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Treating Eating Disorders in the Pre-Adolescent Population
PRESENTED BY:
JULI AGAJANIAN, LMFT, CEDS
&
JULIA CASSIDY, RD, CEDRD
Objectives
1. Be able to identify key medical red flags that need medical/psychological attention
2. Learn creative ways that professionals can work therapeutically with a young adolescent with an eating disorder
3. Understand the importance of the team approach of professionals throughout the entire treatment of a young client
Eating Disorder Physical Signs & Symptoms
Excessive Clothing
Swollen face
Poor skin color
Sunken eyes
Overly defined muscles
Excessive/compulsive exercise
Lack of energy
Fainting spells
Insomnia
Menstrual Irregularities
Laxative/Diuretic Abuse
Hair Loss
Lanugo – (excessive body hair)
Determining Ideal Body Weight
Importance of “Blind Weights”
Use of adolescent growth chart
Exceptions to 25-50% goal range (i.e. loss of menstrual cycle, low heart rate, etc)
WARNING: Clients will try anything to bargain for a lower weight range!
Amenorrhea
Primary – failure of menstruation to occur by age 16. Normal puberty and menses can be delayed with even a 10-15% loss of normal body weight. 1
Secondary – menstruation stops for 3 consecutive months due to eating disorder.
Dangers of amenorrhea... 1 Usdan, L. et al – The Endocrinopathies of Anorexia Nervosa, Endocr
Pract. 2008 November; 14 (8): 1055-1063
Bone Density Scans
Osteopenia (low bone mass) can occur even in young adolescents
Bone density scans should be done if the adolescent has an eating disorder and their menstrual cycle has stopped for more than 6 months
Medical Consequences
Weight loss/gain
Low body fat or high body fat
Low muscle mass
Iron deficiency
Low heart rate
Vitamin D deficiency
Electrolyte imbalance
Constipation
Decreased metabolic rate
Heart failure
Bone density problems
Infertility
Insulin resistance and diabetes
Re-feeding Syndrome
Metabolic problems that can occur when introducing nutrition to patients who are starved or extremely malnourished
Anyone who has had low nutrient intake for 5 consecutive days is at risk of refeeding syndrome
Possible gastric discomfort - bloating, gas, fullness
Fluid shifts may cause swelling (edema) or weight
change
Start refeeding slowly
Behavioral Signs & Symptoms
Food obsession
Refusing previously enjoyed food
Small portions, skipping meals, eating slowly
Body image obsession
Hoarding food or binging
Purging (vomiting) food
Exercise obsession
Increased arguments about food
Psychosocial Risk Factors
Highly sensitive nature
Important social figures commenting on weight (Coach, trainer, Pediatricians)
Health/P.E. Class
Peer issues (breakups, teasing, bullying)
Perfectionism “gone too far”
Trauma/stress
Invalidating home environment/conflict
When more help is needed…
Under 90% of their “Ideal Body Weight” OR significant weight loss/gain
Behaviors or mood symptoms are severe/out of control
Regardless of weight, if symptoms do not improve: requires an eating disorder specialist that can recommend appropriate level of care, monitor behaviors, etc.
Refer for medical workup (labs, EKG, BMI)
Levels of Care for ED:
Outpatient (Therapist, Dietitian, M.D.)- if over 85% of ideal body weight (IBW) and fair/good motivation
Intensive Outpatient (IOP) – about 10-15 hours per week. Must be over 80% IBW with fair motivation, only needing minimal structure
Levels of Care for ED – cont’d..
Partial Hospitalization Program – (PHP) – about 40 hours per week. If over 80% and somewhat motivated, but requiring some structure to not engage in disordered behaviors
Residential Treatment Facility (RTC) – 24 hour care. If under 85%, little to no motivation and requires structure to eat/not purge
Inpatient Hospitalization – Tube feedings, intense medical stabilization. HR less than 40, low weight, severe lab abnormalities
Next Steps
Once a change in level of care is agreed upon by the team of professionals and parents, explain openly to adolescent
Parents are coached ahead of time to expect the worst and not give in to the “Eating Disorder’s” requests
Importance of the professional team providing structure and good communication
Therapeutic Interventions for Adolescents
Build rapport by spending time talking about anything but eating!
Thorough assessment including Motivational Interviewing techniques.
Use their own words.
Help them to connect to their pain and frustration about how their eating behaviors are affecting their life
Validation along with firm boundaries is key!
Therapeutic Interventions (cont’d)…
Sticker chart to earn privileges that will motivate them (prizes, walks, soccer, etc)
Write a story of a dog who…
Gas in a car…
Art Therapy- Draw a Bridge (by Pamela Hayes, ATR)
Draw your ED
Abstract Self Portrait
Draw what you’re feeling now (addresses Alexithymia)
Make your own coloring book (for stress reduction)
Scribble Drawing
Therapeutic Interventions (cont’d)…
Make mealtime fun
Make therapy fun (sessions outside, etc.)
Experiential techniques (Star Wars role play, Family Sculpting, etc.)
Work at building their self-esteem, and encourage parents to help do the same
Therapeutic Interventions (cont’d)…
Use fun outdoor activities to decrease exercise compulsivity (bike rides, walks with family, etc)
Have the client evaluated by psychiatrist. Medications can help, especially if child has a history of OCD
“Bed Rest” – when medically necessary. A natural consequence…
Dietary Interventions
Food fears/fantasy collage
Restaurant exposure
Making peace with food
Grocery store outings
Individual food challenges
Dietary Exposure with Response Prevention
Use of ERP in decreasing anxiety around food and mealtimes – have clients/kids be involved in meal preparation as soon as it is appropriate
Menu planning/Food Logs
Kitchen orientation & Meal Preparation
Education;
Nutrition Groups → teach the clients how the nutrients work in the body, basic nutrition, mindful eating etc.
Kitchen Skills→ teach the clients to cook, bake, grocery shop, etc.
The Therapeutic Family Meal Session
Goal : to aid the family in creating and practicing supportive statements to use during mealtime with their loved one.
Dietitian and Therapist coach family on:
Point out behaviors
Focus on feelings more than food
Share your own feelings (if appropriate)
Ask how to support
Suggestions: “table games”, check-ins after dinner, distracting conversation, etc.
Empower the client
Communication Between Treatment Teams
Communication is key!
Physician should communicate to the rest of team any current medical concerns, weight expectations, and exercise limitations for the client
Dietitian should communicate about dietary guidelines and restrictions and client’s reported struggles
Therapist should stay abreast of medical and dietary issues to prevent sending mixed messages
Team should clearly spell out all guidelines to parents
Final Thoughts:
Our pre-adolescent clients need to feel heard and validated, but also contained and safe by their parents and their treatment teams.
Even when it seems that clients are not motivated to recover, we are planting very important seeds!