Heather Ly (Host): Hi there, everyone. Thanks so much for joining us for this latest episode of Medically Speaking. Joining me today is Dr. Kristen Cercone, who is the lead psychologist and Clinical Director of the Eating Disorder Team at the Children's Psychiatry Clinic. Thanks for being with us today.

Dr. Kristen Cercone: Thanks for having me.

Host: And you are also a certified eating disorders specialist. So, we have the perfect person to talk all about this topic today. What's the one thing that you want people to know, our listeners to know, about eating disorders? If there was one thing, what would that be?

Dr. Kristen Cercone: I would say that recovery is possible, and that your child and you as a family member are stronger than you know.

Host: What do people get wrong when it comes to eating disorders? Maybe you know, what it looks like or who it might affect. What are we not getting right?

Dr. Kristen Cercone: I think the biggest thing that we see is that you can't really tell if someone is suffering from an eating disorder or how sick they are from whatever eating disorder they have by looking at them. So, an eating disorder can affect people from every age, gender, racial background and body size or type weight or shape.

Host: I think one of the things that was interesting to me, especially when we were doing all of the work over the past couple of years with the Festival of Trees and connecting with the different families is talking to some of the families where they were younger boys. I think a lot of times people often think of maybe a teenage girl when it comes to an eating disorder. But I was really blown away by how young, unfortunately, some of these patients are.

Dr. Kristen Cercone: Yeah. We've seen the age of onset shift over the last—I mean, certainly since COVID. I mean, in our current program, our current intensive outpatient program, I would say 50% of the patients that are completing are in IOP or exiting, 50% of them are 12 or under.

Host: Wow. That's shocking. How critical is it that you and your team and really parents get to these kids early and start that intervention and that treatment much earlier? What does that do for the outcome?

Dr. Kristen Cercone: It's crucial. What we know is the earlier it's detected, treated—and treated aggressively—like kind of giving it all you got as soon as you can, that's directly related to outcome.

Host: What does treatment look like for somebody? I guess diagnosis first. And, you know, what do you look at and how do you decide whether or not somebody has severe, you know, restrictive eating or an eating disorder versus being a picky eater or, you know, just sort of a phase? When can we look past it and when do we need to take additional measures?

Dr. Kristen Cercone: Sure. So, I mean, I think when most people think of eating disorders, they think of anorexia nervosa, which is an extreme fear of weight gain and significant weight loss. And we certainly see that in our population and treat that. With that diagnosis and any disorder that includes restrictive eating and weight loss, the first priority is weight restoration. And that can happen. I mean, some teens and kids need that to happen on the inpatient level.

Host: Oh, wow.

Dr. Kristen Cercone: Because the weight loss is so significant and there's other signs of medical instability. So with severe weight loss or even without the weight loss, states of starvation and malnourishment have all sorts of effects on many systems of the body. So, we're looking at like low heart rate, low blood pressure, a drop in body temperature, and those things are really dangerous. So, that would require an inpatient stay for stabilization. And then, that child can transition to another level of care that would be appropriate for their needs. But the goal for any type of restriction is stabilizing that eating behavior and returning to a normal healthy weight for that person.

Host: And so, we certainly can accommodate that, that inpatient portion. But you also mentioned something called the IOP, the intensive outpatient program, which generally speaking is something that's pretty new to us here at Children's and at Kaleida. Prior to this program being started here, there was a time where some patients had to go elsewhere for that kind of treatment. What does it involve? And what does it mean to have it here in Buffalo?

Dr. Kristen Cercone: We're really proud of the fact that we can offer this, especially to our younger kids, because there really was nothing, even regionally for kids under 12, really. I remember before the IOP, we were sending patients—I think the closest, I sent a 10-year-old to Chicago. And then, he was able to shorten his stay—because our IOP was started—and come and finish his treatment with us. But that is just a lot. It's hard enough to send an older child away. But when you're talking about nine, 10, I mean, it's a really difficult age to to be separated from your family.

Host: Yeah. And that particular family, I remember speaking with them. And they said that, you know, dealing with the eating disorder was hard enough. Being away from family was an added level. Parents being away from work, how does that also help sort of the overall dynamic when there is a little bit of stability in terms of being close to home or going to sleep in your own bed at night? How does that help when it comes to recovery?

Dr. Kristen Cercone: Living with these illnesses and having a child with an eating disorder is an incredibly stressful, terrifying experience. So, anything that can provide more stability and support for the family and the child is definitely going to help.

Host: Yeah. So, they can continue on with school. So, the IOP, is it several days a week? Is it several hours at a time? What does it look like for—

Dr. Kristen Cercone: So, it's a three-day-a-week program for three hours per day. So in our IOP, it includes two primary treatment modalities. So, the first one is called family-based treatment. And That is considered the first-line treatment for restrictive eating disorders in children and adolescents. So, what that entails is really empowering the family to do what they already know how to do, which is nourish their child and restore health. So, it's empowering them to kind of take control temporarily over all aspects of nutrition. So, that would include planning meals, preparing them, plating them, and then supervising meal completion and coaching them through that.

Host: Yeah. So essentially, the family in an outpatient setting, and you can offer FBT in regular outpatient with just a therapist and potentially a dietician. in the IOP program, we structure it around that as well. So, there are a lot of different diagnoses that fall under that eating disorder umbrella. You know, I think of anorexia, bulimia. There are others. What is the difference between these different terms?

Dr. Kristen Cercone: So, anorexia nervosa, which is probably what most people think about when they hear an eating disorder involves usually a significant amount of weight loss that would drop a person to being categorized as medically underweight based on their BMI and how their growth looked over a period of time. With that also comes an intense fear of weight gain and a body image, some kind of disturbance in body image or insecurity. We also see body insecurity with bulimia nervosa as well. The difference with that is that there's a binge-purge pattern. And the person has not lost weight to classify them as medically underweight. And they're engaging in a binge-purge cycle of behavior.

Host: Could that be more difficult for a parent to detect maybe? Because if you're not seeing them physically taking part, you know, in the purging aspect of it, if their body is not changing, is it easier sometimes for people to hide?

Dr. Kristen Cercone: I think so depending on the frequency of the binge-purge cycle. I mean, sometimes there's some physical evidence that that's happening, depending on how often it's happening. And I should say too, with anorexia, you can also have binging and purging, that weight is in that medically dangerous range. So, you can have the range of behaviors. It's really we use the weight as kind of the diagnostic criteria.

Host: Yeah. That differential. Are there other diagnoses that maybe aren't talked about as often as bulemia?

Dr. Kristen Cercone: So, there's ARFID, which I feel like more people are learning about. But ARFID, it stands for avoidant restrictive food intake disorder. So, a way to think about ARFID, there's not a body image component. There's not body insecurity. You can certainly have ARFID and anorexia. We have sometimes a child starts off with ARFID, and that anorexia develops later. But ARFID typically presents or starts younger, and it's extreme food selectivity and avoidance. And it can be related to kind of three main categories. The first is a sensory kind of sensitivity. So, a child might have food avoidance related to the texture of food, the smell of food, the temperature of food.

The second broad category is just low interest. They're just not interested in food. It doesn't appeal to them. They might get full really quickly. They don't really get hungry. And the third is aversive consequence. So, something happened as a result of eating their food vomiting episode, a choking episode, a food allergy that usually causes an acute food avoidance, and then rapid weight loss. And you can also have a combination of the three.

Host: With something like ARFID, let's say, you know, you ate something, you got sick from it, and you kind of want to avoid it, I think about, you know, doing that as a kid. I'm like, "I don't really like that anymore," because that's what you connect it to. What's the difference between that or where is it time for a parent to step in and your team to step in where it rises to the level of becoming, you know, more detrimental to the child or more dangerous, because they're avoiding certain things?

Dr. Kristen Cercone: So, significant weight loss. But in kids, sometimes there's not weight loss. There's just stopping of growth. So if you see a kid fall off their growth curve and there's been this pattern of food selectivity, and what they will eat is becoming narrower and narrower, that's a time that I would seek out some assistance with that.

Host: We've done a lot of fundraising. Again, the past couple of Festival of Trees, you've been there to see the support that the community, you know, puts toward programs like this. What does that mean to you, you know, as a clinician? How does it help the patients that you help every day?

Dr. Kristen Cercone: Yeah. I mean, to be in that audience and have even, you know, the head honchos of Kaleida even talking about us and seeing the impact that our work has on the families, it's been incredibly meaningful for me and the rest of the team.

Host: Absolutely.

Dr. Kristen Cercone: And to see mental health getting a little bit more airtime, I think is super important. And I think, it just makes us feel really good about what we're doing day to day.

Host: What can we do to bring those conversations about, you know, mental and behavioral health? And then, under that umbrella eating disorders, how can we get more people talking about it to not feel, you know, any sort of stigma towards it? Because I feel like there might still be some people that, you know, they want to keep it hush hush. It's not something that they want to openly admit to. But I feel like that's part of how we help people, is to get more people talking about it.

Dr. Kristen Cercone: I think continuing to think about outreach to schools and other community agencies and pediatrician's offices, and just getting those conversations to be more natural and just part of what you do. When you go into a doctor's office, when you go into your school counselor's office, when you talk to a teacher, I think all of that will help and just how parents can create more of an environment to invite those kind of hard conversations in too.

Host: Yeah. What types of things should we be looking for as parents? You know, when it comes to children, are there warning signs? Are there things that maybe we're overlooking?

Dr. Kristen Cercone: With eating disorders, I mean, they can be sneaky. Like, I think I read a statistic from a 2015 study recently that 6% of people with eating disorders are medically underweight, which is kind of shocking.

Host: Wow.

Dr. Kristen Cercone: And you can have like really sick people that don't appear sick. And if you think about just anything, any other psychiatric illness, there comes changes in personality and mood and behavior. So if you're seeing that and that might coincide with a change in eating behavior, that's definitely worth a conversation.

Host: I think oftentimes people will think of the food restriction. But also, could we be talking about binging and sort of the opposite end of that that falls under an eating disorder umbrella as well?

Dr. Kristen Cercone: Sure. So in anorexia, part of when we give that diagnosis is they do have to be medically underweight. And then when you don't fit into the medically underweight category, you can still be very, very sick. So, that gets put into kind of like another category of an unspecified eating disorder when you don't have that weight loss. But it still can cause all of the other components of medical instability that you might see in a person with anorexia.

Host: I think we would be remiss if we didn't talk about social media. You know, a lot of us are on our phone scrolling. You see the images of the ideal weight or, you know, the people that do what I eat in a day. And I look at some of these and it just seems so restrictive. You'll get people in the actual comments that say, "No, that's not a diet. That's disordered eating" or, you know, "You have a problem." How big of a problem, I guess, is social media? And what can we do to sort of weed out, you know, what's not reality?

Dr. Kristen Cercone: It's really tricky. I feel like, you know, if we think about how eating disorders come about or like the cause of an eating disorder, what we know about them, they're incredibly complex illnesses. What we think, what our understanding is that there can be this biological maybe vulnerability to developing eating disorder or any psychiatric illness that then interacts with aspects of a person's environment or situation or stressor.

So in COVID, we saw this play out pretty remarkably, particularly with eating disorders. So, you had these kids that maybe, you know, were maybe a little anxious, maybe a little perfectionistic, but that were otherwise functioning well, and maybe their school structure or the structure of sports was almost like a protective factor to developing an anxiety disorder or an eating disorder, then suddenly all that goes away and they have all this unstructured time and way more time on social media where they maybe stumbled upon a situp challenge during COVID or, you know, "You can't do a sport. So, let's do this. Let's get steps in" or whatever; something that maybe starts off as healthy or innocent quickly snowballs into something that isn't. And social media is, you know, you might come across one thing and you watch it. And then, suddenly, as we all know, our feed is populated by very similar content. And it's very easy for anyone to kind of get sucked into that.

Host: Yeah. And people put, you know, their best on there, you know? People aren't necessarily putting, you know, their vulnerable moments, the things that, you know, they see as their weaknesses. So, we're always comparing ourselves to, you know, people's best. So, I think that can be tough as well. You had mentioned, you know, other diagnoses, anxiety, OCD or trauma. How do those again fall into or connect to potentially having an eating disorder?

Dr. Kristen Cercone: Sure. I mean, the percentages range, but about 50% to 70% of patients with an eating disorder also have at least one other psychiatric comorbidity, usually depression, anxiety, OCD, substance use disorders. We also see higher rates of PTSD and ADHD in people with eating disorders.

Host: Is that something that you alone work with a patient on? Or are there various members of your team that will each tackle a different part of a diagnoses and help a patient through?

Dr. Kristen Cercone: So, we adopt a more transdiagnostic model. So, that is kind of the second modality we offer in our IOP program where we're teaching kids how the relationship between their emotional kind of distress or their intense emotional experiences and how that is connected to their eating disorder. So, everything kind of comes together. So, we're essentially helping kids and teens learn how to tolerate uncomfortable emotion, and then approach their life without engaging in problematic symptoms such as eating disorder symptoms or an obsessive compulsive symptom. And that happens alongside the weight restoration.

Host: What does treatment and recovery look like? And I know that seems a little bit like a loaded question because, number one, it's not the same for everybody. But I've heard patients say that there's not necessarily a finish line. For some, this is a continuing or perhaps a lifelong challenge that they're going to face.

Dr. Kristen Cercone: I think it can be for some people. I think in terms of trends, again, the earlier it presents and then is treated, maybe there's less of a risk that it's going to be this chronic condition that you have to manage. However, I would argue that there's still a vulnerability. So, you have to watch, you know, transitional periods of life, times where there might be increased stress. And that's how I talk about it with families and kids. Just like if you had diabetes or any other chronic illness, you have to take care of yourself and manage triggers and pay attention to when you might be more vulnerable so you can protect yourself against relapse.

Host: Talk about the importance of community and these multidisciplinary care teams. Something that, you know, we're very fortunate to have at Golisano Children's Hospital of Buffalo. How does that make it better for the patients that we serve?

Dr. Kristen Cercone: Well, because of, I mean, the complex nature of these illnesses. If you're a therapist or a psychologist treating a patient, you have to work closely with physicians, whoever the physician is. We work with either UBMD Adolescent Medicine Division or pediatricians, local pediatricians. Dieticians are involved. Schools, we connect with. Because all of these pieces, all of these environments that a child is in is very important to making sure that their nutrition stays consistent, and we're reaching the goals we want. And residential programs are higher levels of care. That's kind of built-in. In our IOP program, we have our own dietician, psychiatrists and our therapists. And then, we collaborate with the physicians that are involved.

Host: It takes a village, certainly.

Dr. Kristen Cercone: It really does. It really does.

Host: Talk more about the school program and sort of how the schools play into this and in their role.

Dr. Kristen Cercone: So, the way I work and how I coach my team is we help parents kind of figure out what they need to advocate for in the schools to help their child achieve recovery. So, that might be eating lunch with a friend in the nurse's office. We've had families arrange to FaceTime with their kid during lunch. So, a parent will get on FaceTime with their kid, they'll lunch together. Because we kind of operate under the assumption if we don't see it being consumed, it's not being consumed. And when we're in recovery, especially when we need to gain weight and we want to do it quickly, we need to make sure we're capturing those eating opportunities and making sure the food is getting in to the child.

Host: It's got to be really a good thing that the schools are buying into this as well, because we want what's best for the kids. They want what's best for their students. And again, going back to that sort of team approach. . It's not just your team. It's sort of that greater team, that greater community, right?

Dr. Kristen Cercone: Absolutely. And I even have teachers asking. We have given talks to school events and pediatricians in recent years and good questions about like, "How can we be more mindful of our language around our students, you know, just talking about, you know, teachers talking about their relationship with food and their bodies and how that might be perceived amongst their students. And just people thinking about those things, I think, is a good thing for sure.

Host: What are some of the things, language that we're using, the comments that could potentially be harmful for somebody that maybe has an eating disorder or is at risk, what are the things that we're saying that maybe we should shift away from and how can we be more supportive?

Dr. Kristen Cercone: I think we're all kind of harmed by diet culture and using judgmental language to describe bodies and food. So, trying to keep your language neutral and talking to kids like what food is for, it's for nourishment, it's for fuel. There's foods that do things for our brain and body, and then there's food that's fun. And kind of normalizing the range of food and encouraging and practicing for yourself flexibility with eating in both what you're eating and in situations.

Host: Yeah. I've heard people say, you know, there's no such thing as a bad food. Maybe it's not quite as nutritious for you or, you know, doesn't do as many good things for you, but labeling something as just outwardly bad could be harmful.

Dr. Kristen Cercone: It could be harmful, because then there's like this off-limit mentality, like, "This food is bad." And if you're vulnerable to this type of thinking, it can really exacerbate that rigidity that we see almost always in disordered eating. Like, "I can't have—" We see completely like eliminating food groups or "I can't have any sweets or treats." And that really sets you up for just increased anxiety and slip-ups. Like if we talk about like a binge-purge disorder or where there's any type of binging and purging, there's almost always some level of deprivation that precedes a binge episode. So, you have this restriction, you can't sustain that, or something happens, a stressor, you get upset, there's a binge episode, and then the cycle just kind of repeats.

Host: Yeah. What have you learned from your patients or what's one thing that you've learned that has changed the way that you view recovery and the importance of the work that you do?

Dr. Kristen Cercone: That's a good question. One thing I've learned is that I think what we provide, one of the most important things we provide as clinicians, which is kind of a surprising thing to realize, is we kind of reinstill hope with families, because they come in feeling pretty hopeless. Like, "How did I get here? There's a lot of blaming, like of themselves blame. "This is so scary. Like, what am I supposed to do?" And families really have all they need to do this work. They just need someone to remind them that they can do it.

And I've learned so much from even the families that come in and, like, they might say something to your kid, I'm like, "Oh, I'm going to steal that," you know? And it's remarkable really, I mean, like halfway through the program to witness the shift. Because about halfway through, we hear things like, you know, "My kid is back. " So, they've essentially watching their kid kind of come back to life. And even if you hear that once as a provider, I mean, it makes any part you had in that journey well worth it.

Host: I've spoken with some of your patients, you know, in the storytelling that we've done over the years and they've said exactly that. "If not for Dr. Cercone, I have no idea where we would be. I don't know if I would have my son or my daughter here." When you hear things like that, you know, they're back to being a kid. They're back to being their healthy, happy selves, back to sports,. How does that make you feel? What's that feeling in your heart, knowing that, you know, you and your team have done a good job?

Dr. Kristen Cercone: I always turn it back in the family, because they really are the ones that are in the trenches doing the hard work suffering. And I'm grateful that I got to be a part of that. I'm grateful that this gets to be my life's work, like what a career well spent, if I can have a little bit of a part in that. But the work these families do is just incredible. And the commitment and the showing up and the going through it week after week, sometimes months on, to get their kid well. I mean, it's really something to watch.

Host: Yeah. And something to be incredibly proud of, not only for the families, but for you and your team as well. If somebody knows somebody has a child, or they know somebody who is struggling and they want to reach out for help, how do they get in touch with you and your team? What are the next steps that they have to take?

Dr. Kristen Cercone: So, they would call our intake department and ask for the eating disorder clinic. I usually do if, if they're interested in the intensive outpatient program, I would do that evaluation and kind of decide if that would be appropriate for them or if something else would be more appropriate for them. But that's the first step, is calling your intake number.

Host: Yeah. And certainly nothing to feel ashamed about. You know, you should feel empowered, I would think, to reach out and take that first step to get the help that you need.

Dr. Kristen Cercone: Absolutely.

Host: Any final thoughts that you have for families, you know, who are on this journey or who may be beginning the journey to seeking help?

Dr. Kristen Cercone: I would say trust your gut as a parent, as a caregiver. You know your child. And if you think something's wrong, you should listen to that and reach out. And we can be helpful in getting you on the right track, getting your child back on the right track.

Host: Yeah. And we're very fortunate to have all of these resources at Golisano Children's Hospital of Buffalo, and more exciting things to come in the future when it comes to our mental and behavioral health program. So, stay tuned for more on that. But Dr. Kristen Cercone, thank you so much for being with us. A lot of really great information. You and your team do incredible work and we're happy to highlight that and showcase that.

Dr. Kristen Cercone: Thank you very much. Thanks for having me.

Host: Yes, thank you so much. And thank you for listening to this latest episode of Medically Speaking. We will see you next time.