Evidence Based Treatment - Kartini Clinic for Children and Families

Are social media platforms making eating disorders in children worse?

January 10, 2023 by Morgan O'Toole-Smith

At least one school district in Seattle thinks so. Seattle Public Schools (SPS) has filed a suit in US DIstrict Court alleging that “defendants [social media platforms such as Facebook, TikTok, Instagram, YouTube, and Snapchat] affirmatively recommend and promote harmful content to youth, such as pro-anorexia and eating disorder content.” Essentially it appears SPS is saying such content exacerbates eating disorder symptoms and undermines effective treatment.

Not surprisingly perhaps, the issue is complicated. First some medical facts: eating disorders are biological brain disorders that are highly heritable (estimates – based on twin studies and genome-wide analyses – are as high as 74%; as a reference, that heritability is similar to the heritability of height in humans is estimated around 80%). This means eating disorders run in families and are emphatically NOT lifestyle “choices”, volitional behaviors on the part of patients, the result of bad parenting or the effects of images on social media. Such theories and explanations were once common but have in recent years been completely debunked by rigorous scientific studies (see above).

At Kartini Clinic we like to put it this way: parents don’t cause eating disorders and children don’t choose to have them. Period.

So what about the role of social media?

Consider the following analogy: can a child develop type 2 diabetes (T2DM) from looking at pictures of cheeseburgers? I think most of us would agree this sounds implausible and not very scientific. That’s probably because we understand and acknowledge T2DM to be a biological condition caused by complex interactions of genetics and environment. Eating disorders such as anorexia are no different.

This is not to say social media messaging can’t do any harm, for example by triggering behaviors or making children feel worse about themselves, which in turn could undermine effective treatment. After all, SPS is not alleging that social media platforms cause eating disorders but rather that they are contributing meaningfully (and, crucially, knowingly) to the disease burden on children suffering from these potentially devastating and deadly illnesses.

At Kartini Clinic we certainly do share these concerns, and we would wholeheartedly support efforts such as additional mental health professionals in schools, lesson plans and additional training for teachers provided they are grounded in a scientific understanding of these illnesses. Ultimately the key is to ensure that eating disorders are diagnosed promptly and treated effectively using evidence-based practices (i.e. grounding diagnosis and treatment in physical medicine and using behavioral health interventions such as family-centered treatment: families are almost always part of the solution to treatment in children, not part of the problem). Could the social media companies do better? Certainly. Perhaps they could “pair” content of concern with objective information about the causes, symptoms and potential for effective, life saving treatment of eating disorders in children. Although they aren’t directly responsible for these terrible illnesses, social media platforms could be powerful allies in helping us address this problem more effectively.

See Something, Say Something

March 7, 2019 by Morgan O'Toole-Smith

See something, say something is what the anti-terrorist watch tells us at the airport and in public spaces. When people take individual and collective responsibility for reporting whenever they see something potentially dangerous, something not right, it’s possible to prevent catastrophes.

An alert went out on the AED (Academy of Eating Disorders) listserv from Wendy Oliver-Pyatt, MD who had caught wind of a weight loss study recruiting subjects in Australia under the auspices of Children’s Hospital Westmead (Sydney) and Monash Medical Centre (Melbourne). The lead investigator is Professor Louise Baur; the Sydney Children’s Hospital Network Human Research Ethics Committee approved her proposal.

I did not respond in great detail on the listserv, except to protest children being dieted in general, as I had not yet seen the actual proposal. But now I have seen it. For those of you who wish to read it in its entirety, here is the link.

First, let’s be clear, this is not a study for consenting adults which includes some teens, it is a study designed for children and adolescents. The youngest participants will be 13 and the oldest 17. They are looking for the equivalent of a 5% reduction in body weight in an adult or 0.12 point reduction in BMI z score in an adolescent. They say nothing about the sustainability of this weight loss, just that the fact of it will be considered a “successful endpoint”. We all know that dieting causes weight loss in the short term, but nearly always fails in the long term, so how is this progress?

The study lasts an entire year—which in my view is a very long time to starve a dog, much less a child. You have to have a BMI of between 30-45 to participate, which means that someone – likely several someones – has identified you as “fat” with all the psycho-social ramifications of that. A plethora of lab tests and frequent checks by a dietitian make it look medical, but I do not see pediatricians or adolescent medicine physicians referenced anywhere in the protocol. The dietitians are going to weigh the kids, but no one is checking their pubertal status, which matters a great deal when assessing growth and development; they measure their blood pressure but do not mention monitoring their menstrual status.

So if the teen-aged girls stop menstruating with weight loss and dietary restriction, would that still be a successful outcome?

Incredibly, the year-long study starts with all of the children being taken down to an 800 kcal a day, very low fat (less than 20%) diet consisting of “meal replacements”. Study authors think they will have an attrition rate over the year of 30% — I think it might be closer to 90% (run, children, run!). This painfully low level of initial food intake will last one month (4 weeks) for everyone, after which the subjects will be randomly assigned to one of two arms: the Modified Alternate Day Fasting arm and the Standard Hypocaloric Diet arm.

In the alternate day fasting arm the children will eat 300-600 kcals/day for three non-consecutive days a week and a “healthy diet” not restricted in amounts for the others. The “healthy” bit means they will be “coached” to adhere to the Australian Dietary Guidelines which, if you look at them, state that one should only eat “small amounts of fats” and “mostly low-fat dairy.” Wow! Didn’t they get the memo? Does anyone in the government actually follow the science as it evolves? Children need fat to grow, or as one researcher points out: “Long-term dietary deprivation of (n-3) fatty acids results in measurable changes in the visual and neurological function of primates (Neuringer and Connor 1986).” News flash: we are primates.

There are so many worrisome points (e.g., how does a 13 yr consent to this study?) it is hard to know where to begin, and as I read on I found myself racing from one point to another, dizzy from the effort. Those children who were randomized to the non-fasting arm, or the “standard low calorie” arm as they put it, eat a diet consisting of 1434-1673 kcals/day at age 13 to 14 or 1673-1912 kcals/day for those 15 to17 years of age. Slim pickins! This so-called “healthy” diet is “high fiber” (> 30 gms/day), “moderate” carbohydrate and “moderate” protein, no mention made of dietary fat.

And the psychological “support”? Let’s remember these are kids and now they are very hungry kids who are already shamed by their size/weight and doubtless would blame themselves for any “failure” to comply. For support they see a dietitian at week 20, 26, 36 and then, as “additional support”, receive an email, text or phone call lasting 10-15 minutes at weeks 18, 24, and 48.

You have to ask: they receive support to do what? Stick to the diet?

And don’t be fooled by a raft of psychological tests administered: the Body Appreciation Scale, the EDE-Q, and various quality of life questionnaires, self-esteem questionnaires and depression questionnaires. These are designed to help the study, not the kids, as it merely reports their symptoms, but cannot address them. Nor do I see a protocol for what to do should severe psychological distress arise as a result of the semi-starvation.

All of this is reason enough, in my view, to refrain from allowing your child to participate in a dieting experiment. Try it out on yourself for a month and see what I mean. Now imagine being a 13 year old kid who weighs 250 lbs and who has to live with hunger every day of their life for a full year, at school, on the playground and at home and who then, after all that, “successfully” weighs 237 lbs.

And here’s one more pressing reason not to allow it: it’s cruel.

So I have seen something, and I’m saying something: cease this madness and end this appalling and unethical experiment on children. Please join me. Share this with your colleagues, friends, and elected representatives (if you’re in Australia). Let’s speak up and speak out. And if the authors of this study believe we have misinterpreted their intentions, let’s have an open, respectful, scientific discussion about the merits, before a single child is enrolled. Thank you.

Why Animal Therapy?

May 25, 2017 by Julie O'Toole

8 AM: drop-off time at Kartini Clinic. It’s early, and patients and parents alike have a day of hard work ahead of them. But then… enter Ryla.

Family therapist Lisa Peacock says that one of her favorite moments of the day is seeing the mood in the waiting room transform when Ryla or Baxter, her two therapy dogs, run in to say good morning. That’s one of the simplest but most effective aspects of animal therapy: most people like animals, and having one around makes them happier.

It can also make the clinic feel a little bit more like home. Lots of patients have pets, so having an animal makes them feel more at ease. And this works both ways: as patients work with Ryla, Baxter, and other animals, Lisa helps them develop strategies for using their own pets for comfort and support, preparing them to practice self-care once they are discharged from the clinic. It’s just one answer to a broader question about the many forms recovery can take. What form does your comfort take? Where can you find it in your daily life? Animals are a good answer for many patients– to the point where we’ve had many patients leave the clinic expressing new interest in becoming a vet, or otherwise working with animals.

Especially for the youngest age groups, the animals are a useful centerpiece for developing important social skills, including helping manage impulse control problems, or learning to take turns and share. Older patients, on the other hand, who can feel frustrated by the requirements of treatment, appreciate the animals as a way to demonstrate responsibility. It’s common for teenage patients to worry that they are a burden on their families, they often feel that being in treatment puts them in a constant position of being a recipient of care. A therapy animal gives them another living being to whom they can give love and support – and who accepts their love without judgment. The work is not just about treating patients’ eating disorders, but equipping them with skills and tools to smoothly return to today-to-day life.

Of course, day-to-day life continues even when in treatment, and that’s something that animals help us remember, too. After a difficult appointment or therapy session, seeing Ryla rolling around on the floor can provide much-needed laughter, and a reminder that even in the hardest moments, life goes on… and that includes the good parts.

Finally, animals provide a source of distraction– in a good way. Treatment can be a difficult time for the entire family. But animals can be a source of positive memories and wonderful moments during this rocky journey, something to look back on and feel good about. It can also provide fodder for conversation, something exciting to share at the end of the day– mom, dad, I met a blue-tongued skink!

(The skink is Dan, by the way.)

At Kartini Clinic, we know that there is so much more to eating disorder recovery than just food. Animal therapy is just one of the ways we strive to offer a holistic treatment experience for all of our patients.

Processed Food the Foodie Way

April 13, 2017 by Julie O'Toole

Nearly every day I am anxiously asked whether or not our young patients can have rice “milk,” almond “milk,” soy “milk” or coconut “milk” instead of the whole milk that is on our menu. These inaptly named “milks” are about as related to milk as cheese whiz is to cheese, and although not harmful (and even delicious), should not be mistaken for the white beverage given to early mankind by dairy animals as a source of protein, fat, calcium and vitamins. They are perhaps more properly called soy, rice, almond or coconut “drinks.” What’s in a name? Well, ask the marketers. By labeling them “milk,” parents think they are giving their child a more healthful version of the drink-food that has sustained children the world over. It says it’s milk, right? It must be good for children.

Not all of us carry the genes to split milk sugar (lactose), however, and may need supplements of that enzyme (lactase) to do so. Milk protein allergies do exist, but are thankfully rare. Many populations have solved the lactose problem naturally by pre-fermenting milk before ingesting it, giving us the world of yogurts, kefirs, quarks and cheese, among others.

The New York Times recently ran an article comparing the various plant-based “milks” nutritionally. They are not one size fits all. They say: “…in terms of nutritional content, a recent study in the Journal of Pediatric Gastroenterology and Nutrition confirmed that plant-based beverages vary widely in their nutritional profiles, and the authors recommended that young children drink cow’s milk unless there is a medical reason they cannot.”

The Cliff notes are these: 8 oz of cow’s milk has 8 grams of protein and lots of calcium (in a form that is more easily digested than the calcium added to the plant-based drinks to level the playing field). Coconut milk, for example, has less than a gram of protein and only added calcium. And then some nut or legume-based beverages have been fortified with Xanthan gums and other thickeners to give them a mouth-feel similar to cow’s milk and make them seem less thin and watery. I urge you to read the New York Times summary article or, better still, the study in the Journal of Pediatric Gastroenterology and Nutrition and judge for yourself. We already know pediatric patients do not need to be afraid of the fat.

Oh and by the way, my current favorite myth-challenging article is one looking at the nearly ubiquitous belief that milk causes mucus or phlegm. My mother insisted it did, her mother insisted it did. Well, milk drinkers and dairy product lovers everywhere, I guess we can rest easy.

Five Things Every Parent Should Know About Childhood Eating Disorders

February 28, 2017 by Julie O'Toole

1) Weight loss in children isn’t normal

Imagine you’re a parent of a bright, active 12 year old boy. He gets good grades and has lots of friends. He excels at sports. Then something changes; he begins to lose weight. At his last checkup his pediatrician registers a heart rate in the low 50s. He starts to withdraw, not doing many things he used to enjoy, with the exception of exercise. He now exercises with a new intensity.

His doctor tells you not to worry. “It’s just a stage”, she says. “Don’t make a big deal out if it, or you might make it worse. He has weight loss and a low heart rate because he’s an athlete.” But you have the nagging feeling that something’s wrong. What do you do?

For nearly two decades Kartini Clinic’s internationally recognized team of pediatricians and therapists has diagnosed and treated more than 3000 children from across the country and all walks of life. And we have seen presentations like the one described above hundreds of times.

Our message is always the same: weight loss in children is not normal and should be investigated immediately.

And weight loss shouldn’t be the only concern. Because children are still growing they need to gain weight. An interruption in their past rates of growth and development is a sign of potential trouble ahead. Your child’s growth chart is a critical diagnostic tool that can provide early warnings. Always review your child’s growth chart with their doctor and remember that averages don’t apply to individuals. What matters most for your child’s health should be based on their unique biology.

2) Children are not small adults

In the example above, with a daytime heart rate in the low 50s, this child’s overnight heart rate could be in the 40s. This is dangerous territory for a child. The American Academy of Pediatrics’ hospitalization guidelines recommend admission with a nighttime heart rate below 45, regardless of athleticism. Don’t be fooled into thinking that because Usain Bolt has a resting heart rate in the 40s, it’s OK for your child to do so.

Childhood is an essential period of growth and development, a time when critical biological systems form. Weight loss – or simply a failure to grow and develop normally – could signal a dangerous disruption to these processes.

3) Parents don’t cause eating disorders (and children don’t choose to have them)

This is our motto, and something we make clear to all families from day one. The scientific evidence is unambiguous. Parents don’t cause a child’s eating disorder, any more than they cause Type 1 diabetes or autism. These are both understood to be genetically inherited illnesses. So are eating disorders.

4) Eating disorders are brain disorders and run in families

How do we know this? Decades of research using twins separated at birth has firmly established the heritability of anorexia nervosa (the most thoroughly studied eating disorder) between 50% and 70%. By comparison, heritability of height is about 90%. This means your height is 90% dependent on your parents’ height. The other 10% comes from environment. Equally, anorexia’s high heritability rate implies that it’s largely a biological brain disease, passed from parent to child, but with a significant environmental component. But like many complex illnesses, we don’t yet know enough about what environmental “triggers” lead some who are genetically vulnerable to become ill.

5) If you think something’s wrong, get help

We always tell parents, ‘you are the experts in your child.’ If you think something’s wrong, don’t let your concerns be ignored, even by your pediatrician. Our colleagues in primary care are in a tough position; they don’t want to overreact. Furthermore, eating disorders are thankfully quite rare. However, most doctors don’t have training in diagnosing or treating them. But they do happen, especially to genetically predisposed children. It’s therefore critical to understand the specific risk to your child. A pediatric specialist’s evaluation is the best way to rule out an eating disorder.

See Something, Say Something

Why Animal Therapy?

Processed Food the Foodie Way

Five Things Every Parent Should Know About Childhood Eating Disorders

The Kartini Clinic Difference

Eating Disorder Quick Links

Resource Quick Links

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