Earlier in the semester, I wrote a short paper on the school nurse’s role in preventing and treating eating disorders as part of my study on childhood development. However, upon discussing this topic further with school nurses over recent weeks, I have gained some new insights and was inspired to do more research. Most compellingly, I read an article published in the International Journal of Health Sciences on the importance of early detection and screening for eating disorders, a task that the school nurse is in a “perfect position” (Rindahl, 2017) to undertake.
Like many other serious conditions, eating disorders are more difficult to treat the longer they progress without diagnosis (Rindahl, 2017). Fortunately, in recent years, the Diagnostic and Statistical Manual of Mental Disorders was revised to give a broader and less strict diagnostic criteria to anorexia and bulimia nervosa – for example, one no longer needs to have a BMI of less than 17.5 to be diagnosed with anorexia. This alteration “opens the possibility of diagnosis…earlier than was possible with the DSM-4 criteria,” (Rindahl, 2017) and allows for more prompt treatment. This is critical given that eating disorders are among the most deadly mental illnesses due to both physical effects and the heightened risk for depression and suicide.
At present, no mandated screenings exist for eating disorders in schools, nor national standards to guide nurses or professionals. Additionally, required school screenings are set at the state or local level. Fourteen states mandate body mass index (BMI) testing, primarily to identify overweight and obese students, however, recent studies have called into question the effectiveness and even possible detrimental results of these tests. While beneficial in some aspects, monitoring BMI can also trigger unhealthy behaviors in students with anorexia or disordered eating. Furthermore, some individuals with bulimia may be classified as obese. As a whole, it is clear that BMI testing alone cannot be used to identify eating disorders.
Rindahl’s article concluded by identifying and describing a potentially effective screening tool for school nurses, titled the SCOFF Questionnaire. This resource, created in London at the St. George Medical Hospital, contains only five yes or no questions, requiring only two ‘affirmative answers’ to ‘indicate a risk for anorexia or bulimia’ (Rindahl, 2017). This tool has been praised for both its efficiency and effectiveness, requiring little time for students while still yielding useful results. It has been implemented in nearly a dozen countries. The author also discussed other screening tests, including the Disordered Eating Attitude Scale (DEAS), the Eating Attitudes Test (EAT-26), and Yale Food Addiction Scale (YFAs). However, these were ruled out for various reasons such as focus on a particular type of eating disorder, length, and burden on students. The SCOFF test is a strong initial screening tool, which can then lead to other tests if need be.
While I think that a screening test can be effective for identifying potential eating disorders, I believe that the best way to help students struggling with this is to truly get to know them and understand their normal behaviors, thus allowing the nurse to note deviations or changes. However, in most schools, with hundreds of students, it is difficult to do this. Often the parents or caregivers will be the first to notice unhealthy behaviors in their child. In my future work, I hope to create a culture where parents feel comfortable coming to me with initial concerns about their child’s eating habits. Often the student will not be the one to do this. Eating disorders, as I have learned from personal experience, are unlike a broken leg or stomach bug, where one will voluntarily seek medical treatment. Many are in denial. One school nurse that I spoke with also expressed frustration that she is often the last to know if a student is, for example, returning to school following hospitalization from an eating disorder. Yet if families see school nurses actively involved in the prevention of and screening for eating disorders, perhaps they will be more likely to seek guidance from them when they see their student struggling. This also means that the school nurse must be thoroughly educated on eating disorders, especially among students of the ages that they treat. It will certainly require effort on the part of the school nurse. However, I believe that a combination of annual screenings (much like an annual vision screening for elementary school students), relationships with students and families, professional knowledge of the diseases, and a culture of openly discussing these disorders, the school nurse can effectively identify and help students struggling with eating disorders.
