Treating Eating Disorders in the Pre-Adolescent Population

PRESENTED BY:

JULI AGAJANIAN, LMFT, CEDS

&

JULIA CASSIDY, RD, CEDRD

Objectives

1. Be able to identify key medical red flags that need medical/psychological attention

2. Learn creative ways that professionals can work therapeutically with a young adolescent with an eating disorder

3. Understand the importance of the team approach of professionals throughout the entire treatment of a young client

Adolescent Eating Disorder Signs & Symptoms

Eating Disorder Physical Signs & Symptoms

Excessive Clothing

Swollen face

Poor skin color

Sunken eyes

Overly defined muscles

Excessive/compulsive exercise

Lack of energy

Fainting spells

Insomnia

Menstrual Irregularities

Laxative/Diuretic Abuse

Hair Loss

Lanugo – (excessive body hair)

Determining Ideal Body Weight

Importance of “Blind Weights”

Use of adolescent growth chart

Exceptions to 25-50% goal range (i.e. loss of menstrual cycle, low heart rate, etc)

WARNING: Clients will try anything to bargain for a lower weight range!

Amenorrhea

Primary – failure of menstruation to occur by age 16. Normal puberty and menses can be delayed with even a 10-15% loss of normal body weight. 1

Secondary – menstruation stops for 3 consecutive months due to eating disorder.

Dangers of amenorrhea... 1 Usdan, L. et al – The Endocrinopathies of Anorexia Nervosa, Endocr

Pract. 2008 November; 14 (8): 1055-1063

Bone Density Scans

Osteopenia (low bone mass) can occur even in young adolescents

Bone density scans should be done if the adolescent has an eating disorder and their menstrual cycle has stopped for more than 6 months

Medical Consequences

Weight loss/gain

Low body fat or high body fat

Low muscle mass

Iron deficiency

Low heart rate

Vitamin D deficiency

Electrolyte imbalance

Constipation

Decreased metabolic rate

Heart failure

Bone density problems

Infertility

Insulin resistance and diabetes

Re-feeding Syndrome

Metabolic problems that can occur when introducing nutrition to patients who are starved or extremely malnourished

Anyone who has had low nutrient intake for 5 consecutive days is at risk of refeeding syndrome

Possible gastric discomfort - bloating, gas, fullness

Fluid shifts may cause swelling (edema) or weight

change

Start refeeding slowly

Behavioral Signs & Symptoms

Food obsession

Refusing previously enjoyed food

Small portions, skipping meals, eating slowly

Body image obsession

Hoarding food or binging

Purging (vomiting) food

Exercise obsession

Increased arguments about food

Psychosocial Risk Factors

Highly sensitive nature

Important social figures commenting on weight (Coach, trainer, Pediatricians)

Health/P.E. Class

Peer issues (breakups, teasing, bullying)

Perfectionism “gone too far”

Trauma/stress

Invalidating home environment/conflict

When more help is needed…

Under 90% of their “Ideal Body Weight” OR significant weight loss/gain

Behaviors or mood symptoms are severe/out of control

Regardless of weight, if symptoms do not improve: requires an eating disorder specialist that can recommend appropriate level of care, monitor behaviors, etc.

Refer for medical workup (labs, EKG, BMI)

Levels of Care for ED:

Outpatient (Therapist, Dietitian, M.D.)- if over 85% of ideal body weight (IBW) and fair/good motivation

Intensive Outpatient (IOP) – about 10-15 hours per week. Must be over 80% IBW with fair motivation, only needing minimal structure

Levels of Care for ED – cont’d..

Partial Hospitalization Program – (PHP) – about 40 hours per week. If over 80% and somewhat motivated, but requiring some structure to not engage in disordered behaviors

Residential Treatment Facility (RTC) – 24 hour care. If under 85%, little to no motivation and requires structure to eat/not purge

Inpatient Hospitalization – Tube feedings, intense medical stabilization. HR less than 40, low weight, severe lab abnormalities

Next Steps

Once a change in level of care is agreed upon by the team of professionals and parents, explain openly to adolescent

Parents are coached ahead of time to expect the worst and not give in to the “Eating Disorder’s” requests

Importance of the professional team providing structure and good communication

The Pre-Adolescent Therapy Process:

Therapeutic Interventions for Adolescents

Build rapport by spending time talking about anything but eating!

Thorough assessment including Motivational Interviewing techniques.

Use their own words.

Help them to connect to their pain and frustration about how their eating behaviors are affecting their life

Validation along with firm boundaries is key!

Therapeutic Interventions (cont’d)…

Sticker chart to earn privileges that will motivate them (prizes, walks, soccer, etc)

Write a story of a dog who…

Gas in a car…

Art Therapy- Draw a Bridge (by Pamela Hayes, ATR)

Draw your ED

Abstract Self Portrait

Draw what you’re feeling now (addresses Alexithymia)

Make your own coloring book (for stress reduction)

Scribble Drawing

Therapeutic Interventions (cont’d)…

Make mealtime fun

Make therapy fun (sessions outside, etc.)

Experiential techniques (Star Wars role play, Family Sculpting, etc.)

Work at building their self-esteem, and encourage parents to help do the same

Therapeutic Interventions (cont’d)…

Use fun outdoor activities to decrease exercise compulsivity (bike rides, walks with family, etc)

Have the client evaluated by psychiatrist. Medications can help, especially if child has a history of OCD

“Bed Rest” – when medically necessary. A natural consequence…

DIETARY INTERVENTIONS

Dietary Interventions

Food fears/fantasy collage

Restaurant exposure

Making peace with food

Grocery store outings

Individual food challenges

Dietary Exposure with Response Prevention

Use of ERP in decreasing anxiety around food and mealtimes – have clients/kids be involved in meal preparation as soon as it is appropriate

Menu planning/Food Logs

Kitchen orientation & Meal Preparation

Education;

Nutrition Groups → teach the clients how the nutrients work in the body, basic nutrition, mindful eating etc.

Kitchen Skills→ teach the clients to cook, bake, grocery shop, etc.

The Therapeutic Family Meal Session

Goal : to aid the family in creating and practicing supportive statements to use during mealtime with their loved one.

KEY CONCEPT:

“Food Support”

vs

“Food Police”

Dietitian and Therapist coach family on:

Point out behaviors

Focus on feelings more than food

Share your own feelings (if appropriate)

Ask how to support

Suggestions: “table games”, check-ins after dinner, distracting conversation, etc.

Empower the client

Communication Between Treatment Teams

Communication is key!

Physician should communicate to the rest of team any current medical concerns, weight expectations, and exercise limitations for the client

Dietitian should communicate about dietary guidelines and restrictions and client’s reported struggles

Therapist should stay abreast of medical and dietary issues to prevent sending mixed messages

Team should clearly spell out all guidelines to parents

Final Thoughts:

Our pre-adolescent clients need to feel heard and validated, but also contained and safe by their parents and their treatment teams.

Even when it seems that clients are not motivated to recover, we are planting very important seeds!

Questions?