Eating Disorders in

Children & Adolescents:

Overview & Assessment
Laura Bauman, Ed.S, PLPC, NCC
 Introduction

• Laura Bauman, PLPC, NCC, Ed.S

• baumanl@gibsonrecovery.org
• Facebook blog: Laura Bauman, Food
Freedom Advocate
• Download my binge eating recovery guide!
• https://drive.google.com/file/d/1cMyBIb
n8WspOYk2yaWm4pKS4rP23SU_z/vie
w?fbclid=IwAR2QXakF-8UFR1qCkAU
tY1gCaxcVwTUIArqWp4mtxy9GhvAo
Ej1zs9aGOHQ
 Objectives

• Obtain knowledge on the various types of eating and feeding disorders and learn how to
decipher disordered eating from an eating disorder
• Learn how to recognize eating disorders in the child & adolescent population
• Understand the etiology and maintenance of eating disorders
• Learn about evidence-based screening and assessment tools for eating disorders in
young people
• Discover specific strategies clinicians can use to connect with those struggling
 What do you picture when
you think of the stereotype of
someone with an eating
disorder?
Eating Disorders and the Media
What Eating Disorders Actually Look Like
Eating Disorders in Young People
 A ten-year study indicated that 86% of those with an eating
disorder reported onset before the age of 20. Of that 86%:
• 10% reported onset at 10 years old or younger
• 33% reported onset between the ages of 11 and 15
• 43% reported onset between the ages of 16 and 20
 A child is 242x more likely to develop an eating disorder than
type 2 diabetes
 Eating disorders have the 2nd highest mortality rate of all
mental illnesses
 ED rates have more than doubled in past 10 years
 An individual struggling with an eating disorder is 31x more
likely to die by suicide than general population

(National Association of Anorexia Nervosa and Associated Disorders, 2020;

National Eating Disorders Association, 2008; Grygiel, 2019)
(Favaro, 2018)
 DSM-V Criteria:
Anorexia Nervosa
A.) Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age,
sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than
minimally normal or, for children and adolescents, less than minimally accepted.
B.) Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a
significantly low weight.
C.) Disturbance in the way in which one’s body weight or shape experienced, undue influence of body weight or shape on
self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Specify whether:

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in
which weight loss is accomplished primarily through dieting, fasting, and/ or excessive exercise.
Binge-eating/ purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or
purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas
 DSM-V Criteria:
Bulimia Nervosa
A.) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1.) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most
people would eat in a similar period of time under similar circumstances
2.) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or
how much one is eating)
B.) Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting;
misuse of laxatives, diuretics, or other medications; fasting, or excessive exercise.
C.) The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D.) Self-evaluation is unduly influenced by body shape and weight.
E.) The disturbance does not occur exclusively during episodes of anorexia nervosa.
 DSM-V Criteria:
Binge Eating Disorder
A.) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1.) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most
people would eat in a similar period of time under similar circumstances
2.) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or
how much one is eating)
B.) Binge-eating episodes are associated with three (or more) of the following:
1.) Eating much more rapidly than normal
2.) Eating until feeling uncomfortably full
3.) Eating large amounts of food when not feeling physically hungry
4.) Eating alone because of being embarrassed by how much one is eating
5.) Feeling disgusted with oneself, depressed, or very guilty after overeating
C.) Marked distress regarding binge eating is present.
D.) The binge eating occurs, on average, at least once a week for 3 months.
E.) The binge eating is not associated with the regular use of inappropriate compensatory behavior (e.g., purging, fasting,
excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Case Study

 Parents message you about their child who is binge eating

at home. They feel worried and are hoping for any help or
tips you might have...
 Where do you begin? What are some things you might
explore?
 Helping a Child who is struggling with Overeating
 Behaviors you might see: stealing/ hoarding
food, sneaking food, eating food any time it is
offered whether hungry or not, finishing
one’s food all the time, etc.
 Any of these can often indicate:
 A history of food insecurity
 Parental control around food and/ or seeing
parents or other caregivers diet
 The child’s own self-inflicted dieting
 Can last for a long time as the brain stays
primed for overeating after any form of food
scarcity
Shift the emphasis from
controlling what
children eat to fostering
self-regulation skills
 Examine our own biases about food
 What even is overeating?
 When did the behavior start? What function
is it serving? Is it still working for the child?
 Consider family culture around food
 How are the parents in their relationship with
food?  Does their language around food include
"good" and "bad" foods?  Do they have food
rules they push on the child?

When we don’t trust that food will always be available, we begin eating for survival
rather than in response to our body’s cues
 DSM-V Criteria:
Avoidant Restrictive Food Intake Disorder (ARFID)
A.) An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the
sensory characteristics of food; concern about aversive consequences of eating as manifested by persistent failure to
meet appropriate nutritional and/ or energy needs associated with one (or more) of the following:
1.) Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
2.) Significant nutritional deficiency
3.) Dependence on enteral feeding or oral nutritional supplements
4.) Marked interference with psychosocial functioning
B.) The disturbance is not better explained by lack of available food or by an associated culturally sanctioned
practice.
C.) The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa,
and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
D.) The eating disturbance is not attributable to a concurrent medical condition or not better explained by another
mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of
the eating disturbance exceeds that routinely associated with the condition or disorder , the severity of the eating
disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical
attention.
 DSM-V Criteria:
PICA
A.) Persistent eating of nonnutritive, nonfood substances over a period of at least 1
month.
B.) The eating of nonnutritive, nonfood substances is inappropriate to the
developmental level of the individual.
C.) The eating behavior is not part of a culturally supported or socially normative
practice.
D.) If the eating behavior occurs in the context of another mental disorder (e.g.,
intellectual disability, autism spectrum disorder, schizophrenia, or medical condition
such as pregnancy), it is sufficiently severe to warrant additional clinical attention
DSM-V Criteria:
Rumination Disorder
A.) Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may
be re-chewed, re-swallowed, or spit out.
B.) The repeated regurgitation is not attributable to an associated gastrointestinal or other
medical condition (e.g., gastroesophageal reflux, pyloric stenosis).
C.) The eating disturbance does not occur exclusively during the course of anorexia
nervosa, bulimia nervosa, binge eating disorder, or avoidant/ restrictive food intake
disorder.
D.) If the symptoms occur in the context of another mental disorder (e.g., intellectual
disability or another neurodevelopmental disorder), they are sufficiently severe to warrant
clinical attention
 DSM-V Criteria:
Other Specified Feeding or Eating Disorder (OSFED)

This category applies when symptoms characteristic of a feeding or eating disorder cause
clinically significant distress or impairment in social, occupational, or other important areas
of functioning predominate but do not meet the full criteria for any of the disorders.
Observable Signs in Children & Adolescents
• Significant weight gain or loss, or failure to gain weight according to growth pattern
• Low blood pressure
• Low body temperature/ Cold intolerance
• Low heartrate
• Amenorrhea/ Delayed puberty
• Complaints of nausea, stomachaches, bloating, or constipation
• Complaints of dizziness, weakness, or fatigue
• Swollen salivary glands
• Dry, pale skin
• Fine hair growth on body and thinning hair on head
• Brittle nails, blue nail beds
• Development of perfectionistic tendencies/ all-or-nothing thinking
 Suppose you had a student show up with some of
these signs. How might you approach the situation?

(Bauslaugh & Dixon)

Eating Disorders can serve many functions
 A sense of control
 A way to privately be out of control
 A way for numbing emotions
 An attempt to keep oneself from growing up and/ or maturing sexually
 A coping mechanism for anxiety, depression, or other emotional
distress
 A form of self-punishment or self-harm
 A response to trauma to feel grounded and safe
 A way to replay old patterns from childhood as a means of seeking
connection, avoiding waste, or secrecy around eating
 An escape from boredom, dissatisfaction, or constant chatter in your
head
 A power struggle one feels they can actually win

(Sarah Dosanjh, 2020)

 When might Children & Adolescents be at Risk?
Major life Sports where much
Family history of
transitions (e.g., emphasis is placed
eating disorders or
new school, on shape and
disordered eating
puberty) weight

Negative affect; Obsessive-

The LGBTQ+ depression, anxiety, compulsive or
population ager, stress, perfectionistic
loneliness tendencies

Difficulty
A sense of lack of Troubled personal
expressing
control in life relationships
emotions

History of bullying
and/ or trauma
(AllCEUs Counseling Education, 2021; Waterhous, 2019)
Case Study:
The mother of a 13-year-old at your school suspects that her daughter is restricting food intake and
has begun purging. The student adamantly denies any weight or shape concerns although you note
she has recently been complaining of nausea, stomachaches, bloating, and constipation. Which of
the following is true regarding adolescents with eating disorders? (Check all that apply.)

 Individuals with eating disorders may not recognize that they are ill and/or may be ambivalent
about accepting treatment.

 The parenting style of the mother is usually a primary cause of the eating disorder.

 Family based therapy will not work when there is family conflict.

 When parent and adolescent report different eating behaviors, you should always believe the
adolescent.
Eating Disorder Development
 Etiology of an Eating Disorder
“Genetics loads the gun;
environment pulls the trigger.”

 Genetic traits predisposition

 Competitiveness, perfectionism, compulsiveness,
impulsivity, avoidance, neuroticism, anxiety, low
frustration tolerance

 Triggered by environmental factor

 E.g., trauma, bullying, diet culture, media, family
pressure/ diet talk, stress, sports and activities with a
weight focus, overt parental control during
developmental stages, poverty, etc.

Laura L. Hill & Marjorie M. Scott (2015): The Venus Fly Trap and the Land Mine: Novel Tools for Eating Disorder
Treatment, Eating Disorders: The Journal of Treatment & Prevention
REGULATIO
N
(MacLean, et. al., 2011)
The Impact of
Diet Culture
 Diet Culture
 A system of beliefs that values weight, shape,
and size over health and wellbeing
 Promotes weight loss as a means of attaining
higher status
 Demonizes certain ways of eating and elevates
others
 Assigns hierarchical value to bodies
 Drives one from their values and persuades to
conform to external commands
 Glorifies thinness
 Influences unrealistic and many times
unhealthy body goals such as “thigh gap,” flat
tummy, anti-cellulite, etc.
 Evidence suggests that public
health policies addressing
overweight and obesity may
inadvertently promote weight
stigma and play a significant
role in the development of
eating disorders (NEDC, 2017)

 How can we confront this

 “Diet culture encompasses all the messages that
tell us that we’re not good enough in the bodies we
have, and we’d be more worthwhile and valuable
if our bodies were different. Our culture is SO
embedded with body and weight-centric messages
that they’re sometimes imperceptible. Diet culture
is deeply ingrained in our everyday existence and
prevents us from living our most full and
meaningful lives. To break away from diet culture,
we need first to expose it, then find alternative
ways to feel connected to ourselves, each other,
and the world in a way that moves away from
defining our worth according to our body shape,
weight or appearance.”

– Fiona Sutherland
 Avoid getting into a battle of wills or threatening
to take away the ED behavior(s)

How Not to Refrain from saying anything about weight and

shape
comfort a child
struggling with Avoid discussing your own weight or eating
habits
disordered eating:
Refrain from criticizing, praising, or judging food
choices

Never give advice about weight loss, exercise, or

eating patterns
Excerpt from Helping Children Develop a Positive Relationship with
Food: A Practical Guide for Early Years Professionals

“Someone offers you a cookie. Even if you are planning to take one, you might still say, ‘I shouldn’t.’
Let’s examine this response. By saying, ‘I shouldn’t,’ you are implying that it is wrong to take the
cookie. By taking it anyway, you imply that it is so tempting, you can’t resist.
Thinking back to the concept of self-regulation, we know that a positive relationship with food is one
where a child (or adult) eats in response to their body’s signals. If an adult uses language that implies
guilt (‘naughty but nice’) or demonstrates eating decisions that contradict their initial intentions
(‘oh…go on, then!’), they are not demonstrating self-regulation with eating. More than that, they are
modeling guilt in relation to eating and framing that food as something both bad and desirable. The
cookie becomes laden with moral and emotional meaning.
If you are offered a cookie and say, ‘Yes, please,’ all a watching child will learn is that you wanted a
cookie. If you say, ‘No, thank you,’ they will learn that you didn’t want a cookie. Either of these is fine --
whether or not you accept the cookie is immaterial. But as soon as words like ‘shouldn’t’ or ‘naughty’
are used, children will begin to absorb a sense that sweet, calorific foods have a specific status and
are mixed up with complex feelings about the self.”

(Kingsley, 2017)
Helping Children develop a Healthy Relationship
with Food
 Caregivers/takers decide the what and when
 Children decide the whether and how much

Ex: If a kid skips lunch, they are going to notice they

might feel more hungry, or ravenous in the afternoon,
maybe not even making it until snack time.
The likely result? They remember this and eat lunch the
next day.

“We need children to be eating because their bodies tell

them to, rather than in response to the adults around
them.” – Jo Cormack (2018)
(Kingsley, 2017; Satter)
 Allowing Children to be the Bosses of their Bodies
 Controlling feeding practices hampers a
child's ability to self-regulate
 Controlling feeding behaviors might look
like:
 Pressuring child to eat/ “clean plate club”
 Allowing some foods & not allowing others
 Force-feeding or limiting food intake
 Persuasion, incentivization
 Allowing children to be the boss is not about
letting them eat whatever whenever; adult
sets structure & content. It is about helping
children listen to their bodies/ eat in response
to internal cues (Cormack, 2018)
 Help Parents & Caregivers Understand how they can
help kids during mealtimes:
 Ensuring children have access to the foods they need
 Nurturing conversation
 Building social skills
 Helping children think of one another
 Maintaining a relaxed and positive atmosphere
 Modeling honoring body’s cues
 Ex: “My tummy is rumbling; It will be snack time soon and I am ready for my fruit!”
 Turning down seconds at lunch, stating, “No thank you, I can tell my stomach doesn’t
have any more room because I do not have any hungry feelings anymore.”
 “I am not sure about how this tastes…maybe I will like it next time I try it!”
 Remembering that eating is the child’s job (Cormack, 2018)
Assessment & Screening
 Consider Screening if

 Change in daily behaviors  Signs of physical deterioration (brittle

 Change in personality hair & nails, dry, cold skin, etc.)

 Isolation/ Withdrawing from normal  Loss of energy

activities  Lack of emotional display and/ or
 Difficulty concentrating irritability and outbursts

 Excessive exercise
 Significant weight changes
 Avoiding atmospheres where food is
present
 Preoccupation with weight, food facts,
meal rituals
 SCOFF
Answering "yes" to two or more of the following questions indicates a possible eating
disorder:

 Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?
 Do you worry you have lost Control over how much you eat?
 Have you recently lost more than One stone [~14 lbs] in a 3-month period?
 Do you believe yourself to be Fat when others say you are too thin?
 Would you say that Food dominates your life?

You might also ask:

Over the past four weeks, to what extent have your concerns about your weight/ shape or eating behaviors
interfered with your schoolwork, social life, or caused you to have bad feelings about yourself?
(Morgan et al., 1999)
 Screenings

 Eating Attitudes Test (EAT-26) *ch-EAT for ages 8-13

 Garner et al., 1982

 Eating Disorder Examination Questionnaire, adolescent (EDE-A)

 Fairburn & Beglin, 2008

 Questionnaire on Eating and Weight Patterns-5 (QEWP-5) *QEWP-C for children

 Yanovski, 1994
 Structured Clinical Interview
1.) Binge Eating (amounts & types, frequency, objective vs. subjective)
2.) Purging/ compensatory behavior (self-induced vomiting, laxatives, diet pills, compulsive exercise, fasting)
3.) Eating Patterns and Dietary Restriction (frequency & timing b/w meals & snacks, food avoidance, rituals & rules)
4.) Weight Hx (current weight, lowest & highest weights, pattern of weight fluctuation)
5.) Body Image (body dissatisfaction, influence of weight & shape on self-evaluation, preoccupations, rituals, body
checking & avoidance behaviors)
6.) Previous Treatment (level of care, age, length of treatment, individual and/ or group therapy, medications)
7.) Family Hx (medical & psychiatric)
8.) Cultural Considerations (can provide insight into ideal body type, importance of food, etc.)
9.) Social and Developmental Hx (childhood, adolescent, adult social & academic functioning, abuse & trauma)
10.) Current Psychosocial Functioning and Impairment (relationships, occupational, academic, leisure time &
hobbies, impulsivity)

(Robinson, 2019)
Treatment Strategies
Levels of Care

 Inpatient
 Residential
 Partial Hospitalization (PHP)
 Intensive Outpatient (IOP)
 Outpatient
 Eating disorders
require a
What can we do in the school setting? multidisciplinar
y approach
 Educate yourself on eating disorders, treatment strategies, and resources
 Express your concern to the student
 Invite student to share their thoughts, feelings, and experience, & LISTEN
 Discuss the importance of being seen by a health care provider
 Inform student that you are obliged to inform their parents and school team
 Help parents:
 Understand EDs as a means of coping
 Medical stabilization & weight restoration
 Normalize eating and omit diet culture language & food rules at home
 Interrupt symptoms such as bingeing & purging
 Teach kids to be the boss of their own body

(Bauslaugh & Dixon)

Topics for each Developmental Stage

Regardless of
developmental
level, dispelling the
myths of diet
culture & using a
Health At Every
Size approach is
crucial

(NEDC, 2016)
  Family-Based Treatment (FBT) / Maudsley Approach
Anorexia Nervosa  Enhanced Cognitive Therapy (CBT-E)
 Acceptance and Commitment Therapy (ACT)
 Cognitive Remediation Therapy (CRT)
  Dialectical Behavior Therapy (DBT)
 Enhanced Cognitive Therapy (CBT-E)
Binge-type Eating  Interpersonal Therapy

Disorders  Integrative Cognitive-Affective Therapy for Bulimia Nervosa

(ICAT-BN)
 BED-focused self help
 Acceptance and Commitment Therapy (ACT)
Avoidant/ Restrictive  Exposure Therapy
Food Intake  Cognitive Behavioral Therapy

Disorder (ARFID)  Dialectical Behavior Therapy

  Correcting nutrient deficiencies
Pica  Medication often required for individuals with special needs
  Changes in posture before and after meal
 Removing distractions while eating
Rumination  Reducing stress while eating

Disorder 

Working on triggers
Learning new behaviors for stomach muscles
 Psychotherapy
 Other Specified
 Use treatment most resembling the diagnosis
Feeding or Eating (also including each unique aspect to meet the client’s specific
Disorder (OSFED) needs)
 Some eating disorders are egosyntonic

Shame and stigma

Common Not wanting to give up the function

eating disorder serves
Barriers
Being entrenched in diet culture

Facing familial or other external

pressures
Expanding other life areas

As individual expands other life areas,

eating disorder takes up less space, thus
becomes less important

Eating Disorder Family School Hobbies

 The Spiral of Healing

 A compassionate way to envision one’s recovery journey

 Reminder that progress does not move in a straight line
 Returns to previous patterns are not setbacks
 When the forward progress loops around an old pattern
of thinking or behavior, explore it with curiosity
 Use these “old pattern” loops to examine one’s self-talk
and consider what is needed for self-care
Key Factors to Keep in Mind
 Individuals may not acknowledge their illness
 Validate individual’s need/ desire for control
 Do not threaten to take away the eating disorder behaviors; remind client they are in control and get to
choose whether to use
 Keep in mind you can’t take away the ED behaviors without replacing with something else
 Important to trust the concerns of parents or guardians
 Emphasize that no one chose or caused the eating disorder
 Therapeutic relationship determines client’s willingness to explore behavior patterns,
consider altering eating behaviors, and disclose accurate information
 Malnourished brain cannot take in information like a healthy brain
 May see irritability, confusion, etc.
 Adaptations regarding exams & assignments sometimes needed

(Academy for Eating Disorders, 2016; AllCEUs Counseling Education, 2021)

Motivation determinants

 Counselor-client bond, sense of safety

 Sense of self-efficacy and empowerment
 Client’s having a part in selecting goals for treatment
 Cost/ benefit of current behaviors

(AllCEUs Counseling Education, 2021)

FREE Resources and Trainings!
 Missouri Eating Disorders Council “360 Trainings”
 Visit http://www.moedc.org/training/online-training/ to obtain access

 CBT-E for Eating Disorders

 https://www.cbte.co/self-help-programmes/digital-cbte/#:~:text=CREDO%20are
%20developing%20a%20digital%20form%20of%20CBT-E%2C,in%20the
%20early%20stages%20of%20an%20eating%20disorder.
 Email cbte.training@gmail.com to request access

 Balance Eating Disorder Centre – free virtual trainings!

 Contact webinars@balancedtx.com to get added

 Receive monthly eating disorder trainings straight to your inbox!

 Contact 360EDtraining@wustl.edu to get added

 Ellyn Satter Institute Resources

 https://www.ellynsatterinstitute.org/resources-and-links-professionals/
 Being Me -Promoting Healthy
Body Image resource for
elementary and middle schoolers
 https://healthyschoolsbc.ca/media/22366/asbc-
being-me.pdf

 Ideas for how to incorporate body positivity &

regular eating into lessons across various
subjects & grade levels
 Ideas for the classroom
 Handouts and resources
 Quizzes & education for kids on diet culture
 Age-appropriate assessments
 Example letter/ memo for parents
Specifically for
Parents:

 NEDA Parent Toolkit

 https://www.nationaleatingdis
orders.org/sites/default/files/T
oolkits/ParentToolkit.pdf

 Maudsley Parents – for

parents of children with EDs
 http://www.maudsleyparents.o
rg/
Specifically for Children & Teens

 NEDA text line: (800) 931-2237

 NEDA calls: (800) 931-2237

NEDA chat:
https://vue.comm100.com/visitorside/
html/chatwindow.8c5433a901d191e25
cca73a9250f7a35daeeaf66.html?siteId
=144464&planId=467
 Recommended Readings for Restrictive Eating Disorders
For client:
For clinician/ family:
 Recommended Readings for Binge Eating
For client:
For clinician:
Recommended Readings for All
For Teachers & other School Professionals

 NEDC Eating Disorders in Schools manual

 https://www.nedc.com.au/assets/NEDC-Resources/NEDC-
Resource-Schools.pdf

 Resources for Clinicians specific to Pediatric care

 https://www.hsph.harvard.edu/striped/webinar-resources/

 Purdue Heathy Body Image Lesson Plan for High Schoolers

 https://www.extension.purdue.edu/extmedia/cfs/cfs-737-w.pdf
 Get Involved
 Missouri Eating Disorders Association
 Missouri Eating Disorders Council
 National Eating Disorders Association
 The Alliance For Eating Disorders Awareness
 Multi-service Eating Disorders Association
 National Eating Disorder Information Centre
 Academy for Eating Disorders
 AEDRA Eating Disorder Centre
 National Association of Anorexia Nervosa and Associated
Disorders