This post was originally published March 31, 2016.
In few fields have the twin forces of genetics and neurobiology worked as synergistically to profoundly change conceptualization and treatment as they have in the field of eating disorders. And this is particularly true for pediatric eating disorders, where the stakes are so high and the field so new.
The first description of anorexia nervosa in English by Richard Morton (pictured to the right) in 1689 was presented as part of a medical/scientific treatise on wasting diseases (and, incidentally, described young female AND male patients). The treatment he recommended was rest and food but, in subsequent centuries, the field of eating disorder treatment wandered far from these early understandings.
The shift to to treating the “why”
In the late 20th century, the prevailing understanding of anorexia nervosa was as a condition induced by poor parenting and conflicted family relationships, a view entirely missing from earlier, more medical, observations. By the 1980’s, anorexia nervosa was thought to be a culturally bound disease, one caused by the overemphasis on thinness in the media and Western society in general.
The emphasis of treatment had moved from re-feeding and weight restoration toward a psychoanalytic or psychodynamic focus on understanding “why” a person manifested this condition. Therapists and analysts, rather than physicians, dominated the field. Even when dieticians were involved, they were cautioned to “go gently” on re-feeding and to only offer what the patient would easily accept until their psychological work had done its job.
Whatever may be said for this approach in adults, in children it was a disaster. Allowing a growing child (and their brain) to remain in an under-fueled, underweight status meant that they would become medically compromised and their illness more entrenched as growth stunting moved from temporary to permanent. Gradually, pediatricians were able to convince providers that children were not “miniature adults” but, rather, emergent humans with unique biological needs for whom age-appropriate treatments needed to be developed.
Feeding is the first step to healing
As a result, the focus of the field was able to move away from “why” to “how” and the emphasis of treatment moved back from talk therapy to re-feeding. By restoring patients’ weights to meet their bodies’ needs, their potential to benefit from psychological and social interventions became more realistic. Just as Richard Morton first surmised when he recommended refeeding as a treatment for anorexia nervosa in the 1680’s, our approach to treatment, now, starts with the idea that weight must first (and most critically) be restored in order for the brain to resume normal growth and development trajectories. This must be done before any other therapies are brought into play.
And the future of eating disorder treatment? Like the rest of medicine, pediatric eating disorder treatment is highly likely to undergo another revolution as more becomes known about the genetics, epigenetics and biochemistry involved.