Management of child and adolescent eating disorders: the current evidence base and future directions

Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes

Background: This systematic review investigated the impact of familial factors on individuals aged 10-17 who have clinical signs or symptoms of eating disorders. Simultaneously, it scrutinized the involvement of the family in therapy, as well as other forms of intervention. Methods: The PsycINFO, PubMed, and Scopus databases were used to search for research material comprehensively. After applying specific criteria, 46 articles were deemed suitable and included in the systematic review. The study comprised a cohort of 4794 adolescents who received a diagnosis of either Anorexia Nervosa (AN), Bulimia Nervosa (BN), or Binge-Eating Disorder (BED). In addition, controls were utilized for 1187 adolescents, 1563 parents, 1809 siblings, and 11 other relatives. Results: The connection between family factors and eating disorders is primarily determined by the families' level of functioning, satisfaction with the family dynamic, parents' attitudes toward their children, and the role of food within the family system. Family Therapy was the most used psychotherapeutic approach in the treatment of AN. The incidence of reports in BN closely paralleled that of Cognitive-Behavioral Therapy (CBT) models. Articles about (Enhanced) CBT were exclusively associated with BED. Conclusions: Family-based approaches are crucial in comprehending, preventing, and addressing eating disorders in adolescents. Incorporating the study of family dynamics and actively engaging families in the treatment process can significantly enhance recovery rates and decrease the occurrence of relapses.

Occurrence, sociodemographic, and clinical correlates of eating disorders among a sample of secondary school students in Egypt

Background

Eating disorders are common in adolescents. Data on occurrence rates, sociodemographic correlates, and risk factors in Egyptian population are needed along with better screening tools to inform future research and service development. We aimed to estimate the occurrence of eating disorders in a representative sample of Egyptian adolescent students and to examine the sociodemographic and clinical risk factors associated with eating disorders. So, a multistage random selection of 407 adolescent students from public and private secondary schools in Eastern Tanta, Egypt, was carried out. All participants were subjected to screening using the Eating Attitude Test (EAT) and the eating disorders section of the clinician version of the Structured Clinical Interview for DSM-IV axis-I disorders

Results

Occurrence estimates of anorexia nervosa and bulimia nervosa were 6.1% and 3.2%, respectively. Being female, overweight (BMI = 25–29.9 kg/m2), low self-esteem, and high body shape preoccupation were significantly associated with eating disorders risk among adolescents.

Conclusions

Eating disorders are prevalent in the general adolescent population. The unmet treatment needs in the adolescent population place these disorders as important public health concerns.

An Aristotelian view of therapists' practice in multifamily therapy for young adults with severe eating disorders

BACKGROUND

Eating disorders are serious conditions which also impact the families of adult patients. There are few qualitative studies of multifamily therapy with adults with severe eating disorders and none concerning the practice of therapists in multifamily therapy.

OBJECTIVES

The aim of the study is to explore therapists' practice in multifamily therapy.

RESEARCH DESIGN AND PARTICIPANTS

A grounded theory approach was chosen. Data were collected through participant observation in two multifamily therapy groups and qualitative interviews with the therapists in those groups.

ETHICAL CONSIDERATIONS

The study conforms to the principles outlined in the Declaration of Helsinki. All participants in the multifamily therapy groups received information about the research project and signed consent forms. The data are treated confidentially and anonymised.

FINDINGS

The core category was identified as 'having many strings to one's bow', consisting of three subcategories: 'planning and readjusting', 'developing as therapist and team' and 'regulating the temperature of the group'. This article discusses the empirical findings in the frame of Aristotelian virtue ethics.

Body image perceptions and symptoms of disturbed eating behavior among children and adolescents in Germany

THEORETICAL BACKGROUND

Body image distortions such as perception biases are assumed to be precursors of eating disorders (ED). This study aims to investigate body image perceptions and symptoms of disturbed eating behavior among a sample of 11-17 year-old students in Germany.

METHODS

A cross-sectional survey study was carried out among 1524 students of twelve secondary schools from all school types in North Rhine-Westphalia (Germany). A naturalistic photograph-rating consisting of photographs of young women's bodies was used to examine children's perceptions of female bodies (i.e., perceived average body size and perceived ideal body size of young women). Also, symptoms of disturbed eating behavior were examined.

RESULTS

Compared to statistical data, children and adolescents underestimated the average body size of young women by more than two BMI-points (estimated average BMI = 20), with no differences between boys and girls. Also, girls and boys generally held a slim female thin-ideal (perceived ideal BMI = 19.5), which is nearly three BMI-points below the average body size in the young female population. Girls showed a slightly stronger female thin-ideal than boys. Among all subgroups, early-adolescent girls (13-14 years) displayed the strongest thin-ideal internalization. Nearly one-third of this group perceived a BMI below 18 as ideal female body size. Symptoms of disturbed eating behavior were common among youth and most frequent among adolescent girls (15-17 years). Girls who displayed a bias towards underestimation of female body size and girls who displayed an underweight female thin-ideal were more likely to report harmful dieting behaviors and psychological distress associated with eating, body, and weight.

CONCLUSIONS

This study found that 11-17 year-old girls and boys do not show accurate judgements regarding the average body size of young women. Instead, there is systematic and significant underestimation, indicating considerable perception biases, which may constitute a risk factor for the development and maintenance of ED. Symptoms of disturbed eating behavior were common, especially among girls, and associated with body-related perceptions. Future research will need to clarify the severity and course of these symptoms.

Nourishing the Spirit: Exploratory Research on Ayahuasca Experiences along the Continuum of Recovery from Eating Disorders

Eating disorders (EDs) are serious health conditions that are among the most difficult to treat. Innovative treatments are needed and modalities from across cultures must be considered. Ayahuasca is a psychoactive plant-based tea originally used by Amazonian indigenous groups. A growing body of research points to its promise in the healing of various mental health issues. This study explored the potential therapeutic value of ayahuasca in the context of EDs, including the perceived impact of the preparatory diet and the ayahuasca purge. Sixteen individuals previously diagnosed with an ED participated in a semi-structured interview relating to their experiences with ceremonial ayahuasca drinking. Interviews were analyzed using thematic analysis. Themes presented relate to the reduction or cessation of ED and mental health symptoms, shifts in body perception, and the importance of a ceremonial setting and after-care. For some, the preparatory diet resulted in familiar patterns of concern; however, none felt triggered by the purge in ayahuasca. Ceremonial ayahuasca drinking shows promise in the healing of EDs and warrants further research.

Treatment of anorexia nervosa: a multimethod investigation translating experimental neuroscience into clinical practice

Background

Anorexia nervosa (AN) is a severe psychiatric condition and evidence on how to best treat it is limited.

Objectives

This programme consists of seven integrated work packages (WPs) and aims to develop and test disseminable and cost-effective treatments to optimise management for people with AN across all stages of illness.

Methods

WP1a used surveys, focus groups and a pre–post trial to develop and evaluate a training programme for school staff on eating disorders (EDs). WP1b used a randomised controlled trial (RCT) [International Standard Randomised Controlled Trial Number (ISRCTN) 42594993] to evaluate a prevention programme for EDs in schools. WP2a evaluated an inpatient treatment for AN using case reports, interviews and a quasi-experimental trial. WP2b used a RCT (ISRCTN67720902) to evaluate two outpatient psychological therapies for AN. WP3 used a RCT (ISRCTN06149665) to evaluate an intervention for carers of inpatients with AN. WP4 used actimetry, self-report and endocrine assessment to examine physical activity (PA) in AN. WP5 conducted a RCT (ISRCTN18274621) of an e-mail-guided relapse prevention programme for inpatients with AN. WP6 analysed cohort data to examine the effects of maternal EDs on fertility and their children’s diet and growth. WP7a examined clinical case notes to explore how access to specialist ED services affects care pathways and user experiences. Finally, WP7b used data from this programme and the British Cohort Study (1970) to identify the costs of services used by people with AN and to estimate annual costs of AN for England.

Results

WP1a: a brief training programme improved knowledge, attitudes and confidence of school staff in managing EDs in school. WP1b: a teacher-delivered intervention was feasible and improved risk factors for EDs in adolescent girls. WP2a: both psychological therapies improved outcomes in outpatients with AN similarly, but patients preferred one of the treatments. WP2b: the inpatient treatment (Cognitive Remediation and Emotional Skills Training) was acceptable with perceived benefits by patients, but showed no benefits compared with treatment as usual (TAU). WP3: compared with TAU, the carer intervention improved a range of patient and carer outcomes, including carer burden and patient ED symptomatology. WP4: drive to exercise is tied to ED pathology and a desire to improve mood in AN patients. PA was not increased in these patients. WP5: compared with TAU, the e-mail-guided relapse prevention programme resulted in higher body mass index and lower distress in patients at 12 months after discharge. WP6: women with an ED had impaired fertility and their children had altered dietary and growth patterns compared with the children of women without an ED. WP7a: direct access to specialist ED services was associated with higher referral rates, lower admission rates, greater consistency of care and user satisfaction. WP7b: the annual costs of AN in England are estimated at between £45M and £230M for 2011.

Conclusions

This programme has produced evidence to inform future intervention development and has developed interventions that can be disseminated to improve outcomes for individuals with AN. Directions for future research include RCTs with longer-term outcomes and sufficient power to examine mediators and moderators of change.

Trial registration

Current Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 16. See the NIHR Journals Library website for further project information.

One-year outcome and incidence of anorexia nervosa and restrictive eating disorders among adolescent girls treated as out-patients in a family-based setting

Aims To study the 1-year outcome and to analyse predictors of outcome of a cohort of adolescent girls with anorexia nervosa (AN) or restrictive eating disorders not otherwise specified (EDNOSr) treated as out-patients in a family-based programme at a specialized eating disorder service. To calculate the incidence of anorexia nervosa among treatment-seeking girls younger than 18 in Uppsala County from 2004 to 2006. Methods A total of 168 female patients were offered treatment, and 141 were followed-up 1 year after starting treatment, 29 with AN and 112 with EDNOSr. Results Of the 29 girls who initially had AN, 6 (20%) had a good outcome and were free of any form of eating disorder at follow-up; only 1 (3%) had AN. Of the patients with EDNOSr, 54 (48%) had a good outcome and were free of eating disorders. Three (3%) had a poor outcome and had developed AN. The incidence of AN was 18/100,000 person-years in girls younger than 12 and 63/100,000 in girls younger than 18. Conclusion Restrictive eating disorders, including AN, in children and adolescents can be successfully treated in a family-based specialized out-patient service without in-patient care.

Focus on anorexia nervosa: modern psychological treatment and guidelines for the adolescent patient

Anorexia nervosa is a serious condition associated with high mortality. Incidence is highest for female adolescents, and prevalence data highlight a pressing unmet need for treatment. While there is evidence that adolescent-onset anorexia has relatively high rates of eventual recovery, the illness is often protracted, and even after recovery from the eating disorder there is an ongoing vulnerability to psychosocial problems in later life. Family therapy for anorexia in adolescence has evolved from a generic systemic treatment into an eating disorder-specific format (family therapy for anorexia nervosa), and this approach has been evidenced as an effective treatment. Individual treatments, including cognitive behavioral therapy, also have some evidence of effectiveness. Most adolescents can be effectively and safely managed as outpatients. Day-patient treatment holds promise as an alternative to inpatient treatment or as an intensive program following a brief medical admission. Evidence is emerging of advantages in detecting and treating adolescent anorexia nervosa in specialist community-based child and adolescent eating-disorder services accessible directly from primary care. Limitations and future directions for modern treatment are considered.

Anorexia nervosa: A fresh perspective

Anorexia nervosa is currently presented as a pathologised, psycho-medical feminine phenomenon through aetiological rationalisations and theories. Research results indicate that there have been no improvements in treatment outcomes for anorexia for over 50 years, except, possibly, with forms of family therapy for adolescents. This situation can be seen as critical and calls for alternative ways of understanding anorexia, and consequent different approaches to psychotherapy for persons in relationship with anorexia. This article critically explores these issues, and suggests that such circumstances offer opportunities for alternative post-structuralist approaches for informing different understandings of and working with anorexia in collaborative relational arrangements where the voices of persons in relationship with anorexia are honoured and heard.

Increased set shifting costs in fasted healthy volunteers

We investigated the impact of temporary food restriction on a set shifting task requiring participants to judge clusters of pictures against a frequently changing rule. 60 healthy female participants underwent two testing sessions: once after fasting for 16 hours and once in a satiated state. Participants also completed a battery of questionnaires (Hospital Anxiety and Depression Scale [HADS]; Persistence, Perseveration and Perfectionism Questionnaire [PPPQ-22]; and Eating Disorders Examination Questionnaire [EDE-Q6]). Set shifting costs were significantly increased after fasting; this effect was independent of self-reported mood and perseveration. Furthermore, higher levels of weight concern predicted a general performance decrement under conditions of fasting. We conclude that relatively short periods of fasting can lead to set shifting impairments. This finding may have relevance to studies of development, individual differences, and the interpretation of psychometric tests. It also could have implications for understanding the etiology and maintenance of eating disorders, in which impaired set shifting has been implicated.

Body image disturbance in children and adolescents with eating disorders. Current evidence and future directions

Body image is multifaceted and incorporates perceptual, affective, and cognitive components as well as behavioral features. Only few studies have examined the character of body-image disturbance in children/adolescents with eating disorders. It is unknown whether body-image disturbances in children/adolescent with eating disturbances are comparable to those of adult patients with eating disorders. Body-image disturbance might differ quantitatively and qualitatively according to the cognitive developmental status and the age of the individual. This paper provides an overview of the current evidence for body-image disturbance in children/adolescents with eating disorders, and how they compare with those adults with eating disorders. Current evidence indicates that older adolescent patients show similar deficits as adult patients with eating disorders, in particular for the attitudinal body-image component. However, evidence for a perceptual body-image disturbance in adolescent patients, in particular anorexia nervosa, is not conclusive. Reliable statements for childhood can hardly be made because clinical studies are not available. Investigations of body-image disturbance in children have focused on the predictive value for eating disorders. Limitations of the current evidence are discussed, and future directions for research and therapy are indicated.

A family-based eating disorder day treatment program for youth: examining the clinical and statistical significance of short-term treatment outcomes

This article describes an innovative family-based day treatment program (DTP) for youth with moderate to severe eating disorders. A sample of 65 youth completed a battery of psychological measures pre- and post-treatment and 6 months after program completion. Treatment outcomes were assessed in three main domains: (a) medical stabilization, (b) normalization of eating behavior, and (c) improved psychological functioning. Overall, patients demonstrated statistically significant and clinically meaningful improvements on all outcome measures. Findings indicate that a comprehensive DTP can successfully facilitate positive outcomes in youth with eating disorders and that these improvements can be maintained 6 months post-treatment.

Increasing equity of access to high-quality mental health services in primary care: a mixed-methods study

Background

Evidence-based interventions exist for common mental health problems. However, many people are unable to access effective care because it is not available to them or because interactions with caregivers do not address their needs. Current policy initiatives focus on supply-side factors, with less consideration of demand.

Aim and objectives

Our aim was to increase equity of access to high-quality primary mental health care for underserved groups. Our objectives were to clarify the mental health needs of people from underserved groups; identify relevant evidence-based services and barriers to, and facilitators of, access to such services; develop and evaluate interventions that are acceptable to underserved groups; establish effective dissemination strategies; and begin to integrate effective and acceptable interventions into primary care.

Methods and results

Examination of evidence from seven sources brought forward a better understanding of dimensions of access, including how people from underserved groups formulate (mental) health problems and the factors limiting access to existing psychosocial interventions. This informed a multifaceted model with three elements to improve access: community engagement, primary care quality and tailored psychosocial interventions. Using a quasi-experimental design with a no-intervention comparator for each element, we tested the model in four disadvantaged localities, focusing on older people and minority ethnic populations. Community engagement involved information gathering, community champions and focus groups, and a community working group. There was strong engagement with third-sector organisations and variable engagement with health practitioners and commissioners. Outputs included innovative ways to improve health literacy. With regard to primary care, we offered an interactive training package to 8 of 16 practices, including knowledge transfer, systems review and active linking, and seven agreed to participate. Ethnographic observation identified complexity in the role of receptionists in negotiating access. Engagement was facilitated by prior knowledge, the presence of a practice champion and a sense of coproduction of the training. We developed a culturally sensitive well-being intervention with individual, group and signposting elements and tested its feasibility and acceptability for ethnic minority and older people in an exploratory randomised trial. We recruited 57 patients (57% of target) with high levels of unmet need, mainly through general practitioners (GPs). Although recruitment was problematic, qualitative data suggested that patients found the content and delivery of the intervention acceptable. Quantitative analysis suggested that patients in groups receiving the well-being intervention improved compared with the group receiving usual care. The combined effects of the model included enhanced awareness of the psychosocial intervention among community organisations and increased referral by GPs. Primary care practitioners valued community information gathering and access to the Improving Access to Mental Health in Primary Care (AMP) psychosocial intervention. We consequently initiated educational, policy and service developments, including a dedicated website.

Conclusions

Further research is needed to test the generalisability of our model. Mental health expertise exists in communities but needs to be nurtured. Primary care is one point of access to high-quality mental health care. Psychosocial interventions can be adapted to meet the needs of underserved groups. A multilevel intervention to increase access to high-quality mental health care in primary care can be greater than the sum of its parts.

Study registration

Current Controlled Trials ISRCTN68572159.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Effectiveness of a multimodal inpatient treatment for adolescents with anorexia nervosa in comparison with adults: an analysis of a specialized inpatient setting : treatment of adolescent and adult anorexics

OBJECTIVE

There is evidence for an increased prevalence and an earlier onset of anorexia nervosa (AN) in adolescents. Early specialized treatment may improve prognosis and decrease the risk of a chronic course. The current study evaluates the effectiveness of a multimodal inpatient treatment for adolescent AN patients treated in a highly specialized eating disorder unit for adults.

METHOD

177 adolescents and 1,064 adult patients were included. The evaluation focused on eating behavior, depressive symptoms and general psychopathology.

RESULTS

All measured variables decreased significantly in both groups during inpatient treatment. No differences were found concerning weight gain, improvement of global eating disorder symptomatology as well as depressive symptoms. However, adults showed a higher psychological distress and in this regard also a greater improvement.

CONCLUSION

Results indicate that treating adolescent AN patients in a highly specialized eating disorder unit for adults can be an effective treatment setting for these patients.

The late positive potential as a marker of motivated attention to underweight bodies in girls with anorexia nervosa

OBJECTIVE

In anorexia nervosa (AN), aspects of motivational salience and reward are increasingly discussed. Event related potentials, particularly the late positive potential (LPP), have been investigated as a marker for motivational salience of stimuli, for example in addictive disorders. The aim of this study was to assess the LPP as a possible indicator of motivated attention towards disease-specific pictures of underweight female bodies in adolescents with AN in comparison to typically developing (TD) adolescent girls.

METHOD

13 girls with AN and 18 TD adolescent girls (aged 12 to 18 years) viewed pictures of underweight, normal-weight and overweight women while EEG activity was recorded. An earlier (450-680 ms after stimulus onset) as well as a later time window (850-1250 ms after stimulus onset) of the LPP were examined for the different picture categories. Participants were also asked to rate subjective emotions (fear, disgust, happiness) elicited by the pictures.

RESULTS

Subjective ratings showed no differential experience of emotions for the two groups. For AN patients, highest LPP amplitudes were found for underweight women in the earlier as well as in the later time window. In TD girls, highest amplitudes for pictures of overweight women were observed in the earlier time window.

CONCLUSION

A differential LPP pattern for girls with AN and TD girls when viewing pictures of women's bodies of different weight categories was obtained. Highest amplitudes in AN patients for pictures of underweight women may reflect motivational significance of strongly underweight body shapes.

Psicoterapia como estratégia de tratamento dos transtornos alimentares: análise crítica do conhecimento produzido

O objetivo deste estudo foi empreender uma análise crítica acerca do conhecimento científico produzido sobre a utilização das psicoterapias como estratégia de tratamento dos transtornos alimentares. A partir de buscas nas bases PsycINFO, PePSIC e SciELO, no período entre 1999 e 2011, foram recuperados 35 artigos, categorizados em: psicoterapias breves, grupais, psicodinâmicas, complementares, bem como psicoterapias aliadas a outros tratamentos, como o psicofarmacológico. As abordagens mais frequentemente mencionadas foram psicodinâmicas e cognitivo-comportamentais. A modalidade de atendimento predominante foi a grupal. Ainda que preconizando o uso combinado de diversas estratégias, a literatura é unânime em destacar a importância das psicoterapias no tratamento. A análise crítica evidenciou necessidade de leituras que transcendam a mera identificação de técnicas psicoterápicas consideradas mais eficazes para o tratamento dos transtornos alimentares. Deve-se considerar o contexto mais amplo no qual os tratamentos são propostos, bem como promover um diálogo aberto entre enfoques teóricos, valorizando a pluralidade de saberes e a psicoterapia como prática em permanente transformação.

The value of reusing prior nested case-control data in new studies with different outcome

Many epidemiological studies use a nested case-control (NCC) design to reduce cost while maintaining study power. However, because of the incidence density sampling used, reusing data from NCC studies for analysis of secondary outcomes is not straightforward. Recent methodological developments have opened the possibility for prior NCC data to be used to complement controls in a current study, thereby improving study efficiency. However, practical guidelines on the effectiveness of prior data relative to newly sampled subjects and the potential power gains are still lacking. Using simulated cohorts, we show in this paper how the efficiency of NCC studies that use a mixture of prior and newly sampled subjects depends on the number of newly sampled controls and prior subjects as well as the overlap in the distributions of the matching variables. We explore the feasibility and efficiency of a current study that gathers no controls, relying instead on prior data. Using the concept of effective number of controls, we show how researchers can assess the potential power gains from reusing prior data. We apply the method to analyses of anorexia and contralateral breast cancer in the Swedish population and show how power calculations can be done using publicly available software. This work has important applications in genetic and molecular epidemiology to make optimal use of costly exposure measurements.

Psychological treatment for anorexia nervosa: a meta-analysis of standardized mean change

BACKGROUND

For the German treatment guidelines for eating disorders, the literature on psychological treatment of anorexia nervosa (AN) was reviewed systematically. As a common meta-analysis of randomized clinical trials proved to be impossible, a review of all available clinical trials was conducted, statistically integrating standardized mean change scores. Research questions comprised differential effects of therapeutic techniques and settings as well as determining which weight gains could be expected.

METHODS

After an extensive literature search, studies were selected, rated by 3 independent raters. Weight gain as the main outcome criterion was transformed into standardized mean change scores. Effect sizes were checked for homogeneity.

RESULTS

57 studies containing 84 treatment arms and 2,273 patients could be integrated. Studies differed considerably in quality. The strongest bias identified was reporting selectively on completers or failures, versus intention-to-treat samples. No significant differences between effect sizes could be identified concerning treatment setting, technique or patient characteristics. If treatment time is taken into account, inpatient treatment produced a faster weight gain than outpatient treatment.

CONCLUSION

The study describes weight gains which can be reached in outpatient and inpatient settings. It yielded no salient results speaking for a certain therapy technique, setting or procedure. Treatment guidelines for psychological treatment of AN still have to rely on lower level evidence.

The same but different? Treatment of anorexia nervosa in adolescents and adults

A significant number of patients with anorexia nervosa have to be transferred from child and adolescent mental health services (CAMHS) to adult services. CAMHS and adult services differ in terms of therapeutic approach and the availability of specialist treatment. CAMHS treatment is often based around family interventions, which aim to help parents take control of their child's eating, and patients are often encouraged to 'externalise' the illness. Adult treatment tends to be based around individual therapy, and the patient is encouraged to take personal responsibility for change. The place of inpatient treatment is generally accepted for adults but there is uncertainty about its effectiveness for adolescents. Young people may find it difficult to negotiate the transition between services, and CAMHS and adult services need to work more closely together. Transitions should be carefully planned, with thorough preparation of both patients and their families.

Help Seeking and Access to Primary Care for People from "Hard-to-Reach" Groups with Common Mental Health Problems

Background. In the UK, most people with mental health problems are managed in primary care. However, many individuals in need of help are not able to access care, either because it is not available, or because the individual's interaction with care-givers deters or diverts help-seeking. Aims. To understand the experience of seeking care for distress from the perspective of potential patients from "hard-to-reach" groups. Methods. A qualitative study using semi-structured interviews, analysed using a thematic framework. Results. Access to primary care is problematic in four main areas: how distress is conceptualised by individuals, the decision to seek help, barriers to help-seeking, and navigating and negotiating services. Conclusion. There are complex reasons why people from "hard-to-reach" groups may not conceptualise their distress as a biomedical problem. In addition, there are particular barriers to accessing primary care when distress is recognised by the person and help-seeking is attempted. We suggest how primary care could be more accessible to people from "hard-to-reach" groups including the need to offer a flexible, non-biomedical response to distress.

Assessment Measures for Child and Adolescent Eating Disorders: A Review

BACKGROUND

  Several diagnostic and screening instruments are available for child and adolescent eating disorders. However, limitations have been identified in many of these.

METHOD

  We review the most frequently used assessment measures for eating disorders in children and adolescents.

RESULTS

  Several of the available instruments have significant limitations, although relevant strengths are identified.

CONCLUSIONS

  Limitations in the current available instruments for child and adolescent eating disorders should be addressed in order to improve recognition and treatment.

The effectiveness of a day program for the treatment of adolescent anorexia nervosa

OBJECTIVE

The risks of anorexia nervosa (AN) are well established. Despite its severity, little certainty exists for practitioners, with ethical and financial limitations yielding few controlled studies establishing effective treatments. Thus, other methods of establishing treatment effectiveness are necessary. This study presents preliminary results of an open clinical trial of a day program for adolescents with AN.

METHOD

Participants were 26 anorectic females, 12-18 years, who completed the "Transition Program."

RESULTS

Significant change emerged on measures of weight gain, and behavioral and attitudinal measures of eating pathology. Large effect sizes were evident for weight gain at 6 month follow-up. Preliminary trends suggest that treatment gains on these and other measures of eating pathology were maintained at 6 month follow-up.

DISCUSSION

Preliminary results support day program treatment for adolescents with mild-moderately severe eating disorders. Present outcomes are discussed with respect to the dearth of efficacious treatment options for adolescents.

The use of a parent support group in the outpatient treatment of children and adolescents with eating disorders

Our objective was to measure parents' level of satisfaction and perceived benefits gained from participating in a parent support group as part of an outpatient treatment program. We mailed surveys to 261 parent/guardian participants. Results reflected high satisfaction with the support group. Parents indicated that it assisted them in understanding eating disorders symptoms and treatment and supporting their child struggling with an eating disorder. Additionally, the group was a source of emotional support. Results suggest that inclusion of a parent support group in the outpatient treatment of children and adolescents with eating disorders has important implications for parents.

Feasibility, acceptability, and effectiveness of family-based treatment for adolescent anorexia nervosa: an observational study conducted in Brazil

OBJECTIVE: There is strong evidence that family-based treatment is effective in cases of adolescent anorexia nervosa. Although family-based treatment has been studied in English-speaking countries, there is a need to examine the generalizability of this approach to non-English speaking cultures. This pilot-study aimed to examine the feasibility, acceptability, and effectiveness of family-based treatment in Brazil. METHOD: Observational study of adolescents with anorexia nervosa (excluding menstrual criteria), as determined with the Diagnostic and Well-Being Assessment, referred for treatment at a specialized center in São Paulo, Brazil. The following data were collected at baseline, at the end of treatment, and after six months of follow-up: weight; height; body mass index; menstrual status; Eating Disorder Examination Questionnaire score; and Children Global Assessment of Functioning Scale score. RESULTS: Of 11 eligible patients/families, 9 (82%) enrolled in the study, and 7 (78%) completed the treatment. The mean patient age was 14.64 ± 1.63 years (range, 12.33-17.00 years). The Wilcoxon signed rank test showed statistically significant improvement in weight and body mass index at the end of treatment, as well as after six months of follow-up, at which point none of the patients met the diagnostic criteria for any eating disorder. CONCLUSION: The results suggest that family-based treatment is acceptable and feasible for Brazilian families. Outcomes suggest that the approach is effective in this cultural context, leading to improvements similar to those reported in previous studies conducted in other cultures.

Eating disorders

This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

Researching the mental health needs of hard-to-reach groups: managing multiple sources of evidence

Background

Common mental health problems impose substantial challenges to patients, carers, and health care systems. A range of interventions have demonstrable efficacy in improving the lives of people experiencing such problems. However many people are disadvantaged, either because they are unable to access primary care, or because access does not lead to adequate help. New methods are needed to understand the problems of access and generate solutions. In this paper we describe our methodological approach to managing multiple and diverse sources of evidence, within a research programme to increase equity of access to high quality mental health services in primary care.

Methods

We began with a scoping review to identify the range and extent of relevant published material, and establish key concepts related to access. We then devised a strategy to collect - in parallel - evidence from six separate sources: a systematic review of published quantitative data on access-related studies; a meta-synthesis of published qualitative data on patient perspectives; dialogues with local stakeholders; a review of grey literature from statutory and voluntary service providers; secondary analysis of patient transcripts from previous qualitative studies; and primary data from interviews with service users and carers.

We synthesised the findings from these diverse sources, made judgements on key emerging issues in relation to needs and services, and proposed a range of potential interventions. These proposals were debated and refined using iterative electronic and focus group consultation procedures involving international experts, local stakeholders and service users.

Conclusions

Our methods break new ground by generating and synthesising multiple sources of evidence, connecting scientific understanding with the perspectives of users, in order to develop innovative ways to meet the mental health needs of under-served groups.

[Treatment of anorexia nervosa in young patients in a special care unit at Robert-Debré Hospital (Paris): guidelines and practical methods]

There are no official guidelines for the treatment of anorexia nervosa in young patients. Some recommendations have been proposed by a group of British experts (N.I.C.E., 2004), based on results from controlled studies. Our inpatient care unit takes into account the different dimensions of anorexia nervosa in this subgroup of young patients and proposes an integrated approach including medical care, nutritional care, and psychological care, as suggested by the N.I.C.E. recommendations. We attempt to take into account variables that are unique to these young patients. More specifically, we insist on weight restoration that will permit adequate growth and we do not systematically separate the patient from his or her family. In addition, family therapy or counseling is systematically provided. The aim of this approach is to support parents, to provide psychoeducational guidance, and to help the family acquire new behaviors and new ways of understanding the eating disorder. Most patients are treated on an outpatient basis, but inpatient care is offered when the patient displays severe medical conditions or a severe comorbid psychiatric illness. Anorexia nervosa is a protracted disorder that requires multidisciplinary outpatient medical follow-up, including the intervention of a general practitioner and a psychiatric team.

Review of the literature regarding early intervention for children and adolescents aged 0-15 experiencing a first-episode psychiatric disturbance

AIM

The purpose of this review is to report on existing literature regarding children and adolescents younger than 16 years of age experiencing a first-episode psychiatric disturbance. Rather than providing a comprehensive list of service implications, this paper identifies some of the gaps in knowledge and practice to encourage ongoing analysis regarding better practices for early intervention for children and adolescents experiencing a first-episode psychiatric disturbance.

METHODS

A search was conducted to identify key evidence-based literature published from 1985 to 2007 discussing various aspects of child and youth mental health in Canada, the USA, the UK, Australia and New Zealand. The review also included 'grey' literature. Categories of information include diagnoses, pharmacological and non-pharmacological treatment, prevalence, environmental and other risk factors, and demographic variables.

RESULTS

Understanding first-episode psychiatric disturbance for patients under the age of 16 years is limited because of a scarcity of controlled studies focusing on this population. Programme evaluations are sparse, perhaps because of the small number of specialized units servicing this population. It may be helpful to enlist early intervention psychosis programmes that have been successful in assisting young people aged 16-24 in the development of better practices and care outcomes for younger age groups.

CONCLUSIONS

The authors highlight information that has the potential to assist in optimizing care for those youth younger than 16 years experiencing or exhibiting signs of a first-episode psychiatric disturbance.

Medication management of pediatric eating disorders

This article provides an overview of psychopharmacological treatments for pediatric eating disorders (EDs). Although EDs usually begin in adolescence, there are few pharmacological treatment trials specific to this age group and a paucity of controlled data. Empirical evidence suggests that psychological, behavioural and family interventions should be the primary modalities of treatment for these conditions. In severely underweight patients behavioural weight restoration should be attempted before pharmacological intervention, especially since starvation is known to aggravate obsessional and depressive symptomatology. Evidence from controlled trials supports the use of antidepressants for the treatment of bulimia nervosa (BN) in adults; however, similar studies have not yet been performed in youths. For anorexia nervosa (AN), there are no pharmacotherapies of proven efficacy in either adults or youths. Nonetheless, clinical experience and uncontrolled evidence suggests that some children and adolescents may benefit from thoughtful use of psychotropic medications on an individual basis in the context of a multimodal treatment plan. Regarding binge eating disorder (BED), adult literature shows positive short-term effects on binge eating for both pharmacological (especially selective serotonin reuptake inhibitors) and behavioural interventions, but unclear effects on weight. Clearly, psychopharmacological interventions for pediatric EDs would benefit from more research.

The Individual Within a Condition: A Qualitative Study of Young People's Reflections on Being Treated for Anorexia Nervosa

BACKGROUND

Anorexia nervosa is a mental health problem that can seriously impede the physical, social, and psychological functioning of those who develop it. Unfortunately, outcome for this patient group, even after treatment, is not necessarily promising.

OBJECTIVE

To explore the views of young people about being treated for anorexia.

DESIGN

Qualitative interviews were conducted with 10 adolescents. All interviews were recorded with participants' written consent and transcribed verbatim. A thematic analysis was applied to these data.

RESULTS

Five themes were derived from the analysis: a) accessing appropriate care, b) balancing the physical and psychological, c) qualities required in professionals, d) help from nonprofessional routes, and e) perceived progress.

CONCLUSIONS

Participants were clear about needing to be motivated to change. Practitioners can help by challenging patients in a nonconfrontational manner, treating them as individuals rather than cases of anorexia, and considering their psychosocial and physical functioning. J Am Psychiatr Nurses Assoc, 2008; 13(6), 368.-375. DOI: 10.1177/1078390307309215.

Course and predictors of rehospitalization in adolescent anorexia nervosa in a multisite study

OBJECTIVE

The course and clinical predictors of rehospitalization were studied in a large sample of adolescent patients with anorexia nervosa who had been treated at five European sites and been followed-up.

METHOD

Two-hundred and twelve adolescent patients first admitted for in-patient treatment, aged 10-18 (Mean 14.9) years and 94.8% female, were followed-up for an average of 8.3 years after first admission at sites in (former East and West Berlin, Zurich, Sofia, and Bucharest). Clinical history data were collected by use of standardized item-sheets at first admission. Semi-structured interviews including ratings of eating pathology and psychosocial outcome were performed at follow-up.

RESULTS

About 44.8% (95/212) of the patients required at least one readmission. Rates of rehospitalization were significantly higher at the Eastern sites (Sofia and Bucharest). Significant predictors of readmission were paternal alcoholism, history of anorexia nervosa in the family, eating disorder in infancy, periodic overactivity, lower weight increase at first admission, and lower BMI at first discharge. In a model of logistic regression analysis, five variables (paternal alcoholism, eating disorder in infancy, periodic overactivity, low weight increase during first admission, and low BMI at first discharge) correctly classified 69% of the participants into cases with single or repeated admissions. Patients with repeated admissions had a less favorable long term outcome and had higher rates of persisting psychopathology at follow-up.

CONCLUSION

Rehospitalization reflects the chronic course in a sizable proportion of adolescent patients with anorexia nervosa. Family psychopathology may have an effect both in terms of genetic vulnerability and environmental stress leading to unfavorable courses. The strong effect of insufficient weight gain during first admission and lower BMI at first discharge emphasizes the importance of adequate interventions. Readmissions carry the risk for later poor psychosocial and psychiatric outcomes.

Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial

BACKGROUND

Treatment guidelines identify few adequately powered trials to guide recommendations for anorexia nervosa.

AIMS

To evaluate the effectiveness of three readily available National Health Service treatments for adolescents (aged 12-18 years) with anorexia nervosa.

METHOD

Multicentre randomised controlled trial of 167 young people comparing in-patient, specialist out-patient and general child and adolescent mental health service (CAMHS) treatment.

RESULTS

Each group made considerable progress at 1 year, with further improvement by 2 years. Full recovery rates were poor (33% at 2 years, 27% still with anorexia nervosa). Adherence to in-patient treatment was only 50%. Neither in-patient nor specialist out-patient therapy demonstrated advantages over general CAMHS treatment by intention to treat, although some CAMHS out-patients were subsequently admitted on clinical grounds. In-patient treatment (randomised or after out-patient transfer) predicted poor outcomes.

CONCLUSIONS

First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in-patient facilities.

Treatment perception in adolescent onset anorexia nervosa: retrospective views of patients and parents

OBJECTIVE

To investigate perception of treatment in former patients with anorexia nervosa (AN) and their parents, and to determine whether this was related to outcome and treatment characteristics. Client satisfaction is important for treatment engagement and adherence.

METHOD

Forty-six (of 55) girls with adolescent onset AN, 33 mothers and 26 fathers participated in a follow-up study conducted 8.8 (SD 3.3) years after start of treatment. The former patients were assessed using diagnostic interviews. Only nine participants (19%) had an eating disorder (ED) at follow-up. Perception of treatment was assessed by questionnaires.

RESULTS

Parents reported having an overall positive perception of treatment. However, reports from former patients were significantly more negative than from the parents. In former patients, the "perception of therapists" total score and the items "therapists' knowledge of ED" and "usefulness of pediatric inpatient treatment" correlated with ED symptoms at follow-up. The perception of therapists' scores of the parents were not associated with the ED outcome of their daughters. More family therapy sessions were associated with the former patients' satisfaction with the therapists, while higher age at admission was associated with their mothers' satisfaction.

CONCLUSION

In spite of good ED outcome, former patients were only moderately satisfied with their treatment, whereas parental satisfaction was high.

Olanzapine therapy in anorexia nervosa: psychobiological effects

Dopamine impairments occur in anorexia nervosa. The aim of this study was to see whether treatment with the atypical dopamine antagonist antipsychotic olanzapine improves the disorder. Thirty anorexics, 18 restricted and 12 bingeing-purging, underwent a 3-month course of cognitive behavioral therapy, plus at random and double-blinded oral olanzapine (2.5 mg for 1 month, 5 mg for 2 months) in half and oral placebo in the other half of them. BMI, psychopathological aspects (eating disorder inventory, Hamilton Rating Scale, Buss-Durkee Rating Scale, Yale Brown Cornell for Eating Disorders Rating Scale, temperament-character inventory), and homovanillic acid blood concentrations for dopamine secretion, were monitored at baseline and then monthly during the trial. At the end of the trial BMI, total eating disorder inventory, total Yale Brown Cornell for Eating Disorders Rating Scale, Buss-Durkee Rating Scale, Hamilton Rating Scale scores and in olanzapine-treated patients the subitems of eating disorder inventory ineffectiveness and maturity fear, of Buss-Durkee Rating Scale direct aggressiveness, of temperament-characteristic inventory persistence had improved significantly. When stratified for anorexia nervosa subtype, BMI changes were significant among anorexia nervosa bingeing-purging patient, 'depression' (Hamilton Rating Scale) and 'direct aggressiveness' (Buss-Durkee Rating Scale) among anorexia nervosa bingeing-purging patients, 'persistence' (temprerament-characteristic inventory), among anorexics restricted patients, with a trend toward significance for obsessivity-compulsivity (Yale Brown Cornell for Eating Disorders Rating Scale). homovanilic acid blood levels increased significantly in the cognitive behavioral therapy+olanzapine group. No correlations were observed between homovanilic acid concentrations and psychopathological parameters. The pharmacological treatment can significantly improve specific aspects of anorexia nervosa.

Medical complications in children and adolescents with anorexia nervosa

A gyermek- és serdülőkorban kezdődő anorexia nervosa súlyos, potenciálisan életveszélyes betegség, mely korai halálozáshoz, valamint élethosszig tartó szomatikus és pszichoszociális megbetegedésekhez vezethet. Az állapot jelentős testi szövődményeket okoz a növekvő és fejlődő szervezet csaknem minden szervrendszerében. Bár ezek az eltérések a betegség gyógyulásával, a táplálkozási/táplálási rehabilitációval túlnyomó részben javulnak, némely elváltozás irreverzíbilis marad.A közlemény az elmúlt két évtized idevágó közleményeinek áttekintése alapján összefoglalja a gyermek- és serdülőkorban kezdődő anorexia nervosa szomatikus szövődményeinek evidenciákon alapuló szakirodalmát. Tárgyalja az akut tüneteket, kiemelten foglalkozik a só–víz háztartás zavaraival és az újratáplálási szindrómával, valamint részletezi a kardiovaszkuláris komplikációkat. Összefoglalja a gyermek- és serdülőkori anorexiára speciálisan jellemző elváltozásokat: a csont ásványianyag-tartalom csökkenését és az osteopenia lehetséges terápiás lehetőségeit, valamint a hossznövekedésbeni elmaradást.A szakirodalom áttekintése alapján megállapítható, hogy a gyermek- és serdülőkori anorexia nervosa szomatikus szövődményei különböznek a felnőttek megbetegedéseitől. A sajátságos klinikai megjelenés, a korai kezdet és a hosszú távú következmények ismeretének hiánya miatt szükséges külön tárgyalni a gyermek- és serdülőkori anorexia nervosát a felnőttekétől és felhívni a figyelmet a betegség minél korábbi felismerésének és hatékony terápiájának szükségességére. Egyre nő azon evidenciák száma, melyek az anorexia nervosa felismerésében és kezelésében hangsúlyozzák és elengedhetetlenné teszik a multidiszciplináris szakembercsoportok szerepét.

[Intensive outpatient group treatment for adolescents with eating disorders]

We present an intensive outpatient group treatment for girls with eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder) additionally to/instead of inpatient treatment or individually treatment by psychotherapists. The therapy concept is primarily behaviour therapy oriented, encouraging the self-management-abilities of the patients thereby learning self-determination and responsibility in dealing with their illness. The slow-open group concept provokes group cohesion, solidarity and support among girls, who share similar age-related development-stages and eating disorders. Other than cognitive behaviour therapy and the principles of self-management we use client-centered therapy, art-, dance- and nutritional therapy. For each patient an individual treatment plan is adapted depending on age, individual symptoms, problems and motivation. Each member of the group has to accept defined group rules during the group sessions. The group takes place twice a week and on one Saturday per month. The adolescents stay in their social environment. Transfer of therapeutic success into daily life therefore is immediate and longlasting. Duration of therapy is between four months and one year, longer only in complex cases. Parallel to the parent/patient cooperation a parental psycho-educative group is available.

Emotional, developmental, and behavioral health of American children and their families: a report from the 2003 National Survey of Children's Health

BACKGROUND

Recent children's health surveys have documented a high prevalence of emotional, developmental, and behavioral problems among children. Data from the 2003 National Survey of Children's Health provide new insights into these problems and their association with family function and community participation. These issues have become a current focus of the World Health Organization.

METHODS

Answers to questions of interest from the 2003 National Survey of Children's Health were reported using estimates and SEs of rates. Statistical comparisons of rates with chi2 tests at the 0.05 level were made when relevant.

RESULTS

The most commonly diagnosed problems among children 6-17 years of age were learning disabilities (11.5%), attention-deficit/hyperactivity disorder (8.8%), and behavioral problems (6.3%); among preschoolers, speech problems (5.8%) and developmental delay (3.2%) were most common. One in 200 children was diagnosed with autism. In contrast, rates of parental concerns about emotional, developmental, or behavioral problems were much higher; for example, 41% of parents had concerns about learning difficulties and 36% about depression or anxiety. Children with developmental problems had lower self-esteem, more depression and anxiety, more problems with learning, missed more school, and were less involved in sports and other community activities. Their families experienced more difficulty in the areas of childcare, employment, parent-child relationships, and caregiver burden.

CONCLUSIONS

The most recent National Survey of Children's Health mirrored results of previous surveys regarding rates of diagnosed emotional, developmental, and behavioral problems, including an escalating diagnosis of autism among children. Reported rates of parental concerns about these problems were much higher, suggesting possible underdiagnosis of children's problems. Children with chronic problems had diminished family functioning, more school absences, and less participation in community activities compared with other children. Their parents experienced more difficulty with childcare, employment, and parenting skills. A change in treatment emphasis is needed, away from an exclusive focus on a child's developmental and behavioral problems to one that addresses the impacts of these problems on the family and community participation. A new approach to the way these issues are addressed and managed has the potential to enhance the quality of life for a child, as well as the parents, and to produce more meaningful and tangible solutions to these complex and increasingly evident problems.

Clinical and laboratory characteristics of adolescents with both polycystic ovary disease and anorexia nervosa

In girls evaluated for anorexia nervosa (AN), coexistence of polycystic ovary disease (PCOS) was found when menstrual irregularities existed before weight loss, cessation of menses occurred at a relatively elevated body mass index, and LH and estrogen levels were elevated compared with adolescents with AN alone. In adolescents with PCOS + AN weight gain beyond recommended weight should not be advised.

Recent Developments in Anorexia Nervosa

  This review summarises recent clinical developments, topics of debate, and research findings in relation to anorexia nervosa in children and adolescents. Following an update of diagnostic and prevalence issues, recent developments in treatment approaches are discussed. These cover recommendations for the medical management of anorexia nervosa in young people, as well as psychological interventions for children, adolescents and their families. The question of which type of service setting is most appropriate for the treatment of young people with anorexia nervosa remains a subject of discussion, and recent guidance and work in this area is presented. Finally, the ongoing relatively poor prognosis in terms of general mental health associated with anorexia nervosa is highlighted and the implications for CAMHS practitioners discussed.

Evidence Based Research in CBT with Adolescent Eating Disorders

Cognitive behaviour therapy (CBT) is increasingly becoming the treatment of choice for a number of adolescent mental health problems, including depression (Harrington et al., 1998) and obsessive compulsive disorder (OCD), (March, 1995). In considering the role of CBT in the treatment of adolescent eating disorders, it is helpful to review the phenomenology of anorexia and bulimia nervosa in this age group and to assess the theoretical relevance of a cognitive behavioural approach to their management. The evidence base has been reviewed in the recently published National Institute of Clinical Excellence (NICE) Guidelines on the treatment of eating disorders (NICE, 2004). To date, CBT approaches have not been widely tested in controlled trials in this age group. However, a randomised controlled treatment trial is under way in the North West of England (The TOuCAN Trial), in which CBT is an important component of one of the interventions being studied and this will be described.