Eighty seven percent of eating disorders strike children under the age of twenty. With eating disorder cases now reported in children as young as age five, effective pediatric diagnosis and treatment intervention is critical. The most lethal of all the mental health disorders, anorexia and bulimia remain two of the most widely under-diagnosed, misunderstood, and under-treated diseases of childhood. They require specialized treatment skills and a unique use of a physician's self in relation to both patient and parents. When a singular child walks through the pediatrician's door, that physician must be prepared to attend to the needs of a "crowd," including patient, parents, treatment team professionals, school personnel, etc.


The Challenge of Diagnosis:
The most trusted and available resource for parents and the first line of defense for prevention and cure, pediatricians are the messengers of truth about disorders that rest on a foundation of misconceptions, false logic and denial. The pediatrician's first task is to detect incipient eating disorders in-the-making, and/or critical early signs of disease; this can be accomplished through developing a heightened awareness of an oftentimes invisible and hard-to-access diagnosis.
 - Symptoms of eating disorders will not show up as such in the typical pediatric exam; Diagnostic blood or lab tests, EKG's and bone scans will not indicate the presence of an active disorder until its latter-most stages.
- The child patient cannot be expected to willingly disclose a disease that she fears she cannot live without. Pediatricians need to learn to listen "between the lines" for attitudes and disordered eating patterns that could ultimately trigger a clinical disorder in a genetically susceptible child. Patients and parents frequently consider patterns such as dieting and skipping meals as being "normal."
 - Pediatricians need to learn to proactively screen for such problems. "Give me an idea of what you eat on any typical day." Children too young to accurately report such information may need the help of parents to describe behaviors, habits and attitudes around food, eating and weight management.
 - It goes without saying that physicians need a clear personal understanding and appreciation of what "healthy eating" actually is, so that they can educate parents, who in turn can educate and properly nourish their child. Common myths about healthy eating is that fat-free eating is healthy eating, and that dieting is the best way to lose weight.


The Initial assessment
In assessing the eating disordered child patient, the pediatrician's primary task is to monitor the physical body, establishing the preliminary base-line for the vital signs which will be checked in all follow-up visits. Visit frequency needs to be determined at the pediatrician's discretion, dependent on the needs of the child. The initial assessment of child's physical and emotional health will determine the appropriate venue for care. It is for the medical doctor to decide whether or not the patient has adequate physical leeway or "wiggle room" to initiate the recovery process safely in an out-patient milieu, or if immediate hospitalization will be required.

Indicators for hospitalization include the following criteria:
 - The child is at risk physiologically.
 - The child's mood and emotional incapacity renders him/ her unable to perform daily life tasks, to study and learn at school, to take part in family or social life.
 - The child who has not been able to demonstrate substantive progress towards recovery in out-patient psychiatric care is a candidate for referral to a hospital in-patient or partial day program.

For the child in on-going treatment for an eating disorder, the multi-disciplinary team of professionals will collaborate to make these determinations about care venue throughout the course of treatment. Bottom line, however, the responsibility for the medical well-being of the stricken child lies squarely with the medial doctor. The fate of Terri Schiavo is a clear warning about what can happen when these disorders are over-looked and not treated early on. The law suit brought against the doctor who missed her diagnosis early on is another clear warning.


An Integrative Use of the Physician's Self
The medical/physiological and weight-related aspects of eating disorders that would ordinarily catch the pediatrician's eye and warrant his or her attention, assessment, and care are but the tip of the eating disordered behavioral/emotional/ developmental/genetic "iceberg." Because eating disorders fall "between the cracks" of the medical doctor's purview, expertise, responsibility and interest, the role of the pediatrician with patient and team throughout recovery can be elusive if the doctor does not remain clearly and consistently connected to the needs and progress of both child and recovery process. In one instance, a pediatrician gave "thumbs up" to an eleven year old child whose Mother reported that he "whipped out his weight chart" and dismissed the child from care after she'd been able to gain just enough weight to climb back onto the official weight chart in the category of low/normal. "He says she's okay at the weight she is at." By making this declaration, the doctor inadvertently gave new life to the child's complacency and denial about her disease, and to her determination to lose the weight she'd gained. By failing to recognize that the standard for measuring recovery progress is not in weight gain alone, the physician missed an opportunity to treat the child's still life-threatening disease and to support a parent in her effort to support her child's recovery.


Hard-to-recognize, hard-to-access, and hard-to-treat, eating disorders take lives and/or compromise life quality, even while being coveted, hidden and held close by their victims. The irony of these diseases is that as difficult as recovery is, when cured, victims and families attest to feeling privileged to have experienced this most precious opportunity to facilitate the child's developmental and emotional growth, even while curing the disorder; parents and children alike report feeling gratitude that life and personality returns to the child, while the child lost to loved ones is returned to the family.


12 Guidelines for eating disorder assessment and care

1. As screening diagnosticians, physicians probe to discover imminent or lurking eating disorders and/or disordered eating. I recommend that pediatricians stay vigilant during general physicals, listening for otherwise unspoken issues around food and eating, body image concerns and weight management, particularly in the child experiencing the (early) onset of puberty. Puberty is a major trigger to the onset of disease in the genetically susceptible child.

2. Physicians gather baseline information and monitor weight, vital signs, blood and lab tests (potassium levels), heart function, (EKG), bone density tests, and sleep and eating patterns that could indicate depression or anxiety.  Inquire as to the abuse of laxatives, diuretics, diet pills, Ipecac, and other substances such as alcohol, drugs, and nicotine; asses client for suicidal ideation.

3. The planned frequency of doctor visits will vary according to the physical condition and needs of the child. The pediatric/patient relationship is likely to become a long-term, monitoring connection; the patient should not leave the office without having a future meeting time set up. A competent and cooperative nutritionist on the treatment team who agrees to be responsible for weekly weigh-ins might safely diminish the frequency of medical monitoring.

4. Pediatricians frequently make referrals to out-patient team members and/or milieu care; placement options may include outpatient individual and family treatment, hospital day or partial-day program, inpatient hospitalization for stabilization and re-feeding, long-term residential care or half-way house living, or psychiatric and medication evaluation. In prescribing medication for co-morbid mood disturbances, doctors should be aware that Welbutrin causes seizures in patients who purge.

5. Physicians are responsible for hospitalizing an at- risk child. Tube feeding needs to take place in in-patient settings; re-feeding in the form of compulsory meals occur in partial in-patient milieus. Hospitalization does not cure eating disorders; it can stabilize a compromised physical condition, jump-start a stalled eating process, and prepare the child to better utilize outpatient resources and the environment at home to heal. Indicators for hospital care include: the patient is at risk physiologically; too impaired to function adequately in established life roles; unable to make adequate recovery gains through out-patient treatment.

6. The physician may need to become the de facto case/team manager, though it is more typical for the teams' psychotherapist to assume that role, or for team members to initiate communications based on need.

7. Physicians may assign behavioral tasks and negotiate behavioral "contracts" around weight, eating and the extinction of dysfunctional behaviors, stimulating the capacity for self-awareness, self-determination, and accountability. "Homework" can provide essential diagnostic information as well as opportunities for learning, ultimately enhancing the psychotherapeutic, nutritional and cognitive-behavioral change processes.

8. By taking on the role of "policeman" in demanding treatment compliance, by assuming responsibility for setting limits and extending realistic consequences such as milieu change, or the prohibition of exercise, medical doctors protect the more fragile dynamic of the psychotherapist/patient relationship.

9. It is up to the pediatrician to prescribe a reduction in exertion for the undernourished child. Athletics and exercise should be reduced or curtailed until such time as weight and menstruation are restored and compensatory calories are ingested to accommodate burned calories.

10. Doctors are educators, brokers of recovery through reality-testing and truth. Children and parents need to grasp the often counterintuitive, often paradoxical nature of eating disorders. For instance, weight restoration does not make a thin person fat; eating regular meals enhances metabolic function, resulting in a healthier and more sustained thinness; the child who diets has a greater risk of becoming an overweight adult; fat in a child's diet is essential to facilitate the development of cerebral neurons.

11. Physicians are educators; they need "to say it like it is." In the face of "I can fix this disease on my own," children need to hear the kind, but firm declaration that this statement does not apply to the mal-nourished brain which is incapable of reasonable judgment and effective problem-solving.

12. Physicians, beware communication pitfalls that compound a parent's confusion. Consider the following statements made by otherwise competent physicians.

  -  "You aren't fat and you do eat, so you can't be anorexic." This statement was made by a psychiatrist to a woman in her 20's who is now in her 50's and still struggling actively with her anorexia.

  -  "Your blood tests are normal. You're good to go." This statement was made by an internist to a 23 year old bulimic woman who self-mutilates, drinks, smokes pot and cigarettes, and alternately starves and binges, purging close to everything she swallows.

  -  "I wouldn't worry about it. You aren't about to starve." This same bulimic woman was told this by her medicating psychiatrist, alluding to her slightly overweight figure. By so doing, he discounted her disorder, disregarded her severely damaged and malfunctioning metabolism, demeaned and set back her battle to recover. His statements motivated her continuing commitment to starvation.

  -  "Don't worry. Most women don't have regular menstrual periods till their 20's." This misconception was communicated by a pediatrician to an anorexic athlete who had lost her period.

  -  A pediatrician reassured a child athlete; "Being without your period now is not harming you." This doctor neglected to speak about the dangers of osteopenia and potential infertility. Despite popular belief, forced menstrual regularity brought on by birth control hormones does not alleviate these problems.

  -  A pediatrician prescribed diuretics for a bulimic teenager whose goal was to "eliminate bloating during her period."

  -  The chief psychiatrist in an inpatient adolescent psych unit in a highly respected Chicago hospital, in response to a mother concerned about the fasting of her anorexic teen-ager hospitalized for depression and cutting, replied that she wouldn't be concerned. Americans eat far too much protein, anyway."

  -  The cardiology consultant in the case of the teen whose heart-rate had dipped to 36 beats per minute (sinus bradycardia) reported that the anorexic teenager's exceedingly low heart rate is "the benign indicator of an accomplished athlete," and sent her away "cleared for sports" and leaving the youngster of the mind that she was in sterling health.

  -  Physicians, beware the myth of "stability." A young woman, who had been anorexic for more than two decades, was rapidly losing inches though she maintained her weight at 73 pounds. She assumed that because her weight was "stable," she was "doing well." This woman's weight may have been stable, but the status of her health was not. Stability such as this has been known to lead to premature death of young matrons in their late 30's and early 40's.