Understanding eating disorders in adolescence
Intervention and treatment
Principles of treatment
- Regular doctor’s appointments
- Parents should take control of the child’s nutrition and keep the child safe from the eating disorder (e.g. prevent symptoms)
- Caregivers should supervise all nutrition and provide empathic support at meals
- Limit activity as necessary; focus of treatment must be on weight gain and symptom interruption
- Psychoeducation for parents: recommended website is Canped.ca
- Restoring and regulating nutrition is critical -– this is the only way to reverse all of the medical and psychological complications that arise as a result of inadequate nutritional intake
- In cases where a patient is deemed less than a healthy weight, recovery requires weight restoration; recovery cannot be achieved if a healthy weight is not achieved.
- Food variety should be encouraged, including high density foods and desserts (“No bad foods”; all food has a place and can be enjoyed; we do not want to maintain food phobias)
- Adolescent’s’ nutritional needs are higher than adults’
- Recovering adolescents with restrictive eating disorders will almost always need to eat more than their parents as they attempt to gain weight.
- Adolescents should target plans that include three meals and two to three snacks per day plus any additional snacks following activity/exercise.
- Patients are in a hypermetabolic state when the refeeding starts, so low weight patients often need in excess of 3,000 kcal per day, depending on baseline factors and level of activity
- How many calories do patients need in a day? Although 2100 – 2400 calories/day would be considered normal for most teenage girls to maintain weight, it takes more nutrition than this to gain weight, or for girls who are active; boys need more calories than girls
- Patients are in a hypermetabolic state when the refeeding starts; low weight patients often need in excess of 3,000 kcal per day, depending on baseline factors and level of activity
- For underweight patients, calorie counting should be avoided: parents should be encouraged to give enough food for the young person to be able to gain weight in a consistent manner and to get back to their treatment goal weight. Increasing the nutrition regularly in the early course of treatment is a requirement until weight gain occurs consistently each visit. Once the treatment goal weight has been achieved, parents can slowly decrease the added nutrition to avoid unnecessary added weight gain. At this stage, weight should remain stable and increase according to normal age requirements.
- For patients with eating disorders who don’t need to gain weight, give them enough food to maintain their weight while focusing on the goal of normalizing eating and interrupting eating disorder symptoms (such as binging and purging).
- For underweight patients, during the weight restoration phase, physical activity should be kept to a minimum
- If patients and families insist on the value of exercise, explore options with them as there are no “hard and fast” rules about exercise as long as the patient gains weight (i.e. more activity means eating more food)
- Patients may need to be removed from gym and/or school temporarily (for many anxious patients, they are too stressed at school to eat enough)
- After weight has been restored, the goal is to promote a healthy approach to active living so that health benefits, and not health costs, can be derived.
- The focus should not be exercise for weight control, but for fun and fitness (at a healthy weight).
- Depending on the patient’s overall nutritional status and history, consideration may be given to supplementing nutrition in the early course of treatment with trace vitamins and minerals, vitamin D, and calcium
- Psychotropic pharmacotherapy generally targets co-morbid symptoms of depression and anxiety (which are very common in youth with EDs)
- SSRIs are not effective in malnourished patients. SSRIs can be effective in treating anxiety and depression in weight-restored patients, although patients should be monitored for side effects.
- Limited evidence suggests that the antipsychotic medication olanzapine may be effective in improving weight gain and decreasing obsessive preoccupation with eating disorder thoughts in low weight patients with anorexia nervosa.
Team up with parents to support a young person with an eating disorder
- Help the parents understand the illness and empathize with the child
- Compare the illness to obsessive-compulsive disorder, in which the child has obsessive thoughts telling them that they are “fat” and “eating too much” and feel compelled to have symptoms directed at weight loss
- Recognize that the illness is controlling the child, the child is compelled to lose weight
- Blame the illness, not the patient or the family
- Help the parents prevent opportunity for symptoms
- Provide family therapy focused on making recovery from the eating disorder a priority in the family
- Recommend that the family have regular, supervised meals
- Help the patient cope with the eating disorder thoughts and urges, anger, stress and body image issues
- Treat and offer resources for the depression or anxiety if needed
For patients with AN:
Treatment involves raising anxiety in the family and helping parents to understand that their child will die unless she can be helped to overcome the compulsion to lose weight.
- Help the family to understand that the illness actually is driven by the brain not getting enough nutrition; the only way out of an eating disorder is to eat
- The patient must get to his or her healthy weight and stay there for a few months before the eating disorder thoughts and urges can go away
Recommended psychological therapy
- Family-Based Therapy (also known as ‘Maudsley’ family therapy)
- Parents are empowered to take charge of their child’s nutrition and to be responsible for their weight gain, within a compassionate, non-blaming and supportive environment
- Refer patients to the parent educational website, Canped.ca, for more information on this (other resources e.g. books and videos, are listed on the website)
For patients with Bulimia Nervosa, or normal weight youth with any kind of disordered eating:
- Help youth take regular snacks and meals and not restrict, purge or over-exercise (hunger tends to lead to binging)
- Try to identify specific triggers that make the eating disorder thoughts/urges worse
- Suggest that parents have supportive conversations with the child about expectations around meals and how distractions will be planned for support in a calm and loving manner
- Parents should have conversations outside of meal times, and during periods of low stress
- Structure is key: regular consistent supervised meals and snacks every day
- Help parents deflect the youth’s anger, without getting angry back
- Present yourself as being on their team and wanting to offer support, not as trying to control them
CONSIDER psychological therapy
- Individual or group Cognitive-Behavior Therapy (CBT)
- Help the child separate from, and challenge the ED thoughts
- Dialectical Behavior Therapy (DBT)
- Focused on helping the child to cope with urges without acting on them
Medications for BN
- Studies have shown that SSRIs such as higher dose fluoxetine decrease urges to binge and purge
- SSRIs may also be offered to help in targeting anxiety and/or depression symptoms
- Medications to help with sleep (melatonin, trazodone) may also be considered
- Team up with parents to support a young person with an ED
Empower and encourage parents to:
- Make weight gain a priority for underweight patients
- Help their child eat food that they don’t want to eat and are terrified of eating
- Monitor and distract them after meals, when they feel very agitated with strong urges to purge or exercise
- Increase child’s self-esteem and help them to feel better about themselves (lots of warmth, love and praise)
- Have regular supervised meals
- Stay positive and remain strong against the eating disorder
- Help the young patient maintain a healthy weight until eating disorder thoughts and urges gradually fade away
- Be both firm and empathetic
- Decrease child’s stress (e.g. may need to make changes at school; there is a high association between eating disorders and social anxiety in young people)
- Work on coping skills
Resources on how to do this can be found at Canped.ca
Family Based Therapy (FBT)
Family based therapy (FBT) is an effective evidence based treatment for adolescents with anorexia nervosa and is considered first line treatment when medically stable.
There are three phases:
- Weight restoration
- Returning control of eating back to the patient
- Focus on adolescent development & treatment termination
- The patient is treated in the outpatient setting by an interdisciplinary team.
- Blame is removed from the families, since families do not cause eating disorders.
- Parents/caregivers are empowered to refeed their child back to health.
- The eating disorder is externalized from the child to release blame directed at them.
The role of the primary care clinician:
- Function as a consultant to the parents and therapist
- Monitor for medical stability or weight gain
- Offer feedback to patients and family
- Assess for and treat any co-morbid anxiety, depression or other mental illnesses, or refer to a psychiatrist for treatment of co-morbidities
- Follow up medical visits should be frequent and regular, once a week at the beginning and depending on the severity of the illness.
- The patient should be seen individually then with the parents present.
- The goal is to see consistent weight gains of 0.5-1kg weekly and should be discussed with the parents/caregiver and patient.
- Guidance should be provided to the parents how the weight gain can be achieved
- E.g. 3 meals per day with 2 snacks, reduction in physical activity, temporarily removed from school, etc.
- Most parents have a good sense of how much to feed their child but a dietitian can get involved
- All nutrition eaten by the patient must be observed by the parents/caregivers.
- If it is not observed, it is considered not to have happened.
- Distractions are very helpful support at mealtimes and afterwards, to help distract from the intolerable eating disorder thoughts
- May require a leave of absence or reduced work hours for the parents to facilitate this at the beginning. Physicians can provide letters of support for the parents or school.
- Patients may also need special accommodations at school, or time away from school
Note: Physicians can find a handout for residents and students at “Working with Youth with Eating Disorders: what every trainee needs to know”