15. Feeding & Eating Disorders

What Eating Disorders Can Affect Children and Adolescents?

• AN is a DSM-5 eating disorder characterized by (a) caloric restriction leading to significantly low body weight, (b) intense fear of gaining weight or becoming fat, and (c) disturbance in one's body weight or shape. • BN is a DSM-5 eating disorder characterized by (a) recurrent episodes of binge eating, (b) recurrent inappropriate compensatory behaviors to prevent weight gain, and (c) self-evaluation that is unduly influenced by one's body shape or weight. It occurs at least once a week for at least 3 months. • BED is a DSM-5 eating disorder characterized by (a) recurrent episodes of binge eating, (b) associated features (e.g., eating rapidly, eating when depressed, feeling ashamed), and (c) marked distress. It occurs at least once a week for at least 3 months.

What Is Avoidant/Restrictive Food Intake Disorder?

• ARFID is a DSM-5 feeding disorder characterized by (a) a lack of interest in feeding, (b) avoidance of food based on its sensory qualities, or (c) concerns about the negative consequences of eating. It is associated with weight loss, nutritional deficiencies, or other health/ social impairment. • The transactional model posits that feeding disorders arise through parent-child interactions characterized by children with (a) high physiological arousal, (b) difficult temperament, and (c) parents who are anxious about their child's food intake. • Approximately 1% to 2% of infants and toddlers have ARFID. Prevalence is higher among children with medical illnesses, developmental disabilities, and physical disabilities.

What Causes Child/ Adolescent Eating Disorders?

• Both AN and BN have heritability estimates ranging from approximately .50 to .75. The neurotransmitter serotonin is implicated in both AN and BN and may explain why selective serotonin reuptake inhibitors (SSRIs) are effective in reducing anxiety and negative affect associated with these disorders. • Child sexual abuse is a nonspecific risk factor for eating disorders; sexual maltreatment predicts a wide range of disorders, not only eating problems. • The cognitive-behavioral model posits that bingeing is negatively reinforced by a reduction in hunger whereas purging is negatively reinforced by an alleviation of guilt. • Social-cultural theories for eating disorders include the dual pathway model (i.e., dietary restriction, negative affect) and the tripartite influence model (i.e., peers, parents, media). At the center of both models is an adolescent's pursuit of an unrealistic thin ideal.

What Treatments Are Effective for Youths With Binge Eating Disorder?

• CBT is effective in reducing symptoms of BED in children and adolescents. Therapy typically involves helping youths identify situations and negative emotions that trigger binge eating and challenging cognitive distortions that can lead to negative affect. • IPT is also effective in reducing binge eating. Therapists help youths overcome interpersonal problems that can cause depression, loneliness, or social isolation that lead to binges.

What Conditions Are Associated With Eating Disorders?

• Medical complications associated with AN or BN include electrolyte imbalance, osteopenia, cardiac problems, malnutrition, dry skin, lanugo, enlarged salivary glands, and damage to the esophagus and teeth. Youths with BED are at risk for obesity. • Adolescents with AN or BN are at risk for depression and self-injury, anxiety and obsessive-compulsive behaviors, and substance use problems. • Adolescents with AN often show perfectionism, a personality trait characterized by a rigid and unrealistic pursuit of absolute standards. These youths may also engage in dichotomous (black-or-white) thinking. • Girls with AN or BN often come from families characterized by low autonomy, high conflict, and preoccupation with body shape and weight.

What Are Pica and Rumination Disorder?

• Pica is a DSM-5 feeding disorder characterized by the persistent eating of nonnutritive, nonfood substances that is developmentally and culturally unexpected. It lasts at least 1 month. • Rumination disorder is a DSM-5 feeding disorder characterized by repeated regurgitation of food. It occurs over the period of at least 1 month and must not be attributable to a medical condition or an eating disorder.

What Treatments Are Effective for Feeding Disorders?

• Positive reinforcement is the preferred treatment for pica and rumination. Positive punishment, such as overcorrection or facial screening, can be used with parental consent if positive reinforcement is not sufficient. • The treatment of ARFID can include (a) appetite manipulation to increase children's motivation to eat, (b) contingency management to reinforce eating and avoid escape conditioning, and (c) parent counseling to help generalize skills to the home. • Behavioral interventions are highly effective for young children with feeding disorders.

How Common Are Eating Disorders in Children and Adolescents?

• The lifetime prevalence of AN is 0.5% to 1% of females and less than 0.3% of males. The lifetime prevalence of BN is 1.5% to 4% of females and less than 0.5% of males. The lifetime prevalence of BED is 2.6%. • Recent research suggests that eating disorders exist across countries and cultures. Adoption of western cultural values and acculturation into the United States is associated with increased prevalence. • Onset of AN is typically in early adolescence or early adulthood. Onset of BN is typically in late adolescence or early adulthood. AN is associated with more severe and lasting impairment. • The course of BED often depends on the age of symptom onset. Childhood-onset BED is associated with a history of childhood obesity, binge eating, and dieting as well as greater risk for depression and family problems in later adolescence and adulthood.

What Treatments Are Effective for Youths With Anorexia Nervosa?

• The primary goal of inpatient treatment for AN is weight gain. Staff members administer behavioral protocols that usually involve positive reinforcement for eating and response cost for failing to achieve caloric goals. • Group therapy for AN often relies on supportive collaboration in which senior group members challenge the cognitive distortions and food obsessions of newer members. • Structural family therapy is sometimes used to improve parent-adolescent communication and to help parents meet adolescents' needs for greater autonomy. • The Maudsley Hospital approach to treatment involves (a) initial refeeding by parents, (b) family therapy to improve communication, and (c) increased autonomy for the adolescent.

What Treatments Are Effective for Youths With Bulimia Nervosa?

• The primary goals of CBT are (a) to expose youths to normal food intake while restricting compensatory behaviors and (b) to identify and challenge cognitive distortions that might elicit negative emotions and trigger maladaptive eating. • IPT is based on the notion that relationship problems often coincide with and exacerbate eating disorders. Therapists help youths identify and overcome dysphoria related to (a) grief, (b) role transitions, (c) rule disputes, and (d) interpersonal deficits. • SSRIs are effective in reducing symptoms of BN in adolescents. Combining SSRIs with CBT is more effective than administering SSRIs alone.