Group Suggests Changes to the DSM-V for Children and Adolescents

An international work group on child and adolescent eating disorders has proposed changes to diagnostic criteria for the next version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). According to the group, such changes will improve detection of major eating disorders among younger patients and identification, treatment, and research in these young patients, who are at the highest risk for onset of serious eating disorders.

Noting that malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS) may have more severe and potentially more protracted consequences during youth than during any other age periods, Dr. T. Bravender and members of the Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA) made a number of recommendations for the DSM-V. These included changes to behavioral indicators, to the weight loss criterion in AN, to the amenorrhea requirement in AN, to binge eating criteria in BN and binge eating disorder (BED), as well as changes to criteria for inappropriate compensatory mechanisms in BN (Eur Eat Disord Rev. 2010; 18:79).

Behavioral indicators

Two recommendations involving behavioral indicators are that “behavioral indicators should be permitted to substitute for internally referenced cognitive criteria” and, second, “wording should be added that alerts healthcare professionals to developmental limitations that may preclude the ability to endorse a cognitive criterion.” The Workgroup noted that diagnostic criteria for eating disorders that require complex abstract reasoning may not be valid for children or teens. Instead, behavioral indicators may serve as valid substitutes when a child or teen cannot articulate internal experiences as an adult would. Parents or other caregivers can be enlisted to help assess the response and severity of behavioral indicators of the psychological features of AN and BN.

Weight loss criteria in AN

The Workgroup recommends adding wording to existing weight loss criteria that emphasizes the importance of an individual’s previous growth and maturational pattern when determining “healthy weight,” rather than using population-referenced cut points to determine clinical significance. Reliably defining ideal weight for children and adolescents requires considering developmental trends in growth and physical maturity for each individual. Changes that are suggested include: weight criteria should be framed in a manner that is developmentally sensitive and such criteria must be framed so they are clinically useful with no potential for misuse. This would ensure that individuals who need care would not be denied such treatment based on their weight loss history.

Amenorrhea requirement in AN

The Workgroup also recommended changes to the requirement of amenorrhea in the diagnosis of AN. The Workgroup recommends that “multiple physical systems be evaluated for the clinical management of eating disturbance, but that no single system should be required for diagnosis.” The group notes that the requirement of amenorrhea in the diagnosis of AN is, of course, invalid for prepubescent children, inappropriate for males, and is not reliably reported by patients. They add that the clinical profile of AN complicates determination of sexual maturation rating. In females, the emaciated physical state and low estrogen levels associated with AN may reduce breast size and distort a healthcare professional’s assessment of sexual maturity rating. In males, similar regression may be seen in the effects of lowered testosterone on Tanner stage ratings.

Binge eating criteria in BN and BED

The experience of loss of control, irrespective of the amount of calories consumed during an eating episode, should be considered the hallmark of binge eating behavior in children, according to the Workgroup. A second recommendation is that binge-eating episodes should be a persistent symptom in the diagnosis but a lower frequency and duration are clinically significant in children. Episodes should occur at least once a month during the previous 3-month period for the diagnosis to be made. The group notes that although teens with aberrant eating behaviors have much in common with adults, indicators of disordered eating in children are age-specific and require strategies sensitive to the child’s developmental level. Lower symptom thresholds are recommended for children and teens. Aberrant eating in children and adolescents overlaps significantly with adult manifestations, but behaviors do differ, and a lower threshold of severity will protect children and adolescents from harmful sequelae from their disorders.

Inappropriate compensatory mechanisms in BN

Finally, the group recommends establishing lower thresholds of both symptom frequency and duration to designate clinical levels of inappropriate compensatory mechanisms in children and adolescents. Given the potential severity of extreme weight loss strategies on growth and development, lower thresholds of symptom severity are needed for children and adolescents. Subthreshold levels of extreme weight loss behaviors are clinically significant and predict increased symptom severity as well as concurrent impairment in function.

The initial proposals for revised diagnostic criteria for eating disorders were posted by the American Psychiatric Association’s DSM-V task force on February 10, 2010 (see www.DSM5.org). After a period of public feedback and comment extending to mid-April, the APA’s DSM-V work group, chaired by EDR’s Emeritus Board member Dr. Timothy Walsh, will review the considerable amount of feedback they’ve received and will subsequently consider revising their initial proposals accordingly.