Eating disorders are prevalent in the pediatric population, but these disorders are often underdiagnosed by pediatric health care providers.1 In addition, current evidence suggests that not one, but rather a diverse range of approaches is required for effective treatment of eating disorders. The current gold standard of care includes a multidisciplinary team approach and family-centered treatment.2–4 This article discusses treatment of pediatric eating disorders from a multidisciplinary perspective, focusing on evidence-based psychotherapeutic, dietetic, and psychopharmacological interventions.
Family involvement has been considered an essential component of eating disorder treatment and recovery since the pioneering family therapy work with anorexic children and their families by Minuchin et al.5 The most recent American Psychological Association practice guidelines continue to endorse the inclusion of families during the treatment of children and teenagers with eating disorders.2,3 The family and child with the eating disorder are affecting one another, so therapeutic interventions need to focus on the interactions between and within the family system. Instead of focusing solely on the identified patient, family therapy works to shift relationships and create healthier boundaries to create systemic change. Through these systemic changes, improved relationships between family members help the entire family heal.5
It is important to note that families do not cause eating disorders and are not to blame for their child's mental illness;1,6 however, families can inadvertently get caught in the insidious web of eating disorder dynamics. The family's attempts to deter the eating disorder can actually increase the symptoms and struggles.7 Out of concern and fear for their child's health, caregivers can become frantic and get into emotional power struggles with their child.7 Common pitfalls include begging, rescuing, threatening, or minimizing the problem.7 It is crucial to empathize with parents and let them know that they were doing their best in wanting to care for their child while at the same time redirecting their efforts to be more effective. After all, the more that parents fight with their children about food, the more powerful the food and eating disorder can become. It is helpful to remind parents to not focus on the food, weight, or other details that get them caught up in the struggle.
Instead, professionals stress the importance of educating families and caregivers to learn better ways to respond.1,6,7 Family-based treatment, also called the Maudsley approach, works to empower families to serve as allies in their child's recovery process.1,6 The therapist serves as a consultant, and the family participates through in vivo experiences of coaching their child to eat.6 The family learns distress tolerance, or how to handle emotions when they feel overpowering and the situation does not go as wanted, and also learns assertive communication strategies for more effective interpersonal experiences.6 In the end, the aim is for the child to regain age-appropriate autonomy.6
Another essential component for families with a child in eating disorder recovery is structure and limit setting. Laxter and Garber8 found trends of conflict avoidance in families with a family member struggling with an eating disorder. Thus, family-based interventions, including family therapy, can be helpful in assisting parents to garner the strength to set the firm limits needed to help their child recover. Families who avoid confrontation become concerned about causing distress, so they will continue to avoid it in an effort to appease the situation. Without setting limits, however, the eating disorder will continue to make decisions for the child, thereby leading to a lower rate of recovery. Treatments in the pediatric population often use positive reinforcement to serve as motivation and encouragement for the child to make choices in treatment. Instead of the parent trying to convince the child to make changes or attempting to avoid the need for change altogether, the child with the eating disorder takes the responsibility for change through his or her actions. When the child makes a choice toward recovery, he or she can earn privileges; if he or she chooses the eating disorder behavior, the privilege is not earned. The parents have the advantage of being able to set rules around how privileges are earned and which privileges best suit their child. One example is restricting certain activities (eg, watching television) when the child does not complete meals or is not willing to participate in therapy.
It is also important for the family to learn that eating disorder behavior is not simply willful defiance in the child. Instead, the eating disorder needs to be externalized, or seen as a separate entity from the child. White and Epston,9 founders of narrative therapy, describe externalization as “the person is not the problem, the problem is the problem.” Once the family can see the child as separate from the eating disorder, the family can help their child fight against the eating disorder instead of fighting against the child. Madigan et al.10 explain that eating disorders “dis-member” people through the objectification of their bodies and disconnecting relationships, so family therapy allows the family and child to work together to “re-member” their experiences to create their own narrative. Together, families brainstorm how the eating disorder has affected them and what they can do to overcome this experience.
Because the eating disorder in the child affects the entire family, it is important to include siblings of the child with the eating disorder as appropriate. Siblings can offer a more objective third-party view, and they can benefit from education on their role in the patient's recovery. Although siblings can be helpful through engaging with the patients in distraction or offering positive feedback, it is stressed that they not take on the role of another parent for setting limits.6
Another family intervention includes group therapy with multiple families. Common multifamily group topics are strategies for conflict resolution, communication, and problem-solving or teamwork activities. This is to build a feeling of unity within the family while also creating social support for parents who can relate to other families in treatment.11
Overall, families need to learn how to understand tricks the eating disorder may use to undermine their help. Parents can become divided and in conflict with each other rather than aligned against the eating disorder. This splitting pattern can also replicate between the treatment team and parents: either the caregiver is not seeing the eating disorder as separate from the child and is inadvertently enabling the eating disorder when the team sets limits, or the treatment team starts to identify the patient and family as the problem and then becomes angry and disappointed with the very clients that they are helping.10 Instead of colluding with the eating disorder and reinforcing the pattern of feeling stuck, family-based interventions and systems approaches help patients, families, and treatment teams work together against the eating disorder.
The Academy of Nutrition and Dietetics12 (formerly the American Dietetic Association) states that nutrition intervention, including nutritional counseling by a Registered Dietitian Nutritionist (RDN), is an essential component of the treatment of patients with an eating disorder. An RDN's role in the nutrition care of people with eating disorders is supported by the American Psychiatric Association,2,3 the Academy for Eating Disorders,13 and the American Academy of Pediatrics.1
The RDN will identify nutrition problems that relate to medical or physical conditions, including eating disorder symptoms and behaviors, and assess growth patterns to recommend an appropriate goal weight for the patient. Current guidelines from the American Psychiatric Association recommend targeting weight restoration to reduce risk of recidivism.2 Weight restoration goals should be achieved not simply to the previous highest weight or height but rather to the expected ideal based on growth patterns and maturation. In the absence of documented trends or as clinically appropriate, the ideal body weight can also be determined at the 50th percentile body mass index for age and gender calculated using the current height.14
RDNs are expert at calculating and monitoring energy and nutrient intakes to establish expected rates of weight change. For those needing weight restoration, weight gain velocity of 0.5 to 2 pounds per week is reasonable Some studies have shown better prognosis when weight is gained in a shorter length of time and goal weight is set at a higher rather than minimal levels.15
The RDN will ensure diet quality and regular eating patterns. People with an eating disorder often have particular food rules, rituals, and behaviors. RDNs are uniquely qualified, with their knowledge of food and nutrition, to guide the child and their families away from the extreme and toward normalization. Because of food restrictions and rituals caused by the eating disorder, many times families have changed their approach to eating and are often no longer eating together as a family. The RDN will help the family incorporate family meals into recovery.
When discussing food and weight with parents, it is recommended to begin discussion with the child or adolescent outside of the room. This allows the provider to discuss health concerns directly and parents the opportunity to ask honest questions. When the child returns to the room, discuss changes in concrete terms such as increasing physical activity or calcium-dense foods rather than losing weight. It is recommended to avoid weight talk within the home, avoid dieting, protect from weight teasing, and promote family meals and a healthy body image.16 Encouraging families to enjoy a variety of foods and incorporate flexibility with eating helps children to avoid labeling food as “good” or “bad” or even “healthy” or “unhealthy;” rather, all foods in moderation can be enjoyed in a healthful meal plan and are nourishing for a person's body.
Interventions should focus on health—not weight, and it is important to promote self-esteem, body satisfaction, and respect for diversity in body size. Interventions should focus only on modifiable behaviors (physical activity, intake of sugar-sweetened beverages, time spent watching television). Weight is not a behavior and, therefore, is not an appropriate target for behavior modification.17
Pharmacotherapy is not considered a primary intervention for the treatment of eating disorders.18 Studies of antidepressants, primarily fluoxetine, in the treatment of bulimia nervosa have demonstrated reduced frequency of binge eating and purging episodes in adults,19 with similar data reproduced in the adolescent population.20 Fluoxetine has been approved by the United States Food and Drug Administration (FDA) for the treatment of bulimia nervosa.21 Antidepressants have demonstrated reduction in episodes of binge eating but not significant weight loss in adults with binge eating disorder, although they have not proven effective for the treatment of anorexia nervosa.18 Studies of topiramate has shown reduction in binge eating and purging frequency for bulimia nervosa and binge eating disorders, although problematic side effects can limit tolerability.22,23 Stimulant medications have also been studied, and lisdexamphetamine has been shown to be effective in the treatment of binge eating disorder by reducing binge eating frequency and increasing rates of binge eating cessation,24 although cardiac side effects need to be monitored closely with use of this medication.18 Lisdexamfetamine is FDA-approved for the treatment of binge eating disorder.25 Antipsychotic medications have been studied in the treatment of anorexia nervosa, with second-generation antipsychotic (SGA) medications, primarily olanzapine, showing some efficacy in weight restoration, although these results are not robust and SGAs should be used in combination with other therapeutic interventions.18,26 Given that eating disorders are highly comorbid with other psychiatric illnesses, treating these comorbid conditions is important in the overall treatment of children and adolescents with eating disorders.
Effective treatment of pediatric eating disorders is complex and requires a multidisciplinary approach. Therapy and nutrition interventions are critical for eating disorder treatment, with psychiatric involvement necessary when indicated. Communication and collaboration between providers, although increasingly time consuming and challenging for pediatric providers in the community, is critical to effectively care for children and adolescents suffering from eating disorders. Additionally, ongoing research is needed to improve clinical outcomes for children and adolescents suffering from eating disorders.
- Campbell K, Peebles R. Eating disorders in children and adolescents: a state of the art review. Pediatrics. 2014;134:582–592. doi:. doi:10.1542/peds.2014-0194 [CrossRef]
- American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Eating Disorders. 3rd ed. Washington, DC: American Psychiatric Publishing; 2006.
- American Psychiatric Association. Guideline Watch for the Practice Guideline for the Treatment of Patients with Eating Disorders. 3rd ed. Arlington, VA: American Psychiatric Publishing; 2012.
- Lock J, La Via MAmerican Academy of Child and Adolescent Psychiatry Committee on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015;54(5):412–425. doi:. doi:10.1016/j.jaac.2015.01.018 [CrossRef]
- Minuchin S, Rosman BL, Baker L. Psychosomatic Families: Anorexia Nervosa in Context. Cambrige, MA: Harvard University Press; 1978.. doi:10.4159/harvard.9780674418233 [CrossRef]
- Lock J, Le Grange D. Help Your Teenager Beat an Eating Disorder. New York, NY: The Guilford Press: 2005.
- Treasure J, Smith G, Crane A. Skills-Based Learning for Caring for a Loved One with an Eating Disorder. New York, NY: Routledge: 2007.
- Laxter Y, Garber LB. Pathological conflict avoidance in anorexia nervosa: family perspectives. Contemp Fam Ther. 1998;20(4):539–551. doi:10.1023/A:1021636401563 [CrossRef]
- White M, Epston E. Narrative Means to Therapeutic Ends. New York, NY: W.W. Norton & Company; 1990.
- Madigan SP, Goldner EM, Hoyt MF. A narrative approach to anorexia: discourse, reflexivity, and questions. In: Hoyt MF, ed. The Handbook of Constructive Therapies. San Francisco, CA: Jossey-Bass;1998:380–400.
- Aisen E, Scholz M. Multi-Family Therapy: Concepts and Techniques. New York, NY: Routledge; 2010.
- American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111:1236–1241. doi:. doi:10.1016/j.jada.2011.06.016 [CrossRef]
- Academy for Eating Disorders Medical Care Standards Committee. Eating Disorders: A Guide to Medical Care. 3rd ed. Reston, VA: Academy for Eating Disorders; 2016.
- Phillips S, Edlbeck A, Kirby M, Goday P. Ideal body weight in children. Nutr Clin Pract. 2007;22(2):240–245. doi:. doi:10.1177/0115426507022002240 [CrossRef]
- Mehler PS, Andersen AA. Eating Disorders: A Guide to Medical Care and Complications. 2nd ed. Baltimore, MD: The Johns Hopkins University Press; 2010.
- Golden NG, Schneider M, Wood C. Preventing obesity and eating disorders in adolescents. American Academy of Pediatrics. https://www.aap.org/en-us/continuing-medical-education. Accessed May 18, 2018.
- Danelsdottir S, Burgard D, Oliver-Pyat W. Guidelines for childhood obesity prevention programs. Alliance for Eating Disorders. https://www.aedweb.org/advocate/press-releases/position-statements/guidelines-childhood-obesity.
- Davis H, Attia E. Pharmacotherapy of eating disorders. Curr Opin Psychiatry. 2017;30:452–457. doi:. doi:10.1097/YCO.0000000000000358 [CrossRef]
- Levine LR. Fluoxetine in the treatment of bulimia nervosa. Arch Gen Psychiatry. 1992;49:139–147. doi:10.1001/archpsyc.1992.01820020059008 [CrossRef]
- Kotler LA, Devlin MJ, Davies M, Walsh BT. An open trial of fluoxetine for adolescents with bulimia nervosa. J Child Adolesc Psychopharmacol. 2003;13:329–335. doi:. doi:10.1089/104454603322572660 [CrossRef]
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- McElroy SL, Hudson JI, Capece JA, et al. Topiramate Binge Eating Disorder Research Group. Topiramate for the treatment of binge eating disorder associated with obesity: a placebo-controlled study. Biol Psychiatry. 2007;61:1039–1048. doi:10.1016/j.biopsych.2006.08.008 [CrossRef]
- Hoopes SP, Reimherr FW, Hedges DW, et al. Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 1: improvement in binge and purge measures. J Clin Psychiatry. 2003;64:1335–1341. doi:10.4088/JCP.v64n1109 [CrossRef]
- McElroy SL, Hudson JI, Mitchell JE, et al. Efficacy and safety of lisdexamfetamine for treatment of adults with moderate to severe binge-eating disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72:235–246. doi:. doi:10.1001/jamapsychiatry.2014.2162 [CrossRef]
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- Dold M, Aigner M, Klabunde M, et al. Second-generation antipsychotic drugs in anorexia nervosa: a meta-analysis of randomized controlled trials. Psychother Psychosom. 2015;84:110–116. doi:. doi:10.1159/000369978 [CrossRef]