EATING DISORDERS

1. EATING DISORDERS IN CHILDREN AND ADOLESCENTS Eileen Levy MSN, RN, PMHNP-BC April 6, 2019

2. Pediatric eating disorders are more common than type 2 diabetes and it’s epidemiology is changing with higher rates in younger children , boys and minority groups • The etiology is unknown , but research is indicating an interface among genetics, biological predispositions , environmental & sociocultural influences and psychological traits • Some studies have identified specific chromosomes, genes and proteins may play a role in bulimia nervosa • Adolescence is a critical period of development and can be a window of vulnerability during which and eating disorder can develop

3. Pediatric clinicians are the front line of suspicion /diagnosis of an eating disorder • Low self esteem • depression • Anxiety • Impaired coping skills especially with emotional components • Substance abuse • Body image distortions

4. Types of eating disorders • Anorexia nervosa • Bulemia nervosa • BINGE EATING DISORDER • ARIFID: avoidant restrictive food intake disorder

5. ANOREXIA NERVOSA • MOST OFTEN IN ADOLESCENT FEMALES • BODY IMAGE DISTURBANCES • LACK OF SELF AWARENESS..PREVENTS RECOGNITION THEY MAY BE IN PHYSICAL DANGER • WHEN LOW WEIGHT VIRTUALLY ALL BODY SYSTEMS ARE AFFECTED • CAN BE LIFE THREATENING

6. CHARACTERISTICS • SEVERE/SELECTIVE RESTRICTION OF INTAKE, avoiding meals • RIGOROUS SELF-DENIAL • MAY WISH TO PUNISH ONESELF • IRRITABILITY, MOOD LABILITY, DECREASED CONCENTRATION, DECREASED LIBIDO, OBSESSIVE FEATURES • PERFECTIONISTIC DEMANDS OF SELF, ANXIOUS, RESTRAINED IN CHARACTER, FOCUSES INTENSELY ON DETAILS • Refusing foods once enjoyed, INCREASE IN EXERCISE • Pubertal milestones , linear growth affected • BINGE, PURGE OR LAXATIVE AND/OR DIURETIC ABUSE (1/3-1/2 OF ANOREXIA PATIENTS) • SELF INJURY • SUBSTANCE ABUSE

7. CONTRIBUTING FACTORS • IRREGULAR HORMONE FUNCTIONS-early menarche • GENETICS • NEGATIVE BODY IMAGE/ POOR SELF ESTEEM • DYSFUNCTIONAL FAMILY DYNAMICS(little contact with parents, high expectations, parental discord, critical comments re: weight, eating, shape)) • CERTAIN EXTRACURRICULAR ACTIVITIES: LEAN BODY= ENHANCING PERFORMANCE • FAMILY, CHILDHOOD TRAUMAS, CHILDHOOD SEXUAL ABUSE • CULTURAL, SOCIETAL, PEER PRESSURES (SIGNIFICANT BIRTHDAYS, GRADES, TESTS, ASPIRING TO LOOK LIKE OTHERS ) • LIFE CHANGES (NEW SCHOOL, OFF HANDED REMARKS RE: LOOKS , WEIGHT

8. Positive Body image • Begins at an early age: influenced by caregivers, idols, media, life experiences • Having a picture of ourselves in our mind’s eye • That image and our belief of how others perceive us creates our individual body image • Connected to development of self esteem, a strong identity and our capacity for pleasure

9. Indications of a Disturbance in body image • Unable to accept a compliment • Moods are overly affected by how one thinks or looks • Constantly comparing self to others • May call themselves “fat”, “ugly” or “gross” • Seeks frequent reassurance that their looks are acceptable • Identifies being thin to beautiful, successful, happy, in control • May feel connected to their body as a whole • Often fears being fat, even if slim • Is ashamed of themselves and their body • Strives to create that “perfect image”

10. Anorexia nervosa: warning signs • Is thin and continues to lose weight (15% or greater than medically ideal weight) • Diets even though not overweight, denies hunger • Feels, states is “fat” when is not • Wears loose, bulky clothing to hide weight loss of size • Preoccupied with food, dieting and counting calories/carbs/fats • Avoids mealtimes or eating in front of others • Exercises excessively, even when tired or injured • May overemphasize the importance of body image to self worth

11. Bulemia nervosa • Recurrent episodes of binge eating (discrete period of time, ie. 2 hrs. an amt. of food definitely larger than compared to others) • Sense of lack of control during the episode • Recurrent compensatory vomiting , misuse of laxatives, diuretics or other meds. , fasting or excessive exercising • These episodes occur at least 1x/week for 3 months • Self image is unduly influenced by body weight/size • May feel out of control in other areas in addition to food • May be normal weight or frequent fluctuations in weight • Often retreats to bathroom after a meal/evidence of purging • Skips meals, avoids eating in front of others, eats small portions

12. Bulemia nervosa • Baggy clothes to hide body • Uses gum, mints, mouthwash excessively • Repeatedly dieting • Develops food rituals (eating only a particular food, or food group, excessive chewing, doesn’t allow foods to touch • Develops new food practices such as cutting out entire food groups, vegetarianism, veganism • Steals or hoards foods in strange places • Drinks excessive water or zero calorie drinks • May withdraw from friends or create schedules to accommodate rituals • shows extreme concern with body weight and shape • Calloused knuckles from self induced purging

13. Binge eating disorder • Less likely in children/adolescents (usual average onset =25 y.o. ) • Frequent episodes of bingeing large amounts of food • Also feel out of control • No feeling of guilt or shame • Becomes a vicious cycle as the more distressed the person feels , the more they binge eat • No purging, fasting or excessive exercise…therefore are overweight or obese • Constant dieting, rarely lose weight • Also may hoard, hide food, skip meals, wear baggy clothes

14. Arfid:avoidant-restrictive food intake disorder • Persistent feeding or eating disturbance manifested by avoiding food or ritualistic food intake not caused by scarcity of food • Similar to anorexia involves limitations in amount or type of food consumed But • Does not involve any distress about body shape, size or fear of fatness-----no distorted body image issues • Not picky eating; child does not consume enough calories to grow and develop properly resulting in a stalled weight gain and vertical growth or weight loss

15. ARFIDmust have one of the following • Significant weight loss, failure to achieve expected weight gain or faltering growth in children • Significant nutritional deficiency • Dependence on enteral or oral nutritional supplements • Marked interference with psychosocial functioning

16. Arfid risk factors • Those with autism, adhd, intellectual disabilities are more likely to develop arfid • Children who don’t outgrow picky eating, if whom picky eating is severe are at higher risk • Many children have a co-occurring anxiety disorder and are also at risk for other psychiatric disorders • Greater likelihood of comorbid medical disorders

17. Arfid: warning signs • Dramatic weight loss • Dresses in layers to hide weight loss or stay warm • Reports constipation, Abdominal pain, cold intolerance, lethargic and /or excess energy • Dramatic restriction in types or amounts of food eaten

18. Early access to treatment is crucial • Eating disorders haver the highest mortality rate of any psychiatric disorder • They can cripple the mind and the body • Those with eating disorders experience profound anxiety and body dissatisfaction • The lack or denial of self awareness (and with caregivers) prevents recognition these patients are in danger

19. therefore • Full weight restoration is critical and often involves high calorie diets, allowing for continued growth and development • Weight maintenance is typically inappropriate in the pediatric population • Physical, nutritional and health are all metrics of a full recovery • Pediatric patients with eating disorders have a good prognosis with appropriate care • May utilize scoff (screening tool: sick, control, one stone, fat, food) • Obtain comprehensive medical , family and social hx. And complete review of systems • Treatment thresholds should be low as there are potentially irreversible effects

20. Treatment: • newer paradigm accounts for biological & genetic contributions to eating disorders and views caregivers as crucial allies in treatment (vs. body image and influences) • Nutritional rehabilitation and improving cognitions are the primary initial foci of treatment vs. causation utilizing age appropriate insight developing over time • Family based treatment is essential having the largest based evidence with <12y.o. with restrictive e.d. • Caregivers not blamed , but empowered to refeed their child back to health • Therapists and providers are utilized as consultants • Siblings are engaged as they too are concerned re: their sibling • The e.d. is externalized from the child to release blame for their disorder

21. treatment • Nutritionist/dietician to help determine goal weight • Do not defer to nutritionist, but rather to support empower family and patient • Cognitive behavioral therapy • Individual therapy • ssri(for anxiety, depression , b.n.) • Initial Atypical antipsychotic medications may also decrease anxiety and rigidity and improve early weight gain • Day treatment, intensive outpatient , inpatient venues

22. Tips for children • No food is “good “ or “bad” • Eat when hungry, stop when full • Fitness can include sports, dance, karate, playing • All bodies are different • Teasing hurts • Fat isn’t bad and thin isn’t good • If you are unhappy with your body talk to a trusted adult

23. Tips for caregivers • Encourage healthy eating and exercise • Examine own beliefs and behaviors about weight, body image, success and accomplishment…consider the child’s interpretation of your beliefs • Allow the child to determine when they are full • Talk about acceptability of different body shapes • Discuss dangers of dieting • Appreciate the importance of the messages of caring for the child’s inner being, not how they look • Avoid using food as a reward or punishment • Never plead, bribe, threaten or manipulate around food • Avoid power struggles, criticism, shame, reassurances with child they aren’t fat • Note/Avoid endless conversations about weight, food, calories