The urgent need for greater parent support and better health system experiences to enhance outcomes for pediatric anorexia nervosa: A Commentary on Marchetti & Sawrikar (2023).

Marchetti and Sawrikar's (2024) systematic review of parent illness representations of their child's anorexia nervosa provides a valuable synthesis of 32 qualitative studies. The key themes that emerge paint a concerning picture of parents' perceptions of AN as: difficult to identify and understand; of chronic duration; uncontrollable; severe; and associated with serious consequences. A sense of hopelessness and low-parental self-efficacy was identified. This Commentary explores the key findings of this review in four areas: AN treatment and recovery (control/cure); emotional representations of the illness; parent understanding of the illness (coherence) and its causes; and consequences of the AN. These illness perceptions are discussed along with relevant quantitative investigations of parent experiences, with a view to suggesting how the toll on parents might be reduced and how reducing burdens on parents might also lead to improved timely treatment outcomes. It is proposed that two broad features are needed: improved help-seeking experiences in the health care system; and, more parent-focussed support.

Toward a more comprehensive understanding and support of parents with a child experiencing an eating disorder.

OBJECTIVE: The majority of eating disorder (ED) carer research has been conducted with parents of adult patients, using qualitative methodologies, focusing on carer burden and distress during treatment. This article aimed to use results from a large, national, quantitative survey of parents of child or adolescent patients as a springboard for encouraging a more comprehensive investigation of parent experiences. METHODS: The online survey assessed treatment experiences and parent distress (DASS-21) but also less commonly investigated topics including symptom detection, experiences with primary care providers, and impacts on parent physical and psychological health, romantic relationship, finances, and employment. RESULTS: Key findings included parents (N = 439; 91.6% female): were the first person to notice the ED symptoms in 81.8% of cases; had only a 14.7% chance of a helpful experience with both the first general practitioner and first therapist they saw; needed to see M = 3.55 therapists before finding one that could help; reported worse than normal psychological health (96.0%), physical health (70.5%), and romantic relationship (92.7%); required M = 70.06 days leave from work to care for their child (per household); and 91.8% accessed treatment in the private sector with median out-of-pocket expenses of AUD 10,0001-AUD 20,000. DISCUSSION: Recommendations to address research and practice gaps include: increased focus on supporting initial symptom detection; improving primary care and treatment experiences; and, increasing the number of ED treatment providers. Urgently needed are solutions to the overwhelming demand for services and clearly, more support for parents. Such strategies are vital for reducing the overall burden of EDs. PUBLIC SIGNIFICANCE: Most eating disorder (ED) caregiver research has focused on experiences of supporting adult patients during treatment. This article used a large national survey to explore parent experiences of their child or adolescent's ED in less commonly investigated areas, such as detection, primary care, impact on parent physical and psychological health, romantic relationship, employment and finances. Findings suggested mixed experiences with health care providers and a very significant toll of the illness on the domains measured. Recommendations were provided for how these important areas can be addressed.

Is guided self-help family-based treatment for parents of adolescents with anorexia nervosa on treatment waitlists feasible? A pilot trial.

OBJECTIVE: The aim of the study was to assess the feasibility (recruitment and retention) of an online 12-session guided self-help family-based treatment (GSH-FBT) for families on the waitlist for face-to-face FBT utilizing trainee psychologists to assist carers of children with anorexia nervosa (AN) or atypical AN. METHOD: The primary outcomes were feasibility of GSH-FBT for families on the waitlist and secondary exploratory outcomes examined improvement of child and parental function. RESULTS: Of 187 eligible families on the waitlist, 24 (13%) expressed interest in the study; 16 (67%) of these families completed baseline, 13 (54%) completed GSH-FBT over a 6-month recruitment period. Children (mean age = 13.92, SD = .86; mean body mass index [BMI] centile = 29.47, SD = 24.80) had an average weight gain of 6 kg (BMI centile effect size = 2.61, 95% CI: 1.77-3.44) and a decrease in eating disorder behaviors (effect size = 1.11, 95% CI: .27-1.95). Improvements also occurred for general mood and behaviors in the child, and the impact of eating disorder symptoms on their functioning. Parents reported improvements in knowledge, skills, and confidence in managing AN. DISCUSSION: Use of this low-cost intervention while families are on the waitlist for FBT is engaging and useful but strategies to improve initial recruitment are needed. PUBLIC SIGNIFICANCE STATEMENT: Although most eligible families did not enroll in an online 12-session guided self-help family-based treatment for families on the waitlist for face-to-face FBT for anorexia nervosa, families who participated found it engaging. The children experienced improvements in BMI centile, eating and behavior. Parents reported increased confidence, knowledge, and skills. We need to examine how families can be encouraged to participate on online training when on waitlists for treatment.

Impact of guidance on intervention adherence in computerised interventions for mental health problems: a meta-analysis.

Web-based interventions are increasingly used for the prevention, treatment and aftercare of mental disorders. A crucial factor to the efficacy of such online programmes is adherence to the intervention content and procedure. It has been frequently suggested that adherence in web-based interventions is low and little is known about which factors influence adherence. To increase intervention uptake and completion, studies increasingly include interventions with some form of guidance. Guided interventions have been shown to have higher efficacy, however, evidence for the impact on adherence is limited and mixed. This meta-analysis explored the impact of human guidance on intervention completion in web-based mental health interventions. A total of 22 studies were included with interventions primarily targeting symptoms of depression and anxiety disorders. Results showed that guidance significantly increases the average amount of intervention completion [g = 0.29, 95% confidence interval (CI) 0.18-0.40] and the proportion of intervention completers [log odds ratio (OR) = 0.50, 95% CI 0.34-0.66] with small effects. On average, full completion rates were 12% higher in guided intervention groups. This meta-analysis demonstrated that guidance in web-based mental health interventions does increase adherence, but more research is required to better understand the specific mechanisms between guidance, adherence and outcomes.

The relationship between social media use and disordered eating in young adolescents.

BACKGROUND: The relationship between social media (SM) use and disordered eating (DE) has not been adequately explored in young adolescents. METHODS: Data from 996 Grade 7 and 8 adolescents (n = 534 girls; M age = 13.08) was investigated. DE cognitions (Eating Disorder Examination-Questionnaire [EDE-Q]), DE behaviors (Project Eating Among Teens), and SM use measures related to Facebook, Instagram, Snapchat, and Tumblr were completed. RESULTS: DE behaviors were reported by 51.7% of girls and 45.0% of boys, with strict exercise and meal skipping the most common. A total of 75.4% of girls and 69.9% of boys had at least one SM account where Instagram was the most common, used by 68.1% of girls and 61.7% of boys. Global EDE-Q scores were significantly higher for girls and boys with each type of SM account, except for Facebook and Instagram for girls. A greater number of SM accounts was associated with higher DE scores for both cognitions and behaviors. Girls with Snapchat and Tumblr accounts and boys with Snapchat, Facebook and Instagram were significantly more likely to have both DE behaviors and over-evaluation of shape and weight in the clinical range. Greater daily time spent using Instagram was associated with significantly higher Global EDE-Q scores and DE behaviors for girls, while this pattern was also found for Snapchat usage and DE behaviors for girls. CONCLUSIONS: A clear pattern of association was found between SM usage and DE cognitions and behaviors with this exploratory study confirming that these relationships occur at younger-age than previously investigated.

Depressive symptoms, alcohol and other drug use, and suicide risk: Prevention and treatment effects from a two-country online eating disorder risk reduction trial.

OBJECTIVE: Eating disorders are known to have high comorbidity, and the current report outlines the impact of an online eating disorder risk reduction program on brief, self-report measures of depressive symptoms, alcohol and other drug use, and suicidality. METHOD: An online pragmatic, randomized-controlled trial was conducted with N = 316 young-women (M age = 20.80 years) across Australia and New Zealand. Media Smart-Targeted (MS-T) was a 9-module program released weekly while control participants received positive body image tips. Prevention effects (asymptomatic at baseline) and treatment effects (symptomatic at baseline) were investigated. RESULTS: MS-T participants were 94% and 91% less likely than controls to develop Moderate or higher depressive symptoms at 6-month (MS-T = 3.3%; controls = 35.4%) and 12-month follow-up (MS-T = 3.4%; controls = 29.4%), respectively. MS-T participants did not commence using recreational drugs at any assessment point, compared to 18.2% of controls at a least one assessment point. Regarding treatment effects, MS-T participants were 84% more likely to no longer be using recreational drugs at 12-month follow-up (MS-T = 60%; controls = 21.1%). Mutitvariate logistic regressions revealed group, depressive symptoms and alcohol use to be significant predictors of elevated suicide risk, where being an MS-T participant, without depressive symptoms and not drinking alcohol, significantly lowered likelihood of developing elevated suicide risk. Disordered eating at post-program mediated the relationship between group and depressive symptoms across post-program to 12-mnoth follow-up. DISCUSSION: MS-T shows promise as a program with important mental health benefits in addition to previous reports of lowered eating disorder diagnosis, risk and impairment.

Internet eating disorder prevention.

PURPOSE OF REVIEW: Internet prevention of eating disorders is a relatively new field that is expanding rapidly. We review randomized controlled trial designs examining the efficacy of Internet prevention in eating disorders that have emerged from 2016. RECENT FINDINGS: Our literature search identified five studies that used randomized controlled trial designs to examine the efficacy of Internet prevention in eating disorders. All of the studies represented indicated prevention, that is, young women who have body image concerns. Three specific approaches were examined: media literacy, cognitive dissonance, and cognitive behavior therapy. All studies indicated significantly more impact of the intervention than a control condition, with between group effect sizes at follow-up ranging from 0.24 to 0.42. SUMMARY: Although Internet interventions for eating disorders may be less effective than face-to-face interventions, and attrition increases when populations are used that reflect real-world usage, these interventions have an important role in a stepped-care approach. Future research should make direct comparisons of different Internet programs with a view to helping us understand who will gain most benefit out of which approach, including who requires moderated Internet approaches and who does not.

Media Smart-Targeted: Diagnostic outcomes from a two-country pragmatic online eating disorder risk reduction trial for young adults.

BACKGROUND: Diagnostic outcomes in eating disorder (ED) risk reduction trials are important but rarely reported. METHODS: An online pragmatic randomized-controlled trial was conducted with young-adult women in Australia and New Zealand seeking to improve their body image. Media Smart-Targeted (MS-T) was a 9-module program released weekly while control participants received tips for positive body image. Eating Disorder Examination-Questionnaire (EDE-Q) scores from baseline and 12-month follow-up were used to investigate two outcomes: ED onset in those who were asymptomatic at baseline (prevention effects); and, ED remission in those who met diagnosis at baseline (treatment effects). RESULTS: MS-T participants were 66% less likely than controls to develop an ED by 12-month follow-up (nonsignificant). MS-T participants who met ED criteria at baseline were 75% less likely than controls to still meet diagnostic criteria at follow-up. This effect was significant and remained so for both those who did and who did not access external face-to-face ED treatment during the trial. CONCLUSIONS: While further investigations are necessary, MS-T has fully automated procedures, low implementation costs, the potential to be delivered at-scale to assist those assist those where face-to-face services are limited or not available (e.g., remote areas).

Online prevention of disordered eating in at-risk young-adult women: a two-country pragmatic randomized controlled trial.

BACKGROUND: Disordered eating (DE) is a widespread, serious problem. Efficacious prevention programs that can be delivered at-scale are needed. METHODS: A pragmatic randomized controlled trial of two online programs was conducted. Participants were young-adult women from Australia and New Zealand seeking to improve their body image. Media Smart-Targeted (MS-T) and Student Bodies (SB) were both 9-module interventions released weekly, whilst control participants received positive body image information. Primary [Eating Disorder Examination-Questionnaire (EDE-Q) Global], secondary (DE risk factors) and tertiary (DE) outcome measures were completed at baseline, post-program, 6- and 12-month follow-up. RESULTS: Baseline was completed by 608 women (M age = 20.71 years); 33 were excluded leaving 575 randomized to: MS-T (N = 191); SB (N = 190) or control (N = 194). Only 66% of those randomized to MS-T or SB accessed the intervention and were included in analyses with controls; 78% of this sample completed measures subsequent to baseline. Primary intent-to-treat (ITT) analyses revealed no differences between groups, while measure completer analyses found MS-T had significantly lower EDE-Q Global than controls at 12-month follow-up. Secondary ITT analyses found MS-T participants reported significantly higher quality of life-mental relative to both SB and controls (6-month follow-up), while MS-T and controls had lower clinical impairment relative to SB (post-program). Amongst measure completers, MS-T scored significantly lower than controls and SB on 5 variables. Of those with baseline DE, MS-T participants were significantly less likely than controls to have DE at 12-month follow-up. CONCLUSIONS: Given both programs were not therapist-moderated, MS-T has potential to achieve reductions in DE risk at low implementation costs.

Do universal media literacy programs have an effect on weight and shape concern by influencing media internalization?

The current study examined whether media internalization, found to mediate the relationship between selected prevention programs and outcomes, mediated the impact of two universal prevention programs that targeted risk factors for eating disorders and obesity, namely weight concern, and shape concern. Students randomized to a media literacy (Media Smart) program (N = 269, 65% females, mean age 12.97 years) and a healthy lifestyle (Life Smart) program (N = 347, 69% females, mean age 13.07 years) were included in the analyses. There were four waves of data (baseline, end of intervention, 6- and 12-month follow-up). Latent growth curve modeling was used to explore whether group assignment influenced levels of media internalization, and whether that in turn influenced change over time of our two outcome variables. Being randomly allocated to Media Smart as opposed to Life Smart resulted in less growth of both outcome variables through the influence on decreasing levels of media internalization. Findings provided support for the suggestion that media literacy programs exert an impact on outcomes related to eating disorder risk through changes to media internalization. Future research should examine whether these mechanisms of change differ between girls and boys.

Outcomes of three universal eating disorder risk reduction programs by participants with higher and lower baseline shape and weight concern.

OBJECTIVE: To investigate if baseline shape and weight concern (SWC) moderated outcomes in Prevention Across the Spectrum, a randomized-controlled trial (RCT) of 3 school-based programs aimed at reducing eating disorder and obesity risk factors. METHOD: N = 1,316 Grade 7 and 8 girls and boys (M age = 13.21 years) across three Australian states were randomly allocated to: Media Smart; Life Smart; Helping, Encouraging, Listening and Protecting Peers Initiative (HELPP) or control (usual school class). Moderation was explored by testing interaction effects for group (Media Smart; Life Smart; HELPP; Control) × moderator (SWC: higher-SWC; lower-SWC) × time (post-program; 6-month follow-up; 12-month follow-up), with baseline risk factor scores entered as covariates. RESULTS: Moderation effects were found for shape concern, weight concern, eating concern, regular eating (i.e., meal skipping), physical activity, body dissatisfaction, dieting, and perfectionism. Post-hoc testing found eating concern at post-program was the only variable where higher-SWC Media Smart participants experienced a reduction in risk relative to controls. Both higher-SWC Life Smart and HELPP participants reported an increase in eating concern relative to controls and both groups were skipping more meals than controls at 12-month follow-up. Amongst lower-SWC participants, Media Smart was the only group to experience a benefit relative to controls (physical activity). CONCLUSIONS: This study highlights the need for moderator analyses to become more routinely conducted in universal trials, to ensure that participants across baseline risk levels are benefiting and not harmed from program participation. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:66-75).

How perfectionism and ineffectiveness influence growth of eating disorder risk in young adolescent girls.

While perfectionism is widely considered to influence risk for eating disorders, results of longitudinal studies are mixed. The goal of the current study was to investigate a more complex model of how baseline perfectionism (both high personal standards and self-critical evaluative concerns) might influence change in risk status for eating disorders in young adolescent girls, through its influence on ineffectiveness. The study was conducted with 926 girls (mean age of 13 years), and involved three waves of data (baseline, 6- and 12-month follow-up). Latent growth curve modelling, incorporating the average rate at which risk changed over time, the intercept (initial status) of ineffectiveness, and baseline perfectionism, was used to explore longitudinal mediation. Personal standards was not supported as contributing to risk but results indicated that the higher mean scores on ineffectiveness over the three waves mediated the relationship between higher baseline self-critical evaluative concerns and both measures of eating disorder risk. The relationship between concern over mistakes and change in risk was small and negative. These results suggest the usefulness of interventions related to self-criticism and ineffectiveness for decreasing risk for developing an eating disorder in young adolescent girls.

School-based eating disorder prevention: a pilot effectiveness trial of teacher-delivered Media Smart.

AIM: This pilot study tested teacher-delivered Media Smart, a school-based eating disorder prevention program that has achieved significant benefits when delivered by health professionals. METHOD: Two Grade 7 classes (N = 51; M age = 12.43 years) participated, with one randomly allocated to Media Smart (n = 27; 67% girls) and the other to a control condition of usual lessons (n = 24; 37% girls). Program feasibility was assessed by teacher self-report, whereas student self-report of shape and weight concern (primary outcome variable) and seven additional risk factors were measured at baseline, post-program and 6-month follow up. RESULTS: Teacher ratings of program feasibility revealed that 25 of the 29 (86.2%) program activities were taught with 96% of activities rated as either highly (19 activities) or moderately (5 activities) valuable for students. Mixed model analyses were conducted using a 2 (group: Media Smart, control) × 2 (time: post-program, 6-month follow up) × 2 (gender: girls, boys) design, with baseline scores as a covariate. A not-significant trend for group favouring Media Smart was observed for shape and weight concern (Cohen's d effect size [d] = 0.32), whereas significant effects were found for feelings of ineffectiveness (d = 0.52) and weight-related peer teasing (d = 0.68). CONCLUSIONS: The program was feasible for teacher delivery and showed some promising results, supporting a more substantial randomized-controlled effectiveness trial.

Depression as a moderator of benefit from Media Smart: a school-based eating disorder prevention program.

OBJECTIVE: To investigate if baseline depression moderated response to Media Smart, an 8-lesson school-based program previously found to achieve a long-term risk reduction effect in young adolescents. METHOD: 540 Grade 8 students (M age = 13.62 years, SD = .37) from 4 schools participated with 11 classes receiving the Media Smart program (126 girls; 107 boys) and 13 comparison classes receiving their normal lessons (147 girls; 160 boys). Shape and weight concern, media internalization, body dissatisfaction, dieting, ineffectiveness, and perceived pressure were the outcome variables. RESULTS: Moderation was indicated by significant interaction effects for group (Media Smart; Control) × moderator (high depression; low depression) × time (post-program; 6-month follow-up; 2.5-year follow-up), with baseline entered as a covariate. Such effects were found for shape and weight concern, media internalization, body dissatisfaction, ineffectiveness and perceived pressure. Post-hoc testing found high depression Media Smart participants scored significantly lower than their control counterparts at post-program on shape and weight concern, media internalization and dieting, whereas low depression Media Smart participants scored significantly lower on shape and weight concern at 2.5-year follow-up. DISCUSSION: Media Smart achieved a reduction in eating disorder risk factors for high-depression participants and a reduced rate of growth in risk factor scores for low-depression participants. Trial registry name: Australian New Zealand Clinical Trials Registry. URL: http://www.anzctr.org.au. Registration identification number: ACTRN12608000545369.

Life Smart: a pilot study of a school-based program to reduce the risk of both eating disorders and obesity in young adolescent girls and boys.

OBJECTIVE: To develop and pilot Life Smart, an eight-lesson program aimed at reducing risk factors for both eating disorders and obesity. METHODS: Grade 7 girls and boys (N = 115) from one independent school were randomly allocated to the Life Smart (two classes; N = 51) or control (three usual classes; N = 64) conditions. Risk factors were measured at baseline and post-program (5 weeks later). RESULTS: Life Smart was rated as moderately enjoyable and valuable by participants. ANCOVAs with baseline as a covariate revealed a significant main effect for group favoring Life Smart for shape and weight concern (Effect Size [ES] = .54), with post-hoc testing finding girls particularly benefited on this variable (ES = .78). CONCLUSIONS: Feedback was generally favorable, with some suggestions for even more interactive content. The program showed more promise with girls. Informed by these findings, the program underwent revisions and is now being evaluated in a randomized controlled trial.

Interactive programme to enhance protective factors for eating disorders in girls with type 1 diabetes.

AIMS: This study evaluated the effectiveness of a pilot programme in enhancing protective factors for eating disorders in young girls with type 1 diabetes (T1D). METHODS: Twenty girls with T1D (M age = 11.06 years) attended two 4-h group sessions. A 4-week baseline control period was compared against changes at post-programme and at 1-month follow-up on measures of eating disorder risk factors and indicators of glycaemic control. RESULTS: At post-intervention, significant improvements were found for self-efficacy related to diabetes management, self-esteem, body-esteem,thin-ideal internalization and perfectionism. These gains were maintained at 1-month follow-up. Participants were also rated by their parents as assuming more responsibility for specific diabetes-related tasks at follow-up. CONCLUSIONS: A brief interactive programme can favourably impact protective factors for disordered eating. The development of effective disordered eating prevention strategies for girls with T1D is an urgent priority and the current study is a first step in this direction.

Examination of the Sociocultural Attitudes Towards Appearance Questionnaire-3 in a mixed-gender young-adolescent sample.

Thin-ideal (or media) internalization is an important eating disorder risk factor that has become a central target of many prevention programs. However, evidence for its valid assessment in young, mixed-gender, adolescent samples is limited, and the current study is the first to explore the psychometric properties of the 30-item Sociocultural Attitudes Towards Appearance Questionnaire-3 (SATAQ-3; J. Thompson, P. van den Berg, M. Roehrig, A. S. Guarda, & L. J. Heinberg, 2004) in a nonadult community sample. Two samples of Grade 8 students (M age = 13.68 years), totaling 680 girls (N = 332) and boys (N = 348) completed the SATAQ-3 and other measures, whereas a smaller sample (N = 123) of Grade 10 girls (M age = 15.01 years) served as a comparison group for supplementary analyses. Principal component analyses (PCA) with data from Sample 1 (N = 201) revealed 4 factors with eigenvalues > 1.0, similar to the original authors' structure but with some cross-loading occurring between the Pressures and Internalization-General scales. Confirmatory factor analyses (CFA) were conducted with data from Sample 2 (N = 479) on the factor solution found in the PCA. The model did not fit well, leading to further revisions based on removal of cross-loading items and CFA modification indices, resulting in a 19-item, 4-factor solution with acceptable fit. Examinations of validity and reliability were generally acceptable. The overall findings suggest that an abbreviated version of the SATAQ-3 might be more appropriate than the original version with young-adolescent, mixed-gender audiences. Further examinations of the psychometric properties of the SATAQ-3 with this demographic are indicated.

A longitudinal investigation of the impact of disordered eating on young women's quality of life.

OBJECTIVE: The extent to which subclinical levels of disordered eating affect quality of life (QOL) was assessed. METHOD: Four waves of self-report data from Survey 2 (S2) to 5 (S5) of a national longitudinal survey of young Australian women (N = 9,688) were used to assess the impact of any level of disordered eating at S2 on QOL over the following 9 years, and to evaluate any moderating effects of social support and of depression. RESULTS: At baseline, 23% of the women exhibited some level of disordered eating, and they scored significantly lower on both the physical and the mental component scores of the SF-36 at every survey; differences in mental health were still clinically meaningful at S5. Social support and depressive symptoms each acted as a moderator of the mental component scores. Women with both disordered eating and low social support, or disordered eating and depression, had the worst initial scores; although they improved the most over time, they still had the lowest scores at S5. Higher social support at baseline resulted in women with disordered eating being largely indistinguishable from women without disordered eating who had low social support. Lower levels of depression resulted in women with disordered eating having a significantly better QOL than women with high levels of depression, regardless of eating status. CONCLUSIONS: This is the first study to examine the long-term impact of subclinical levels of disordered eating on QOL, and it suggests that even apparently minor levels of symptomatology are associated with significant and far-reaching deficits in well-being.