Eating Disorders in Children and Adolescents

1. Eating Disorders in Children and Adolescents • MRCPsych Course • Dr Gisa Matthies

2. History • Anorexia nervosa recognised condition in the late 19th century (1873) Ernest-Charles Lasègue named the condition L’Anorexie Histerique Sir William Gull coined the term anorexia nervosa

3. Early onset ED • Collins 1894: 7 year old girl • Marshall 1895: 11 year old girl

4. 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)

5. Diagnosis and Classification • Both ICD 10 and DSM IV under review • Planned updates: • -ICD 11-2015 • -DSM V-2013

6. 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

7. 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)

8. 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)

9. 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 9

10. 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 10

11. 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

12. 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

13. Currin et al 2005, BJP

14. Childhood Eating disordersBritish National Survey< 13 years • Incidence: • 3/100,000 • AN: 37% • BN: 1.4% • EDNOS: 43% • 50% admitted to hospital Nicholls et al 2011

15. Prevalence of adolescent ED (no UKdata) • AN overall about: 0.4 -2% • BN overall: ~1-2% • EDNOS most common ED

16. 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

17. Aetiology of Eating disorders • multifactorial/ complex • interaction between • -genetic • -biological • -psychological • -socio-cultural factors …creates susceptibility

18. 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

19. Biological Factors • Perinatal Factors • Physiological • -Oestrogens • -Reward processing • -Appetite regulation

20. 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)

21. 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’

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

23. 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

24. 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

25. 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

26. 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

27. 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)

28. Medical/nutritional assessment • Intake < 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

29. NutritionalRisk • History • duration of low weight • rapid weight loss (> 1kg/week) more destabilising • menarcheal status • Current Status • BMI centile (Percentage weight for height) • haemodynamic stability • Pulse < 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

30. 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

31. Comorbitdities are common consequence of starvation or separate • AN: • -Depression • -OCD • -Anxiety • -Social phobia • -ASD BN: -Depression -Self harm -Substance misuse -Impulse disorders -ADHD

32. Riskmultidimensional, short term andlong term • Physical • Psychological • Social • Educational

33. 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

34. Psychological Risks • ~25% of deaths in AN are due to suicide • Risk of self harm is increased • Comorbities are common

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

36. Educational Risks • Loss of education • Failure to achieve educational potential

37. 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

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

39. 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.

40. 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.

41. 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.

42. 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.

43. 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

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

45. Minnesota semi-starvation studyAncel Keys

46. 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

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

48. The Golden Cage • The enigma of anorexia nervosa Hilde Bruch, 1978