3 Eating Problems in Children and Adolescents
Neville H. Golden, M.D.
Rollyn M. Ornstein, M.D.
Medical professionals, including pediatricians, adolescent medicine specialists, and primary care practitioners, are uniquely suited for the early identification of eating problems in children and adolescents because patients in this age group are usually seen at regular intervals. However, the diagnosis of an eating disorder in this age group can be particularly challenging because these patients frequently fail to endorse cognitions typically associated with eating disorders (e.g., feeling fat, fearing weight gain, concern about body shape or weight) but may instead present with vague physical complaints such as nausea, difficulty swallowing, or abdominal pain after eating. Physicians working with youths would therefore benefit from additional information about the unique presentation of children and adolescents with feeding and eating problems. In particular, physicians would be helped by understanding the changing nosology of feeding and eating disorders as described in DSM-5 (American Psychiatric Association 2013) that may affect the diagnostic labels applied to eating problems in youths. Especially notable in DSM-5 is the development of a revised diagnostic category now entitled avoidant/restrictive food intake disorder (ARFID) and the inclusion of rumination disorder and pica in feeding and eating disorders in DSM-5.
The aim of this chapter is to provide a practical approach for pediatricians, adolescent medicine physicians, primary care practitioners, and other professionals who may need to assess children and adolescents with potential feeding or eating disorders. Given the aforementioned challenges of differing presentations in youths and the recently updated diagnostic scheme, this chapter provides assistance in the assignment of the diagnosis of a feeding or eating disorder in a child or adolescent. Guidance is offered for conducting a careful history and physical examination, and suggestions are offered for the exclusion of other medical and psychiatric conditions as part of this evaluation. The reader is encouraged to view Video 2, “Assessing eating problems in the primary care setting.”
Epidemiology and Nosology of Eating Disorders
Although eating disorders have historically been considered diseases of affluent white adolescent females, data on epidemiology suggest changes over the past few decades (Pike et al. 2013). Increased prevalence rates have been identified among ethnic and racial minorities (Alegria et al. 2007; Marques et al. 2011; Nicdao et al. 2007; Taylor et al. 2007) and in countries where eating disorders were traditionally not reported (Chandra et al. 2012; Chisuwa and O’Dea 2010; Eddy et al. 2007; Jackson and Chen 2010; Lee et al. 2010). Although the onset of eating disorders was previously more common during middle to late adolescence, more recent studies indicate that the age at onset for both anorexia nervosa (AN) and bulimia nervosa (BN) has been decreasing (Favaro et al. 2009; van Son et al. 2006), with a significant increase in the numbers of individuals under age 12 presenting for treatment (Madden et al. 2009; Nicholls et al. 2011; Pinhas et al. 2011) and a notable increase in females ages 15-19 presenting with AN (van Son et al. 2006). Data also suggest an increase in the identification of males with eating disorders (Swanson et al. 2011) and a reduced female-to-male ratio in younger patients with restrictive eating disorders (Madden et al. 2009; Nicholls et al. 2011; Pinhas et al. 2011), highlighting the importance of broadening perceptions with relation to the sex and the presentation of individuals with feeding and eating disorders.
Under the DSM-IV diagnostic classification scheme, more than 50% of children and adolescents with eating disorders were assigned the diagnosis of eating disorder not otherwise specified (EDNOS), because they did not meet full criteria for either AN or BN, or they had an entirely different disorder (Eddy et al. 2008; Peebles et al. 2010). A goal of DSM-5 was to improve the clinical utility of the eating disorder diagnostic categories and decrease the need to employ the EDNOS category. Early studies demonstrated that application of the DSM-5 criteria leads to significant decreases in the proportion of EDNOS diagnoses and modest increases in both AN and BN diagnoses in children, adolescents, and young adults (Machado et al. 2013; Ornstein et al. 2013; Stice et al. 2013). In clinical samples of younger patients referred to specialized eating disorder programs, 5%-23% meet criteria for ARFID (Fisher et al. 2014; Nicely et al. 2014; Norris et al. 2014; Ornstein et al. 2013).
Basic Screening for a Feeding or Eating Disorder
Physicians can play a key role in identifying early eating problems among children and adolescents during health maintenance visits or preparticipation sports physical examinations. A critical element in screening for a feeding or eating disorder is the measurement of height and weight to plot body mass index (BMI; weight in kilograms divided by height in meters squared [kg/m2]), which should be examined at each visit, with close attention paid to any significant change in percentiles for height, weight, or BMI. The degree of change and current status are important in determining level of concern. Children and adolescents who fail to make expected weight gain during a period of growth, even if they have not lost any weight, should be assessed further. Parents of a preteen or adolescent should be asked specific questions about concerns they may have regarding their child’s dietary intake (e.g., limited consumption, greatly decreased range of foods eaten), physical activity, excessive weight concerns, or inappropriate dieting. In girls, primary or secondary amenorrhea in the context of dieting or excessive exercise should be a red flag. Any suspicion of a possible eating disorder requires a more comprehensive assessment, which may or may not be possible given the time and resource constraints of the physician’s practice and the patient’s insurance plan. If additional time cannot be spent on evaluation, the clinician should refer the patient to an eating disorder specialist.
Initial Medical Assessment for a Suspected Eating Disorder in a Child or Adolescent
The initial medical assessment of the child or adolescent who may have an eating disorder may be performed by a pediatrician, adolescent medicine specialist, or primary care practitioner. This evaluation aims to establish current eating disorder symptoms, develop a preliminary diagnosis, exclude other causes of weight loss or vomiting, evaluate for any associated medical complications, and, as appropriate, initiate a plan for treatment and ongoing monitoring. A mental health professional may be needed to perform a psychological assessment to evaluate for common comorbid psychiatric illnesses such as affective or anxiety disorders.
History
When a child or adolescent initially presents for an evaluation of a possible feeding or eating disorder, the health care provider should usually start by obtaining a history with both parent and patient together. Observing the interaction between child and parent(s) can be informative. Subsequently, the physician should speak individually with the child or adolescent and the parent(s) to ask each party about specific related disordered behaviors, such as purging, compulsive exercising, and other habits. Skilled interviewing can reveal any “hidden agenda” and clarify any discrepancies in perspective between parent(s) and child. For example, the clinician can ask the child or adolescent what he or she has been told about the reason for the appointment; the physician can then observe whether the parent automatically answers for the child or interrupts and whether the child speaks freely or looks to the parent to answer. With regard to the presented problem, the chief complaint may be weight loss, but it also may be amenorrhea, weakness, dizziness, fatigue, abdominal pain, nausea, vomiting, or a combination of complaints. A detailed history can usually differentiate an eating disorder from another etiology for symptoms. Sample questions that might be asked in this interview are provided in Table 3–1 and illustrated in Video 2.
Video Illustration 2: Assessing eating problems in the primary care setting (3:24)
Physical Examination
A thorough physical examination is an essential component of the assessment of a child or adolescent suspected of having an eating disorder. Height should be obtained using a wall-mounted stadiometer, and post-voiding weight should be measured with the patient wearing only a hospital gown. The physician should calculate BMI, plot it on the Centers for Disease Control and Prevention charts (www.cdc.gov/growthcharts/clinical_charts.htm), and determine the percentage of median BMI (patient’s BMI/median BMI χ 100). It is important to review the patient’s previous weights and heights on the growth chart to determine whether growth arrest has occurred. Particular attention should be paid to obtaining vital signs, including oral temperature and orthostatic measurements of heart rate and blood pressure (measured when the patient is lying down and again 2 minutes after standing). It is not uncommon for significant bradycardia, hypotension, and hypothermia to be present. Physical examination may reveal loss of subcutaneous fat, prominence of bony protuberances, and lanugo hair on the back, trunk, and arms. Dental enamel erosion and enlargement of the parotid and salivary glands may be present in those who purge. Russell’s sign, or calluses on the dorsum of the hand that are caused by the central incisors when the fingers are used to induce vomiting, may be evident. Examination of the heart may reveal a midsystolic click or murmur from mitral valve prolapse. Assessment of sexual maturity rating (Tanner staging for development of breasts and pubic hair for girls or for genitals and pubic hair for boys) is important to evaluate for pubertal delay or arrest. Common physical signs noted in children and adolescents with eating disorders are listed in Table 3–2, and conditions that would suggest a need for inpatient medical hospitalization are listed in Table 3–3.
History of present illness When did your eating habits change? Why did they change? What is the most you ever weighed? How tall were you then? When was that? What is the least you ever weighed in the past year? How tall were you then? When was that? What would you like to weigh? Are there specific body parts you would wish to change? What have you eaten in the last 24 hours? Calorie counting? Fat-gram counting? Carbohydrate counting? Food restrictions? Recent vegetarianism? Excessive noncaloric fluid intake? Do you eat with others? Do you eat outside of your home? Do you exercise? How much, how often, and what level of intensity? How do you feel if you miss exercising? Have you engaged in binge eating? Frequency? Have you purged by self-induced vomiting? Frequency? Do you use laxatives, diuretics, or diet pills? Have you ever had any previous treatment for an eating disorder or other mental health issue? If there is a suspicion of avoidant/restrictive food intake disorder, may add these questions: Do you have any fears about vomiting or choking? Have you ever experienced or witnessed episodes where someone choked on food? Have you ever used oral nutritional supplementation or tube feedings? When? Would you describe yourself/your child as a picky eater? Are you bothered by characteristics of food related to smell, taste, texture, or color? Past medical history Birth history, neonatal course, feeding history, episodes of gagging or other intolerances to food, and texture/sensory issues Medical or mental health problems, hospitalizations, and surgeries Menstrual history (girls) At what age did you have your first period (if applicable)? Were your menstrual cycles regular prior to the eating disorder? When was your last menstrual period? Family history Medical problems, recent illnesses, or deaths (e.g., obesity, diabetes, cardiovascular disease) Family members with weight loss efforts, possible eating disorder Mental health history, alcoholism, and/or substance abuse Review of systems General: weight changes, sleep habits, fevers, night sweats, heat/cold intolerance, hair loss Cardiovascular: chest pain, heart palpitations Respiratory: shortness of breath, cough with or without exertion Gastrointestinal: abdominal pain, fullness/bloating, early satiety, nausea, dyspepsia, reflux symptoms, vomiting, diarrhea, constipation Musculoskeletal: weakness, numbness/tingling, pain, swelling Neurological: headaches, dizziness, syncope Psychiatric: symptoms of depression, anxiety, obsessive-compulsive disorder, substance abuse, physical and/or sexual abuse |
Laboratory Investigations
Recommended laboratory tests are shown in Table 3–4. Laboratory tests are not diagnostic per se, but they may help confirm an eating disorder diagnosis by excluding other causes of weight loss or vomiting. Despite a patient’s significant weight loss and severe dietary restriction, laboratory tests are usually normal.
Anorexia nervosa |
Bulimia nervosa |
|
General |
Low weight Loss of subcutaneous fat Proximal and intercostal muscle wasting Prominence of bony protuberances Hypothermia |
Weight usually normal |
Skin |
Dry skin with hyperkeratotic areas Yellowish discoloration (carotenemia) Lanugo Acrocyanosis Hair loss or thinning Pitting and ridging of nails |
Russell’s sign (calluses on dorsum of hand caused by self-induced vomiting) |
Cardiovascular |
Bradycardia Hypotension Orthostasis Peripheral edema Systolic murmur sometimes associated with mitral valve prolapse Electrocardiographic abnormalities—bradycardia, low voltages, prolonged QTc |
Electrocardiographic abnormalities, particularly QTc prolongation |
Gastrointestinal |
Scaphoid abdomen with stool palpable in left-lower quadrant Elevated transaminases |
Parotid and salivary gland enlargement Dental enamel erosion Loss of gag reflex Dental caries, gingivitis, stomatitis, glossitis Abdominal distension after meals |
Metabolic/endocrine |
Amenorrhea Cold intolerance, hypothermia Growth retardation Delayed puberty |
Oligomenorrhea or normal menses; amenorrhea also possible |
Musculoskeletal |
Muscle wasting Low bone mineral density with pathological fractures |
Usually normal weight Usually normal bone mineral density |
Neurological |
Cognitive and memory dysfunction Depression Anxiety |
Cognitive and memory dysfunction Depression Anxiety |
Hematological |
Easy bruising, petechiae Thrombocytopenia Leukopenia Anemia |
Medical Complications
Many of the medical complications of eating disorders are secondary to the effects of malnutrition and/or purging behavior. As described in the following subsections, almost every organ system may be involved.
Fluid and Electrolytes
Patients with eating disorders may present with dehydration and abnormal serum levels of sodium, potassium, chloride, phosphorus, magnesium, carbon dioxide, and blood urea nitrogen. Electrolyte disturbances, most commonly hypokalemia, are more likely in those patients who are vomiting and/or abusing laxatives or diuretics. Hyponatremia can occur in those who “water load” (i.e., consume large amounts of water to temporarily appear to weigh more) and can lead to seizures, coma, and death. Serum phosphorus levels may be normal on presentation but can drop during the process of refeeding, and careful monitoring is needed if physicians are overseeing an outpatient weight gain regimen for patients who are underweight. Hypophosphatemia may play a role in the development of cardiac arrhythmias and sudden unexpected death seen during refeeding (Katzman et al. 2014). Hypomagnesemia is more common among patients who purge (Raj et al. 2012).
≤ 75% median body mass index for age and sex Dehydration Electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia) Electrocardiographic abnormalities (e.g., prolonged QTc or severe bradycardia) Physiological instability Severe bradycardia (heart rate <50 beats/minute daytime; <45 beats/minute at night) Hypotension (<90/45 mmHg) Hypothermia (body temperature <96°F or 35.6°C) Orthostatic increase in pulse (>20 beats/minute) or drop in blood pressure (>20 mmHg systolic or >10 mmHg diastolic) Arrested growth and development Failure of outpatient treatment Acute food refusal Uncontrollable bingeing or purging Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis) Comorbid psychiatric or medical condition that prohibits or limits appropriate outpatient treatment (e.g., severe depression, suicidal ideation, obsessive-compulsive disorder, type 1 diabetes mellitus) |
Note. One or more of the indications justifies hospitalization.
Source. Adapted from Golden et al. 2015.
Cardiovascular System
In patients with eating disorders, resting heart rates may be as low as 30-40 beats per minute, both systolic and diastolic blood pressures may be low, and there may be orthostatic changes in both pulse and blood pressure. These changes reflect an adaptive response to reduced energy intake and are generally seen in the restrictive eating disorders. Heart size is reduced and exercise capacity is diminished, but cardiac output and left ventricular function are usually preserved. A silent pericardial effusion may be present (Ramacciotti et al. 2003). Electrocardiographic abnormalities include sinus bradycardia, low voltage complexes, a prolonged QTc interval, increased QT interval dispersion, first- and second-degree heart block, and various atrial and ventricular arrhythmias. Congestive heart failure does not usually occur in the starvation phase but can occur during refeeding.
Complete blood count and erythrocyte sedimentation rate Urinalysis Chemistry profile including blood urea nitrogen, creatinine, albumin, and electrolytes (sodium, potassium, calcium, phosphorus, and magnesium) and liver function tests Serum amylase level (if patient is vomiting) Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone levels Serum luteinizing hormone, follicle-stimulating hormone, estradiol, and prolactin (if patient is amenorrheic) Serum 25-hydroxyvitamin D level Electrocardiogram Dual-energy X-ray absorptiometry (DXA) Optional laboratory tests include Celiac screen Upper gastrointestinal tract series and small-bowel series Magnetic resonance imaging of the head |
Gastrointestinal System
Among patients with eating disorders, bloating and constipation are frequent complaints and reflect delayed gastric emptying and decreased intestinal motility. Liver aminotransferases are elevated in 4%-38% of patients with AN and improve with nutritional rehabilitation (Narayanan et al. 2010). Weight loss can lead to the superior mesenteric artery syndrome, a condition that is characterized by pain and vomiting after eating and is caused by extrinsic compression of the duodenum by the superior mesenteric artery where it originates from the aorta. Rapid weight loss can also be associated with gallstone formation.
Recurrent vomiting results in erosion of dental enamel, esophagitis, Mallory-Weiss tears, and possibly esophageal or gastric rupture. Prolonged recurrent vomiting may cause Barrett’s esophagus, which is a precancerous condition. Laxative abuse can be accompanied by bloody diarrhea. Serum amylase may be elevated in individuals who are bingeing or purging. Acute pancreatitis occasionally occurs. Total protein and serum albumin levels are usually normal in patients with eating disorders, in contrast to patients with other forms of malnutrition.
Endocrine System
Growth retardation and short stature can occur in children and adolescents who develop an eating disorder prior to completion of growth (Lantzouni et al. 2002; Modan-Moses et al. 2003). This is more likely to occur in adolescent boys with AN because they grow, on average, for 2 years longer than girls. Catch-up growth can occur with nutritional rehabilitation; however, even with intervention, these adolescents may not reach their genetic height potential (Lantzouni et al. 2002). Pubertal delay can occur in those who develop AN prior to completion of puberty. In girls, primary or secondary amenorrhea is common and usually follows weight loss but has been shown to precede weight loss in 20% of cases (Golden et al. 1997). Levels of luteinizing hormone, follicle-stimulating hormone, and estradiol are low, often in the prepubertal range. In males, testosterone levels can be low. In addition to suppression of the hypothalamic-pituitary-gonadal axis, hypothalamic dysfunction is evidenced by disturbances in satiety, difficulties with temperature regulation, and inability to concentrate urine. There is activation of the hypothalamic-adrenal axis with high levels of serum cortisol. The low T3 (triiodothyronine) syndrome or sick euthyroid syndrome, is caused by an adaptive response to malnutrition or chronic illness and is frequently seen. Disturbances in thyroid function resolve with nutritional rehabilitation and should not be treated with thyroid replacement hormone. A serum 25-hydroxyvitamin D level that is below 30 ng/mL indicates vitamin D insufficiency and requires treatment to replenish vitamin D stores.
Musculoskeletal System
Because adolescence is a critical time for accrual of peak bone mass, reduced bone mineral density for age is a serious long-term complication of AN. It occurs in both boys and girls (Misra et al. 2008) and is associated with increased fracture risk even after patients recover from the eating disorder (Lucas et al. 1999; Vestergaard et al. 2002).
Hematological System
In patients with eating disorders, suppression of the bone marrow leads to leukopenia, anemia, and thrombocytopenia (Misra et al. 2004). Anemia is usually secondary to bone marrow suppression but may also be due to dietary deficiency of vitamin B12, folate, or iron. The erythrocyte sedimentation rate is usually low secondary to decreased hepatic production of fibrinogen. The presence of an elevated sedimentation rate should arouse suspicion for another diagnosis.
Neurological System
The major neurological complications of eating disorders are syncope, seizures (secondary to electrolyte disturbances), and structural brain changes noted on imaging studies (Golden et al. 1996; Katzman et al. 1996). Muscle weakness and a peripheral neuropathy can also occur. Volume deficits of both gray and white matter have been identified in low-weight patients with AN, and neuropsychological testing has demonstrated impairment of attention, concentration, and memory, with deficits in visuospatial ability. These abnormalities improve substantially or disappear entirely with weight restoration.
Differential Diagnosis
The differential diagnosis of an eating disorder in a child or adolescent includes a variety of medical and psychiatric conditions that can be responsible for the presented symptoms. An outline of the differential diagnosis is shown in Table 3–5. It is important to exclude any other gastrointestinal conditions, such as inflammatory bowel disease or celiac disease, that can lead to pain and discomfort related to eating, weight loss, and growth retardation. However, it is also possible for an eating disorder to coexist with another condition.
Specific Eating Disorder Diagnosis and Associated Problems in Children and Adolescents
Anorexia Nervosa
Peak age at onset for AN is during mid-adolescence (ages 13-15 years), but children as young as 6-7 years may present with the classic syndrome. In older age groups, approximately 10% of patients with AN are male, but in those younger than age 14 years, one in six is male (Pinhas et al. 2011). Core features of AN include restriction of energy intake, leading to low body weight for age, sex, and development; fear of gaining weight or of becoming fat; and disturbance in the way in which one’s body weight or shape is perceived. Children and younger adolescents frequently do not endorse fear of gaining weight or body image dissatisfaction, but with revisions to DSM-5, reliance on identifying behaviors that interfere with weight gain improves diagnostic utility in younger patients. In DSM-5, amenorrhea has been eliminated as one of the required diagnostic criteria for AN.
Medical conditions Inflammatory bowel disease Malabsorption: cystic fibrosis, celiac disease Endocrine conditions: hyperthyroidism, Addison’s disease, diabetes mellitus Collagen vascular disease Central nervous system lesions: hypothalamic or pituitary tumors Malignancies Chronic infections: tuberculosis, HIV Immunodeficiency Psychiatric conditions Mood disorders Anxiety disorders Somatization disorder Substance use disorders Psychosis |
The medical findings associated with AN in children and adolescents are similar to those in adults, with a couple of exceptions. First, children and adolescents may become medically compromised much more rapidly than adults because of reduced nutritional reserves and increased metabolic demands for growth and development. Thus, significant medical complications can occur with a smaller relative amount of weight change or in the context of rapid weight loss. Second, certain complications such as growth retardation, interruption of puberty, and interference with peak bone mass acquisition and brain development have a greater impact in children and adolescents and are potentially irreversible. For children and adolescents with AN, ongoing medical monitoring in the primary care practitioner’s office every 1-2 weeks is essential to ensure continued weight gain and to monitor for medical stability.
Bulimia Nervosa
Peak age at onset of BN is in late adolescence or early adulthood; however, BN does occur in children younger than age 14 years, and there is evidence that the age at onset for BN is decreasing (Favaro et al. 2009; van Son et al. 2006). Comorbidity of BN with affective disorders, anxiety disorders, personality disorders, and substance use disorders is high. The core features of BN include recurrent episodes of binge eating and recurrent compensatory behaviors (vomiting, laxatives, diuretics, fasting, exercising) to prevent weight gain, both occurring on average at least once a week for 3 months. The diagnosis of BN should be considered for any adolescent with weight and body image concerns and marked fluctuations in weight. On physical examination, particular attention should be paid to the three objective physical signs of BN: parotid hypertrophy, dental enamel erosion, and Russell’s sign. Similar to AN, a multidisciplinary treatment approach is recommended. The role of the medical provider is to ensure medical stability and monitor for electrolyte disturbances associated with unhealthy weight-control practices.
Avoidant/Restrictive Food Intake Disorder
ARFID in DSM-5 is a revision and significant expansion of the DSM-IV diagnosis called “feeding disorder of infancy or early childhood.” ARFID describes some individuals who previously were given a diagnosis of EDNOS and is frequently seen in younger patients but can occur at any age. The preponderance of males with ARFID is higher than with AN. Patients with ARFID may present with clinically significant restrictive eating, leading to weight loss or lack of weight gain, growth retardation, nutritional deficiencies, reliance on tube feeding or oral nutritional supplements, and/or disturbances in psychosocial functioning. Individuals with ARFID may have sensory problems related to the taste, smell, color, or texture of food, resulting in a limited variety of food consumed. Some have a fear of swallowing or an inability to swallow food, especially solid or lumpy foods, which often follows either a personal or witnessed choking episode. Others have a fear of vomiting, with resultant food refusal. Some patients with ARFID have symptoms of depression and/or anxiety and may offer somatic complaints as to why they are not eating (e.g., “my belly hurts”). To make a diagnosis of ARFID, avoidance or restriction of food cannot be better justified by another medical condition or psychiatric disorder; however, these disorders can coexist with the eating disorder, as long as the severity of abnormal eating behaviors necessitates further clinical attention (American Psychiatric Association 2013).
Because the criteria for ARFID are new in DSM-5, there is no validated assessment tool or formalized evaluation to aid clinicians in this diagnosis.1 Recent studies have shown that the prevalence of ARFID in newly diagnosed patients presenting to adolescent medicine eating disorder programs ranges from 5% to 14% (Fisher et al. 2014; Ornstein et al. 2013; Norris et al. 2014).
Rumination Disorder
Rumination disorder is the repeated, unforced regurgitation of recently eaten food over at least a 1-month period, occurring multiple times per week and often daily. It is not associated with nausea or part of any medical illness (e.g., gastroesophageal reflux disease), but the diagnosis can be made concurrently with a medical condition, as long as the other condition is not the only reason for the behavior. Although rumination has been believed to occur most commonly in infants and individuals with developmental disabilities, it also occurs in children, adolescents, and adults of normal intelligence. It may be difficult to differentiate between regurgitation and self-induced vomiting; however, the behavior is effortless and does not serve as a method of weight control. Rumination may help to self-soothe or self-stimulate, especially in those with mental disabilities, whereas in others, it seems to be related to anxiety. The behavior can often be witnessed by clinicians (Chial et al. 2003).
Pica
The distinguishing feature of pica is the ingestion of one or more nonnutritive, nonfood substances on a continual basis for at least 1 month. The diagnosis of pica cannot be made before age 2, and the behavior cannot denote an endorsed cultural, religious, or social practice. Pica can be observed with other mental disorders (e.g., developmental disabilities, autism spectrum disorder, schizophrenia); it is only given as a separate diagnosis if the eating behavior is serious enough to warrant additional clinical management (American Psychiatric Association 2013).
Conclusion
Because eating disorders have recently become more prevalent among younger patients, it is incumbent upon pediatric health care providers to recognize the signs and symptoms and to make prompt diagnoses or refer to specialists as necessary. DSM-5 has the potential to improve clinical utility via more specific diagnostic categories.
Key Clinical Points
- When evaluating a child or adolescent with a possible eating disorder, the clinician needs to take a history from the patient and parents together, as well as from each individually.
- Skeletal growth retardation or growth in a prepubertal or early pubertal child without concomitant weight gain should be recognized as significant and akin to weight loss.
- Children and adolescents with eating disorders can become medically compromised much more rapidly than adults, and frequent monitoring for medical safety is recommended. Although amenorrhea has been removed as a diagnostic criterion for anorexia nervosa in DSM-5, it can still serve as a useful indicator of malnutrition and clinical severity.
- Although bulimia nervosa was often thought to occur primarily in older adolescents, younger patients are presenting with significant clinical symptomatology, which may represent a diagnostic continuum. The DSM-5 change in the minimum frequency criterion for binge eating and inappropriate compensatory behaviors to once weekly should help to include more patients in this category.
- Avoidant/restrictive food intake disorder is a newly articulated disorder in DSM-5 that is seen typically in younger patients, with a higher preponderance of males. More research is needed to elucidate its diagnosis, complications, and treatment.
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1 The Eating Disorder Assessment for DSM-5 (EDA-5; Sysko et al. 2015) does provide an assessment guide for ARFID, but no information about its performance is yet available. Refer to Part 3, “Assessment Tools,” in this volume for additional information.