Using session recordings to understand the content of community-based treatment for childhood anxiety disorders and response to technology-based training.

OBJECTIVE: The goal of the current study is to advance efforts to increase the quality of care for childhood anxiety disorder (CADs) through (1) detailing the content of community-based treatment sessions, (2) exploring the validity of therapist surveys, (3) examining the influence of setting differences, and (4) testing the effects of a technology-based training on use of nonexposure strategies. METHODS: Thirteen therapists were randomly assigned to technology-based training in the use of exposure therapy or treatment as usual (TAU) for CADs. Therapeutic techniques were coded from 125 community-based treatment sessions. RESULTS: Consistent with survey responses community therapists spent the majority of session time reviewing symptoms (34% of session time), implementing nonexposure cognitive behavioral therapy (CBT; 36%), and rarely engaged in exposure (3%). An integrated behavioral health setting was associated with greater endorsement of exposure on survey, p < 0.05, although this difference was not significant in session recordings, p = 0.14. Multilevel models indicated that technology-based training that has been shown to increase exposure, also decreased use of nonexposure CBT techniques (2% vs. 29%, p < 0.001). CONCLUSION: The study supports the validity of survey-based findings that community-based care for CADs consists of non-exposure CBT techniques. Efforts should be invested in dissemination of within-session exposure.

Insufficient Assessment and Treatment of Vitamin D in the Medical Management of Adolescents with Anorexia Nervosa.

PURPOSE: Suboptimal vitamin D levels are implicated in low bone mineral density, a common medical complication of anorexia nervosa. This study aimed to examine the frequency of vitamin D assessment and treatment for adolescents with anorexia nervosa in outpatient medical management. DESIGN AND METHODS: Retrospective chart review was used to examine 179 adolescents (M age = 15.5 years, SD = 2.2), newly diagnosed with anorexia nervosa at a tertiary care medical center in the United States between January 2000 and July 2016. RESULTS: Only 16% of patients (n = 29) received serum vitamin D assessments following diagnosis, of whom 52% had suboptimal vitamin D levels (n = 15). Only three patients with suboptimal vitamin D were advised to begin supplementation. No patients in our sample were encouraged to begin prophylactic vitamin D supplementation. CONCLUSIONS/PRACTICE IMPLICATIONS: Findings from this study highlight the critical need for widespread care team education about vitamin D assessment and treatment in the medical management of adolescents with anorexia nervosa, particularly in light of the potentially serious consequences of bone mineral density.

Assessing for Eating Disorders: A Primer for Gastroenterologists.

Eating disorders involve irregularities in eating behavior that may cause gastrointestinal (GI) symptoms. Consequently, many patients with eating disorders seek gastroenterological healthcare at some point in their illness, with many seeking this care even before they seek treatment for and/or diagnosed with their eating disorder. As such, the gastroenterology provider is in a unique position to identify, manage, and facilitate treatment for an eating disorder early in the course of the illness. Although assessing eating disorders is already a difficult task, the identification of eating disorders in patients with GI disease represents an even greater challenge. In particular, common GI symptoms, such as nausea, vomiting, and bloating, may disguise an eating disorder because these symptoms are often viewed as a sufficient impetus for dietary restriction and subsequent weight loss. In addition, the focus on identifying an organic etiology for the GI symptoms can distract providers from considering an eating disorder. During this prolonged diagnostic evaluation, the eating disorder can progress in severity and become more difficult to treat. Unfortunately, a misconception that hinders eating disorder detection is the notion that the rate or method of weight loss is associated with an eating disorder. Regardless of whether weight loss is slow or rapid, purposeful or accidental, eating disorder behaviors and thought patterns may be present. Unidentified eating disorders are not only dangerous in their own right but also can interfere with effective management of GI disease and its symptoms. As such, it is imperative for the GI provider to remain well versed in the identification of these diseases.

Development and initial validation of the Support for Healthy Lifestyle (SHeL) questionnaire for adolescents.

This study developed and provided initial validation for the Support for Healthy Lifestyle (SHeL), a set of scales designed to measure adolescent-perceived social support of healthy eating and physical activity. Item pool development utilized a prior focus group study of adolescents' perceptions of socially supportive behavior and a review of the literature on social support for health behavior change in adolescents. Exploratory factor analysis of the item pool completed by 220 adolescents, internal consistency estimates, and expert review of items and consensus resulted in 9 scales for the SHeL: Family Healthy Eating Support, Family Physical Activity Support, Family Hypocritical Control, Peer Health Eating Support, Peer Physical Activity Support, Peer Undermining, Professional Healthy Eating Support, Professional Physical Activity Support, and Professional General Support. Scale internal reliability estimates were α = 0.73-0.96. Supporting construct validity, the SHeL showed a pattern of stronger correlations between measures of the same source (parent/peer) and target behavior (healthy eating/physical activity) and stronger correlations with corresponding Sallis scales vis-à-vis other Sallis scales, with exceptions related to peer support for healthy eating. Divergent validity was somewhat limited, including in two instances, the SHeL scale was more strongly correlated with another SHeL scale. Supporting criterion validity, often the SHeL scales were correlated with related health behaviors. This study provided important psychometric information for a new measurement of social support for health behavior for adolescents. Further research with larger, more diverse, and treatment-seeking populations is needed to provide further validation of the SHeL and to begin to establish normative scores.

Medical Assessment and Triage of Pediatric Patients with Anorexia Nervosa in Primary Care.

OBJECTIVE: To examine the medical assessment and triage of pediatric patients with anorexia nervosa (AN) initially seen in primary care. METHODS: A retrospective cohort study was conducted for all pediatric patients with AN who had eating/weight concerns and initially identified symptoms in primary care in a single health care system between January 1, 2010, and December 31, 2016. Information on presenting concern, medical assessment/laboratory tests, clinical diagnoses, treatment recommendations, and referrals were abstracted from the medical record. RESULTS: Forty-one (mean age = 13.7 years; SD = 2.2) pediatric patients with AN had eating/weight concerns and initially identified symptoms in a primary care. Overall, only 5% (n = 2/41) of patients received an AN diagnosis during the index visit; a minority were assessed for electrolyte disturbance (n = 20), electrocardiogram abnormality (n = 18), hypothermia (n = 13), binge/purge behaviors (n = 13), orthostatic hypotension (n = 2), or dehydration (n = 1), and only 56% (n = 23) received triage consistent with practice recommendations. Although 61% (n = 25) met criteria for inpatient admission, inpatient hospitalization was recommended for only 2 patients. Patients who received triage consistent with practice recommendations received AN diagnosis and treatment significantly earlier than those who did not (p < 0.01 and p = 0.001, respectively). CONCLUSION: Findings suggest that pediatric patients with AN may not be receiving medical assessment and triage per practice recommendations in the primary care setting. Understanding barriers to evidence-based care for pediatric eating disorders may inform provider education and system-wide changes to enhance outcomes in these patients.