Treatment for Adolescents & Young Children
By John Samanich, MD
A growing concern in the field of eating disorders is the increasingly earlier onset and prevalence of these illnesses in the childhood and young adolescent populations. Historically, anorexia nervosa tends to have a higher occurrence at approximately 14 and 18 years old, whereas bulimia nervosa tends to manifest in the late teenage and young adult years. Unfortunately, however, the ages of onset have shifted downward to younger and younger children. What is important to understand is that the nature of eating disorders in young people is somewhat different than their older counterparts and distinctly different in the pediatric population. The origin of eating disorders is as unique as the individual themselves, but among the historically classic cases, there are many common diagnostic characteristics.
Anorexia Nervosa: Transition Periods
In anorexia, these traits include highly anxious, perfectionistic, rigid, resistant to change, and eager to please. Therefore, it is of little surprise that symptoms begin to occur during the ages that coincide with stressful transition points: middle school to high school, high school to college, and high school to the workforce. That is not to imply these transition points are the cause for illness, as the roots of anorexia have been long established with a child’s inherent temperament, genetics, and perception to the stressors of their environment. The periods of transition are stressful for anyone, but for those who have a predisposition towards anxiety, anorexia becomes a way to cope with the insecurities and uncertainties that they may have about themselves or the world. Of course earlier and earlier exposure to the media and social pressures to appear thin play a role, but remember these pressures are present in the lives of both affected and unaffected children.
Bulimia Nervosa: Identity Dissatisfaction
The origin of bulimia nervosa follows along many of the same lines as anorexia nervosa, but there are some distinct differences. Bulimia tends to occur later in adolescents when identities have become more established. It is often when these individuals are uncomfortable or dissatisfied with this identity that bulimic symptoms begin to arise. Purging behavior rarely occurs in children and young adolescents, but when it does it is usually part of an anorexic, purging subtype.
Early Maturity & Challenges
The reason for eating disorders manifesting earlier is unclear, but we can postulate that it is because children are expected to mature earlier and earlier. Society has hastened children to take on more grown-up roles and responsibilities sooner in their psychosocial development and problems have followed in suit, including eating disorders. The human brain is limited in how quickly it can achieve its cognitive development and reach the milestones of concrete and abstract thinking. This is why early onset eating disorders often appear atypical in presentation. Children are developing eating disorders before they have reached a level cognitively and psychosocially where it would make sense to them as a response to stress.
In the adolescent population (ages 13–16) eating disorders rarely establish themselves diagnostically as clearly anorexic or bulimic. Generally, there is a mixture of symptoms and more often than not, the symptoms do not fulfill diagnostic criteria for anorexia or bulimia but rather eating disorders not otherwise specified (EDNOS). The etiology of eating disorders is often unclear as well.
Younger adolescents (ages 10–13) who suffer share many similar characteristics, psychologically and socially, with their older counterparts but their symptoms are not as mature or established. Their maladaptive eating patterns are much more concrete and rigid, as are their cognitions, with eating behaviors often a direct reaction to what is happening in the child’s life. These might be a response to peer rejection, anger toward a parent, or being teased and called “fat” by peers.
Once begun, the behaviors themselves are just as concrete and often more rigid and predictable than seen in older children. Often, a child’s eating will be much more obsessive in quality, with continuing behaviors that are no longer connected to the original cause, often taking on a life of their own. For example, a child may eat only specific foods or need them prepared in a specific manner.
The younger adolescent population poses its own set of unique challenges based on the child’s developmental level. The treatment team must keep in mind that these children still think in concrete terms and therefore treatment must recognize and cater to that. Parents must work with the team toward setting up specific goals for the child to follow and must be consistent in supporting these goals. Parents need to take an active role at home in making sure that the adolescent completes her meals if she is restricting. Behaviors need to be monitored closely after meals to directly prevent purging. This includes not allowing the younger adolescent to use the bathroom without supervision at least two hours after a meal and possibly switching the child’s bedroom to prevent unsupervised use of the bathroom at other times. Intrusive steps such as these are not usually taken with older adolescents.
In the preadolescent population (ages 6–10) the etiology and behaviors surrounding eating disorders are distinctly different. The most common chief complaints heard from parents are 1. “My child choked on a piece of food a few weeks ago and now won’t eat,” and 2. “My child is a ‘finicky eater’ and will only eat foods X, Y, and Z.” These are disorders of eating, but not classically eating disorders; however, these children are no less debilitated, often being severely underweight and medically unstable. In the first case, the response of the child is a fearful or phobic response to a traumatic event. The child’s ensuing behaviors are that they will refuse solid foods and will only accept soft or liquid foods. The intervention here is to slowly introduce new foods each time presenting progressively more anxiety-provoking food. This can be a slow and difficult process, but it does work and can be augmented by using a reward system.
The second scenario is much more complex and difficult to treat. Here the child has developed a security in only a few select foods without any traumatic or identifiable stressor. The child will resist any different food and will often fight tooth and nail against it. The cause is often unclear and usually irrational, sometimes even recognized as such by the child. The eating is rigid, obsessive in nature, and most often upsetting to the child herself because of the social and family discord it causes. The symptoms are similar to obsessive-compulsive disorder (OCD) and often present the same way. There is no FDA approved medication for eating disorders in this age group but treating the obsessive nature of these symptoms and the anxiety around them, similar to the treatment for OCD, is a safe and often powerful intervention
Children and adolescents should not be considered as just “small adults” in the assessment and treatment of eating disorders. The etiology of these illnesses can be as amorphous as their diagnosis and treatment. The treatment is a challenging task, requiring multimodal intervention by doctor, therapist, dietician, and most importantly family. Any parent who is concerned about their child’s eating habits should check with a medical professional about these issues. Early intervention and treatment provides the best prognosis for recovery, as eating disorders can be a chronic condition that grows and matures with the child, becoming entrenched in the process.
As a clinician who works extensively with these children, I find the biggest obstacle to treatment is the initial step of seeking the necessary help because of denial on the part of parents, as well as a lack of understanding of the illness. It is true that a lot of children are just “finicky eaters” but some are really sick and need additional care. Having a child see a trained professional can help differentiate the two, and facilitate the appropriate treatment.
About the Author
John G. Samanich, MD, is the Director of Adolescent Psychiatry at the Wilkins Center. He specializes in Child, Adolescent, and General Psychiatry. He has expertise in diagnosing and treating Attention Deficit Hyperactive Disorder (ADHD), school-related concerns, substance abuse, eating disorders, self-esteem issues, anxiety, and depression. Dr. Samanich is experienced with the medical management of adults with psychiatric needs.
Reprinted with permission from Eating Disorders Recovery Today Spring 2008 Volume 6, Number 2 ©2008 Gürze Books