Eating Disorders in Children and Adolescents

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Eating Disorders in Children and Adolescents

• MRCPsych Course
• Dr Gisa Matthies

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History

• Anorexia nervosa recognised condition in the late
  19th century (1873)

Ernest-Charles Lasègue named the condition
LAnorexie Histerique
Sir William Gull coined the term anorexia nervosa
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Early onset ED

• Collins 1894 7 year old girl
• Marshall 1895 11 year old girl

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• A girl seven and a half years old of healthy
  ancestry who persistently refused food for ten
  weeks prior to her admission. The physical
  stigmata of malnutrition were reported but more
  remarkable were the mental phenomena. These
  included deceitfulness, intense selfishness,
  self absorption and vanity. ...was effusively
  pious in conversation though she used foul
  language to the nurses. She concealed food in her
  bed and expressed herself as not wishing to
  improve (
  Collins, 1894)

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Diagnosis and Classification

• Both ICD 10 and DSM IV under review
• Planned updates
• -ICD 11-2015
• -DSM V-2013

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DSM-IV-TR (2000)

• Eating disorders
• -anorexia nervosa
• -bulimia nervosa
• -eating disorder not otherwise specified
• Feeding and eating disorders of infancy or early
  childhood
• -pica
• -rumination disorder
• -feeding disorder of infancy and early childhood

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ICD-10 (1992)

• Eating disorders (F50)(behavioural syndromes
  associated with physiological disturbances and
  physical factors)
• -anorexia nervosa (F50.0)
• -atypical anorexia nervosa (F50.1)
• -bulimia nervosa (F50.2)
• -atypical bulimia nervosa (F50.3)
• -overeating associated with other psychological
  disturbance (F50.4)
• -vomiting associated with other psychological
  disturbance (F50.5)
• -other eating disorder (F50.8)
• -eating disorder, unspecified (50.9)

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ICD-10 cont.

• Other behavioural and emotional disorders with
  onset usually occurring in childhood and
  adolescence (F98)
• -feeding disorder of infancy and childhood
  (F98.2)
• -pica of infancy and childhood (F98.3)

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ICD-10 diagnostic guidelines AN

• body weight at least 15 below expected weight,
  or BMI 17.5 or less
• weight loss is self induced
• body image distortion, dread of fatness as an
  intrusive overvalued idea and patient imposes low
  weight threshold on her-/himself
• widespread endocrine disorder
• amenorrhoea (women)
• loss of sexual interest and potency (men)
• if onset prepubertal the onset of puberty is
  delayed or arrested

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ICD-10 diagnostic guidelines Bulimia nervosa

• persistent preoccupation with eating and
  irresistible craving for food, episodes of
  overeating
• patient attempts to counteract the fattening
  effects of food vomiting, purgative abuse,
  starvation,use of drugs
• psychopathology morbid dread of fatness and
  sharply defined weight threshold, well below
  premorbid weight

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Epidemiology

• Incidence of AN (2000)
• UK 4.7/100,000 in year 2000 (age and gender
  adjusted)
• females 8.6/100,000
• males 0.7/100,000
• females 10-19 years 34.6/100,000

Currin, 2005
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Bulimia Nervosa- Incidence (2000)

• 6.6/100,000 (age and gender adjusted)
• females 12.4/100,000
• males 0.7/100,000
• females 10-19 years 35.8/100,000

Currin, 2005
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Currin et al 2005, BJP
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Childhood Eating disordersBritish National
Surveylt 13 years

• Incidence
• 3/100,000
• AN 37
• BN 1.4
• EDNOS 43
• 50 admitted to hospital

Nicholls et al 2011
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Prevalence of adolescent ED (no UK data)

• AN overall about 0.4 -2
• BN overall 1-2
• EDNOS most common ED

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• Strictly defined eating disorders are uncommon
• ED behaviours and EDNOS commoner than previously
  thought
• Disordered eating behaviours are common in
  adolescents
• Females are more affected than males
• No clear social patterns
• ED occur across countries

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Aetiology of Eating disorders

• multifactorial/ complex
• interaction between
• -genetic
• -biological
• -psychological
• -socio-cultural factors
  

creates susceptibility
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Genetic Factors

• Twin studies
• heritability estimates ranges
• 31-76 for AN in adults
• 28-83 for BN in adults
• significantly hereditable
• note genetic factors become more prominent after
  puberty

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Biological Factors

• Perinatal Factors
• Physiological
• -Oestrogens
• -Reward processing
• -Appetite regulation

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Psychological Factors

• Anxiety disorders (OCD)
• Personality traits harm avoidance, rule abiding,
  rigid, perfectionism
• Low self esteem
• Sexual Abuse non specific for AN, but significant
  minority
• Sexualised trauma and BN (specific association)

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Psychodynamic theories

• Hilde Bruch 1904-1984 German born American
  psychoanalyst
• eating problems as a solution or camouflage for
  problems of living
• having failed to develop a sense of self as
  independent and entitled to take initiative

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Sociocultural Factors

• increase in developing countries ( mass media)
• Bullying teasing by peers, social pressure to be
  thin
• Exposure to social network media

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Course and Outcome AN

• mean crude mortality rate 5.0
• of surviving patients
• -full recovery in less than 1/2
• -improvement 1/3
• -20 chronic course of disorder
• 40 probability of a comorbid mental disorder at
  follow up
• better outcome and lower mortality in adolescent
  onset AN

Steinhausen, 2002
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Course and Outcome BN

• Mean crude mortality rate 0.3
• Full recovery 45
• Considerable improvement 27
• Chronic protracted course 23
• Comorbidity at follow up affective disorder
  most frequent

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Assessment

• Child/YP
• -psychological
• -physical (including diet history)
• The family strength and difficulties
• Wider context social and educational factors
• Risks short and long term
• Maintaining factors
• Motivational issues
• Engagement (child and family)
• Consent to treatment, Confidentiality issues

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Family assessment

• Account of difficulties and context in which they
  arose
• Current eating patterns (typical day)
• Who has control and responsibility for eating
• Explore mealtime dynamics

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Family assessment

• Family hx of mental disorder, current parental
  mental health
• Family relationships, extended family (tension,
  support)
• Parents capacity to work together in the interest
  of their children
• Communication style
• Family attitudes, beliefs about food, weight
  shape
• Social context
• Developmental hx (feeding, attachment, premorbid
  personality)

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Medical/nutritional assessment

• Intake lt 1000 kcal/day for some time likely
  significant risk of cardiovascular decompensation
• Self induced vomiting and purging exacerbate
  risks, due to electrolyte disturbance and
  possibility of cardiac arrhythmia
• Vegetarian diet likely to be deficient in a
  number of essential nutrients
• Children will generalise restriction to fluid as
  well as food intake

Nicholls, 2012
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Nutritional Risk

• History
• duration of low weight
• rapid weight loss (gt 1kg/week) more destabilising
• menarcheal status
• Current Status
• BMI centile (Percentage weight for height)
• haemodynamic stability
• Pulse lt 50, ask for ECG
• Muscle weakness, peripheral neuropathy signs of
  serious nutritional deficit (SUSS test sit up,
  squat, stand up without using hands)
• Future
• predicted intake
• fluid intake restricted or excessive

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Individual assessmentEating disorder
psychopathology

• Eating behaviours, patterns, current intake,
  dietary restrictions rules,compensatory
  behaviours, binge eating
• Beliefs about weight and shape
• Preoccupation with weight and shape
• Concerns about eating
• Fear of weight gain
• Self evaluation with respect to weight shape or
  eating
• Motivation to change

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Comorbitdities are common
consequence of starvation or separate

• AN
• -Depression
• -OCD
• -Anxiety
• -Social phobia
• -ASD

• BN
• -Depression
• -Self harm
• -Substance misuse
• -Impulse disorders
• -ADHD

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Riskmultidimensional, short term and long term

• Physical
• Psychological
• Social
• Educational

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Physical Risks

• Electrolyte imbalance, low blood glucose,cardiac
  abnormalities
• Purging subtype of AN most dangerous, low
  potassium levels can lead to cardiac arrhythmia
• GI bleeding, mesenteric artery syndrome
• Chronic malnutrition in growing children can lead
  to stunting, delay in sexual development
• Chronic malnutrition causes osteoporosis and/or
  infertility
• Chronic malnutrition and effect on the developing
  brain not known, studies suggest damage to
  cognitive development, MRI suggest show cerebral
  atrophy

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Psychological Risks

• 25 of deaths in AN are due to suicide
• Risk of self harm is increased
• Comorbities are common

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Social Risks

• Impact of severe eating disorders on families
• Risk of family conflict and family breakdown
• Financial burden of care and attending
  appointments

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Educational Risks

• Loss of education
• Failure to achieve educational potential

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Assessment of BN

• Explore nature of emotions around binge episodes
  and the frequency of bulimic symptoms
• Explore motivation
• Often kept secret from family and friends, engage
  individual first, then explore family support can
  be achieved
• Common self harm, substance misuse, low mood
• Link between BN and negative sexual experiences

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Treatment

• NICE guidelines (2004) were due for revision 2011
• there was not enough new evidence to revise
• mostly consensus rather than strong evidence

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NICE for all EDAdditional considerations for
children and adolescents

• Family members, including siblings, should
  normally be included in the treatment of children
  and adolescents with eating disorders.
  Interventions may include sharing of information,
  advice on behavioural management and facilitating
  communication.
• In children and adolescents with eating
  disorders, growth and development should be
  closely monitored. Where development is delayed
  or growth is stunted despite adequate nutrition,
  paediatric advice should be sought.
• Healthcare professionals assessing children and
  adolescents with eating disorders should be alert
  to indicators of abuse (emotional, physical and
  sexual) and should remain so throughout
  treatment.
• The right to confidentiality of children and
  adolescents with eating disorders should be
  respected.
• Healthcare professionals working with children
  and adolescents with eating disorders should
  familiarise themselves with national guidelines
  and their employers policies in the area of
  confidentiality.

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NICE - AN

• Family interventions that directly address the
  eating disorder should be offered to children and
  adolescents with anorexia nervosa. B
• Children and adolescents with anorexia nervosa
  should be offered individual appointments with a
  healthcare professional separate from those with
  their family members or carers.
• The therapeutic involvement of siblings and
  other family members should be considered in all
  cases because of the effects of anorexia nervosa
  on other family members.
• In children and adolescents with anorexia
  nervosa, the need for inpatient treatment and the
  need for urgent weight restoration should be
  balanced alongside the educational and social
  needs of the young person.

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NICE - BN

• Adolescents with bulimia nervosa may be treated
  with CBT-BN adapted as needed to suit their age,
  circumstances and level of development, and
  including the family as appropriate.

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Extreme Physical Risk

• Feeding against the will of the patient is a
  highly specialised procedure requiring expertise
  in the care and management of those with severe
  eating disorders and the physical complications
  associated with it. This should only be done in
  the context of the Mental Health Act 1983 or
  Children Act 1989.

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Refeeding Syndrome

• fluid and electrolyte dysregulation
• severe hypophosphatemia, hypokalemia,
  hypomagnesemia, abnormal glucose metabolism,
  deficiencies in vitamins and trace elements
• serious cardiac, neurological and haematological
  dysfunction
• 27.5 of inpatient adolescents undergoing
  refeeding developed hypophosphatemia (lowest day
  4) Ornstein et al, 2003

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Treatment

• Collaboration, communication, consistency
• Family based treatment
• Individual therapy
• Medical and nutritional interventions

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Minnesota semi-starvation study Ancel Keys
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TOuCAN

• A randomised controlled multicentre trial of
  treatments for adolescent anorexia nervosa
  including assessment of cost-effectiveness and
  patient acceptability the TOuCAN trial
• SG Gowers,1 AF Clark,2 C Roberts,3 S Byford,4 B
  Barrett,4 A Griffiths,1 V Edwards,5 C Bryan,1 N
  Smethurst,1 L Rowlands1 and P Roots6
• BJPsych 2007

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Junior MARSIPAN

• Management of Really Sick Patients under 18 with
  Anorexia Nervosa
• College Report CR 168
• January 2012

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The Golden Cage

• The enigma of anorexia nervosa

Hilde Bruch, 1978
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