Pediatric Eating Disorders

Introduction

Eating disorders are potentially life-threatening illnesses that have a particularly detrimental impact on growth and development in children and adolescents. While eating disorder treatment can be complex, early diagnosis and intervention in primary care settings improves outcomes for these youth.

• The Centers for Disease Control (CDC) has reported that disordered eating behaviors are common among teens. 18.7% of females and 7.7% of males reported going 24 hours or longer without eating to lose weight or keep from gaining weight in the last month. Further, 6.6% of females and 2.2% of males reported vomiting or using laxatives to manage weight.
• The number of adolescents meeting criteria for an eating disorder is smaller, but still significant.
  • Lifetime prevalence for Anorexia Nervosa is 0.5% to 2% with peak age of onset of 13-18 years
  • Lifetime prevalence for Bulimia Nervosa is 0.9% to 3% with an age of onset of 16-17 years
  • Lifetime prevalence for Binge Eating Disorder is ~2-3%
• Rates have increased following the COVID-19 pandemic. Children and adolescents are presenting to hospitals with eating disorders at higher rates and with greater severity of illness.
• It is worth noting that eating disorders are chronically underdiagnosed, so rates are likely higher than what is reported in the literature.

Screening for Eating Disorders

Pediatricians are uniquely positioned to routinely screen for eating disorders as part of their annual well child visits. These screenings should involve regular monitoring of height and weight plotted on growth charts. Clinical interview should include questions on diet changes, body image dissatisfaction, changes in exercise patterns, and experience of weight stigma. Best practice is to ask both the child and caregiver about some of these behavior changes as there is often shame and secrecy involved in eating disorders. Parents may be noticing changes without realizing their child has developed an eating disorder. It can also be helpful to ask the patient and caregiver to complete a 24-hour diet recall as eating disorder beliefs about food may skew symptom endorsement. There are a few brief screening tools that providers can incorporate into their visits:

• SCOFF
• Eating Attitudes Test (EAT-26)
• Eating Disorder Examination Questionnaire (EDE-Q)

Outpatient management of eating disorders

When caught early, eating disorders can be effectively managed in outpatient care. Ideally, a multidisciplinary team consisting of a therapist, PCP, and dietician (if needed) can partner to support these patients. The PCP will monitor weight trend in those needing to weight restore with a goal of patient gaining a ½ to 1 pound a week. This is done through increasing food intake and decreasing physical activity. Weekly visits are recommended initially until steady weight gain is established.

The therapist will also be meeting with patient and family weekly to help them interrupt eating disorder behaviors (restriction, binge eating, purging, excessive exercise). Family-based treatment (FBT) has the strongest evidence base for children and adolescents. The core tenants of FBT are that the caregivers are the main agents of change, the caregivers and treating providers take an agnostic view as to the cause of the eating disorder, the therapist takes a consultative stance, and everyone works to externalize the illness from the patient. The focus is on interrupting behaviors and helping caregivers feed their child. Therapy sessions should help caregivers identify accommodation behaviors they might be engaging in to reduce their child’s distress. The therapist works with caregivers on how to use behavioral strategies to set firm and consistent expectations around meal completion. The therapist works primarily with the caregivers in early stages of treatment, especially when the child or adolescent has low motivation to change.

Indications for higher level of care

• Medical Hospitalization
  • Acute food refusal
  • Uncontrollable bingeing and purging
  • Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.)
• Partial Hospitalization (Day Treatment)
  • Comorbid psychiatric or medical conditions that interfere with outpatient treatment (e.g., severe depression, suicidal ideation, obsessive compulsive disorder, type 1 diabetes mellitus)
  • Failure of outpatient treatment (e.g., losing weight, increased functional impairment)
  • Severe malnutrition

Eating Disorders Program at Children's Hospital Colorado

For more information, providers can call 720-777-6200 or visit the website.

• 7 day a week, partial hospitalization program
  • Extended day 7:30 AM-6 PM (breakfast through dinner)
  • Regular day 8:30-4 (breakfast and dinner at home)
  • All patients start in extended day and then progress to regular day as they begin transferring parent supported nutrition to home setting.
• Average length of stay is 5-7 weeks
• Team members: Psychiatry, Psychology, Master's level therapists, Registered Dieticians, Nurses, Counselors, Adolescent Medicine consultation
• Therapy: Individual, family, group, multi-family group, parent group, creative arts
• Therapeutic Models: Family Based Treatment (adapted for higher levels of care), Emotion Focused Family Therapy, Unified Protocol
• Our treatment focuses on the caregivers as agents of change. They are provided instruction in parent supported nutrition and involved in all aspects of their child’s treatment. Caregivers learn to manage mealtimes at home and provide the necessary supervision to interrupt eating disorder behaviors.
• Our goal is to provide families with the core skills necessary to continue treatment in a more traditional outpatient therapy setting (e.g., weekly sessions) after discharge.

Common questions from caregivers

• "Why doesn't my teen want to get better?"
  • Eating disorders are ego syntonic. Many teens do not want to let go of their eating disorder as they are using it to cope with difficult emotions. As their parent, you need to take on the role of fighting this illness for them at the onset.
• "Why can't I let my kid leave the last few bites on the plate?"
  • Even this minor amount of restriction is a "win" for the eating disorder and allows the child to have some control over the eating episode. A few bites quickly become whole items and it snowballs from there.
• "Can my kid exercise if she is eating meals?"
  • It depends. Sometimes kids are physically ready to resume exercise before they are psychologically ready. If they are still focused on burning calories and using exercise as a compensatory behavior after eating, then it is best to hold off. We recommend starting with family activities like a walk and sports that involve social interaction.

Additional resources for eating disorders

Websites

• National Eating Disorders Association
• Families Empowered and Supporting Treatment of Eating Disorders
• Academy of Eating Disorders
• National Institutes of Health
• Emotion Focused Family Therapy

Books

• Survive FBT: Skills Manual for Parents Undertaking Family Based Treatment (FBT) for Child and Adolescent Anorexia Nervosa (Ganci)
• Help your Teenager Beat An Eating Disorder by (Lock & Le Grange)
• Skills-based caring for a Loved One with an Eating Disorder. The New Maudsley Method (Treasure)
• What Causes Eating Disorders and What do they Cause: An essential introduction for anyone who would like to understand eating disorders and how to overcome them (Frank)