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Eating Disorders in Children and Adolescents

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Title: 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 Las├Ęgue named the condition
LAnorexie 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
Surveylt 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 UK data)
  • 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 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
29
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

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 and long 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 study Ancel 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
49
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