Holding risk without panic: a CAMHS dietitian's view on when to escalate

In CAMHS eating disorder work, risk rarely arrives all at once.

Most young people do not suddenly become medically unwell overnight. More often, the warning signs are there weeks earlier. Lunch is skipped more often. Portions shrink. Meals take longer. Walking increases. Parents sound more tired. School becomes harder. Weight drops again. Everyone hopes next week will be better.

By the time panic enters the room, risk has often been building quietly for some time.

Knowing when to increase support, request urgent medical review or recommend admission is rarely about one number in isolation. It is about recognising deterioration early and responding before a crisis becomes the only option.

Dietitians have an important role in this. We are often closest to the detail of intake, weight change, family meal support and nutritional decline. We may notice problems before they become obvious elsewhere.

One of the most common mistakes in CAMHS eating disorder care is overvaluing a snapshot and undervaluing a trajectory.

A single weight matters less than the direction of travel. A pulse matters less when separated from intake, hydration, function and recent loss. Normal blood tests do not automatically mean safety.

A young person at 92% weight-for-height, who is losing weight weekly, becoming more rigid, unable to complete meals and socially withdrawing, may be of greater immediate concern than someone at a lower percentage who is medically stable, increasing intake and engaging with treatment. Likewise, a young person within an average weight range may falsely reassure if there has been rapid weight suppression from their established growth curve. Medical instability does not always correlate neatly with appearance or body size.

Children and adolescents are still developing. Risk includes not only current physiology, but interrupted growth, pubertal delay, menstrual disruption, compromised bone health, cognitive slowing and the wider developmental cost of malnutrition. Weight loss is measurable. Growth failure is often quieter. Both matter. Dietitians are often well placed to bring this trajectory thinking into the room.

Dietitians are sometimes the first to recognise that the current plan is no longer working.

We may notice:

• Three meals becoming two

• Snacks disappearing

• “I had breakfast,” meaning half a yoghurt

• Foods narrowing to very low-energy options

• Meal plans completed only through exhausting supervision

• Rising distress around foods recently tolerated

• Increased walking, pacing or standing

• Weight maintenance achieved only through intense family effort

These details can look small in isolation. Together, they often tell the story early:

• A normal blood result does not cancel out a collapsing intake.

• A calm presentation in clinic does not always mean safety.

Some young people become very skilled at looking fine while becoming less safe. I have also seen apparent ‘mild’ cases deteriorate quickly after weeks of false reassurance.

Not every deterioration requires hospital admission. Many young people can be safely supported in the community with stronger input. That may include:

• More frequent reviews

• Bloods or ECG

• Stronger parent-led meal support

• Pausing sport or exercise

• Intensified family-based treatment

• School adjustments

• A joint MDT review

• Clear thresholds for urgent reassessment

Community treatment should feel active and containing, not like waiting for collapse.

Hospital admission can be lifesaving, but it is not a complete solution. It may restore medical stability, interrupt acute deterioration and create breathing space for families. It does not automatically resolve fear of food, family strain or the need for a strong discharge plan. Good escalation thinking considers not only how to admit, but how to step back into the community safely afterwards.

Escalation decisions are not always difficult because information is missing. Sometimes they are difficult because professionals interpret the same information differently.

One clinician may focus on normal bloods, another on rapid weight loss. A school may report a young person who looks exhausted and unable to concentrate, while clinic presentation appears calm and polite. A parent may describe chaos at home, while the appointment feels relatively contained. This is where shared formulation matters. Delay often happens not through lack of care, but through fragmented thinking.

Useful team questions include:

• What is each person seeing?

• What has changed over the last month?

• What risk is immediate, and what risk is cumulative?

• What might we be underestimating?

Good escalation decisions are rarely made alone.

Common warning signs include:

• Ongoing weekly weight loss despite treatment

• Inability to increase intake

• Syncope, dizziness or marked fatigue

• Bradycardia or concerning observations

• Dehydration

• Vomiting, purging or laxative use

• Refusal of monitoring

• Severe meal distress preventing intake

• Rapid mood decline

• Suicidality or self-harm risk

• School non-attendance due to illness severity

• Parents unable to sustain meal support safely

Often it is not one factor. It is several appearing together.

School can also be an early warning system. Declining concentration, missed lunches, withdrawal from peers, increased distress around PE, or falling attendance may signal worsening nutritional and psychological risk before a medical crisis develops.

In CAMHS, risk does not only sit with the young person. Parents may be frightened, divided, burnt out or overwhelmed. One parent may understand the seriousness, while the other minimises it. Mealtimes may dominate family life. Siblings may be affected. Families can reach a point where they are trying very hard but no longer coping.

A young person whose medical markers are borderline but whose carers are exhausted and unable to supervise meals may be less safe than numbers suggest. Equally, a family who is anxious but organised, aligned and able to lead meals may safely hold significant risk at home with close support. I have seen families hold extraordinary levels of risk at home when properly supported.

Family assessment is not an optional extra in CAMHS eating disorder care. It is part of risk assessment

Families remember how clinicians speak in high-risk moments. We do not need to frighten them, but we do need to be honest. Useful language often sounds like:

• “I am concerned by the direction things are going.”

• “This is not an emergency today, but it needs a stronger response now.”

• “Your child may look calm, but nutritionally they are deteriorating.”

• “We may manage this at home, but only with tighter support.”

• “If these markers worsen, we will need urgent medical review.”

Clear language reduces anxiety better than vague reassurance.

Dietitians are not there simply to count calories or update meal plans. We help teams understand what nutritional deterioration looks like before crisis develops. We translate reduced intake into medical risk, slowed growth into urgency, food rules into functional impairment and weight trends into clinical meaning.

Sometimes we are the person saying, gently but clearly: “This is no longer enough.” At other times we may be the person saying: “This is serious, but we can still hold it safely if we act now.” Both are valuable.

Holding risk well requires calm thinking, timely action and clear communication. Young people need teams who notice early change and respond proportionately. Families need steady leadership. Colleagues need clear nutritional formulation.

The dietitian’s role is not to create alarm or false reassurance. It is to recognise when risk is rising, explain what that means and help the team respond before admission becomes unavoidable.

When this is done well, the difference is felt by the whole team – and most importantly, by the young person and family who needed someone to notice in time.