Supporting Prepubertal Children with anorexia nervosa – a clinician’s experience

Five patients under the age of twelve have presented with Anorexia Nervosa in the last six months to our community CAMHS Eating Disorders Team, in the North of England, representing 16% of our average annual caseload.

When underlying themes from the clinical work were explored, we found that there was a wide range of difficulties, similar to those often seen, in both generic and eating disorder community CAMHS work. These included issues of attachment, safeguarding, elite competitive sporting activities and difficulties with family mental and physical ill health.

All five children required acute care, in the form of paediatric admission, for monitored refeeding at the beginning of treatment. This highlights the rapid physical compromise that can occur in younger patients and also the systemic difficulties in the early recognition of eating disorders in younger patients, by the wider community.

Our team experienced additional challenges in engaging families in the therapeutic process of planning for and achieving Paediatric discharge. We observed raised parental anxiety about physical compromise, which at times undermined parents’ efforts to refeed their child.

We acknowledged that (unlike adolescent onset Anorexia Nervosa) it is more difficult to measure restoration of physical health in prepubertal children, as pubertal physical development has not yet occurred.

Recent published research reflects these difficulties in presentation and treatment. A large child surveillance study (Nicholls et al. 2011) suggests that the incidence of childhood onset Anorexia Nervosa may be increasing, although data in this area remains limited. This study surveyed early onset cases of eating disorders in patients less than 13 years and found that the average time to presentation to services was over 8 months.  This study also highlighted that there is a poorer prognosis in this age group, with 50% being admitted to hospital early on in their presentation to service and most still in treatment one year later (Nicholls et al 2011, Hudson et al 2012).

Recent re-classification of eating disorders in DSM-5 (American Psychiatric Association 2013), combines feeding and eating disorders into one category. This presents an opportunity to consider the experience of eating, growth and development across the lifespan and in the context of treatment (Nicholls 2015).

Implications

Increased awareness of the possibility of anorexia nervosa in prepubertal children may increase early detection and access to intervention. Studies have suggested that training of GPs, Pediatricians and teaching staff may be key interventions to promote early detection (Neubauer et al 2014, Hudson et al 2012, Nicholls 2015). This is an area warranting further research.

Our teams’ reflection on these five cases led us to consider the importance of taking a good early feeding and attachment history to inform future family based therapeutic work.  We found that acute paediatric hospital admission to address physical health needs can interfere with the systematic gathering of such information by mental health specialists which highlighted to us the need to find effective ways of doing this.

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). APA.

Hudson, LD, Nicholls, DE, Lynn, RM et al (2012) Medical instability and growth of children and adolescents with early onset eating disorders. Archives of Disease in Childhood, 97: 779–84.

Neubauer K, Weigel A, Daubmann A, Wendt H, Rossi M, Löwe B, Gumz A (2014) Paths to first treatment and duration of untreated illness in anorexia nervosa: are there differences according to age of onset? European Eating Disorders Review 22(4):292-8

Nicholls DE, Barrett E (2015) Eating Disorders in Children and Adolescents British Journal of Advances 21 (3) 206-216.

Nicholls, DE, Lynn, R, Viner, RM (2011b) Childhood eating disorders: British national surveillance study. British Journal of Psychiatry, 198: 295–301.

This is an independent article and the views are not necessarily those of ACAMH.

Discussion

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Very interesting ..over last 2 weeks i was dealing with 2 cases of 13 years old girls who presented with severe anorexic symptoms …red risk category in Marsipan risk screen …

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