Information ⬇
Editors
Eating Disorders Among Children and Adolescents
Essentials
- Eating disorders usually start in the adolescence. They are more common among girls than among boys.
- The possibility of an eating disorder should be kept in mind; patients seldom report it themselves.
- Basic investigations are performed in the primary care. The more specific diagnosis and planning of treatment are the responsibility of a specialized care unit.
General remarks
- An eating disorder refers to states where the eating behaviour changes in a way that endangers the physical and mental development. The adolescent defines her-/himself principally through eating and body weight/size. Eating and weight gain are often associated with strong anxiety and fear.
- The spectrum of eating disorders is vast. The most common disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder (BED). In addition, atypical/partial clinical pictures have become more general in ever younger persons.
- Early reaction to the symptoms improves prognosis.
- Even small children can have different kinds of eating disorders that often relate to problems in the early interaction.
- Symptoms linked to the eating disorder have a bearing on the required treatment.
Aetiology
- Currently eating disorders are considered to be multifactorial in origin. Neurobiological, genetic, sociocultural and family factors, as well as factors related to individual development predispose to eating disorder symptoms.
- The onset is usually in adolescence and is in relation to the pubertal change, active growth of the body and the mental development phase.
- Anorexia nervosa most commonly emerges between 14 and 24 years of age. Bulimia appears typically at the age of 16-20 years.
- Eating disorders are 10-15 times more common among girls than boys.
- Bulimia is more common than anorexia nervosa.
- The symptoms of the eating disorder may alternate between anorexia and bulimia during the course of the illness.
Diagnostic criteria for anorexia nervosa
- The patient does not want to maintain his or her normal body weight.
- The patient's weight is at least 15% below that expected for age and height.
- The patient feels her-/himself to be obese despite underweight.
- The patient is strongly afraid of gaining weight.
- There is no other sickness that would explain the loss of weight.
Diagnostic criteria of bulimia nervosa
- Personal experience of being obese, strong fear of gaining weight
- Persistent preoccupation with eating and an irresistible urge or compulsive need to eat
- Repeated episodes of binge eating where control over eating is lost
- After the episode of binge eating, the person attempts to eliminate the ingested food e.g. by vomiting and by abuse of purgatives or diuretics.
- Anorexia nervosa generally starts gradually.
- Losing weight can either be very rapid or very slow. Generally the patients continue to go to school; they go on with their hobbies and feel great about themselves. Therefore the families are usually surprised to find that their child suffers from malnutrition.
- The following questions from the original SCOFF screening tool are helpful in the assessment of patients with suspected eating disorder (each positive answer gives one point; 2 or more points suggest an eating disorder).
- Do you make yourself sick (i.e. do you try to vomit) because you feel uncomfortably full?
- Do you worry that you have lost control over how much you eat?
- Have you recently lost more than 6 kg (one stone, 14 lb) in a 3-month period?
- Do you believe yourself to be fat when others say you are too thin?
- Would you say that food dominates your life?
- As a part of initial investigations, eating and exercise habits as well as history of growth and menstruation are recorded. Assessment of a child or adolescent must be done in collaboration with his/her parents.
- Anorectic adolescents deny their symptoms, and motivation and provision of information (psychoeducation) to the adolescent and the parents is important in the initial phase.
- Somatic symptoms include:
- disappearance of menstruation
- the slowing of metabolism, constipation
- slow pulse, low blood pressure
- cyanotic and cold limbs especially distally
- reduction of subcutaneus tissue
- Bulimic adolescents are aware that their eating habits are not normal, but the feelings of guilt and shame delay the seeking of treatment, and the symptoms may remain undisclosed for a long time.
- Bulimia also causes physical symptoms
Laboratory findings
- Normal laboratory findings do not exclude the possibility of eating disorder.
- In anorexia nervosa
- Slight anaemia
- Leucopenia
- Thrombocytopenia
- Blood glucose concentrations on the lower border of normal
- Often small plasma concentration of alkaline phosphatase
- In bulimia
- Electrolyte imbalances
- Increased serum amylase
Differential diagnosis
- Somatic diseases causing weight loss (e.g. malabsorption, diabetes, disturbances of the thyroid function, malignancies)
- Psychiatric diseases: severe depression, psychosis, use of drugs
- The initial survey and basic investigations are to be performed in the primary care.
- If the suspected eating disorder is confirmed, the situation needs to be discussed with the patient and the parents and further treatment should be arranged. Mild eating disorders may be treated by an intervention within primary care.
- The adolescent and his or her family should be made aware of the seriousness of the disorder by providing sufficient information already in the initial phase.
- Sometimes it takes time to motivate the patient to participate in the treatment.
- The treatment is divided into
- If the state of malnutrition is life threatening, the patient is first treated in a somatic ward. Simultaneously, psychiatric examination and treatment are to be started.
- In psychiatric examination, the diagnosis of the eating disorder is confirmed and the contributing factors and associated symptoms are investigated.
- Among adolescents, the best evidence is on the effectiveness of family therapy that initially aims at supporting the parents in restoring a normal diet for the patient.
- According to clinical experience, psychophysical physiotherapy is helpful to a significant proportion of eating disorder patients especially in the beginning of treatment for normalizing the patient's body image and increasing the control of anxiety.
- In further treatment, individual therapy should be arranged for the adolescent. The aim of the therapy is to reinforce the correction of the eating disorder behaviour, to help in putting right the factors that contributed to the eating disorder and maintained it and to promote the adolescent's development.
- A prolonged state of malnutrition and insufficient outpatient care are reasons to direct a patient into forced treatment.
- Early intervention and direction to treatment improves prognosis Early Intervention in Anorexia Nervosa.
- Symptoms of anorexia and bulimia may alternate during the illness.
- Eating disorders comprise a severe group of diseases that are difficult to treat. The prognosis for the near future of patients with anorexia nervosa is good, but for the long term the prognosis is worse. The mortality risk in anorexia nervosa is still about 5%. Death is most commonly caused by changes related to starvation or by suicide.
- The prognosis of bulimia is initially good, but the risk of relapse is strong.
- Eating disorders are associated with accompanying psychiatric symptoms, especially mood disorders, anxiety disorders, obsessive-compulsive disorders, psychotic disorders and autism spectrum disorders Autism Spectrum Disorders. Bulimia may be associated with impulse control disorders and predisposition to alcohol or drug addiction.
Evidence Summaries ⬆