Eating Disorders in Adolescents and Older Children

After completing this article, readers should be able to:Eating disorders are potentially life-threatening conditions experienced with increasing frequency by older children and adolescents, especially females. These conditions share several features, including dysfunctional eating habits (frequently related to underlying psychosocial issues such as depression, low self-esteem,family dynamics, or environmental problems), disturbance in body image, and change in weight(ranging from extreme loss of weight in anorexia nervosa to fluctuation around a normal to moderately high weight in bulimia nervosa). The feeding patterns may extend from voluntary restriction of food intake to episodic binge eating (often with a compulsive quality) that may be associated with compensatory behaviors ranging from ritualistic exercise to self-induced vomiting. Excessive concerns about negative body image drive many of the daily behaviors exhibited by young people who have eating disorders, who also have few alternative coping mechanisms for various developmental concerns. Once these dysfunctional patterns are established, they can be very difficult to alter because they serve as coping mechanisms and have their own addictive qualities. The pediatric practitioner has a primary role in the early identification and treatment of mild eating disorders and a collaborative role with appropriate colleagues in adolescent medicine, developmental-behavioral pediatrics, psychology, psychiatry,nutrition, and physical therapy to help patients who have established or severe eating disorders.The often extreme weight loss seen in anorexia nervosa (AN) in combination with the associated medical complications facilitates recognition and the early initiation of treatment. Bulimia nervosa (BM)and binge eating disorder (BED) are more likely to go unnoticed because they lack the extreme physiologic manifestations of starvation and typically are associated with normal or high weight. The purpose of this article is to review and clarify the classification, diagnosis,epidemiology, pathogenesis, clinical aspects,and management of eating disorders(with an emphasis on BN and BED)to facilitate successful care and to update an earlier article on the topic(Kreipe RE. Pediatr Rev. 1995;16:370–379). A thorough understanding of these conditions by the pediatric clinician is needed for trust and family involvement. Although the psychiatric aspects of these conditions are prominent, they will not be discussed in detail here.A new classification scheme related to behavioral and mental health concerns for children and adolescents,the Diagnostic and Statistical Manual for Primary Care (DSM-PC),was published in 1996 by the American Academy of Pediatrics to fill a gap in the American Psychiatric Association’s classification of mental illnesses, the DSM-IV. Older children and younger adolescents may exhibit behaviors that do not meet full DSM-IV criteria, yet still deserve attention. The two specific complexes in the DSM-PC related to eating disorders are: 1) dieting/body image behaviors and 2) purging/binge-eating behaviors.There are two levels of pathology for both of these behavior patterns that are not healthy, but do not fulfill DSM-IV criteria for an eating disorder. In DSM-PC, variationsconstitute minor deviations from normal that still might be of concern for a parent or clinician; problemsconstitute more serious manifestations representing the earliest evidence of eating disorders. For clarity, the DSM-PC hierarchical schema has been combined with the DSM-IV diagnostic criteria related to eating disorders in Tables 1, 2, and 3. An adolescent who exhibits dieting and voluntary food limitation in an obsessive pursuit of thinness and a systematic fear of gaining weight that extends beyond a simple dieting/body image variation(V65.49), but that is not yet sufficiently intense to meet criteria for AN (307.10) would be classified as having a dieting/body image problem (V69.1).There is a great deal of overlap between an eating problem in DSM-PC and an eating disorder not otherwise specified (ED-NOS)(Table 3), making the distinction between these two conditions difficult. Complicating the classification of eating disorders further is the frequent use of the term “disordered eating” to include a range of subthreshold deviations from “normal,”which are defined arbitrarily by the individual applying the label, as well as the lack of agreement about what constitutes normal eating habits. Fortunately, it rarely is necessary to make narrow classification distinctions in clinical practice because the majority of attention needs to focus on the presenting attitudes,behaviors, signs, and symptoms, and not on labeling. Throughout this article“eating disorder” or “disordered eating” will be used as generic terms for dysfunctional habits and attitudes related to eating and weight control.The outstanding feature of AN is persistent and severe restriction of energy intake (especially fat),generally in combination with compulsive exercise in an inexorable pursuit of thinness. Patients tend to monitor their intake obsessively, often attempting to limit their overall daily intake to fewer than 1,000 kcal and fewer than 10 g fat. Dieting and exercise frequently begin with reasonable habits and goals, but they quickly escalate and become uncontrollable, even though patients may protest to the contrary. As habits become progressively more unhealthy, parents may attempt to control eating or force weight gain. This adds to the individual’s internal conflict related to the need to lose weight.An outstanding feature of AN is not merely a desire to be thin, but a relentless drive to be thinner; as each goal weight is reached, it is replaced by a lower target, leading to progressive weight loss. These behaviors serve to improve the patient’s sense of self-efficacy, but they also may be associated with depression. Thus, there often is a tendency for patients to defend their habits or to deny that any problem exists—other than the need to lose more weight.Younger patients who have AN may not fit this profile; they are more likely to fail to gain weight as expected than to lose large amounts of weight. In addition, due to cognitive limitations, younger patients may be unable to describe their inner turmoil and merely exercise compulsively or refuse to eat certain categories of food because engaging in these habits lowers their stress levels.Clinically, patients who have AN may be dichotomized into a restrictive type, as just described, or a binge-eating/purging type if they intermittently engage in “bulimic”behaviors. Almost 50% of patients who have AN go through a phase during their illness when they binge eat. However, most do not actually eat large amounts of food. Rather,they feel guilty when they eat“forbidden” foods of high caloric or fat content or when they eat more than they had planned, and they experience these episodes as binges. They interpret such behavior as being “out of control” relative to when they successfully limit their intake to a few hundred calories at a meal. When a patient who has AN reports binge eating, it is important to detail the volume and content of what is eaten at these times. Otherwise, if she or he maintains a low weight(an unexpected occurrence with true binge eating), the clinician may assume erroneously that the patient is purging to prevent weight gain.When true binge eating (eating a large of food in a the clinical two should be BN and is from AN by weight often of and a drive for thinness. The body image patients who have also may be often in the of not as as they In who have AN as even when on the between the of the caloric content of and the and frequency of or patients who have BN can range from being to being moderately with a body image than is seen in of BN is binge eating by compensatory behavior to the body of Patients BN is have in these dysfunctional habits at a for who have a eating problem also engage in these behaviors and have a negative by weight and body but episodes are the behaviors are not as intense as seen in BN is a compensatory used by more than of patients who have BN to weight gain binge eating of purging include self-induced of adolescents who have on the or and the use of or Patients also may use exercise or as compensatory mechanisms to gaining weight an of binge Although self-induced is a frequent is binge is the of to of patients who have AN may intermittently to control weight eating more than that the eating of BN is to may and of this is through that are to the body of the of However, or a combination of both may be the primary used to weight often Patients who have BN are more likely than who have AN to be in eating but in their use of and or and manifestations of Patients who have also their eating patterns as being but of an However, their internal of may be just as who have BN or are at of being mechanisms to weight gain BN from binge eating episodes compensatory mechanisms to weight but with frequent at people who have are eating is associated with eating due to a sense of and with of or during and a eating large amounts of food in a at as a or to at a for as not binge However, engaging in and in compensatory weight control habits as may to an eating of this is by a who high as a at a weight of he by with by When he for the he that the at he the of in a to and he and unable to when he the weight control in the of in the he it difficult to established habits and to the unable to eat guilty and as compulsive but it is as an of an in DSM-IV. criteria for include a frequency of binge eating of at a for it has been as a eating is about the treatment of especially children and However, it is from that is an problem patients in the of and should be especially about patients who gain weight disorders are not in the than of patients are more than are more than are adolescents when they their eating disorder. patients are from to but patients can be of any or that the of eating disorders and adolescents of is than and that to of to of older adolescent and young BN is more high and than or high with a around of However, a by the that of adolescents engage in self-induced purging as a of their weight. Although there are for children and experience with in that it is at as as the conditions of eating disorders that do not meet full diagnostic criteria but still a to the and of adolescents or in the DSM-PC in an to of females. that many in and feel a need to or lose weight are at of potentially habits. The in for eating disorders is for by in the of and diagnostic criteria also to the of eating disorders. Although a of adolescents who have eating disorders, most of who have eating disorders have BN or they are more likely to engage in binge eating and in with as by the patient of and are not well but a combination of and most likely to the and of these disorders. a to both AN and the of eating disorders (especially subthreshold eating disorders as in the in and of who had AN to be the in the The also a between AN and BN in of have in the range of 50% to AN and to 50% for to be on the that there is an underlying to eating disorders. and environmental a but the majority of to these do not an eating to the of an eating disorder is of is the most the levels of tend to and food and lower levels are associated with The to be in patients who have AN when they are but from BN also is associated with levels of and colleagues interpret these as evidence that a disturbance of may a for the of a of that are to both AN and BN and that as dieting or binge may by in and are in both AN and but these tend to be and and weight is about the role of in that to BN and include with and family that may an eating disorder in a individual include with the developmental of to such as of the physical of and issues related to the of a and of high or family or to with stress also may an eating disorder. Patients who have eating disorders control” when in weight control especially when behaviors such as from about they or that parents make eat their Thus, the of an eating disorder can be by with or but the disorder also can a for coping with these and are two important that have been discussed in the of both BN and Patients who have BN or are to have both a family and a of depression. often is difficult to patients are because they have the eating disorder or the eating disorder is a clinical of an disorder. Although there to be a of adolescents who have BN than the at large or than who have patients who have BN have such the of or a of should be during patient because treatment needs to these issues as well as the specific concerns by the who go on restrictive are at for the of both dieting and binge eating because starvation can obsessive focus on food and of loss of with an and gain in weight and A in this is the to gain weight is to at for the of eating disorders include and and adolescents who have low adolescent experience a in during the from to Although may a that related to body and about role in and experienced by patients who have eating disorders are related to the various habits used to control patients are in about symptoms, but experience such as the for or the that adolescents are in completing such or in to do feel about with eating eat in or eat large amounts of food in a to lose weight or control weight by or or more about what do for and and should be as with any clinical with an adolescent the should be with the goal of a of to help the patient feel and not merely to an eating or is on the of the starvation and in physiologic than binge eating, there tend to be fewer physical in these two conditions than in and more to the of physiologic than to the of an eating disorder. are related to binge eating and is important to any of weight loss or of weight of weight loss can include food restriction (often fewer than 1,000 and purging or of and eating disorder behaviors include and binge eating is associated with weight gain and of large amounts of food. eating and may in is who have but it in about of who have BN and is in Although or or can an due to from vomiting. the of a body image is an important of the for any patient who is of having an eating disorder because it will the of the drive for thinness and for binge eating in to the with physical a of eating a daily food will for physical weight and and and The of weight for can be by for patients younger than 10 of or the body in in can be used for patients 10 and older to if they are the normal range of weight for A body weight to of with a of to for the for is for and and with to about weight for are for children and are more than at younger body weight can be for who have their by the for and for each of in include an between and of more than or Patients who have from or also have but do not have or weight the can become of BN on physical can from due to binge eating and it is not seen with binge eating or in of due to to can be associated with but it has been related more to than to the frequency or of vomiting. is an or on the the of the or of the by from by of these not the of but their is of of BN from and When it is more likely due to to high levels of and or to to than to low and are specific physical of than weight gain and complications and the of an eating disorder is a clinical is in patients are due to the weight control habits used by the or the 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the of eating disorders and the of treatment that are established in practice make this difficult. a body of evidence from on the need for treatment to and issues related to the and of an eating aspects of treatment focus on the physiologic a goal for weight and range are For patients who have this weight loss and gaining weight. most patients who have BN are of normal the focus a weight for binge eating and eating patients who have are to moderately the limit of their weight the focus is to change eating patterns into eating, but management also may include a for weight loss. the patterns for who have eating disorders is to a of and to is important to monitor weight patients who have BN or may begin their intake due to fear of weight gain they are to the frequency of binge eating and patients who have AN may their by large of or to their at of and specific as well as physical are A patient who has AN and is weight may be to have a low and specific and may have evidence of a should be in the and treatment of adolescents who have eating disorders. 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Although AN often is the eating BN and are more prominent, especially older pediatric Patients who have these conditions may be more difficult to because they may not have the extreme weight loss and caloric restriction in they may engage in behaviors that are more difficult to change because of their addictive and because of the lack of associated medical complications in the of A new diagnostic scheme by the to and that do not meet the full criteria for eating disorders, but still deserve medical and psychiatric attention. The primary care practitioner can help patients at levels of