Screening, Symptom Recognition and Referral to Treatment for

Screening, Symptom Recognition

and Referral to Treatment

for Eating Disorders in

Pediatric Primary Care Settings

Holly C. Gooding, MD, MSc

Physician - Division of Adolescent/Young Adult Medicine

Boston Children’s Hospital

Assistant Professor of Medicine and Pediatrics

Harvard Medical School

Course Instructors

Sara Forman, MD

Director of Outpatient Eating Disorders Program

Clinical Chief, Division of Adolescent/Young Adult Medicine

Boston Children’s Hospital

Assistant Professor of Pediatrics

Harvard Medical School

Disclosure Statement

• No one involved in creating this webinar has

any financial disclosures or conflicts of interest

to report

Webinar Orientation

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Learning Goals

1. Describe eating disorders (EDs) and gaps in care among

youth in the United States

2. Discuss potential signs of EDs in youth as well as options

for ED screening within pediatric primary care

3. Describe treatment options for youth with EDs

4. Demonstrate a tool to help you refer patients to local

specialists when screening indicates concern

Academy for Eating Disorders:

“The Purple Brochure”

(Academy for Eating Disorders, 2016)

Question:

Who do you think of when you picture

the stereotype of someone with

an eating disorder?

Eating Disorders Overview

• Serious mental illnesses with a wide range of medical

complications

• Common across gender, sex, age, race/ethnicity,

socioeconomic status, and body shapes/sizes

• People of all weights can engage in unhealthy weight

control behaviors

• Disparities in diagnosis, treatment, health outcomes

• In children: failure to gain expected weight or height or

interruption of pubertal development should raise concern

(Academy for Eating Disorders, 2016)

Eating Disorders in

Diagnostic and Statistical Manual-5 (DSM)

• Anorexia nervosa (AN): Restriction + disturbance of body

image + fear of gaining weight

• Bulimia nervosa (BN): Binge eating +

purging/compensatory behavior + self-evaluation unduly

influenced by shape/weight

• Binge eating disorder (BED): Binge eating

without purging

(American Psychiatric Association, 2013)

• Avoidant/restrictive food intake disorder (ARFID):

Weight loss, nutritional deficiency without weight or

shape concerns; , food consumption is limited based on

the food's appearance, smell, taste, texture, or a past

negative experience

• Other specified feeding & eating disorder (OSFED): Does

not meet full criteria for other eating disorders, but has

specific disordered eating behaviors (e.g., restricting

intake, purging, binge eating)

(American Psychiatric Association, 2016)

Eating Disorders in

Diagnostic and Statistical Manual-5 (DSM)

Prevalence

Diagnosis Lifetime Prevalence

(13-18 year olds)

Anorexia Nervosa 0.3%

Bulimia Nervosa 0.9%

Binge Eating Disorder 1.6%

(Swanson et al., 2017)

Prevalence

(Swanson et al., 2017)

Boys of color > White boys

Lesbian, gay, bisexual youth

> Heterosexual youth

Transgender youth > Cisgender youth

Mortality

• EDs have among the highest mortality rates of any

psychiatric disorder

• Increased risk of suicide associated with all sub-types

of EDs

• Standardized mortality ratios (SMRs):

(Swanson et al., 2017)

(Arcelus et al., 2011)

Stereotypes & Access to Treatment

• EDs are underdiagnosed and undertreated

• Misleading stereotypes that only thin, white, affluent

females are affected by eating disorders can lead to under-

recognition in other groups

(Merikangas et al., 2011)

(Sonneville et al., 2018)

Disparities in Treatment

Perceived need

for ED treatment

ED diagnosis Past year ED

treatment

Males < Females Males < Females Males < Females

Non-affluent < Affluent Non-affluent < Affluent

(Sonneville et al., 2018)

Eating Disorders in Your Office?

Importance of Early Detection & Intervention

• Early detection and intervention are critical to

reversing medical complications and improving

psychiatric outcomes

• Primary care providers can support patients in

accessing treatment and achieving recovery

• Significant weight changes/fluctuations

• Sudden changes in eating behaviors

• Sudden changes in exercise patterns,

excessive/compulsive exercise

(Academy for Eating Disorders, 2016)

Consider Screening for EDs

if You See Signs Including…

• Body image disturbance, drive to lose weight despite

low/normative weight

• Abdominal complaints in the context of weight loss

behaviors

• Use of appetite suppressants, laxatives, diuretics, etc

(Academy for Eating Disorders, 2016)

Consider Screening for EDs

if You See Signs Including…

Source: https://commons.wikimedia.org/wiki/File:Russell%27s_Sign.png

Via Creative Commons. Author: “User:Kyukyusha”

Russell’s Sign

Source: https://commons.wikimedia.org/wiki/File:Sinus_Bradycardia.jpg

Via Creative Commons. Artist: Andrewmeyerson.

Sinus Bradycardia

Changes in

Expected

Weight

Trajectory

Impact of Weight Stigma

• Can increase the risk for all eating disorders and can

deter individuals from seeking treatment

• Be aware of the unintended consequences of our

conversations about weight

• Focus on health behaviors and well-being

How to Screen for

Eating Disorders

Ways to Screen for EDs in Primary Care

• Validated tools: SCOFF, ESP, EDY-Q (recommended

for ARFID)

• As part of other health screening: PHQ-9

• Single questions about dieting and/or weight or

shape concerns

(Morgan et al., 2000) (Pfizer, 1999) (Cotton et al., 2003)

(Hilbert et al., 2016)

Specific Screening Questions

• “Are you on a diet?”

• “Are you dieting?”

• “Do you have any concerns about your weight or

body shape?”

(Gooding et al., 2016)

Video Vignette #1

Bulimia nervosa presenting in a young adult using a

single question:

“Do you have any weight or shape concerns?”

SCOFF

Do you make yourself sick (vomit) because you feel uncomfortably full?

Do you worry you have lost control over how much you eat?

Have you recently lost more than one stone (6.35 kg or 14 lbs) in a

three-month period?

Do you believe yourself to be fat when others say you are too thin?

Would you say food dominates your life?

(Morgan et al., 2000)

SCOFF

Yes to 2+ questions → need for a more comprehensive

assessment

Additional questions with high sensitivity and specificity for

bulimia nervosa:

1. Are you satisfied with your eating patterns?

2. Do you ever eat in secret?

(Morgan et al., 2000)

Eating Disorders Screen for Primary care (ESP)

• Are you satisfied with your eating patterns?

• Do you ever eat in secret?

• Does your weight affect the way you feel about

yourself?

• Have any members of your family suffered with an

eating disorder?

• Do you currently suffer with or have you ever suffered in

the past with an eating disorder?

(Cotton et al., 2003)

PHQ-9

(Pfizer, 1999)

Video Vignette #2:

Possible binge eating disorder identified via response

to question 5 on the PHQ9. Clinician conducts further

screening using the SCOFF.

When Screening

Indicates Concern:

What Next?

• Further evaluation, including lab tests

• Conversations with parents or guardians

• Follow-up appointments

• Referral to treatment

(Academy for Eating Disorders, 2016)

Next Steps May Include:

• Patients may not acknowledge their illness

• Important to trust the concerns of parents or

guardians

• Emphasize that no one chose or caused the

eating disorder

 reduce stigma and promote

acceptance of treatment

(Academy for Eating Disorders, 2016)

Key Factors to Keep in Mind:

The Basics of Treatment

Goals of Treatment

• Nutritional rehabilitation

• Weight restoration

• Medical stabilization

• Resumption of menses

• Cessation of disordered eating behaviors

(Academy for Eating Disorders, 2016)

• Restore regular meal patterns

• Manage co-morbid conditions

• Avoid potential complications

Outpatient Treatment:

Multidisciplinary Approach

• Medical Provider

Vital signs, weight checks,

and blood testing as

needed

• Psychopharmacologist

Medications

• School Nurse/Counselor

Can add extra support

• Nutritionist

Meal planning, caloric

requirements,

micronutrients

• Psychotherapist

Individual and Family

Based Treatment

Levels of Care

• Outpatient

• Intensive outpatient

• Partial hospitalization

• Residential

• Inpatient

• Telehealth = promising new option to

increase access to care

Indications for Immediate

Hospitalization

• Severe dehydration or malnutrition

• Electrolyte disturbance

• Vital sign abnormality

• Serious comorbid diagnoses

• Acute refusal of food

• Suicidality

Video vignette #3

Anorexia nervosa presenting as a

change in an adolescent’s growth chart.

OPENPediatrics.org Group Site

https://www.openpediatrics.org

Follow the steps to create a new account:

OPENPediatrics.org Group Site

• Eating disorders affect many people, including many

who do not fit common stereotypes

• Screening in primary care can help patients get into

appropriate treatment and increase chances of recovery

• There are accessible, free resources available to find

appropriate specialists for your patients

Summary

Webinar Creators

Katelyn Ferreira, MPH

Sara Forman, MD

Holly Gooding, MD, MSc

❖

Suman Ambwani, PhD

S. Bryn Austin, ScD

Erin Gibson, MPH

Megan Kipp, MEd

Jordan Levinson, BA

Webinar Vignette Actors

❖

Suman Ambwani, PhD

Courtney Brown, BA

Danielle Ferreira

Jessica Lin, MD

Cameron Nereim, MD

Frinny Polanco Walters, MD

U.S. Department of Health and Human Services Offices and Agencies:

• Office on Women’s Health

• Agency for Health Care Quality and Research

• Centers for Disease Control and Prevention

• Food and Drug Administration

• Health Resources and Services Administration

• Substance Abuse and Mental Health Services Administration

• National Institute of Mental Health

Federal Supporters

Community Partners

Funders

• Ellen Feldberg Gordon Challenge Fund for Eating

Disorders Prevention Research

• Jennifer Perini Fund for Eating Disorders Prevention

Research

• Office on Women’s Health

• MCHB/HRSA training grants T71-MC-00009, T76-MC-

00001

References

• Academy for Eating Disorders. (2016). Eating Disorders: A Guide to Medical Care (3rd Ed.).

Retrieved from Academy for Eating Disorders Website:

https://www.aedweb.org/learn/publications/medical-care-standards

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: American Psychiatric Publishing.

• Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality Rates in Patients With Anorexia

Nervosa and Other Eating Disorders. Archives of General Psychiatry, 68(7), 724-731.

• Cotton, M.-A., Ball, C., & Robinson, P. (2003). Four Simple Questions Can Help Screen for Eating

Disorders. Journal of General Internal Medicine, 18(1), 53–56.

• Gooding, H.C., Cheever, E., Forman, S.F., Hatoun, J., Jooma, F., Touloumtzis, C., & Vernacchio, L.

(2017). Implementation and Evaluation of Two Educational Strategies to Improve Screening for

Eating Disorders in Pediatric Primary Care. Journal of Adolescent Health, 60(5), 606-611.

• Hilbert, A., & van Dyck, Z. (2016). Eating Disorders in Youth-Questionnaire. English version.

University of Leipzig: http://nbn-resolving.de/urn:nbn:de:bsz:15-qucosa-197246.

References

• Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a Brief Depression

Severity Measure. Journal of General Internal Medicine, 16(9), 606–613.

• Merikangas, K.R., He, J., Burstein, M., Sendsen, J., Avenevoli, S., Case, B., Georgiades, K., et al.

(2011). Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the

National Comorbidity Survey Adolescent Supplement (NCS-A). Journal of the American Academy

of Child & Adolescent Psychiatry, 50 (1), 32-45.

• Morgan, J.F., Reid, F., & Lacey, J.H. (1999). The SCOFF Questionnaire: A New Screening Tool for

Eating Disorders. The BMJ, 319, 1467-1468.

• Sonneville, K.R. & Lipson, S.K. (2018). Disparities in Eating Disorder Diagnosis and Treatment

According to Weight Status, Race/Ethnicity, Socioeconomic Background, and Sex among College

Students. International Journal of Eating Disorders, 51(6), 518-526.

• Swanson, S.A., Crow, S.J., Le Grange, D., Swendsen, J., & Merikangas, K.R. (2011). Prevalence and

Correlates of Eating Disorders in Adolescents: Results From the National Comorbidity Survey

Replication Adolescent Supplement. Archives of General Psychiatry, 68(7), 714-723.

• The Alliance for Eating Disorders Awareness. Treatment Center & Practitioner Directory. Retrieved

from https://www.findedhelp.com.

Thank you!

Questions?

Thank you!

Please email erin.gibson@childrens.harvard.edu with

any questions.