The Adolescent Who Refuses Food and the Family Who Want Discharge

High-risk features:

• BMI 13.8 - severe malnutrition; risk of refeeding syndrome and cardiac complications rises steeply below BMI 15.
• Heart rate 48 bpm - significant bradycardia; a marker of starvation and a risk factor for arrhythmia.
• Temperature 35.9°C - hypothermia, another marker of severe malnutrition.
• Exercise in the bathroom at night - purging behaviour by activity, hidden, and occurring unsupervised; increases energy deficit and cardiac risk.
• Adolescent with rapid weight loss - high medical instability.

Immediate priorities:

1. Medical stabilisation - continuous or frequent cardiac monitoring, lying/standing BP and pulse, temperature; correct any electrolyte disturbance; check phosphate, magnesium, potassium, and renal function before and during refeeding.
2. Refeeding protocol - start low and go slow, with phosphate, potassium and magnesium monitoring; do not allow rapid refeeding. Involve a dietitian and paediatric team.
3. Supervision - 1:1 observation, including after meals and at night, to prevent exercise and purging; bathroom supervision with dignity.
4. Establish capacity and consent - she is 15; assess her competence to refuse treatment. If she lacks capacity for this decision, treatment can proceed in her best interests under child/mental health legislation, with parental involvement where appropriate.
5. Engage the family - the parents' disagreement must be managed; a family meeting with clear medical explanation, and if necessary legal advice on consent, is needed.
6. Psychological treatment - family-based treatment (Maudsley model) is first-line for adolescent anorexia nervosa; start as soon as medically safe.

Exam point: the answer must combine medical risk assessment (refeeding, cardiac) with legal/ethical reasoning about a minor's refusal and parental disagreement.

Framing. This is a conflict between parental authority, the young person's own wishes, and the clinical duty to prevent serious harm. It is not simply 'the father is wrong'.

Steps:

1. Assess the young person's capacity/competence to make this decision. A 15-year-old with severe malnutrition may have impaired decision-making due to the illness itself (cognitive effects of starvation), but competence must be assessed, not assumed.
2. Assess risk of discharge - BMI 13.8, bradycardia, hypothermia and covert exercise mean discharge carries a real risk of cardiac death. Document the risk explicitly.
3. Meet the family - explain the medical findings in plain language, with the paediatric team present; address the father's belief that it is 'a phase'. Explore his concerns (fear, stigma, cost, family conflict) rather than dismissing them.
4. Legal routes - if the parents do not agree and the young person is at serious risk, the options depend on jurisdiction: child protection referral, application to court for a specific issue order or wardship, or mental health legislation if the criteria are met. In many jurisdictions, a parent cannot simply remove a child against medical advice when there is a risk of serious harm; the clinical team should seek urgent legal advice rather than physically blocking discharge.
5. If discharge occurs against advice - document the advice given, the risks explained, the follow-up offered, and ensure a safe discharge plan (outpatient review, crisis contact, GP letter). Do not abandon the family.
6. Ethics - respect for autonomy (of both the young person and parents), beneficence/non-maleficence, and the child's best interests. The young person's views should be heard, but best interests can outweigh them when the risk is high.

Exam point: the correct answer uses the legal framework and family engagement, not confrontation, and documents the risk assessment and the advice given.

Interpretation. Secret exercise and hiding food are eating-disorder behaviours persisting despite apparent engagement. Early weight gain does not mean recovery; the illness often intensifies its behaviours as weight increases and the patient's fear of weight gain grows. This is a predictable phase, not a treatment failure.

Management:

1. Increase structured supervision - meals and 30–60 minutes after meals, bathroom supervision, and a clear behavioural protocol agreed with the team. This is supportive, not punitive.
2. Do not confront punitively - explore what the behaviour is doing for her (anxiety reduction, control) and address the underlying fear.
3. Continue family-based treatment - parents are supported to take charge of meals and to manage exercise at home; this is the evidence-based approach for adolescents.
4. Review the meal plan and weight targets with the dietitian; ensure the rate of gain is safe and agreed.
5. Monitor medical status - repeat ECG and electrolytes if behaviours persist.
6. Address the family conflict - the parents' disagreement may be feeding the behaviour; family work should continue.

Exam point: the correct answer recognises that secret behaviours are a sign of the illness, not of 'manipulation', and responds with structured, supportive, evidence-based care rather than discharge or punishment.