Adolescent Eating Disorders: Here’s Help Keeping Up With an Evolving Field

Among the latest revisions to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders — as reflected in the DSM-5, released in 2013 — are expanded categories for feeding and eating disorders (see sidebar below).

While earlier DSM versions included anorexia nervosa, bulimia nervosa and the catchall “eating disorder not otherwise specified” (ED-NOS), DSM-5 introduced two new categories — binge eating and avoidant/restrictive food intake disorder (ARFID) — to increase options for actionable diagnoses.

“Lumping together all those who did not have anorexia nervosa or bulimia into ED-NOS, or unspecified eating disorders, was not helpful for treatment centers trying to figure out what works best for distinct groups of patients,” explains Ellen Rome, MD, MPH, Head of the Center for Adolescent Medicine at Cleveland Clinic Children’s.

“Some of the same treatments are useful, such as family-based refeeding for children and adolescents who restrict their intake, but we’re still fine-tuning what works,” adds Dr. Rome, who was among the experts on a working group that proposed changes to the criteria for eating disorders in advance of DSM-5. “Having new categories for binge eating and ARFID allows us to look at outcomes for these patients and learn how to improve our quality of care.”

Clinical pearls from the latest literature

Since the release of DSM-5, Dr. Rome has co-authored several studies and other journal articles that point to the importance of the new categories and the impact on patients and providers. Here are a few examples and insights from each:

• In a retrospective case-control study of more than 700 8- to-18-year-olds published in the Journal of Adolescent Health, Dr. Rome and peers at seven other hospitals confirmed that patients with ARFID are demographically and clinically distinct from those with anorexia nervosa and bulimia nervosa. Among the distinctions, they concluded that patients with ARFID are significantly underweight, have a longer duration of illness and are more likely to have comorbid medical or psychiatric symptoms.
• In a Society for Adolescent Health and Medicine position paper, Dr. Rome and colleagues documented top-level evidence that most adolescent eating disorders can be managed on an outpatient basis and midlevel evidence that inpatient refeeding protocols for patients with anorexia nervosa can be more aggressive than previously recommended.
• In a concurrent review article, Dr. Rome and the rest of the position paper writing group (see point above) emphasized that family-based therapy has strong support as first-line psychological treatment for adolescents with anorexia nervosa. They noted that it’s useful for other adolescent eating disorders too.

Putting family at the fore

Dr. Rome says the centrality of family-based therapy, also known as the Maudsley method — where parents assume an important role in ensuring that their children achieve early and lasting weight restoration — is a relatively recent trend.

“It represents a change from the 1990s, when parents were cut out of the equation. We used to do ‘parentectomies,’” she quips. “But it turns out that kids get better faster if parents are part of the equation.”

One of the Maudsley method’s tenets is family-based refeeding, which can be supported by a pediatrician or dietitian versed in eating disorders. Family-based refeeding has three stages:

1. Parents are in charge of all meals.
2. Parents are in charge of all meals except one meal or snack.
3. Adolescents pick their food but ask parents if they are meeting all their nutritional needs. Parents help add to the plate if the teen underpicks portions or certain food groups.

“Patients in families that do the Maudsley method correctly — where the kid gains weight in the first month — are most likely to be recovered a year later,” says Dr. Rome.

“Our approach is to help empower parents to feed their kids appropriately and to free families from the eating disorder mindset,” she adds. “We try to help kids and their parents see the child/adolescent as separate from the eating disorder.”

Red flags for eating disorders

“If a family member, teacher, peer or pediatrician hears alarm bells about an eating disorder, pay attention,” advises Dr. Rome. She says warning signs include:

• Skipping or avoiding meals
• A change in eating habits, such as a switch to veganism or vegetarianism
• Heart rate under 60
• Repetitive dieting
• Obsessive rituals around preparing and eating food
• Repetitive body-checking behaviors, such as weighing oneself or waist-pinching
• Fainting, dizziness or fatigue
• Sensitivity to cold

“The adolescent may not have a disorder at that moment, but weekly or monthly follow-up may be needed to ensure they aren’t developing one,” she notes.