ISSUES IN ADOLESCENTS AND CHILDREN
From Cutting-Edge Issues in Adolescent Psychiatry: Substance Abuse, Psychopharmacology, and Forensics, presented
by the American Society for Adolescent Psychiatry and Southwestern Medical Center
Educational Objectives
| The goal of this program is to improve treatment of children and adolescents with mental illnesses. After hearing and
assimilating this program, the clinician will be better able to:
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 | 1. Diagnose anorexia nervosa and bulimia nervosa and distinguish subtypes of each.
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| 2. Describe medical conditions associated with starvation and with bingeing and purging.
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| 3. Manage the treatment of patients with anorexia and bulimia nervosa.
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| 4. Discuss the significance (in the context of the current epidemic of obesity in the United States) of weight gain
in children and adolescents who take atypical antipsychotics.
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| 5. Monitor children and adolescents who take atypical antipsychotics for weight gain, glucose intolerance, prediabetes,
and diabetes.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the
planning committee reported nothing to disclose.
Acknowledgements
Drs. Rickin and Meltzer were recorded at Cutting-Edge Issues in Adolescent Psychiatry: Substance Abuse, Psychopharmacology,
and Forensics, held March 27-30, 2008, in Boston, MA, and sponsored by the American Society for
Adolescent Psychiatry and Southwestern Medical Center. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
| EATING DISORDERS IN CHILDREN AND ADOLESCENTS —Eric Rickin, MD, Assistant Professor of Psychiatry,
Western Psychiatric Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
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| Introduction: little literature on eating disorders in adolescents; information often must be extrapolated from
data on adults
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| Definitions: criteria from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
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| Anorexia nervosa: refusal to maintain minimal (85%) body weight for age and height; failure to maintain weight
due to weight loss or failure to make expected weight gain during growth period (in Europe, ideal body weight
calculated from body mass index [BMI], but in United States, tables from variety of sources used); intense fear
of gaining weight or becoming fat, even though underweight; disturbance in experience of weight or body shape,
undue influence of body weight or shape on self-evaluation, or denial or seriousness of low weight; amenorrhea
does not occur in all women and will be dropped as criterion in Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition, (DSM-V; speaker recommends disregarding it under DSM-IV); types—restricting type
(food intake restricted, with no binge eating or purging behavior); binge eating/purging type (normal amount of
food eaten, followed by binge eating or purging behavior)
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| Bulimia nervosa: eating large amount of food in discrete period (<2 hr) that is more than most people would eat, or
loss of control over eating during episode; recurrent inappropriate compensatory behavior (eg, self-induced vomiting,
misuse of laxatives, diuretics, enemas, or other medications, fasting, excessive exercise) to prevent weight
gain; binge eating and compensatory behaviors occur, on average, at least twice weekly for 3 mo; self-evaluation
unduly influenced by body shape or weight; does not occur exclusively during episodes of anorexia nervosa;
types include purging type (regular engagement in self-induced vomiting or misuse of laxatives, diuretics, or enemas)
and nonpurging type (use of other inappropriate compensatory behaviors such as fasting or exercise); bulimia
differentiated from purging-type anorexia nervosa by extremely low weight in latter
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| Eating disorder not otherwise specified (NOS): any eating disorder that does not fully meet criteria for anorexia or
bulimia nervosa; most common diagnosis among those who seek treatment; spectrum includes behaviors of anorexia
and bulimia nervosa, and binge-eating disorder (defined as binge eating without compensatory behaviors
of bulimia nervosa; patients often overweight or obese, have distress from binge eating; bingeing at least 2 days/
wk for 6 mo; will be separate diagnosis in DSM-V)
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| Epidemiology and outcomes: anorexia nervosa—preva-lence 0.3% to 1%; female-to-male ration 10:1; peak age
at onset, 15 to 19 yr; tends to be chronic; 50% to 60% recover, 30% improve, and 7% to 15% experience chronic
course; mortality 5.6% per decade in patients with chronic course (highest of any psychiatric disorder); bulimia
nervosa—prevalence 1% to 3%; female-to-male ratio 10:1; peak age at onset, late teens to early 20s; fluctuating
short-term course, with cycles of remission and exacerbation; high relapse rates; no increased risk for death
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| Etiology: unknown but multifactorial; biologic—family and twin genetic studies suggest strong genetic component;
genetic-linkage and association studies implicate several susceptibility loci; neurotransmitter studies indicate dysregulation
in serotonin, dopamine, and/or norepinephrine; psychologic—low self-esteem; perfectionism; neuroticism,
difficulties in self-soothing or affect regulation; people with anorexia nervosa tend to be obsessive, rigid, and
harm-avoidant; those with bulimia nervosa tend to be impulsive and have difficulties with self-regulation; results
of Minnesota Starvation Experiment showed that starvation itself causes many behaviors seen in anorexia nervosa;
family and sociocultural—high levels of family conflict; parental preoccupation with weight and shape; unrealistically
high expectations for achievement; sociocultural overvaluation of thin-body ideal
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| Medical issues associated with starvation: cardiovascular—hypotension and orthostasis; sinus bradycardia;
QTc and T-wave changes on electrocardiography (ECG); edema (etiology unknown; worst in patients with purging-type
anorexia nervosa during refeeding); gastrointestinal (GI)—constipation; decreased gastric motility; nutritional
hepatitis (rare); hypercholesterolemia; endocrine—decreased basal metabolic rate; disturbances in growth
hormone, cortisol, and thyroid function tests; hypoglycemia; decreased libido; possible amenorrhea;
hematologic—bone marrow hypoplasia; leukopenia with relative lymphocytosis; anemia; nervous system—
seizures in ≤5%; depression; sleep disturbance; poor concentration; apathy; weakness; paresthesias; hypothermia;
hyperacuity to noise and light; structural brain changes on magnetic resonance imaging (MRI)
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| Medical issues associated with bingeing and purging: GI-related—hyperamylasemia and parotid gland enlargement;
pancreatitis (check lipase, not amylase); esophageal reflux; gastric dilation/perforation; upper GI bleeding;
gastroduodenal ulcers; erosion of tooth enamel and periodontitis; cardiovascular—arrhythmias due to
hypokalemia; cardiomyopathy (due to use of emetics); biochemical disturbances—decreased levels of potassium,
sodium, phosphorus (especially during refeeding), magnesium, and calcium; metabolic alkalosis (due to vomiting);
metabolic acidosis (due to use of laxatives)
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| Management: patient must have primary care physician for managing medical issues; patients often need frequent
laboratory tests and ECGs; approach must be multifocal (medical management, psychotherapy, psychopharmacology)
and multidisciplinary (psychiatrist, therapist, dietitian, primary care physician); levels of care available include
acute hospital, day hospital, intensive outpatient, outpatient, and residential; consider residential (ie,
hospitalization) if weight <75% of ideal body weight, to stabilize and treat physical complications, to interrupt
binge-purge cycle, vomiting, or laxative abuse that poses medical risks, and/or if patient has comorbid psychiatric
disorder, especially depression and/or suicidality
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| Treatment of anorexia nervosa: restoration of weight cornerstone of treatment; psychotherapy includes family
therapy for children and adolescent patients, and cognitive behavioral therapy for adults; Maudsley/Lock-
LaGrange program trains family members to be primary therapists in home; phase 1 devoted to refeeding, lasts 3
to 5 mo; phase 2 comprises negotiations for new relationship patterns; phase 3 comprises dealing with adolescent
issues and termination; pharmacotherapy—not primary treatment but may be useful for comorbidities; antidepressants
not effective in patients with <85% of ideal body weight and do not help in maintenance treatment;
atypical antipsychotics may help decrease anxiety and body-image distortions; benzodiazepines may help decrease
anxiety in short term
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| Treatment for bulimia nervosa: selective serotonin reuptake inhibitors (SSRIs) moderately helpful in decreasing
bingeing and purging; studies just beginning with topiramate (use cautiously); avoid bupropion, due to increased
risk for seizures; cognitive behavioral therapy
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| ATYPICAL ANTIPSYCHOTICS AND METABOLIC SYNDROME IN ADOLESCENTS AND CHILDREN —
Bruce Meltzer, MD, Assistant Professor of Pediatrics and Child Psychiatry, University of Massachusetts Medical
School, Worcester
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| Introduction: most data on metabolic syndrome from studies in adults; difficult to assess cardiovascular risk and
medication effects in children, whose height, weight, and BMI constantly change; guidelines include the Adult
Treatment Protocol (ATP) and guidelines of World Health Organization (WHO); WHO guidelines stress prevention
of insulin resistance, prediabetes, and diabetes (“which [are] actually not uncommon among kids”); insulin resistance
and prediabetes best predictors of who develops metabolic syndrome
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| Obesity: ideal BMI, 19 to 21; mortality increases as BMI >21 or <19; known since antiquity that death more common
among overweight people than among lean; recent studies show obesity and death more common among severely
and persistently mentally ill (although some statistics not corrected for suicide); abnormal glucose tolerance
in young children associated with low rates of diabetes, but by early adolescence, glucose intolerance progresses to
prediabetes and to frank diabetes
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| Risk factors for metabolic syndrome: in adults, prediabetes, obesity, and elevated blood pressure (BP); early
evidence indicates these risk factors also present in children; National Health and Nutrition Evaluation Study
(NHANES) shows that BP starts to become elevated in people who are as little as 5% overweight; autopsy findings
on youth killed in accidents show fatty streaks and raised lesions (predictors of coronary artery disease) already
present in 15- to 24-year-olds
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| Population-based risks: 15% of children in United States overweight; obesity rates for individuals 2 to 19 yr of age
doubled in last 3 decades, and tripled for children 6 to 11 yr of age; takes ≈10 yr from onset of insulin resistance to appearance
of first symptoms of diabetes; however, the heavier the individual, the faster the progression; poverty, more
than any other factor, associated with obesity; Mississippi, Alabama, and West Virginia were states with highest rates
of obesity in 2002; in 1994, Alabama and Louisiana had obesity rates >6%; unclear why rates of obesity and death
higher in people with severe and persistent mental illness (may be sedentary lifestyle, may be that genetic factors that
predispose to mental illness also predispose to obesity)
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| Second-generation (atypical) antipsychotic medications: associated with weight gain in many cases; as of 2003,
all antipsychotic agents must carry warning about risk of developing hyperglycemia and diabetes; as number of prescriptions
for atypical antipsychotics rose, number of prescriptions for typical antipsychotics remained stable; speaker
suggests this is because primary care providers more comfortable prescribing atypical antipsychotics; “boys are vastly
over-represented” in prevalence of use of atypical antipsychotics from birth to 19 yr of age; data supporting safety and
efficacy of atypical antipsychotics in children and adolescents very limited; weight gain single greatest concern
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| Ziprasidone: study shows children and adolescents respond differently to ziprasidone than do adults; young people
gained weight on ziprasidone, compared to molindone, and to adolescents (“gaining weight is awful”); another
study showed that patients who gained weight improved psychiatrically, indicating that those patients were compliant
with medication regimen
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| Schizophrenia and diabetes: association known since 1919 (before discovery of antipsychotic medications); at
that time, rates of diabetes in patients with schizophrenia 2 to 4 times greater than in general population; quadrupled
with introduction of chlorpromazine (Thorazine)
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| Not everyone gains weight: no method to predict which patients will gain weight on atypical antipsychotics;
dose-response relationship not seen in clinical use; weight of patients on olanzapine must be monitored carefully;
few studies available on weight gain and aripiprazole in adolescents (tends to be weight-neutral in adults)
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| Monitoring: growth charts available from Centers for Disease Control and Prevention (www.cdc.gov); Hispanic
and Asian American children tend to follow different course from white children; consensus protocol for monitoring
children and adolescents derived from adult literature; suggests examining family history, and monitoring
weight, waist circumference, BP, fasting blood glucose, and fasting lipid profile; speaker able to incorporate all
monitoring and screening on 1-page form in his own practice
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| Diet recommendations: in speaker’s program, children told to pay attention to “4 Ss,” ie, seconds, sweets, snacks,
and soda (not just regular sodas; some evidence indicates that diet sodas, by unclear mechanism, drive appetite); recommendations
for cholesterol screenings—positive family history (proband with cardiovascular event before 50 yr of
age in males, age 60 yr in females); if total cholesterol <240 mg/dL, speaker obtains nutrition consultation and focuses
on psychoeducation and encourages physical activity; if total cholesterol >240 mg/dL, high-density lipoprotein (HDL)
cholesterol >160 mg/dL, or triglycerides >300 mg/dL, consider medication; some types of oral contraceptives can increase
low-density lipoprotein (LDL) cholesterol; dietary interventions—reduce calories and saturated fats; increase
whole grains, fruits, and vegetables; eat fruits for snacks; speaker’s program encourages children to get ≈2 hr/day of
exercise (“we write prescriptions for exercise”); dietary maxims—portion control; impulse control; appropriate food-
group selection; healthy exercise
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Suggested Reading
Biederman J et al: A prospective open-label treatment trial of ziprasidone monotherapy in children and adolescents
with bipolar disorder. Bipolar Disord 9:888, 2007; Chavez B et al: Atypical antipsychotics in children with pervasive
developmental disorders. Paediatr Drugs 9:249, 2007; Couturier J, Lock J: A review of medication use for children
and adolescents with eating disorders. J Can Acad Child Adolesc Psychiatry 16:173, 2007; Couturier J: New developments
in child and adolescent eating disorders. J Can Acad Child Adolesc Psychiatry 16:151, 2007; Crook ED, Peters
M: Health disparities in chronic diseases: where the money is. Am J Med Sci 335:266, 2008; Diabetes Prevention
Trial-Type 1 Diabetes Study Group: Effects of insulin in relatives of patients with type 1 diabetes mellitus. N
Engl J Med 346:1685, 2002; Eaton DK et al: Centers for Disease Control and Prevention (CDC). Youth risk behavior
surveillance--United States, 2007. MMWR Surveill Summ 57:1, 2008; Fleischhaker C et al: Clinical drug monitoring
in child and adolescent psychiatry: side effects of atypical neuroleptics. J Child Adolesc Psychopharmacol 16:308, 2006;
Goldschmidt AB et al: Subtyping children and adolescents with loss-of-control eating by negative affect and dietary
restraint. Behav Res Ther 46:777, 2008; Jensen PS et al: Management of psychiatric disorders in children and adolescents
with atypical antipsychotics: a systematic review of published clinical trials. Eur Child Adolesc Psychiatry 16:104,
2007; Kalm LM, Semba RD: They starved so that others be better fed: remembering Ancel Keys and the Minnesota
experiment. J Nutr 135:1347, 2005; Kaye W: Neurobiology of anorexia and bulimia nervosa. Physiol Behav 94:121,
2008; Khan SS, Mican LM: A naturalistic evaluation of intramuscular ziprasidone versus intramuscular olanzapine
for the management of acute agitation and aggression in children and adolescents. J Child Adolesc Psychopharmacol
16:671, 2006; Lock J et al: Is family therapy useful for treating children with anorexia nervosa? Results of a case series.
J Am Acad Child Adolesc Psychiatry 45:1323, 2006; Loeb KL et al: Open trial of family-based treatment for full
and partial anorexia nervosa in adolescence: evidence of successful dissemination. J Am Acad Child Adolesc Psychiatry
46:792, 2007; Morrison JA et al: The pediatric metabolic syndrome. Minerva Med 99:269, 2008; Muñoz-Solomando
A et al: Cognitive behavioural therapy for children and adolescents. Curr Opin Psychiatry 21:332, 2008;
Robertson J, Shilkofski N, eds: The Harriet Lane Handbook: A Manual for Pediatric House Officers, 17th Edition.
Danvers, MA: Mosby, 2005; Rutherford L, Couturier J: A review of psychotherapeutic interventions for children
and adolescents with eating disorders. J Can Acad Child Adolesc Psychiatry 16:153, 2007; Vito J et al: Advanced pediatric
psychopharmacology. J Child Adolesc Psychopharmacol 16:498, 2006.
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