Pediatric Eating Disorders

The Children’s Hospital at Saint Francis and TulsaKids Magazine have teamed up to bring parents a series of videos and articles about important children’s health and wellness topics. You can find them under the heading PJ’s Corner in TulsaKids Magazine, along with the complete written and video interview on TulsaKids’ website. Today, we’re talking to Dr. Scott Moseman about Pediatric Eating Disorders. Scott Moseman, M.D., CEDS, is medical director of Laureate Psychiatric Clinic and Hospital’s eating disorders program.

Q: We often associate eating disorders with teenage girls with anorexia or bulimia. Can you define pediatric eating disorders, and then talk about some of the most common types?

A: Probably in the last 30-40 years, the thing that’s changed about mental health is that we see things on a developmental spectrum. Halfway through the 20^th century, the belief was that mental health issues were all due to parenting, how children were raised, or what environmental exposures they had. I think we now see that kids are born with a certain type of wiring that can be predisposed to anxiety issues, depressive issues, ADHD and other kinds of problems. We see mental health across a developmental spectrum that may or may not continue into adulthood.

Eating disorders are really stress and anxiety disorders in which the individual chooses to utilize the manipulation of food to try to take care of themselves and to try to feel in more control. Anorexia nervosa, which is a pediatric disorder, usually strikes around menarche in females, and sometimes in the early teens for males.

Bulimia, where there is binge-eating and some sort of undoing of that binge-eating, or binge-eating disorder, can certainly happen in latency-age kids, or kids probably younger than the age of 12 or 13, but that is less common.

Especially in females, the hormones that come along with puberty do make depression, anxiety and eating issues more common. But we do see eating issues in younger kids, especially regarding pediatric obesity. There can be some behavioral and binge implications in some of those younger patients.

There’s another illness called Avoidant Restrictive Food Intake Disorder, or ARFID. There is a subsection of kids, particularly young kids, who are basically extreme picky eaters. Our sensitivities are different when we are younger. I have multiple kids at home – some are more adventurous or less adventurous eaters. ARFID is really a case – again, probably together with sensory issues and some stress or anxiety issues – where there’s a huge limitation of foods. For example, kids may only eat five, six or seven foods. Sometimes, those foods don’t have the full nutrients that the patient needs, and as a result, they can have other complications.

Some of those patients will develop other eating disorders as they get older. For other patients, their sensitivities will decrease, and they may grow out of those illnesses. But they are all illnesses that need treatment. ARFID is probably more common before the teenage years, while most of the other eating disorders are more common during the teenage years.

Q: What causes eating disorders and how common are they? You mention anxiety being involved. Are eating disorders a symptom of something else?

A: That is the question that is on the mind of science a lot. A lot of times in mental health or mental illness, we do describe things phenomenologically. You’re sad, get depressed, you’re anxious – we recognize that there’s a spectrum of illnesses and different ways our brain responds to those.

I like to look at patients in a broader way. I view neurologically how my patients present. Do they have brain-stress resiliency issues? In other words, if your brain runs into a situation in which it doesn’t go exactly how you want, you respond in some way. I think we can think of people in our lives who are more anxious and would tend to respond by either shutting down or getting nervous, or by trying to manipulate and fix things. On the other hand, some people are very laid back and easy-going. They take things as they come. I do think some of these reactions are hard-wired into us, and that they can happen when we’re young. I think eating disorders do affect people that have brain-stress resiliency issues.

I work with Dr. Sahib Khalsa at Laureate Institute for Brain Research, and right now we are actually doing research to look at both GI systems and brain systems, especially the insula. How do the brain and body interact differently in someone who gets an eating disorder and someone who doesn’t. What might be a risk?

We know that kids who grow up with self-esteem issues, kids that grow up with anxiety – especially if they’re avoidant in their anxiety – kids that grow up with somatic illness, headaches, stomachaches and a lot of GI-oriented anxiety issues are more likely to develop something like anorexia. I think those are the questions that science is still trying to get to.

Fortunately – I have a teenage daughter myself who’s in high school. Many girls by the time they’ve entered high school have been on a diet. Many high school girls in the last 30 days have tried to restrict their eating. Rates of anorexia are still about 1 percent in females. Eating disorders in general affect 3-5 percent of people, so there’s probably some underlying issue that is relieved when they manipulate their eating. Unfortunately, that relief over time can become a problem.

Q: Do males also suffer from eating disorders?

A: Women, including young women, suffer both depression and anxiety at a higher rate than men, which is probably related to hormone and hormone-related issues. Those are probably hormones that also make women good mothers later on if they have children. There is almost a 30 percent lifetime incidence of depression and anxiety for females. The number is less for males.

However, we’re certainly seeing more pressure being put on males and males’ bodies. Also, more males are talking openly about symptoms. This isn’t just an illness that can affect females, and as a result, we’re seeing more eating disorders in males, though it’s still more common in females.

What is interesting is that in something like ARFID, there’s less sexual differences or distribution. It’s probably equally likely to happen in both. And sometimes, because ARFID can happen more commonly in people who are on the autism spectrum, there is even some leaning to males.

Q: Are younger children who have extreme food avoidance more likely in adolescence to have eating disorders like anorexia nervosa or bulimia?

A: It’s a good question. I would say that there is a subset of the population that may have body image issues, which can morph into anorexia. I think it happens. I would say it’s more common that, generally, they will develop out of it. Some still may not eat a wide compendium of foods, but it’s enough that they can exist and get their needs met.

Unfortunately, I don’t think we have good studies that show exactly what kids with ARFID are like in 10 years. That would be a good study. But I think that a fair amount of them grow out of it unless other things come along for the ride. They’ve actually chosen to manipulate food, so it might be more likely that, as they become teens, they’ll continue to do so in a different way.

Q: What’s the difference between a kid who’s a picky eater and a child who has a problem? How do parents know?

A: Anxiety exists in us as a species for a reason because it’s adaptive and it helps us survive. We know that anxiety is tied to intelligence. We know that anxiety is tied to empathy, and those are things that we want our children to have. And I think the same thing happens around eating. There are even some genetic reasons why people can be picky eaters. There’s actually one gene that can affect how certain vegetables might taste, more bitter or less bitter. And when you’re a kid, all sensitivities are turned up.

So, for all mental illnesses, for me, it really becomes about function. When a kid comes into my office, no matter what they’re presenting with, I think a kid should be able to eat, sleep, go to school, have some friends, and do the normal developmental kid stuff. If they say, “I don’t want to eat, so I don’t go to lunch, and I don’t hang out with friends,” or if they have some nutritional deficiencies, or are not meeting their normal growth curve because they don’t eat enough nutritious foods, or have anxiety around eating and can’t go to school or leave home, if they’re having panic attacks, then I would say, “OK, now this is getting in the way of normal function.”

Two out of my three kids at home are picky eaters. I was. Now I eat fine. Some picky eating can be due to other sensitivities that kids will tend to outgrow. In that scenario, you’re just saying, “Can we meet needs, and can everybody pick the same restaurant?” But over time, if these kids are only eating a certain type of chicken nugget, only from a certain restaurant and only eating these three other things, and parents are going out of their way to accommodate them, these kids are really struggling. Some of them will need feeding tubes to meet their nutritional and medical needs. And treatment can be hard and frustrating because it’s really about slowly exposing them to more food over time. Hopefully at the same time, we’re able to step back and see the bigger developmental picture as well.

Q: What are the treatments for pediatric eating disorders?

A: At Laureate, we’re lucky. We have one of the longest-running treatment programs in the country and it’s a not-for-profit treatment program. And we’ve been running since the ‘80s. We have inpatient and outpatient services available. Like any other illness, our goal is to treat an eating disorder with the least amount of intervention that we can. All eating disorders do not come in the same severity.

I’m going to be a little bit artificial in dividing them up, but if I look at anorexia or a restricting illness, you do have to make sure the patient’s brain and body are nourished. When their brain and body aren’t nourished, their heads don’t work as well, therapies don’t work as well, and the brain just has a harder time thinking. Then you treat the underlying anxiety, so that they’re not choosing to manipulate their food intake when they get anxious.

Bulimia, or binge-eating, tends to be more of an impulse than anorexia. The person feels anxious as well, but their goal tends to be how to make their brain feel better as soon as possible. We then treat their anxiety and help them avoid impulsive behaviors such as binge-eating. We also make sure they don’t have other impulsive behaviors like taking drugs or alcohol.

The key with both bulimia and anorexia is trying to treat the anxiety while maintaining nutrition and avoiding things that actually make them feel worse over time. That can be having them see an outpatient dietician, engaging parental support, or it may take 24/hour a day care, for people with extreme malnutrition who need six moderate meals a day, and therapy for sometimes weeks or months at a time.

Q: What is the long-term effectiveness of treating eating disorders? Is this something that people will have throughout their lives? Or is there a cure?

A: There are different severities, so people have different results from treatment. In anorexia nervosa, for instance, over the longitude of the illness, between 8-10 percent of people that get it die from it. It can be a very serious illness over time. That being said, about 90 percent of people will find some sort of recovery. I’ve seen that take as little as several months and as much as several years.

To give two examples from medicine, I would say it can be like asthma. If you’re having attacks, you might be younger, your body adapts and grows. And as you get older, you may hardly ever have an attack again and don’t even have asthma anymore. Others might find that they need chronic therapy over time.

Alcohol and drugs would be the other example. Sometimes people will say, “I got sober.” In European countries, they do controlled drinking, so not everybody has to be completely sober, and they do fine with that level of drinking. Other people will say, “No. Every day I wake up thirsty and remind myself why I need to stay sober today. And if I go back and have one drink, I’m going to fall over the edge.” I think that’s what’s interesting about humans and human brains. They act differently.

I’ve been here 19 years now. It’s family week this week, and we asked a patient that I had a few years ago to come speak to our patients in the hospital. She was there with her husband and her two-year-old baby girl. Her message was: “I don’t think about eating, I’m doing my life and doing things I want to do.” That happens a lot. I think treatment is much better than it was 20 years ago. We do a lot better job about not blaming families and, in fact, using families as a structure and support for patients. They support the patient’s eating and provide the emotional support they need. We also know a lot more about the medicines and how they work over time. So, I think we do a better job, but it’s still an illness that has a lot of morbidity and mortality that needs prompt and complete treatment.

Q: What signs and symptoms should parents be looking for? If they are concerned, what should they do?

A: Being a parent myself, I think just taking an active part in your kids’ lives and what’s happening with them is important. As they become teenagers, our kids don’t always want us to be around and be available, but I still think it’s important. Make sure you’re making your pediatrician appointments.
Notice changes in dress, changes in weight and changes in their ability to eat. Are they eating with you, or are they eating privately? Do you notice changes in their skin tone? A mistake we make is thinking only about weight loss when it comes to eating disorders. Sometimes with bulimia, or binge eating, your child’s weight can stay the same, possibly even go up a tiny bit. These can all be signs of eating disorders. Be aware of eating attitudes and behaviors.

I have kids in sports and other activities, and I know family meals are hard. I think the loss of the family meal is really a loss for us as a society. To sit down together, ask about your kid’s day, the highs and lows. You can notice if your kids are eating, if they’re doing OK. Do they have friends? I think life gets so busy that we forget to pay attention to the important things.

The first place to start can be with your pediatrician. Do they see changes? We’re a “healthy at any size” program, so we don’t believe that people should be a certain weight, but most of us will be a certain height and weight throughout our lives if we’re eating a reasonable, balanced diet. But if your kid falls off that, or that trajectory changes, it could be a warning sign.

Notice any change in functioning, especially how they eat, and what they’re willing to eat. Is there lots of talk about their body, the way they look and are they acting unsure about that? My sister’s a pediatrician within the Saint Francis Health System, and she may refer patients to me. Sometimes patients are just thin. Sometimes there’s not a reason. And I think sometimes we get so tied up in obesity issues that we forget to notice kids whose changes in eating may have them falling off the growth curve on the lower side. If you have a kid who has generally run higher on the growth curve, but is now average or low, check in to see how they’re eating. Being aware of those changes.

If you do need help, we have a full compendium of resources here at Laureate. There are several excellent people in the community. Parents are lucky to have a treatment center in Tulsa with a lot of professionals who are very adept at treating eating disorders.

Q: As parents, then, we should be checking in during those family dinners, having an awareness of any changes in our kids?

A: Yes. Teenagers often don’t want to sit down and have a face-to-face chat. But if you’re busy eating, or you’re busy driving to a practice when they don’t have to look you in the face, let them talk about what they want to talk about. Even if it seems uninteresting to you because it does open up a line of communication. You can learn who they’re hanging with, who their friends are, notice changes in grades, changes in what they want to participate in. They can be all signs of depression and anxiety in general, of which sometimes eating can certainly be involved.

Q: How do you approach that conversation if you do have concerns about your child?

A: If you’re talking to teenagers, sometimes the normal response is annoyance and, they may say, “You’re an idiot.” That’s being a teenager. Or the response may be more like, “Nothing’s wrong! I don’t know what you’re talking about.” Pay attention to your reaction and listen to their response. Sometimes it can just be saying, “I notice you’re not eating with the family anymore.”

A lot of patients I see are much more aware of mental health than we were growing up. For example, I get a lot of cases where friends are noticing that their friend’s not eating at school, and they’re the ones informing parents. They may say, “Hey, Frank or Susie has stopped eating with us, or they’re on some calorie-counting app on their phone, and I have concerns about them.” Take them seriously enough to investigate.

Sometimes over-anxious parents come to see me. I don’t have a problem saying, “Nope, this looks normal, but here are the signs to watch for. If this happens, go ahead.” That probably happens less often than the patients I see from California who have waited to seek help. They say, “Well, I knew her weight was going down a year ago, didn’t think it was a big deal, and now we’re traveling halfway across the country because her heart rate’s 45, and there’s not good treatment around us. So, we’re having to travel to Tulsa, Oklahoma, to get three months’ worth of care.”

Ask the question. There’s never a convenient time. It’s never convenient to talk about sex and friends and mental health and those kinds of things. And teenagers might not appreciate it at the time, but I still think it’s very necessary to do.