Eating Disorders · Adolescent
Eating Disorders
Anorexia · Bulimia · Binge-Eating · ARFID — each with distinct physiology and different risks.
🎨 Analogy
Eating disorders are not about food — they're about control, emotion regulation, and distorted perception. Think of anorexia as a brain that has hijacked the reward system: starvation feels like control and success, not deprivation. The body sounds alarm after alarm — fatigue, cold intolerance, hair loss — but the cognitive distortion mutes those signals. Bulimia is different — it's a cycle of emotional flooding followed by purging as a pressure valve. The food is almost incidental; it's the emotional storm underneath that drives everything.
| Disorder | Core Feature | Physical Signs | Labs | Treatment |
|---|---|---|---|---|
| Anorexia Nervosa | Restriction of energy intake → significantly low weight. Intense fear of weight gain. Distorted body image. | Bradycardia, hypotension, hypothermia, lanugo, amenorrhea, dry skin, hair loss, muscle wasting, edema (refeeding) | ↓ K, ↓ Na, ↓ Mg, ↓ Phos, ↓ glucose, ↑ BUN (dehydration), ↑ LFTs, leukopenia, anemia, ↓ T3 (sick euthyroid) | Nutritional rehabilitation ⭐; FBT (family-based treatment) for adolescents; medical stabilization if unstable vitals; SSRI limited evidence for core AN; olanzapine for severe weight gain resistance |
| Bulimia Nervosa | Recurrent binge-purge cycles ≥1×/week × 3 months. Weight typically normal. | Russell's sign (calluses on dorsal hand knuckles ⭐), parotid gland hypertrophy, dental enamel erosion, perioral excoriations | ↓ K (hypokalemia ⭐ — most dangerous), ↓ Cl, metabolic alkalosis (from purging), ↑ amylase (salivary) | CBT ⭐ (most evidence-based); fluoxetine (Prozac) FDA approved for bulimia ⭐; nutritional counseling |
| Binge-Eating Disorder (BED) | Recurrent binge episodes without compensatory purging. Associated with shame/distress. | Often overweight/obese; metabolic complications | Metabolic syndrome labs if obese | CBT ⭐; lisdexamfetamine (Vyvanse) — FDA approved for BED in adults; SSRIs for mood comorbidities |
| ARFID (Avoidant/Restrictive Food Intake Disorder) | Restriction not driven by body image — sensory aversion, fear of choking/vomiting, low appetite. Often younger children + ASD. | FTT, nutritional deficiencies, growth impairment | Nutritional deficiencies based on restricted foods | Exposure-based CBT; OT for sensory feeding; feeding therapy; no fear of weight gain distinguishes from AN |
🚨 Anorexia — Medical Admission Criteria
HR <50 bpm · Systolic BP <90 mmHg · Orthostatic hypotension · Temp <96°F · Glucose <60 mg/dL · K <3.0 mEq/L · Rapid weight loss · Syncope → admit for medical stabilization and supervised refeeding.
⚠️ Refeeding Syndrome
Dangerous ↓ phosphorus when severely malnourished patient is re-fed too quickly. Hypophosphatemia → cardiac arrhythmias, heart failure, seizures, death. Start nutrition slowly and monitor electrolytes closely.
💡 Highest Mortality
Anorexia nervosa has the highest mortality rate of any psychiatric disorder — primarily from cardiac arrhythmias (bradycardia, QT prolongation) and suicide. Russell's sign = bulimia. Parotid enlargement + dental erosion = purging behavior.
Anxiety · Most Common Pediatric MH
Anxiety Disorders
Separation anxiety · GAD · OCD — anxiety is the most common mental health condition in children.
Separation Anxiety Disorder
- Developmentally excessive fear of separation from attachment figures
- Normal separation anxiety peaks 8–18 months — disorder = beyond what's expected
- School refusal, physical complaints (stomachache, headache) on school days
- Nightmares about separation; refusal to sleep alone
- Duration: ≥4 weeks (children) / ≥6 months (adults)
- Most common anxiety disorder in children under 12
- Treatment: CBT ⭐ + school re-engagement; SSRI if moderate-severe
Generalized Anxiety Disorder (GAD)
- Excessive, uncontrollable worry about multiple topics (school, health, family, world events)
- Duration: ≥6 months
- ≥1 physical symptom in children (adults need ≥3): restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
- "What if" thinking; perfectionism; reassurance-seeking
- Children often worry about catastrophic events, performance, punctuality
- Treatment: CBT ⭐ first-line; SSRI (sertraline, fluoxetine) if CBT insufficient
OCD — Obsessive-Compulsive Disorder
- Obsessions: recurrent, intrusive, unwanted thoughts/images/urges that cause distress
- Compulsions: repetitive behaviors or mental acts performed to reduce distress from obsessions
- Time-consuming (>1h/day) OR causes significant impairment
- Common themes: contamination (handwashing), harm, symmetry/ordering, religious scrupulosity
- Child may recognize obsessions as excessive — or may not (especially young children)
- Associated: tic disorders, ADHD, anxiety disorders, PANDAS
- Treatment: ERP (Exposure and Response Prevention) CBT ⭐ — first-line; SSRI (fluvoxamine, sertraline) — first-line pharmacotherapy; combined most effective
PANDAS — Board Special Topic
- Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
- Sudden, dramatic onset or exacerbation of OCD or tic symptoms following Group A Strep infection
- Hallmark: abrupt onset of symptoms (overnight) following strep throat ⭐
- Also: choreiform movements, emotional lability, separation anxiety, enuresis
- Workup: throat culture, strep serology (ASO titer, anti-DNase B)
- Treatment: treat strep infection (penicillin/amoxicillin); OCD/tic treatment as usual; IVIG for severe refractory cases (controversial)
💡 Anxiety Treatment Hierarchy
CBT (Cognitive Behavioral Therapy) = first-line for all pediatric anxiety disorders. SSRI = first-line pharmacotherapy when medication indicated. Combined CBT + SSRI = most effective for moderate-severe anxiety and OCD. Benzodiazepines: avoid in children — risk of dependence, cognitive blunting, rebound anxiety.
Mood Disorders · Depression & Bipolar
Mood Disorders
MDD · DMDD · Bipolar — mood disorders in children look different than in adults. Know the pediatric presentations.
Major Depressive Disorder (MDD)
DSM-5 Criteria — MDD
- ≥5 symptoms for ≥2 weeks, including at least one of:
- Depressed mood (or irritable mood in children ⭐)
- Loss of interest or pleasure (anhedonia)
- Plus ≥4 of: sleep changes, appetite/weight change, psychomotor changes, fatigue, guilt/worthlessness, difficulty concentrating, suicidal ideation
- Causes clinically significant impairment
- Key pediatric difference: irritability is a core feature (not just sadness) ⭐
Pediatric MDD — Unique Features
- Irritability often predominates over sadness in children
- Somatic complaints: headaches, stomachaches, fatigue
- School refusal, declining grades
- Social withdrawal, loss of interest in activities
- Adolescents: may present with increased sleep, increased appetite, anhedonia
- Always screen for suicidal ideation — PHQ-A (adolescent version) starting age 12
- Screen for bipolar before starting antidepressants (risk of manic switch)
MDD Treatment
1
Psychotherapy — CBT or IPT
CBT (Cognitive Behavioral Therapy) or IPT (Interpersonal Therapy) — first-line for mild-moderate. CBT most evidence-based for pediatric depression.
2
SSRI — First-line medication ⭐
Fluoxetine (Prozac) — FDA approved for MDD age ≥8 ⭐. Escitalopram — FDA approved age ≥12. Black box warning: antidepressants may ↑ suicidal ideation in children/adolescents — monitor closely in first weeks.
3
Combined CBT + SSRI
Most effective for moderate-severe MDD — TADS study confirmed superiority of combination over either alone.
4
Psychiatric referral
If: severe, psychotic features, suicidal ideation with plan/intent, refractory, bipolar suspected.
Suicide Risk Assessment
- Universal screening: PHQ-A or Columbia Suicide Severity Rating Scale (C-SSRS) at every adolescent visit
- Ask directly: "Are you having thoughts of hurting yourself?"
- Risk factors: prior attempts, family history, substance use, LGBTQ+ identity (discrimination exposure), access to firearms, recent losses, history of abuse
- Protective factors: family support, connectedness, reasons for living, mental health treatment
- Means restriction counseling: firearm removal/safe storage ⭐ — most impactful modifiable risk factor
- Safety planning + crisis resources with every at-risk patient
Disruptive Mood Dysregulation Disorder (DMDD)
DMDD — Key Facts
- Severe, recurrent temper outbursts (verbal or behavioral) grossly out of proportion to the situation
- Outbursts ≥3×/week; persistently irritable/angry mood between outbursts
- Duration: ≥12 months; onset before age 10; diagnosed ages 6–18
- Outbursts occur in ≥2 settings (home, school, peers)
- Key distinction: DMDD = persistent irritability + outbursts, but NO discrete episodes of elevated/expansive mood (distinguishes from bipolar) ⭐
- Treatment: CBT, parent management training, SSRI for depressive features; stimulants if comorbid ADHD
Bipolar Disorder
Pediatric Bipolar — Overview
- Characterized by distinct episodes of mania or hypomania alternating with depression
- Manic episode (≥7 days or any duration if hospitalized):
- Elevated, expansive, or irritable mood + ↑ goal-directed activity
- Grandiosity, ↓ need for sleep (not insomnia — feels rested on 2–3h), pressured speech, racing thoughts, distractibility, impulsivity, high-risk behavior
- Pediatric mania often looks different: mixed states common, rapid cycling, irritability predominates
- Often misdiagnosed as ADHD, ODD, or DMDD
DMDD vs. Bipolar — Critical Distinction
- DMDD: chronic persistent irritability + outbursts; NO discrete manic episodes; continuous mood problem
- Bipolar: discrete episodic changes in mood and function; periods of elevated/euphoric mood; grandiosity; ↓ need for sleep
- Key question: "Are there distinct episodes where the child is clearly different from baseline?"
- Bipolar = episodic. DMDD = chronic baseline irritability.
Bipolar Treatment
- Mood stabilizers: lithium ⭐ (FDA approved ≥12 for bipolar), valproate, lamotrigine
- Atypical antipsychotics: aripiprazole, quetiapine, risperidone — FDA approved for pediatric bipolar mania
- Avoid antidepressants alone — can precipitate manic switch ⭐
- Psychoeducation + family therapy + mood tracking
- Lithium monitoring: levels, TSH, BMP, renal function; therapeutic range 0.6–1.2 mEq/L
Behavioral · Disruptive
Oppositional Defiant Disorder · Conduct Disorder
ODD and conduct disorder exist on a continuum — ODD is defiant, conduct disorder crosses into violation of others' rights.
ODD — Oppositional Defiant Disorder
- Pattern of angry/irritable mood + argumentative/defiant behavior + vindictiveness
- ≥4 symptoms × ≥6 months, present with ≥1 person outside sibling
- Three categories: angry-irritable mood, argumentative-defiant behavior, vindictiveness
- Directed at authority figures (parents, teachers)
- Does NOT involve aggression toward others or violation of rights
- Most common behavioral disorder; often precedes conduct disorder
- Strong association with ADHD (~40% comorbidity)
- Treatment: parent management training ⭐ (PMT); CBT; treat comorbid ADHD
Conduct Disorder (CD)
- Repetitive and persistent pattern of behavior violating others' basic rights or major social rules
- ≥3 criteria in past 12 months (≥1 in past 6 months) across 4 categories:
- 🔴 Aggression to people/animals — bullying, fighting, use of weapons, cruelty
- 🔴 Destruction of property — arson, vandalism
- 🔴 Deceitfulness/theft — breaking/entering, shoplifting, lying
- 🔴 Serious rule violations — truancy, running away
- Childhood-onset (<10 years) has worse prognosis than adolescent-onset
- Strong predictor of antisocial personality disorder in adulthood
- Callous-unemotional traits (lack of empathy, guilt) = specifier; worst prognosis
- Treatment: Multisystemic Therapy (MST) ⭐, functional family therapy, treat comorbidities
ODD vs. CD vs. DMDD
| Feature | ODD | CD | DMDD |
|---|---|---|---|
| Core | Defiance + irritability toward authority | Violates rights of others | Chronic irritability + outbursts |
| Aggression | Verbal; no physical harm | Physical; weapons; cruelty | Outbursts; not predatory |
| Rights violated | No | Yes ⭐ | No |
| Mood | Irritable/angry | Often callous | Persistently irritable |
| Treatment | PMT, CBT | MST, family therapy | CBT, PMT, SSRI |
Child Maltreatment · Mandatory Reporting
Child Maltreatment
Physical abuse · Sexual abuse · Neglect · Medical child abuse — you are a mandatory reporter. Suspicion is enough.
🚨 Mandatory Reporting
Healthcare providers are mandatory reporters in all US states. You are required to report reasonable suspicion of child abuse or neglect to child protective services (CPS) — you do NOT need proof. Failure to report is a legal violation. Never confront the parent/caregiver before reporting.
Physical Abuse — Red Flags
- Injury inconsistent with stated mechanism or developmental stage
- Delay in seeking medical care
- Changing or inconsistent story between caregivers
- Bruising in non-mobile infants (bruises on babies who don't cruise = NAT ⭐)
- Bruising in unusual locations: ears, neck, trunk, buttocks, genitalia (vs. shins/forehead = normal)
- Burns: cigarette burns (circular, punched-out), immersion burns (stocking/glove pattern, no splash marks)
- Fractures suspicious for abuse (see MSK module): posterior rib, classic metaphyseal, multiple ages
- TBI: subdural hematoma + retinal hemorrhages in infant = abusive head trauma (shaken baby) ⭐
Abusive Head Trauma (AHT)
- Formerly "shaken baby syndrome"
- Triad: subdural hematoma + retinal hemorrhages + encephalopathy ⭐
- Infant with altered mental status, seizures, vomiting — no clear mechanism
- Bulging fontanelle, hypotonia, apnea
- Workup: head CT/MRI, ophthalmology (retinal hemorrhages), skeletal survey
- Subdural in multiple compartments at different ages = repeated trauma
- High morbidity and mortality
Sexual Abuse
- Often no physical findings — normal exam does NOT rule out abuse ⭐
- Behavioral signs: age-inappropriate sexual knowledge or behavior, regression, fear of specific person, nightmares
- Physical signs (when present): hymenal tears, bruising of genitalia, anal lacerations, STI in prepubertal child
- Any STI in prepubertal child = sexual abuse until proven otherwise ⭐
- Referral to SANE (Sexual Assault Nurse Examiner) or child advocacy center (CAC)
- Forensic interview — trained interviewer; do NOT interview child yourself repeatedly
- Prophylaxis: HIV PEP if indicated, STI prophylaxis, emergency contraception if postpubertal
Neglect & Medical Child Abuse
- Neglect: most common form of maltreatment; failure to provide basic needs (food, shelter, supervision, medical care, education)
- Signs: FTT, poor hygiene, untreated medical conditions, school truancy, inappropriate dress for weather
- Medical child abuse (formerly Munchausen by proxy): caregiver fabricates or induces illness in a child to gain medical attention
- Child repeatedly hospitalized with unexplained symptoms that resolve when caregiver is absent
- Caregiver appears overly attentive and knowledgeable; welcomes hospitalizations
- Management: covert video surveillance (hospital), multidisciplinary team, CPS, separate child from caregiver
💡 Workup for Suspected Physical Abuse
Skeletal survey (all children <2 years with suspected NAT) · Head CT or MRI · Ophthalmology for retinal hemorrhages · CBC, coagulation studies (rule out bleeding disorder) · LFTs, lipase, urinalysis (abdominal trauma) · Photographs of injuries · CPS report.
Substance Use Disorders · Adolescent
Substance Use Disorders
Alcohol · Tobacco · Cannabis · Opioids — screen at every adolescent visit, use motivational interviewing.
Screening — CRAFFT Tool ⭐
- Validated screening tool for adolescent substance use
- C — Car: ridden in a car driven by someone (including self) who was high/drunk?
- R — Relax: use substances to relax, feel better, or fit in?
- A — Alone: use substances while alone?
- F — Forget: use substances and forget things you did?
- F — Friends/Family: told you to cut down?
- T — Trouble: gotten into trouble while using?
- Score ≥2 = positive screen → further assessment
- Screen annually starting at age 12
Alcohol Use Disorder
- Most widely used substance in adolescents
- Binge drinking: ≥4 drinks (female) or ≥5 drinks (male) within 2 hours
- Alcohol use disorder: DSM-5 criteria — 2+ symptoms in 12 months (craving, tolerance, withdrawal, impaired control, continued use despite problems)
- Wernicke's encephalopathy: thiamine deficiency from chronic alcohol — confusion, ataxia, ophthalmoplegia → give thiamine before glucose
- Withdrawal: seizures, DTs (delirium tremens) — life-threatening; treat with benzodiazepines
- Treatment: MI, CBT, naltrexone (adults; limited pediatric data), family therapy
Cannabis (Marijuana) Use Disorder
- Most commonly used illicit substance in adolescents
- THC significantly more potent than decades ago
- Adolescent brain particularly vulnerable — use before age 18 associated with ↑ risk of psychosis, depression, anxiety, cognitive impairment
- Cannabinoid hyperemesis syndrome: cyclic vomiting relieved by hot showers — pathognomonic ⭐
- Cannabis use disorder: tolerance, withdrawal (irritability, insomnia, ↓ appetite), continued use despite problems
- Treatment: MI, CBT; no FDA-approved pharmacotherapy
Opioid Use Disorder
- Heroin, prescription opioids (oxycodone, hydrocodone), fentanyl
- Fentanyl now contaminates most illicit drug supply — ↑ overdose risk dramatically
- Overdose triad: miosis + respiratory depression + altered mental status ⭐
- Treatment of overdose: naloxone (Narcan) — opioid antagonist; repeat doses may be needed for fentanyl ⭐
- MOUD (Medications for Opioid Use Disorder):
- Buprenorphine/naloxone (Suboxone) — first-line for adolescents with OUD; FDA approved ≥16 years
- Methadone — maintenance for adults; rarely in adolescents
- Naltrexone (Vivitrol) — extended-release IM; requires full detox first
- Naloxone should be prescribed to all patients at risk and their families
💡 Tobacco/Nicotine — Vaping
E-cigarettes (vaping) now most common tobacco product used by adolescents. Nicotine highly addictive; adolescent brain particularly vulnerable. EVALI (e-cigarette or vaping product use-associated lung injury) — bilateral pulmonary infiltrates, hypoxia; associated with Vitamin E acetate in THC vapes. Screening + cessation counseling at every visit. NRT, varenicline, bupropion for cessation (adolescent data limited).
Board Quick Quiz · Flip to Reveal
Mental Health Flash Cards
tap any card to flip ↓
Teen with anorexia nervosa, HR 46, BP 82/50, K 2.8. What do you do?
Admit for medical stabilization. Criteria met: HR <50, BP <90, K <3.0. Start supervised nutritional rehabilitation slowly — watch for refeeding syndrome (↓ phosphorus).
Russell's sign, parotid enlargement, dental erosion, and hypokalemia in an adolescent with normal BMI. Diagnosis?
Bulimia nervosa. Russell's sign = calluses on dorsal knuckles from self-induced vomiting. Hypokalemia = most dangerous complication. First-line: CBT + fluoxetine (FDA approved).
Which eating disorder has the highest mortality rate of any psychiatric disorder?
Anorexia nervosa — primarily from cardiac arrhythmias (bradycardia, QT prolongation) and suicide. Family-based treatment (FBT) is first-line for adolescents.
Child develops sudden-onset OCD symptoms overnight after a strep throat infection. Diagnosis?
PANDAS — Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Key: abrupt onset following GAS infection. Treat strep + manage OCD symptoms.
Which SSRI is FDA approved for MDD in children age ≥8? Which for bulimia?
MDD age ≥8: Fluoxetine (Prozac) ⭐. MDD age ≥12: Escitalopram. Bulimia: Fluoxetine (Prozac) — same drug, FDA approved for both. Black box: monitor for suicidal ideation.
How does pediatric depression present differently than adult depression?
Children often present with irritability rather than sadness as the core feature. Also: somatic complaints (stomachaches, headaches), school refusal, social withdrawal — not classic "sad mood" adults show.
DMDD vs. Bipolar — what is the single most important distinguishing feature?
DMDD = chronic, persistent irritability without discrete manic episodes. Bipolar = episodic — discrete periods of elevated/euphoric mood, grandiosity, ↓ need for sleep. Bipolar is episodic. DMDD is continuous.
You suspect a child is being abused. What is required before you file a CPS report?
Nothing — only reasonable suspicion is required. You do NOT need proof. Mandatory reporting applies to suspicion alone. Never confront parents before reporting. Failure to report is a legal violation.
Infant with altered mental status, seizures, bulging fontanelle. CT shows bilateral subdural hematomas. What exam is mandatory next?
Ophthalmology for retinal hemorrhages — completes the triad of abusive head trauma (AHT). Also: skeletal survey, coagulation studies, CPS report. Do NOT let the caregiver remain alone with child.
Adolescent presents with cyclic vomiting that is relieved by hot showers. Diagnosis?
Cannabinoid hyperemesis syndrome — pathognomonic pattern. Hot showers relieve symptoms temporarily. Occurs with heavy, chronic cannabis use. Treatment: stop cannabis use.
Opioid overdose — what is the triad and what do you give?
Triad: miosis + respiratory depression + altered mental status. Treatment: Naloxone (Narcan) IM or IN — repeat as needed (fentanyl may require multiple doses). Prescribe naloxone to all at-risk patients and families.
CRAFFT score — what score is positive and triggers further assessment?
Score ≥2 is a positive screen → further assessment for substance use disorder. CRAFFT = Cars, Relax, Alone, Forget, Friends/Family, Trouble. Screen annually starting age 12.