Good evening everybody and welcome to this webinar hosted by the Mental Health Professionals Network. My name's Steve Trumbull and I'll be your facilitator tonight. I would welcome you all. I'm not sure how many people we have logged in. There's been a lot of interest in this webinar so I'm sure we've got a good number of people on board. I'll begin by acknowledging the traditional custodians of the land, seas and waterways across Australia webinar presenters and US participants are located. We pay our respects to Elders past, present and future for the memories, the traditions, the culture and hopes of Aboriginal and Torres Strait Islander Australia. So welcome again. So there's our panel. I'll start by introducing myself as a general practitioner but head of medical education at the University of Melbourne Medical School. And we do have a good collection of people tonight. I'm not going to run through their bios in detail because you've had those circulated with the webinar invitation. However, I will introduce Dr Stephanie DeMiano. Hello Stephanie. So Stephanie is a clinical psychologist as you've seen and also a researcher and she'll be focusing on the research aspects of this condition of body image issues as we get into that part of the webinar. But Stephanie, I'm interested. You've recently launched a new program at your Butterfly Foundation called Butterfly Body Bright. Can you tell us a bit more about that? Thanks Steve and hello everyone. Yes, so recently at Butterfly Foundation we've launched Butterfly Body Bright which is a body image program for primary schools and it adopts a whole school approach. So we provide schools with school culture guidelines, staff training, age appropriate lessons and resources for families with the aim to promote positive body image and healthy attitudes and behaviors towards the body eating and physical activity in children. Fantastic. That sounds very, very worthwhile. Thanks for that. We're going to head across the continent now to the land of the free Western Australia. Andrew, a very big hello from those of us here in Victoria and we envy you. Now Andrew, you're a general practitioner but you've got an unusual style of general practice I suppose. But how common are body image issues within your general practice and general practice in general I suppose? Hi Steve and hi everyone. Yeah, in general practice I would say it's usually something we have to think about and screen for rather than what actually presents to us. So I definitely have to work a bit harder to pick these things up and that's just a good thing that we'll be talking about tonight. Great. Excellent. We're looking forward to hearing your input. Now back here in Victoria, hello Fiona Sutherland. How are you? You surprised me by describing yourself as a non-diet dietitian and I feel really bad that I've got this far through life without knowing that there were non-diet dietitians. Can you explain a bit about what that means? Sure Steve and hello everybody. Thank you so much MHPN for having us here tonight. Steve don't worry. I'm more than happy to have some long conversations with you about this in particular. It is a passion topic of mine. So for those of you who aren't aware, non-diet dietitians are somewhat seen as specialists in weight inclusive care, which means that we take an evidence based health first approach to helping people in all body sizes across different ages, genders, different procuring conditions for people to adopt behaviors which is focusing really on health and well-being rather than primarily on weight loss. The second important factor associated with being a non-diet dietitian is that we acknowledge very clearly the harms of the pursuit of intentional weight loss. So that's what we're going to be talking a bit about tonight and how we can really take a weight inclusive, weight neutral approach to body image concerns. Wonderful. Well thank you for that. I'm really pleased to know that you exist. That's great. And then also on our panel we have Dr Rachel Cohen. Rachel you're a clinical psychologist based in New South Wales. Please tell me what is the impact of social media use on body image? That's been such a popular question heading into this webinar. Yes, so I was interested in this turn up to actually why I did my PhD a few years ago on social, the impacts of social media in body image. And what we know is it's not just, it's great that we don't have to say it's just all social media use that is bad, but we do know what I did find in my research is that specific types of engagement with social media does have really negative impacts on body image. And that's specifically photo based activities, things like the way we take photos of ourselves, selfies, manipulating those, scrutinizing those, investing in them in that way, following appearance based accounts. And using social media in those kinds of ways does have a very negative impact. But on the flip side, what I also found was exposure to body positive posts. So types of content that encourages more positive body image, more diversity in appearance and really celebrating our flaws is really associated with more positive impacts on body satisfaction, body appreciation. And so that can be a positive and fruitful avenue for social media use. Okay, well, that's probably the best news I've heard all day that there is some positive aspect to social media and that in that area. So thank you for that. So now let's have a look at the learning outcomes on the next slide, which are to identify. So by looking at body image, we hope to give you the opportunity to identify red flags for body issues and children and people have been asking questions about those red flags in the weeks leading up to the webinar. We will talk about how to have conversations with children and their family who may be experiencing body image issues and people have been asking what actual words you use in those conversations, because that can be pretty, pretty tricky. We'll talk about the importance of prevention and promotion of positive body image and also the importance of collaboration, which is really why this network exists and appropriate referrals when providing care to people who have body image concerns. Now, given that we've got four great presenters, I'm not going to go through the case study in detail because hopefully you've all had a read of that. You know about Harper's situation and where she is in life and what's going on in her family. And there are plenty of cues there, I guess, that you would have picked up on when reading through that. But let's go on now to actually hearing from our presenters or our participants as to their views on this particular case. So next slide, please, that can rip into it. So, Stephanie, as foreshadowed, you're going to talk us through some of the research which underpins this field. So over to you. Thanks, Steve. So I wanted to start by just, I guess, talking a little bit about body image in children and what we know from a research perspective. So we know that childhood is an important time for the development of body image, be that positive or negative body image. And what the research really shows is that during pre-adolescent years can be a time for the onset of a number of unhelpful and potentially dangerous behaviors when we're thinking about potential risk factors in disorders. And recently mentioned earlier the butterfly body rights program. And in developing that, we conducted a survey with 165 adults with a lived experience of having developed body image or eating concerns during primary school years. And what it showed was that 93% reported that their primary school body image concerns got worse when they entered adolescence. It didn't get better for any of them. And the remaining 7% said it sort of stayed the same as, you know, being a concern for them. So that alongside other research that we have in the field really highlights the need for prevention efforts during childhood as well as effective early intervention. Next slide. And so I just wanted to touch on that lived experience survey in a little bit more detail because there were some behaviors that were reported on in that that really highlighted what can be happening already in childhood that I thought was important. So 64% started restricted dieting, 77% engaged in disordered eating behaviors and 33% engaged in excessive exercise during their child primary school years. I think what was quite alarming was that 43% of respondents reported developing an undiagnosed eating disorder between the ages of 5 and 12, which when we're talking about early identification was just a statistic that really kind of jumped out. And then 30% went on to be diagnosed with an eating disorder either in late primary school or into adolescence. So it really highlights the need to make primary schools and parents and anyone working with children aware of these issues in childhood and that it's not just something that starts to happen when kids reach adolescence, for example. Next slide. So it's important to acknowledge that a child's body image is influenced by a range of risk and protective factors. So there's biological factors, psychological factors and sociocultural factors. And I want to just touch on two of the sociocultural factors that were particularly relevant. I thought in the case study for tonight. So next slide. So the first is familial factors. So we know that families are important role models for children for a whole range of reasons. But when it comes to body image and a child's relationship with eating and food, the language that a family uses around food and body can be really influential. So, for example, using terms like healthy versus unhealthy or good versus bad can really start to create an unhelpful dichotomy for children that may result in feelings of guilt or shame when eating foods that are, you know, considered the unhealthy foods. So considering this particular case study with Harper's dad saying, you know, it's a good habit to eat healthy food when she's talking about no longer eating sandwiches, is that potentially then interpreted by Harper as sandwiches are unhealthy or bad foods for her to be eating? Another way that families are influential is their behaviors around food and the body. So for example, we know that Kelly Harper's mum is frequently dieting and what the research quite consistently shows us is that maternal dieting can be quite influential particularly for their daughter's relationship with food and eating and can have quite a negative impact. So it's important to acknowledge that families are an important influence in terms of setting some real foundational thinking around the body food and physical activity for children. It's also really important that families are not felt to blame if their child ever develops an eating disorder. We know that in the same way that so many factors influence child's body image, the same thing is for developing an eating disorder. There's a whole host of, you know, complex interaction between so many factors that lead a person to an eating disorder. Next slide. And so the other one that I just wanted to talk about the other influence is peer factors. So we know that peers are important to children, particularly as they move into the school years. And one of the leading risk factors for body dissatisfaction is appearance-based teasing, which often can occur from peers. And so what the research has shown is that up to 58% of primary school age children have reported being teased about their appearance or weight by peers. And in that lived experience survey that I mentioned earlier, 65% of those respondents identified appearance-based teasing or comments as contributing to their body image concerns. So one, I guess, consideration in this is around families and schools and communities having a no tolerance to appearance teasing or negative comments about appearance. Because what the research really shows is that it doesn't actually need to be the extent of bullying to have a negative impact on a child. So they're the sort of two factors that I think I wanted to highlight from tonight's case study. But in closing, I think a child's body image, as mentioned, can be influenced by numerous factors. And it's important that a child's experience with their body and body dissatisfaction is in disregarded just because they're a child. Because what we do know is that early identification and intervention can make the world of difference. So thank you. Great. Thanks, Stephanie. And I'm sure what Stephanie said has raised some questions for people. So please do use that speech bubble down the bottom right-hand corner of your screen in order to post some questions. We'll get to those at the end. So now we'll go to the case. And here we have little Harper, who's been brought into the general practice clinic by her mum. With tummy pains, or I guess she's been old for that sort of speech, but for tummy pains. And she's spoken or she's with the GP who's asked if there's anything different that she's eaten today that might have upset her tummy. And Harper replies to the GP by saying she'd mostly been eating healthy food like mum and dad. So that's the sort of opening point. And we'll go now to Dr Andrew Leitch over there in Perth. So Andrew, it's your general practice that the families come into. Take us through how you would approach a case such as Harper's presenting to begin with. Thanks, Steve. So Harper's come in and look, I was a little surprised to think an eight-year-old would have concerns about body image. But as Stephanie has already told us, everyone, young, too old, can have a relationship and a feeling about their body image. And so it is something as a GP that we might need to be thinking about in children. And it might not be immediately obvious as these families come in with a child with tummy pain. It might not be obvious that this is actually has a far deeper issue going on underlying why Harper's feeling the tummy pain. So it might take a bit thinking broadly and digging a little deeper and asking the right sort of questions in a sensitive manner. Next slide, please. And in fact, body images ranked as one of the top three concerns for young people in Australia. So even though we might not see it immediately in our office in the GP clinic, as part of our overall assessment of children, as we see them often, it might be something in the back of our mind that we need to think about given it is a concern. Next slide. So a structure here might be helpful in terms of dealing and seeing Harper. It can be a little bit overwhelming sitting down and having a family coming in with concerns around mental health as it is. But as I said, it might not be immediately obvious. So where do we go? I think looking towards the biological, psychological, social side as we are always good at doing with other consults is a good starting point. So inquiring a little bit into Harper's development, her history, her growth, you know, her medical background, anything that's been going on for her up until now might be a good starting point. Simple questions, keeping it fairly open and relaxed. And then more a little bit about Harper's interests and health and, you know, her general well-being at school and how she's going and if she's thriving. The examinations, the tricky bit, isn't it? So we need to know here, is this a true issue with an eating disorder? Is Harper actually struggling with her way? How do we do that? Do we weigh her and then feed back to parents about the way? I tend to think that's not appropriate. I think we do need to do a physical examination.  And then as part of that, as a routine part of the examination, doing her height and doing her weight and tracking that on our own medical software, which often is able to be done, that might be discreetly done so that we can check how she's tracking. Is there a medical issue or not here with Harper and her growth? Next slide. And I forgot to mention in the biological side, thinking about any blood tests that might be required as well to expand on that. And we're not dealing necessarily with an eating disorder as yet. But if we were thinking about that, there's some really good resources online on the Inside Out website, which might take you down some of the other medical tests you could think about. So the psychological side, mental health past and present, really important here. How resilient is Harper? Is she coping really well at school with her friendships? Is there anything going on for her? And certainly there may be some bullying here. So how is she coping? Is she sleeping well? And is she functioning otherwise, getting through her school work? Or is she sort of falling in a heap in a way? So I might do that in a really roundabout way with Harper and talk to her about, as I said, some of her interests, what she likes to do, what are some of the things she likes to do at school with her friends. Start to work a little bit of an understanding of Harper's world before moving into some of the more difficult questions around, well, are you feeling a bit scared or worried about something? And certainly here it sounds like there is some concern about food and you might start to get some of those answers out in those conversations. Also family history, really important. Is there a family history of mental illness? And this is going to happen over a couple of concerts. Inevitably, they're booked for a 15-minute session. We're going to have to get them back. And maybe even review Harper's family together. Parents are on their own. Next slide. Socially, we've gone biological, psychological, now social world of Harper. What is going on with the bullying? And what are they saying? What are they doing to Harper? And how is that affecting her and her mood? Is she linked online? And we've already talked a little bit about social media and the impact that might have on body image. What is Harper doing online? Does she have a phone yet? Is she on some of these various social channels? Next slide. It's a little bit more around onto the management side of things. Now, having conversations in a GP setting can be tricky. And then we have to be sensitive to them. And to care for how we word certain things like food. And probably move more towards keeping those topics to me and the parent negative language around weight. Next slide. And remembering also that Harper's parents actually think they're doing a fantastic job. This is a really healthy family. They're exercising every day. They're eating all this wonderful food. So be careful not to judge parents. And we can't necessarily tell them how to parent. We support them to give them some tips and be sensitive and empathetic to what's going on at home. So helping them to understand about healthy lifestyle and what that might mean and have some of these conversations with them on their own. Next slide. We've also got some other tips here just about. Next slide, please. So maybe making it out, but it's not the focus of the whole family having meals out together, including all sorts of food groups, rather just focusing on one and taking that social media focus out of the household. Next slide. Now, if there's concerns in a GP, a GP is a really good at this in sort of screening for mental health disorders or eating disorders. If we are concerned about the health or the mental health of Harper and her family, we might need to consider a referral onto a child psychologist and or a dietician. We may end up using one of the new mental health care plans to do that or a pediatrician for further assessment. And as I said, being really thorough with that and following Harper and her family up over time is a good way to do that. Next slide. Great. Thanks for that, Andrew. That was fabulous. There are a couple of issues with your internet connection. I think your premium might have unplugged you from the NBN as part of the succession plan. But anyway, we did pick up everything you said, I'm sure. And also the questions coming in are fantastic. Everybody's getting in amongst the issues for this family. There are over 800 people online. And I think nearly all of them have asked a question about how we talk about food without labelling it healthy and unhealthy. So this is a fabulous introduction to Fiona Sutherland, who's now going to talk to us because Andrew has used a plan to access Fiona's services for the family. So Fiona, over to you. Thanks, Dave. And thank you, Andrew, for the referral. I appreciate it. So some things I'm holding in mind as I'm understanding a little bit more about Harper is how the family value of quote, unquote health and healthy eating is being defined and expressed within this family. And most notably how this translates into food, eating, and body-related attitudes and beliefs. I'm really interested in Dad's interpretation of a response to Harper's request for changes of lunch and how this kind of fit in, again, to the family's values around how they define health. I'm also alerted to Harper's gastrointestinal distress or her sore tummy, which for many dietitians, we have a pretty decent understanding that any kind of otherwise unexplained symptoms are, you know, it's really, really common amongst different age groups, amongst different-sized children, different human beings that this can be related to food and body-related anxiety. Next slide, please. So in terms of first steps, we might be asking, you know, why would a GP in this particular case refer to a dietitian? So the first point is that for somebody who, for a GP whose parents and the child are presenting with an unexplained gastrointestinal complaint or the child wants to eat more healthily, this is something that a dietitian hears from parents allosh. So it might not be that parents are concerned about the child, but that the child themselves, across different age groups, some as young as five or six, are expressing a desire to eat more healthily. So for me, this is a red flag, definitely for further investigation, particularly related to food, eating, and body-related concerns. So I introduced myself as a non-dietitian, and I have been an eating disorder specialist for 20 years as well, and more recently found myself definitely more a body image specialist across the age span, across different body sizes, genders, and different ways humans turn up. So having met with many, many, many people over many years of practice, a specialist referral either to an eating disorder to a non-dietitian or somebody who self-identifies as health at every size or haze aligned really steps up the speciality of somebody who will be able to investigate a case like this with much more thoroughness. We tend to be specialists in more of the food and eating and body image related and intersecting ways that these kind of behaviors turn up in young people. So I would be requesting to meet with both parents, ideally without Harper present. In my experience, and this is born over quite a number of years of working with families, including in eating disorder care, that I have observed that is not a good idea for young people to be presented to the dietitian. And the main thing is listening to lived experience. Teenagers and adults who are so-called taken to a dietitian tend to internalize a sense of there's something wrong with me and also paints the dietitian in not a very good light as well as somebody who is there to tell them what to do, tell them what not to do, and certainly people's experiences with my colleagues have been many and varied and have also been quite harmful and negative too. I'm very sorry to say. Next slide. So when I'm meeting with Harper's parents, there are a few key things I'm really listening for. I'm listening for language which really tells me a bit about their own food-eating and body-related attitude. At this particular time, I might not give any kind of cues or refrains depending on the relationship I'm able to build with Harper's parents, but I'll be listening really carefully to anything that strikes me as maybe illustrating dichotomous or black-and-white beliefs as maybe language that is used around a house that I'm thinking to myself, okay, if that's the kind of language that's been used around an eight-year-old, then this is where I might help and support parents to be able to shift the way that they are speaking about food-eating in the house. I would be also looking at a longitudinal view of Harper and asking them about any changes that they have noticed in Harper, whether that is related to her own food and eating-related behaviors, or whether they've noticed a change in her body's shape, which might be distinct from or might be alongside some regular childhood growth. And I would also be really noticing whether the parents were on the same page or whether they, what they agreed with each other or whether there was any conflict over what they disagreed with. This just offers me some really valuable information about how much they agree on and disagree on with regards to Harper. I'd be gently, very, very gently inquiring about their own history with food-eating and body image and just taking notes along the way, which might help me to understand how to support Harper with Harper's parents. And I'd definitely be really working hard to aim to maximize engagement so that we can work together over time. So the next steps is in working with Harper's parents, I'm really aiming to support them to build a home environment where ultimately Harper can be protected as much as possible. I think we can all recognize that in this culture, it's impossible to cocoon our kids entirely that they are going to be exposed to some food-eating and body-related messages and that alongside protecting her in the home environment, also about building her resilience and helping her over time understand the positioning of these messages and to reduce any kind of internalisation, personalisation or shame-based responses. I'll be also aiming to build parents' awareness of their own histories and their own food-eating and body-related beliefs and help them together as a team through the work to support a family where positive nutrition, positive food-related behaviors can be undertaken as a whole family. I would be definitely in contact with Rachel as a potential psychologist and we'd be kind of divvying up our roles with regards to red flags and usually I'd be handing that over to a psychologist but depending on what Rachel has on her plate, that might be something we negotiate together. I would definitely be asking permission for a high-consent process to be speaking with a teacher, with a school, with a principal, with a school-based organisation and I'd be contacting the Butterfly Foundation to hand on their school-based resources and link the school in with those resources. So that's me. Thank you very much for having me. Thank you very much indeed, Fiona. So you have practised really well and you've made contact with Rachel and through Andrew you've made a referral on the team care arrangements to Rachel or through Mental Health Care Plan I guess for a psychologist's perspective. So over to you, Rachel. Thank you. So if this was presented to me on the first basis I'd be just doing an assessment and I would also only be seeing the parents just to be looking out for is there a full-blown eating disorder or an eating disorder diagnosis going on or is this more in that kind of early intervention, prevention, psycho-education phase. So the main things in the assessment that I'll be looking out for in terms of red flags for eating disorders is I'd be asking the parents very specific questions because especially in this family who is doing a great job and really does value health, they might not pick up on certain behaviours that might be actually red flags for some eating disorder thoughts or behaviours. So the more specific we can be in asking these questions, the more helpful it is for them to actually detect it rather than kind of very open-ended questions. So I'll be asking specifically around has there been demonstrating a more increased interest in food and exercise, becoming more obsessive and rigid in her thinking and less flexible. Has she been cutting out certain food groups which we are noticing with the sandwiches and the juice box to stopping to eat previously enjoyed food? Does she have an increased focus on body weight and shape? So obviously she's making some of those comments but maybe we're also seeing things in her behaviour like body checking and mirror checking. So body checking might be things like they might notice Harper kind of measuring around her wrist or around her waist, pulling out pieces of skin around her body, maybe seeing the way her body is fitting in her clothes, checking the mirror and also at the same time we might be seeing some body avoidance. So avoiding looking in reflective surfaces of wearing baggy clothes so that she cannot see her body. So picking up on any of these kind of behaviours. Any sudden weight changes. So in gains or loss. Avoidance of social situations. So we are seeing some withdrawal in Harper and kind of some self-consciousness being around people or in certain environments at the shop. But also we might notice that she's avoiding kind of family meals or eating in public with friends. We might notice some compensatory behaviour. So I'd be asking around purging, diuretic or laxative misuse or any kind of diet supplements. But also around, you know, maybe they're noticing that she's doing some compensatory exercise behaviour. So maybe she's doing kind of some sit-ups in her bed after dinner or maybe they're noticing she's using the stairs or pacing around the house a lot more and so kind of some things like that. And also in terms of her actual eating behaviours there might be some subtle nuance changes in her eating where she might be picking at food using smaller bowls and plates, eating more slowly, maybe extra chewing and napkin to hide if she's spitting out food, sleeping in to skip breakfast or going to bed early to skip dinner and some other subtle behaviours like that. Next slide please. So if I was picking up that there might be more of an eating disorder diagnosis or picture going on, I would be approaching this from a family-based treatment approach and this is a very non-blame approach as the previous presenters had spoken about. The illness is externalised from the child and we really start to empower the parents to understand the origins of change. So with somebody who's eight years old and any children, I'd be primarily working with the parents and using them to refeed half part and develop a more balanced relationship with food. This would be a very much a team-based approach so I would be using the GP who would be or she would be monitoring for medical stability on a weekly basis often because there's obviously many medical implications of an eating disorder. I'd be engaging with them, support the parents with stabilising and normalising food and eating and I would very much be engaging with someone like Fiona who has a non-diet approach because the last thing a child like this needs is to be put on a diet and so it'd be really supporting the parents in developing a healthier relationship with food. A psychiatrist if there's medication necessary and there's part of the eating disorder care plan so after 20 sessions they need to have seen a psychiatrist or a pediatrician to get a further 20 and I'd be liaising with the school as appropriate. If this was the more early intervention prevention case that would be an awesome opportunity I'd love to see that more and I would be providing lots of psychoeducation to the family around what to look out for also really emphasising the severity of what this might mean and look like if it does progress further because some parents don't realise that it is a really slippery slope and helping the family set up an environment that promotes positive body image. Next slide please. So what this might look like is really educating the parents around how to model positive body image and so that is demonstrating an acceptance of one's body despite its flaws focusing on health and function of the body not how it looks and encouraging to see beauty and diverse range of appearance and also an internal attribute so learning to complement Harper and themselves and others based on personality traits accomplishments to see inside them as opposed to just how they look and on that note stopping really appearance focus commentary so that's both negative or positive comments about one's own and others appearance so that's even things like telling your daughter oh you look so beautiful and people think that's a great way to boost self esteem but really encouraging them to actually emphasise things like you're so kind or I love your curiosity and helping them to see themselves much more than just how they look it really important is to avoid diets so we know from all the research that diets can lead to many more negative implications socially, emotionally psychologically and physically including weight gain they're not so even in the whole household to avoid talks around diets the previous presenters have spoken around the language around food which is really important but encouraging eating and exercise behaviours for the function and the health gains rather than how it impacts our weight and our shape and encouraging them to monitor the exposure to appearance focus media so both passively whether there's magazines lying around the house TV shows they're watching but also the social media both the families engaging in and what they're what Harper might be seeing and also what her engagement might be so these children are sponges so it's not necessarily what we're directly doing with them but what they're seeing and how they're seeing us engage with the world and finally to really encourage them to have conversations with Harper about body image issues so puberty ranges from around 8 to 16 years old and so naturally she is entering a really vulnerable time and it's very often that these kids can misinterpret normal growth changes during puberty and that can be a significant contributor to the onset of body image issues so really welcoming conversations and encouraging them to guide her through that rather than shy away from it and yeah so that will be my main points thank you Thanks Rachel and thanks to all of you for your presentations and keeping so close to each other's time I must say a question that's coming up again and again in the questions now and also leading into the webinar was about the age which you'd become concerned about a child now Harper's age Stephanie can you enlighten us on any research which indicates when you might start to take what the child's saying more seriously if they're making comments about their appearance or reading? Yeah absolutely Steve so I think really any age is a concern so at any point that a child's making any negative comments about their appearance I think it would be about questioning why they're saying what they're saying so I think obviously children can repeat things that they hear without sort of thinking about it but sometimes it's an issue there's you know an underlying issue and concern that's going on from a research perspective quite consistently the research is showing particularly for girls that from the age of 6 can be an important stage or age for the onset of body dissatisfaction so it's quite young. Okay so then what about I mean if you're on Rachel I guess when might you see the child on their own I mean we're sort of with the parents now when at the other end I guess when would you feel comfortable talking primarily to Harper rather than her parents? Yeah so when I'm doing family based therapy that would be involving both the child and the parents if it's more this preventative level then I would be speaking to the parents but at any stage if Harper or the parents want individual engagement with Harper I'd be definitely welcoming that but it would be more about kind of addressing the self-esteem issues resilience and in terms of this early body image piece it's really about in terms of kind of her self-worth pie chart trying to decrease the slice that is focused on body image and appearance and really trying to increase the other domains of her self-worth so I'd be working on that with her primarily from any age. As you said before her kindness or her curiosity or some other quality that you might remark on. Other interests relationships and domains in her life that give her a sense of self-worth and importance. All right and Andrew I mean family medicine is what general practice is also called. What sort of decisions do you make about when you might see Harper as an individual patient rather than as a child with parent? I might not see her on her own unless I've got an excellent rapport with her and her family but definitely creating a space within the consult room remembering that she is our patient she's the she's the focus here so creating space that might be sitting separately in the room with her and just chatting one to one or drawing with her to to build that rapport and allowing her time to express anything that might be going on for her so that's probably how to approach it in an eight year old. And I mean I don't think it's revealing too much to the audience that we did spend some time as a team heading into this webinar talking about the issue about the the GP's role in the developmental review I suppose and you were very careful in what you said about the height and weight measurement with Harper that you would sort of fold that into the overall physical examination. Yes I think you know that's one thing we're really good about is screening and prevention and preventative health and that each state has a book that we even record this data into but our practice software also is able to record this sort of data and give us a plot of how things are going over time that's information for me that might be useful for parents as we move forward but I certainly wouldn't make that the focus and incorporate that into an overall physical health check is the key here to make sure there's nothing medical going on but also to be sort of starting to pay attention to the concerns that Harper's coming in with. Sure and that fits with what both you and Stephanie said about the biopsychosocial model that making sure that the biopart is dealt with not ignored and Fiona referred to that as well but that it doesn't dominate or become seen as a organic issue rather than that. So one thing that I must say I hadn't remembered for a long time is just how political the child's lunchbox is everybody's got an opinion about what's in the child's lunchbox and questions have been asked on the side about how you go about that when you might have a situation where supposedly I guess well-meaning teacher has snatched something out of Harper's lunchbox and returned a note to the parents saying please don't put this unhealthy food in Harper's lunchbox or whatever be a proper parent or something equally as passive-aggressive as the comment was made. What does the panel think about that how would we deal with that sort of question from the parents about how you can engage with the teachers at school about not policing Harper's eating in that way. So I might jump in with this one if that's okay first. Just briefly this is a really amazing opportunity for parents to be advocates for their child and to have a conversation, a thoughtful conversation with the teacher around their expectations and from a teacher's point of view it's actually not a teacher's role to take charge of what is sent from the parent. There is many many different reasons why parents pack particular foods in a child's lunchbox and it really is just a snapshot of the food that a child will eat over a day and then over a week as well. And so in advocating for their child the parents can really ask the teacher and show gratitude for their role in their child's life in terms of their teaching and really firmly but generally request that no further comments are made about the child's lunch and that they they've got it, you know that they will be taking charge of that and however much Harper wants to eat in whatever order Harper wants to eat it is what they are requesting from the teacher. Okay any other thoughts from the panel? Yeah so I think I would just add that I agree with Fiona and I think what we've seen from a research perspective that lunchbox comments from teachers and notes sent home can actually lead to food shaming which can spiral into a whole range of issues for a child and so it's about trying to show respect for all food and celebrating food preferences and so encouraging teachers and school staff to really just show respect for whatever is in a child's lunchbox and as Fiona said that there's a reason why that is packed in a lunchbox and I've heard of cases with fruit they don't have fruit in their lunchbox but they've had fruit for breakfast and they have fruit when they get home and so it's like they're kind of covered and so it's just sort of about teachers not always having the awareness of what else is going on in a child's life and that being okay. Thanks for that now I'm intrigued by the image of Kelly the mother who's obviously an Instagram fan or whatever and she's engaged Harper in that activity as well.   How are you going to bring that up? So I think that it's important to also you know as Andrew said we're not to shame the parent so I wouldn't be coming on too strong it's more about opening up that exploration for the mother and using you know Harper's feedback where she has said it's made herself avoiding things now using that to kind of engage with the mother in a conversation about how do you think it makes her feel what might be happening here because obviously she doesn't have any ill intentions and you know there is no blanket rule that for some people who might be posting pictures of a child it might not impact them in any negative way so it's not that it's a there's a right or wrong thing to do but in this specific case we can see it is having an impact on Harper so it's really having the conversation eliciting that feedback from both of the parents in understanding how it might be impacting Harper and what are other ways that we can approach it. Sure and I mean the case also tells us about Brandon the father who's also spending a lot of time at the gym and seems to be maybe the ringleader and getting the family engaged in physical activities together that doesn't look like a bad thing to me doing these activities together but I think there's a bit of a hint in this in the case about them being proud of their family achievements at this event sort of those physical activities also a bit problematic if there's that degree of competitiveness and display involved. I think that that comes back to the language that may be used around that physical activity from the family's perspective so I think that if the family are talking about that they're going to the gym or that they're doing these workouts or that they're engaging in this physical activity because they're trying to lose weight or gain muscle then that may be problematic. However engaging in physical activity as a family is actually a really positive strategy and a really great way to have children and encourage families. Fiona you were going to comment as well on that? Yeah I would concur with Stephanie I think that it's really around the broader context in which exercise is viewed and a lot of the underlying beliefs and attitudes around exercise particularly as we can acknowledge that in our broader culture that it is a very dominant narrative that exercise is not only used for flexibility, strength and endurance but is also used as a body modification strategy I guess and that's across all age groups. Children from very young are seeing peers and they're seeing parents and siblings and family members working out and then that can be accompanied by body and appearance based comments and it doesn't take much for a child to link A with B with C especially when they don't necessarily have that emotional maturity to be able to critique how A and B and C are culturally influenced or how they're not related to one another that it can become problematic in an intertwined way. Okay Andrew what are your thoughts on that? Steve yeah I think this is one of those conversations we need to have in a separate consultation with Callie and Brandon possibly organize a follow up separate appointment just to go through where they're at and remembering that they probably don't feel there is anything wrong that they actually feel this is working really well for them so being careful not to pass judgement to talk about the good things that they are doing in the family and maybe to use some generalizations but using social media frequently with children around can impact things like body image, is that something you've thought about or is that something you think you could work on in terms of when you use it and how you use it with Harper. So just keeping it really general and offering some suggestions in that sort of manner I think might be a good way to work through it with them in general practice. Okay somebody's actually asked the question about whether the GP would be the area where you'd be the first point of contact for a teacher maybe to suggest that a child be taken to. I don't know I'm sort of not confident that all GPs would be switched on to this condition or this issue as perhaps you are, I don't know are you known in the area Andrew there's only three GPs in person? No, not necessarily I mean I see everything as most GPs would and as the start it's not obvious when you see the first presentation here of tummy pain it's not obvious what's actually going on here so I think most GPs would think okay well maybe this is a tummy bug or just a tummy ache let's get you back let's see how things go and maybe it'll unravel over time rather than being immediately obvious I think it would be challenging for a GP to pick up those nuances and those sort of hints that something's going on here and it might not be the first point of call it might be something that comes in down the track so it's a challenging one Steve and actually speaking of hints to what's going on I must say I'd forgotten about Zoe who's the younger sister who's six and I can't think of it was I think it might have been it was Fiona I think or it was Rachel I think who said that having the opportunity to be preventative would be wonderful I mean would anybody actively seek out Zoe to I guess if you're working with the parents that would have an impact on Zoe as well but might you be concerned about Zoe the states and Kingsley might follow the same path so I would hope that again as we said that this opportunity to help with the parents would change a lot of things in that family but I think some of the school based interventions that Stephanie has spoken to there are some wonderful things out there that are in that very early preventative state that's not targeted that they're not bringing in an individual who hasn't shown anything but really can address these earlier on through kind of more general settings like schools or things like that Thanks for that and actually somebody was asking the question about the Butterfly Foundation Stephanie and access to it is that a national organization or is it New South Wales and do you have a list I guess of go to people Yes so the Butterfly Foundation is a national organization and we have a national helpline that anyone can call so often we have people concerned about themselves or a carer as well as other professionals in the space and there is actually a database of health professionals that specialize in eating disorders so people can call to sort of get referrals to an appropriate health professional Right alright thanks for that Any other comments from the panel at this time we've got about 10 minutes of discussion to go The only thing if you don't mind I would like to comment on is that it's probably notable that Harper at this point in time has been named as a female and that across all genders these kind of presentations are incredibly common and in fact that young males, young boys can actually be missed because things emerge can emerge differently and there's a lot of assumptions made about body image and social media and females and so forth Sorry might things emerge differently for the brother Mason who's two years older So it's interesting because when you mentioned Zoe I was thinking oh yeah there's the older brother as well and so I think it's worthwhile speaking for example to the parents that whether regardless of the kind of health professional role we're in is that we ask about any changes that they've noticed in all of their children so Harper might be the canary in the coal mine so to speak she might be the one that's kind of you know being presenting with a few more overt symptoms than the other children but that it is not uncommon for multiple siblings to have very have some similar experiences that is definitely not to say that all children experience things in the family the same way because that's definitely not the case but that Mason could well have been protected in some ways you know perhaps yes and in other ways might be exposed in exactly the same way Okay thanks for that so back to Harper though what if she actually were overweight by definition Andrew if you did your metrics and discovered that she was actually over the no third centile for weight or something like that for her height would that change the way people are approaching her who wants to go Rachel looks like you're up Yes I'm happy you're bringing that up because I think something that is really important is that often when we picture you know even speaking to what Fiona just said we kind of picture this young you know thin girl actually eating disorders do not you know I've seen all types of weights, shapes and forms and I think it's really important that we don't minimise somebody who comes in a larger body who might be presenting with a similar presentation and I would actually address this in the exact same way from a psychological point of view we know that you know talking about food and health in this type of way is going to lead to much more adaptive behaviour in people of all sizes and actually any type of weight stigmatising language has worse implications for both ends of the spectrum so I would be addressing it very much the same and I think it really is an important thing that we don't just think there's a problem when there is a BMI we also see people who are the normal healthy weight range but actually they can still have medical issues going on and that's why as Andrew suggested before I would really be encouraging people to use the if they're using an insorted care plan there's a template on inside out which actually indicates what medical observations to be doing and also what labs to be running because there's lots of different things outside of just a weight shift that might be going on on a psychological level lots of different things that are going on even if they're in a normal weight overweight or underweight any other thoughts Stephanie yeah so I just add to that I guess taking a step back from an eating disorder and just thinking about it more from a prevention and body image perspective that what we know is that children are more likely and adults as well are more likely to engage in health promoting behaviors if they have a positive body image and so trying to help a child in any shape or size feel good about themselves is more likely to result in more nutritious eating regular physical activity doing things that they enjoy participating in life then if at any point a child feels shame for their body size thanks Stephanie and a few questions have come in about what if the child is not typical for child is particularly maybe not neurotypical so maybe with some fixations on food and then the other area is of course if the child comes from a culture where food might be viewed quite differently I wonder if any of you have any thoughts about those questions Fiona I saw you nodding vigorously I'm a very vigorous nodder so I think when it comes to children for example who are neurodivergent or who are from cultures that we ourselves might not be familiar with and therefore you know would have to do a probably a bit of learning to understand so maybe some some food related culture the culture related food beliefs but there are some wonderful specialists out there who can really I'm just going to speak for my profession there are some wonderful pediatric dieticians who would be able to be assisting so what we'd be looking for is somebody who is a non diet dietician but that also has some speciality or some interest in maybe autism spectrum disorder or maybe it's all different ways that neurodivergent can turn up what we are understanding now is that there is quite an increasingly large overlap between disordidating and neurodivergent presentations and so this is something that we're all having to rapidly up skill to be able to kind of tease out where one thing starts and another thing begins so that we can really help an individual and help a family get the services that they need Fantastic thanks any other thoughts from the panelists particularly about children from cultures where food is front and centre in family conversations So I think again that sort of comes back to that idea I think that we touched on with like the lunchbox policing around just celebrating different food services and so I think that at a community level we can try to do that and in schools we can try to do that and I think it's again whether we provide resources to families that are around how they converse around food and meal time certainly what we know is that meal times can be quite a protective factor for eating disorders in children and adolescents about connecting with each other and the conversation rather than focusing on the food So I think where there is I guess that culture around food as being important then makes that about celebration times and things like that rather than what are you eating and eat that all off your plate and those sorts of things which can be quite triggering for some young people That takes us to food preparation as well There was a really interesting question about meal time quite apart from the actual eating of food but would any of you have suggestions for the family about how they might involve the children in food preparation as the family gets together in the evening if that happens I mean certainly any kind of family oriented connection that can happen around food whether that is shopping preparing cooking, eating enjoying each other's company and again it's about context so taking an 8 year old shopping and label reading with them for example would be something that we would be discussing with the parents is not a good idea however taking kids shopping and helping them to discover lots of different maybe seasonal fruits and vegetables for example or something that comes in a new flavor or including them even in maths, budgeting things like that that parents are really creative and although we tend to be energy poor these days but that there are lots of ways and I think the critical aspect of this is that we're not doing those activities with an agenda so that we're not including kids for example in meal preparation with the agenda of them eating in a particular way or that we're not including them in anything around food with an agenda to get them to kind of get them to kind of change anything in particular that wouldn't happen naturally anyway that we're doing it for the purposes of connection and for to increase a sense of maybe you know respect for food and respect for family and finding joy I think that a lot of families especially now have lost a lot of joy in food because things are very very stressful it is a stressful time I'm going to circle around and come back like an old dog to my turf I want to get back to asking you Fiona about the non diet dietitions I mean how available it sounds like it's an initial referral decision for other health professionals about which bifurcation they take is that true that you said it would take a diet route or a non diet route for non dietitions we tend to make ourselves fairly obvious by naming that on a website or naming that on our referral database we tend to try to put it right out there to signal to other providers that we are welcome and the kind of approach that we pay so you have helped me to realise that we perhaps need to be doing a better job with that and I appreciate the platform you've given us today I think from a GPs perspective what we will be thinking about is anything related to food eating and body concern across the weight spectrum from very small to very large especially if there is any co-occurring conditions that a non diet dietition is a little, I guess we would say is a little safer to refer to and if there's anything that we need to refer on to then we'll certainly be able to Thanks for that and maybe the final question this has been asked a few times is about the possibility of family therapy and whether you'd be curious any of you as practitioners would be curious about what influences were on the parents with the next generation up and the generation beyond that would anybody delve into that sort of approach with the parents of going back to their own influences? Yes I'll speak to that I guess if we're doing strict family based therapy when there's a kind of VA eating disorder going on the approach is actually very much not to look at origin to focus on refeeding the child first it's kind of the approaches really if your child was drowning in the ocean you wouldn't stand on the sand thinking what caused what or whose fault was that you just dive in and save them but very much once the child is stabilized that's a really important place to go but also if we're not in that kind of full blown we need to medically stabilize the kid and it's more in those kind of other the other approach treatment approach I discussed before which is that early intervention prevention that's a hundred percent where I'd go so it would be very much exploring from a family systems approach it's exploring family origins and again that helps to also take away the blame and to normalize you know what was their learning what was their upbringing like to bring awareness around the language that was in their family and how that impacted them and how they might be passing that on forward so I'd definitely be exploring that with them. Thanks very much so obviously the family have their challenges ahead but I think as practitioners you've certainly not added to those challenges you've engaged with the family very appropriately but let's just have a quick two-minute summary if we could from each of you about your your thoughts about the case and where to from here so Stephanie why don't we start with you. Thanks Steve so I guess I'd like to just highlight I think as I said earlier that it's important to recognize that these issues can start in childhood and that if schools are looking for resources or programs to promote positive body image then to have a look at butterfly foundation education programs and butterfly body bright for primary schools and also within those programs of resources that health professionals can share with families about what families can be doing at home to promote positive body image with a real sort of strength focused and non non blaming focus. Thanks for that so Andrew we came to you first so we'll go to you now for your reflections. Just like Stephanie said practice a non-judgmental approach to this family being aware you know being sensitive to that they're trying to see things from their perspective really and then as a GP practicing that biopsychosocial approach ensuring that we've covered the biology off the medical side of the child as importantly as we look at psychological aspects of this case and when concerned involving a team you know we don't have to do this alone involving a multidisciplinary team that can support us and Harper and her family in their journey. Right thank you very much indeed it is indeed a journey and Fiona I think we'd go to you next. Thanks Steve so some of the most important things for us to remember as health providers is that what we say and do especially on that first encounter or those first sequence of encounters really matters it matters to the child and it matters to the family as well so echoing what both Stephanie and Andrew said about taking a non-judgmental approach and by that I don't assume that anybody would be overtly judging and also it's worthwhile acknowledging that there are some shifts that we can sometimes make in the language that we're using when we can be a bit more thoughtful about the what when how and why particularly when it comes to things like food and nutrition and things like weight and weight changes that really we can really support parents to acknowledge that they're doing the best they can in a culture which is really quite messed up when it comes to food and eating and bodies so parents aren't usually going to get a lot of help from the broader culture if anything they're going to get more confused than ever so that sequence of appointments or that first encounter with health professionals in my experience is extremely pivotal It really is a make or break moment isn't it so thank you for those insights and finally Rachel your reflections Yes, I think as Stephanie said body image concerns start young but what's also important to know is that they're pervasive and they continue well beyond adolescence so this is a really unique opportunity to both empower the family but also to develop positive body image in Harper and whoever's in front of us so positive body image is a distinct construct there's a lot more meaning to it and has really a plethora of positive outcomes for the person in front of us so it's really important to take this more holistic and long term approach in trying to develop a broader picture of who they are, how exercise and food and health fits into their world for them and really empower them in developing that more positive body image Fantastic Many important words coming through what everybody said there about positive words, positive image so thank you so much indeed for everything you've said tonight if we could ask everybody to stay on just while we finish up there's a few things I need to ask of all the participants but I will first of all thank you to the panel Rachel, Stephanie, Andrew and Fiona you've just been fantastic tonight very inspiring working in a difficult area and doing it very very well I am going to ask the participants to please fill out the exit survey, push that button and fill out the exit survey before you leave us tonight it's the pie chart icon at the lower right corner of the screen next to the speech bubble or waste until the webcast ends and the request will pop up for you to fill out the feedback form you also will receive a link from MHPN that has connects to the recording of the activity and also to get your certificates of statement certificates of attendance for those of you who need those now there's plenty coming up to finish out the year a couple I'm saying that in October but here we go a few things to mention on the webinars you can see there there's the interdisciplinary approach to caring for people living with obsessive compulsive disorder which is on Thursday the 28th of October I'll be hosting that once, hope to see a lot of you then next one on emerging minds considerations in social and emotional well being of Aboriginal and Australian children and families that's on the 10th of November then there's the primary health network on trauma informed care in older Australians have a webinar on Thursday the 18th of November and then the last webinar for 2021 is on generalized anxiety disorder on the 6th of December the podcast program so please stay tuned and you will hear about the new eating disorders series being released in November which I suspect will be of interest to the people who joined if you'd like to join discussions with other professionals at a local level then project officers are available to help you to establish or to join an existing MHPN network across Australia be that metropolitan regional rural and remote so there are currently 373 networks around the country there's an online map on the website that will show you that you can contact Jackie on an email address that you'll see there on your screens and the map there's a link after you finish the survey so it's time to finish before I close though I would like to acknowledge the lived experience of people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present I particularly want to mention that this is national carers week and to acknowledge the amazing work that 2.65 million carers in Australia do every day all day so thank you all very much for your participation this evening we hope to see you at the next webinar good night