Eating Disorders

IN THIS ISSUE: Eating Disorders | Philip Bialer | Seat at the Top Table | A&E

Eating Disorders: SIG Leaders Challenge APA Proposed Guidelines

‘Draft paper focuses on adult behaviors—treating children is different’

Leaders of the Academy’s Pediatric C-L Psychiatry SIG have submitted a detailed and comprehensive response, endorsed by the ACLP Board of Directors, to a draft document from the American Psychiatric Association (APA) on treating patients with eating disorders.

APA’s Guideline Writing Group drafted Practice Guideline for the Treatment of Patients with Eating Disorders after a systematic review of evidence.

SIG chairs Laura Markley, MD, FAAP, FAPA, FACLP, and Susan Turkel, MD, FAACAP, DFAPA, FACLP, say the draft “focuses significantly on patterns and perceptions that are more prevalent in adults” and point out differences based on the American Academy of Child and Adolescent Psychiatry’s (AACAP’s) Practice Parameter for the Treatment of Children and Adolescents with Eating Disorders as well as their extensive clinical experience of treating children and adolescents with eating disorders.


Laura Markley (left), MD, FAAP, FAPA, FACLP, and Susan Turkel, MD, FAACAP, DFAPA, FACLP
Laura Markley (left), MD, FAAP, FAPA, FACLP, and Susan Turkel, MD, FAACAP, DFAPA, FACLP

Why we must challenge the draft guidelines
Management of eating disorders in pediatric patients is in itself challenging and the input of consultation-liaison child and adolescent psychiatrists is critical, given that many of the most significantly ill patients end up receiving care in the inpatient medical setting, say the SIG leaders.

Eating disorders present more than 50% of the time with at least one additional psychiatric diagnosis, which may be premorbid or as a secondary effect of starvation on the brain. Patients often exhibit depressed mood, anxiety (particularly obsessive thinking patterns and compulsive behaviors), delusional beliefs, and other abnormal behaviors which often prove difficult to manage. They may be subsequent to the eating disorder itself or to an associated increased risk of intentional self-injury and suicide attempts.

Often, pediatric inpatient psychiatric settings will not accept suicidal or self-injurious eating disorder patients because they cannot provide adequate monitoring, dietary supervision, and specialized behavioral support. Most pediatric specialized residential eating disorder programs will not accept patients who are at risk for medical instability or who display associated suicidal or disruptive behavior.

Intensive, family-based therapy is key to recovery, but resources are few, psychosocial complexities are high, and parent and patient follow-through is a challenge.

The SIG leaders have found that many eating disorder patients remain on inpatient pediatric medicine units and require C-L Psychiatry management for prolonged periods. The C-L psychiatrist is the often the lynchpin of a complex network of care providers, including nurses, pediatric medical specialists, psychologists, dieticians, teachers and bedside staff, working to enact complex treatment and behavioral plans that stress safety and harm reduction in addition to nutritional restoration.

Young children with anorexia
The SIG leaders have worked with children as young as four or five with anorexia, and witnessed bulimia most often starting in mid-adolescence—contrary to the draft’s assertion that bulimia is more common than anorexia in younger patients. Quoting references, they say:

Anorexia Nervosa symptoms may be expressed differently in childhood and adolescence as compared to adulthood. Children and adolescents are often incapable of verbalizing abstract thoughts; this leads to a high prevalence of somatic symptoms in many psychiatric illnesses in youth, and eating disorders are no exception. Underlying emotions and motivations for the aberrant eating behavior are often not apparent to children, and often they lack insight into, and an inability to express, their emotional state.

As a result, as stated in the AACAP parameter, “parental reports about the child’s behavior are critical, as self-report is often unreliable because of a lack of insight, minimization, and denial by the child or adolescent.” The development of these beliefs and behaviors happens over time, leading caregivers to remain unaware until the weight loss eventually escalates and becomes more immediately apparent as a problem. Thus, the need for immediate intervention is critical because the assumption can be made that the disorder has been present for much longer than the awareness of it.

The parameter also notes that: “Young patients sometimes report an initial drive for thinness, but often claim that they are trying to eat less, avoid fattening foods, and exercise more for health reasons.” This is consistent with the SIG leaders’ experiences of seeing a high rate of youth proclaiming the restricting is due to adopting a vegetarian or vegan lifestyle, due to abdominal pain or other gastrointestinal symptoms, or their insistence that they want to gain weight and are trying but can’t. Presenting the patient with a “vegan-friendly” option with high caloric or protein content in these cases will likely be met with resistance, which can further assist in dissolving the façade and revealing the underlying fear of weight gain.

Differences in approach
The draft APA Guideline cites references stating that the practice of “blinded” weighing of patients is “controversial,” and indicates support of patients becoming involved in monitoring their weight throughout treatment, with consideration of stage and setting of treatment. “We believe it would be beneficial to clarify that in early phases of Anorexia Nervosa treatment for children and adolescents, especially those in the starved-state, we do not recommend allowing the patient to become involved in monitoring weight,” say the SIG leaders. “Early in treatment, emphasis should be nutritionally restoring physical and mental health, while discouraging fixation on a number that can fluctuate for many reasons subsequent to the eating disorder itself.”

The SIG leaders also express concerns regarding the proposed objective criteria for inpatient medical hospitalization. They review that the DSM-5 suggests that clinicians rate the level of severity of Anorexia Nervosa (mild to extreme) in adults based on current body mass index (BMI). But in children and adolescents, lack of expected gain or growth should be considered rather than severity based on age and gender norms according to BMI percentiles. If longitudinal growth charts are available, deviations from individual growth trajectories can be observed and are more useful. The SIG leaders discourage development of criteria based upon percentages of “Median BMI” as this fails to take into account that there are patients being treated for significant malnutrition whose weight and/or BMI are within “normal” range, which can occur following precipitous weight loss in a patient who had been overweight. At present, say the SIG leaders, there is little scientific basis for using weight compared to a “norm” as a marker of severity in children and adolescents; the most helpful approach is to watch the patient’s own growth trends over time.

Interventions for best outcomes
Family-centered interventions have been found to be the most effective interventions for childhood Anorexia Nervosa, say the SIG leaders who also point out: “There is also the frequent phenomenon of children being parented by someone with an eating disorder, or complex family dynamics underlying and complicating the child’s symptoms. Familial denial is often prominent, necessitating clinicians to rely more on observed behavior than reported symptoms.”

Interventions to address the eating disordered behaviors should be initiated as soon as possible. According to Wilfey, et al: “Interventions that break maladaptive behavior patterns before they become ingrained have greater potential for success. This is particularly noteworthy because shorter duration and reduced severity of symptoms are associated with better outcomes; recovery rates for adolescents with eating disorders are higher than those for adults. Thus, through early intervention, children and adolescents are more likely to respond to treatment.”

The SIG leaders conclude: “Overall, we have found the [proposed] APA Guideline to be redundant and wordy, which we fear will decrease its utility. Additionally, given that eating disorders and their precursor behaviors tend to present in childhood and adolescence, it would be prudent to amend the guidelines to be more congruent with the recommended care of pediatric patients, as has been clarified in the AACAP guidelines.”


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