Eating disorders in adolescents: Principles of diagnosis and treatment

Nutritional disturbances

Nutritional disturbances are a hallmark of eating disorders and are related to the severity and duration of dysfunctional dietary habits. Although abnormalities of minerals, vitamins and trace elements can occur, they generally are not clinically recognized (22). Deprivation of energy (calories) and protein on the other hand are especially important to identify because these elements are crucial to growth (23). Moreover, there is evidence that adolescents with eating disorders may be losing critical tissue components, such as muscle mass, body fat and bone mineral (5,21,24), during a phase of growth when dramatic increases in these elements should be occurring. Complete and ongoing assessment of nutritional status is the basis of management of nutritional disturbances in adolescents with eating disorders.

Position: The evaluation and ongoing management of nutritional disturbances in adolescents with eating disorders should take into account the specific nutritional requirements of patients in the context of pubertal development and activity level.

Psychosocial disturbances

Eating disorders that develop during adolescence interfere with adjustment to pubertal development (25) and the accomplishment of the developmental tasks necessary to become a healthy functioning adult. Social isolation and family conflicts arise at a time when families and peers ought to provide a milieu to support development (1,26). Issues related to self-concept, self-esteem, autonomy, separation from the family, the capacity for intimacy, affective disorders (eg, depression and anxiety) and substance abuse should be addressed in a developmentally appropriate manner (27).

All patients should be evaluated for co-morbid psychiatric illness, including disorders of anxiety, depression, dissociation and behaviour. Because adolescents usually live at home or interact with their families on a daily basis, the role of the family should be explored during both evaluation and treatment.

Position: All adolescents with an eating disorder should be evaluated for co-morbid psychiatric illness. Mental health intervention for adolescents with eating disorders should address not only the psychopathology characteristics of eating disorders, but also the accomplishment of the developmental tasks of adolescence and the specific psychosocial issues central to this age group. For most adolescents, family therapy should be considered as an important part of treatment.

Treatment guidelines

Because of the complex biopsychosocial aspects of eating disorders in adolescents, the assessment and ongoing management of these conditions appear to be optimal with an interdisciplinary team consisting of professionals from medical, nursing, nutritional and mental health disciplines (27). Physical and occupational therapy may be useful adjuncts to treatment. Health care providers should have specific experience in treating eating disorders as well as expertise in working with adolescents and their families. They should be knowledgeable about normal adolescent physical and emotional development.

Both in-patient and out-patient treatments need to be available to adolescents with eating disorders (27,28). Factors that would justify in-patient treatment include significant malnutrition, physiological or physical evidence of medical compromise (such as vital sign instability, dehydration or electrolyte disturbances) even in the absence of significant weight loss, arrested growth and development, failure of out-patient treatment, acute food refusal, uncontrollable binging, vomiting or purging, family dysfunction that prevents effective treatment, and acute medical or psychiatric emergencies (28). The goals of treatment are the same in a medical or psychiatric in-patient unit, a day program or out-patient setting: to help the adolescent achieve and maintain both physical and psychological health.

The expertise and dedication of the members of a treatment team who work specifically with adolescents and their families are more important than the particular setting. In fact, traditional settings such as a general psychiatric ward may be less appropriate than an adolescent medical unit, if one of the latter is available (18,28-30). Some evidence suggests that the outcome for patients treated in adolescent medicine units (both out-patient and in-patient) may be better than that of those treated in traditional psychiatric settings with adult patients (28-30). Smooth transition from in-patient to out-patient care can be facilitated by an interdisciplinary team that provides continuity of care in a comprehensive, coordinated, developmentally oriented manner. Health care specialists with an interest in adolescents are familiar with working not only with the patient, but also with the family, school, coaches and other agencies or individuals who are important influences on healthy adolescent development. Given the evidence that eating disorders can be associated with relapse, recurrence, crossover and the later development of other psychiatric disorders, treatment should be of sufficient frequency, intensity and duration to provide effective intervention.

Position: Adolescents with eating disorders require evaluation and treatment focused on biological, psychological and social features of these complex, chronic health conditions. Assessment and ongoing management should be interdisciplinary and is best accomplished by a team consisting of medical, nursing, nutritional and mental health disciplines. Treatment should be provided by health care providers who have expertise in managing adolescent patients with eating disorders and are knowledgeable about normal adolescent physical and psychological development. Hospitalization of an adolescent with an eating disorder is necessary in the presence of malnutrition, clinical evidence of medical or psychiatric decompensation or failure of out-patient treatment. Ongoing treatment should be delivered with appropriate frequency, intensity and duration.

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