Therapist adherence to family-based treatment for adolescents with anorexia nervosa: A multi-site exploratory study.

OBJECTIVE: This exploratory study is the first to examine family-based treatment (FBT) adherence and association to treatment outcome in the context of a large-scale, multi-centre study for the treatment of adolescents with anorexia nervosa. METHOD: One hundred and ninety recorded FBT sessions from 68 adolescents with anorexia nervosa and their families were recruited across multiple sites (N = 6). Each site provided 1-4 tapes per family over four treatment time points, and each was independently rated for therapist adherence. RESULTS: There were differences in adherence scores within and between sites. ANOVA produced a main effect for site, F(5, 46) = 8.6, p < .001, and phase, F(3, 42) = 12.7, p < .001, with adherence decreasing in later phases. Adherence was not associated to end of treatment percent ideal body weight after controlling for baseline percent ideal body weight (r = .088, p = .48). CONCLUSIONS: Results suggest that FBT can be delivered with adherence in phase one of treatment. Adherence was not associated with treatment outcome as determined using percent ideal body weight.

Classification of childhood onset eating disorders: A latent class analysis.

This study tested the hypothesis that latent class analysis (LCA) would successfully classify eating disorder (ED) symptoms in children into categories that mapped onto DSM-5 diagnoses and that these categories would be consistent across countries. Childhood onset ED cases were ascertained through prospective active surveillance by the Australian Paediatric Surveillance Unit, the Canadian Paediatric Surveillance Program, and the British Paediatric Surveillance Unit for 36, 24, and 14 months, respectively. Pediatricians and child psychiatrists reported symptoms of any child aged ≤ 12 years with a newly diagnosed restrictive ED. Descriptive analyses and LCA were performed separately for all three countries and compared. Four hundred and thirty-six children were included in the analysis (Australia n = 70; Canada n = 160; United Kingdom n = 206). In each country, LCA revealed two distinct clusters, both of which presented with food avoidance. Cluster 1 (75%, 71%, 66% of the Australian, Canadian, and United Kingdom populations, respectively) presented with symptoms of greater weight preoccupation, fear of being fat, body image distortion, and over exercising, while Cluster 2 did not (all p < .05). Cluster 1 was older, had greater mean weight loss and was more likely to have been admitted to an inpatient unit and have unstable vital signs (all p < .01). Cluster 2 was more likely to present with a comorbid psychiatric disorder (p < .01). Clusters 1 and 2 closely resembled the DSM-5 criteria for anorexia nervosa and avoidant/restrictive food intake disorder, respectively. Symptomatology and distribution were remarkably similar among countries, which lends support to two separate and distinct restrictive ED diagnoses.

The effect of multiple family therapy on weight gain in adolescents with anorexia nervosa: pilot data.

OBJECTIVE: Preliminary research suggests that multiple family therapy (MFT) may be an effective intervention for adolescent anorexia nervosa (AN). This study compared the extent of weight restoration for patients enrolled in one year of MFT compared to a matched control group receiving treatment as usual (TAU). METHOD: A retrospective chart review was performed using data from 25 MFT cases matched to 25 controls on age, diagnosis and year of entry to the eating disorder program. RESULTS: Both cases and controls experienced significant weight restoration, however patients enrolled in MFT were restored to a higher mean percent ideal body weight than the TAU group (99.6% (±7.27%) vs. 95.4 (±6.88); p<0.05). CONCLUSIONS: MFT may be more effective than TAU in restoring weight in adolescents with AN.

OBJECTIF: La recherche préliminaire suggère que la thérapie multifamiliale (TMF) peut être une intervention efficace pour les adolescents souffrant d'anorexie mentale (AM). Cette étude a comparé l'étendue de la reprise de poids pour les patients inscrits à une TMF d'un an comparativement à un groupe témoin apparié recevant le traitement usuel (TU). MÉTHODE: Un examen rétrospectif des dossiers a été mené à l'aide des données de 25 cas de TMF appariés à 25 témoins selon l'âge, le diagnostic et l'année d'entrée dans le programme des troubles alimentaires. RÉSULTATS: Les cas et les témoins ont eu des reprises de poids significatives, mais les patients inscrits à la TMF ont repris un pourcentage moyen plus élevé de leur poids corporel idéal que le groupe du TU (99,6% [±7,27 %] c. 95,4% [±6,88]; p<0,05). CONCLUSIONS: La TMF peut être plus efficace que le TU pour la reprise de poids des adolescents souffrant d'AM.

Attentional biases to body shape images in adolescents with anorexia nervosa: an exploratory eye-tracking study.

Body image distortion (BID) plays an important role in the etiology and maintenance of anorexia nervosa (AN). Previous studies of BID in AN showed small biases in visual scanning behavior (VSB) towards images of body shapes. The aim of this study is to investigate biases in VSB when body shape images compete with images with a different theme (social interactions) for subjects׳ attention. When images of thin body shapes (TBS) were presented alongside images of social interactions, AN patients (n=13) spent significantly more time looking at TBSs rather than at social interactions, but controls (n=20) did not. When images of fat body shapes (FBS) were presented alongside images of social interactions, AN patients spent significantly more time looking at FBSs rather than at social interactions, but controls did not. When images of TBSs, FBSs and social interactions were presented alongside each other, AN patients demonstrated a hierarchy in their attention allocation, choosing to spend the most viewing time on TBS images, followed by FBS images and then images with social interactions. Under the three experimental conditions, AN patients demonstrated large biases in their visual scanning behavior (VSB). Biases in VSB may provide physiologically objective measures that characterize patients with AN.

The canadian eating disorder program survey - exploring intensive treatment programs for youth with eating disorders.

OBJECTIVE: To explore and describe philosophies and characteristics of intensive eating disorder (ED) treatment programs based in tertiary care institutions across Canada. METHOD: A ninety-item survey examining ED services for adolescents was developed, piloted, and completed by 11 programs across Canada. Information pertaining to program characteristics and components, governance, staffing, referrals, assessments, therapeutic modalities in place, nutritional practices, and treatment protocols were collected. RESULTS: The results highlight the diversity of programming available but also the lack of a unified approach to intensive eating disorder treatment in youth. CONCLUSIONS: This report provides important baseline data that offers a framework that programs can use to come together to establish assessment and treatment protocols as well as a process for outcome evaluation. Continued collaboration will be essential moving forward to ensure Canadian youth, regardless of geographic location, receive the necessary treatment required to attain and sustain recovery.

OBJECTIF: Explorer et décrire les philosophies et les caractéristiques des programmes de traitement intensif des troubles alimentaires (TA) menés dans des institutions de soins tertiaires au Canada. MÉTHODE: Un questionnaire en 90 items examinant les services de TA pour adolescents a été mis au point, piloté et rempli par 11 programmes pancanadiens. L'information concernant les caractéristiques et les composantes des programmes, la gouvernance, la dotation en personnel, l'aiguillage, les évaluations, les modalités thérapeutiques instaurées, les pratiques nutritionnelles et les protocoles thérapeutiques a été recueillie. RÉSULTATS: Les résultats mettent en évidence la diversité des programmes offerts mais également, l'absence d'une approche unifiée du traitement intensif des troubles alimentaires chez les adolescents. CONCLUSIONS: Ce rapport offre d'importantes données de départ constituant un cadre que peuvent utiliser les programmes pour s'assembler et établir des protocoles d'évaluation et de traitement ainsi qu'un processus d'évaluation des résultats. La collaboration continue sera essentielle dorénavant pour faire en sorte que les adolescents canadiens, peu importe l'emplacement géographique, reçoivent le traitement nécessaire pour atteindre et faire durer le rétablissement.

Trading health for a healthy weight: the uncharted side of healthy weights initiatives.

Healthy eating and weight initiatives have been incorporated into many schools to combat the growing obesity problem. There is little research, however, on the effectiveness of these programs or any inadvertent harmful effects on children's mental health. Our aims were to report on how school-based healthy weights initiatives can trigger the adoption of unhealthy behaviours for some children. This is a case series of four children seen at specialized eating disorder clinics. Each child attributed eating pattern changes to information garnered from school-based healthy eating curricula. Unanticipated consequences of these initiatives are described and alternative approaches are discussed.

Delirium and refeeding syndrome in anorexia nervosa.

OBJECTIVE: To review the literature on delirium and refeeding syndrome in patients with anorexia nervosa (AN) and present case examples in an attempt to identify common clinical features and response to therapy. METHOD: A comprehensive literature review was completed. In addition to the cases identified in the literature, we present two additional cases of our own. RESULTS: We identified a total of 10 cases (all female; mean age 19 years old, range 12-29 years); 2/3 of the cases had similar clinical features predating the delirium and during refeeding. DISCUSSION: Delirium, albeit rare, can be associated with the refeeding syndrome in low weight patients with AN. During the initial refeeding phase, close monitoring of medical, metabolic, and psychological parameters are important in establishing factors that may elevate risk. Early detection and treatment of delirium using nonpharmacologic and pharmacologic means are also important to help minimize the effects of this potentially deadly condition.

Incidence and age-specific presentation of restrictive eating disorders in children: a Canadian Paediatric Surveillance Program study.

OBJECTIVES: To document and describe the incidence and age-specific presentation of early-onset restrictive eating disorders in children across Canada. DESIGN: Surveillance study. Cases were ascertained through the Canadian Paediatric Surveillance Program by surveying approximately 2453 Canadian pediatricians (a 95% participation rate) monthly during a 2-year period. SETTING: Canadian pediatric practices. PARTICIPANTS: Pediatricians and pediatric subspecialists. MAIN OUTCOME MEASURES: A description of clinical presentations and characteristics of eating disorders in this population and the incidence of restrictive eating disorders in children. RESULTS: The incidence of early-onset restrictive eating disorders in children aged 5 to 12 years seen by pediatricians was 2.6 cases per 100 000 person-years. The ratio of girls to boys was 6:1, and 47.1% of girls and 54.5% of boys showed signs of growth delay. Forty-six percent of children were below the 10th percentile for body mass index, 34.2% were initially seen with unstable vital signs, and 47.2% required hospital admission. Only 62.1% of children met criteria for anorexia nervosa. Although children with anorexia nervosa were more likely to be medically compromised, some children who did not meet criteria for anorexia nervosa were equally medically unstable. CONCLUSIONS: Young children are seen with clinically significant restrictive eating disorders, with the incidence exceeding that of type 2 diabetes mellitus. These eating disturbances can result in serious medical consequences, ranging from growth delay to unstable vital signs, which can occur in the absence of weight loss or other restrictive eating disorder symptoms.

Nocturnal enuresis in adolescents with anorexia nervosa: prevalence, potential causes, and pathophysiology.

OBJECTIVE: The aim of this study was to determine the prevalence and potential causes of secondary nocturnal enuresis (NE) in adolescents with anorexia nervosa (AN). METHOD: Adolescents with AN completed the Incontinence Symptom Index-Pediatric (ISI-P), a self-report urinary incontinence survey. Those who had NE associated with the onset of AN on the ISI-P completed a comprehensive clinical and laboratory evaluation, including urinary flow measurements. RESULTS: The prevalence of NE in adolescents with AN was 17.0% (10 of 59). The overall frequency of day- and night-time urinary incontinence symptoms in adolescents with AN was 62.7%; urgency incontinence, 57.6%; stress incontinence, 32.2%; and insensate incontinence, 17.0%. Nine of the 10 adolescents with NE had secondary NE and confirmed that bedwetting ceased after weight restoration. DISCUSSION: Decreased functional bladder capacity and detrusor instability may contribute to the NE observed in this population. The high prevalence of NE in adolescents with AN warrants further study to determine the potential causative pathways. Clinicians who work with adolescents with AN should assess for this problem.

The experience of siblings of adolescents with eating disorders.

PURPOSE: To qualitatively and quantitatively explore the experience and QOL of siblings of AEDs. To date, there is little research on the quality of life (QOL) and the effect an eating disorder (ED) has on the siblings of adolescents with an eating disorder (AEDs). METHODS: Siblings were recruited between January 2008 and April 2008. Inclusion criteria included siblings aged 10-18 years old and living with a sibling with an ED. Exclusion criteria included having an ED, or major psychiatric disorder, or a communication problem that interfered with their participation. Siblings completed a general assessment questionnaire, the Pediatric Quality of Life inventory 4.0 Generic Core Scales and Eating Attitudes Test-26 (EAT-26). Focus group interviews were conducted until saturation was achieved and thematic analysis was employed. RESULTS: Twenty siblings (14 females) of 17 AEDs (15 females) participated. All but one sibling scored within the normal range for the Eating Attitudes Test-26. Key themes identified included a desire to understand the ED, acute awareness of ED behaviors and thoughts, challenges in understanding noneating-related obsessive behaviors, increase in family conflict and arguments, compassion and concern for the AED, feelings of loss and sacrifice, overwhelming sense of responsibility for the AED, and a sense of pervasiveness of the ED in all aspects of their lives. The siblings' accounts of these themes were noted to be fraught with contradictions. Eighty percent reported that their QOL was negatively affected by the onset of their siblings' ED. CONCLUSION: Clinical attention and further research into the experience of siblings of adolescents with ED is needed.

Second-degree atrioventricular block (Mobitz Type I) in an adolescent with anorexia nervosa: intrinsic or acquired conduction abnormality.

Anorexia nervosa (AN) can cause both functional and structural cardiac complications, including a variety of different conduction abnormalities. This is the first case report of symptomatic diurnal second-degree atrioventricular (AV) block (Mobitz Type I) in an adolescent with AN. We present a 12-year-old girl with AN, restrictor sub-type who reported cardiac symptoms during weight gain, at the time of the initial diagnosis of AV block. Second-degree AV block (Mobitz Type I) is discussed as a possible complication of the AN, as well as being an intrinsic conduction system disease.

Disordered eating in Jewish adolescent girls.

OBJECTIVES: To examine the presence and nature of disordered eating attitudes and behaviours among Jewish Canadian adolescents, as compared with non-Jewish Canadian adolescents in an urban community. A secondary goal was to examine whether rates of eating-disordered behaviour differed among the adolescents based on the degree of Jewish religious observance. METHOD: High school students (n = 868) from the Toronto area completed a demographic and religious practice questionnaire together with the Eating Attitudes Test (EAT), a self-report test that discriminated adolescents with syndromal eating disorders from normal adolescents. RESULTS: Jewish females aged 13 to 20 years, but not males, reported significantly more disordered eating behaviours and attitudes, compared with their non-Jewish female counterparts. Twenty-five percent of Jewish females, as compared with 18% of non-Jewish females, scored above the clinical cut-off for the EAT. No differences in vulnerability to disordered eating were found within the group of Jewish females or males related to their degree of religious observance. CONCLUSIONS: Adolescent Jewish females, but not males, appear to be at greater risk for abnormal attitudes and behaviours related to eating, compared with their non-Jewish female peers. While the reasons for this finding are unclear, this study is a step toward improving understanding of the relations between sex, culture, religion, and the development of eating disorders. Culturally sensitive and sex-specific prevention strategies and treatment interventions are indicated.

Ana and the Internet: a review of pro-anorexia websites.

OBJECTIVE: The purpose of this article is to describe the content of pro-anorexia websites, both qualitatively and quantitatively. METHOD: An Internet search protocol was developed to identify pro-anorexia websites. A grounded theory approach was used to generate themes from Internet-based information. Basic descriptive analysis was employed to report on key website characteristics. RESULTS: Twenty pro-anorexia websites met inclusion criteria. Saturation of themes was achieved after review of 12 websites. Key website characteristics included purpose of website (75%), information about webmaster (67%), website disclaimers (58%), and information on "tips and tricks" (67%). Religious metaphors, lifestyle descriptions, and "thinspiration" (inspirational photo galleries and quotes that aim to serve as motivators for weight loss) were frequently present. A total of 10 themes were generated. The most prevalent themes included control, success, and perfection. CONCLUSION: Health-care providers and caregivers should be aware of pro-anorexia websites and their content, as these websites contain information that promote and support anorexia nervosa.

A community-based training program for eating disorders and its contribution to a provincial network of specialized services.

The Ontario Community Outreach Program for Eating Disorders is a pilot training project within the eating disorder programs at the University Health Network--Toronto General Hospital (TGH) and the Hospital for Sick Children. This system provides ongoing training, consultation, and research evaluation in areas ranging from prevention through to tertiary care, in the hopes of increasing the capacity of practitioners to respond to the healthcare pressures of those experiencing eating disorders. A total of 3,315 health care practitioners and educators in Ontario participated in community-based training workshops. A pre-post analysis of participants' self-report evaluations was conducted using chi-square analyses. The findings revealed that there was a statistically significant increase in participants' (a) knowledge of eating disorders and of body image issues and (b) level of comfort to either treat clients with eating disorders or teach a curriculum on body image. The contribution of the training program to the development of a provincial network of specialized eating disorder services, designed to promote the public's access to timely and appropriate care for the full spectrum of eating disorders, are discussed.

Developing a feminist-informed model for decision making in the treatment of adolescent eating disorders.

In 1997 the Child and Family Clinic treatment team at Southlake Regional Health Centre (SLRHC) in Newmarket Ontario, Canada created the Eating Disorders Program, which included a day treatment program for adolescents with eating disorders. When first conceived, this day treatment program was the first of its kind in Ontario. The multi-disciplinary team created a feminist-informed model centered on developing joint decision making relationships among team, client, and family through sustained and transparent communication and negotiation. This model for decision making has evolved through careful deliberation and ethical reflection in the planning and provision of care.

Gender-role conflict and suicidal behaviour in adolescent girls.

OBJECTIVE: This study examined whether gender-role conflict influenced the suicidal behaviour of adolescent girls. METHOD: We designed a checklist and used it to perform a chart review. RESULTS: Gender-role conflict was associated with suicidal behaviour in 26.79% of the adolescent girls, and 2.68% of the adolescent boys, that we studied. CONCLUSIONS: Gender-role conflict plays an important role in the suicidal behaviour of girls. At present, there is no published research examining the impact of gender-role conflict on suicidal adolescents.