Comprehensive Nursing Notes: Bulimia in Children
An Evidence-Based Guide for Nursing Professionals
Table of Contents
Introduction to Bulimia in Children
Bulimia nervosa in children is an increasingly prevalent eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to prevent weight gain. While traditionally associated with adolescence and early adulthood, there is growing evidence of bulimia in children as young as 8-9 years old, making early identification and intervention crucial.
The prevalence of bulimia in children has risen significantly in recent decades, with increases particularly noted in younger populations. According to recent data, hospitalizations for eating disorders in children under 12 years increased by 119% between 1999 and 2006, highlighting the critical need for pediatric-specific approaches to treatment and management.
As nursing professionals, understanding the unique presentations and challenges of bulimia in children is essential for providing appropriate care, support, and guidance to affected children and their families. This guide aims to provide comprehensive information about the identification, diagnosis, and management of bulimia in children, focusing on evidence-based nursing interventions in both hospital and home settings.
Important Note
Bulimia in children often presents differently from the adult version of the disorder. Children may not articulate body image concerns as clearly, may not meet all diagnostic criteria, and may exhibit more varied compensatory behaviors. Despite these differences, the medical and psychological consequences are equally serious and sometimes more concerning due to the impact on growth and development.
Identification and Diagnosis of Bulimia in Children
Identifying and diagnosing bulimia in children requires a comprehensive approach that considers developmental stage, possible comorbidities, and age-appropriate assessment methods. Early detection is critical for successful treatment outcomes.
Diagnostic Criteria
According to the DSM-5, the diagnostic criteria for bulimia nervosa include:
| Criteria | Description | Special Considerations in Children |
|---|---|---|
| Recurrent Binge Eating | Eating large amounts of food in a discrete period with sense of lack of control | Children may not articulate “loss of control” but may show distress after eating |
| Compensatory Behaviors | Self-induced vomiting, laxative/diuretic misuse, excessive exercise, fasting | Children may use different methods like spitting out food or engaging in excessive physical play |
| Frequency | At least once a week for 3 months | May not meet frequency criteria but still experience significant impairment |
| Self-evaluation | Unduly influenced by body shape and weight | May express concerns differently (e.g., wanting to be “strong” or “fit” rather than “thin”) |
| Not exclusively during AN | Disturbance does not occur exclusively during anorexia nervosa | Overlap and transition between eating disorder types is common in children |
Clinical Alert
Many children with significant bulimic behaviors do not meet full DSM-5 criteria but still require clinical attention. The category of “Eating Disorder Not Otherwise Specified” (EDNOS) or “Other Specified Feeding or Eating Disorder” (OSFED) may be more appropriate for these cases.
Clinical Presentation
Bulimia in children may present with a variety of physical and behavioral signs that nurses should be vigilant in recognizing:
Physical Signs
- Normal or slightly above/below normal weight (weight may not be an indicator)
- Dental erosions due to exposure to stomach acid
- Russell’s sign (calluses on knuckles from induced vomiting)
- Parotid gland enlargement
- Electrolyte imbalances (hypokalemia, hypochloremia)
- Dehydration signs
- Gastrointestinal complaints (constipation, bloating)
- Cardiac irregularities (arrhythmias, orthostatic hypotension)
- Menstrual irregularities in females
- Growth delays or stunting in younger children
Behavioral Signs
- Frequent bathroom visits after meals
- Food hoarding or stealing
- Secretive eating patterns
- Unusual food rituals/preferences
- Excessive concern about weight/shape
- Extreme or rigid exercise routines
- Social withdrawal, especially during mealtimes
- Anxiety around food or meal preparation
- Collecting diet foods, laxatives, or diuretics
- Running water in bathroom to mask vomiting sounds
BULIMIA Mnemonic for Assessment
This mnemonic can help nurses quickly assess for key signs of bulimia in pediatric patients:
- B – Binge eating episodes (large amounts in short periods)
- U – Under strict dieting or irregular eating patterns
- L – Lack of control during eating episodes
- I – Induced vomiting or other purging behaviors
- M – Minimum of two binge-eating episodes weekly
- I – Image distortion (body image concerns)
- A – Anxiety about weight gain despite normal weight
Assessment Tools
Several validated tools can assist nurses in screening for bulimia in children:
| Tool | Age Range | Description |
|---|---|---|
| SCOFF Questionnaire | 12+ years | 5-question screening tool with high sensitivity; score ≥2 suggests further assessment |
| EAT-26 (Eating Attitudes Test) | 10+ years | 26-item questionnaire assessing eating behaviors and attitudes |
| ChEAT (Children’s Eating Attitudes Test) | 8-13 years | Modified version of EAT with age-appropriate language |
| BEDS-7 (Brief Eating Disorder Screen) | All ages | 7-item screen for eating disorders in pediatric settings |
| EDI-C (Eating Disorder Inventory for Children) | 9-12 years | Comprehensive assessment for younger children |
Nursing Assessment Guidelines
When assessing for bulimia in children, nurses should:
- Create a private, non-judgmental environment for assessment
- Use developmentally appropriate language and questions
- Obtain collateral history from parents/caregivers (children may deny symptoms)
- Review growth charts for unusual patterns or plateaus
- Assess for comorbid conditions (anxiety, depression, OCD)
- Document specific eating patterns, including timing, amounts, and behaviors
- Perform a thorough physical examination with special attention to vital signs
- Order appropriate laboratory tests (electrolytes, CBC, thyroid function)
- Consider family dynamics and social environment in assessment
Nursing Management of Bulimia in Children: Hospital Setting
Hospital-based management of bulimia in children is typically reserved for cases with severe medical complications, failed outpatient treatment, or significant psychiatric comorbidities. Nursing care in this setting focuses on medical stabilization, nutritional rehabilitation, and establishing behavioral interventions.
Admission Criteria
Indications for Hospitalization in Pediatric Bulimia
- Severe electrolyte disturbances (potassium <3.2 mmol/L, chloride <88 mmol/L)
- Cardiac arrhythmias or prolonged QTc interval
- Hemodynamic instability (syncope, orthostatic hypotension)
- Esophageal tears or hematemesis
- Severe dehydration
- Acute psychiatric emergency (suicidal ideation)
- Failed outpatient treatment
- Inability to maintain adequate nutrition without supervision
- Severe comorbid conditions requiring intensive management
- Rapid weight loss despite outpatient intervention
Initial Hospital Assessment
Upon admission, nurses should conduct a comprehensive assessment of children with bulimia:
Medical Assessment
- Complete set of vital signs, including orthostatic measurements
- Comprehensive physical examination
- Laboratory studies:
- Electrolytes (sodium, potassium, chloride, bicarbonate)
- Complete blood count
- Liver function tests
- Renal function panel
- Thyroid function tests
- Glucose level
- Calcium, magnesium, phosphate levels
- ECG to assess for arrhythmias or prolonged QTc
- Gastrointestinal assessment (abdominal examination)
- Dental examination if possible
Psychosocial Assessment
- Mental status examination
- Assessment for comorbid psychiatric conditions
- Suicide risk assessment
- Family dynamics evaluation
- Understanding of eating disorder behaviors
- Previous treatment history
- School functioning/academic impacts
- Social support systems
- Motivation for treatment and recovery
- Coping skills assessment
Monitoring Parameters for Hospitalized Children with Bulimia
| Parameter | Frequency | Critical Values/Notes |
|---|---|---|
| Vital signs | Q4h initially, then Q8h when stable | HR <50 bpm, orthostatic changes (↑HR >20 bpm or ↓BP >10mmHg) |
| Weight | Daily, same time, after voiding, in hospital gown | Fluctuations >0.5kg in 24h may indicate water loading or hidden weights |
| Fluid intake/output | Every shift | Monitor for water loading or fluid restriction |
| Meal supervision | All meals and snacks | 30-60 minutes of supervision post-meals to prevent purging |
| Bathroom monitoring | As needed | Supervised bathroom visits if purging risk is high |
| Electrolytes | Daily until stable, then every 2-3 days | K+ <3.2 mmol/L requires immediate intervention |
| ECG | On admission, then as indicated | QTc >450ms requires cardiology consult |
| Mental status | Every shift | Assess for anxiety, depression, suicidal thoughts |
Nursing Interventions for Hospitalized Children with Bulimia
Nutritional Interventions
- Structured meal plan: Implement a regular meal schedule (3 meals, 2-3 snacks) designed by a registered dietitian
- Meal supervision: Provide supportive presence during meals to ensure adequate intake and prevent compensatory behaviors
- Post-meal support: Engage patient in distraction activities for 30-60 minutes after meals to reduce purging urges
- Nutrition education: Provide age-appropriate education about nutritional needs and consequences of malnutrition
- Food exposure: Gradually introduce feared foods in a supportive environment
- Dietary supplements: Administer supplements as prescribed for nutritional deficiencies
- Monitor for refeeding syndrome: Watch for signs like edema, cardiovascular changes, and electrolyte shifts
Medical Interventions
- Electrolyte replacement: Administer oral or IV electrolyte replacement as prescribed
- Fluid management: Monitor hydration status and administer fluids as needed
- Medication administration: Administer medications for symptom management (antidepressants, antiemetics)
- Cardiac monitoring: Monitor ECG changes and vital signs, especially in severely compromised patients
- GI symptom management: Address constipation, bloating, and other GI symptoms common in recovery
- Dental care: Provide oral hygiene instruction to minimize dental erosion
Psychosocial Interventions
- Therapeutic alliance: Establish a trusting, non-judgmental relationship with the child
- Emotional support: Provide validation and normalize feelings around food and body image
- Cognitive behavioral techniques: Assist with identifying triggers and developing coping strategies
- Family involvement: Include family in treatment planning and education
- Group therapy facilitation: Support participation in appropriate therapeutic groups
- Coping skills training: Teach stress management, distress tolerance, and emotional regulation
- Body image work: Facilitate appropriate activities to improve body image
NURSES Mnemonic for Hospital Management
A guide for prioritizing care for hospitalized children with bulimia:
- N – Nutrition stabilization and meal monitoring
- U – Understand psychological triggers and provide support
- R – Restore electrolyte balance and hydration
- S – Support family involvement in treatment
- E – Educate about healthy eating patterns
- S – Safety monitoring (prevent purging behaviors)
Evidence-Based Practice
Research shows that hospitalized children with bulimia benefit from a multidisciplinary approach involving nursing, medicine, nutrition, and mental health services. Regular team meetings to coordinate care and consistent approaches to meal support are associated with better outcomes. Flexibility in meal plans based on individual needs rather than rigid protocols has shown improved adherence and reduced treatment resistance.
Nursing Management of Bulimia in Children: Home Setting
Most children with bulimia are managed in outpatient settings. Nursing management at home involves education, support, and coordination of care between the child, family, and healthcare team. The goal is to establish healthy eating patterns, eliminate compensatory behaviors, and address underlying psychological factors.
Family Involvement
Family-based treatment (FBT), also known as the Maudsley approach, has shown effectiveness in treating bulimia in children and adolescents. This approach positions parents as the primary resource in helping their child recover from the eating disorder.
Parents take control of eating
Gradual return of control to child
Establish healthy identity
Nursing Support for Family-Based Treatment
- Parent education: Teach parents about bulimia in children, its medical consequences, and treatment approaches
- Skills training: Help parents develop skills for meal supervision and management of purging behaviors
- Communication coaching: Guide family members in supportive communication that separates the child from the eating disorder
- Sibling support: Provide education and support for siblings to understand their role in recovery
- Family system assessment: Identify family patterns that may unintentionally maintain the eating disorder
- Parental alignment: Support parents in presenting a united approach to treatment
- Empowerment: Encourage parents to trust their abilities to help their child
Important Note
In family-based treatment for bulimia in children, parents should be empowered to take charge of meals, but NOT blamed for causing the eating disorder. Nurses should emphasize that eating disorders have multiple complex causes, and parenting style is not the primary cause.
Meal Support Strategies
Effective meal support is critical for managing bulimia in children at home. Nurses can provide the following guidance to families:
Pre-meal Strategies
- Create a calm environment free from distractions
- Establish regular meal and snack times
- Involve child in meal planning when appropriate
- Prepare portions in advance to reduce anxiety
- Have distraction activities planned for after meals
- Ensure all family members know their supportive role
- Limit food-related discussions before meals
During-meal Strategies
- Model normal eating behaviors as a family
- Provide supportive but firm encouragement
- Avoid commenting on food choices or amounts
- Use distraction techniques like conversation
- Set appropriate time limits for meals (30-45 minutes)
- Address anxiety with validation and reassurance
- Maintain a positive, matter-of-fact atmosphere
Post-meal Strategies
- Supervised period: Maintain supervision for 30-60 minutes after meals to prevent purging
- Distraction activities: Engage in board games, crafts, reading, or other activities that occupy hands and mind
- Emotional support: Acknowledge discomfort without reinforcing eating disorder beliefs
- Bathroom monitoring: Establish clear guidelines for bathroom use after meals if purging is a concern
- Positive reinforcement: Acknowledge completion of meals with appropriate praise
- Journaling: Encourage expression of feelings through writing or art
- Relaxation techniques: Practice deep breathing, progressive muscle relaxation or guided imagery
Home Monitoring
Monitoring the progress of a child with bulimia at home is essential for ensuring recovery. Nurses should advise families on the following monitoring parameters:
| Parameter | Frequency | What to Look For/Document |
|---|---|---|
| Weight | Weekly (by healthcare provider, not at home) | Stability within healthy range, no rapid fluctuations |
| Meal completion | Each meal and snack | Portions consumed, resistance, time to complete |
| Purging behaviors | Daily | Bathroom visits after meals, evidence of vomiting, laxative use |
| Exercise patterns | Daily | Duration, intensity, compulsive nature, resistance to limits |
| Mood and anxiety | Daily | Changes in mood, anxiety around meals, general distress |
| Physical symptoms | As they occur | Dizziness, fatigue, palpitations, abdominal pain |
| Medication compliance | As prescribed | Taking medications as directed, side effects |
HOME CARE Mnemonic for Bulimia Management
Key components of home management for bulimia in children:
- H – Help parents establish meal structure
- O – Observation of eating patterns and behavior
- M – Monitor for purging behaviors
- E – Emotional support for the entire family
- C – Communication that separates child from disorder
- A – Activities for distraction post-meals
- R – Reinforcement of progress, not appearance
- E – Education about normal nutrition and development
Practical Tips for Parents
- Keep a food and mood journal to identify triggers for binge-purge episodes
- Remove scales from the home to reduce focus on weight
- Lock medications, including laxatives and diet pills
- Establish a regular family meal routine with everyone eating together when possible
- Create a “coping skills toolbox” with cards listing healthy coping strategies
- Practice role-playing difficult social situations involving food
- Join parent support groups to share experiences and strategies
Telehealth Nursing Support
Nurses can provide ongoing support for families managing bulimia in children at home through telehealth services:
- Regular video check-ins to review meal plan adherence
- Virtual meal support sessions to coach parents through difficult meals
- Remote monitoring of vital signs and symptoms
- Medication management and side effect assessment
- Crisis intervention for acute episodes
- Coordination with other healthcare team members
- Educational sessions on nutrition and eating disorder management
Control of Bulimia in Children
Controlling bulimia in children involves a comprehensive approach that includes prevention, early intervention, and strategies to maintain recovery and prevent relapse. Nurses play a crucial role in all aspects of control.
Prevention Strategies
Primary prevention aims to reduce the incidence of bulimia in children through awareness, education, and early identification of risk factors.
Individual-Level Prevention
- Promote healthy body image from early childhood
- Teach media literacy to counter unrealistic body ideals
- Develop healthy coping skills for stress and emotions
- Encourage balanced nutrition without labeling foods as “good” or “bad”
- Screen for early warning signs during routine check-ups
- Address comorbid mental health concerns promptly
- Promote physical activity for fun and health, not weight control
Family-Level Prevention
- Discourage diet talk and weight-focused comments
- Avoid using food as reward or punishment
- Create positive family meal experiences
- Model healthy eating and body image
- Emphasize body functionality over appearance
- Develop open communication about feelings
- Recognize and address family stress
- Address any parental eating disorders
Community-Level Prevention
- Implement school-based body positivity programs
- Train teachers to identify early warning signs
- Create policies against weight-based bullying
- Provide education to coaches about healthy athlete nutrition
- Develop community resources for early intervention
- Advocate for responsible media portrayals of bodies
- Support mental health services in schools
Nursing Role in Prevention
Nurses can take an active role in preventing bulimia in children through:
- Screening: Incorporate eating disorder screening into regular health assessments
- Education: Provide age-appropriate education about healthy eating, body development, and media literacy
- Early identification: Recognize early warning signs like preoccupation with food, dieting, or body dissatisfaction
- Advocacy: Promote school policies that discourage weight-based teasing and disordered eating
- Parent guidance: Offer guidelines for promoting healthy body image and eating habits
- Professional development: Train other healthcare providers and educators on early detection
- Public health initiatives: Participate in community programs promoting positive body image
Relapse Prevention
Relapse is common in eating disorders, including bulimia in children. Developing a structured relapse prevention plan can significantly improve long-term outcomes.
| Common Triggers | Warning Signs | Coping Strategies |
|---|---|---|
| Stress at school/home | Increased food rituals | Deep breathing, mindfulness exercises |
| Negative body comments | Body checking behaviors | Positive affirmations, media break |
| Social events with food | Avoiding eating with others | Pre-planning, support person present |
| Life transitions | Return of rigid exercise | Journal emotions, extra therapy sessions |
| Conflict with peers/family | Secretive behaviors | Communication skills, conflict resolution |
| Perfectionism-triggering events | All-or-nothing thinking | Challenge cognitive distortions |
RELAPSE Mnemonic for Prevention of Bulimia Recurrence
Essential components of relapse prevention for bulimia in children:
- R – Recognize early warning signs
- E – Establish regular meal patterns
- L – List personal triggers and high-risk situations
- A – Ask for help when struggling
- P – Practice healthy coping skills regularly
- S – Self-monitoring without judgment
- E – Embrace setbacks as learning opportunities
Long-term Management
Long-term management of bulimia in children focuses on sustaining recovery and addressing ongoing needs as the child develops.
Long-term Management Plan
- Stepped care approach: Gradually reduce intensity of treatment as recovery progresses
- Regular monitoring: Continue periodic assessments even after acute symptoms resolve
- Developmental transitions: Plan for additional support during key developmental stages (puberty, school transitions)
- Booster sessions: Schedule periodic therapy “boosters” to reinforce skills
- Comorbidity management: Address anxiety, depression, or other mental health concerns
- Identity development: Support healthy identity formation beyond the eating disorder
- Family maintenance: Continue family therapy as needed to sustain healthy dynamics
Recovery Milestones
Recovery from bulimia in children can be monitored through these key milestones:
- Elimination of binge-purge episodes for extended periods
- Establishment of regular, adequate nutrition
- Normalization of physiological parameters (lab values, vital signs)
- Development of healthy coping strategies for emotional regulation
- Improved body image and reduced preoccupation with weight/shape
- Re-engagement with age-appropriate social activities
- Improved family communication and functioning
- Development of identity beyond the eating disorder
Special Considerations for Ongoing Care
- Monitor for crossover to other eating disorders (anorexia, binge eating disorder)
- Address emerging comorbidities like substance use or self-harm
- Provide education about reproductive health as the child matures
- Ensure coordination between pediatric and adult services during transition of care
- Support development of healthy relationships with food as child gains independence
- Monitor for impact of social media and peer influences
Case Studies: Bulimia in Children
Case Study 1: Early Intervention
Patient: Emma, 11-year-old female
Presentation: Emma was brought to her pediatrician by concerned parents who noticed frequent bathroom visits after meals, missing food from the pantry, and complaints about feeling “fat” despite normal weight. She recently started middle school and joined a competitive gymnastics team.
Assessment: Screening revealed emerging bulimic behaviors including occasional binge eating followed by self-induced vomiting (2-3 times weekly for the past month). Physical exam showed normal weight-for-age, mild parotid swelling, and slight erosion of dental enamel. Laboratory results revealed mild electrolyte abnormalities.
Nursing Management:
- Family-based treatment initiated with parents taking responsibility for all meals
- Post-meal supervision implemented for 60 minutes
- Parent education provided on meal support techniques and monitoring for purging
- Weekly outpatient visits for weight monitoring and electrolyte checks
- Coordination with school nurse to ensure consistent approach during school hours
- Psychoeducation for Emma about nutritional needs during puberty and sports
Outcome: With early intervention, Emma’s bulimic behaviors resolved within 8 weeks. Ongoing therapy addressed body image concerns and perfectionistic tendencies. Parents received guidance on supporting healthy athletic participation without overemphasizing weight or appearance.
Case Study 2: Hospital Management
Patient: Jayden, 13-year-old male
Presentation: Admitted to pediatric unit following syncope during basketball practice. History revealed secret binge eating and self-induced vomiting for 6 months, excessive exercise, and recent use of laxatives. Weight was stable but laboratory results showed severe hypokalemia (K+ 2.8 mmol/L) and metabolic alkalosis.
Assessment: Physical examination revealed orthostatic hypotension, tachycardia, and mild dehydration. Cardiac monitoring showed prolonged QTc interval (470ms). Psychosocial assessment identified significant anxiety, perfectionism, and bullying related to body image.
Nursing Management:
- Immediate electrolyte replacement and cardiac monitoring
- Structured meal plan with 1:1 supervision and 60-minute post-meal monitoring
- Bathroom supervision due to high purging risk
- Daily vital signs, weight monitoring, and laboratory tests
- Anxiety management techniques including guided imagery and progressive muscle relaxation
- Family therapy sessions to establish meal support strategies for discharge
- Education for parents and patient about medical complications of purging
- Coordination with psychiatry for anxiety management
Outcome: After 5 days of hospitalization, Jayden’s electrolytes normalized and QTc returned to normal range. He was discharged to intensive outpatient treatment with a comprehensive safety plan, including scheduled meals, supervised bathroom use after eating, and regular outpatient monitoring.
Case Study 3: Relapse Prevention
Patient: Sofia, 14-year-old female with history of bulimia since age 12
Presentation: Successfully completed 6 months of outpatient treatment with resolution of binge-purge behaviors. Now facing transition to high school and parents concerned about relapse risk. Sofia reports increased anxiety about new social environment and body comparison with peers.
Assessment: Currently weight-stable without binge-purge episodes for 4 months. No medical complications present. Psychosocial assessment reveals increased body checking behaviors, anxiety about food choices, and concerns about making friends in new school environment.
Nursing Management:
- Development of personalized relapse prevention plan identifying specific triggers
- Collaboration with school nurse for discreet check-ins during initial transition
- Booster family therapy sessions focusing on maintaining structure while promoting appropriate autonomy
- Teaching Sofia mindfulness techniques for managing anxiety triggers
- Creation of a “coping skills toolbox” with personalized strategies
- Regular but less frequent monitoring visits (biweekly, then monthly)
- Connection to peer support group for teens with eating disorder history
- Education on managing social media exposure and body image challenges
Outcome: Sofia experienced increased urges to binge during the first month of school but successfully used her coping skills without engaging in eating disorder behaviors. Monthly check-ins continued throughout freshman year with gradual transition to quarterly maintenance visits.
Resources for Nurses
Professional Organizations
- National Eating Disorders Association (NEDA)
- Academy for Eating Disorders (AED)
- International Association of Eating Disorders Professionals (IAEDP)
- Society for Adolescent Health and Medicine (SAHM)
- American Psychiatric Nurses Association (APNA)
- Pediatric Nursing Certification Board (PNCB)
Clinical Resources
- AED’s Medical Care Standards Guide
- NEDA’s Toolkits for Healthcare Providers
- Maudsley Parents: Resources for Family-Based Treatment
- Eating Disorders in Children and Adolescents: A Clinical Handbook
- Practice Parameter for the Assessment and Treatment of Children and Adolescents with Eating Disorders (AACAP)
Educational Opportunities
- Certification programs for eating disorder specialists
- Continuing education courses on pediatric eating disorders
- Annual conferences focusing on childhood and adolescent eating disorders
- Online training modules for meal support techniques
- Webinars on latest evidence-based treatments
Patient Education Materials
- Age-appropriate books about body image and eating disorders
- Family guides for supporting children with bulimia
- Meal support handouts for parents
- Apps for recovery support and meal tracking
- Support group information for patients and families
Recommended Reading for Nursing Professionals
- Lock, J., & Le Grange, D. (2015). Help Your Teenager Beat an Eating Disorder (2nd ed.). Guilford Press.
- American Academy of Pediatrics. (2010). Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics, 126(6), 1240–1253.
- Bryant-Waugh, R., & Lask, B. (2013). Eating Disorders in Childhood and Adolescence (4th ed.). Routledge.
- Neumark-Sztainer, D. (2011). Preventing Obesity and Eating Disorders in Adolescents: What Can Health Care Providers Do? Journal of Adolescent Health, 44(3), 206–213.
- Rome, E. S., et al. (2016). Children and Adolescents with Eating Disorders: The State of the Art. Pediatrics, 134(3), 582–592.