Eating Disorders in Children and Adolescents

Updated Definitions: What did DSM-5 Actually Change?

Challenges to prior versions (DSM-IV and DSM-IV, Text Revision, or DSM-IV-TR) stemmed from the narrowness of criteria for anorexia nervosa (AN) and bulimia nervosa and broadness of the definition for the former category titled Eating Disorder Not Otherwise Specified (ED-NOS). In one study, more than 50% of patients did not meet the DSM-IV or DSM-IV-TR criteria for either AN or bulimia nervosa. The process of “lumping” a diverse group of patients poses challenges for performing useful outcome studies because what works therapeutically and psychopharmacologically in patients with AN may not be the same as what works best in patients with bulimia nervosa, for example. Broad categorization also presented challenges for reimbursement in the United States, where some insurers covered AN but not necessarily ED-NOS, thereby limiting days of needed treatment for some patients in past years. Earlier editions also did not recognize that very young children as well as adolescent boys might develop eating disorders. The new definitions for the various eating disorders are found in Box 15.1 . The goal of the revised categories was to help clinicians and therapists choose the right interventions in a timely fashion so as to optimize treatment outcomes. ^,

For AN, the illness is still defined by self-starvation, in order to get to and maintain an abnormally low body weight, combined with an intense fear of becoming fat. Specific changes include the elimination of amenorrhea as a criterion, as amenorrhea does not necessarily predict medical risk or treatment outcome. Furthermore, the absence of menses does not apply to premenarchal girls, males, or postmenopausal women. In prior versions, the definition included only those individuals at less than 85% of expected weight. DSM-5 changes this criterion to low weight in the context of age, gender, developmental trajectory, and physical health. In plainer words, if a child falls off a growth curve or crosses percentiles, that change should ring the clinician’s alarm bells for an eating disorder.

In DSM-5, bulimia nervosa continues to be characterized by episodes of binge eating (bulimia stems from the Greek phrase “appetite like a bull”), followed by inappropriate compensatory behaviors to avoid weight gain. These compensatory behaviors can include vomiting, laxative abuse, abuse of diuretics or diet pills, and hyperexercising (also called overexercising; in layperson’s terms, these individuals used to be labeled as patients with “orthorexia,” although that term has now evolved in the lay literature to mean “overly healthy eating”). Individuals with diabetes mellitus and AN or bulimia nervosa might precipitate weight loss by misusing and/or withholding insulin, called in layperson’s terms “diabulimia.” These colloquial terms may pop up in the literature but are not found in DSM-5, which also eliminated the specific subtypes (purging and nonpurging). The new version of DSM reduces the requirement for binges to only once weekly for 3 months instead of twice or more weekly over 3 months. The lowered frequency stemmed from the lack of difference in psychopathology or treatment outcomes between patients with once-a-week cycles of binges and purges versus more binge-purge episodes.

New subcategories in DSM-5 were designed to help distinguish different treatment needs and eventual outcomes between various subtypes. Binge eating disorder is defined by binges without inappropriate compensatory behaviors. Wonderlich et al. described this group as more obese, with greater functional impairment. These individuals were also more likely than obese patients without eating disorders to progress to metabolic syndrome. Again, this DSM category has opened up reimbursement for diagnosis and treatment in the United States, including the potential use of new medications (see later discussion in this chapter).

DSM-5 also included a new category, Avoidant/Restrictive Food Intake Disorder or ARFID, renaming the former DSM-IV category of “feeding disorder of infancy or early childhood.” These children, adolescents, and adults fail to meet their nutritional needs for reasons other than weight control. They may begin to avoid food after a choking or gagging incident, with fear of repeating that sensation. Another child or adolescent may develop ARFID after a vomiting illness, with fear of ever vomiting again. Abdominal pain, dislike of the sensory characteristics of certain foods, and other factors may keep a child from receiving the nutrients needed for growth. Unlike the child with AN, these children do not state that they fear weight gain or do not want to grow; rather, they fear the consequences of eating (abdominal pain, eating a food the picky eater would rather avoid, or other challenges). ARFID cannot be diagnosed in settings where some foods are avoided for religious/cultural reasons or from lack of availability.

A PubMed search from March 2018 found 48 citations on ARFID over the 5 years since introduction of DSM-5, reflecting the differences in recognition and treatment that this group of patients represents. Table 15.1 shows the current wording that defines ARFID; however, problems with Criterion A have been found, leading to a recommendation by the ARFID Criterion A Working Group to recommend a change to DSM-5. Criterion A.4, or marked interference with psychosocial functioning, is currently placed as a subcategory below the stem “An eating or feeding disturbance … with failure to meet appropriate nutritional and/or energy needs.” An example of the lack of clarity involves cases that many centers had seen of children and adolescents who remained on their growth curve but at great cost to the family. For instance, one child was still gaining and growing, but this child’s rural family had to drive 2 hours each way to obtain specific foods that this child would eat, with all other foods refused. Other children had not fallen off the growth curve but would eat only specific foods and were incapable of eating outside of the home, thus limiting school function and family involvement in the world or community. Of over 1215 individuals meeting the criteria for ARFID from seven programs in the Working Group, the change in wording to delete the phrase “as manifested by persistent failure to meet appropriate nutritional and/or energy needs” in Criterion A would keep all cases of ARFID still recognizable and within this category. Thus, a young person still growing appropriately but pathologically avoiding certain foods could still fall within the category of ARFID. This proposal has been approved by the DSM Steering Committee of the American Psychiatric Association (awaiting public comment, private communication with Dr. B. Timothy Walsh, chair of the Working Committee, October 1, 2018).

In a retrospective study of 712 patients presenting over 1 year to seven adolescent medicine divisions for evaluation of disordered eating, 98 (13.8%) met the criteria for ARFID. Within this subgroup, 28.7% had been picky eaters since early childhood, 21.4% experienced generalized anxiety, 19.4% displayed gastrointestinal symptoms, 13.2% had a history of vomiting or choking, 4.1% had food allergies, and 13.2% had other reasons for their restricted eating. In a study of young persons with ARFID presenting to a pediatric gastroenterology clinic, 33 ARFID patients were divided into four groups: those with insufficient intake and/or little interest in feeding (57.6%), those with limited diets due to sensory characteristics of the foods (21.2%), those who had experienced an aversive or traumatic food-related event (9.1%), and those who had other reasons for food avoidance (12.1%). ^, Several studies have noted that ARFID patients are likely to be younger, male, and with a longer duration of illness than those with AN. These children also have a higher incidence of comorbid medical and/or psychiatric disorders compared with young persons with other eating disorders as well as higher rates of obsessive compulsive disorder, generalized anxiety disorder, and autism spectrum disorders.

Recognizing Eating Disorders in Children and Adolescents

Eating disorders may often be missed or their diagnosis delayed by primary care providers and subspecialists. Pediatricians must take seriously any concern from a parent or other caring adult that a child or adolescent may be developing an eating disorder; many of these patients either already have or are in the process of hard wiring maladaptive eating attitudes and behaviors that could be prevented or treated with earlier intervention. ^, Eating disorders affect young people of all races, ethnicities, and socioeconomic backgrounds; children living in poverty with these conditions continue to be underrecognized, with challenges including lack of access to care as well as assumptions that eating disorders occur only in upper-middle-class communities. Eating disorders may also be “invisible” in obese populations, where individuals may be cheered on for decreasing weight from 220 to 180 lb even if they have done so with significantly disordered eating; they may be at as much risk medically as a teen decreasing his or her weight from 120 to 80 lb, but in the latter case the family and physician will be more likely to recognize a problem and react appropriately.

In the office, questionnaires such as the SCOFF (see Table 15.1 ) have been validated in adults but not in children. Many eating disorder centers use the EDE-Q or the 26-item modified Eating Attitudes Test (EAT) or the children’s version, the chEAT; these larger questionnaires take 5 to 10 minutes to complete but provide more sensitive screening.