Challenges to Treatment of Eating Disorders in Children
by Melinda Parisi, PhD
Program Director, Center for Eating Disorders Care University Medical Center of Princeton at Plainsboro
Children with eating disorders appear to be increasing in number and decreasing in age. Epidemiologic studies demonstrate that the prevalence of eating disorders in children and adolescents has progressively risen since the 1950s; what’s more, eating disorders are occurring at younger and younger ages (Rosen, 2010). At University Medical Center of Princeton at Plainsboro we work with children as young as age 8, and eating disorders can be seen in even younger children. Children with eating disorders present a unique set of challenges related to recognition, assessment, and treatment: They are not just smaller versions of adults or even adolescents, and treatment must be tailored to children’s particular developmental needs. It is especially important to provide effective, age-appropriate care when one considers the substantial toll that eating disorders take on children’s physical, psychological, and social growth and development; furthermore, good outcomes are very possible, especially with early and determined intervention. This article outlines some of the diagnostic and treatment issues involved in working with eating disordered children (essentially those under age 13), though some of this discussion may be extended to adolescents.
Challenges to assessment and diagnosis
Blurred boundary between normal and abnormal. One of the first complications to recognizing eating disorders is that there is not a clear dividing line between normal and abnormal eating behavior in children. Many children go through “picky eating” phases that are developmentally normal, and they usually grow out of them over time and without intervention. How, then, does one determine whether a given behavior, though likely troubling to parents, is likely to be transient, or whether it is an indication of a more problematic condition? Bryant-Waugh and Nicholls (2011) offer a useful framework to help assess whether problematic eating behavior is clinically significant:
- Nutritional adequacy: Is the child’s diet nutritionally sufficient to prevent physical risk in the short- and/or longer-term?
- Impact on physical development: Is the child’s eating behavior likely to impact weight, growth, and physical development?
- Impact on social development: Is the child’s eating behavior impacting social and emotional development (such as causing the child distress or causing the child to avoid social experiences)?
- Impact on relationships: Is the child’s eating behavior affecting family functioning and relationships with caregivers?
These authors suggest that problems in any one of these areas provide appropriate justification for intervention.
Differences in expression. An additional challenge to the early recognition of eating disorders in children is that they often present quite differently from older patients. Children have not fully developed their verbal and abstract reasoning skills, limiting their ability to understand and describe their thoughts, motivations, and behavior (Bravender et al, 2007). Accordingly, despite engaging in behavior that explicitly contributes to weight loss, children often do not endorse fear of fat and cognitive distortions about weight/shape; indeed, these very concepts have limited validity in this age group. Instead, they may refuse food based on claims that they are not hungry, that they feel bloated or nauseated, or that they are afraid of vomiting or choking. Children may also demonstrate a very strong movement compulsion (O’Toole, 2014). Just as it does in older patients, this may present itself as excessive exercise. However, other children may instead exhibit persistent, compulsive activity and an inability to sit for any length of time. For example, a child might stand or even run in place during typically sedentary tasks such as watching TV or doing homework.
ARFID. With the publication of DSM-5, Avoidant/Restrictive Food Intake Disorder (ARFID) replaced the previous DSM-IV diagnosis Feeding Disorder of Infancy and Early Childhood, which required an age of onset prior to age 6 in order to make the diagnosis. The new ARFID diagnosis expands the previous category and identifies individuals presenting with various clinically meaningful restrictive eating disturbances, such as:
- Refusal to eat due to problems with the sensory characteristics, such as smell or texture, of food
- Significant anxiety about eating following an event such as choking or vomiting, resulting in food refusal
- General absence of interest in eating or desire for food
While ARFID is likely to present in infancy or childhood, it can also present or persist into adulthood (Kenney & Walsh, 2013). The new ARFID diagnosis provides a diagnostic alternative for those children with restrictive eating that is not related to fear of weight gain. Ultimately, however, treatment considerations are much the same as for those with other eating disorders: Full weight restoration and normalization of eating behavior is essential.
Assessing weight and target weight
Variability in the degree and timing of height and weight changes during puberty presents a further challenge to the assessment of children (and a related treatment issue of determining an appropriate target weight). Many children present not with weight loss, but with failure to gain weight while actively growing, and some children will experience stunted growth as a result of malnutrition. There is a lack of expert consensus on how to determine both expected body weight and target weight in children and adolescents (Golden, Jacobson, Sterling, & Hertz, 2008; LeGrange, Doyle, Swanson, Ludwig, Glunz, & Kreipe, 2012). Measures based solely on height and weight (such as absolute BMI) are not optimal for this age group, as these parameters change with normal maturational processes. Consideration of a child’s BMI percentile for age and gender is of much greater utility; however, even a child with a normal-looking percentile can be very ill, if that percentile represents a significant drop from the child’s previous growth curve. O’Toole (n.d.; 2014) outlines several important factors to consider when determining an appropriate target weight, taking into consideration the child’s degree of pubertal development, the child’s weight before the onset of the eating disorder, and whether the child is growth-stunted. She advocates for weight gain to the point of resumption of a healthy state, whereby the child returns not only to normal medical parameters (such as heart rate, blood pressure, temperature), but also to a normal developmental trajectory, including physical (resumption of growth and the advancement of puberty) and psychosocial (such as returning to school) aspects.
Additional treatment challenges
Children’s psychological immaturity. As previously noted, children have not yet developed sophisticated cognitive and emotional skills. As a result, one can’t have adult-level expectations for treatment engagement. It is important not to wait for the child to express desire to get well, but to take action regardless of the child’s intrinsic motivation. Furthermore, interventions must be developmentally appropriate. Psychotherapy is not likely to be the instrument of change early in treatment, if at all; instead, diligent refeeding is the essential treatment strategy. Parents are central to this process, and, for most children, some form of family-based intervention should provide the core of treatment.
Sense of urgency. The urgency of full weight restoration/ symptom interruption in children can’t be overstated. Returning a child to a normal developmental trajectory as quickly as possible is critical, as prolonging the illness has significant negative (and potentially enduring) implications for children’s physical and psychosocial growth and development. It is therefore necessary to establish and adhere to an appropriately aggressive rate of weight gain. O’Toole (2014) recommends setting clear benchmarks and avoiding negotiating with the eating disorder, noting that without weight restoration, there can be no recovery.
Hospitalization. Many children will do very well in outpatient settings. However, eating disorders are severe illnesses, and despite the best efforts of patients, families, and outpatient clinicians, there are times that hospitalization is necessary. Inpatient treatment allows for medical stabilization, prompt weight restoration, and symptom interruption, as well as intensive psychosocial interventions for both patients and families. The American Academy of Pediatrics (Committee on Adolescence, 2003) has established the following criteria for hospitalization:
- Anorexia Nervosa
- Less than 75% ideal body weight or ongoing weight loss despite intensive management
- Refusal to eat
- Body fat less than10%
- Heart rate
- Less than 50 beats per minute during the daytime
- Less than 45 beats per minute at nighttime
- Systolic pressure less than 90
- Orthostatic changes in pulse (greater than 20 beats per minute) or blood pressure (greater than10mm Hg)
- Temperature less than 96°F
- Bulimia Nervosa
- Serum potassium concentration less than 3.2 mmol/L
- Serum chloride concentration less than 88 mmol/L
- Esophageal tears
- Cardiac arrhythmias including prolonged QTc
- Suicide risk
- Intractable vomiting
- Failure to respond to outpatient treatment
Hospitalization may occur in primarily medical or mental health settings, and will often have a specialized eating disorders treatment component.
Summary and additional resources
Children have the best prognosis when the disorder is identified early, and intervention is applied rapidly and aggressively. Effective, age-appropriate assessment and treatment is therefore essential. The assessment and management of children with eating disorders is clearly a broad and complex topic. The following resources can provide additional helpful information:
- Eating Disorders: A Parent’s Guide by Rachel Bryant-Waugh and Bryan Lask
- Eating Disorders in Children and Adolescents: A Clinical Handbook Edited by Daniel Le Grange and James Lock
- Kartini Blog: http://www.kartiniclinic.com/blog
Bravender, T., Bryant-Waugh, R., Herzog, D., Katzman, D., Kreipe, R.D., Lask, B., Zucker, N. (2007). Classification of child and adolescent eating disturbances. International Journal of Eating Disorders, 40, S117-S122.
Bryant-Waugh, R., & Nicholls, D. (2011). Diagnosis and classification of disordered eating in childhood. In LeGrange, D., & Lock, J. (Eds.), Eating disorders in children and adolescents: A clinical handbook. New York: Guilford Press.
Committee on Adolescence (2003). Identifying and treating eating disorders. Pediatrics, 111, 204-2011.
Golden, N.H., Jacobson, M.S., Sterling, W.M., & Hertz, S. (2008). Treatment goal weight in adolescents with anorexia nervosa: Use of BMI percentiles. International Journal of Eating Disorders, 41, 301-306.
Kenney, L., & Walsh, B.T. (2013). Avoidant/restrictive food intake disorder (ARFID). Eating Disorders Review, 24.
LeGrange, D., Doyle, P.M., Swanson, S.A., Ludwig, K., Glunz, C., & Kreipe, R.E. (2012). Calculation of expected body weight in adolescents with eating disorders. Pediatrics, 129, e438-e446.
O’Toole, J. (n.d.). Determining target weight ranges and ideal body weight. Retrieved from http://feast-ed.org/TheFacts/DetermineBodyWeight/aspx.
O’Toole, J. (2014). Anorexia Nervosa in the Very Young Child. Presentation at the Annual meeting of the International Association of Eating Disorders Professionals, St. Petersburg, FL.
Rosen, D.S. (2010). Clinical report: Identification and management of eating disorders in children and adolescents. Pediatrics, 126, 1240-1253.