Binge Eating Disorder in Children and Adolescents

Introduction

Binge eating is defined as the consumption of an objectively large amount of food (larger than what most people would consume under similar circumstances) coupled with a sense of loss of control over the eating ¹. Binge eating disorder (BED) is characterized by recurrent episodes of binge eating, in addition to associated features, such as distress about the eating, secrecy of eating, or eating in the absence of hunger ¹. Binge eating was first described by Albert Stunkard in the 1950s, but was not integrated into clinical diagnoses until the publication of DSM-III in 1980 with the addition of “bulimia” which was later renamed bulimia nervosa. In subsequent DSM editions, the understanding of binge eating increased, leading to the inclusion of BED as a formal diagnosis in DSM-5 in 2013.

Binge eating disorder is commonly associated with obesity, as the diagnosis is distinguished from bulimia nervosa by the absence of compensatory behaviors to eliminate calories consumed. Thus, recent studies of BED in children and adolescents have utilized samples of children with overweight or obesity. Initial research on binge eating, however, was in the context of bulimia nervosa in normal weight adolescents (see ² for historical review of this research). The association between binge eating and obesity leads to direct physical health consequences, and there are also associated psychological consequences such as greater rates of depression ^3,4.

Diagnosis

As noted, DSM-5 defines BED by the following: the recurrence of binge eating episodes characterized by:

• the consumption of a large amount of food

• the loss of control over eating (see Table 1)

Table 1.

Criteria for binge eating episode

	Large amount of food	Not large amount of food
Loss of control over eating	Objective binge episode	Subjective binge episode
No loss of control	Overeating	Normal eating

These episodes must occur at least once per week on average over the prior three months. A diagnosis of other specified feeding and eating disorder: BED of low frequency or duration would be given to someone with less frequent or enduring binge episodes. In addition to the binge episodes, individuals meeting BED criteria must endorse at least three of the following features:

• eating much more rapidly than normal

• eating until feeling uncomfortably full

• eating large amounts of food when not physical hungry

• eating alone because of being embarrassed by how much one is eating

• feeling disgusted with oneself, depressed, or very guilty after overeating

Finally, the diagnosis requires distress regarding binge eating and the absence of compensatory behaviors (such as purging).

The diagnosis of binge episodes in children and adolescents can be challenging for a number of reasons. First, the definition of an objectively large amount of food during development can be difficult and uncertain ^5,6. Indeed, a child’s caloric intake may vary due to growth spurts and changes in activity ⁷. Furthermore, report of food intake, as well as the ability to articulate loss of control can be challenging in children and adolescents. For this reason, clinician-expert interviews are necessary rather than reliance on self-report in order to better characterize an eating episode as a binge ⁸. Even with interviews, we still rely on self-reported food intake, which is poorly related to actual objectively measured intake ⁹. Verbal descriptions of portion and/or pictures of portions of food may aid in the assessment ¹⁰.

Second, the criterion of loss of control may be difficult for children and adolescents to understand. Tanofsky-Kraff and colleagues ⁶ have used terms like “numbing” or “zoning out” to help children conceptualize loss of control (LOC). Although challenging to assess, the inclusion of LOC in the measurement of binge eating is vital, as it is associated with more psychosocial impairment than overeating alone ⁵. Marcus and Kalarchian ¹¹ proposed alternative BED criteria for children that highlights the LOC feature and eliminates the objectively large amount of food.

Their criteria include:

• recurrent episodes of binge eating, defined by both of the following

  • food seeking in the absence of hunger (e.g., after a full meal)

  • a sense of lack of control over eating (e.g., endorse that “When I start to eat, I just can’t stop”)

• binge episodes are associated with one or more of the following

  • food seeking in response to negative affect (e.g., sadness, boredom, restlessness)

  • food seeking as a reward

  • sneaking or hiding food

• symptoms persist over a period of 3 months

• eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa

These criteria were not officially adopted into the DSM-5, nor have they received much direct investigation through research. However, they are included here to highlight the uncertainty in the field about whether the current criteria can be applied to children and adolescents without adaptation.

Prevalence, Risk, and Consequences

A number of studies have attempted to estimate prevalence, incidence, and sex differences in BED in adolescents and children. There is a range of numbers for these values, in part due to differences in measurement/assessment tools used for BED, in particular self-report survey vs. diagnostic interviews. Most studies reveal prevalence rates between 1–3%, with about twice as many girls reporting binge eating compared to boys (for example, see ¹²).

Risks for the development of BED are not definitively known, particularly for childhood binge eating. However, a study of very young children followed from birth to age 5 years was able to identify maternal eating disinhibition, hunger, body dissatisfaction, body mass index (BMI), and history of overweight predicted secretive eating by age 5 in the child ¹³. Although secretive eating is not equivalent to binge eating, one feature of binge eating for BED diagnosis is eating alone due to embarrassment, which may be related. Other prospective studies of risk factors for BED have identified dieting and negative affect as consistent risk factors for binge eating ^14–17. Overvaluation of weight predicted weekly binge eating in a sample of overweight adolescent girls ⁴. Eating in the absence of hunger and loss of control eating in childhood predicted BED and binge eating behavior in adolescence ^18,19. Among children who displayed eating in the absence of hunger at age 7, BMI, anxiety, depression, dietary restraint, emotional disinhibition, and body dissatisfaction predicted binge eating at age 15 ¹⁸.

Age of onset for BED appears to be during late adolescence, although estimates range into early adulthood ^11,20. One study of treatment-seeking children and adolescents with obesity found greater odds of binge eating in Caucasians compared to African-Americans ³, although studies of adults have found similar rates of binge eating in Black and White women ²¹.

Youth with binge eating have higher adiposity, waist circumference, depressive symptoms, and disordered eating ³. Children with persistent LOC eating over 4 to 5 years showed greater depressive symptoms and disordered eating attitudes than those without LOC eating ¹⁹. Among adolescent girls with overweight who were engaging in weekly binge eating, those who overvalued weight reported greater depressive symptoms ⁴.

Treatment

Treatment for BED in children and adolescents has not been adequately studied. To date, only a handful of studies have investigated such treatments in randomized controlled trials. Treatments for adult BED with current evidence in adults include guided self-help cognitive behavioral therapy (gshCBT) and interpersonal psychotherapy (IPT) ²², as well as dialectical behavior therapy (DBT) ²³. CBT-based treatments focus on regulating eating patterns and addressing eating related thoughts that contribute to symptoms. IPT aims to resolve interpersonal difficulties that are thought to maintain binge eating. DBT involves identifying emotion-related triggers to binge eating and teaching strategies to manage and tolerate those emotions without engaging in binge eating.

One study investigated the use of a 16-week CBT self-help online intervention for high school students who were greater than or equal to 85^th percentile in BMI and engaging in binge eating or overeating at least once per week in the prior 3 months, finding that it reduced BMI z-scores and objective and subjective binge episodes, as well as reducing weight and shape concerns compared to a waitlist control group ²⁴. Adolescents with more frequent objective overeating or binge eating at baseline had greater reductions in BMI at follow-up ²⁴. Another study conducted an 8-session CBT group-based intervention for adolescent girls with recurrent binge eating and found greater reductions in binge eating in the CBT group compared to treatment as usual ²⁵. A third trial investigated the use of a 12-session IPT group compared to a health education group in small sample of 12–17 year old girls. Of those with baseline LOC eating (n=20), girls in the IPT group had greater reductions in LOC than those in the health education group. This finding was replicated in a larger sample with effects on LOC eating, as well as binge eating ²⁶. A case report of DBT in an adolescent patient suggested it could be adaptive for use in this younger age group to treat BED, with the addition of family sessions ²⁷. Another study examined DBT-informed treatment for treating binge eating in adolescent girls with both DBT and a behavioral weight loss treatment showing reductions in eating disorder symptoms ²⁸.

Other studies assessing reductions in binge eating in response to treatment in youth have investigated the behavior in the context of weight loss treatments. One study found that binge eating was reduced after a 16-week CBT-based weight loss program ²⁹. The treatments included CBT components of behavior change such as self-monitoring, problem solving, motivation, and relapse prevention, as well as either a “peer enhanced adventure treatment” or “supervised aerobic exercise” components ²⁹. Change in binge eating over the course of treatment was also associated with change in physical appearance self-concept, global selfconcept, and physical self-worth ²⁹. Another study of behavioral and pharmacologic weight loss programs found that binge eating decreased over time with treatment and that baseline binge eating did not impact weight loss over the course of treatment ³⁰.

Given that family-based treatment (FBT) for anorexia nervosa and bulimia nervosa currently show some of the highest rates of remission for adolescents with those eating disorders ^31,32, it is likely that a family component or focus in the treatment of BED in children and adolescents would improve outcome. Indeed, a trial of CBT for BED in adolescents ages 12–20 including parent education is underway ³³, although results are not yet published. Even parent education, however, may not be sufficient, as children’s inhibitory control, which may be particularly relevant for an impulse control behavior like binge eating, may still be developing naturally throughout adolescence ³⁴. Family-based treatment for BED would directly involve the family, particularly the parents, in helping the child or adolescent change behavior. Given the efficacy of FBT for bulimia nervosa, which also is characterized by recurrent binge eating, it is worth pursuing trials of this treatment for BED in this age group.

Summary/Discussion

Binge eating disorder is prevalent in children and adolescents and is associated with both physical and psychological impairments. Importantly, there is some controversy over whether the diagnosis should be modified for children, specifically focusing on loss of control as the primary feature related to pathology rather than the quantity of food consumed during an eating episode. Because many studies note late adolescence as the peak age of onset for BED, research on younger children and adolescents is particularly lacking, but given that prevalence among younger samples is still high, and the presence of any binge eating behavior is even greater ¹² it is vital that more resources be directed toward improving the identification, assessment, and treatment of BED in youth. A recent review confirmed this need, showing evidence that adolescents with BED are at increased risk of developing obesity, substance use, suicidality, and other psychological problems ⁸.

Of note, although evidence suggests BED is more common in females than males, BED has the highest prevalence of any eating disorder in males. Despite this, most studies of treatments in adolescents have been conducted in female samples. Thus, there is a great need for studies examining treatments of BED in male adolescents. To date, we are lacking strong evidence-based treatments even for female adolescents, although preliminary evidence suggests that IPT, CBT, and DBT may show some efficacy. Internet or app-based interventions may be particularly fruitful given preliminary evidence supporting the use of an online intervention for binge eating in adolescents ²⁴, as well as findings that some adolescents may find online treatments more acceptable than in-person ³⁵.

KEY POINTS

• Binge eating disorder is prevalent in children and adolescents, often showing onset during adolescence.

• Current evidence-based treatments exist for adults with binge eating disorder, but research in children and adolescents is needed.

• Loss of control over eating may be more important in diagnosing binge eating in children than an objectively large amount of food.

• Despite greater incidence of binge eating disorder in males than other eating disorders, there is still a higher incidence of binge eating disorder in females.

SYNOPSIS

Binge eating disorder often onsets during adolescents, yet the diagnosis and treatment of the disorder in this age group has been inadequately studied. Diagnostic criteria and challenges in making the diagnosis in children and adolescents are reviewed, as well as prevalence rates, current treatment options, and complications.