Childhood Eating Disorders

American society places a lot of focus on eating practices, weight and body appearance. Obesity rates in children, adolescents and adults have risen over the past several decades and our diet’s impact on physical health has become an essential topic for healthcare providers to address with families. At the same time, eating disorder prevalence has steadily increased.

Eating disorders in children are becoming more common

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 results in significantly improved outcomes and prognosis. 

Given the prevalence and severity of eating disorders in children, primary care providers (PCP) can play a key role identifying symptoms and connecting families to the right care.

• 22% of children and adolescents worldwide experience symptoms of disordered eating.
• Lifetime prevalence of eating disorders is 9% in the United States, although eating disorders are chronically underdiagnosed in youth.
• Anorexia nervosa has a mortality rate of 5% to 6%, which is the second highest of any mental illness behind opiate addiction.
• 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.

Screening for eating disorders in teens and children

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.

Providers should ask questions about diet changes, body image dissatisfaction, changes in exercise patterns and experience of weight stigma. Asking both the child and caregiver about some of these behavior changes is the best practice as eating disorders often involve shame and secrecy. Parents may notice these changes without realizing their child has developed an eating disorder.

It can also be helpful to ask the child and caregiver to complete a 24-hour diet recall as eating disorder beliefs about food may skew symptom endorsement. Providers can incorporate a few brief screening tools into their visits:

• SCOFF
• Do you make yourself Sick because you feel uncomfortably full?
• Do you worry you have lost Control over how much you eat?
• Have you recently lost more than One stone (14 lb/6.3 kg) in a three-month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?

One point for every "yes." A score of 2 or more indicates a likely eating disorder and should prompt further evaluation

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

Assessing the severity of eating disorders in adolescence or childhood

When you identify a patient as at-risk during screening, you must complete further assessment to determine next steps for treatment. It's important to gather multiple data points to determine the severity of symptoms, as most patients are likely to deny or rationalize their symptoms. Additionally, family members can unknowingly rationalize eating disorder symptoms or be unaware of the extent of symptom severity.

You should interview patients and parents separately and ask about historical and current eating practices, exercise habits, ideal weight beliefs, trauma, substance use and family psychiatric history. Additionally, reviewing past and current medical and nutritional records can help identify potential problems and may illuminate discrepancies if a patient is denying symptoms.

Outpatient management of pediatric and teen eating disorders

When caught early, providers in outpatient care can effectively manage eating disorders. Ideally, a multidisciplinary team consisting of a therapist, PCP and dietitian (if needed) partner to support these patients. The PCP should monitor weight for those needing to re-gain weight with the goal of the patient gaining a half pound to 1 pound a week. Consider having patients complete weight check-ins wearing hospital gowns as some patients will hide objects in their clothing to artificially increase their weight. We recommend weekly visits until the child establishes steady weight gain.

The therapist will also meet with the 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 focus is on curbing harmful behaviors and helping caregivers sustain a healthy diet for their child.

Therapy sessions will help caregivers identify and explain 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 completing meals.

When to refer to a higher level of care for eating disorders

It’s important that PCPs know what level of care to refer a child to based on their behavior.

Providers should refer patients for medical hospitalization if they’re showing these signs:

• Acute food refusal
• Uncontrollable bingeing and purging
• Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.)

Physicians should refer children to a partial hospitalization program if they’re displaying these signs:

• 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

The Eating Disorder Program at Children's Colorado is a valuable resource for providers in Colorado and the surrounding region. The program has been treating pediatric eating disorders for more than 30 years and offers a comprehensive evaluation to determine an appropriate treatment plan based on individual patient needs. The program offers services for children and adolescents through age 18.

If providers think a child needs a comprehensive evaluation and eating disorder treatment plan, they can refer families to schedule an evaluation appointment with our Eating Disorder Program by calling 720-777-6200.

Our Program offers:

• Partial hospitalization care seven days a week
• Psychiatric providers, psychologists, master's level therapists, registered dietitians, nurses, counselors and adolescent medicine providers  
• Individual, family, group, multi-family group, parent group and creative arts therapy
• Several therapeutic models: Family-based treatment (adapted for higher levels of care), emotion-focused family therapy and unified protocol

Our treatment also focuses on caregivers as agents of change. They’re 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.

Additional resources on eating disorders

The following organizations offer additional, reliable information about pediatric eating disorders:

• National Eating Disorders Association
• National Association of Anorexia Nervosa & Associated Disorders
• Families Empowered and Supporting Treatment of Eating Disorders
• Academy of Eating Disorders
• National Institutes of Mental 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 (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)