Understanding Eating Disorders in Children and Adolescent Population

Abstract

Eating disorders (EDs) are increasingly recognized in children and adolescents. Anorexia nervosa (AN) and bulimia nervosa (BN) are less common in children and adolescents than adults, but both disorders can occur in this age group. Binge-eating disorder (BED) is the most common ED in children and adolescents and is more prevalent in females than males. EDs may present differently in children and adolescents than in adults, and parents or caregivers may be the first to notice changes in eating patterns or body weight. Diagnostic criteria for EDs in children and adolescents include disturbances in eating behavior, weight or shape concerns, and significant distress or impairment in social, academic, or occupational functioning.

Multidisciplinary approaches are recommended for treating EDs in children and adolescents, including medical management, nutritional counseling, and psychological interventions. Evidence-based treatments for AN and BN include family-based therapy, cognitive-behavioral therapy, and interpersonal psychotherapy. Cognitive-behavioral therapy and interpersonal psychotherapy are recommended for children and adolescents with BED. Hospitalization may be necessary in severe cases.

Early identification and intervention are crucial for improving treatment outcomes and reducing the risk of long-term complications. Treatment approaches should be tailored to developmental and cultural needs and involve a multidisciplinary team. Continued research is needed to improve early detection, prevention strategies, and treatments for this vulnerable population. EDs in children and adolescents are a significant public health concern that can have serious physical and psychological consequences. It is important for healthcare providers and caregivers to be aware of the signs and symptoms of EDs in young people and to seek prompt and appropriate treatment

Keywords

Eating disorders children adolescent

Introduction

Eating disorders (EDs) are characterized by disordered eating behaviors, distorted body image, and an intense fear of weight gain or becoming overweight. EDs can occur in children, adolescents, and adults, but the prevalence and nature of these disorders differ across age groups. EDs in children and adolescents have been recognized as a significant public health concern due to their potential long-term physical and mental health consequences. This review aims to provide an overview of the epidemiology, etiology, clinical features, and treatment of EDs in children and adolescents.

Recent Advances in Classification of Eating Disorders

The Diagnostic and Statistical Manual (DSM-5) and the International Classification of Diseases (ICD-11) both list 6 primary eating and feeding disorders. They include the well-known diagnoses of binge-eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa (AN). Three additional illnesses have been included, which were previously generally considered to be childhood disorders. They include pica, rumination disorder, and avoidant-restrictive food intake disorder. Moreover, the DSM-5 offers remission definitions, severity indicators, and subtype qualifiers.

The criteria for AN no longer require a person to report a “fear of fatness,” or weight gain, or amenorrhea, and there are severity criteria based on body mass index (BMI) levels. People with a BMI in the normal range but who have other symptoms resembling those with AN may be diagnosed with Atypical AN. The diagnosis of BN has broadened to include binge eating and compensatory weight loss behaviors occurring once a week for 3 months in DSM-5 or 1 month in ICD-11. The diagnosis of BED requires a minimum frequency of weekly binge eating for several months, and marked distress associated with binge. EDs that do not meet the criteria of one of the central EDs are now classified as Other Specified Feeding or Eating Disorder (OSFED or Unspecified Feeding or Eating Disorder (UFED) in the DSM-5 or as Other Feeding or Eating Disorder in ICD-11. Atypical AN, night eating syndrome, purging disorder, and subthreshold BN and BED can be classified under OSFED. These changes have implications for clinicians and public health as they require expanded prevention initiatives, clinician awareness, and health service infrastructure to ensure adequate identification and management of the diverse spectrum of EDs.^1,2

Epidemiology of Eating Disorders

The prevalence of EDs in children and adolescent populations worldwide varies depending on the study and the population sampled and is underestimated due to the lack of awareness and recognition of EDs in this population.

A meta-analysis published in the Journal of Adolescent Health in 2021 estimated the global prevalence of EDs in children and adolescents to be 1.8% for AN, 1.8% for BN, and 2.8% for BED.³

Another study published in the Journal of Adolescent Health in 2019 estimated the prevalence of EDs in a sample of adolescents from 11 countries. The study found that the prevalence of any ED was 5.5% in the sample.⁴

Recent studies indicate a 2.4% to 4.3% lifetime prevalence of AN, with a higher incidence in females (10:1), particularly in adolescent girls and college-aged women, which typically start in early to mid-adolescence.⁵

BN is an ED more common in women than men, with a lifetime prevalence of approximately 2% and a point prevalence of 0.6% in women. The average age of onset is late adolescence to young adulthood, and there is evidence to suggest that earlier detection may be contributing to a perceived decrease in the age of onset.⁵

ED prevalence in Asia is lower than in the West, but rates are increasing. A review of 56 studies estimated AN, BN, and BED lifetime prevalence in Asia as 0.3%, 0.5%, and 1.4%, respectively, but varied by region.⁶ AN was higher in East Asia (0.5%) than in Southeast Asia (0.1%), while BN and BED were higher in Southeast Asia (0.9% and 2.1%) than in East Asia (0.3% and 0.5%).^3,6

The prevalence rates of EDs in Asia may be underestimated due to cultural factors and globalization. There is limited research on the prevalence of EDs, specifically in children and adolescents in India.⁷

A study published in the Journal of Adolescent Health in 2018 reported the prevalence of disordered eating behaviors among school-going adolescents in North India. The study found that 2.2% of the sample reported disordered eating behaviors.⁸

Research on EDs in India is limited due to the lower prevalence of ED in the country. However, with the increasing influence of Western culture, there is a need for more research. Cultural differences between the East and West affect how ED is presented and diagnosed in India. There is a unique form of AN in India where people are less concerned about body fat/shape and more about somatic complaints. This has been termed as a “non-fat phobic” variant of AN.⁹ Food restriction is also culturally accepted for “cleansing the bowel” when unwell. Culturally sensitive diagnostic tools and locally relevant epidemiological data are needed from community and hospital settings in India.¹⁰

Pathophysiology of Eating Disorders

While the exact causes of EDs remain unclear, recent research has identified several biological, psychological, and environmental factors that contribute to the development and maintenance of these disorders.

Biological Factors

One of the critical biological factors associated with EDs is dysregulation of the brain’s reward system, particularly in response to food. Research has shown that individuals with AN have reduced activity in the brain’s reward centers when exposed to food stimuli, which may contribute to their avoidance of food and hyperactivity. On the other hand, individuals with BN and BED have been found to have heightened reward responses to food, which may perpetuate their binge-eating behaviors.¹¹

Another biological factor implicated in EDs is inflammation. Studies have shown that individuals with AN and BN have elevated levels of inflammatory markers in their blood, which may contribute to the physical and mental health problems associated with these disorders. In addition, changes in gut microbiota composition have also been linked to the development of EDs, particularly to the regulation of appetite and mood.¹²

Psychological Factors

Negative body image and low self-esteem have long been identified as crucial factors in developing EDs. Recent research has also highlighted the role of perfectionism, anxiety, and obsessive-compulsive traits in developing and maintaining these disorders. For example, individuals with AN tend to exhibit high levels of perfectionism and anxiety, while individuals with BN often report obsessive-compulsive symptoms.¹³

Environmental Factors

Environmental factors such as childhood trauma, societal pressure to attain thinness, and cultural ideals of beauty have also been implicated in developing EDs. For example, studies have found that individuals who experience childhood trauma are more likely to develop EDs later in life, possibly due to the impact of trauma on self-esteem and body image.¹⁴

Understanding these underlying mechanisms is essential for developing more effective treatments for individuals with EDs.

Different Eating Disorders

Anorexia Nervosa

AN disorder causes people to have an abnormally low body weight and a strong desire to be thin. Those with this disorder may use methods such as restricting food intake, purging, or exercising excessively to lose weight or prevent weight gain. They are often scared of gaining weight and may view their body distortedly, believing they are overweight even when they are not. Their self-image becomes centered on their weight and shape, and they may not realize the medical dangers of being underweight.

Salient Features of DSM 5 Diagnostic Criteria for AN (AN)

Restriction of energy intake relative to requirements, leading to a significantly low body weight

Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain, even though at a significantly low weight.

Disturbance in the way in which one’s body weight or shape is experienced

Subtypes

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior.

Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (ie, self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Level of severity specifier is dependent on BMI.¹

Physical Findings in AN^5,15

Starvation and purging both have harmful effects on the body’s systems, with negative consequences that worsen with time.

Gastrointestinal: prolonged gastrointestinal transit, constipation

Cardiovascular: hypotension, bradycardia, prolonged QT, arrhythmias, cardiomyopathy

Dermatological: dry, scaly skin and brittle hair, lanugo hair

Endocrine and metabolic: hypoglycemia, hypokalemia, hyponatremia, hypothermia, altered thyroid function, hypercortisolemia, amenorrhea, delay in puberty, arrested growth, osteoporosis

Hematologic: anemia, leukopenia, thrombocytopenia

Neurological: peripheral neuropathy, loss of brain volume: ventricular enlargement, sulcal widening, cerebral atrophy (corrects with weight gain)

Oral: dental caries

Skeletal: osteopenia

Renal: renal calculi, acute kidney injury

Liver: transaminitis, liver failure

Reproductive: amenorrhea, infertility^5,15

Differential Diagnosis

Certain medical conditions, such as inflammatory bowel disease, malignancies, thyrotoxicosis, and diabetes, can sometimes be confused with AN. In rare cases, AN can be caused by a brain tumor. Diagnosis can also be problematic in patients with major depressive disorder or schizophrenia. Severe depression can cause a loss of appetite or a belief that food is undeserving, while those with schizophrenia may avoid food due to delusions of being poisoned.^5,15

Course and Prognosis

Recovery rates vary, with some fully recovering and others remaining chronically ill. Maintaining weight restoration after treatment is linked to better outcomes, while a lower BMI and weight loss after treatment is associated with poorer long-term outcomes. A high-energy diet before discharge may improve outcomes.^5,15

A shorter duration of AN is a significant predictor of recovery after 4 years and 8 years.^16,17 A study also found that individuals with less than one year of therapeutic contact were more likely to experience relapse.¹⁸ Another factor that predicted a shorter time to recovery was a higher percentage of average body weight at the beginning of treatment, which was associated with both full and partial recovery¹⁹

Bulimia Nervosa

BN involves recurring episodes of binge eating followed by compensatory behaviors such as self-induced vomiting, laxative use, or fasting. Despite maintaining an average weight, individuals with BN are intensely preoccupied with their shape and weight. Diagnosis requires objectively significant binge episodes and loss of control. Compensatory behaviors aim to control weight but often lead to a cycle of binge eating and restriction. Strict eating rules can also contribute to binge episodes and compensatory behaviors.^1,5

Salient Features of DSM-5 Diagnostic Criteria

Recurrent episodes of binge eating: an episode of binge eating is characterized by both of the following:

Eating, in a discrete period (eg, within any 2 hours), an amount of food that is larger than what most individuals would eat in a similar period and a sense of lack of control over eating during the episode

Recurrent inappropriate compensatory behaviors

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months

Self-evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during episodes of AN

Level of severity specifier is based on the number of inappropriate compensatory behaviors per week.

Physical Findings Mainly due to the Effects of Starvation or Vomiting

These are specific problems related to purging.^5,15

Gastrointestinal: constipation or steatorrhea, gastric or duodenal ulcers, pancreatitis, esophageal or gastric erosions/perforation

Hematological: leukopenia or lymphocytosis

Oral: dental erosion

Renal: acute renal injury

Cardiovascular: arrhythmias, cardiac failure (sudden death)

Endocrine and metabolic: electrolyte disturbances (K⁺, Na⁺, Cl⁺, metabolic acidosis [laxatives] or alkalosis [vomiting])

Course and Prognosis

Recovery rates for BN are better, with about 45% achieving full recovery and 23% experiencing some improvement. Factors that predict the outcome of BN are not apparent, although studies have examined several potential prognostic factors, such as illness duration, age of onset, severity, rapid symptom reduction during treatment and comorbid diagnoses.^5,20

Binge Eating Disorder

BED is associated with binge eating, loss of control, and emotional distress without compensatory behaviors.

Salient Features of DSM 5 Diagnostic Criteria¹

Recurrent episodes of binge eating: an episode of binge eating is characterized by both of the following:

Eating, in a discrete period (eg, within any 2 hours), an amount of food that is larger than what most people would eat

A sense of lack of control over eating during the episode

The binge-eating episodes are associated with 3 (or more) of the following:

Eating much more rapidly than usual.

Eating until feeling uncomfortably full.

Eating large amounts of food when not feeling physically hungry.

Eating alone because of feeling embarrassed by how much one is eating.

Feeling disgusted with oneself, depressed, or very guilty afterward

Marked distress regarding binge eating is present

The binge eating occurs, on average, at least once a week for 3 months

The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in BN and does not occur exclusively during the course of BN or AN

Level of severity specifier is based on number of binge-eating episodes per week.

Differential Diagnosis

BN and BED can be associated with atypical depression, which includes symptoms like overeating and oversleeping during low-light months.²¹

50% of patients with these disorders have ADHD, 15% have impulsive behaviors like substance abuse, compulsive shopping, and multiple sexual relationships. They may have erratic sleep patterns, intense emotions, and self-harm tendencies. They may also meet criteria for other personality disorders like borderline personality disorder or bipolar II disorder.^22,23

Course and Prognosis

BED has a better prognosis than anorexia and BN, with over 80% of individuals fully recovering after 5 years. The majority of those who recover don’t receive treatment. Short-term studies also show high recovery rates, with over 50% achieving complete remission after 6 months. However, BED increases the risk of obesity and overweight, which can lead to health complications.⁵

Avoidant/Restrictive Food Intake Disorder (ARFID)

ARFID causes significant consequences, including nutritional deficiencies and psychosocial problems, due to restrictive eating behavior. The behavior can result from disgust with food textures or smells, anxiety around eating, or stressful mealtimes. Unlike anorexia and bulimia, it’s not motivated by concerns about shape or weight. ARFID should only be diagnosed if the behavior is severe enough to require clinical attention and not in the context of another disorder. Cultural or social eating behaviors should not be considered in diagnosis.^1,5

Salient Features of DSM 5 Diagnostic Criteria¹

An eating or feeding disturbance (eg, apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs 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

Marked interference with psychosocial functioning

The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice

The disturbance can’t be explained by lack of food or cultural practices, nor by anorexia or bulimia. It can’t be attributed to a medical or mental disorder, unless the severity exceeds what is typically associated and requires additional clinical attention

Differential Diagnosis

Avoidant-restrictive food intake disorder may be misunderstood as simply picky eating, but signs such as concurrent low weight or failure to grow at an appropriate rate for their age could indicate the presence of an ED.

Pica

Pica is the repeated consumption of nonfood items, but cultural practices involving nonfood items should not be diagnosed as pica. It’s common in people with developmental delays or pregnant women, and if it’s severely impairing, it can be diagnosed alongside another ED.

Salient Features of DSM 5 Diagnostic Criteria¹

Persistent eating of nonnutritive, nonfood substances which is inappropriate to the individual’s developmental level over a period of at least 1 month.

The eating behavior is not part of a culturally supported or socially normative practice

Differential Diagnosis

People with autism, intellectual disability, schizophrenia, or certain physical disorders (such as Kleine-Levin syndrome) may also exhibit pica. However, pica should only be diagnosed as a serious disorder if it is serious enough to require medical attention.^5,15

Rumination Disorder

Rumination disorder is a condition where individuals repeatedly bring back and re-chew or re-swallow food they have already eaten before spitting it out.

Salient Features of DSM 5 Diagnostic Criteria

Repeated regurgitation of food over a period of at least 1 month which is not attributable to an associated gastrointestinal or other medical condition (eg, gastroesophageal reflux, pyloric stenosis).

The eating disturbance does not occur exclusively during the course of other EDs.

If the symptoms occur in the context of another neurodevelopmental, they are sufficiently severe to warrant additional clinical attention.

Differential Diagnosis

The differential diagnosis for rumination disorder includes psychogenic vomiting, purging EDs (not yet recognized as a separate ED category), and various somatic disorders.

Other Specified Feeding and Eating Disorders (OSFED)¹

This category applies to presentations with feeding and ED symptoms causing significant distress or impairment but not meeting full criteria for any specific disorder. The “other specified” category communicates the specific reason for not meeting criteria.

Examples of clinical presentations that can be specified using the “other specified” designation include the following.

Atypical AN: AN criteria met, but weight within or above normal range

BN (of low frequency and/or limited duration): BN criteria met, except for less frequent binge eating and compensatory behaviors or shorter duration

Binge-eating disorder (of low frequency and/or limited duration): BED criteria met, except for less frequent binge eating behaviors or shorter duration

Purging disorder: Recurrent purging behavior to influence weight or shape in the absence of binge eating.

Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating which cause distress/impairment, not explained by external factors, other EDs, medication, or medical conditions.

Unspecified Feeding or Eating Disorder

UFED is a diagnosis when symptoms of a feeding/ED cause significant distress but don’t meet full criteria for a specific disorder. Clinicians use it when information is lacking or not specified. It is used in emergency rooms where a specific diagnosis can’t be made quickly.

Management of Eating Disorders

Building a positive relationship with patients with EDs, particularly AN, is vital. These individuals may feel ashamed to discuss their condition and reluctant to seek help. Asking them to gain weight may also provoke anxiety. Therefore, it is important to address their resistance to treatment and increase their motivation for change.^24,25

Treating EDs effectively requires a multidisciplinary team of healthcare professionals, such as psychiatrists, psychologists, dieticians, and primary care physicians. The goal of treatment is to assist individuals in developing a healthy and sustainable relationship with food and their body.^26,27

Treatment Goals

Primary goal: To disrupt problematic behaviors related to feeding and eating, and to stabilize weight if necessary.

Secondary goal: To address distorted thoughts, attitudes, and beliefs that maintain the disordered behaviors, particularly in AN and BN.

Tertiary goal: Treating psychiatric comorbidities, which are common in EDs.

Steps in Management

Step 1: Establish a diagnosis. A complete medical evaluation, including physical examination and lab tests, and a psychiatric evaluation to identify underlying mental health conditions, are essential.

Step 2: To develop a treatment plan tailored to the individual’s specific needs. This typically involves a combination of psychotherapy, medication, and nutritional counseling.

Evaluation of Symptoms of Eating Disorder

The assessment may involve gathering information about the patient’s food intake, family history of EDs, psychiatric disorders, substance use, obesity, and attitudes towards eating, exercise, and appearance. By identifying target symptoms and behaviors, the clinician can personalize the treatment plan for the patient.

Evaluation of Physical Status of the Patient

To diagnose and manage EDs, a healthcare professional who is familiar with the common physical findings of these disorders should conduct a comprehensive physical examination. This should include checking vital signs such as heart rate, blood pressure, and temperature, as well as measuring the patient’s height, weight, and BMI. The physician should also pay close attention to the carotenemia (yellowing of skin), peripheral edema, lanugo, hair loss or thinning, swelling of parotid, dental caries glands, scarring on the dorsum of hands, and signs of self-injurious behavior such as scars and burns.^5,28,29

Treatment Setting

Patients with EDs can receive treatment in various settings, including inpatient, residential, partial hospitalization, and outpatient care. For individuals who have difficulty gaining weight outside of a structured program, hospitalization may be necessary for patients with a rapid or persistent decline in oral intake, weight loss despite intensive outpatient care, stressors that interfere with eating, past medical instability, co-occurring psychiatric problems, or resistance to participate in treatment outside of a supervised setting. Timely intervention is essential because shorter duration of illness is associated with improved outcomes.³⁰

Indications for hospitalization²⁹

One or more of the following indications justify hospitalization in an adolescent with an eating disorder:

< 75% median BMI for age and sex

Dehydration

Electrolyte disturbance (hypokalemia, hyponatremia, and hypophosphatemia)

ECG abnormalities (eg, prolonged QTc or severe bradycardia)

Physiological instability:

Severe bradycardia (heart rate <50 beats/minute at daytime; <45 beats/minute at night)

Hypotension (<90/45 mm Hg)

Hypothermia (body temperature <96F, 35.6C)

Orthostatic increase in pulse (>20 beats per minute) or

Orthostatic decrease in blood pressure (>20 mm Hg systolic or >10 mm Hg diastolic)

Arrested growth and development

Failure of outpatient treatment

Acute food refusal

Uncontrollable bingeing and purging

Acute medical complications of malnutrition (eg, syncope, seizures, cardiac failure, pancreatitis)

Comorbid psychiatric or medical condition that prohibits or limits appropriate outpatient treatment (eg, severe depression, suicidal ideation, obsessive compulsive disorder, type 1 diabetes mellitus).

Anorexia Nervosa

The initial goal is to establish a positive relationship and involve the patient in treatment planning. Family members may assist with refeeding in children and adolescents.

Assessment of the degree of malnutrition: Height and weight should be measured and BMI calculated (weight in kg divided by height in m²) and plotted on growth charts.²⁹

Laboratory Investigations: These are helpful in identifying medical complications and guiding treatment decisions. In particular, blood tests can reveal necessary information about an individual’s nutritional status, electrolyte balance, liver function, and hormonal levels. These tests can help clinicians determine if the individual is malnourished, dehydrated, or suffering from organ damage. Other laboratory investigations may include bone density scans to assess for osteoporosis or bone loss

Nutritional Rehabilitation

Inpatient hospitalization is the most efficient option for AN treatment due to close medical supervision. Structured treatments use behavioral protocols to normalize weight and address compensatory behaviors, with a range of individual and group therapies provided.

Structured ED treatment begins at 1,500 to 1,800 calories daily, gradually increasing until a 3,500 to 4,000 calorie diet is reached. High-calorie nutritional supplements or nasogastric feeding may be used, with a goal of 1 to 2 kg of weight gain weekly to reach a BMI of over 18.5 kg/m² or 85% ideal body weight (IBW), ideally above 20 kg/m² or 90% IBW. Determining an individual’s treatment goal weight range should consider their height, weight, BMI, age of puberty onset, and current pubertal stage. After weight restoration, continued therapy and stepped care systems may be utilized to prevent relapse and address underlying issues. Various psychotherapy options are available.

Risk of Refeeding Syndrome

Refeeding syndrome is dangerous in people with EDs, especially those who have been malnourished and undergo rapid refeeding. It happens because the body changes how it processes food after being malnourished for a long time, which can cause hypophosphatemia, hypokalemia hypomagnesemia, and thiamine deficiency. This can lead to serious symptoms like confusion, seizures, arrhythmias, respiratory distress, and even death.

Treatment involves careful monitoring of minerals and slowly increasing food intake. Hospitalization and mineral supplements may be necessary in severe cases. To prevent refeeding syndrome, special medical and nutritional support and regular mineral level checks are necessary during the refeeding process.

Pharmacotherapy

There have been fewer advancements in pharmacological treatments for AN. However, there have been some small trials with second-generation antipsychotics, like olanzapine, with mixed results. A recent 16-week outpatient placebo-controlled trial of olanzapine for adults with AN showed a moderate effect on weight gain, but the rate of weight gain was very small, and there were no differences in metabolic outcomes.³¹ Antidepressants have little direct evidence for treatment in AN, but may be used for co-morbid major depression.³²

Psychological Therapies

Cognitive Behaviour Therapy—Enhanced (CBT-E), are the recommended first-line treatment for all types of EDs. CBT-E is typically delivered in 40 sessions for AN. Shorter versions of CBT-E, like online guided self-help CBT, have been developed but may not be as effective as therapist-led CBT-E.⁵

Family-based treatment (FBT) is the leading therapy for children and adolescents with AN.³²

It is a treatment that involves parents and is effective for teenagers with AN. FBT has 3 phases, with the first phase focused on restoring the patient’s weight, the second phase returning control overeating to the adolescent, and the third phase addressing adolescent development and treatment termination. During FBT, the medical provider’s main role is to monitor and manage the patient’s physical health and communicate with the family and therapist about the medical findings. As the teenager progresses through FBT, less frequent medical check-ups are needed.²⁹

For adolescents with AN, it is just as effective to have a short hospitalization for medical stabilization followed by treatment with Family-Based Therapy (FBT) by an experienced team, rather than a longer hospitalization for weight restoration³⁴

Bulimia Nervosa

BN can cause dehydration in individuals due to loss of fluids from inappropriate compensatory behaviors. Dehydration can lead to symptoms such as rapid heart rate, low blood pressure when standing up, and abnormal lab results, like high creatinine levels and blood urea nitrogen, indicating prerenal azotemia. These issues can be resolved by resuming average food and fluid intake, but in some cases, short-term intravenous hydration may be necessary to relieve symptoms and reverse lab abnormalities more quickly.⁵

Antidepressants, particularly fluoxetine, have been extensively studied and are considered effective for treating BN. Higher doses of fluoxetine are more effective in disrupting binge eating and purging, and it has fewer side effects than other medications. Tricyclic antidepressants, monoamine oxidase inhibitors, and topiramate have also demonstrated efficacy in randomized-controlled trials of BN, but have significant side effects and should be used with caution.^5,28

Psychological Therapy

Family-based therapy is one of the first-line treatments recommended by NICE for adolescents with BN. CBT is an alternative therapy that, when delivered as guided self-care, produces faster improvement in binge eating than family-based therapy.^35,36

Binge Eating Disorder

Medications such as SSRIs and TCAs have effectively reduced binge eating episodes in individuals with BED, while topiramate has been shown to reduce binge eating and aid in weight loss. Orlistat, a weight loss medication, has not been studied extensively in treating BED and does not reduce binge eating. Stimulants like lisdexamfetamine have been approved by the FDA for short-term treatment of BED, but long-term data on their effectiveness and safety is limited.⁵

CBT is effective for BED, with over 50% of individuals abstaining from binge eating after treatment. IPT may be more effective than CBT, while DBT shows promise but requires further research. However, CBT does not result in weight loss for overweight or obese individuals.³⁷

ARFID and other Disorders

There is little research on effective treatments for ARFID, Pica, or Rumination Disorder. Therefore, behavioral strategies that have been found helpful for other EDs are often adapted and used to normalize behaviors in individuals with these disorders ³⁷

Recent Advances in Treatment

Recent progress in understanding the brain circuits involved in EDs has sparked interest in using neuromodulation as a treatment option, particularly for individuals with severe illness who have not responded to other established treatments.³⁸

rTMS has been studied both as a way to test theories about the neurobiology of EDs, and as a potential treatment option.³⁹ Deep brain stimulation, a more intensive treatment approach, has been tested in 16 patients with AN who did not respond to other treatments. The initial results have been promising.⁴⁰

Although more research and development are necessary to improve the clinical usefulness of many treatments for children and adolescent population, positive outcomes suggest that progress is being made towards developing effective, evidence-based treatments for EDs.

Summary

EDs in children and adolescents are a significant public health concern that can have serious physical and psychological consequences. Early identification and intervention are crucial for improving treatment outcomes and reducing the risk of long-term complications. Treatment approaches for children and adolescents with EDs should be tailored to their developmental and cultural needs and involve a multidisciplinary team. Continued research is needed to improve early detection, prevention strategies, and treatments for this vulnerable population

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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Understanding Eating Disorders in Children and Adolescent Population

Abstract

Keywords

Introduction

Recent Advances in Classification of Eating Disorders

Epidemiology of Eating Disorders

Pathophysiology of Eating Disorders

Biological Factors

Psychological Factors

Environmental Factors

Different Eating Disorders

Anorexia Nervosa

Salient Features of DSM 5 Diagnostic Criteria for AN (AN)

Subtypes

Physical Findings in AN5,15

Differential Diagnosis

Course and Prognosis

Bulimia Nervosa

Salient Features of DSM-5 Diagnostic Criteria

Physical Findings Mainly due to the Effects of Starvation or Vomiting

Course and Prognosis

Binge Eating Disorder

Salient Features of DSM 5 Diagnostic Criteria 1

Differential Diagnosis

Course and Prognosis

Avoidant/Restrictive Food Intake Disorder (ARFID)

Salient Features of DSM 5 Diagnostic Criteria 1

Differential Diagnosis

Pica

Salient Features of DSM 5 Diagnostic Criteria 1

Differential Diagnosis

Rumination Disorder

Salient Features of DSM 5 Diagnostic Criteria

Differential Diagnosis

Other Specified Feeding and Eating Disorders (OSFED) 1

Unspecified Feeding or Eating Disorder

Management of Eating Disorders

Treatment Goals

Steps in Management

Evaluation of Symptoms of Eating Disorder

Evaluation of Physical Status of the Patient

Treatment Setting

Indications for hospitalization 29

Anorexia Nervosa

Nutritional Rehabilitation

Risk of Refeeding Syndrome

Pharmacotherapy

Psychological Therapies

Bulimia Nervosa

Psychological Therapy

Binge Eating Disorder

ARFID and other Disorders

Recent Advances in Treatment

Summary

Footnotes

Declaration of Conflicting Interests

Funding

References

Physical Findings in AN^5,15

Salient Features of DSM 5 Diagnostic Criteria¹

Salient Features of DSM 5 Diagnostic Criteria¹

Salient Features of DSM 5 Diagnostic Criteria¹

Other Specified Feeding and Eating Disorders (OSFED)¹

Indications for hospitalization²⁹