Course:KIN366/ConceptLibrary/EatingDisordersinChildren

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Movement Experiences for Children
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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
Email: shannon.bredin@ubc.ca
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An eating disorder is a condition in which there is excessive concern about the control of body weight and shape, accompanied by inadequate, irregular or uncontrolled food intake (Rachael Bryant, 1995; David S. Rosen, 2010). The most commonly known types of eating disorders are Anorexia nervosa (AN) and Bulimia nervosa (BN). There are other sub-types of eating disorders that both children and adolescents suffer from that are recognized as eating disturbances, but because they fail to meet the diagnostic criteria for Anorexia nervosa and Bulimia nervosa, they cannot be classified under these specific categories. (A. S. Robb,2001; Rachael Bryant, 1995).

Classification/Definition

The different forms of eating disorders in children include Anorexia nervosa, Bulimia nervosa, and other eating disturbances that are classified as sub-type eating disorders.

Anorexia nervosa is defined as an intense fear of gaining weight or becoming fat; refusal to maintain body weight at or above a minimally normal weight for age and height, or failure to grow/gain weight during a period of expected growth, leading to a body weight of 85% of expected weight, accompanied by low self-esteem and a poor body image (Ellen S. Rome, 2012;A.S. Robb,2001).

"Bulimia nervosa is defined as frequent binge eating (at least twice per week for a minimum of three months), characterized by consuming large quantities of food in a short period of time and lacking a sense of control over food intake during the binge. This is followed by unusual frequent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting, abuse of laxatives and diuretics, excessive exercising or fasting (Ellen S. Rome, 2012, A.S.Robb, 2001)

Besides Anorexia nervosa and Bulimia nervosa, there are other sub-categories of eating disorders classified as eating disturbances that are not otherwise specified (ED-NOS) (Ellen S. Rome, 2012). Some individuals may have a mindset consistent with AN but show no signs of weight loss, in which case it will not be possible for a practitioner to diagnose the patient with AN. Similarly, individuals with a binge eating disorder (no purging), night eating syndrome and those who chew and spit, are categorized under ED-NOS (Ellen.S.Rome, 2012). There are still some challenges in identifying characteristics unique to the sub-categories and combining them. Inconsistencies with the diagnostic classification of eating disorders have also led to some treatment and prognostic challenges (A.S.Robb, 2001).


Predictive Factors

Eating disorder is a complex and multi-factorial illness. There are numerous causes that can promote and lead to disordered eating, including biological, psychological and/or environmental factors (J.Treasure, 2010). In the past years eating disorders were primarily associated with psychological, environmental, and socio-cultural abnormalities, but in recent years studies have also identified genetic and heritable causes that may lead to the development of this illness (J.Treasure, 2010).

Genetic Factors

Multiple studies show that eating disorders can be heritable and there may be a possible genetic predisposition for contracting this illness. Recent twin and family studies have found that Anorexia nervosa, Bulimia nervosa and ED-NOS are complex genetic illnesses, and for each disorder the predicted heritability ranges from 50% to 83% (J.Treasure, 2010). Researchers in other twin and family studies have also identified a genetic link on Chromosome 1 that can be found in multiple family members of an individual with either Anorexia nervosa, Bulimia nervosa and/or associated behavioral traits such as compulsivity (J.Treasure,2010; P.Patel, 2002). This finding shows an inheritance pattern found amongst family members of other patients previously diagnosed with an eating disorder (P.Patel, 2002) Another study suggests that an individual related to an immediate family member who has suffered or is currently suffering from an eating disorder, is 7 to 12 times more likely to suffer from an ED themselves (P.Patel, 2002).

Social/Environmental Factors

Environmental factors play an important role in the developmental course of a child/adolescent, beginning as early as the time of conception. Prenatal complications that occur during the course of pregnancy and/or premature birth can predispose a child towards developing an eating disorder (Ellen S.Rome, 2012). Parent(s) may inadvertently contribute a child developing an eating disorder. Studies show that being perceived as overweight by one’s parent(s) and being female, are strong predictive factors of the development of eating disorders (Ellen S.Rome, 2012). Other predictive causes may include having an overweight parent(s) who are concerned about their own weight, shape and/or eating habits and who are constantly conversing about it (Ellen S.Rome, 2012);David Rosen, 2010). High parental expectations and over-anxious parents can also consciously/unconsciously put psychological pressure on their child and promote the development of eating disorders (Ellen S.Rome, 2012). Weight-related teasing of a child is anther predictive factor of eating disorder development — calling a child chubby or overweight will not enhance their ability to manage weight, diet or exercise (D.Neumark-Sztainer, 2008). There are also other social and interpersonal issues that could promote this illness, such as fashion cultures placing excess value on thinness, which encourages extreme dieting and weight control behaviors (P.Patel, 2002). Teasing, bullying and criticism focused on weight, shape and food, drastically increase the risk of developing an eating disorder in children and adolescents (J.Treasure, 2010; Ellen S.Rome, 2012). During the child’s development and into puberty, children and adolescents become more self-conscious while they are constantly trying to figure themselves out. Therefore negative comparisons between an individual’s body shape and that of the so-called ideal body type, contributes to low self-esteem, which can motivate or even force a child/adolescent to unrealistically attempt to achieve that ideal image (J.Treasure, 2010). The media plays an enormous role when it comes to idealization of thinness and the stigmatization of fatness — the blame for the increase in the incidents of eating disorders in children and adolescents, are often laid at the feet of the media (Ellen S.Rome, 2012; J.Treasure, 2010). They inadvertently put excessive pressure on society by portraying images of idealized slim body shapes of models and celebrities, which again motivates children/adolescents to adopt weight-controlling behaviors in order to achieve slimness. In addition to these predictive factors, neglect and/or sexual and physical abuse and violence, increase the risk of developing an eating disorder as well (Ellen S.Rome, 2012).

Signs

Disordered eating behaviors in children may influence their physical and mental development. Some of the signs associated with eating disorders include:

  • Constant adherence to increasingly strict diets, regardless of their weight
  • Habitual trips to the bathroom immediately after eating
  • Secretly binging on large amounts of food
  • Misuse of laxatives, diuretics and/or diet pills
  • Excessive or compulsive exercising, often several hours per day
  • Withdrawal from friends and family, particularly when concern is shown
  • Avoidance of meals or situations where food may be present
  • Rapid weight loss, which the person may try to conceal with loose clothing
  • Preoccupation with weight, body size and shape
  • Obsessive behavior over calorie intake and burnt calories


Prevalence/Epidemiology

Estimated overall prevalence for Anorexia nervosa remains at 1%, with Bulimia nervosa currently at 4% (Ellen S.Rome, 2012). Even though eating disorders are typically detected in young girls, the number of boys and young men with disordered eating behaviors is also increasing, especially at earlier ages (Ellen S.Rome, 2012). A study of a large sample of American children aged 9–14 years reported that 7% of boys and 13% of girls displayed disordered eating behaviours (J.Treasure, 2010). ED-NOS including night eating syndrome, binge eating disorder and other sub-categories are currently estimated at 10% prevalence (Ellen S.Rome,2012). In past years, Bulimia nervosa was found predominantly in a slightly older population than Anorexia nervosa, with comparably fewer cases detected before the age of 14 years. However in recent years, more patients under the age of 14 have been reporting binges and purges of more than twice per week for at least three consecutive months (Ellen S.Rome, 2012).


Diagnosis

History Taking

In order to establish a diagnosis, comprehensive evaluations including careful history and physical examinations, are often performed in a pediatric primary care setting. Competent and confident healthcare providers who feel comfortable assessing and handling children in such sensitive situations, are encouraged to do so (David Rosen, 2010). The initial evaluation includes establishing the diagnosis, evaluating medical and nutritional status, determining severity and performing an initial psychosocial evaluation (David Rosen, 2010). The initial mental health assessment usually starts with the parent(s) and child/adolescent together (Ellen S.Rome, 2012). The clinician will start by asking questions and then analyze the responses he/she receives in order to assess the patient’s social functioning at home, in school and with friends (Ellen S.Rome, 2012; F Khan, 2011).This initial evaluation will also assess the patient’s obsession with food and weight and his/her understanding of the diagnosis and his/her willingness to receive help (David Rosen ,2010). In this process the pediatrician may identify other psychiatric disorders such as depression, anxiety and/or obsessive-compulsive disorder, which may be a predictive factor of disordered eating (David Rosen ,2010). Suicidal ideation and history of sexual and/or physical abuse or violence will also be evaluated since they are major contributors to eating disorders associated with mortality (David Rose, 2010). Suicidal thoughts and attempts are relatively common in patients with binge and purging behaviors. When assessing the child/adolescent, it is also critical to evaluate the parent’s reaction to the disorder. Parental denial or indifference of the illness and their inconsistent views about the treatment, may affect the recovery process and the course of the illness (David Rosen 2010).

Physical Examination

The second part of the diagnosis involves a thorough physical examination, which should include measuring the patients height, weight obtained in a hospital gown after voiding (bodily process of discharging waste matter), and calculating the patients BMI (Ellen S.Rosen, 2012). Some children and adolescents have a tendency to become overly focused on the numbers they read on the scale, so many healthcare providers prefer “blinded weights”, where the patient is weighed facing backwards on the scale so they cannot see the numbers (Ellen S.Rosen, 2012). This strategy tends to help reduce the patient’s anxiety during the visit. Vital signs, including blood pressure (BP) and heart rate (HR) are also obtained, first in a supine position and then standing, in order to assess for a drop in diastolic BP or an elevated HR of at least 20bpm indicating orthostatic hypotension (Ellen S.Rosen, 2012). Urine samples are taken in order to examine the patient’s ketone and protein-uria levels and to determine if water loading has occurred or/and if dehydration is present (Ellen S.Rosen, 2012; A. Meyer, 2007). In case of dehydration, the patient may have an elevated heart rate (Ellen S.Rosen, 2012; A. Meyer, 2007). An absolute critical part of the diagnosis is the detailed head-to- toe examination. When a child is being thoroughly examined, the clinician is looking for a number of signs including Parotitis occurring with vomiting, dental erosions on the occlusal and lingual surfaces from acid passing up and out as opposed to candy/food causing erosions in a more common pattern, calluses on the first knuckles caused by the repetitive hitting of teeth against the area during purging, and hypothermia (Ellen S.Rosen, 2012).

Prognosis

The prognosis of eating disorders in children and adolescents is very diverse throughout literature and results depend on a variety of factors, such as methodology, definitions of recovery, and duration of follow-up in reported studies (D.Rosen, 2010). Outcomes in children and adolescents where their condition has been detected at an early stage are significantly better and more optimistic than the outcomes reported in adults (D.Rosen, 2010). The majority of children and adolescents will partially or fully recover over time after consistent long-term treatments and regular follow-ups (D.Rosen, 2010). In order to see improvement in the physical and behavioral condition of a patient, all parties involved, including the patient, families and clinicians, must be prepared to engage in a protracted treatment process that may last 10-15 years (D.Rosen, 2010). Roughly 70% to 80% of children and adolescents who have successfully completed their treatment plans and follow-ups, have achieved partial or complete recovery (D.Rosen, 2010). However, progression is protracted and a high rate of residual psychiatric disorders, predominantly depression and anxiety will remain or even newly develop after recovery from an eating disorder. In general, children and adolescents with an earlier age of onset, shorter duration of symptoms and better parent-child relationships, seem to have a better prognosis (D.Rosen, 2010).

Effects on Daily Life and Movement

Children with eating disorders experience many different psychological and physical complications that can affect their day-to-day lives. Children/adolescent who binge may experience weight gain, which may discourage them from engaging in sports or simply playing with other children. They may have low self-esteem and have feelings of shame or guilt, which may interfere with their daily lives and lead to a continuum of maladaptive behaviors as a coping strategy (Ellen S.Rome, 2012). Children/adolescents with anorexia nervosa restrict their calorie intake and starve themselves. Starvation has major effects on brain, bone, heart, and other organs (Ellen S.Rome, 2012). Children with AN experience high levels of fatigue, which hinders them from being physically active. They will also have decreased bone density, which can make them more susceptible to fractures and injuries (Ellen S.Rosen, 2012). They will lack energy, motivation and healthy physical and mental conditions to engage in daily physical activities due to the restriction of food intake and/or the constant mental strain.


Practical Application

Pediatrician

In order to prevent eating disorders, pediatricians and families need to work together. The following list may serve as a guide for pediatricians:

  • Every pediatrician need to be knowledgeable about the risk factors and early signs and symptoms of disordered eating behaviors and eating disorders.
  • The pediatrician must help families and children learn to apply principles of proper nutrition and physical activity and avoid an unhealthy emphasis on weight and dieting.
  • Age and gender appropriate charts should be used to calculate and plot weight, height and BMI — this is sensitive information that should be used wisely to help the patient.
  • Pediatricians should take the time to screen patients for disordered eating and related behavior, and be prepared to intervene when necessary.
  • Pediatricians should monitor patients with eating disorders for medical and nutritional complications, or refer such patients to a specialist.
  • Pediatricians need to be familiar with treatment resources in their communities and elsewhere, so that they can plan or facilitate multi-disciplinary care for their patients.


Parents and Families

  • Need to be able to identify and recognize signs and symptoms of disordered eating behaviors and eating disorders — early detection may lead to an earlier recovery.
  • Avoid teasing or making negative comments about a child’s body shape, weight and food intake — rather set the example and provide healthy alternatives.
  • Avoid conversing about your own or other people’s diets and weight issues, especially when you notice that this affects your child adversely.
  • Do your utmost to be a good role model by eating a healthy and balanced diet and engage in regular, moderate physical exercise if at all possible.
  • Compliment children on a regular basis and point out their strengths — be patient, loving and encouraging.
  • Communicate with your child on a regular basis and try to create an open and healthy relationship, so that he/she feels comfortable sharing their feelings with you.
  • Plan and prepare family meals at least once a day where the entire family can spend some time together and talk about their day — try to create a relaxed atmosphere where everybody will be eager to participate.


References

  1. Rosen, D. (2010). Clinical Report—Identification and Management of Eating Disorders in Children and Adolescents. American Academy of Pediatrics, 126(6), 1-16. Retrieved February 10, 2015, from www.pediatrics.org/cgi/doi/10.1542/peds.2010-2821
  2. Rome, E. (2012). Eating Disorders in Children and Adolescents. Current Problems in Pediatric and Adolescent Health Care, 42(2), 28-44. Retrieved February 1, 2015, from http://www.sciencedirect.com.ezproxy.library.ubc.ca/science/article/pii/S1538544211001684
  3. Bryant-Waugh, R., & Lask, B. (1995). Annotation: Eating Disorders in Children. Journal of Child Psychology and Psychiatry, 36(2), 191-202.
  4. Robb, A. S. (2001). Eating disorders in children. diagnosis and age-specific treatment. The Psychiatric Clinics of North America, 24(2), 259.
  5. Khan, F., & Chowdhury, U. (2011). Eating disorders in children and adolescents. British Journal of Medical Practitioners, 4(1), 10.
  6. Meyer, A. (2007). Eating disorders in children and adolescents. MMW Fortschritte Der Medizin, 149(18), 27.
  7. Treasure, J. (2010). Eating Disorders. The Lancet, 375(9714), 583-593. Retrieved February 1, 2015, from https://www-clinicalkey-com.ezproxy.library.ubc.ca/#!/content/playContent/1-s2.0-S0140673609617487?scrollTo=#top
  8. Patel, P; Wheatcroft, R; Park, R; Stein, A (2002). The Children of Mothers With Eating Disorders. Clinical Child and Family Psychology Review 5 (1), 1.
  9. Neumark-Sztainer D, Eisenberg ME, Fulkerson JA, Story M,Larson NI (2008). Family meals and disordered eating in adolescents.Longitudinal findings from Project EAT. ArchPediatr Adolesc Med 162(17),22.