Chapter 13: Feeding and Eating Disorders

PICA

• eating of nonnutritive, nonfood substances over a period of at least a month

• minimum age of onset of at least 2 years to differentiate it from more normative mouthing of objects common in infants

Rumination Disorder

• repeated regurgitation of food, which is then rechewed, swallowed, or spit out

• while rumination disorder can co-occur with an ID, ASD or other developmental problem, it is not separately coded unless it requires clinical attention in the treatment plan.

Avoidant/Restrictive Food Intake Disorder (ARFID)

• characterized by either avoidance of eating or restriction in the types of foods that are consumed

• significant adverse health outcomes or impair psychosocial functioning, as indicated by at least one of the following: significant weight loss or failure to meet growth milestones, a nutritional deficiency,

Anorexia Nervosa (AN)

• is characterized by three major criteria: significant curtailment in energy intake leading to significantly low weight, fear of gaining weight or presence of behaviors that interfere with weight gain, and disturbance in perceived weight or shape

• can be subtyped as either binge-eating/purging type or restrictive type

Bulimia Nervosa (BN)

• consists of three major features: binge-eating episodes, compensatory behaviors designed to prevent weight gain, and self evaluation that is disproportionately influenced by body weight and shape

• binge is defined as a discrete period (e.g., two hours) in which the individual consumes an inordinately large amount of food,

• Compensatory behaviors include purging, excessive exercise, fasting, and misuse of substances

Binge-Eating Disorder (BED)

• characterized by episodes of binge eating without the presence of compensatory behaviors discussed above for BN

• occur at least once a week for at least three months

• marked distress and at least three of the following: eating more rapidly than normal, eating until uncomfortably full, eating large amounts when not hungry, eating alone because of embarrassment, and feeling negative afterward

Assessment Strategies

• Feeding Disorders Assessment

• Eating Disorders Assessment

Eating Disorders Assessment

• Eating Disorders Inventory-3

  • make an accurate assessment of symptoms to determine issues such as level of treatment

• Eating Disorders Examination Questionnaire

  • can also be used to assess for the severity of a wide range of eating disorder (ED) symptoms

Feeding Disorders Assessment

• For pica, the assessment should include a full medical evaluation not only to identify acute complications but also to uncover potential underlying etiologies, such as malnutrition or vitamin or mineral deficiencies

• Rumination disorder also necessitates a medical examination to rule out medical etiologies and to assess for medical complications such as malnutrition.

• ARFID also requires a medical evaluation to rule out any underlying medical etiology as well as medical sequelae of the avoidant or restrictive eating

PICA Treatment

• Psychoeducation for the parent (e.g., childproofing home from objects that might be ingested)

• Behavior therapy (time out, overcorrection) to decrease pica behaviors and to increase more normative adaptive behaviors.

• Environmental enrichment interventions, such as play therapy, may be an adjunctive treatment

Rumination Treatment

• Psychoeducation for the parent

• Behavioral treatments that include activities that are incompatible with regurgitation behaviors at high-risk times

• Enhancement of caregiver–infant relationship

• Stabilization of family stressors

ARFID Treatment

• Behavioral interventions to help caregivers normalize eating and increasing the range of foods consumed

• Psychoeducation for parents, including creating a calm eating environment and avoiding coercive techniques, such as forcing the child to eat everything that is on the plate

• Use of counter conditioning by introducing a novel food in combination with a preferred food as a way of broadening the eating repertoire

• Cognitive behavioral therapy approaches are recommended for older children, adolescents, and adults, including techniques such as exposure, cognitive restructuring, and systematic desensitization

Anorexia Nervosa Treatment

• Family-based treatment (FBT) is recommended as the most effective intervention for children and adolescents who experience AN, with the most research support of any treatment studied to date

Anorexia Treatment Phase One

• Goals

  • (a) encouraging all family members to increase motivation for treatment,

  • (b) providing a referral for medical monitoring and agreeing upon a weight that must be maintained if the client is to stay in outpatient treatment,

  • (c) placing an emphasis on the seriousness and potential morbidity of the disorder,

  • (d) providing a thorough rationale as to why the parents will be temporarily taking control over their child’s eating, and

  • (e) keeping a focus on weight gain as the primary goal in counseling during Phase One

Anorexia Treatment Phase Two

• phase begins when the client has gained weight and the parents no longer struggle with having to force their daughter to eat nutritious meals and snacks on a regular basi

• parents slowly give her back her autonomy over eating choices

Anorexia Treatment Phase Three

the focus begins to turn away from eating and weight gain, and more toward normal adolescent developmental issues, such as dating, peers, academics, and increasing independence

Treatment of Bulimia Nervosa (BN)

• Cognitive behavioral therapy (CBT) is the recommended treatment for BN in older children and adolescents

• it remains the first-line treatment for child and adolescent BN

BN Treatment Phase One

• The goals of phase one (generally eight twice-weekly sessions) include:

  • (a) building a relationship with the client so that she is motivated and committed to treatment;

  • b) providing psychoeducation about the CBT model, the consequences of extreme dieting, and the ineffectiveness of purging methods such as vomiting, laxative, and diuretic abuse; and

  • (c) establishing weekly weighing procedures so that she will realize she is not gaining weight as she begins to eat on a more normal basis.

• introduction of regular eating patterns so that the client (with the assistance of her family) begins to plan and eat three meals per day and two snacks, with no more than a four-hour interval between eating.

BN Treatment Phase Two

he counselor may need to spend additional time on the client’s motivation and commitment to change, or to determine whether she is following her eating plan

BN Treatment Phase Three

• to begin to help the client change her attitudes and behaviors that stem from her overvaluation of weight and shape concerns.

• cognitive restructuring exercises to help her changing belief patterns about the importance of weight and shape them in determining her success or worth as a person

• A second goal of Phase Three is to reduce dietary restraint.

• learn new ways for managing negative moods and stressful events

BN Treatment Phase Four

• is to explore the idea of termination so that the client can maintain her improvements without the support of a counselor.

• can renew her commitment to regularly scheduled, nutritionally sound eating patterns, to refrain from dieting because this will set her up for binges, to identify areas needing continued improvement, and to plan for how she might cope with certain triggers or a relapse

Treatment for Binge Eating Disorder (BED)

conceptualized through a dietary restraint model (Stice et al., 2008) and an emotion dysregulation model

CBT for BED

• is recommended as the first line of treatment for adolescents who are immersed in a cycle of dieting and binge eating and who tend to overvalue weight and shape in determining their self-worth

• the goal is to eliminate dieting by normalizing eating and to decrease the importance of weight and shape

Interpersonal Therapy (IPT) for BED

• counselors using IPT do not discuss diets, food, or weight, and instead target relationship enhancement

• is generally recommended for clients who have significant impairment in their relationships, lack adequate social support, and lack skills to effectively express feelings with others

Interpersonal Role Disputes (BED)

• In the IPT approach, the counselor can assist the client in first creating a history of her relationship conflicts.

• The counselor then helps her assess the particular stage of the conflict:

  • negotiation (relationship is still open to improvements), impasse

  • (relationship is stuck with neither person being willing to change), or

  • dissolution (relationship is considered beyond repair).

Interpersonal Role Transitions

• Clients who have problems with role transitions are those who have difficulties in letting go of one role and stepping into a new one.

• Adolescents undergo many transitions during this period, including the transition to puberty, changing schools, the onset of dating, peer pressures, and negotiating new roles with parents

• Recommended strategies

  • Define the previous role.

  • Fully examine the new role.

  • Realistically explore what the new role requires