Eating Disorders in Complex Adolescents

December 18, 2022

Information

Rebecca Kamody, Ph.D.

Assistant Professor in the Child Study Center, Licensed Clinical Psychologist

Meeting the Complexities of Adolescent Mental Health -- November 5th, 2022

ID9315

To CiteDCA Citation Guide

00:00OK. So whenever I'm giving
00:03a talk on this topic,
00:04I always start with this image. For
00:07any folks that are in mental health,
00:09whether working in clinic based settings
00:11and your own practice in our school systems,
00:14you've probably encountered these
00:16silos that that come up often with
00:18complex presentations in adolescents
00:20and to I think Wendy's point in
00:22younger youth as well of treatments
00:25being quite siloed for one another.
00:27And I think that we've seen
00:29it really that epitomized
00:31in eating disorder care which I'll
00:33talk more about down the line is
00:35how it's become kind of such a
00:37niche area that it's often something
00:38that a lot of providers, unless it's
00:41been a specialty area of training,
00:43maybe have have some tentativeness
00:45with with approaching and managing.
00:47And so we're hoping and talking about
00:50these complex adolescents where
00:51this is often one component of a multi
00:54component presentation thinking about
00:56how best to navigate when you have
00:59a patient or a student or anyone
01:01raising some of these concerns and
01:03what's the right way to go?
01:05Because I think right now,
01:06again,
01:07with the siloed nature of care and
01:08such an uptick in cases as many
01:11of you have probably encountered,
01:12referrals to eating disorder
01:14specialists are often quite lengthy
01:17in terms of the wait list.
01:20So why has this become so siloed?
01:22I wish I had a a very clear straightforward
01:25addressable answer for everybody today,
01:26but it really has for some reason
01:28eating disorders have become
01:29this niche area and mental health
01:31training as well as medical training.
01:32So when I talk with my colleagues
01:34in the pediatric hospital in
01:36adolescent medicine for this,
01:37they talk about that,
01:38that same experience of that it's
01:40kind of you do eating disorders or you don't,
01:43which has really led to again,
01:45despite the fact that we often see
01:48co-occurring depression, anxiety,
01:49Um,
01:50other self injurious behaviors and number
01:52of concerning kind of presentations,
01:54it becomes this,
01:55this separate thing that we treat.
01:59So before going into a lot of those complex
02:02comorbidities and thinking about today,
02:04we're really talking about meeting the
02:06needs of of adolescents and I want to hit
02:08on some really important factors related
02:10to identity that are misrepresented when
02:13we're thinking about eating disorder
02:15treatment as well and assessment.
02:17So I invite everyone here just to think
02:19about what image comes to mind when you
02:21hear the term eating disorder and I show
02:23here the images that, when you Google
02:24it, are the first ones that come up and
02:27and yes these are presentations
02:30of adolescent and young adults, white
02:32females that are experiencing low weight.
02:35But there's this very clear idea
02:37of when you say eating disorder,
02:39what it looks like.
02:40And now I don't think that this
02:41is limited to eating disorder.
02:42I think to the point in both Michael
02:44and Youngsun's talk of hitting on
02:47of some of the different groups
02:49that are kind of unduly affected
02:51by depression and suicidality,
02:54we often have a misrepresentation.
02:57So in reality we know that feeding
02:59and eating disorders are complex
03:01and heterogeneous presentations
03:02that a lot of times couldn't be more
03:05different from one another.
03:06Now despite we lump all eating
03:09disorders into this one camp,
03:11a lot of times the co-occurring
03:13concerns and the presentations and
03:15what we're addressing therapeutically
03:16are more overlapping with non-eating
03:19disorder presentations and we'll hit
03:20on some of that of when we're thinking
03:23about what to keep an eye out for.
03:26So I pop up here the DSM or diagnostic
03:28manual's definition of eating and
03:30feeding disorders to just hit on
03:33how broad it ends up being and what
03:35we're having to consider and or what
03:37we're thinking about with feeding
03:39and eating disorders.
03:40So in essence to meet criteria,
03:42a persistence disturbance in eating
03:45or eating related behaviors that results
03:47in an altered consumption of food and
03:50significantly impairs functioning,
03:51either physical or psychosocial.
03:53So in essence if it's clinically significant and
03:56it has to do with food,
03:57then it it fits in that camp.
03:59So you can imagine the variety of what
04:02that means and what that looks like.
04:05Hitting some on then to that point
04:07of the diversity that we actually
04:09see an eating disorder presentations
04:10based on a number of aspects of
04:13identity and again that image
04:15that often comes to mind,
04:16these are some prevalence rates that
04:18have been put forward by both the
04:21National Eating Disorder Association as
04:24well as the association for or the ANAD.
04:30So we actually see that BIPOC
04:32individuals are significantly less
04:34likely than their white counterparts
04:36to have been asked by a provider
04:38about eating disorder symptoms.
04:40This is even in the context of when
04:42self reporting eating disorder concerns.
04:44So raising this to think about the
04:46students that you may be working with
04:48in some of just the data that we have
04:50of how some of these things can be
04:52missed in different systems of care.
04:55BIPOC individuals are half as
04:57likely to be diagnosed or receive
04:59treatment when experiencing clinically
05:02significant eating disorder concerns.
05:04Black individuals and Black youth
05:06are significantly less likely to
05:08be diagnosed with a presentation
05:10of restricting like anorexia,
05:12but may but experience the condition
05:13as a result for a longer period of time
05:16and develop more likely to develop than
05:19what we call a protracted presentation.
05:21And in reality,
05:23Black teenagers are 50% more likely
05:25to exhibit compensatory behaviors or
05:28bulimic behaviors of purging, excessive
05:31exercise, in addition to the binge behaviors.
05:34Similarly,
05:35we see that being more present in
05:38Hispanic and Latinx youth.
05:40We see actually Asian college
05:42students reporting higher rates
05:44of restriction as well as higher
05:47rates of body dissatisfaction.
05:51To a point that I will, I could give
05:53money talks on this and I know Ashley
05:55Rutherford will be hitting on considerations
05:57in gender dysphoria this afternoon,
05:59but this is something I think for anyone
06:02working with adolescents in school
06:03systems or clinical settings to be
06:05aware of is the clinically significant
06:07concerns of disordered eating in both
06:09sexual and gender minority individuals.
06:12And this is going to be very broad
06:15strokes overview but we see in gay
06:17men and gay adolescents or self
06:20reporting gay adolescents seven times
06:22more likely to report binge eating and
06:2512 times as likely to report purging.
06:28Significantly more likely to engage
06:31in any compensatory behaviors,
06:33to the point of an important distinction
06:35that would be happy to answer questions
06:37about our talk more about the distinction
06:39of being a sexual and gender minority.
06:41But in transgender individuals,
06:43we see eating disorders four times
06:46higher than their cisgender classmates.
06:48One in three individuals, this is again
06:51based on prevalence studies,
06:52reporting using disordered eating as
06:54a way to modify their body without
06:57hormones is just some research that
06:59we've been replicating within our
07:01gender program and we see gender
07:04dysphoria and body dissatisfaction
07:06often key links in disordered eating.
07:09And this is again true for not just
07:12our binary trans masculine and
07:14trans feminine individuals,
07:15but also for non binary individuals.
07:20To build on the last talk of our
07:21high risk presentations that we often
07:23have to think of these co-occurring
07:25concerns that it will then carry
07:27over into the afternoon specifically
07:29in gender minority youth.
07:32This is a kind of just a highlight
07:34why we can't treat these things
07:36separately. In some prevalence work
07:39that has looked at comorbidities
07:41of eating disorders with suicide,
07:44suicidal ideation and suicide
07:46attempts actually, in individuals who
07:48identify as trans both
07:49binary and non binary, research showed
07:52that for those youth who identify as
07:54both trans and having a history of
07:57an eating disorder being 20 times
07:59based on the odds ratios to have
08:01attempted suicide in the past year.
08:04Then two really important
08:06comparison groups,
08:06both cisgender females with an
08:08eating disorder who are already
08:10at higher risk for suicide,
08:11as well as trans individuals
08:13without an eating disorder.
08:15And to the point of the last talk,
08:16that is also a very high risk population.
08:19We also see that about 3/4 of trans
08:22youth with an eating disorder
08:25endorse either suicide attempts,
08:27suicidal ideation or engaging in non
08:29suicidal self injury within the last year.
08:31So again,
08:32this is to highlight in the purpose
08:33of our our talk today why we have
08:36to think about these high risk
08:37adolescents very holistically and
08:39and of these complex interacting
08:41kind of presentations that they're
08:45experiencing as well.
08:47I'm hitting on some other things,
08:49just considerations that we do see
08:51higher rates of disordered eating
08:52concerns in individuals with physical
08:54disabilities and individuals with autism
08:57and other forms of neurodiversity,
08:58including ADHD,
09:00as well as
09:03in individuals with ASD traits.
09:08And again building on the points that I
09:10think Wendy had raised up that we can't,
09:12even though we often think about adolescence,
09:13young adult with eating disorders,
09:15thinking about those risk
09:16factors at a younger age.
09:18In some prevalence work that has been
09:20done in the school systems over 40% of
09:231st to 3rd grade girls in the sample,
09:25in a nationally representative sample,
09:27reporting wanting to be thinner.
09:30Over 80% of 10 year old children reported a
09:33fear of being fat or fat being a bad thing.
09:36Close to half of 9 to 11 year olds
09:38in the sample reporting sometimes
09:40are very often on diets.
09:42Now what I highlight here is this is
09:44the self report of a 9 to 11 year old.
09:46So what that diet entails is not
09:48clear and may not actually be the
09:51behaviors of severe restriction,
09:52but that we're thinking about that
09:54cognitive mindset of I need to lose weight
09:56or there's something wrong with my body.
09:58We see a high prevalence of adolescent
10:01girls engaging in compensatory
10:03behaviors and and maladaptive dieting
10:06behaviors.
10:07And in college samples,
10:10over 90% of women reporting attempting
10:12to control their weight due to
10:15dissatisfaction with body and dieting.
10:18So an important piece to consider here
10:20with all these risk factors though and
10:22what we'll get back to in terms of
10:24again what populations are affected is
10:26actually when we're looking at truly
10:29what's income encompassed by that
10:31the diagnosis of an eating disorder.
10:33And yes,
10:33there are those specifically
10:35related to severe restriction,
10:36but actually less than 6% of
10:38individuals with eating disorders are
10:40actually in the underweight zone.
10:41So that clinically significant impairment
10:43on life that that is associated
10:46with having an eating disorder.
10:48Less than 6% of individuals who meet
10:50criteria for other types of eating disorders,
10:53whether bulimia,
10:54binge eating,
10:55other presentations that we'll
10:57talk about are actually look like
10:59what society has decided in eating
11:02disorder looks like.
11:03And so yeah despite what all the
11:05all this data shows us,
11:07there's a swag stereotype that exists
11:09and thinking about the students and
11:11patients that you work with and
11:13some of what can lead to hesitancy
11:15of endorsing some of these behaviors
11:17is that to have an eating disorder
11:19you, it's a skinny white affluent
11:21girl when we know that as a result,
11:24a number of our current treatment
11:26models are based on samples and this
11:29population sample of affluent, young adult,
11:31cisgender, neurotypical, white women.
11:32A big part of this that that will
11:35hit on briefly is also because
11:36of some of the models of care and
11:38often self pay models to accessing
11:41eating disorder treatment.
11:43And the swag stereotype that we see
11:46even what what what's illustrated?
11:48So to head on broadly and I'll be
11:50mindful time to go through quickly
11:52to hit more on kind of treatment
11:54approaches that could be used in
11:55the school systems more robustly.
11:57But thinking about the diagnosis
11:59that are
12:00encompassed in that eating and
12:02feeding disorder presentation.
12:04So we have pica, rumination disorder,
12:07avoidant and restrictive
12:08food intake disorder,
12:09I'll hit on each of these,
12:10this is something called ARFID
12:12that I'm sure folks are hearing
12:14more and more about, anorexia,
12:16bulimia and then binge eating disorder.
12:19The really tough part,
12:21especially in from a developmental
12:23lens with adolescence is based
12:25on DSM criteria classification
12:27to meet one of these diagnosis
12:29is mutually exclusive.
12:30And so for anybody who works with
12:33children or adolescents to and to.
12:34I think a really important point
12:36that Dr. Bloch had raised in the
12:38last study of how sometimes our
12:39models of care for both assessment
12:41and treatment for youth are
12:42based on adult models of things,
12:45it's not uncommon that we see more of either
12:49sub threshold presentations that
12:50are still clinically significant
12:52or things that kind of blend a few
12:54of these boxes and so then we end
12:56up with this catch all term of the
12:59other specified feeding and eating
13:01disorder when it is probably more
13:04accurate to have to dually identify
13:06the clinical conceptualization
13:08of multiple diagnoses.
13:11So I used this infographic as a as
13:13opposed to having to just walk you all
13:16through the specific DSM diagnoses.
13:19But to hit on broadly what we're
13:21thinking of with these different
13:22presentations and the conceptualization
13:24and to highlight why they're so
13:27actually distinctly different
13:28despite being lumped together,
13:30anorexia is what is more of
13:32that quintessential traditional
13:34idea of what an eating disorder is.
13:36So it's having significantly
13:38low weight or significantly low
13:40restriction that is associated with
13:42the unrealistic idea about body image
13:45and an intense fear of gaining weight.
13:47Now really important components here
13:49and thinking about what the students
13:51and patients that you're working with
13:52is even when you are seeing low weight
13:54to meet criteria for for anorexia,
13:56it is that intense fear of gaining
13:59weight and then the unrealistic idea
14:01of body image is something that we call
14:04kind of an overvaluation of weight and shape.
14:07So when you're thinking about
14:08kind of an adolescent or
14:10child or adult sense of self,
14:12their weight and body shape being one
14:14of the most important factors for that.
14:17And this is a really important piece
14:19to hit on because it is often what
14:21leads to kind of hesitancy to actually
14:23disclosing that that's happening
14:25or seeking treatment is when we
14:27all have things that are important
14:29to how we view ourselves as people.
14:31If if you're a provider in the school
14:33systems or clinical provider a lot
14:35of times you're work is a part of
14:37it and maybe being a parent or a
14:38daughter or a son or you know a
14:41a friend,
14:41a partner to somebody and maybe
14:43ways that we contribute to society.
14:45All these factors that impact how we
14:48evaluate ourselves and our judgment
14:50of ourself and youth and adult
14:52when experiencing anorexia is that
14:54there's such an over emphasis put
14:56on weight and shape that actually
14:58the getting better, the having to
15:00increase intake is almost telling
15:02all part of their brain that
15:04what they're doing is bad or wrong.
15:06So it really it's it's what we
15:08have to do to get better is almost
15:10antithetical to everything that
15:12their brain is telling them.
15:14Bulimia is, you know,
15:15it's interesting as I've had a
15:17colleague say that bulimia is a
15:20diagnosis of the past because now
15:22we're seeing much more of anorexia,
15:25binge purge type system,
15:26a lot of restrictions,
15:27significantly low weight.
15:28But with bulimia, it is a true binge episode.
15:31So a significantly large amount
15:33of food and an experience of loss
15:35of control couldn't have stopped
15:37self with then followed by some
15:39type of compensatory behavior.
15:40So over exercise, severe
15:42fasting after the fact,
15:44or of course, purging behaviors,
15:47use of laxatives, even diuretics.
15:50Binge eating disorder is in
15:52essence the bulimia without the
15:54without the purging behaviors.
15:56So we still are seeing that eating
15:58that significantly large amount
15:59of food. An important component
16:01here to identify for the
16:03clinical distress is the sense of
16:05loss of control. A patient wants
16:06you know,
16:07we talked about like the trains left
16:08the station, couldn't have stopped
16:10self if tried, and so there's feelings of
16:13guilt and disgust associated afterwards.
16:16Rumination disorder and Pica are
16:18those that we won't hit on these
16:20ones as much because these are more
16:22common in youth and adolescents with
16:27neurodevelopmental disabilities.
16:28So rumination is the regurgitation,
16:30it's not the purging, regurgitation
16:32into the mouth and re swallowing and
16:36then pica eating the non food objects.
16:39ARFID, or avoidant restrictive
16:41food intake disorder,
16:43this is one that we're seeing
16:44quite an uptake in the pandemic.
16:45And actually this really complicated
16:47blurred line between that and
16:49anorexia because what ARFID is
16:52is severe restriction, low weight,
16:54malnutrition, malnutrition in youth/
16:55adolescents for reasons that don't
16:57have to do with that point I was
17:00saying of an overvaluation of weight
17:01and shape or fear of gaining weight.
17:04So we often see it due to a fear
17:06of or an avoidance of
17:08negative consequences.
17:09So,
17:09for example,
17:10we've seen quite a number of youth
17:12with GI complicated GI histories
17:13that will then avoid eating
17:15because there's a fear of pain.
17:17Or we often see, because of food sensitivity,
17:19the textures of things,
17:21severe restriction or kind of an
17:24unawareness of their own hunger cues.
17:26The challenging part here is when
17:28these were developed, ARFID, anorexia,
17:30considered quite separate.
17:31But if you imagined all those points,
17:33I was saying of how especially
17:35young youth and adolescents are
17:37at such high risk for these,
17:38um,
17:39disordered eating concerns based
17:40on societal kind of body image on
17:43things that can be thrown at them.
17:45You may have an adolescence who
17:47it started as this avoidance and
17:49restricting more indicative of
17:50ARFID though we also have body
17:52image concerns that are very
17:54understandable and adolescent so.
17:56So this is where some of those diagnostic
17:58lines become quite blurred.
18:02And so often we think about here,
18:04I would say we, we like to try to
18:06pull these things apart and say
18:08that there's those presentations
18:10of restriction like anorexia,
18:11anxiety, pain sensory, ARFID, pica,
18:14dysregulation, loss of control,
18:16bulimia, binge eating.
18:18But really there's this overlap,
18:19they really are more of these Venn diagrams,
18:21which again can make things like
18:24accessing appropriate assessment
18:25and treatment quite tricky.
18:29I share these rates because I know
18:31we're hitting a lot on today with
18:33the uptick during the pandemic.
18:34These are actually the most recently
18:36published rates by NIMH from
18:38their National Comorbidity survey
18:39and the Adolescent Supplement.
18:41So this was from about 20 years ago
18:43and we have seen a significant increase
18:45during the pandemic that I'll hit on.
18:47But you see even at that time and prior to
18:50the current kind of crisis that we're in,
18:53you see what you saw by the time of 18,
18:55close to 4% of females and 1.5%
18:58of males meeting criteria
19:00for an eating disorder.
19:02Now during the pandemic,
19:04just like any of the concerns
19:05that we're talking about today,
19:07it has just kind of significantly
19:10been exacerbated.
19:11So there's this,
19:12I remember this editorial that came
19:14out in May of 2020 and it was the
19:16COVID-19 and the implications for eating
19:18disorders and it kind of anticipated
19:20that we were going to see an uptick,
19:21but completely underestimated kind
19:23of what has actually happened. And the
19:27first publication pertinent to the
19:29children and adolescents that we're
19:31talking about a very severe cases
19:33that highlighted the increase
19:34in the most severe cases,
19:36so these are going to be youth
19:38who are hospitalized medically
19:39for the complications associated
19:41with restrictive eating,
19:42so issues with vitals, what's going on
19:44with the heart and you know that that
19:46they have to be in the hospital to be
19:48weight restored and stabilized,
19:50we saw published in July of 2021 from a
19:54hospital in Michigan that just noting
19:56the difference in admission rates
19:58and it being significantly higher
20:00that now in the last year we've seen
20:03replicated throughout the country
20:04as well as in Europe,
20:06and I'll hit on some of the data
20:08that we've actually seen at the
20:10children's hospital in New Haven.
20:12When we think about what's
20:14exacerbated those prevalence rates,
20:15it really was the pandemic created a
20:17perfect storm for eating disorders to grow,
20:20both those related to restriction as
20:21well as those with loss of control.
20:23So there's this greater susceptibility
20:25to illness just associated with
20:27being in the pandemic.
20:29The presentation of,
20:30you know,
20:30much related to eating disorders in
20:32the camp of restricting being about
20:34control and what you're doing is
20:36taking away all control about the
20:38environment and really isolating
20:40somebody and really being socially connected
20:42are some of the most protective factors
20:45here. And then there's the amount
20:47of virtual interaction,
20:48only seeing your peers online,
20:50only seeing filtered images of your
20:52friends online and the dangers
20:54of social media on body image.
20:56So not only only getting to connect via
20:58zoom and having to see yourself on screen,
21:01but then everything that you
21:02see online through social media
21:04engendering a more negative body image.
21:06And so I'm I'm sure that folks had
21:08seen that the time of when the pieces
21:11coming out from the the Facebook and
21:12Instagram whistleblower of the
21:14algorithms that they actually identified
21:17that once youth and adolescents
21:19were starting to look at like
21:21any types of thing on Instagram
21:23related to to body image,
21:25even more positive body image,
21:27some of the algorithm could take
21:28them to pro Ana or pro anorexia
21:30sites because it increases the
21:32clicks of things and so that there
21:34really are a lot of these dangers
21:36to what could be vulnerability
21:38factors for the youth currently.
21:41When we're looking specifically, and
21:43for those of us that are in
21:45Connecticut, at what we've actually
21:46seen at Yale New Haven Children's
21:48Hospital to highlight this increase.
21:50So these are again youth hospitalized
21:52for the severe medical complications
21:54associated with restrictive eating.
21:56We did a medical record review
21:58of the three years prior to the
22:00start of the pandemic and had 48
22:02children hospitalized for those
22:04severe medical complications.
22:06And then in looking in just the first
22:08year and a half of the pandemic,
22:09we saw already 60.
22:11So we'll be looking again at the
22:13end of this calendar year for that
22:15full three-year period and of
22:17course not expecting just doubles,
22:19but to just show that in that time
22:20period we would expect it to more than
22:22double or maybe even triple to what
22:24we saw the three years before the pandemic.
22:28We also saw an increase
22:29in the length of stay.
22:30This was both due to lack of resource
22:33and available for disposition or
22:35for where to refer folks as well
22:37as what we saw of the increase
22:39in severity presentation.
22:40To the point that's been raised
22:42about how much more concern
22:44we're seeing in younger youth,
22:46a significantly higher number of youth
22:48under the age of 13 being hospitalized
22:51for the severe medical complication.
22:53Requiring medical, um, psychiatric medication,
22:56more patients
22:58requiring discharge to a higher
23:00level of care and again,
23:01what we've seen around the country.
23:04To hit on some of the severity and why,
23:07including in the talk today and thinking
23:08of how to provide more resources,
23:10eating disorders are among the
23:13deadliest mental illnesses,
23:15second only to opioid overdoses.
23:17Anorexia specifically has a
23:19relapse rate of approaching 50%.
23:21So even when technically
23:23going into remission,
23:25one in two individuals will relapse.
23:28The standardized mortality ratio,
23:30or what that means of somebody at
23:32an age with anorexia compared to
23:35somebody without is six times as
23:37likely to to have early mortality.
23:40This is a really important point to
23:42working with children and adolescents.
23:43It's about one in five individuals who,
23:46once meeting criteria for individual
23:48develop what we call a severe
23:49and protracted illness,
23:50which means it does never get
23:53better until the until death.
23:55We see a death about once every hour
23:57attributed to an eating disorder.
23:59And among individuals with anorexia,
24:02we do see those higher rates
24:03of suicide and of course,
24:05the medical complications
24:06associated with an early death.
24:11Eating disorders cost a great deal
24:13to both our hospital systems and,
24:15so this is again why we continue
24:17to think about other ways to both
24:19meet of course public health costs,
24:21but more so the individual need of
24:23our of our patients and students.
24:25Really important point here,
24:26again this isn't for those very severe
24:29restrictive presentations of anorexia,
24:31but about one in 10 individuals
24:33in their life meet criteria,
24:34clinical criteria for an eating disorder.
24:36This includes all those of the
24:39binge eating, bulimia,
24:40ARFID, so important to highlight
24:42to again the likelihood of a number
24:45of students or patients that you
24:47have that may be meeting criteria but
24:50not sharing. Our treatment
24:52approaches that I'll hit on where
24:54we're really working to build because
24:55we we haven't really hit on the
24:58most effective strategies yet.
24:59And unfortunately we don't have
25:01medications that actually are FDA
25:03approved or shown to be effective
25:05currently for addressing eating
25:07disorder concerns in adolescents.
25:08We do have some efficacy
25:10in adults. Often when we see
25:12medications being used and if any
25:14folks have questions on that,
25:15we fortunately have a number of
25:17psychiatrists here on our panel today, as
25:19treating those co-occurring conditions.
25:21So the co-occurring depression
25:23or anxiety or other concerns.
25:26So to the point of the high comorbidities,
25:28the high comorbidities again already
25:30hitting on the higher rates that
25:32we see in individuals with gender
25:34dysphoria as well as the higher
25:36rates of suicidal ideation.
25:37We do see greater negative long
25:39term effects when there are those
25:41associated comorbidities and why
25:43we want to treat the whole child.
25:45We see over half of adolescents with
25:48anorexia having some type of mood disorder.
25:51The challenge here is that it's
25:53the chicken or the egg question
25:55just because severe starvation
25:56can, of course,
25:59impact mood. We see about one in
26:02four individuals with anorexia meeting
26:04criteria for an anxiety disorder.
26:06One in four individuals have
26:09experiencing a substance abuse concern,
26:12most prevalent those associated
26:13with weight loss,
26:14including cocaine and amphetamines, and high
26:17rates of OCD in individuals with anorexia.
26:21One of an important distinction here
26:23is because there is often such an
26:25obsession related to food and body
26:27image, a co-occurrence of OCD is
26:29only considered truly a co-occurring
26:31disorder if the OCD symptoms occur
26:34outside of eating and weight concerns.
26:38I highlight here again also just to
26:40show that these complex adolescents
26:42and how all of these pieces come
26:44together that actually the NYSARC
26:46data set that looks, it's an adult
26:48data set that looks at a nationally
26:51representative sample across the
26:53country had, based on self report
26:55from adults who had had a lifetime
26:57diagnosis of eating disorder of an
26:59eating disorder showing how high,
27:01how high suicide attempt rates were.
27:03So especially in that anorexia
27:06binge purge type, so
27:07experiencing like a loss of
27:09control with eating and purging,
27:10but still having that very
27:11significantly low weight.
27:15And the reality is despite us
27:17really understanding this,
27:18we continue to be in a crisis of care
27:20in treating patients with anorexia.
27:22And this is true for adolescents.
27:23This is a wonderful, a wonderful
27:25read for anybody who has free time,
27:27just about a page and 1/2 paper
27:29that was in the journal JAMA
27:30Psychiatry last year that highlights
27:32kind of all the reasons for this.
27:34And why our team is really thinking
27:36again about meeting the complex
27:37needs of adolescence is how we've
27:39really developed into this siloed
27:41nature of care from funding sources
27:43to how clinical care is provided.
27:45And why we really have to think
27:47about innovative ways of addressing,
27:48especially through prevention efforts.
27:52So some of the common evidence based
27:54treatments for eating disorders and I
27:55I often like to say evidence informed
27:57just because even though and you know
27:59I think of course very highly of all
28:01these approaches, is our remission rates
28:03aren't where we would like them to be.
28:06So but these are the ones that we
28:08are often using to when somebody is
28:10engaged in eating disorder treatment
28:11I'll hit on some of the most the
28:13most common ones and the most
28:16frequently used. So in adolescents,
28:19so if you if you have any students
28:21or patients that you are seeing
28:22truly it is restricting and we need
28:25to focus on weight restoration,
28:27family based treatment is one of
28:29the most effective modalities
28:31for weight restoration.
28:33What this therapeutic approach
28:35entails and is in essence the idea
28:39that when somebody has entered into
28:41the eating disorder mindset right, and
28:43that they're that for an adolescent
28:45that isn't able to think as clearly
28:47because of the way that it really
28:49has kind of taken over thought
28:50processes and the way that that,
28:52because of that overvaluation of
28:54weight and shape is getting in
28:56the way of engaging in things like
28:58cognitive behavioral strategies.
28:59The idea from a developmental lens is
29:01that we have to turn over nurturing the
29:04the child or adolescent to the parent.
29:06So this,
29:06the first phase is the parents
29:08kind of have to completely take
29:10over the weight restoration phase.
29:12Then there's a second phase of
29:14really trying to transition back over
29:16control to eating to the adolescent
29:17and then thinking before launching
29:19of how to address some of those
29:21factors that may have contributed
29:23to the eating disorder in the 1st place.
29:26Now because of this FBT, or family
29:28based treatment, is the most
29:30effective for weight restoration,
29:32but it does not work for all families.
29:34And so this is one of the places that
29:36we're getting into with these complex
29:38adolescents is for anybody here and I
29:40know you know probably everybody here
29:41who works with children and adolescents,
29:43some of the rule outs for things
29:45like this are you know the more toxic
29:47or negative family dynamics or any
29:49issues in the family system that
29:51would get in the way of treatment.
29:53That parents have to be available to
29:55do refeeding at all the meals and be
29:57monitoring those things and if there
29:59are things like co-occurring suicidality
30:01or high risk behaviors that it's
30:03it's often a counter indicator for
30:05family based treatment alone, itself.
30:07So that makes, as we're seeing this
30:10uptick this uptick in very complex cases,
30:13often things that we can pull from
30:15for this approach,
30:16but can be difficult to only
30:18implement when we have to address
30:20these other high risk concerns.
30:22Some of the other strategies then
30:24that we think about as well are
30:27things pulling from for example
30:29cognitive behavior therapy.
30:30So what CBT for eating disorders
30:32looks at is in essence a multi stage
30:35approach of both kind of starting
30:38with where somebody is at right after,
30:41especially more so after that immediate
30:43weight restoration that we need some
30:45stabilization there because again
30:46if somebody is in such a place of
30:49starvation or malnutrition engaging
30:51in cognitive strategies
30:53to change thoughts is you know an
30:56untenable task in a lot of ways.
30:58So we have to have that immediate
31:00stabilization and then we're focusing
31:02on really what are the roots of
31:04what's kind of perpetuated the
31:06disordered eating behavior.
31:07So things related to body image
31:09and addressing those concerns, the
31:11dietary restraint,
31:12how do we just restructure our
31:14schedule in day to make sure getting
31:16enough, and then identifying events,
31:17moods and stressors and preparing
31:20to address for what could be
31:22more stressors moving forward.
31:25Another very interesting approach
31:26that people pull from is I'm
31:28sure folks here are familiar with
31:31dialectical behavior therapy.
31:32What radically open dialectical behavior
31:34therapy is actually almost the opposite,
31:37to the extent or another end
31:39of the spectrum.
31:40So with the idea of DBT being
31:42for presentations of severe
31:44emotional dysregulation,
31:46radically open DBT focuses on
31:49presentations of maladaptive over control.
31:52So you think about, and the idea with
31:54um,
31:54with individuals or youth with that,
31:57with something like anorexia are
31:59often very disconnected from
32:01others, socially isolating, feeling
32:03a distance that leads to
32:05the depression and anxiety,
32:06and really wanting to mask those feelings.
32:08And so,
32:08so much of what the approach here
32:10is about being able to engage
32:12in more open expression,
32:14becoming more socially connected,
32:15feeling safe and secure.
32:17So it really is focusing in some ways
32:20similar to other approaches of that
32:22social and interpersonal connectedness.
32:24I always like to bring this one into
32:26the talk as well because I think that
32:29it highlights even the the model
32:31here highlights why the pandemic
32:32was so damaging for eating disorders
32:35is we're saying being socially
32:36connected to others is so protective
32:39for eating disorders because you
32:41you know if you're so isolated and
32:43so focused on the eating disorder
32:44and the restricting the foods,
32:46itself that being connected
32:47with others is really protective
32:49against that and that was taken
32:51away during the pandemic and had
32:53to be for the sake of
32:54of isolation.
32:57And then there is an approach here
32:59thinking of some almost just pragmatic
33:01and having resources for folks
33:04here that are looking for you know,
33:06I'm seeing some some students or
33:07people that I work with some eating
33:09concerns that I would like to address.
33:11It's not needing to go to a specialty
33:14eating disorder facility or requiring
33:16that type of intervention, is the
33:18integrative modalities therapy.
33:20So in essence what the authors did here
33:22was take a number of the treatment
33:24approaches and create a buffet.
33:25So it's not a a structured protocol.
33:27Um, it is a manual but basically takes a
33:29lot of the evidence based interventions
33:31that we have for eating concerns and
33:34has resources both for clinicians to
33:37utilize different formats used for group,
33:39for parent work,
33:40for individual work that
33:42hits on the foundations of these
33:44different ones that I mentioned.
33:46So they take the foundations of
33:48family based treatment and doing
33:49some family work without having to
33:51do purely the family based treatment
33:53model, using acceptance and mindfulness
33:55based approaches, focusing on again
33:57because that dietary restraint that
33:59pack and happens, engaging in more
34:02regulative and appetite of eating.
34:04So that structure of how to
34:06reconfigure those cues to let you know
34:08when you're hungry and full and then
34:09really focusing on body acceptance.
34:11So,
34:12so this is a wonderful one that I
34:14think is a great resource for anybody
34:16working with students or patients
34:18in these age ranges because it does
34:20have the pieces that you can kind of
34:22pull from and you can download what
34:24why you can't download the whole
34:26manual online and it does have
34:28to be purchased they are,
34:29I do highlight that all of their
34:31worksheets and things are freely
34:32available online and they have
34:34available for folks to download.
34:38So before and, trying to be mindful of making
34:40time for discussion points or questions,
34:43I do want to hit on some of the
34:44things that are most effective here.
34:46And one we're thinking about what this
34:48uptick in concerns and what's actually
34:50most effective to caring for youth with
34:52these concerns is that early detection
34:54is the the most effective thing.
34:56So it is, unfortunately we've gotten
34:57to this place with the crisis and
34:59care that we're in of having to be so
35:01reactive that a lot of times people
35:03aren't able to access care until you
35:05are requiring going to the hospital.
35:06But really what we know, because
35:09how these presentations can become
35:11so severe and protracted, is early
35:13detection and addressing those things
35:15that can lead to those,
35:17those very severe presentations
35:18is going to be the most effective.
35:20And so there are some really
35:23wonderful prevention programs that
35:24are really aimed at this.
35:26So one thinking specifically to school
35:28systems but have been implemented in
35:31other settings are things known as
35:33the body project. So for folks who
35:37aren't familiar,
35:38it's what's called a cognitive
35:40dissonance based program.
35:41It was actually developed to be
35:43implemented in high schools with
35:45with high school girls and what it
35:48does is really engender or promote
35:50a positive body image and social
35:52connectedness with the idea of then
35:54being a preventative approach to
35:56developing disordered eating concerns.
35:58Now of course during the course of
35:59the pandemic when at home for all the
36:02reasons that our behavioral health
36:03concerns escalated in the 1st place
36:05was quite difficult to implement.
36:06So what the the approach does is really
36:09challenge unwanted body comments,
36:11focuses on improving body image
36:14and connects other,
36:15connects students and patients with
36:17others that are impacted by the
36:20complicated relationship of food
36:21and exercise and really focuses
36:23on that validation.
36:25Because again,
36:26eating disorders are such isolating
36:28presentations that really feeling
36:30connected to others and validated in a,
36:32is a way of being protected and commits
36:35to making positive change as a group.
36:37So for folks that that are interested
36:39just to provide one resource and
36:41know no conflicts of interest on my
36:43end to disclose just thinking more
36:45of resources that are available.
36:47They do have workshops and things
36:48online to both train individuals who
36:50are interested in running such groups
36:52or even providing to students and
36:54families and patients of, for some
36:56of their online resources as well
36:58that really focuses on again that
37:00way of engendering healthy body
37:02images and self esteem within the
37:04school systems and really addressing
37:06more of that prevention.
37:08As opposed to why do we react when somebody,
37:11when something develops so significantly
37:12to require being in the hospital.
37:14But these all these things that we
37:16know that are risk factors for getting
37:18to that point and really building
37:20more healthful both connections
37:22with others and healthful practices,
37:24learning those things early on in
37:27a validating environment. OK.
37:29And I will stop there
37:33and would be open to any questions that
37:36that have been raised by the group.
37:43So I unmuted Nicole.
37:46I don't know if you want to ask your
37:49question or you want me to ask it.
37:51Oh yeah, I can definitely do that.
37:55My biggest struggle is I work with younger
37:58adolescents and I can usually see risk
38:01factors for eating disorders and they're
38:04not meeting criteria for diagnosis.
38:06What would you suggest as the best treatment,
38:09especially if there's minimal parent
38:12engagement and their behaviors can be
38:16impacting the risk? For reference,
38:18I'm in a school based clinical setting.
38:22Nicole, it's a really great question and I
38:25think that this is a crux of some of our,
38:27I guess to highlight why I think
38:29preventative work is so much more important
38:31is there's this whole idea of like a
38:33clinical staging model of probably what
38:35you are seeing are the patients that
38:37if when intervention doesn't happen,
38:39we end up seeing those more, you know,
38:41severe presentations and that question
38:43comes up of why don't we intervene earlier.
38:46To that point,
38:47I completely hear what you're saying.
38:49We're then it's hard to often get parental
38:51engagement to get the appropriate resources.
38:52Right.
38:53Because if somebody's not meeting criteria
38:55for a diagnosis that we can put down
38:57all the, all of the things that can make
38:59it more of a challenge for providers.
39:01I think really what I what we know
39:04across eating disorder presentations,
39:07what are some of the underlying
39:09challenges with the exception of those
39:12that are more related to like food
39:14sensitivity and if it truly is like
39:17a fear avoidance of textures or
39:19or pain, is the the benefits of body
39:22acceptance.
39:23So this is true of whether somebody's
39:25experiencing more loss of control or
39:27purging behaviors or more restrictive
39:29eating is really engendering and
39:31focusing on those pieces.
39:32So that even though it's the
39:34interesting part of eating disorder
39:35treatment of when somebody has developed
39:37a very, very severe presentation,
39:39almost what we have to do to stabilize
39:41them is so opposite of what
39:44actually helps long term right is
39:45because it's so focused on on the food,
39:48just getting into enough calories.
39:49But when you have somebody with more
39:51of that sub threshold presentation
39:53or the subclinical and you can
39:55really focus more so on engendering
39:57that positive body image and if
39:59possible to be able to identify what
40:01are some of those things at home that
40:04actually might be doing the opposite
40:05in a strength based way for parents,
40:07right.
40:07If the child can identify things
40:09that do make them want to skip meals
40:11or you know really focusing on
40:13that communication of it to really
40:15promote as opposed to here is what
40:17parents are doing wrong, right.
40:18But rather here's what we just
40:20know would be the most helpful.
40:23Yeah, that's great.
40:24Thank you.
40:28So I'll ask a follow up question to Nicole's.
40:31I don't quite know how to ask the question.
40:33So Rebecca, try to make some sense of it.
40:37I guess I was just thinking in if I were
40:39in schools the thing I'd be really struggling,
40:42there are multiple things that
40:43I'd really struggle with in
40:45in sort of helping these kids,
40:47the first one is sort of thinking about
40:49group level, school level interventions
40:52versus individual interventions and just
40:55here are your thoughts more
40:57about that and then what,
40:59what should someone do if
41:01they actually see a kid
41:04sort of struggling
41:05in this school setting,
41:07like what's the appropriate
41:09place of teachers and
41:12and adults to intervene and have
41:15what's an effective way to
41:17actually think about intervening?
41:20Both really great questions.
41:21I think that to the point of
41:23the individual versus group,
41:25I think when resources are available
41:27for group and if it is kind of being
41:30more implemented in a school setting,
41:32that's always what I would
41:33go with because again,
41:34I think that there's that to the point of
41:36how these presentations can be so isolating,
41:39it's that really it can be very
41:41validating and supportive.
41:42Now the reason that I bring up
41:44in the schools that that does
41:46seem and feel safer is when there
41:48are really severe presentations
41:50sometimes that can be less helpful
41:52right at like the inpatient level
41:53or things like that where more of
41:55because people aren't really in
41:56that place often of being ready
41:58to make changes of sharing some of
42:00the ways to more engage in the
42:03more problematic eating behavior.
42:05So group at higher levels of care
42:07aren't always the most effective
42:08but in the school based setting when
42:10we're thinking more from preventative,
42:12sub threshold presentations,
42:14getting socially connected,
42:15normalizing that it makes sense
42:17that these students are feeling
42:19uncomfortable about their bodies in this way,
42:21trying to promote more healthful ways
42:23that actually and healthful ways
42:26of managing relationships with food,
42:27as well as thinking about promoting
42:29not focusing on food so much what
42:31are the other kind of things we're
42:33focusing on in life that makes life
42:35worth living is the most protective.
42:38When doing individual work
42:40though to that point I think ways
42:41to continue to just provide that
42:43validating environment is the most
42:45important thing of kind of normalizing
42:47why this makes so much sense that
42:49the youth is struggling with it and
42:51also you providing that validation
42:53and acceptance to try to make change
42:57to then challenge some of those more
42:59negative thoughts. I think to the
43:01point or the to the question about
43:03the resources though and where to go,
43:05one of the you know, a lot of times
43:07as part of kind of series of talks
43:09I often have to give a talk on why
43:11parents are often very much in
43:12denial of realizing how severe their
43:14their child's presentation is.
43:16So I raised this to your point Dr
43:18Bloch is I think that that's something
43:20for school providers to be mindful
43:22of is just that we we do see with
43:26presentation with eating disorder
43:27concerns more more frequently we
43:30see parents kind of being resistant
43:32to acknowledging the severity of it
43:34because so many of the behaviors
43:36start very healthfully.
43:38And then there's this this thin line
43:40of when it does become maladaptive
43:42and these are, because these are often
43:45students or children who present
43:46as very high achieving,
43:48they're a bit anxious maybe you
43:50know kind of have, do really well in
43:52school doing all the things right
43:54and seeing things start to go in
43:56this scary more negative direction
43:58parents are understandably avoidant of.
44:00So there's been some qualitative
44:02work with parents who have
44:03you know in the interviews they
44:04talk about like "we had to be at the
44:06point of having go to the hospital
44:07before I could even
44:08acknowledge what was going on."
44:10So I think for school providers
44:12that are noticing those things,
44:14trying to think about how to
44:15approach with parents in that very
44:17supportive way and just being mindful
44:19of the parent potentially being
44:21very resistant to this feedback.
44:23And so very much in a
44:24non judgmental observation of just
44:26what has been noticed at school.
44:27The student is isolating more.
44:29The student is sitting alone
44:30at lunch and not eating.
44:31Just providing the data without
44:33any judgment to it and then
44:35providing some of the
44:37um, the ideas for resources to the families.
44:40I think approaching the if,
44:43I think offering to the child if
44:44there are groups going on is always
44:46a valuable thing and things that
44:48can be more related to the social,
44:50the social connection.
44:51I think though,
44:53unless the child is actually
44:55raising the eating concerns,
44:56that can be a quite a challenging
44:58things to raise at school because
45:00it is something that really just
45:01as part of the presentation
45:03is kept so much more hidden.
45:07OK, last question because I
45:09don't want to stand between
45:11people and the and their lunch.
45:13I guess another thing,
45:14I may be projecting a little bit on
45:16to the people who work at schools,
45:18but another thing that would worry
45:21me about trying to implement some
45:23of these more school based group
45:26interventions is not having anything
45:28to do with the kids that you identify
45:31as having more severe problems
45:33if you did the interventions.
45:35And so I guess it's two parts.
45:36Could you really do the interventions
45:38if you don't have a good place
45:39to send kids who are struggling?
45:42And then are there any places that
45:45are good resources for families?
45:48It's a great question.
45:49So I guess highlighting to the point of
45:51unfortunately the place that we're in is,
45:53there is and this is why we're
45:55trying to do more work of making
45:58eating disorder care more robustly
46:00available because it has become
46:02these very siloed niche areas.
46:04Those specialty places often do
46:06have more significant wait lists.
46:08But I think to the point of seeing more
46:11subclinical or less severe presentations
46:13but still clinically notable of
46:15wanting to address making sure just
46:17connected to a mental health provider
46:19to address what's often the
46:21co-occurring concerns is very important
46:23that then can integrate some of the
46:25work related to to body image concerns.
46:28I think for if they are seeing more
46:31significant presentations but a
46:33lack of kind of access to an eating
46:35disorder specific facility,
46:37there is a program called equip EQUIP
46:42that is a telehealth resource that
46:46provides an interdisciplinary team.
46:49And virtually for families who
46:50aren't able to access it,
46:52again in person care is always preferred,
46:55but they they do integrate elements of
46:57family based treatment as well as with
46:59strategies from things like CBT or DBT.
47:01And I know for some of our families
47:04that haven't been able to access the
47:06appropriate kind of levels of care,
47:09it is a resource that we have
47:11used with some success.