How Are Eating Disorders Diagnosed in Children and Adolescents?
Nine percent of the world’s population will struggle with an eating disorder in their lifetime, with the most common age of onset being between 12–25 (STRIPED/Volpe et. al., 2016). Healthcare providers like you are instrumental in getting young patients the care they need early on. The sooner an eating disorder is caught, the better the treatment outcomes.
But what happens after you’ve recognized the symptoms and referred your patient for specialized care? In this blog, we will explore the assessment process for eating disorders in children and adolescents, shedding light on the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
The Eating Disorder Assessment Process
To refer a patient to The Emily Program, contact Admissions at 888-364-5977 or fill out this online referral form. Upon referral, an admissions specialist will gather some basic information about your patient and answer any questions you may have. They will then schedule your patient’s eating disorder intake assessment.
During the assessment, your patient will have a conversation with one of our dedicated intake therapists. This comprehensive evaluation will cover a range of topics including the patient’s current and historical relationship with food, body image concerns, and any specific eating disorder behaviors. The assessment typically lasts between 45-60 minutes, allowing the intake therapist to thoroughly evaluate the patient’s symptoms and needs, and ultimately provide an accurate diagnosis. Based on this assessment, the intake therapist will also recommend the most appropriate level of care for your patient.
Diagnostic Criteria for Eating Disorders
Proper treatment begins with an accurate diagnosis. At The Emily Program, we rely on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as part of our comprehensive eating disorder assessments.
The most common age of onset for anorexia is 12 years old, with onset after age 25 being less common (Swanson, Crow, et al., 2011). Physical effects of anorexia in young patients are largely due to energy insufficiency and may include overt symptoms such as hair loss, dry skin, constipation, and fatigue. For the youngest patients, however, linear growth may slow or halt completely, and puberty may slow or halt for adolescents. These effects may be less obvious initially to medical providers and parents.
The diagnostic criteria for anorexia are:
- 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
- Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight
- Two subtypes:
- Restricting Subtype (AN-R): Absence of recurrent binge eating or purging behavior for at least three months. Weight loss is accomplished primarily through fasting, dieting, and/or excessive exercise.
- Binge-Purge Subtype (AN-B/P): During the last three months, individual has engaged in recurrent binge eating or purging behavior.
Bulimia typically emerges during adolescence or young adulthood. The physical signs to look out for in your young patients include issues with teeth including loss of enamel or increased cavities, swelling in hands and feet, swelling of the cheeks or jaw, and weight fluctuations. Your patient’s parents may notice that patients excuse themselves often to the bathroom following meals.
The diagnostic criteria for bulimia are:
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is larger than what most individuals would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode
- 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
- The binge eating and compensatory behaviors both occur, on average, at least once a week for 3 months
- Self-evaluation is unduly influenced by body shape and weight
- The disturbance does not occur exclusively during episodes of anorexia nervosa
Binge eating disorder (BED)
The prevalence rate of binge eating disorder (BED) in children and adolescents is between 1–3%, with about twice as many girls reporting binge eating in comparison to boys (Bohon, 2019). Risks for the development of BED in children and adolescents include dieting, body dissatisfaction, a history of being “overweight,” anxiety, and depression.
The diagnostic criteria for BED are:
- An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode
- The binge eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of feeling embarrassed by how much one is eating
- Feeling disgusted with oneself, depressed, or very guilty afterward
- Marked distress regarding binge eating is present
- The binge eating occurs, on average, at least once a week for 3 months
- The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa
Avoidant/Restrictive Food Intake Disorder (ARFID)
Avoidant/restrictive food intake disorder (ARFID) can affect people of all ages, but it is especially common in children and young adolescents. Patients with ARFID may be younger than patients with anorexia or bulimia and may also have had a longer duration of illness prior to presentation (Fisher, Rosen, et al., 2014). ARFID can prevent a child or adolescent from meeting their nutritional needs, which can have far-reaching, long-lasting health consequences.
The diagnostic criteria for ARFID are:
- An eating or feeding disturbance (e.g., apparent lack of interest in eating or feeding; avoidance based on 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:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nutritional supplements
- Marked interference with psychosocial functioning
- The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice
- 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
- The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder
Other Specified Feeding or Eating Disorder (OSFED)
Not every child and adolescent with an eating disorder fits neatly into one diagnosis. Sometimes they exhibit behaviors from a combination of disorders, their symptoms present to a greater or lesser degree, or their struggle with feeding, food, exercising, or body image is completely unique. When this occurs, your young patient may be diagnosed with Other Specified Feeding or Eating Disorders (OSFED).
The diagnostic criteria for OSFED are:
- Presentations in which symptoms characteristic of a feeding and eating disorder that 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 in the feeding and eating disorders diagnostic class.
- Eating disorders that fall under OSFED include:
Looking Beyond the Diagnosis
While the DSM can be a helpful tool for diagnosing and treating eating disorders, it is important to remember that eating disorders are as diverse and complex as the people who experience them. No two illnesses are exactly alike, and many individuals present with unique variations that do not align neatly with the DSM’s diagnostic criteria.
At The Emily Program, our approach is comprehensive and personalized, designed to meet the specific needs and circumstances of each person we care for. We address the whole person, tailoring our evaluations and treatments to ensure that each individual receives the care and support they truly need.
ABOUT THE AUTHOR
Anna Tanner, MD, FAAP, FSAHM, CEDS-S
Dr. Anna B. Tanner (she/her) is Vice President of Child and Adolescent Medicine for Accanto Health, the parent company of The Emily Program, Veritas Collaborative, and Gather Behavioral Health. In this role, she has the opportunity to help our youngest patients access treatment across our system with age-appropriate medical care. She works with our child and adolescent medical sites across The Emily Program and Veritas Collaborative brands and also enjoys providing direct care to patients at Veritas’ Atlanta facility.
Dr. Tanner is driven to provide research-based medicine to our youngest patients and is passionate about preventing the long-term effects of eating disorders in children and adolescents. Medical complications in eating disorders are often treated through an age-neutral lens, yet children and adolescents have unique medical complications related to growth and development.
Dr. Tanner is a board-certified pediatrician who has specialized in the care of complicated adolescent patients, in particular patients with eating disorders, for almost 25 years. Dr. Tanner completed medical school and residency at Vanderbilt University and then remained there to serve on the Pediatrics faculty in the Division of Young Adult and Adolescent Medicine.
Dr. Tanner has been very involved in advocacy and education efforts and serves on national and international committees for eating disorders education. She speaks frequently across the United States on the Medical Complications of Eating Disorders, especially as they affect children and young adolescents, and contributed a book chapter on that topic in the 4th edition of Dr. Philip S. Mehler’s Eating Disorders: A Comprehensive Guide to Medical Care and Complications.
Dr. Tanner currently serves as an Adjunct Assistant Professor of Pediatrics for Emory University School of Medicine and Morehouse School of Medicine. She is co-chair of the Academy of Eating Disorders (AED) Medical Care Standards Committee and a member of the International Association of Eating Disorders Professionals (IAEDP) Curriculum Committee. Dr. Tanner is a Fellow in the Society for Adolescent Health and Medicine (SAHM), a Certified Eating Disorder Specialist and a Certified Eating Disorders Supervisor. She has been named by Atlanta magazine as a “Top Doctor” every year from 2013 to 2023 and named by Castle Connelly as an Exceptional Woman in Medicine and one of America’s Most Honored Doctors.