SYMPOSIUM: PSYCHIATRY
Behavioural eating
disorders
Ben Lewis
Dasha Nicholls
Abstract
The eating disorders, anorexia nervosa (AN), bulimia nervosa (BN) and
binge eating disorder (BED), manifest through distorted or chaotic
eating and in the case of AN and BN are characterised by a morbid
preoccupation with weight and shape. Whilst recent changes in diag-
nostic criteria have changed the landscape to some extent, eating dis-
orders and partial syndromes, including avoidant/restrictive food
intake disorder (ARFID), remain relatively common and early recogni-
tion and intervention is helpful. Aetiology is multifactorial, with high
heritability. Prognosis overall is good but treatment can be long and
intensive, significantly impacting families. An integrated multidisci-
plinary approach is essential, working collaboratively with families
and young people. Psychological interventions focus on the eating
disorder, supported by medical monitoring and dietetic guidance.
Although working with families is the backbone of treatment for AN,
young people also need opportunities for confidential discussion.
For BN, family or individual approaches may be equally effective. Ev-
idence for effectiveness of psychopharmacological agents is limited in
both AN and BN. Psychological and pharmacological approaches may
both be of benefit for BED. Cases of ARFID require individualised ap-
proaches, often involving anxiety reduction. Paediatric expertise is of
particular value in the assessment and management of acute malnutri-
tion and complications secondary to disordered eating behaviours, in
the early stages of re-feeding, and in the monitoring and management
of long-term complications such as growth retardation, pubertal delay
and osteopenia. This article offers an overview of eating disorders in
children offering advice for clinicians who will undoubtedly encounter
them in clinical practice.
Keywords adolescent; anorexia nervosa; bulimia nervosa; child;
eating disorders
Introduction
The eating disorders, anorexia nervosa (AN), bulimia nervosa
(BN) and binge eating disorder (BED), manifest through distorted
or chaotic eating and in the case of AN and BN are characterised
by a morbid preoccupation with weight and shape (Tables 1e3).
Ben Lewis BA BMBCh MRCPsych is a Specialist Registrar (ST5) in Child
and Adolescent Psychiatry, Feeding and Eating Disorders Service,
Department of Child and Adolescent Mental Health, Great Ormond
Street Hospital for Children NHS Trust, London, UK. Conflicts of
interest: none declared.
Dasha Nicholls MBBS MRCPsych MD is a Consultant in Child and
Adolescent Psychiatry and Honorary Senior Lecturer, Feeding and
Eating Disorders Service, Department of Child and Adolescent
Mental Health, Great Ormond Street Hospital for Children NHS Trust,
London, UK. Conflicts of interest: none declared.
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These behaviours and the associated cognitions differentiate
eating disorders from other psychological problems associated
with abnormal eating, including feeding disorders.
Debate about feeding and eating disorders classification has
been prominent in recent years due to the process of revising the
two major classification systems for mental disorders, the Diag-
nostic and Statistical Manual for Mental (DSM) Disorder and the
International Classification of Diseases (ICD). This remains only
partly resolved as DSM-5 was published in 2013, whilst ICD-11 is
not expected to be published until 2018. The main challenge for
the DSM-5 revisions was addressing evidence that the majority of
those presenting with clinically significant eating disorders did
not fulfil diagnostic criteria for AN or BN, and were therefore
classified as have an eating disorder not otherwise specified
(EDNOS). Changes to the diagnostic criteria addressed this by
broadening the definition of AN and BN. DSM-5 also identified
BED, previously incorporated in EDNOS, as a separate diagnosis.
Additional changes in DSM-5 reframed feeding problems as
food intake disorders, and removed age related criteria (previ-
ously feeding disorders required onset before age 6 years). These
presentations are now classified as the new diagnosis of Avoi-
dant/Restrictive Food Intake Disorder (ARFID) (Table 4). In
addition to recognition and diagnosis, paediatric expertise is vital
in management of malnutrition and other acute medical com-
plications, and of long-term complications such as the impact on
growth, development and bone density.
Epidemiology
Within the Western world, eating disorders are seen regardless of
class, culture and ethnic group. Increasingly eating disorders are
recognised as a significant problem in non-western cultures too.
It appears to be increasing in frequency. Even prior to DSM-5
revisions the number of young people in the UK directly
affected by eating disorders increased significantly between 2000
and 2009. The incidence rates (per 100,000) for all eating dis-
orders were: aged 10e14, 64.5 (female) and 17.5 (male); aged 15
e19, 164.5 (female) and 17.4 (male).
Eating disorders are common
The prevalence of AN is around 0.3e0.5%, with a peak age of
onset between 15 and 18, cases steadily increasing from age 10 and
occurring in children as young as 7. High-risk populations (ath-
letes, models, ballet dancers) have higher prevalence rates. BN
tends to occur later. The prevalence is just under 1%, with a
slightly later mean age of onset with cases reported from about 12
years. It is rare before puberty and is much less likely to come to
clinical attention. Prevalence rates for BED range from around 2
e3% although unlike AN and BN, peak incidence is after adoles-
cence. BED is probably under-recognised, and in young people
may look more like loss of control over eating than true bingeing.
Eating disorders are significantly more common in
girls and young women than in boys
Female gender is the strongest risk factor for eating disorders, but
this can lead to under-recognition in boys. In AN there is marked
increase in female-to-male ratio following puberty, leading to an
overall ratio of around 11:1. For BN the ratio is around 30:1,
whilst BED is thought to be much closer to equal. Presentation is
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 SYMPOSIUM: PSYCHIATRY

Diagnostic features of anorexia nervosa (adapted from DSM-5 and ICD-10 criteria)
C AN is characterised by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat
C Weight lost or maintained at less than 85% of expected weight for height and age, or failure to make weight gain during a growth period
C Fear of gaining weight or becoming fat, even though underweight
C Disturbance in the way one’s body weight and shape is experienced (body image distortion), undue influence of body weight or shape on self-
evaluation, or denial of the seriousness of low body weight
C Weight loss is achieved by restriction of food intake and specific avoidance of ‘fattening foods’ and/or: self-induced vomiting, self-induced
purging, excessive exercise, use of appetite suppressants/diuretics
C If bingeing or purging behaviours are absent, this is known as restrictive anorexia nervosa; if present, as binge purge anorexia
C NB: Amenorrhoea has been removed by DSM-5 as a diagnostic criterion

Table 1

Diagnostic features of bulimia nervosa (adapted from DSM-V and ICD-10 criteria)
C Persistent preoccupation with eating and recurrent episodes (over a period of months) of binge eating, which are characterised by: eating a large
amount of food in a short period of time AND a sense of lack of control while eating
C Attempts to counteract the ‘fattening’ effects of food by use of compensatory behaviours such as: self-induced vomiting, purgative abuse,
alternating periods of starvation or excessive exercise, use of drugs such as appetite suppressants, diuretics, thyroid preparations or, in di-
abetics, misuse of insulin
C Psychopathology consisting of a morbid dread of fatness and setting of a target weight way below what might be considered healthy
C Bulimia nervosa may follow on from a period of anorexia nervosa, but would only be diagnosed if the patient is no longer significantly
underweight
C Bingeing and associated compensatory behaviours occurring on average weekly for at least 3 months

Table 2

precipitating factors (triggers) and perpetuating (maintaining)

Criteria for Binge eating disorder (BED) e summarised
from DSM-5
C Recurrent episodes of binge eating*
C Binges associated with at least three of:
 Eating faster than usual
 Eating alone due to embarrassment by volume of food
 Still eating large amounts despite not being hungry
 Eating until uncomfortably full
 After eating feeling depressed, guilty or ashamed
C Distress about the bingeing
C Bingeing occurs at least once a week (on average) for 3 months
C Unlike bulimia nervosa there are no recurrent and inappropriate
compensatory behaviours, and the bingeing does not occurring
only during episodes of AN or BN
* binge eating
 Eating an amount of food larger than most people would
eat in that time and in those circumstances
 A sense or feeling of a lack of control over the eating
Table 3
similar in both sexes, except for a male tendency to be concerned
over shape rather than weight.
Pathology and pathogenesis
Biological, psychological and sociocultural factors all have a role
in aetiology, which include predisposing factors (risks),
factors. Such a formulation is useful as a working hypothesis to
guide treatment interventions. Having some understanding of
how the eating disorder has come about in the young person’s
life will likely be helpful to them and their parents once it comes
to relapse prevention stage. However, symptom management
and targeting maintaining factors are the initial priority. For
example, if weight-related teasing is identified as a trigger,
addressing bullying will not in itself address the eating disorder.
By contrast, if perfectionism or athleticism are predisposing and
maintaining risk factors, these may need to be addressed during
the recovery process.
There is considerable evidence for genetic contributions to
individual symptoms, attitudes and behaviours, such as self-
induced vomiting, or perfectionism traits, which increase risk
within individuals. Puberty may also activate some aspects of
genetic heritability. Family studies, twin studies and adoption
studies, have provided heritability estimates of 60e75% for AN
and 30e80% for BN.
Understanding the aetiology of eating disorders has been
subject to definite ‘fashions’. Recent interest in the neurobio-
logical aspects is thanks largely to advances in neuroimaging,
and molecular genetics. This is not to devalue sociocultural
theories, which may be more relevant in understanding changing
epidemiology as well as individual risk within families. Culbert
et al. (2015) confirmed a number of sociocultural influences as
important: media exposure and pressures for thinness and
nonspecific personality factors including negative emotionality/
neuroticism and perfectionism. Current data support the theory

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Criteria for avoidant/restrictive food intake disorder (ARFID) e summarised from DSM-5
C A disturbance in eating or feeding resulting in a persistent failure to meet developmentally appropriate nutritional and/or energy needs
C The disturbance is associated with one (or more) of the following:
 Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
 Significant nutritional deficiency
 Dependence on enteral feeding or oral nutritional supplements
 Significant interference with psychosocial functioning
C The behaviours are not better explained by lack of available food or by an associated culturally sanctioned practice
C The behaviour does not occur exclusively during the course of An or BN, and there is no evidence of a disturbance in the way one’s body weight
or shape is experienced
C The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. If does occur in the
presence of another condition/disorder, the behaviour exceeds what is usually associated, and warrants additional clinical attention

Table 4

that psychological and environmental factors interact with and
influence the expression of genetic risk to cause eating pathol-
ogy. Conceptualising eating disorders as ‘brain disorders’ may
help overcome stigma and trivialisation these disorders
engender, but should not exclude the need to look at the obvious
social and cultural factors that play a role.
Course of the disease(s)
Eating disorders in young people present at varying levels of
severity, from mild, short duration illnesses to long-standing
chronic conditions with significant impact on quality of like,
continuing into adulthood. A clear approach to interventions based
on severity at presentation is currently lacking although there is
ongoing research in this area. Accurate diagnosis is important. In
adolescents with AN (but not BN or BED) there is evidence that
treatment with family therapy for anorexia (FT-AN) in the early
stages of illness can potentially stop illness progression.
There are three stages of recovery described during the course
of early-onset AN. In Stage 1 the eating disorder is predominant,
characterised by food preoccupation with weight and shape
concerns. Denial is common. Stage 2 brings increased asser-
tiveness, the young person expressing powerful, negative feel-
ings, often directed towards parents or professionals. It is
important to warn parents to expect this, which can last around 6
months, and herald it as part of recovery. Stage 3 brings more
age-appropriate expression of feelings. This description of the
recovery process fits neatly with the three stages of treatment
described in the empirically supported family based therapy
(FBT) that would usually be the first line.
BN tends to have a more chronic and fluctuating course.
Identification is often delayed, the nature of the disorder being
easier to conceal than AN. Often conceptualised as a coping
strategy at difficult times, and highly mood related, it is often
likened to addictive disorders. BED has been found to be rela-
tively persistent and its course similar to that of BN (DSM-5).
Outcome and prognosis
Overall, studies reveal good outcomes in adolescents with AN of
between 49% and 75% after 10 or more years follow-up,
although even with intensive treatment, recovery can be slow.
In adolescents in treatment for AN, recent studies have shown
that the proportion achieving a ‘good’ outcome was 19% at 1
year, 33% at 2 years and 64% at 5 years. For patients with
established illness, time to recovery is estimated at around 5
years. Around 10% will have a severe and enduring eating dis-
order, for which outcome is poor, with the highest mortality and
morbidity of any psychiatric disorder. There are fewer studies on
the outcome of adolescent BN, although full recovery is expected
in over 50% of patients. Once a young person has recovered from
the eating disorder, secondary psychopathology may remain;
most commonly depression or anxiety disorders.
Diagnosis
The history is best taken with the whole family together,
informing them at the start of the assessment the need for indi-
vidual time with the young person, and a physical examination.
Assessment should be regarded as the first step in treatment and
an important opportunity to engage and motivate the young
person and family. Eating disorder psychopathology can be
identified through subjective report by the young person or
parental reports of disordered eating behaviours that may not be
disclosed by the young person. Age-appropriate semi-structured
interviews are the gold standard for eliciting eating disorder
psychopathology, such as the Eating Disorder Examination
(EDE), although interview by an experienced clinician is usually
adequate. Increasingly self-report questionnaires are used as
alternative to clinical interview and there are pros and cons to
this approach.
If diagnosis remains uncertain following a thorough clinical
assessment increasing food intake often clarifies the diagnosis. If
fear of weight gain is present, active weight loss behaviours will
ensue. Similarly, a fear of swallowing will become more obvious
if certain foods are avoided or only liquids can be managed (and
therefore may indicate a diagnosis of ARFID).
A risk assessment is essential in determining ‘what
next’?
Risk assessment requires establishing current eating patterns and
a typical day’s intake, as well as specific questions about
compensatory behaviours. Current intake gives important infor-
mation regarding risk of nutritional deficiencies, and is important
in establishing how re-feeding should be tailored safely.

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Onset is often slow and insidious, with acute deterioration
expected once it comes to light. Children often stop drinking as
well as eating. A full history also addresses family risk and
protective factors, such as history of mental disorder, and the
role of the extended family. Marital relationships are only of
relevance in relation to parents’ capacity to work together in the
interests of their child. Family attitudes and beliefs about food,
weight and shape influence the way eating disorders are
addressed within the family context and may therefore affect
prognosis. Social context (housing, employment and financial
situation) and practical considerations are important for treat-
ment planning. A developmental history should include feeding
and early attachment, and premorbid personality including
perfectionism, peer relations, obsessional traits, separation anx-
iety, autism spectrum disorder traits and self-esteem.
Eating disorder psychopathology, mood and psychological
risk (e.g. suicidal ideas or self-harm) are best assessed individ-
ually although parental accounts should be sought. It is helpful to
ask about eating patterns, current intake, dietary restrictions and
rules (such as calorie limits, set eating times), compensatory
behaviours (purging, laxatives, exercise) and binge eating. Be-
liefs and preoccupation about weight and shape, concerns about
eating, fear of weight gain, self-evaluation with respect to weight
shape or eating and motivation to change are all key to making a
diagnosis and treatment plan.
Physical assessment (Table 5)
AN carries considerable serious physical risks and needs careful
monitoring. Early, robust intervention is vital to prevent or
reverse significant physical complications. In BN, physical
problems are caused by frequent vomiting and potential
excessive use of laxatives. Some of the complications of AN and
BN are due to lack of energy, some to metabolic disturbance
and some to endocrine disturbance (of hypothalamic origin)
(Table 6). Some are potentially life-threatening, whilst others are
Physical assessment
What to look for on physical examination
CWeight, height and BMI centiles (or % median BMI if
below 2nd centile) falling or below 9th BMI centile
CBradycardia and orthostatic changes in pulse or
blood pressure, based upon age-appropriate norms
CHypothermia
CDull, thinning hair
CSunken cheeks, sallow skin/skin integrity
CLanugo hair
CDelayed pubertal development for age/atrophic breasts
CPitting oedema in peripheries
CCold extremities/acrocyanosis/weak peripheral pulses
CDehydration (skin turgor, mouth, tongue)
CMuscle wasting
C Signs of bingeing/purging e.g. dental erosion, callouses on fingers
C Signs of vitamin deficiency
Table 5
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associated with long-term compromise of health. The Junior
MARISPAN guidelines (Management of really Sick Patients under
18 with Anorexia Nervosa: http://www.rcpsych.ac.uk/files/
pdfversion/CR168.pdf) provide a risk assessment framework as
a basis for determining medical risk and immediate management.
Acute physical risks will be frequently assessed and managed by
local paediatricians who commonly report a lack of confidence in
this area.
Complications unique to younger patients, due to the dynamic
nature of growth and development, are growth retardation, pu-
bertal delay or arrest, and reduction of peak bone mass. An
atypical picture needs an open mind and a thorough medical
review. Common differential diagnoses include gastrointestinal
disease (e.g.: Crohn’s), chronic disease affecting appetite and
growth (e.g.: renal failure), endocrine disorders, intracranial
pathology and other psychiatric disorders such as obsessive
compulsive disorder and depression.
Nutritional assessment should consider the past, present and
future: duration of low weight, rapidity of weight loss, menar-
cheal status, body mass index (BMI) centile (or % median BMI),
haemodynamic stability and future predicted intake (often over-
estimated). Fluid intake may be restricted (to lose weight) or
excessive (to increase weight temporarily). Rapid weight loss
(more than 1 kg/week) can cause medical instability even if the
child is not underweight. Muscle weakness and peripheral neu-
ropathy are signs of serious nutritional deficit. Local protocols
agreeing thresholds for paediatric admission are important.
Growth slows and even stops during a period of starvation.
After starvation is over, catch-up growth can occur. Our best
guess for the ‘dose’ of starvation needed to have a permanent
effect on height is 4 years before completion of growth. There are
case reports of people going through puberty in their mid to late
20s, and anecdotal accounts of menarche at nearly 50.
Between 25% and 40% of young people with AN will have
osteopenia on bone density scan. Studies have shown fracture
When to worry
C<85% BMI for age (between 2nd and 9th centile) is underweight.
<70% high risk
CPulse <50 (45 at night); BP <80/50; orthostatic changes in pulse
(>20 bpm) or blood pressure (>10 mm Hg)
C<35.0  C
C No signs of puberty at 13; premenarcheal at 15
CNormal capillary refill >3 seconds
CIf visible in older child, suggests >5%
CDifficulty sitting up from supine, and rising from squat to standing
(SUSS test) without use of hands
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 SYMPOSIUM: PSYCHIATRY
Physical complications of eating disorders
Medical complications of calorie restriction
C Cardiovascular
C ECG abnormalities e Bradycardia; T wave inversion; ST segment depression;
prolonged QT interval; dysrhythmias (SVT, VT); percardial infusions
C Gastrointestinal system
C Delayed gastric emptying; slowed GI motility; constipation; bloating; fullness;
hypercholesterolaemia; abnormal liver function (carotenemia)
C Renal
C Increased blood urea (from dehydration and reduced GFR) with
increased risk of renal stones; polyuria (from abnormal ADH secretion);
depletion of Na and K stores; peripheral oedema with re-feeding due to
increased renal sensitivity to aldosterone
C Haematology
C Leucopenia; anaemia; iron deficiency; thrombocytopenia
C Endocrine
C Sick thyroid syndrome (low T3); amenorrhoea; growth failure; osteopenia
C Neurological
C Cortical atrophy; seizures
Table 6
incidence and prevalence are higher in adolescents and young
adults with and the long-term fracture risk is around three times
that of the general population. Interpretation of reduced bone
density in AN in young people should consider the impact of
pubertal delay and growth failure on bone size.
Management
General
Eating disorder treatment in children and adolescents presents
many challenges to the clinician. Young people with AN are
terrified at the thought of eating and weight gain, and at best
ambivalent about receiving help. They may be suffering physical
effects from their eating behaviours, impairing their capacity to
think. Many patients do not accept that they are unwell, and are
often brought to treatment by family members.
Parents often experience first-line healthcare professionals as
minimising eating difficulties on initial presentation. Eating dis-
orders are unlikely to resolve on their own once they have reached
the stage of clinical presentation; a ‘wait and see’ approach is
contraindicated. Standardised weight monitoring should be
established as soon as concerns arise. Parents often report changes
in behaviour, such as social withdrawal, altered eating behaviours,
secretiveness, and ritualized and restricted activities, long before
low weight is apparent. Recent guidance mandates referral for
specialist care as soon as an eating disorder is identified, with
thresholds for routine versus urgent cases (https://www.england.
nhs.uk/wp-content/uploads/2015/07/cyp-eating-disorders-
access-waiting-time-standard-comm-guid.pdf).
Written information is important, followed by the time to
answer questions and to discuss areas of concern. Professionals
should recommend resources for parents and children on eating
disorders in the younger population (see below). Parents and
children need a clear statement about diagnosis, the likely course
and possible complications of the illness, and proposed treatment.
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Medical complications of purging
C Fluid and electrolyte imbalance
C Low K; low Na; low Cl
C Chronic vomiting
C Oesophagitis; dental erosions; oesphageal tears;
rarely rupture and pneumonia
C Use of ipecac/laxatives
C Myocardial damage; renal stones; low Ca;
low Mg; low KCO3
C Amenorrhoea
Treatment aims are to gain weight (AN), establish regular and
healthy eating, and reduce risk (all eating disorders), address
related symptoms such as anxiety or depression, and facilitate
psychological and physical recovery. It is useful to acknowledge
the cognitive effects of starvation, which intensify similar
cognitive aspects of AN. Starvation can increase obsessionality,
perfectionism, low self-esteem; and can lead to increased gastric
emptying which adds to feelings of fullness. Early weight gain in
treatment has been linked with better long-term outcomes.
The treatment evidence base in young people is limited, and
in some areas, such as BED, almost non-existent. Guidelines,
such as the NICE guidelines (National Collaborating Centre for
Mental Health, 2004, currently in the process of being updated),
are therefore largely based on consensus expert views. Treatment
must address both physical and psychological aspects of the
condition. Early intervention in a developmentally appropriate
and specialised treatment setting is likely to produce the best
outcome. A combination of integrated interventions offered by a
multidisciplinary team is needed. In most situations, parents
should be involved in treatment.
Psychological interventions
Ideally, young people with eating disorders should be treated as
outpatients. Although family work is the backbone of child and
adolescent mental health, children and adolescents should also
be offered individual appointments separate from their family or
carers. Psychological interventions need to focus on both the
eating behaviours and the young person’s thoughts about their
weight and shape, alongside clear expectations for weight gain in
the case of AN. Effective treatment requires a skilled multidis-
ciplinary team.
For AN, the first-line treatment is FT-AN, weekly or more
frequently at first, supported by regular medical monitoring and
dietetic input. What sets FT-AN apart is the central role played by
parents throughout therapy. The model supports parents being in
 SYMPOSIUM: PSYCHIATRY
charge of their child’s eating until the young person is well
enough to share responsibility. Family interventions address the
eating disorder directly, with behaviour change focussed on the
maintaining behaviours of AN. The key ethos is that parents are
seen as a resource to the resolution of the problem, and not as
causative. This work can be undertaken with the family all
together (conjoint family therapy) or with parents separately
(parental counselling); the latter may be useful when there is
high expressed emotion within the family. Individual therapy has
a role, especially for older adolescents who might be expected to
take more responsibility, or where the young person’s family is
not willing or able to participate in family therapy. The evidence
base for individual therapy is weaker. If obsessive-compulsive
features are marked, progress in treatment may be slower.
Alongside outpatient treatment, growth monitoring is
required. Regular progress reviews are important and all pro-
fessionals involved should have clear, documented roles and
responsibilities. Increasingly, more intensive methods of outpa-
tient treatment are being sought, because of questions about the
effectiveness and cost-effectiveness of inpatient treatment.
Outreach services and home based treatment teams can
contribute to decreased need for inpatient admission, while
intensive family approaches such as ‘multifamily therapy’
continue to be trialled.
For BN, empirical evidence supporting treatment options for
adolescents remains limited beyond case series. Outcomes for
family therapy for bulimia are probably comparable to individual
CBT and supportive therapy. In practice, it seems reasonable to
offer choice and assess the individual circumstances of the young
person and their willingness to involve, and likely support of,
their parents.
A 2015 review of BED from the United States suggests CBT is an
effective treatment for some people by improving specific behav-
ioural and eating domains such as reducing binge frequency and
improving binge abstinence. In the case of ARFID little research
has yet been conducted into treatment options. In general treat-
ment should be individualised on the basis of the main feeding or
eating difficulty and the factors contributing to aetiology.
Medications
The evidence base for the use of psychotropic medication in
eating disorders is relatively weak. A literature review by the co-
author (BL e unpublished data) looking at AN in adolescents
concluded there was no evidence for use of the antidepressants
selective serotonin re-uptake inhibitors (SSRIs), although the
studies identified were predominantly focussed on eating disor-
der psychopathology, and the patients were still low weight
when being treated. In AN, depression often lifts with improved
nutritional state but if not, then antidepressants, usually SSRIs
such as Fluoxetine, at this stage may have value.
Antipsychotic medications are commonly prescribed in AN.
However the same literature review concluded was that there
was no evidence for their use in the adolescent population. Not
only were there no significant positive outcomes with regards to
weight gain (or associated outcomes), of concern were metabolic
and cardiovascular side effects, which are of particular relevance
in people with malnutrition.
Occasionally nutritional supplements and hormonal support
are indicated, most often as damage limitation in chronic illness
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or during acute re-feeding. These should only be considered by
specialists in conjunction with the rest of the treating team. The
use of hormone replacement for the treatment of impaired bone
density is rarely indicated. The mainstay of treatment remains
weight gain and nutritional rehabilitation. In consultation with a
specialist multidisciplinary team, transdermal oestrogen may be
considered by way of damage limitation for severe bone deple-
tion. Improvement in bone density is not usually seen in the first
year of treatment, but after 1e2 years.
Evidence for the effectiveness of SSRIs in BN is stronger, with
high-dose Fluoxetine being the treatment of choice, although the
evidence comes from adult studies as there are no studies
exclusively in adolescents. The 2015 review of BED found
modest benefit from second-generation antidepressants for
achieving BED specific outcomes, such as reducing frequency of
binge eating episodes.
Re-feeding
The aim of re-feeding is healthy weight restoration in the least
invasive way. Wherever possible, re-feeding is done orally and at
home if safe. The child needs clear expectations about what they
need to manage. Dietetic input can be very helpful but is not
necessary in supporting parents in this regard. Typically for
weight gain aim is 0.5 kg/week for outpatients and between 0.5
and 1 kg for inpatients, weekly. This generally requires between
3500 and 7000 extra calories a week. In the past starting with a
low intake and building up to full requirements slowly had been
thought to be safest. However more recently a quicker approach
and managing medical risks should they arise has been advo-
cated. This has been backed up by a recent RCT by O’Connor
et al. (2016) looking at re-feeding adolescents with AN with a
higher energy intake than usually recommended (1200 vs 500
kcal/day). This resulted in greater weight gain but without an
increase in associated re-feeding complications, thus challenging
many re-feeding guidelines.
In hospital treatment
The decision to admit a young person with an eating disorder is
made for one of four reasons:
1. A rapid deterioration in medical state therefore requiring
medical stabilisation;
2. Marked depression, suicidal ideation or intent;
3. Other major psychiatric disturbance;
4. Intensive therapeutic support that cannot be otherwise pro-
vided in outpatient setting.
Paediatric admission works best if close links remain between
paediatric and mental health services especially if locally agreed
protocols are in place. It is helpful, and important, to distinguish
the need for medical stabilisation from re-feeding. Young people
may find it easier to eat at home, if the risks can be managed.
Psychiatric admission is a serious decision, with admissions
often lasting 4e6 months or more. The following need to be
considered prior to psychiatric admission for an eating disorder:
 Can care be provided in an age-appropriate setting and as
close to home as possible?
 Consider potential side effects of inpatient admission,
including isolation from family, increased resistance.
 Balancing indices of admission with the educational and
social needs of the child/adolescent.
6 Ó 2016 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: PSYCHIATRY
 The long-term effects on the family, including time
commitment and emotional effects of admission.
 Early consideration of transition plan to outpatient services
on discharge.
In recent years there has been increasing debate about the role
of inpatient care. The debate has tended to focus on the issue of
continuing inpatient care for weight normalisation once medi-
cally stable compared with brief admission followed outpatient
or day hospital treatment. Systematic review of the trial data has
not been helpful in settling the argument. This concluded there
was no difference in treatment outcomes between the different
treatment settings and different lengths of inpatient treatment.
However inpatient treatment was significantly more expensive
than both outpatient and day patient treatment.
In AN, once in a healthy weight range, meal plans need to be
adapted to allow for continuing growth and the nutritional de-
mands of puberty. Although weight gain is ultimately associated
with improvement in all aspects of functioning, initially it may
increase eating disordered behaviour (in an attempt to eliminate
the extra weight), anxiety and distress. Nasogastric feeding is
considered only when patients are medically compromised or are
unable to gain weight with supported meals and re-feeding
regimens.
Consent to treatment is needed and treatment against the
patient’s or parents’ wishes is always a last resort. Treatment
against consent is a highly specialised procedure requiring
expertise in the care of patients with severe eating disorders. In
England and Wales it can be done in the context of the Mental
Health Act 1984 or Children Act 1989, which allow a young
person’s refusal of treatment to be over-ridden. Parental consent
should not be relied on indefinitely, and clinicians should ensure
the legal basis for clinical action is clear. The NICE guidelines for
eating disorders recommend seeking a second opinion when
consent issues are highlighted.
Adolescents’ views of treatment
Young people with eating disorders say that without the moti-
vation to get well, they struggle to make use of treatment. They
value being listened to, and their views respected, even if ulti-
mately decisions need to be made against their wishes. When
treatment is experienced as disempowering or punitive, they
tended to reject and fight against it.
Parents’ views
We know the burden on parents/carers is high with some studies
showing around 50% suffering anxiety and around 30% with
depression. Recent work has shown that the level of burden is
perceived as higher than carers of people with schizophrenia.
What parents report finding helpful include ‘being firm and
presenting a united front, support and understanding, connecting
with other parents in similar situations’. Parent peer support
groups are very powerful in this respect. A number of in-
terventions have been developed including carer self-help in-
terventions using online or book based resources; guided self-
help over the phone, online or in person; as well as carer
workshops which people attend of a frequency ranging from
weekly to monthly. A review of carer-focussed interventions,
found improvement in carer distress and reduced burden asso-
ciated with the carer role. They also found changes in caregiving
PAEDIATRICS AND CHILD HEALTH --:-
Please cite this article in press as: Lewis B, Nicholls D, Behavioural eating disorders, Paediatrics and Child Health (2016), http://dx.doi.org/
10.1016/j.paed.2016.08.005
behaviours, such as expressed emotion, which are thought to
maintain the illness. Importantly these interventions are easy to
disseminate and deliver.
Parents want clinicians to include them in treatment, support
and guide them in their child’s care and demonstrate positive
attitudes toward them. The implications for clinicians include the
need for sensitivity to parents’ vulnerability, ensuring congru-
ence between clinicians’ and parents’ expectations about treat-
ment, and strengthening formal channels of communication.
Follow-up
In determining length of follow-up, it is important not to focus
solely on whether eating disorder symptoms are present, but to
think more broadly about the extent to which coping strategies
for the future stresses have been developed, ongoing risk and
impairment, and whether the young person is equipped for
developmental tasks appropriate to their age. In practice, young
people usually want to leave outpatient treatment before clini-
cians and their parents want to discharge them. Regular reviews
of progress and treatment are needed to inform changes in
treatment intensity. Monitoring of physical outcomes, e.g. bone
density and menstruation, may need to continue beyond psy-
chological intervention. Careful transition to adult services is
needed for chronic cases.
Prevention
The efficacy of prevention remains equivocal. A literature review
focussing on young adults (12e25 years) highlighted psycho-
education based programmes as being minimally effective in
producing behaviour change, outside of increasing knowledge.
Instead programs utilising active prevention components such as
cognitive dissonance or dissonance induction may produce
larger effects. Research indicates these interventions show
promise in changing attitudes associated with eating pathology
over the short term; however further trials involving long term
follow-up are needed to determine if lasting effects are possible.
Media literacy programs have also shown promise and incor-
porating active dissonance exercises and simple CBT seem more
effective than targeting weight and eating behaviours. In-
terventions targeting high risk female adolescents, especially
those age 15 and over, have greater impact than universal de-
livery. Interventions for children and younger adolescents family
involvement or other systemic factors need to be considered. For
example, there are concerns about the impact of anti-obesity
messages such as ‘fat is bad’ for children with a perfectionist
and literal mind. No prevention programme specifically designed
for parents has been reported in the literature to date to our
knowledge. A
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Practice points
C Diagnosis can be based on either a young person’s or carer’s
report
C Eating disorders are rarely self-limiting and when detected im-
mediate referral to specialist services is advised
C Underweight is a serious physical health issue which requires
careful risk assessment, often by, or in conjunction with, paedi-
atric services
C The most important skill is engagement and motivational
enhancement, for which a collaborative and information sharing
stance is helpful
C Most patients should be treated on an outpatient basis, provided
risks can be managed safely. Both physical and psychological
risks can increase at first with intervention
C The burden of caring for a young person with an eating disorder is
high and adequate support for parents and siblings is essential
C If inpatient psychiatric admission is deemed necessary the aim
should be for discharge to day patient or outpatient services as
soon as appropriate
8 Ó 2016 Elsevier Ltd. All rights reserved.