentary Group on Body image, Central YMCA (2012) Reflections on Body. Available from: image.http://bit.ly/ YQuhNl [last accessed 25 July 2013]. Bowers, H., Manion, I., Papadopoulos, D., & Gauvreau, E. (2012). Stigma in school-based mental health: Perceptions of young people and service providers. Child and Adolescent Mental Health. Carter, J.C., Stewart, D.A., Dunn, V.J., & Fairburn, C.G. (1997). 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The role of teachers and other educators in the prevention of eating disorders and child obesity: What are the issues? Eating Disorders, 13(3), 261– 278. Accepted for publication: 25 June 2013 © 2013 The Authors. Child and Adolescent Mental Health © 2013 Association for Child and Adolescent Mental Health. doi:10.1111/camh.12039 We don’t know how to help 7