Performer Advisory Board

The Child Performer Advisory Board to Prevent Eating Disorders:

Recommendations to the New York State Commissioner of Labor

(Click Here for pdf of Child Advisory Board Recommendations on NYS Dept of Labor website)

April 15, 2009

Overview

The Child Performer Advisory Board wishes to thank the Commissioner of Labor M. Patricia Smith and the State of New York for the opportunity to make the following recommendations regarding the establishment of guidelines for employment of child performers and models for preventing eating disorders. These recommendations are presented as required by New York State Labor Law, Sec 154.i We hope these recommendations will lead to regulations that will significantly improve the health and well being of performers and models under the age of 18 living and/or working in New York State.

The Department of Labor is uniquely positioned to address this serious health problem among an occupational group that may be particularly at risk for developing eating disorders within an age range that correlates with the most common ages of onset for illnesses that respond best to early identification and treatment.

The Board’s mandate comes from Bill S6158 Justification which states, “Eating disorders, such as anorexia nervosa and bulimia nervosa are biologically-based illnesses that are influenced by environmental factors, including societal and other pressures to be thin.” Eating disorders generally develop during adolescence and young adulthood. According to a recent report, lifetime prevalence estimates of anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women, and .3% .5%, and 2.0% among men.ii Eating disorders are associated with many potentially serious medical complications, some of which may cause long-lasting disability. Notably, anorexia nervosa is associated with the highest mortality rate of a psychiatric illness. These facts have been highlighted by the recent deaths of young professional models due to the complications of anorexia nervosa and by previous deaths and illnesses suffered by entertainment professionals with eating disorders.iii

The Board recommends these following guidelines in hopes that they will educate young people who work as performers and/or models, along with their parents, physicians and employers, about the dangers of eating disorders and the importance of prevention, identification and treatment for these serious conditions. Additionally, the Board intends through these guidelines to help NewYork State achieve a healthier workforce, including helping young workers to continue their careers in the entertainment industry should they so choose. These recommendations include enhanced requirements for physical assessment as part of the permit application process to improve the likelihood of proper identification and treatment referral for those with eating disorders. In addition, we recommend permit limitations, if needed, to assure proper evaluation and treatment of an eating disorder.

The Board was challenged by the legislative wording that required it to consider guidelines “requiring medical or mental health screenings, by medical or mental health professionals with demonstrated expertise in the diagnosis for persons suspected of having an eating disorder.”iv The Board spent significant time discussing the realities of specialized eating disorder assessment and treatment, recognizing that the numbers of eating disorder “experts” are few and that requiring an expert screening would be logistically difficult and perhaps excessively burdensome economically to the child performer and parent. The Board therefore developed resource and educational materials for all physicians to use in the physical assessment that will be a necessary component of the child performer permit process.v,vi ,vii

The Board’s recommendations place most of the responsibility for eating disorder screening upon the applicant, his/her parent or guardian, and the applicant’s physician, where the Board believes such responsibility ought to reside. The employer’s responsibility remains mainly in the area of ensuring that all covered performers and models have the proper permit before employment begins.

We hope that these recommendations are shared with the New York State Department of Education that permits child models, as well as with relevant agencies such as Department of Health and Office of Mental Health.

Since raising awareness about eating disorders was a central goal of the Board’s mission, and remains a crucial aspect in improving the rates of proper identification and treatment, the Board members have offered to participate in a media campaign announcing the new regulations.

The Board anticipates the need to periodically review the effectiveness of these recommendations and to update the permit procedures if necessary. The Board would be happy to reconvene in two years or sooner if the Commissioner wishes their assistance on this important matter.

Recommendations

I. The Board makes the following recommendations to the Commissioner of Labor regarding the consideration of Body Mass Index standards (BMI) or weight and height standards and the requiring of medical or mental health screenings, by medical or mental health professionals with demonstrated expertise in the diagnoses and treatment of eating disorders, for persons suspected of having an eating disorder:

A) The Department requires that in order to obtain a child performer permit an applicant of any age demonstrate evidence of a recent (within the previous 12 months) physical exam performed by a pediatrician, adolescent medicine specialist, family practice physician or internist which would include an eating disorder screening as part of the exam.

B) The Commissioner of Labor recommends to the Department of Education that an eating disorder screening be added to the already required physical exam for an applicant to obtain a child model permit. This will achieve parity in the physical exams required for child performers and models in order to prevent and detect eating disorders.

C) The Department requires that an applicant’s physician submit a certification of physical fitness to the Department attesting that the applicant is physically able to work, as is the case with regular employment and child models regulated by the Department of Education. The Department shall keep the physical fitness certification on file for 1 year to be renewed annually.

D) The Department uses the current Department of Education AT-16 as a model for the certification of physical fitness with the following modifications:

1. Include a time limit on the validity of the physical fitness certification. This will ensure that an applicant who has been identified as possibly having an eating disorder comply with treatment and that his/her condition be monitored. The physician may limit the validity of the certification to expire before 1 year. If the certificate of physical fitness expires, then the permit will be invalidated. The time limits placed on the validity of the certification may be 90, 180, or 240 days depending on the physician’s determination for treatment or monitoring needed.

2. The physician answer the following questions prior to an attestation statement and signature on the certification of physical fitness:

Is there evidence that this applicant may have an eating disorder? Y N

Do you recommend that the applicant receive treatment for an eating disorder? Y N

Is this applicant healthy enough to work? Y N

Do you place a time limit on the validity of this physical fitness certification because you want to monitor or treat an eating disorder? Y N

E) The Department provides the following guideline to the screening physician to aid in the assessment of the presence of a possible eating disorder and serves as a basis for treatment recommendation and/or referral for treatment.

a) Is the BMI percentile < 5th percentile?

b) Is there evidence that the individual has demonstrated failure to achieve expected weight gain?

c) Is the individual’s menstrual history normal?

d) Does the applicant endorse symptoms and or physical manifestations of an eating disorder?

F) The Department provides information to the screening physician about the importance of the certification process and provides information on accessing educational materials on eating disorders.

G) The Department provides the following information to the screening physician. The Department may choose to provide the outline via direct mail or fax to the physician or provide the applicant with the outline to bring to the physician who will perform the physical exam. The Department shall post the outline on the Department website.

1) The physical exam required to obtain the child performer or child model permit must include an eating disorder screening. The screening must include measurement of height, weight, calculation of Body Mass Index (BMI) and BMI percentile. The physical exam must also include vital signs, menstrual history and a review of the physical manifestations associated with eating disorders.

2) The physical exam must include inquiry into eating behaviors, e.g., using the American Medical Association Guidelines for Adolescent Preventive Services (GAPS) assessment or the mnemonically titled SCOFF questionnaire. These assessment tools are shown below:

GAPS: These questions will help us get to know you better. Choose the answer that best describes what you feel or do.

a. Are you satisfied with your eating habits? Y Y

b. Do you ever eat in secret? Y N

c. Do you spend a lot of time thinking about ways to be thin? Y N

d. In the past year,have you tried to lose weight or control your weight by vomiting, taking diet pills, or starving yourself or skipping meals? YN

e. Do you exercise or participate in sport activities that make you sweat and breathe hard for 20 minutes or more at a time at least three or more times during the week? YN

SCOFF:

a. Do you make yourself SICK when you feel uncomfortably full?

b. Do you worry you have lost CONTROL over how much you eat?

c. Have you recently lost more than 14 pounds within three months? (this quantity is known in Great Britain as ONE stone’s worth ofweight)

d. Do you believe you are FAT when others say you are too thin?

 e. Would you say that FOOD dominates your life?

II. The Board makes the following recommendations to the Commissioner of Labor regarding the consideration of Body Mass Index standards (BMI) or weight and height standards and requiring referrals for treatment of eating disorders:

A) The Department uses the outline below as a guideline for the treatment of Eating Disorders.

B) The Department provides outline below to the screening and/or treating physician to be reviewed in consideration of the issuance of certificate of physical fitness for the Child Performer Permit and Child Model Permit.

C) The Department posts the outline on the NYS DOL website where parents, physicians and employers may view it.

Treatment guidelines for the screening/ treating physician A physician may choose to refer an applicant for treatment based on the applicant’s BMI percentile and/or their behavioral analysis. The Board recommends that the physician use the recommended treatment outlines as follows which are based on the APA recommendations and Board experience.

1. Treatment recommendations based on Body Mass Index (BMI) percentiles for age.

Use body mass index percentiles for age

a) <5th percentile

  • Medical stabilization including re-feeding on an inpatient medical unit.
  • No exercise

b) 5 to <10th percentile

  • Intensive outpatient programming
  • Partial Hospitalization
  • Residential Treatment
  • No exercise

c) >10th percentile ␣

Outpatient treatment

• Therapist

  • One to two times per week Individual, group, family therapy is indicated CBT, DBT, IPT recommended forms of therapy

• Dietician

  • One to two times per week Weekly weights Establish specific meal plans consistent with treatment goals
  • Physician Medical monitoring
  • Visits q4 weeks
  • Expectations - 1/2lb to 1lb weight gain per week - Maintain healthy behaviors
  • Exercise - Weight bearing exercise with normal menstrual cycle and/or acceptable bone density

2. Treatment recommendations based on behavioral profile and presence or absence of co morbid conditions.

Multiple methods of compensatory behavior ␣ Intensive Outpatient Programming, Partial Hospitalization,

Residential treatment Medical abnormalities (i.e. low K)

␣ Medical Stabilization Significant weight loss or gain in less then one month without medical complications

␣ Intensive Outpatient Programming, Partial Hospitalization, Residential treatment

Suicidal/Homicidal Ideation/Attempt or Self harming behaviors ␣ Inpatient Psychiatric Admission with discharge to Intensive

Outpatient Programming, Partial Hospitalization, Residential

treatment if SA/HA is related to ED Debilitating Anxiety and/or Depression related to Eating Disorder

␣ Intensive Outpatient Programming, Partial Hospitalization, Residential treatment

␣ GAF of 45 or less Inpatient Psychiatric Admission with discharge to Intensive Outpatient Programming, Partial Hospitalization, Residential treatment if SA/HA is related to ED

␣ Use of healthy exercise

Co morbid substance abuse and or dependence ␣ Intensive Outpatient Programming, Partial Hospitalization,

Residential treatment

III. The Board makes the following recommendations to the Commissioner of Labor regarding employment restrictions for persons diagnosed with or suspected of having eating disorders:

A) The Department requires that an employer post the regulations for child performers and models including information about eating disorders and resources in a conspicuous place in his or her establishment.

B) The Department conducts coordinated and targeted enforcement efforts with all involved agencies (Education Department, Department of Consumer Affairs, etc) among employers who employ child performers and models especially among the modeling industry and second dance companies, apprentice companies and or junior companies which employ performers covered by Article 4A of NYS Labor Law.

C) The Department requires that in order to obtain or renew a Certificate to Employ Child Performers, an employer must attest that they have reviewed the educational materials regarding eating disorders either by a web site attestation or on the application itself and the attestation will include the date and list the employer’s title.

D) The Department requires that in order to obtain the child performer permit, in the statement of parental consent that the consenting adult (parent or guardian) attest that they and the applicant have reviewed the educational materials on eating disorders.

E) The Department receives reports of suspected eating disorders among models and performers from employers, parents or physicians or from whomever the Department deems appropriate.

F) The Department revokes a Child Performer’s permit with good cause such as, where a physician reports to the Department that a certification of physical fitness is no longer valid because a performer has discontinued treatment.

G) The Department provides the parent or guardian of a performer whose permit is being considered for revocation, notice of the considered revocation and the opportunity to address the issues causing the considered revocation.

IV. The Board makes the following recommendations to the Commissioner of Labor regarding education and educational materials for such child performers and models, their parents and/or guardians and their employers regarding awareness and recognition of eating disorders and referral and treatment information of eating disorders such as anorexia nervosa and bulimia nervosa.

A) The Department makes available on their website and in hard copy form in multiple languages, educational materials covering the following topics developed from the existing educational materials listed further below:

• Recognizing eating disorders: Including the signs & symptoms of the disorders and associated behaviors.

• The consequences of eating disorders and unhealthy weight control behaviors.

• Referral sources, including the NYS Comprehensive Care Centers for Eating Disorders and National Eating Disorders Association.

B) The Department maintains a presence at performer and model venues and has educational materials available at the venues.

C) The Department develops an employer/industry educational seminar presentation on the regulations for Child Performers and Models and where possible, invites an expert on eating disorders to discuss eating disorders at such educational seminars or presentations.

Educational Materials/ Resources

NEDA National Eating Disorders Association

http://www.nationaleatingdisorders.org/

http://www.nationaleatingdisorders.org/information-resources/parent-toolkit.php

http://www.nationaleatingdisorders.org/information-resources/educator-toolkit.php

http://www.nationaleatingdisorders.org/information-resources/resources-and-links.php http://www.nationaleatingdisorders.org/uploads/file/information-resources/VideoList.pdf http://www.nationaleatingdisorders.org/information-resources/treatment-professionals.php http://www.nationaleatingdisorders.org/information-resources/ask-an-expert/warning-signs.php

Academy for Eating Disorders

http://www.aedweb.org/eating_disorders/diagnoses.cfm

http://www.aedweb.org/eating_disorders/outcomes.cfm

http://www.aedweb.org/eating_disorders/consequences.cfm

http://www.aedweb.org/eating_disorders/treatment.cfm

http://www.aedweb.org/eating_disorders/index.cfm http://www.aedweb.org/public/hcaccess.cfm

http://www.aedweb.org/public/EDsearch.cfm

New York State Department of Health

www.health.state.ny.us

http://www.health.state.ny.us/diseases/chronic/eating_disorders/guidelines.htm http://www.health.state.ny.us/diseases/chronic/eating_disorders

Comprehensive Care Centers for Eating Disorders

http://www.health.state.ny.us/diseases/chronic/eating_disorders/comprehensive_care_centers.

Western NY Comprehensive Care Center for Eating Disorders

www.nyeatingdisorders.org Northeastern

NY Comprehensive Care Center for Eating Disorders

www.amc.edu/patient/services/neccced

Metropolitan NY Comprehensive Care Center for Eating Disorders

www.eatingdisordercenterofexcellence.org

National Institute of Mental Health

http://www.nimh.nih.gov/health/publications/eating-disorders/index.shtml

NYS Office of Mental Health

http://www.omh.state.ny.us/omhweb/resources/eating_disorders.html http://www.omh.state.ny.us/omhweb/booklets/eatingdisorder.html

Other Resources

http://www.edreferral.com/

http://www.naph.org/

http://www.iadms.org

http://www. Artsmed.org

http://www.opheliasplace.org

http://www.bulimiaguide.org

http://www.feast-ed.org

http://www.athealth.com/Add_eatingdisorder,html

http://www.info@maudsleyparents.org

Board Members

Deborah Allton-Maher, Eastern Counsel American Guild of Musical Artists, AFL-CIO. Union representing Dancers, Singers, Stage Production Staff in Dance and Opera Companies

Drew Anderson, Ph.D. Associate Professor of Clinical Psychology SUNY, Albany

Emme Aronson, Model and Media Consultant, Emme Associates, Inc.

Evelyn Attia, M.D. Director, Columbia Center for Eating Disorders, Clinical Professor of Psychiatry at Columbia University and Director, Metro NY Comprehensive Care Center for Eating Disorders.

Keith-Thomas Ayoob, EdD, RD, FADA Associate Clinical Professor of Pediatrics at Albert Einstein College of Medicine. Clinical Pediatric Nutrition practice for 25 years.

Bradley Bayou, Fashion Designer, Bradley Bayou Couture

Bob Boyett, Broadway Producer

Mary Ellen Clausen, Founder & Executive Director Ophelia’s Place, Inc.

Mary Daley, NYS Department of Education

Nancy Fox, Screen Actors Guild, National Director of Policy and Strategic Planning. Responsible for national legislative policy including child performer employment issues.

Stewart Gabel, M.D. Medical Director, Children and Family Services, NYS Office of Mental Health

Lynn Grefe, Chief Executive Officer, National Eating Disorders Association

Linda Hamilton, Ph.D. Clinical Psychologist specializing in eating disorders.Wellness Consultant, New York City Ballet

Stanley Hertz, M.D. Child Psychiatrist specializing in the evaluation and pharmacological treatment of children and adolescents with eating disorders.

Sondra Kronberg, MS, RD, CDN Co- founder and Nutritional Director of Eating Disorder Associates Treatment and Referral Centers of NY, an outpatient treatment facility. A National Liaison to NEDA.

Tamara Markowitz, Agent, Tamara Markowitz Talent

Barbara Metzger, M.S. Director, Special Projects, Division of Chronic Disease Prevention and Adult Health, NYS Department of Health

Rachel Moore, Executive Director, American Ballet Theater

Julie Morison, Ph.D. Clinical Psychologist, Director of Psychological Services, Comprehensive Care Center of Northeastern New York Albany Medical Center

Alan Simon, President, On Location Education

Mary Tantillo, Ph.D., RN, CS Western NY Comprehensive Care Center for Eating Disorders

i Labor Law S154

ENDNOTES

ii Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58. Epub 2006 Jul 3.

iii Bill S6158, Labor Law S154 iv Labor Law S154 v Morgan, Reid, and Lacey. SCOFF questionnaire. BMJ. 1999 Dec;319:1467- 1468 vi GAPS Guidelines fro Adolescent Prevention Survey, American Medical Association vii American Psychiatric Association, Practice Guidelines for the Treatment of Patients with Eating Disorders, 3rd Edition. Am J Psychiatry. 163(7), July 2006.

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