Doi:10.1016/s1054-139x(03)00326-4

JOURNAL OF ADOLESCENT HEALTH 2003;33:496 –503 Position Paper of the Society For Adolescent Medicine Eating disorders are complex illnesses that are affect- height and weight gain during normal puberty, the ing adolescents with increasing frequency They absence of menstrual periods in early puberty along rank as the third most common chronic illness in with the unpredictability of menses soon after men- adolescent females, with an incidence of up to 5% arche, limit the application of those formal diagnostic Three major subgroups are recognized: a re- criteria to adolescents. Many adolescents, because of strictive form in which food intake is severely limited their stage of cognitive development, lack the psy- (anorexia nervosa); a bulimic form in which binge- chological capacity to express abstract concepts such eating episodes are followed by attempts to mini- as self-awareness, motivation to lose weight, or feel- mize the effects of overeating via vomiting, catharsis, ings of depression. In addition, clinical features such exercise, or fasting (bulimia nervosa); and a third as pubertal delay, growth retardation, or the impair- group in which all the criteria for anorexia nervosa or ment of bone mineral acquisition may occur at sub- bulimia nervosa are not met. The latter group, often clinical levels of eating disorders Younger called “eating disorder not otherwise specified” or patients may present with significant difficulties EDNOS, constitutes the majority of patients seen in related to eating, body image, and weight control referral centers treating adolescents Eating disor- habits without necessarily meeting formal criteria for ders are associated with serious biological, psycho- logical, and sociological morbidity and significant emy of Pediatrics has identified conditions along the mortality. Unique features of adolescents and the spectrum of disordered eating that still deserve at- developmental process of adolescence are critical tention in children and adolescents It is essential considerations in determining the diagnosis, treat- to diagnose eating disorders in the context of the ment, and outcome of eating disorders in this age multiple and varied aspects of normal pubertal group. This position statement represents a consen- growth, adolescent development, and the eventual sus from Adolescent Medicine specialists from the attainment of a healthy adulthood, rather than United States, Canada, United Kingdom, and Aus- merely applying formalized criteria.
tralia regarding the diagnosis and management ofeating disorders in adolescents. In keeping with thepractice guidelines of the American Psychiatric As- Medical Complications
sociation and the American Academy of Pediat- No organ system is spared the effects of eating rics this statement integrates evidence-based toms occurring in adolescents with an eating disor-der are primarily related to weight-control behaviorsand the effects of malnutrition. Most of the medicalcomplications in adolescents with an eating disorder improve with nutritional rehabilitation and recovery Diagnostic criteria for eating disorders such as those from the eating disorder, but some are potentially found in the Diagnostic and Statistical Manual of irreversible. Potentially irreversible medical compli- Mental Disorders, Fourth Edition (DSM-IV) are cations in adolescents include: growth retardation if not entirely applicable to adolescents The wide the disorder occurs before closure of the epiphyses variability in the rate, timing and magnitude of both Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010 vomiting structural brain changes noted on Table 1. Indications for Hospitalization in an Adolescent
cerebral tomography, magnetic resonance imaging and single-photon computerized tomography stud- One or more of the following justify hospitalization: 1. Severe malnutrition (weight Յ75% average body weight predisposing to osteoporosis and increased fracture 2. Dehydration3. Electrolyte disturbances (hypokalemia, hyponatremia, risk. These features underscore the importance of immediate medical management, ongoing monitor- ing and aggressive treatment by physicians who understand adolescent growth and development.
Severe bradycardia (heart rate Ͻ 50 beats/minute Hypotension (Ͻ 80/50 mm Hg)Hypothermia (body temperature Ͻ 96° F) Orthostatic changes in pulse (Ͼ 20 beats per minute) or Nutritional disturbances are a hallmark of eating disorders and are related to the severity, duration, and timing of dysfunctional dietary habits. Signifi- cant dietary deficiencies of calcium, vitamin D, fo- late, vitamin B12 and other minerals are found 10. Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.) 11. Acute psychiatric emergencies (e.g., suicidal ideation, acute protein, calcium and vitamin D are especially impor- tant to identify, since these elements are crucial to 12. Comorbid diagnosis that interferes with the treatment of the eating disorder (e.g., severe depression, obsessive Moreover, there is evidence that adolescents with compulsive disorder, severe family dysfunction) eating disorders may be losing critical tissue compo-nents (such as muscle mass, body fat, and boneminerals during a phase of growth when affective disorders (especially depression) of 50%– dramatic increases in these elements should be oc- 80% for both anorexia nervosa and bulimia nervosa; curring. Detailed assessment of the young person’s a 30%– 65% lifetime incidence of anxiety disorders nutritional status forms the basis of ongoing man- (especially obsessive-compulsive disorder and social phobia) for anorexia nervosa and bulimia nervosa; a12%–21% rate of substance abuse for anorexia ner-vosa; and a 9%–55% rate for bulimia nervosa. Esti- Psychosocial And Mental Health Disturbances mates of comorbid personality disorders among pa- Eating disorders that occur during adolescence inter- tients with eating disorders range form 20% to 80% fere with adjustment to pubertal development All patients should therefore be carefully and mastery of developmental tasks necessary to evaluated for comorbid psychiatric conditions.
becoming a healthy, functioning adult. Social isola-tion and family conflicts arise at a time when familiesand peers are needed to support development Issues related to self-concept, self-esteem, Eating disorders are associated with complex biopsy- autonomy, and capacity for intimacy should be ad- chosocial issues that, under ideal circumstances, are dressed in a developmentally appropriate and sensi- best addressed by an interdisciplinary team of med- tive way Given that adolescents with eating ical, nutritional, mental health and nursing profes- disorders usually live at home and interact with their sionals who are experienced in the evaluation and families on a daily basis, the role of the family should treatment of eating disorders and who have expertise be explored during both evaluation and treatment with particular attention given to the issues Various levels of care should be available to of control and responsibility for the adolescent adolescents with eating disorders (outpatient, inten- sive outpatient, partial hospitalization, inpatient hos- Studies emphasize a frequent association between pitalization or residential treatment centers) eating disorders and other psychiatric conditions.
Factors that justify inpatient treatment are listed in Important findings include a lifetime incidence of JOURNAL OF ADOLESCENT HEALTH Vol. 33, No. 6 the Society for Adolescent Medicine in 1995 are recurrence, crossover (change from anorexia nervosa in agreement with the recent revision of the Ameri- to bulimia nervosa or vice versa) and comorbidity, can Psychiatric Association practice guidelines for treatment should be of sufficient frequency, intensity the treatment of patients with eating disorders and duration to provide effective intervention.
the recently published American Academy of Pedi- Mental health evaluation and treatment is crucial atrics policy statement on identifying and treating for all adolescents with eating disorders. The treat- eating disorders and the American Dietetic As- ment may need to continue for several years To sociation position on nutrition intervention in the date, there is a paucity of research on the treatment treatment of eating disorders In children and of adolescents with anorexia nervosa. Evidence- adolescents, physiologic or physical evidence of based research supports family-based treatment for medical compromise can be found even in the ab- sence of significant weight loss. Not infrequently, inpatient treatment becomes necessary because of Cognitive behavioral therapy is used in adults with failure of outpatient treatment. In severely malnour- anorexia nervosa but has not been evaluated in ished patients, the risk of the “refeeding syndrome” adolescents. There is some recent evidence to suggest should be avoided through gradual increase of ca- that although antidepressants are of no clinical value loric intake and close monitoring of weight, vital in promoting weight gain, fluoxetine may be helpful signs, fluid shifts and serum electrolytes (including in reducing the risk of relapse of symptoms in older adolescents with anorexia nervosa whose weight has been restored The most effective treatment for sary. Short-term nasogastric feeding may be neces- older adolescents with bulimia nervosa is cognitive sary in those hospitalized with severe malnutrition.
behavioral therapy that focuses on changing the There is no evidence to support the long- term role of specific eating attitudes and behaviors that maintain Optimal duration of hospitalization has not been been shown to reduce binge eating and purging by established, although there are studies that have 50% to 75% In addition, interpersonal psy- shown a decreased risk of relapse in patients who are chotherapy and dialectical behavior therapy discharged closer to ideal body weight compared to have also demonstrated some beneficial effect in patients discharged at very low body weight older adolescents with bulimia nervosa. Medications The overall goals of treatment are the same in a may also be helpful in older adolescents with a medical or psychiatric inpatient unit, a day program,or outpatient setting: to help the adolescent achieve co-morbid depression or obsessive or compulsive and maintain both physical and psychological The optimum treatment of the osteopenia associ- The expertise of the treatment team who work ated with anorexia nervosa remains unresolved. Cur- specifically with adolescents and their families is as rent treatment recommendations include weight res- important as the setting in which they work. Tradi- toration with the initiation or resumption of menses, tional settings, such as a general psychiatric ward, calcium (1300 – 1500 mg/day) and vitamin D may be less appropriate than an adolescent medical (400 IU/day) supplementation and carefully moni- tored weight-bearing exercise While hormone evidence suggests a good outcome for patients replacement therapy is frequently prescribed to treat treated on adolescent medicine units On a osteopenia in anorexia nervosa there are no specialized psychiatric inpatient eating disorders documented prospective studies that have demon- unit for adolescents, Strober et al showed that 76% of strated the efficacy of hormone replacement therapy patients met criteria for full recovery. This prospec- tive study had a 10 –15 year follow-up period and placement therapy can cause growth arrest in the also showed that time to recovery was protracted, adolescent who has not yet completed growth ranging from 57–79 months Smooth transition The monthly hormone-induced withdrawal bleeding from inpatient to outpatient care can be facilitated by can also be misinterpreted by the adolescent as an interdisciplinary team that provides continuity of return of normal menstrual function and adequate care in a comprehensive, coordinated, developmen- weight restoration, and therefore interfere with the tally-oriented manner. Given the rate of relapse, Many older adolescents who have had health insurance, no longer have it as young adults and Interdisciplinary treatment of established eating dis- withdraw from treatment owing to loss of coverage.
orders can be time-consuming, relatively prolonged Some insurers have limited or even reduced the age and extremely costly. Lack of care or insufficient up to which students can continue to be covered as treatment can result in chronicity with major medical dependants under their parents’ insurance. Some complications, social or psychiatric morbidity and older adolescents who have lost insurance are unable even death. Barriers to care include lack of insurance, to obtain new coverage because of limited eligibility coverage with inadequate scope of benefits, low based on the preexisting condition exclusions that reimbursement rates, and limited access to health are imposed by some insurance companies The care specialists and appropriate interdisciplinary withdrawal of treatment owing to loss of insurance teams with expertise in eating disorders, which may often occurs at an age when unemployment or be owing either to geography or insurance limita- temporary employment, without benefits, is the tions. In addition to these extrinsic barriers, patients norm; and individuals who are ages 18 through 24 and families often demonstrate ambivalence or resis- years lack insurance at a higher rate than any other tance to the diagnosis or treatment, which threatens active engagement in the recovery process.
In most insurance plans the scope of benefits for treatment of eating disorders is currently insuffi-cient. The labeling of the disorder as a purely psy- The Internet and “Pro-ana sites” chiatric illness by some insurance companies usually Approximately 49% of teenagers worldwide, have limits the ability of health care providers to meet the access to the Internet Therefore, many teenagers medical, nutritional and psychological needs of pa- are able to access health information and other tients in either the medical or psychiatric setting. In resources on the Internet. In addition to accessing addition, some insurance companies limit the num- reputable sites, adolescents also have access to web- ber of hospitalizations permitted per year, restrict the sites that provide young people with harmful con- number of outpatient visits per year, establish life- tent. Such websites include pro-anorexia (“pro-ana”) time caps on coverage, and preclude payment of and pro-bulimia (“pro-mia”) websites which are some medical practitioners. Many plans limit the devoted to the maintenance, promotion, and support number of nutrition visits to one per year and the of an eating disorder. The proliferation of “pro-ana” number of mental health visits to 6 or fewer per year.
and “pro-mia” websites is of great concern. These In addition, some treatment institutions have age websites provide young people with ideas about limit policies that negatively affect treatment and how best to starve themselves or purge and how toavoid the detection of these behaviors by clinicians.
limit access to care for older adolescents who may These websites often promote anorexia nervosa and not satisfy the age limits at the institution able to bulimia nervosa as a lifestyle choice and not as a provide the most appropriate care. The low reim- disease. The number of such sites far exceeds that of bursement rates for psychosocial services that are professional or recovery sites Professionals common among insurers result in fewer qualified should be aware of the existence of these sites and professionals being available who are willing to care their content. Patients who wish to access medical for teenagers and young adults with eating disor- information from the Internet, should be encouraged ders. Lack of compensation for care that is provided to seek out the websites of more reputable profes- by hospitals, physicians and other professionals threatens the survival of existing programs. Insur-ance reimbursement for care provided by multipledisciplines is an essential element of appropriatetreatment but is far from the norm. Comprehensive insurance coverage is important for adolescents suf- Several issues deserve further study. Examples in- fering from the full spectrum of disorders, ranging clude: (a) identification of psychosocial, psychiatric from disordered eating to those with severe and and biological risk factors that are associated with chronic eating disorders. Treatment should be dic- eating disorders in young people; (b) the prevention tated by generally accepted guidelines and of eating disorders for adolescents who are at high should be based on clinical severity of the condition.
risk; (c) creation and validation of brief, developmen- JOURNAL OF ADOLESCENT HEALTH Vol. 33, No. 6 tally-appropriate screening tools for use by primary accomplished by a team consisting of medical,
care providers; (d) new therapeutic modalities for nursing, nutritional and mental health disci-
the treatment of osteopenia and osteoporosis in an- plines. Treatment should be provided by health
orexia nervosa (type and amount of exercise, efficacy care providers who have expertise in managing
of calcium/Vitamin D supplementation, DHEA, the complexities of adolescent eating disorders.
IGF-1 and the bisphosphonates); (e) comparison of In addition, treatment should be provided by
outcome of different treatment approaches, includ- health care providers who have expertise in
ing early, interdisciplinary outpatient models; (f) managing adolescents with eating disorders and
improved delineation of diagnostic subgroups with who are knowledgeable about normal adoles-
respect to prognosis and treatment, and in particular, cent physical and psychological growth and de-
further clarification of the EDNOS subgroup; and (g) velopment. Hospitalization of an adolescent
efficacy of psychopharmacologic agents. These stud- with an eating disorder is necessary in the pres-
ies will require collaboration of multiple disciplines ence of severe malnutrition, physiologic insta-
from numerous sites in multicenter protocols. Publi- bility, severe mental health disturbance or fail-
cation of these studies in peer-reviewed medical ure of outpatient treatment. Ongoing treatment
journals and discussion at conferences are encour-aged as a means of promoting and disseminating should be delivered with appropriate frequency,
results of such studies and collaboration.
intensity and duration until complete resolution.
6. Adolescents with eating disorders should not be
Position:
denied access to care because of absent or inad-
1. The diagnosis of an eating disorder should be
equate health care coverage. Coverage should
considered when an adolescent engages in po-
provide reimbursement for inpatient, partial
tentially unhealthy weight-control practices,
hospitalization and outpatient interdisciplinary
demonstrates obsessive thinking about food,
treatment that is dictated by the severity of the
weight, shape or exercise, or fails to attain or
clinical situation and takes into account the
maintain a healthy weight, height, body compo-
developmental needs of the patient, should en-
sition or stage of sexual maturation for gender
compass the comprehensive range of benefits
and age. An eating disorder can still be present
and providers needed, and should provide reim-
in the absence of established diagnostic criteria.
bursement at adequate levels. Adolescent health
2. Because of the potentially irreversible effects of
care providers should work with insurance com-
an eating disorder on physical, psychological
panies to define appropriate strategies for the
and emotional growth and development in ado-
management of adolescents with eating disor-
lescents, the high mortality and the evidence
suggesting improved outcome with early treat-
7. The Society for Adolescent Medicine does not
ment, the threshold for intervention in adoles-
support the content of pro-anorexia and pro-
cents should be lower than in adults.
bulimia websites and discourages the creation
3. The evaluation and ongoing management of
and dissemination of these controversial and
nutritional disturbances in adolescents with eat-
potentially dangerous sites.
ing disorders should take into account the nutri-
8. Further research is essential to address unan-
tional requirements of adolescents in the context
swered questions in the field of adolescent eat-
of their age, pubertal development, and physical
ing disorders. Research priorities include pre-
activity level.
4. Mental health intervention for adolescents with
intervention,
eating disorders should address the psycho-
exploration of the pathogenesis of early onset
pathologic characteristics of eating disorders, the
eating disorders, improvement of the current
specific psychosocial tasks that are central to
diagnostic classification system to consider the
adolescence, and possible comorbid psychiatric
unique spectrum of early-onset eating disorders
conditions. Family-based treatment should be
and the development of effective treatments for
considered an important part of treatment for
adolescent eating disorders. We also call upon
most adolescents with eating disorders.
private and public agencies to provide necessary
5. The assessment and treatment of adolescents
funding to allow for advancement of knowledge
with an eating disorder should be interdiscipli-
in the prevention, etiology, and treatment of
nary and, under ideal circumstances, is best
eating disorders in adolescents.
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