Somatic Symptom Disorders

SYMPOSIUM: PSYCHIATRY

Behavioural eating disorders Ben Lewis

Dasha Nicholls

Abstract The eating disorders, anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED), manifest through distorted or chaotic

eating and in the case of AN and BN are characterised by a morbid preoccupation with weight and shape. Whilst recent changes in diag- nostic criteria have changed the landscape to some extent, eating dis- orders and partial syndromes, including avoidant/restrictive food intake disorder (ARFID), remain relatively common and early recogni- tion and intervention is helpful. Aetiology is multifactorial, with high heritability. Prognosis overall is good but treatment can be long and intensive, significantly impacting families. An integrated multidisci- plinary approach is essential, working collaboratively with families and young people. Psychological interventions focus on the eating disorder, supported by medical monitoring and dietetic guidance.

Although working with families is the backbone of treatment for AN, young people also need opportunities for confidential discussion. For BN, family or individual approaches may be equally effective. Ev- idence for effectiveness of psychopharmacological agents is limited in both AN and BN. Psychological and pharmacological approaches may both be of benefit for BED. Cases of ARFID require individualised ap- proaches, often involving anxiety reduction. Paediatric expertise is of particular value in the assessment and management of acute malnutri- tion and complications secondary to disordered eating behaviours, in the early stages of re-feeding, and in the monitoring and management of long-term complications such as growth retardation, pubertal delay and osteopenia. This article offers an overview of eating disorders in

children offering advice for clinicians who will undoubtedly encounter them in clinical practice.

Keywords adolescent; anorexia nervosa; bulimia nervosa; child; eating disorders

Introduction

The eating disorders, anorexia nervosa (AN), bulimia nervosa

(BN) and binge eating disorder (BED), manifest through distorted

or chaotic eating and in the case of AN and BN are characterised

by a morbid preoccupation with weight and shape (Tables 1e3).

Ben Lewis BA BMBCh MRCPsych is a Specialist Registrar (ST5) in Child and Adolescent Psychiatry, Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Trust, London, UK. Conflicts of interest: none declared.

Dasha Nicholls MBBS MRCPsych MD is a Consultant in Child and Adolescent Psychiatry and Honorary Senior Lecturer, Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Trust, London, UK. Conflicts of interest: none declared.

PAEDIATRICS AND CHILD HEALTH 26:12 519

These behaviours and the associated cognitions differentiate

eating disorders from other psychological problems associated

with abnormal eating, including feeding disorders.

Debate about feeding and eating disorders classification has

been prominent in recent years due to the process of revising the

two major classification systems for mental disorders, the Diag-

nostic and Statistical Manual for Mental (DSM) Disorder and the

International Classification of Diseases (ICD). This remains only

partly resolved as DSM-5 was published in 2013, whilst ICD-11 is

not expected to be published until 2018. The main challenge for

the DSM-5 revisions was addressing evidence that the majority of

those presenting with clinically significant eating disorders did

not fulfil diagnostic criteria for AN or BN, and were therefore

classified as have an eating disorder not otherwise specified

(EDNOS). Changes to the diagnostic criteria addressed this by

broadening the definition of AN and BN. DSM-5 also identified

BED, previously incorporated in EDNOS, as a separate diagnosis.

Additional changes in DSM-5 reframed feeding problems as

food intake disorders, and removed age related criteria (previ-

ously feeding disorders required onset before age 6 years). These

presentations are now classified as the new diagnosis of Avoi-

dant/Restrictive Food Intake Disorder (ARFID) (Table 4). In

addition to recognition and diagnosis, paediatric expertise is vital

in management of malnutrition and other acute medical com-

plications, and of long-term complications such as the impact on

growth, development and bone density.

Epidemiology

Within the Western world, eating disorders are seen regardless of

class, culture and ethnic group. Increasingly eating disorders are

recognised as a significant problem in non-western cultures too.

It appears to be increasing in frequency. Even prior to DSM-5

revisions the number of young people in the UK directly

affected by eating disorders increased significantly between 2000

and 2009. The incidence rates (per 100,000) for all eating dis-

orders were: aged 10e14, 64.5 (female) and 17.5 (male); aged 15

e19, 164.5 (female) and 17.4 (male).

Eating disorders are common

The prevalence of AN is around 0.3e0.5%, with a peak age of

onset between 15 and 18, cases steadily increasing from age 10 and

occurring in children as young as 7. High-risk populations (ath-

letes, models, ballet dancers) have higher prevalence rates. BN

tends to occur later. The prevalence is just under 1%, with a

slightly later mean age of onset with cases reported from about 12

years. It is rare before puberty and is much less likely to come to

clinical attention. Prevalence rates for BED range from around 2

e3% although unlike AN and BN, peak incidence is after adoles-

cence. BED is probably under-recognised, and in young people

may look more like loss of control over eating than true bingeing.

Eating disorders are significantly more common in girls and young women than in boys

Female gender is the strongest risk factor for eating disorders, but

this can lead to under-recognition in boys. In AN there is marked

increase in female-to-male ratio following puberty, leading to an

overall ratio of around 11:1. For BN the ratio is around 30:1,

whilst BED is thought to be much closer to equal. Presentation is

� 2016 Elsevier Ltd. All rights reserved.

Diagnostic features of anorexia nervosa (adapted from DSM-5 and ICD-10 criteria)

C AN is characterised by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat

C Weight lost or maintained at less than 85% of expected weight for height and age, or failure to make weight gain during a growth period

C Fear of gaining weight or becoming fat, even though underweight

C Disturbance in the way one’s body weight and shape is experienced (body image distortion), undue influence of body weight or shape on self-

evaluation, or denial of the seriousness of low body weight

C Weight loss is achieved by restriction of food intake and specific avoidance of ‘fattening foods’ and/or: self-induced vomiting, self-induced

purging, excessive exercise, use of appetite suppressants/diuretics

C If bingeing or purging behaviours are absent, this is known as restrictive anorexia nervosa; if present, as binge purge anorexia

C NB: Amenorrhoea has been removed by DSM-5 as a diagnostic criterion

Table 1

Diagnostic features of bulimia nervosa (adapted from DSM-V and ICD-10 criteria)

C Persistent preoccupation with eating and recurrent episodes (over a period of months) of binge eating, which are characterised by: eating a large

amount of food in a short period of time AND a sense of lack of control while eating

C Attempts to counteract the ‘fattening’ effects of food by use of compensatory behaviours such as: self-induced vomiting, purgative abuse,

alternating periods of starvation or excessive exercise, use of drugs such as appetite suppressants, diuretics, thyroid preparations or, in di-

abetics, misuse of insulin

C Psychopathology consisting of a morbid dread of fatness and setting of a target weight way below what might be considered healthy

C Bulimia nervosa may follow on from a period of anorexia nervosa, but would only be diagnosed if the patient is no longer significantly

underweight

C Bingeing and associated compensatory behaviours occurring on average weekly for at least 3 months

Table 2

Criteria for Binge eating disorder (BED) e summarised from DSM-5

C Recurrent episodes of binge eating*

C Binges associated with at least three of:

� Eating faster than usual � Eating alone due to embarrassment by volume of food � Still eating large amounts despite not being hungry � Eating until uncomfortably full � After eating feeling depressed, guilty or ashamed

C Distress about the bingeing

C Bingeing occurs at least once a week (on average) for 3 months

C Unlike bulimia nervosa there are no recurrent and inappropriate

compensatory behaviours, and the bingeing does not occurring

only during episodes of AN or BN

* binge eating

� Eating an amount of food larger than most people would eat in that time and in those circumstances

� A sense or feeling of a lack of control over the eating

Table 3

SYMPOSIUM: PSYCHIATRY

similar in both sexes, except for a male tendency to be concerned

over shape rather than weight.

Pathology and pathogenesis

Biological, psychological and sociocultural factors all have a role

in aetiology, which include predisposing factors (risks),

PAEDIATRICS AND CHILD HEALTH 26:12 520

precipitating factors (triggers) and perpetuating (maintaining)

factors. Such a formulation is useful as a working hypothesis to

guide treatment interventions. Having some understanding of

how the eating disorder has come about in the young person’s

life will likely be helpful to them and their parents once it comes

to relapse prevention stage. However, symptom management

and targeting maintaining factors are the initial priority. For

example, if weight-related teasing is identified as a trigger,

addressing bullying will not in itself address the eating disorder.

By contrast, if perfectionism or athleticism are predisposing and

maintaining risk factors, these may need to be addressed during

the recovery process.

There is considerable evidence for genetic contributions to

individual symptoms, attitudes and behaviours, such as self-

induced vomiting, or perfectionism traits, which increase risk

within individuals. Puberty may also activate some aspects of

genetic heritability. Family studies, twin studies and adoption

studies, have provided heritability estimates of 60e75% for AN

and 30e80% for BN.

Understanding the aetiology of eating disorders has been

subject to definite ‘fashions’. Recent interest in the neurobio-

logical aspects is thanks largely to advances in neuroimaging,

and molecular genetics. This is not to devalue sociocultural

theories, which may be more relevant in understanding changing

epidemiology as well as individual risk within families. Culbert

et al. (2015) confirmed a number of sociocultural influences as

important: media exposure and pressures for thinness and

nonspecific personality factors including negative emotionality/

neuroticism and perfectionism. Current data support the theory

� 2016 Elsevier Ltd. All rights reserved.

Criteria for avoidant/restrictive food intake disorder (ARFID) e summarised from DSM-5

C A disturbance in eating or feeding resulting in a persistent failure to meet developmentally appropriate nutritional and/or energy needs

C The disturbance is associated with one (or more) of the following:

� Significant weight loss (or failure to achieve expected weight gain or faltering growth in children) � Significant nutritional deficiency � Dependence on enteral feeding or oral nutritional supplements � Significant interference with psychosocial functioning

C The behaviours are not better explained by lack of available food or by an associated culturally sanctioned practice

C The behaviour does not occur exclusively during the course of An or BN, and there is no evidence of a disturbance in the way one’s body weight

or shape is experienced

C The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. If does occur in the

presence of another condition/disorder, the behaviour exceeds what is usually associated, and warrants additional clinical attention

Table 4

SYMPOSIUM: PSYCHIATRY

that psychological and environmental factors interact with and

influence the expression of genetic risk to cause eating pathol-

ogy. Conceptualising eating disorders as ‘brain disorders’ may

help overcome stigma and trivialisation these disorders

engender, but should not exclude the need to look at the obvious

social and cultural factors that play a role.

Course of the disease(s)

Eating disorders in young people present at varying levels of

severity, from mild, short duration illnesses to long-standing

chronic conditions with significant impact on quality of like,

continuing into adulthood. A clear approach to interventions based

on severity at presentation is currently lacking although there is

ongoing research in this area. Accurate diagnosis is important. In

adolescents with AN (but not BN or BED) there is evidence that

treatment with family therapy for anorexia (FT-AN) in the early

stages of illness can potentially stop illness progression.

There are three stages of recovery described during the course

of early-onset AN. In Stage 1 the eating disorder is predominant,

characterised by food preoccupation with weight and shape

concerns. Denial is common. Stage 2 brings increased asser-

tiveness, the young person expressing powerful, negative feel-

ings, often directed towards parents or professionals. It is

important to warn parents to expect this, which can last around 6

months, and herald it as part of recovery. Stage 3 brings more

age-appropriate expression of feelings. This description of the

recovery process fits neatly with the three stages of treatment

described in the empirically supported family based therapy

(FBT) that would usually be the first line.

BN tends to have a more chronic and fluctuating course.

Identification is often delayed, the nature of the disorder being

easier to conceal than AN. Often conceptualised as a coping

strategy at difficult times, and highly mood related, it is often

likened to addictive disorders. BED has been found to be rela-

tively persistent and its course similar to that of BN (DSM-5).

Outcome and prognosis

Overall, studies reveal good outcomes in adolescents with AN of

between 49% and 75% after 10 or more years follow-up,

although even with intensive treatment, recovery can be slow.

In adolescents in treatment for AN, recent studies have shown

PAEDIATRICS AND CHILD HEALTH 26:12 521

that the proportion achieving a ‘good’ outcome was 19% at 1

year, 33% at 2 years and 64% at 5 years. For patients with

established illness, time to recovery is estimated at around 5

years. Around 10% will have a severe and enduring eating dis-

order, for which outcome is poor, with the highest mortality and

morbidity of any psychiatric disorder. There are fewer studies on

the outcome of adolescent BN, although full recovery is expected

in over 50% of patients. Once a young person has recovered from

the eating disorder, secondary psychopathology may remain;

most commonly depression or anxiety disorders.

Diagnosis

The history is best taken with the whole family together,

informing them at the start of the assessment the need for indi-

vidual time with the young person, and a physical examination.

Assessment should be regarded as the first step in treatment and

an important opportunity to engage and motivate the young

person and family. Eating disorder psychopathology can be

identified through subjective report by the young person or

parental reports of disordered eating behaviours that may not be

disclosed by the young person. Age-appropriate semi-structured

interviews are the gold standard for eliciting eating disorder

psychopathology, such as the Eating Disorder Examination

(EDE), although interview by an experienced clinician is usually

adequate. Increasingly self-report questionnaires are used as

alternative to clinical interview and there are pros and cons to

this approach.

If diagnosis remains uncertain following a thorough clinical

assessment increasing food intake often clarifies the diagnosis. If

fear of weight gain is present, active weight loss behaviours will

ensue. Similarly, a fear of swallowing will become more obvious

if certain foods are avoided or only liquids can be managed (and

therefore may indicate a diagnosis of ARFID).

A risk assessment is essential in determining ‘what next’?

Risk assessment requires establishing current eating patterns and

a typical day’s intake, as well as specific questions about

compensatory behaviours. Current intake gives important infor-

mation regarding risk of nutritional deficiencies, and is important

in establishing how re-feeding should be tailored safely.

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SYMPOSIUM: PSYCHIATRY

Onset is often slow and insidious, with acute deterioration

expected once it comes to light. Children often stop drinking as

well as eating. A full history also addresses family risk and

protective factors, such as history of mental disorder, and the

role of the extended family. Marital relationships are only of

relevance in relation to parents’ capacity to work together in the

interests of their child. Family attitudes and beliefs about food,

weight and shape influence the way eating disorders are

addressed within the family context and may therefore affect

prognosis. Social context (housing, employment and financial

situation) and practical considerations are important for treat-

ment planning. A developmental history should include feeding

and early attachment, and premorbid personality including

perfectionism, peer relations, obsessional traits, separation anx-

iety, autism spectrum disorder traits and self-esteem.

Eating disorder psychopathology, mood and psychological

risk (e.g. suicidal ideas or self-harm) are best assessed individ-

ually although parental accounts should be sought. It is helpful to

ask about eating patterns, current intake, dietary restrictions and

rules (such as calorie limits, set eating times), compensatory

behaviours (purging, laxatives, exercise) and binge eating. Be-

liefs and preoccupation about weight and shape, concerns about

eating, fear of weight gain, self-evaluation with respect to weight

shape or eating and motivation to change are all key to making a

diagnosis and treatment plan.

Physical assessment (Table 5)

AN carries considerable serious physical risks and needs careful

monitoring. Early, robust intervention is vital to prevent or

reverse significant physical complications. In BN, physical

problems are caused by frequent vomiting and potential

excessive use of laxatives. Some of the complications of AN and

BN are due to lack of energy, some to metabolic disturbance

and some to endocrine disturbance (of hypothalamic origin)

(Table 6). Some are potentially life-threatening, whilst others are

Physical assessment

What to look for on physical examination

CWeight, height and BMI centiles (or % median BMI if

below 2nd centile) falling or below 9th BMI centile

CBradycardia and orthostatic changes in pulse or

blood pressure, based upon age-appropriate norms

CHypothermia

CDull, thinning hair

CSunken cheeks, sallow skin/skin integrity

CLanugo hair

CDelayed pubertal development for age/atrophic breasts

CPitting oedema in peripheries

CCold extremities/acrocyanosis/weak peripheral pulses

CDehydration (skin turgor, mouth, tongue)

CMuscle wasting

CSigns of bingeing/purging e.g. dental erosion, callouses on fingers

CSigns of vitamin deficiency

Table 5

PAEDIATRICS AND CHILD HEALTH 26:12 522

associated with long-term compromise of health. The Junior

MARISPAN guidelines (Management of really Sick Patients under

18 with Anorexia Nervosa: http://www.rcpsych.ac.uk/files/

pdfversion/CR168.pdf) provide a risk assessment framework as

a basis for determining medical risk and immediate management.

Acute physical risks will be frequently assessed and managed by

local paediatricians who commonly report a lack of confidence in

this area.

Complications unique to younger patients, due to the dynamic

nature of growth and development, are growth retardation, pu-

bertal delay or arrest, and reduction of peak bone mass. An

atypical picture needs an open mind and a thorough medical

review. Common differential diagnoses include gastrointestinal

disease (e.g.: Crohn’s), chronic disease affecting appetite and

growth (e.g.: renal failure), endocrine disorders, intracranial

pathology and other psychiatric disorders such as obsessive

compulsive disorder and depression.

Nutritional assessment should consider the past, present and

future: duration of low weight, rapidity of weight loss, menar-

cheal status, body mass index (BMI) centile (or % median BMI),

haemodynamic stability and future predicted intake (often over-

estimated). Fluid intake may be restricted (to lose weight) or

excessive (to increase weight temporarily). Rapid weight loss

(more than 1 kg/week) can cause medical instability even if the

child is not underweight. Muscle weakness and peripheral neu-

ropathy are signs of serious nutritional deficit. Local protocols

agreeing thresholds for paediatric admission are important.

Growth slows and even stops during a period of starvation.

After starvation is over, catch-up growth can occur. Our best

guess for the ‘dose’ of starvation needed to have a permanent

effect on height is 4 years before completion of growth. There are

case reports of people going through puberty in their mid to late

20s, and anecdotal accounts of menarche at nearly 50.

Between 25% and 40% of young people with AN will have

osteopenia on bone density scan. Studies have shown fracture

When to worry

C<85% BMI for age (between 2nd and 9th centile) is underweight.

<70% high risk

CPulse <50 (45 at night); BP <80/50; orthostatic changes in pulse

(>20 bpm) or blood pressure (>10 mm Hg)

C<35.0 �C

CNo signs of puberty at 13; premenarcheal at 15

CNormal capillary refill >3 seconds

CIf visible in older child, suggests >5%

CDifficulty sitting up from supine, and rising from squat to standing

(SUSS test) without use of hands

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Physical complications of eating disorders

Medical complications of calorie restriction Medical complications of purging

C Cardiovascular

C ECG abnormalities e Bradycardia; T wave inversion; ST segment depression;

prolonged QT interval; dysrhythmias (SVT, VT); percardial infusions

C Gastrointestinal system

C Delayed gastric emptying; slowed GI motility; constipation; bloating; fullness;

hypercholesterolaemia; abnormal liver function (carotenemia)

C Renal

C Increased blood urea (from dehydration and reduced GFR) with

increased risk of renal stones; polyuria (from abnormal ADH secretion);

depletion of Na and K stores; peripheral oedema with re-feeding due to

increased renal sensitivity to aldosterone

C Haematology

C Leucopenia; anaemia; iron deficiency; thrombocytopenia

C Endocrine

C Sick thyroid syndrome (low T3); amenorrhoea; growth failure; osteopenia

C Neurological

C Cortical atrophy; seizures

C Fluid and electrolyte imbalance

C Low K; low Na; low Cl

C Chronic vomiting

C Oesophagitis; dental erosions; oesphageal tears;

rarely rupture and pneumonia

C Use of ipecac/laxatives

C Myocardial damage; renal stones; low Ca;

low Mg; low KCO3 C Amenorrhoea

Table 6

SYMPOSIUM: PSYCHIATRY

incidence and prevalence are higher in adolescents and young

adults with and the long-term fracture risk is around three times

that of the general population. Interpretation of reduced bone

density in AN in young people should consider the impact of

pubertal delay and growth failure on bone size.

Management

General

Eating disorder treatment in children and adolescents presents

many challenges to the clinician. Young people with AN are

terrified at the thought of eating and weight gain, and at best

ambivalent about receiving help. They may be suffering physical

effects from their eating behaviours, impairing their capacity to

think. Many patients do not accept that they are unwell, and are

often brought to treatment by family members.

Parents often experience first-line healthcare professionals as

minimising eating difficulties on initial presentation. Eating dis-

orders are unlikely to resolve on their own once they have reached

the stage of clinical presentation; a ‘wait and see’ approach is

contraindicated. Standardised weight monitoring should be

established as soon as concerns arise. Parents often report changes

in behaviour, suchas socialwithdrawal, altered eatingbehaviours,

secretiveness, and ritualized and restricted activities, long before

low weight is apparent. Recent guidance mandates referral for

specialist care as soon as an eating disorder is identified, with

thresholds for routine versus urgent cases (https://www.england.

nhs.uk/wp-content/uploads/2015/07/cyp-eating-disorders-

access-waiting-time-standard-comm-guid.pdf).

Written information is important, followed by the time to

answer questions and to discuss areas of concern. Professionals

should recommend resources for parents and children on eating

disorders in the younger population (see below). Parents and

children need a clear statement about diagnosis, the likely course

and possible complications of the illness, and proposed treatment.

PAEDIATRICS AND CHILD HEALTH 26:12 523

Treatment aims are to gain weight (AN), establish regular and

healthy eating, and reduce risk (all eating disorders), address

related symptoms such as anxiety or depression, and facilitate

psychological and physical recovery. It is useful to acknowledge

the cognitive effects of starvation, which intensify similar

cognitive aspects of AN. Starvation can increase obsessionality,

perfectionism, low self-esteem; and can lead to increased gastric

emptying which adds to feelings of fullness. Early weight gain in

treatment has been linked with better long-term outcomes.

The treatment evidence base in young people is limited, and

in some areas, such as BED, almost non-existent. Guidelines,

such as the NICE guidelines (National Collaborating Centre for

Mental Health, 2004, currently in the process of being updated),

are therefore largely based on consensus expert views. Treatment

must address both physical and psychological aspects of the

condition. Early intervention in a developmentally appropriate

and specialised treatment setting is likely to produce the best

outcome. A combination of integrated interventions offered by a

multidisciplinary team is needed. In most situations, parents

should be involved in treatment.

Psychological interventions

Ideally, young people with eating disorders should be treated as

outpatients. Although family work is the backbone of child and

adolescent mental health, children and adolescents should also

be offered individual appointments separate from their family or

carers. Psychological interventions need to focus on both the

eating behaviours and the young person’s thoughts about their

weight and shape, alongside clear expectations for weight gain in

the case of AN. Effective treatment requires a skilled multidis-

ciplinary team.

For AN, the first-line treatment is FT-AN, weekly or more

frequently at first, supported by regular medical monitoring and

dietetic input. What sets FT-AN apart is the central role played by

parents throughout therapy. The model supports parents being in

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SYMPOSIUM: PSYCHIATRY

charge of their child’s eating until the young person is well

enough to share responsibility. Family interventions address the

eating disorder directly, with behaviour change focussed on the

maintaining behaviours of AN. The key ethos is that parents are

seen as a resource to the resolution of the problem, and not as

causative. This work can be undertaken with the family all

together (conjoint family therapy) or with parents separately

(parental counselling); the latter may be useful when there is

high expressed emotion within the family. Individual therapy has

a role, especially for older adolescents who might be expected to

take more responsibility, or where the young person’s family is

not willing or able to participate in family therapy. The evidence

base for individual therapy is weaker. If obsessive-compulsive

features are marked, progress in treatment may be slower.

Alongside outpatient treatment, growth monitoring is

required. Regular progress reviews are important and all pro-

fessionals involved should have clear, documented roles and

responsibilities. Increasingly, more intensive methods of outpa-

tient treatment are being sought, because of questions about the

effectiveness and cost-effectiveness of inpatient treatment.

Outreach services and home based treatment teams can

contribute to decreased need for inpatient admission, while

intensive family approaches such as ‘multifamily therapy’

continue to be trialled.

For BN, empirical evidence supporting treatment options for

adolescents remains limited beyond case series. Outcomes for

family therapy for bulimia are probably comparable to individual

CBT and supportive therapy. In practice, it seems reasonable to

offer choice and assess the individual circumstances of the young

person and their willingness to involve, and likely support of,

their parents.

A 2015 review of BED from the United States suggests CBT is an

effective treatment for some people by improving specific behav-

ioural and eating domains such as reducing binge frequency and

improving binge abstinence. In the case of ARFID little research

has yet been conducted into treatment options. In general treat-

ment should be individualised on the basis of the main feeding or

eating difficulty and the factors contributing to aetiology.

Medications

The evidence base for the use of psychotropic medication in

eating disorders is relatively weak. A literature review by the co-

author (BL e unpublished data) looking at AN in adolescents

concluded there was no evidence for use of the antidepressants

selective serotonin re-uptake inhibitors (SSRIs), although the

studies identified were predominantly focussed on eating disor-

der psychopathology, and the patients were still low weight

when being treated. In AN, depression often lifts with improved

nutritional state but if not, then antidepressants, usually SSRIs

such as Fluoxetine, at this stage may have value.

Antipsychotic medications are commonly prescribed in AN.

However the same literature review concluded was that there

was no evidence for their use in the adolescent population. Not

only were there no significant positive outcomes with regards to

weight gain (or associated outcomes), of concern were metabolic

and cardiovascular side effects, which are of particular relevance

in people with malnutrition.

Occasionally nutritional supplements and hormonal support

are indicated, most often as damage limitation in chronic illness

PAEDIATRICS AND CHILD HEALTH 26:12 524

or during acute re-feeding. These should only be considered by

specialists in conjunction with the rest of the treating team. The

use of hormone replacement for the treatment of impaired bone

density is rarely indicated. The mainstay of treatment remains

weight gain and nutritional rehabilitation. In consultation with a

specialist multidisciplinary team, transdermal oestrogen may be

considered by way of damage limitation for severe bone deple-

tion. Improvement in bone density is not usually seen in the first

year of treatment, but after 1e2 years.

Evidence for the effectiveness of SSRIs in BN is stronger, with

high-dose Fluoxetine being the treatment of choice, although the

evidence comes from adult studies as there are no studies

exclusively in adolescents. The 2015 review of BED found

modest benefit from second-generation antidepressants for

achieving BED specific outcomes, such as reducing frequency of

binge eating episodes.

Re-feeding

The aim of re-feeding is healthy weight restoration in the least

invasive way. Wherever possible, re-feeding is done orally and at

home if safe. The child needs clear expectations about what they

need to manage. Dietetic input can be very helpful but is not

necessary in supporting parents in this regard. Typically for

weight gain aim is 0.5 kg/week for outpatients and between 0.5

and 1 kg for inpatients, weekly. This generally requires between

3500 and 7000 extra calories a week. In the past starting with a

low intake and building up to full requirements slowly had been

thought to be safest. However more recently a quicker approach

and managing medical risks should they arise has been advo-

cated. This has been backed up by a recent RCT by O’Connor

et al. (2016) looking at re-feeding adolescents with AN with a

higher energy intake than usually recommended (1200 vs 500

kcal/day). This resulted in greater weight gain but without an

increase in associated re-feeding complications, thus challenging

many re-feeding guidelines.

In hospital treatment

The decision to admit a young person with an eating disorder is

made for one of four reasons:

1. A rapid deterioration in medical state therefore requiring

medical stabilisation;

2. Marked depression, suicidal ideation or intent;

3. Other major psychiatric disturbance;

4. Intensive therapeutic support that cannot be otherwise pro-

vided in outpatient setting.

Paediatric admission works best if close links remain between

paediatric and mental health services especially if locally agreed

protocols are in place. It is helpful, and important, to distinguish

the need for medical stabilisation from re-feeding. Young people

may find it easier to eat at home, if the risks can be managed.

Psychiatric admission is a serious decision, with admissions

often lasting 4e6 months or more. The following need to be

considered prior to psychiatric admission for an eating disorder:

� Can care be provided in an age-appropriate setting and as close to home as possible?

� Consider potential side effects of inpatient admission, including isolation from family, increased resistance.

� Balancing indices of admission with the educational and social needs of the child/adolescent.

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SYMPOSIUM: PSYCHIATRY

� The long-term effects on the family, including time commitment and emotional effects of admission.

� Early consideration of transition plan to outpatient services on discharge.

In recent years there has been increasing debate about the role

of inpatient care. The debate has tended to focus on the issue of

continuing inpatient care for weight normalisation once medi-

cally stable compared with brief admission followed outpatient

or day hospital treatment. Systematic review of the trial data has

not been helpful in settling the argument. This concluded there

was no difference in treatment outcomes between the different

treatment settings and different lengths of inpatient treatment.

However inpatient treatment was significantly more expensive

than both outpatient and day patient treatment.

In AN, once in a healthy weight range, meal plans need to be

adapted to allow for continuing growth and the nutritional de-

mands of puberty. Although weight gain is ultimately associated

with improvement in all aspects of functioning, initially it may

increase eating disordered behaviour (in an attempt to eliminate

the extra weight), anxiety and distress. Nasogastric feeding is

considered only when patients are medically compromised or are

unable to gain weight with supported meals and re-feeding

regimens.

Consent to treatment is needed and treatment against the

patient’s or parents’ wishes is always a last resort. Treatment

against consent is a highly specialised procedure requiring

expertise in the care of patients with severe eating disorders. In

England and Wales it can be done in the context of the Mental

Health Act 1984 or Children Act 1989, which allow a young

person’s refusal of treatment to be over-ridden. Parental consent

should not be relied on indefinitely, and clinicians should ensure

the legal basis for clinical action is clear. The NICE guidelines for

eating disorders recommend seeking a second opinion when

consent issues are highlighted.

Adolescents’ views of treatment

Young people with eating disorders say that without the moti-

vation to get well, they struggle to make use of treatment. They

value being listened to, and their views respected, even if ulti-

mately decisions need to be made against their wishes. When

treatment is experienced as disempowering or punitive, they

tended to reject and fight against it.

Parents’ views

We know the burden on parents/carers is high with some studies

showing around 50% suffering anxiety and around 30% with

depression. Recent work has shown that the level of burden is

perceived as higher than carers of people with schizophrenia.

What parents report finding helpful include ‘being firm and

presenting a united front, support and understanding, connecting

with other parents in similar situations’. Parent peer support

groups are very powerful in this respect. A number of in-

terventions have been developed including carer self-help in-

terventions using online or book based resources; guided self-

help over the phone, online or in person; as well as carer

workshops which people attend of a frequency ranging from

weekly to monthly. A review of carer-focussed interventions,

found improvement in carer distress and reduced burden asso-

ciated with the carer role. They also found changes in caregiving

PAEDIATRICS AND CHILD HEALTH 26:12 525

behaviours, such as expressed emotion, which are thought to

maintain the illness. Importantly these interventions are easy to

disseminate and deliver.

Parents want clinicians to include them in treatment, support

and guide them in their child’s care and demonstrate positive

attitudes toward them. The implications for clinicians include the

need for sensitivity to parents’ vulnerability, ensuring congru-

ence between clinicians’ and parents’ expectations about treat-

ment, and strengthening formal channels of communication.

Follow-up

In determining length of follow-up, it is important not to focus

solely on whether eating disorder symptoms are present, but to

think more broadly about the extent to which coping strategies

for the future stresses have been developed, ongoing risk and

impairment, and whether the young person is equipped for

developmental tasks appropriate to their age. In practice, young

people usually want to leave outpatient treatment before clini-

cians and their parents want to discharge them. Regular reviews

of progress and treatment are needed to inform changes in

treatment intensity. Monitoring of physical outcomes, e.g. bone

density and menstruation, may need to continue beyond psy-

chological intervention. Careful transition to adult services is

needed for chronic cases.

Prevention

The efficacy of prevention remains equivocal. A literature review

focussing on young adults (12e25 years) highlighted psycho-

education based programmes as being minimally effective in

producing behaviour change, outside of increasing knowledge.

Instead programs utilising active prevention components such as

cognitive dissonance or dissonance induction may produce

larger effects. Research indicates these interventions show

promise in changing attitudes associated with eating pathology

over the short term; however further trials involving long term

follow-up are needed to determine if lasting effects are possible.

Media literacy programs have also shown promise and incor-

porating active dissonance exercises and simple CBT seem more

effective than targeting weight and eating behaviours. In-

terventions targeting high risk female adolescents, especially

those age 15 and over, have greater impact than universal de-

livery. Interventions for children and younger adolescents family

involvement or other systemic factors need to be considered. For

example, there are concerns about the impact of anti-obesity

messages such as ‘fat is bad’ for children with a perfectionist

and literal mind. No prevention programme specifically designed

for parents has been reported in the literature to date to our

knowledge. A

FURTHER READING Allan R, Sharma R, Sangani B, et al. Predicting the weight gain

required for recovery from anorexia nervosa with pelvic ultraso- nography: an evidence-based approach. Eur Eat Disord Rev 2010; 18: 43e8.

Bailey AP, Parker AG, Colautti LA, Hart LM, Liu P, Hetrick SE. Mapping the evidence for the prevention and treatment of eating disorders in young people. J Eat Disord 2014 Feb 3; 2: 5.

� 2016 Elsevier Ltd. All rights reserved.

Practice points

C Diagnosis can be based on either a young person’s or carer’s

report

C Eating disorders are rarely self-limiting and when detected im-

mediate referral to specialist services is advised

C Underweight is a serious physical health issue which requires

careful risk assessment, often by, or in conjunction with, paedi-

atric services

C The most important skill is engagement and motivational

enhancement, for which a collaborative and information sharing

stance is helpful

C Most patients should be treated on an outpatient basis, provided

risks can be managed safely. Both physical and psychological

risks can increase at first with intervention

C The burden of caring for a young person with an eating disorder is

high and adequate support for parents and siblings is essential

C If inpatient psychiatric admission is deemed necessary the aim

should be for discharge to day patient or outpatient services as

soon as appropriate

SYMPOSIUM: PSYCHIATRY

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