Download eating disorders in the younger child: is it really an ed?

Rollyn M. Ornstein, M.D.
Associate Professor of Pediatrics
Division of Adolescent Medicine and Eating Disorders
Penn State Hershey Children’s Hospital
Learning objectives
 Recognize the various presentations of eating
disorders in younger patients.
 Describe the problems with the current DSM-IV
diagnoses for feeding and eating disorders in youth
and identify a proposed, renamed diagnosis in the
upcoming DSM-5.
 Discuss treatment options for younger patients with
eating disorders.
Case 1-Pt MH
 Almost 13 yo female with 25-pound weight loss over
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the past year (Ht 60 inches, 94 pounds
71 pounds,
BMI 14.5)
Fear of being 100 pounds, became a vegetarian, dietary
restriction to < 800 kcal/day, started running
Amenorrhea, bradycardia, hypotension
Admitted to child PHP, dx’d with AN as well as anxiety
disorder with OCD traits, started on fluoxetine
Gained 20 pounds over 10 weeks, had resumption of
menses
Case 2-Pt GH
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11 yo female with 20-pound weight loss over 2-3 months
Frequent complaints of abdominal pain
Anxiety and depression symptoms
Most recently with total refusal (mom feeding her with a
spoon)
 59 inches, 67 ¾ pounds, BMI 13.8, bradycardia and
hypotension
 Admitted to PHP briefly and then inpatient psychiatric
stay x 3 weeks with NGT feeds; treated with mirtazapine
and olanzapine; went back to PHP x 6 weeks
 Discharged at 94.6 pounds (gained ~27 pounds in 3
months)
Case 3-Pt SH
 11 yo female with restricted nutrition and weight loss of
8 pounds, intense fear of choking, unable to swallow
solid food
 Symptoms started about 7 months before presentation
after an influenza illness with severe pharyngitis,
waxed and waned but exacerbated at the beginning of
the school year after an allergic reaction (possibly to
onions)
 Height 55 inches, weight 59 pounds, BMI 13.7 (<<3rd
percentile)
 In PHP for 10 weeks, gained 5 pounds, no meds
Case 4-Pt LK
 13 yo female with 1 ½-year h/o eating disorder sx, initially
restriction and 10-pound weight loss, began purging after
meals 9 months ago because her parents were concerned
by her restriction
 Seen by PCP with multiple complaints, e.g. fatigue,
malaise, insomnia headaches, stomach aches; finally
admitted to the ED symptoms; also with oligomenorrhea
 Ht 61 inches, weight 95 pounds, nl VS
 Admitted to PHP, diagnosed with ED NOS (purging
disorder) as well as anxiety disorder, started on fluoxetine,
remains purge-free, anxiety is reduced
Feeding problems
 25-45 % of normally developing
children
 80% of developmentally delayed
children
 Some transient
 No evidence based guidance re: what is
a clinically significant feeding difficulty
Four main parameters appear
important
 Nutritional adequacy of diet
 Impact of feeding disturbance on weight, growth and
physical development (to include oral motor skills)
 Impact of feeding disturbance on social and emotional
development
 Impact of feeding disturbance on interaction with
caregiver and family function
Epidemiology of EDs in children
 Incidence of EDs may be increasing in younger age
groups
 ED admissions in US increased by 119% from 1999-
2000 (2%) to 2005-2006 (4%)
(Zhao & Encinosa, HCUP, 2009)
 Available surveillance studies of restrictive EDs in
children 5-12 years old
 British Isles (Nicholls et al., 2011): 3.01/100 000 (37% AN)
 Canada (Pinhas et al., 2011): 2.6/100 000 (62% AN)
 Australia (Madden et al., 2009): 1.4/100 000 (37% AN)
 Children with clinically significant restrictive EDs are
most often seen by PEDIATRICIANS!
From Pinhas et al., 2011
Symptom profiles of eating
disorders in younger patients
 Fear of weight gain, preoccupation with body
weight/shape, excessive exercise
 Underweight with frequent somatic complaints, NO
weight/shape concerns, no binge eating
 Self-induced vomiting and binge eating, NOT
underweight
Nicholls et al., 2011
DSM-IV: Feeding Disorder of
Infancy or Early Childhood
 A. Feeding disturbance as manifested by persistent
failure to eat adequately with significant failure to gain
weight or significant loss of weight over at least 1 mo.
 B. The disturbance is not because of an associated
gastrointestinal or other general medical condition
(e.g. esophageal reflux).
 C. The disturbance is not better accounted for by
another mental disorder (e.g. Rumination Disorder) or
by lack of available food.
 D. The onset is before age 6 years.
Problems with current FDIC criteria
 Excludes those growing normally despite abnormal
patterns/nutritionally deficient or limited diet
 Concept of organic vs. non-organic basis
 majority of children have multiple components to the
problem, i.e. both behavioral and physiologic
 Excludes those with onset AFTER 6 yo
 Forces many into the ED NOS category instead
 Not very specific
Childhood onset anorexia nervosa
 Ages 7 and up
 Important developmental differences
 Psychological and physical
 Limited capacity for self-reflection and difficulty
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expressing thoughts and feelings with words
Diagnosis may need to take parental report into account,
child’s subjective experience, and direct clinical
observation
Need to assess impact by reviewing previous growth and
maturational trajectory and genetic potential
Proportion of boys higher than in adolescents
Common comorbidities-OCD, depression
Other childhood avoidance of food
or restricted food intake
 Characterized by inadequate food intake
 Characterized by restricted range of food
intake
 Characterized by avoidance due to specific
fear
Characterized by inadequate
food intake
 Food Avoidance Emotional Disorder (FAED)=a
disorder of emotions in which food avoidance was a
prominent feature in the presenting complaint; no
specific motive
 School-age and adolescents
 Weight loss and/or poor eating more likely to bring to
clinical attention than manifest anxiety
 Possible childhood variant of somatoform disorder
Characterized by restricted range
of food intake
 Appearance, smell, texture, taste, and/or temperature
 Color, brand-specific
 Interferes with ability to eat with family, peers
 Nutritional compromise, lethargy, concentration
problems, poor oral-motor skills
 Parents experience significant anxiety and frustration
which exacerbates the situation
 Selective eating, perseverant eaters, food neophobia,
sensory food aversions
Characterized by avoidance due to
specific fear
 Functional dysphagia
 Fear of swallowing, choking, gagging, vomiting
 May have experienced a traumatic event as trigger
 Often present in acutely unwell state with significant
weight loss
 NO body image preoccupation or desire for weight loss
 Respond well to treatment for phobia
 Desensitization, gradual exposure, and anxiety management
 Often get confused with AN and are referred to ED
clinicians
Great Ormond Street criteria
 Anorexia nervosa
 Food avoidance emotional disorder
 Selective eating
 Functional dysphagia
 Bulimia nervosa
 Pervasive refusal syndrome
From Nicholls et al., 2000
Feeding problems in context of
neurodevelopmental disorders
 Texture, taste, brand, presentation, appearance
 May or may not result in failure to gain weight or weight
loss
 Food refusal, failure to eat usual family diet, inappropriate
rate of eating, obsessive eating patterns, failure to accept
novel foods, inappropriate mealtime routines
 Resulting from common ASD features, e.g. attention to detail,
perseveration, fear of novelty, sensory impairments, and
biological food intolerances
 History of enteral feeds
oral feeding
difficulty making transition to
Selective (picky)eating
 Extreme faddy eating persisting into middle childhood
and beyond, perseverative feeding disorder
 Highly limited range of foods
 Often soft carb-based finger foods
 May not have developed chewing skills/use a knife and
fork
 Extreme reluctance to try new foods (neophobia)
 May have sensory integration issues
 Exclusion from social norms around eating
Selective (picky)eating
 Parents often give up battling but are concerned about
impact on physical and/or social development
 Not usually underweight
 Often anxious and develop an avoidance-reinforced
anxiety associated with new foods
 Anticipatory nausea, fear of vomiting or choking
 Only type of early feeding problem that has been
linked to later EDs, especially AN
 More common in boys
 Common in ASD
Food avoidance emotional disorder
 Avoidance of food to a marked degree in the absence of the
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characteristic psychopathology of EDs in terms of weight
and shape cognitions
Know they are underweight, would like to be heavier, and
don’t know why they can’t achieve this
Fear of being sick, “not hungry”, “can’t eat”, “hurts my
tummy”
Some cases may be precursors to “true” EDs
Comorbid obsessional anxiety or depression may be
present but is not the cause of food avoidance
Need to address any other medically unexplained sx
Food phobias
 Can occur in isolation or as
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part of a GAD or OCD
Nature of fears varies with
developmental stage
Usually secondary events and
may have clear trigger events
Rigid eating patterns
Restricted range of foods
Can be associated with food
allergies
Sometimes restricted
quantity
weight loss
 Fear of vomiting
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(emetophobia)
Fear of contamination or
poisoning
Fear of choking or swallowing
(functional dysphagia)
Fear of consequences of
hypercholesterolemia
Associated depression, panic
attacks, social anxiety,
compulsions, separation
difficulties
Functional dysphagia
 Swallowing difficulties associated with fear of choking
 Globus hystericus or phagophobia
 Can be isolated symptom of acute onset, often
following trauma or as a feature of other disorders
 Found clinically in pt’s with FAED, selective eating,
food refusal, and sometimes AN
 Associated with other anxiety symptoms and
somatization disorder
 Managed with combo of psychoeducation, graded
desensitization and exposure, behavioral rewards,
family therapy, and sometimes anxiolytic meds
Food refusal
 Usually occurs at some point
in child’s development
 Toddler tantrums, spitting
out food, linked to other
oppositional behavior
 In older children, associated
with other defiant behaviors
 Delaying eating by talking,
trying to negotiate what food
will be eaten, getting up from
table during meals, refusing
to eat much at meal and then
requesting food immediately
afterwards
 Most nutrition gained
through snacking
 In otherwise compliant
children, may start after
trigger event leading to
avoidance, subsequent events
perpetuate the symptom
(serves psychological need)
 Can progress to become
severe
 Pervasive refusal syndrome
 Extreme post-traumatic
stress reaction, suspected
abuse
Coming soon to a theater near you
DSM-5
Changes for AN to help classify
younger patients
 Take normal growth and development into
consideration as far as weight parameters
 Remove amenorrhea criterion
 Behavioral manifestations as opposed to cognitive
symptoms
DSM-5: Avoidant/Restrictive
Food Intake Disorder
 A. Eating or feeding disturbance (including but not limited to
apparent lack of interest in eating or food; avoidance based on
the sensory characteristics of food; or concern about aversive
consequences of eating) as manifested by persistent failure to
meet appropriate nutritional and/or energy needs associated
with one or more of the following:
 1. Significant weight loss (or failure to gain weight or faltering growth
in children);
 2. Significant nutritional deficiency;
 3. Dependence on enteral feeding;
 4. Marked interference with psychosocial functioning.
DSM-5: Avoidant/Restrictive Food
Intake Disorder
 B. There is no evidence that lack of available food or an
associated culturally sanctioned practice is sufficient to
account alone for the disorder.
 C. The eating disturbance does not occur exclusively
during the course of Anorexia Nervosa or Bulimia
Nervosa, and there is no evidence of a disturbance in
the way of which one's body weight or shape is
experienced.
 D. If the eating disturbance occurs in the context of a
medical condition or another mental disorder, it is
sufficiently severe to warrant independent clinical
attention.
DSM5: Avoidant/Restrictive Food
Intake Disorder
Three main subtypes:
 individuals who do not eat enough/show little interest
in feeding;
 individuals who only accept a limited diet in relation
to sensory features;
 individuals whose food refusal is related to aversive
experience.
Why did we start our program?
 Existing PHP couldn’t admit patients under 14 years
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due to school regulations
Inpatient Child and Adolescent Psychiatry unit was
relocated to Harrisburg (~25 minutes away)
Starting to see more patients under 14 with significant
eating disorders ± other psychopathology requiring
higher level of care
Wanted to create a program with more family
involvement, i.e. a family-centered approach
Started on August 4th, 2008
Interdisciplinary treatment team
 Medical
 Medical stabilization, labs, monitor re-feeding process
 Nutrition
 Develop, monitor and modify meal plan according to progress
 Psychiatrist
 Assess for use of psychotropic medications
 Therapist
 Individual, family and group therapy, development of
behavioral contingencies
 Psychiatric Assistant
 Observations of therapeutic meals and implementation of
behavior plans
What does a day look like?
 Breakfast 7:00-8:00 with
 Lunch 11:00-12:00 with
parents and staff
 Groups 8:00-11:00
staff
 Group 12:00-1:00
 Transition 1:00-1:30
 School 1:30-3:30
 Art therapy, music
therapy, experiential,
feelings, etc.
 Pulled for various appt’s
(medical, nutrition,
therapy, psychiatry)
 Individual and family
therapy sessions-one
each/week
 Snack 2:30-3:00
 Dismissal
 Fridays-weekend
planning
Family-centered approach
 Parents and families incorporated into treatment and re
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feeding process
Attend a therapeutic meal daily
Provide psycho-education on eating disorders and
management of eating disordered behavior
Attend all sub-specialty appointments
Participate in a support group, multi-family meal-planning
group and family therapy sessions
In charge of the meal plan while at home and are given
behavioral training and assistance with developing
contingencies
Exposure-response prevention
 Behavioral intervention typically used for anxiety and
phobias
 When applied to eating disorders, patients are repeatedly
exposed to feared foods
 Response prevention refers to blocking compulsive behaviors
such as vomiting, exercise or restriction
 Hildebrandt et al. (2010) concluded that interventions in
family based treatment mimics those used in exposure and
response prevention.
 Steinglass et al. (2011) proposed that ERP may be a new and
beneficial approach to prevention relapse in individuals
with AN
Stages of Treatment
Assessment
 Evaluation and observation
 Psychoeducation for parents
and patients
 Weight restoration and medical
stabilization
 Titrating meal plan and
monitoring medical status
 Treating GI symptoms
 Compliance with meal plan and
challenges
 Eating 100% and completing
challenges in program and
home
 Goal of decreased anxiety
and distortion surrounding
food/weight
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 Generalizing Eating Behaviors
Across Settings
 ~ last 4 weeks
 Given progressively more
time away from program
 Patient autonomy when
distress over challenges and
meal plan diminishes
 Transitioning to intuitive
 May start towards the end of
program
 Patients are weight restored
and exhibiting minimal
distortions surrounding food
and weight
 May start decreasing meal
plan and/or adding activity
Data from our PHP:8/08-5/12
 Total sample: 173 patients
 8 – 16 years
 92% female; 8% males
 Four Groups
 Anorexics - 53%
 Anxious Restrictors - 23%
 Bulimics/Patients that Vomit - 12%
 Eating Disorder NOS - 12%
Anorexia Profile
 93/173 = 54%
 Mean age at
presentation= 14 yrs
 Female: Male= 95.7
%:4.3%
 % of BW lost=19
 82.5 % MBW
 Eating disorder symptoms
 Restricted nutrition (100%)
 Use of supplementation (19%)
 Fears of choking and/or vomiting
(1%)
 Texture and/or sensitivity issues
(25.64%)
 Reports of body image disturbance
(87%)
 Cognitive distortions about food and
weight (90%)
 Purge- Vomiting (2%)
 Purge- Exercising (68%)
 Clinical comorbidities
 Anxiety (37%)
 Mood Disorder(37%)
 Learning disorders (2%)
ARFID profile
 39/173 = 23%
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Eating disorder symptoms
 Restricted nutrition (94.87%)
 Use of supplementation (46.15%)
 Fears of choking and/or vomiting
(43.59%)
 Texture and/or sensitivity issues (25.64%)
 Fewer reports of body image
disturbance***
 Cognitive distortions about food, not
weight***
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Clinical comorbidities
 Anxiety (71.79%)
 Depression (23.08%)
 OCD (20.51%)
 PDD (12.82%)
 ADHD (10.26%)
 PTSD (5.13%)
 Learning disorders (26%)
 Mean age at
presentation=11.1 yrs
 Female : Male=79.5% :
20.5 %
 % of BW lost: 11
 87.3% MBW
Bulimia Profile
 20/173 =12%
 Mean age at
presentation=14 yrs
 Female: Male=95.7 % :
4.3%
 % of BW lost: 6
 108 % MBW
 Eating disorder symptoms
 Restricted nutrition (100%)
 Use of supplementation (19%)
 Fears of choking and/or vomiting (1%)
 Texture and/or sensitivity issues
(25.64%)
 Reports of body image disturbance
(87%)
 Cognitive distortions about food and
weight (90%)
 Purge- Vomiting (95%)
 Purge- Exercising (13%)
 Clinical comorbidities
 Anxiety (37%)
 Mood Disorder(37%)
 Learning disorders (2%)
EDNOS profile
 21/173 =12%
 Age at presentation M =
14.2
 Gender: Female: 90.5 %
Male: 2%
 % of BW lost: 15
 93% MBW
 Eating disorder symptoms
 Restricted nutrition
(100%)
 Reports of body image
disturbance (95%)
 Cognitive distortions
about food and weight
(95%)
 Clinical comorbidities
 Anxiety (14%)
 Mood Disorder(76%)
What were the cases????
 Case 1 MH
 Case 2 GH
 Case 3 SH
 Case 4 LK
AAP Recommendations
1.
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4.
Pediatricians need to be knowledgeable about the risk factors and
early signs and symptoms of disordered eating and eating disorders.
When counseling families on preventing obesity, pediatricians should
focus on healthy eating and building self-esteem while still
addressing weight concerns. Care needs to be taken not to
inadvertently enable excessive dieting, compulsive exercise, or other
potentially unhealthy weight management strategies.
Pediatricians should be encouraged to calculate and plot weight,
height, and BMI by using age- and gender-appropriate charts and
assess menstrual status in girls at annual health supervision visits.
Pediatricians should screen patients for disordered eating and related
behaviors and be prepared to intervene when necessary.
AAP Recommendations
5.
6.
7.
8.
Pediatricians should monitor or refer patients with eating disorders
for medical and nutritional complications.
Pediatricians need to be familiar with treatment resources in their
communities so that they can coordinate or facilitate
multidisciplinary care.
Pediatricians can play a role in primary prevention during office visits
and through school-based and community interventions with a focus
on education, early screening, and advocacy.
Pediatricians are encouraged to advocate for legislation and policy
changes that ensure appropriate services for patients with eating
disorders, including medical care, nutritional intervention, mental
health treatment, and care coordination, in settings that are
appropriate for the severity of the illness.
Resources
 Rosen DS and The Committee on Adolescence. Identification and
Management of Eating Disorders in Children and Adolescents.
Pediatrics 2010. 126 (6): 1240-1253.
 Academy for Eating Disorders, 2011. Critical Points for Early
Recognition and Medical Risk Management in the Care of Individuals
with Eating Disorders. (available as pdf)