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Eating Disorders - Part I - Recognition.

With all of the media coverage childhood obesity is getting these days, it's easy to forget about another food-related problem at the other end of the spectrum. It is less common but potentially much more deadly. And that is eating disorders.

The number of children and adolescents being diagnosed with eating disorders has increased steadily and significantly over the last 50 years. While relatively rare--less than 1% of adolescent girls have an eating disorder--eating disorders are serious mental health illnesses with significant morbidity and mortality. In fact, anorexia nervosa has the highest fatality rate of any psychiatric diagnosis. For this reason, early recognition and treatment of eating disorders is critical.

In this first installment of a two-part article, I will focus on helping parents to understand eating disorders and to recognize suspicious signs, symptoms and behaviors that may suggest an eating disorder diagnosis. (In the next installment, I will review treatment options and give parents guidelines for how to support their children with eating disorder.) Eating disorders are categorized as "anorexia nervosa," "bulimia nervosa "or "eating disorder not otherwise specified."

The definition of anorexia nervosa according to the DSM-V (the Diagnostic and Statistical Manual of Mental Disorders, fifth edition) includes an intense fear of gaining weight or becoming fat despite being underweight and an inability to maintain body weight at or above a minimally normal weight for age and height. The DSM-IV used the term refusal, which implied a willfulness on the part of the sufferer. But the restricting that these children do is anything but willful. Our society struggles to understand anorexia nervosa. So many people I meet think it's as simple as, "just eat."

The DSM-IV also included amenor-rhea as a criterion for diagnosis, which the DSM-V dropped. This is because the criterion could not be applied to males (who more and more are being diagnosed with eating disorder), pre-menarchal girls, girls on contraceptives or post-menopausal women.

The DSM-V criteria for the diagnosis of bulemia nervosa include recurrent episodes of binge eating as well as recurrent behaviors aimed at compensating for or preventing weight gain such as self-induced vomiting, laxative, enema or diuretic abuse, fasting, or engaging in excessive exercise.

Despite these definitions, more than half of children and adolescents with disordered eating do not meet all of the criteria to fit the diagnosis of either anorexia nervosa or bulemia nervosa. These children are categorized as having "eating disorders not otherwise specified" or ED-NOS.

With the stakes so high--that is with the increased mortality rates for children with eating disorders--it is imperative that parents and doctors recognize these "outliers" and get children into appropriate treatment as soon as possible.

The causes of eating disorders are complicated. There may be some genetic predisposition as they occur with more frequency in patients with a family history of mood disorders and/or eating disorders. Girls who go through puberty earlier or children who are obese are also at increased risk. This may have its roots in teasing or bullying at school.

Some eating disorders start out as simple dieting which then gets out of control. A past history of physical and/or sexual abuse is common in children with eating disorders and may reflect the children's attempt to control their environment in whatever way they can.

Certain personality traits such as perfectionism and low self-esteem are prevalent in children with eating disorders. They also tend to be high achievers in sports and school and are often compliant people-pleasers. Social factors such as the stigmatization of obese children and adolescents and the media's fixation on unrealistically thin models may be contributing factors in the development of eating disorders.

Certain sports that promote weight loss or thinness such as wrestling, gymnastics, cheerleading, figure skating and ballet may also inadvertently promote the development of eating disorders.

Eating disorders go hand in hand with other mental illnesses such as anxiety and depression. Each must be recognized and addressed for treatment to be successful.

Since children with eating disorders deny their illness and may wear loose or baggy clothing to hide their weight loss, parents and medical staff alike must have a high index of suspicion when it comes to recognizing the signs of eating disorders.

Behaviors that can be red flags include the sudden shift to a vegetarian, vegan or low fat diet or the sudden scrutiny of food labels. Parents may notice the child taking smaller portions, eating much more slowly or claiming to be "not hungry" at mealtime. Children who weigh themselves several times a day or who exercise several times a day or at odd times of day should be suspected of having an eating disorder.

As the child with an eating disorder becomes more and more ill, his or her body image becomes increasingly distorted. Eating becomes an increasinly more painful experience and the child may not tolerate eating with family or friends. Consequently, children with eating disorders can become very isolated. Secretive behaviors like hiding food and pretending to have eaten can occur. Children who head for the bathroom after eating may be purging or even exercising.

Children and adolescents who are obese or overweight represent a special population. They are at high risk for developing an eating disorder and yet, because of their higher weight, this may go unrecognized for a long period of time. This is significant because it is well-known that children who are diagnosed and begin treatment early have a higher rate of success than those who are recognized later.

Having experienced first-hand the terrible effects of this devastating illness with my 15-year-old foster daughter, I am determined to help other parents to recognize signs of eating disorders early so these children can be offered effective treatment.

In the next installment of this two-part article, I will review some of the known effective treatments for this disorder and also offer parents strategies and resources for supporting their sons and daughters through the treatment process.

Carolyn Roy-Bornstein is a pediatrician in private practice. She has been interviewed on radio and television about the new concussion guidelines for student athletes. Her memoir Crash: A Mother, a Son, and the Journey from Grief to Gratitude explores her own family's experience with her son's traumatic brain injury at the hands of a drunk driver. Read more at her web site
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Title Annotation:Pediatric Points
Publication:Pediatrics for Parents
Date:May 1, 2013
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