Early-onset anorexia nervosa and related eating disorders

Early onset anorexia nervosa: Multidisciplinary hospital intervention in a 1-year follow-up study

BACKGROUND

Early onset anorexia nervosa (EOAN) is a subclassification of AN, defined by an onset before 14 years, and characterized by specific demographic, neuropsychological, and clinical features. The present study aims to provide naturalistic data on a wide sample with EOAN, focusing on psychopathological and nutritional changes occurring in the context of a multidisciplinary hospital intervention, as well as the rate of rehospitalizations during a 1-year follow-up.

METHOD

Observational, naturalistic study adopting standardized criteria for EOAN (onset before 14 years). EOAN were compared to adolescent-onset AN (AOAN) patients (onset after 14 years) by demographic, clinical, psycho and treatment variables. Psychopathology was assessed at admission (T0) and discharge (T1) with self-administered psychiatric scales for children and adolescents (SAFA) subtests for Eating Disorders, Anxiety, Depression, Somatic symptoms, and Obsessions. Then, potential differences of T0-T1 changes in psychopathological and nutritional variables were assessed. Finally, rates of re-hospitalizations at 1-year post-discharge follow-up were assessed with Kaplan-Meier analyses.

RESULTS

Two-hundred thirty-eight AN individuals (EOAN = 85) were enrolled. When compared to AOAN, EOAN participants were more frequently males (X2 = 5.360, p = .021), more frequently received nasogastric-tube feeding (X2 = 10.313, p = .001), and risperidone (X2 = 19.463, p < .001), obtained a greater T0-T1 improvement in body-mass index percentage (F[1.229] = 15.104, p < .001, η2 = 0.030), with higher 1-year freedom from re-hospitalization (hazard ratio, 0.47; Log-rank: X2 = 4.758, p = .029).

CONCLUSION

In this study, describing the broadest EOAN sample available in literature so far, EOAN patients received specific interventions and obtained better outcomes at discharge and follow-up when compared to AOAN. Longitudinal, matched studies are required.

Clinical features of children and adolescents with anorexia nervosa and problematic physical activity

PURPOSE

Problematic physical activity (PPA) is a symptom commonly present in patients suffering from anorexia nervosa (AN). This study aims to refine the clinical description of children with early-onset AN and adolescents with standard-onset AN and associated PPA, in order to better understand their associated features, and to offer them adapted care and physical activity programs.

METHODS

107 participants treated at the Salvator University Hospital Centre of Marseille for AN were retrospectively evaluated by the Exercise Dependence Scale Revised concerning PPA. Other self-report questionnaires were used to evaluate eating disorder, anxiety and depressive symptoms, quality of life, emotions, sleep, and attention deficit disorder with or without hyperactivity.

RESULTS

In the entire sample, the presence of PPA was associated with significantly higher levels of eating disorder (EDI-2: p = 0.001) and body image concerns (p = 0.002), anxiety (STAI-Y-trait: p = 0.013) and depression (p = 0.006), as well as significantly lower psychological well-being (p < 0.001) and quality of life (p < 0.001) and impaired sleep (PSQI: p = 0.008). The early-onset group showed a lower prevalence of PPA than the standard-onset group (p < 0.05) but their clinical symptomatology, when this symptom was present, was significantly more severe (EDI-2: p < 0.01; BSQ: p < 0.05; CDI: p < 0.05; STAI-Y-trait: p < 0.05).

CONCLUSION

PPA appears to be associated with more severe features in patients with early-onset AN, which seems to differ from standard-onset. It seems necessary to refine our knowledge on the involvement of PPA in the severity of AN, especially in patients with early-onset AN who remain little studied so far.

LEVEL OF EVIDENCE

Level V, descriptive study (evaluation data retrospectively studied).

Estimated Prevalence and Care Pathway of Feeding and Eating Disorders in a French Pediatric Population

Feeding and Eating Disorders (FED) are mostly described in infants and adolescents but are less well-known in children. Information on the prevalence of FED in the general pediatric population is still limited. The aim of this study was to estimate the prevalence and the care pathway of FED in a population aged 0-18 years old, using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 classification. Two physicians interviewed 401 families using a questionnaire including demographics, BMI, dietary behavior data, and age-appropriate screening tools. Qualitative and quantitative variables were compared using the Chi² test and Student's t-test, respectively. After a headcount adjustment based on the French population by age group, the estimated prevalence rate was 3% [95%CI (1.7-5.1)] for Avoidant and Restrictive Food Intake Disorder (ARFID), and 9.7% [95%CI (7.2-13.0)] for Unspecified FED (UFED), which included other restrictive and compulsive FED. The median age for ARFID was 4.8 years (0.8-9 years), and 7.5 years (0.6-17 years) for UFED. The interviews did not identify cases of anorexia, bulimia, binge eating disorder, other specified FED, pica or rumination. Only 15.2% of children with an FED were receiving medical care. The development of validated pediatric screening tools, as well as the training of health professionals in children FED is necessary.

First presentation of restrictive early onset eating disorders in Asian children

OBJECTIVE

This study aims to describe the spectrum of children with restrictive early onset eating disorders (EOEDs), defined as below 13 years of age, presenting to a tertiary institution in Asia and comparing them with older adolescents with eating disorders.

METHODS

This is a retrospective case review of Asian children who were treated in an eating disorder center. Baseline characteristics and inpatient management at first presentation of children younger than 13 years of age (EOED) were compared to those in older adolescents.

RESULTS

A total of 288 patients with restrictive eating disorders were analyzed with 53 (18%) patients having onset younger than age 13 at initial presentation. There were no significant differences in percentage weight loss and hospitalization rates between the two age groups. Patients with EOED presented with significantly shorter duration of symptoms, and lower rates of secondary amenorrhea. More patients with EOED required phosphate supplementation compared to those in older age group.

CONCLUSION

Despite having a shorter duration of illness, Asian children with EOED had similar percentage weight loss and rates of admission due to malnutrition as those in older Asian adolescent patients. This study underlined the severity of EOEDs and the need for early recognition and medical assessment.

Clinical characteristics of early onset anorexia nervosa

The aim of the current paper is to evaluate clinical characteristics of 30 children with early onset anorexia nervosa (EO-AN; age = 12.2 ± 1.6 years) compared with 30 patients with adolescent onset AN (AO-AN; age = 15.9 ± 0.7 years) and 60 age-matched healthy controls. Statistical analyses included one-way analyses of variance with three planned comparisons and chi-square tests. Compared with AO-AN, EO-AN patients displayed more restrictive eating behaviour (p = 0.038), received more tube-feeding (p = 0.024), and had less problems with self-esteem (p < 0.001) and perfectionism (p = 0.001). EO-AN patients have similar eating disorder pathology (p = 0.183), body-image distortion (p = 0.060), and number of hospitalizations (p = 0.358) as AO-AN. Only a third of EO-AN patients suffer from low self-esteem. Overall, core AN pathology seems similar in EO-AN and AO-AN. However, EO-AN patients show differences in their pathological eating behaviour and the need for tube-feeding.

[What Are the Individual, Family, and Social Characteristics Differentiating Prepubertal from Pubertal Anorexia Nervosa?]

Prepubertal anorexia nervosa may entail multiple physical effects. When the onset occurs before puberty, the disorder might be associated with a poorer prognosis and a greater resistance to treatment. Until now, prepubertal anorexia nervosa studies have mostly dealt with symptomatology, but rarely with associated factors.

OBJECTIVE:

This study aims to differentiate prepubescent from pubescent anorexia nervosa regarding individual, family and social characteristics.

METHOD:

At admission in programs specialized in eating disorders, female patients (n = 19 prepubertal and 126 pubertal) and their parents filled in questionnaires (EDI-3, BDI II, IPPA, FACES IV, IDPESQ) on key individual, family and social characteristics associated with anorexia nervosa. Prepubertal and pubertal patient results were compared for each measured variable. Pubertal development and anorexia presence were assessed by a paediatrician in all patients.

RESULTS:

Prepubertal patients account for 13.8% of all cases and have a lower percentile rank than pubertal patients. The many questionnaire results showed little or no difficulty at personal, family or social level and no difference with older patients.

CONCLUSIONS:

These results contribute to challenge our current understanding of prepubertal anorexia nervosa and the prepubescent patient capacity to report their difficulties, which highlights the importance of using several respondents when defining clinical profiles.

Avoidant/Restrictive Food Intake Disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is an entirely new diagnosis in the DSM-5. ARFID replaces "feeding disorder of infancy or early childhood," which was a diagnosis in the DSM-IV restricted to children 6 years of age or younger; ARFID has no such age limitations and it is distinct from anorexia nervosa and bulimia nervosa in that there is no body image disturbance. ARFID involves a complex and heterogenous etiology, which is reviewed herein. What is known to date regarding the characteristics and medical and psychiatric comorbidities of this patient population are described and compared to other eating disorders. Evaluation and management strategies are also discussed. No data yet exist regarding ARFID׳s prognosis and prevention; however, recommendations to guide parents in establishing appropriate infant and child feeding practices are provided.

Positive Narrative Therapy for an Unspecified Eating Disorder: A Child Case Report

A new sequential multicomponent treatment (cognitive behavioral therapy followed by well-being-enhancing narrative strategies) was applied for an unspecified eating disorder in a 10-year-old boy for reducing symptoms and improving well-being. Both distress and well-being were assessed with self and observer ratings at baseline, posttreatment, and 3-, 6-, 12-month follow-up. An ABA design was used and reliable change indexes were calculated as outcome measures. This new sequential psychotherapeutic approach, which integrated standard cognitive behavioral therapy with narrative strategies addressed at promoting well-being in a child patient diagnosed with an unspecified eating disorder, was able to reduce symptoms and to foster his resources and positive behaviors. The patient himself, his parents, and teachers confirmed these improvements. This case report shows the clinical usefulness of a new sequential psychotherapeutic approach for treating an unspecified eating disorder in a child. It provides psychotherapists with relevant clinical implications concerning the emotional and interpersonal dimensions involved in this disabling condition.

Death Anxiety, Perfectionism and Disordered Eating

Recently, death anxiety, or dread of death, has been proposed as a key transdiagnostic process underlying the anxiety disorders, depressive disorders, somatic disorders, and trauma and stressor-related disorders. In fact, it has been argued that death anxiety underlies all psychopathology, and is more fundamental than perfectionism, a process which was previously considered the root of mental illness. However, there has been a paucity of research examining the relationship between death anxiety and the eating disorders, although these conditions have been found to be strongly related to perfectionism. The present study therefore aimed to examine whether death anxiety is related to disordered eating, and whether death anxiety is a better predictor of disordered eating than perfectionism. A sample of 164 participants (132 female), average age 33.55 years (SD= 15.45 years), completed an online survey comprising background questions (age, sex, diagnosed psychiatric disorder), the Eating Attitudes Test — 26 item version (EAT-26), the Almost Perfect Scale — Revised (APS-R), the Rosenberg Self-Esteem Scale (RSES), and the Death Anxiety Scale (DAS). The findings of a hierarchical multiple regression analysis with EAT-26 as the dependent variable, age entered at Step 1, the RSES and APS-R entered at Step 2, and the DAS entered at Step 3 showed that only death anxiety and self-esteem were independent predictors of disordered eating at Step 3. A simultaneous multiple regression analysis was subsequently run with age and the APS-R alone as predictors of EAT-26 scores. This analysis showed that perfectionism was only a predictor of disordered eating when death anxiety and self-esteem were not included in the regression model. Death anxiety and self-esteem both appear to be important transdiagnostic processes.

Healthy Perfectionism in the Gifted

The results of a series of empirical studies on perfectionism in the gifted are reviewed. Contrary to common beliefs, results indicate that perfectionism is not greater in the gifted. Perfectionism has a hierarchical structure with both healthy and unhealthy forms. These two forms are separate constructs rather than extreme ends of a single continuum. High personal standards, often a source of concern for parents and educators of the gifted, are associated with the healthy form of perfectionism. While parents have an impact on perfectionism in their children, evidence to date suggests that parental impact is quite modest.

An Examination of the Multidimensional Perfectionism Scale with a Sample of Academically Talented Children

The Multidimensional Perfectionism Scale (MPS; Frost, Marten, Lahart, & Rosenblate, 1990) was constructed and normed on an all-female college student sample. The present study is a psychometric examination of the instrument for use with a mixed-gender sample of 855 academically talented children who were participating in the longitudinal Developmental Study of Talented Youth conducted by the Center for Talented Youth of Johns Hopkins University. The internal consistency of the MPS total score was .87; coefficient alphas for the subscales ranged from .67 to .90. The matrix of intercorrelations of MPS subscales was consistent with that obtained with the college sample used to develop the instrument. A confirmatory item factor analysis demonstrated an acceptable degree of fit. A factor analysis of raw scores on the MPS subscales yielded two factors. The first factor appears to represent dysfunctional perfectionism, the second factor reflects healthy perfectionism. The scores on these factors were correlated with the five-factor domain scores obtained on the NEO-FFI. The first factor correlated most strongly with N (Neuroticism); the second factor correlated most strongly with C (Conscientiousness).

Treatment of Adolescent Anorexia Nervosa Using Manualized Family-Based Treatment

This article reports on the treatment of an adolescent girl with anorexia nervosa using a manualized family therapy approach. The therapy used proceeds through three phases. The first phase encourages parents to take charge of refeeding their daughter while separating the illness from the patient. The second phase promotes the adolescent once again eating on her own, and the third phase aims at general adolescent issues that have been affected by anorexia nervosa. The family therapy reported on her has been shown to be effective in clinical trials and this case illustrates the basic therapeutic processes and outcomes that can be expected.

Childhood Anorexia Nervosa Compared with Low Weight Food Intake Disorder Without Weight and Shape-Related Psychopathology: A Retrospective Study of 102 Patients

Objective

To compare the clinical presentation of children with anorexia nervosa (AN group) with that of children with low‐weight food intake disorder without weight and shape‐related psychopathology (non‐AN group).

Method

Medical and psychiatric data were obtained from the case records of a consecutive series of 102 children with an eating disorder and a pronounced low weight who were below the age of 13 at the start of treatment.

Results

Fifty‐eight patients constituted the AN group, and 44 constituted the non‐AN group. The non‐AN group was younger and had a longer duration of symptoms than the AN group. The non‐AN group also had a lower maximum premorbid weight and shorter stature. There were no differences in medical severity, but the AN group had more psychiatric treatment.

Discussion

The non‐AN group seems to have a medically equally severe disorder as the AN group, but is less often detected and properly treated. Copyright © 2016 The Authors European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd

Risk factors for elevated liver enzymes during refeeding of severely malnourished patients with eating disorders: a retrospective cohort study

BACKGROUND

There are few previous reports regarding the cause and evolution of liver injury in patients with anorexia nervosa (AN) during the refeeding process, and its management remains controversial. This study aimed to determine the risk factors for elevated liver enzymes during refeeding and their effect on the therapeutic process in severely malnourished patients with eating disorders.

METHODS

In a retrospective cohort study of 167 female inpatients in a single hospital from January 2004 to March 2015, 67 who had normal alanine aminotransferase (ALT) levels on admission were divided into two groups according to the presence or absence of elevated ALT levels during refeeding, and then compared.

RESULTS

The median age and body mass index (BMI) of the patients on admission were 22 [interquartile range (IQR), 16-33] years and 12.2 (IQR, 11.1-13.0) kg/m², respectively. Compared with their cohorts, significantly more patients in the early onset age group (<15 years old) had elevated ALT levels during refeeding (67% vs. 33%, p = 0.033), as did patients with longer median time to nadir BMI (3.0 vs. 0 days, p = 0.03). In addition, onset age [odds ratio (OR): 0.274; 95% confidence interval (CI): 0.077-0.981; p = 0.047] and time to nadir BMI (OR: 1.271; 95% CI: 1.035-1.56; p = 0.022) were significantly associated with the odds of elevated ALT levels during refeeding.

CONCLUSIONS

The results of this study suggest that early age at onset may be a potential risk factor for elevated ALT levels during refeeding in severely malnourished patients with eating disorders. Furthermore, elevated ALT levels during refeeding were significantly associated with delay in the start of weight gain. No significant relationship was found between the amount of initial prescribed calories and elevated ALT levels during refeeding. The median time to maximum ALT was 27 (IQR, 21-38) days after the refeeding process started.

Early-onset anorexia nervosa in girls with Asperger syndrome

Eating disorders frequently occur in conjunction with autism spectrum disorders, posing diagnostic and therapeutic difficulties. The comorbidity of anorexia nervosa and Asperger syndrome is a significant clinical complication and has been associated with a poorer prognosis. The authors are presenting the cases of an eleven-year-old girl and a five-and-a-half-year-old girl with comorbid eating disorders and Asperger syndrome.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

OBJECTIVES

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014.

METHODS

The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified.

RESULTS

In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice.

CONCLUSIONS

Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management.

EXPERT REVIEWERS

Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Essprobleme im Kindesalter

Essstörungen im Kindes- und Jugendalter werden immer häufiger und eine frühzeitige Erkennung ist von großer Bedeutung. Neben den „klassischen” Essstörungen besteht eine Anzahl von Essproblemen im Kindesalter, die sich durch vermeidende oder restriktive Nahrungsaufnahme kennzeichnen und zurzeit nicht im DSM-IV Klassifikationssystem aufgeführt werden. Ziel der Untersuchung war es, das Vorkommen dieser Essprobleme in einer allgemeinen, schulbasierten Stichprobe in der Schweiz zu untersuchen und die psychometrischen Kennwerte eines kurzen Screeningfragebogens zur Erfassung vermeidend oder restriktiver Nahrungsaufnahme im Selbstbericht zu ermitteln. Es beantworteten 730 Kinder im Alter von 8 – 13 Jahren den Eating Disturbances in Childhood–Questionnaire (EDCh-Q). 29.8 % der Kinder gaben an, vermeidendes oder restriktives Essverhalten aufzuzeigen. Der EDCh-Q zeigte insgesamt gute Itemcharakteristika. Die vierfaktorielle Struktur konnte bestätigt werden, allerdings mit geringen internen Konsistenzen der Subskalen. Untergewichtige Kinder gaben häufiger an, Symptome einer Nahrungsvermeidung mit emotionaler Störung aufzuzeigen. Vermeidendes oder restriktives Essverhalten ist nicht unüblich bei Kindern im Schulalter. Der EDCh-Q ist ein diagnostisch orientierter Screeningfragebogen zur Identifizierung dieser Essprobleme in der mittleren Kindheit. Weitere Forschung ist wünschenswert zur Validierung des EDCh-Q in allgemeinen und klinischen Stichproben.

[Anorexia nervosa in the light of neurocognitive functioning: New theoretical and therapeutic perspectives]

INTRODUCTION

Anorexia nervosa is a serious psychiatric disorder, for which very few validated therapeutic strategies exist. The specific sociocognitive style of anorexic patients has already been described in the 1960s: it involves a concrete style with abstraction difficulties. Current neuropsychological tests have contributed to a more precise definition of these difficulties.

NEUROPSYCHOLOGICAL DATA

IS THERE A SPECIFIC COGNITIVE PROFILE?: Contrary to common beliefs, these patients' intellectual performances are not superior to those of the general population. However, detailed comparisons of profiles on the Weschler Scales suggest difficulties in synthesizing information and better abilities in concrete problem solving.

EXCESSIVE ATTENTION TO DETAILS

The dominant hypothesis concerning the attentional dimension is the existence of a weakness in central coherence, resulting in superior detail processing and a weakness in global integration. This trend appears to be stable even after the normalization of nutritional status.

IMPAIRED COGNITIVE FLEXIBILITY

The impairment of set-shifting abilities leads to rigidity, expressed by inflexibility and perseveration, both in reasoning and behaviour. This reduced cognitive flexibility appears to persist after recovery, and may constitute a familial trait. In addition, this likely endophenotype seems to be independent from obsessional traits.

CONTROVERSIAL SOCIAL SKILL

Alexithymia is frequently described in anorexic individuals. It is the verbal description of feelings which seems to be particularly impaired. It may explain underlying difficulties in empathy. Indeed, these subjects have lower scores on emotional tests drawn from the theory of mind. These cognitive abnormalities are well documented in pervasive developmental disorders. NEUROANATOMICAL DATA: NEUROIMAGING IN SUPPORT OF LIMBIC AND FRONTO-STRIATAL ABNORMALITIES: Evidence from neuroimaging suggests abnormalities in cortical and subcortical structures, involving the temporal and orbito-frontal lobes. Various functional hypotheses are formulated, involving fronto-striatothalamic circuits, amygdala or insula. IS ANOREXIA NERVOSA A DEVELOPMENTAL DISORDER?: Pervasive developmental disorders are over-represented among anorexic subjects in comparison to the general population. Conversely, restrictive and selective eating disorders are more frequent among individuals presenting an autistic spectrum disorder.

THERAPEUTIC IMPLICATIONS AND FUTURE DIRECTIONS

In view of the common cognitive and neuroanatomical data that are found in anorexia nervosa and neurodevelopmental disorders, we adhere to the hypothesis that anorexia nervosa may be similar to a neurodevelopmental disorder. Clinical observations suggest that this hypothesis may be especially relevant in the early forms of anorexia nervosa. These cognitive data confirm the potential relevance of new therapeutic modalities such as cognitive remediation. Initial results from its application to anorexia nervosa seem promising.

CONCLUSION

A review of the recent literature highlights the possible existence of a developmental impairment of cortical and subcortical structures, associated with specific abnormalities in cognitive development such as a weakness in central coherence, reduced set-shifting ability and poor social skills. On this basis, cognitive remediation may be a promising therapeutic innovation.

Clinical outcomes of a novel, family-centered partial hospitalization program for young patients with eating disorders

AIM

Eating disorders (ED) in children and younger adolescents are becoming more evident, but there is a small evidence base for their management in this population. We hypothesized that a new family-centered partial hospital program for young patients would be effective in promoting weight gain, as well as improvement in psychiatric symptoms.

METHODS

A retrospective chart review of 56 patients treated in the program between August 2008 and November 2009 was performed. Historical data, anthropometric variables and scores from psychological instruments [Children's Eating Attitudes Test (ChEAT), Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS)] were collected on admission and at discharge. After exclusion, 30 patients were available for statistical analysis, using paired t-tests. The primary outcome variables were improvement in weight and change in total ChEAT score. Secondary outcomes included improvements in the CDI and RCMAS scores. Multivariate analysis included linear regression models that controlled for patient-specific fixed effects.

RESULTS

The cohort was 87% female with a mean age of 12.8±2 years; 60% were diagnosed with ED not otherwise specified. Two-thirds had a co-morbid depressive and/or anxiety disorder. Change in weight was significant (p<0.0001), as were improvements on total ChEAT (p<0.0001), CDI (p=0.0002), and RCMAS (p<0.0001) scores. No historical factors were correlated with improvement, nor was use of psychotropic medications. Length of stay in weeks significantly predicted greater weight gain (p=0.004, R2=0.26).

CONCLUSIONS

Patients treated in a family-centered partial hospital program had significant improvements in weight and psychological parameters. This approach holds significant promise for the management of young ED patients.

Use of gastrostomy tubes in children and adolescents with eating disorders and related illnesses

PURPOSE

The aim of this case series was to describe five youths with psychiatric illnesses who underwent feeding tube placement as part of their treatment.

METHODS

The database of a Canadian academic tertiary care eating disorder program was used to identify patients with feeding tubes.

RESULTS

Five patients with feeding tubes were identified in the database of more than 600 patients. Of the five patients, two had anorexia nervosa and three suffered from food refusal as a result of a psychiatric illness unrelated to body image issues. For each patient, the tube was placed only after standard methods of treatment had failed, including repeated hospitalizations and in two cases, residential treatment. The primary goal of placing the tube was to allow for outpatient management of the patient. In all five cases, the healthy weight was restored, and four of the five patients experienced a significant improvement in independent eating behavior. Four of the five patients were found to have had their tube removed when this article was being written. None of the patients required further hospitalizations and no serious relapses were found to have occurred.

CONCLUSION

This case series demonstrates that gastrostomy tube feeding can be an effective intervention to allow patients with eating disorders to be treated as outpatients. The limitations of this study include the small study size, the retrospective nature of the study, and the short follow-up after tube removal. Further study is needed to evaluate the psychological effects of enterostomy feeds in patients and their families.

Eating behaviour and body satisfaction in mediterranean children: the role of the parents

Although the prevalence of fully expressed Eating Disorders is rare in young children, childhood eating disturbances are fairly common. Parents can play a facilitating role for the development of overweight and eating problems among their children. The aim of this study is to detect the possible relationships between children’s eating attitudes and behaviour and the parents’ beliefs about eating habits and body shape of their offspring.

This survey was conducted in the area of Arezzo (Italy), on 900 children, aged 7-12, and on their parents/substitute caregivers. The Kids’ Eating Disorder Survey questionnaire, and the CIBUS questionnaire were administered.

A fully expressed Eating Disorder was diagnosed in two kids only. KEDS total score and weight/dissatisfaction subscale score positively correlated with parents’ answers to the following CIBUS’ items (How do you consider the body shape of your son/daughter? How much does your son/daughter eats? Have you ever thought of putting your son/daughter on a diet?). Positive correlations between the children BMI, desired BMI and the aforementioned CIBUS’ items were found.

The prevalence of formal Eating Disorders in children aged 7-12 is low. Children appear to be more preoccupied with their weight than with their body shape. Parents’ beliefs about the offspring’s body shape and eating habits have a relevant impact on children’s eating attitudes and behaviour.

Burden of eating disorders in 5-13-year-old children in Australia

OBJECTIVE

To collect nationally representative epidemiological data on early-onset eating disorders (EOEDs) in children.

DESIGN

Prospective, active surveillance using the Australian Paediatric Surveillance Unit with key informant design.

SETTING

Child health specialists in Australia (July 2002 to June 2005).

PATIENTS

Incident cases of EOEDs in children aged 5-13 years.

MAIN OUTCOME MEASURES

Disease rates, demographic characteristics, clinical features and complications, hospitalisation, psychological comorbidity, and concordance of clinical features with Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) criteria.

RESULTS

We identified 101 children aged 5-13 years with EOEDs (median age, 12.2 years; range, 5.5-13.9 years), of whom one in four were boys. Most were hospitalised (78%), and the mean duration of hospitalisation was 24.7 days (range, 1-75 days). More than 70% of inpatients were admitted to specialised eating disorder units in paediatric teaching hospitals. Among inpatients, 37% met DSM-IV diagnostic criteria for anorexia nervosa; although 61% had life-threatening complications of malnutrition, only 51% met weight criteria. Psychological symptoms were similar to those in adults with anorexia nervosa: 67% of inpatients met both psychological diagnostic criteria for anorexia nervosa (fear of weight gain/fatness and misperception of body shape). Of 19 postmenarchal girls, 18 had secondary amenorrhoea. Nasogastric feeding was used in 58% of inpatients, and 34% received psychotropic medications.

CONCLUSIONS

This is the first prospective national study of EOEDs. It demonstrates the limitations of applying DSM-IV diagnostic criteria for anorexia nervosa to young children; the high proportion of boys affected by EOEDs; and the significant psychological comorbidity and high frequency of hospitalisation associated with EOEDs. Potentially life-threatening medical complications are common at presentation, suggesting possible missed diagnoses and a need for education of health professionals. The study underlines the severity of EOEDs and the need for joint medical and psychiatric specialist management.

Prediction of disturbed eating attitudes in adolescent girls: a 3-year longitudinal study of eating patterns, self-esteem and coping

OBJECTIVE

The purpose was to examine the extent to which yearly assessments of eating patterns and attitudes, self-esteem and coping strategies over a 3-year period among adolescent girls predicted the degree of disturbed eating attitudes at the year 3-assessment. Our main hypothesis was that such attitudes year 3 would be predicted by eating attitudes, restrained, emotional, and external eating behaviour, as well as by low self-esteem and coping by acting out or avoidance.

METHOD

Three-hundred and seventy- eight Swedish adolescent girls were assessed once a year for three years.

RESULTS

The results suggest that eating patterns and attitudes were the strongest predictors of disturbed eating attitudes year 3. Self-esteem and coping had a limited predictive value for eating attitudes year 3, and the effect of self-esteem appeared to be mediated by coping.

DISCUSSION

The results suggest that early eating patterns (e.g., more disturbed eating attitudes and restrained eating behaviors) and attitudes are potentially important predictors for the development of more serious eating disturbances among adolescent girls.

No differences are seen in the regional cerebral blood flow in the restricting type of anorexia nervosa compared with the binge eating/purging type

AIMS

Anorexia nervosa (AN) is subdivided into the restricting type (AN-R) and the binge-eating/purging type (AN-BP), but differences in cerebral blood flow between patients with these types of AN and healthy controls have not been investigated.

METHODS

The present study was designed to elucidate any such differences using resting single photon emission computed tomography (SPECT) studies to compare the differences in cerebral perfusion among both types of AN and a healthy control group. Resting regional cerebral blood flow was assessed using SPECT with technetium-99m hexamethylpropyleneamine oxime in 13 female AN-R patients, 13 female AN-BP patients, and 10 healthy women as controls with 3-D stereotactic surface projections.

RESULTS

The analytic program of the SPECT images showed bilateral decreased perfusion of the subcallosal gyrus (SCG), midbrain and posterior cingulate gyrus (PCG) in both AN-R and AN-BP patients, as compared with the controls. There were no clear differences between the AN-R and AN-BP groups. There were no significant differences in cerebral blood flow between patients with AN-R and AN-BP.

CONCLUSIONS

Abnormalities of the neuronal circuits containing the SCG, midbrain and PCG are possibly relevant to trait-related AN.

Clinical, psychological and personality features related to age of onset of anorexia nervosa

BACKGROUND

To investigate the relationship between age of onset and clinical and personality features of patients with anorexia nervosa (AN).

SAMPLING AND METHOD

We assessed 250 outpatients with AN with the Temperament and Character Inventory, the Eating Disorder Inventory 2, the Beck Depression Inventory and the Body Shape Questionnaire. The patients were subdivided into 3 groups: early (n=73), intermediate (n=96) and late onset (n=81), based on age of onset of symptoms.

RESULTS

The early-onset group shows higher body dissatisfaction, maturity fear, impulsivity and asceticism than the other 2 groups. This group shows a greater character fragility, as described in particular by a lower self-directedness, than the other 2 groups.

CONCLUSIONS

Even several years after the onset of the disorder, early-onset subjects affected by AN seem characterized by a more disturbed personality, with a higher body dissatisfaction than late-onset subjects affected by AN and a pursuit of thinness based on an ascetic drive.

The Circadian Variation of Cortisol Secretion in Patients with Anorexia Nervosa in Childhood and Adolescence after Recovery of Body Weight by Treatment Using Gas Chromatography/Mass Spectrometry in Selected Ion Monitoring

Anorexia nervosa (AN) is a chronic psychiatric disorder which is characterized by patient-induced weight loss. Complications in many organ systems can be seen in AN such as cardiovascular, gastrointestinal, and endocrine system including hypothalamic-pituitary-adrenal axis, even after recovery of body weight by treatment. Urinary steroid profile analysis using gas chromatography/mass spectrometry (GC/MS) in selected ion monitoring (SIM) has been reported to be useful for the diagnosis of abnormal steroidogenesis in newborn infants, childhood, and adults. The aim of this study was to analyze the circadian variation of cortisol secretion in patients with anorexia nervosa (AN) in childhood and adolescence after recovery of body weight by treatment using GC/MS in SIM. The subjects were 7 healthy young adults (20–23 yr of age, BMI 19.7–24.8 kg/m²) and 5 AN patients in childhood and adolescence (13–19 yr of age), who had recovered body weight by treatment (BMI 15.4–19.3 kg/m²; 3^rd–25^th to 50^th percentile). Urine samples were collected for 26 hours (from 21:00 to 23:00 next day) at each urination. In each sample, the cortisol metabolites were measured by GC/MS in SIM. The sum of all cortisol metabolites was calculated as mg/g creatinine. In all 5 AN patients in childhood and adolescence, the circadian variation of the sum of cortisol metabolites was observed and was similar to that in healthy young adults. Although our data are preliminary, in patients with AN in childhood and adolescence, who have recovered body weight by treatment, the circadian variation of cortisol secretion may be conserved.

How do children with eating disorders differ from adolescents with eating disorders at initial evaluation?

PURPOSE

To compare the clinical presentation of children with eating disorders (ED) to that of adolescents with ED.

METHODS

Demographic, medical, and psychiatric data of all 959 in- and outpatients (85 males, 874 females) 8-19 years of age diagnosed with ED that presented to an academic center between 1997 and 2005 were examined via retrospective record review. Young patients (n = 109) were defined as aged < 13 years at presentation, and older patients (n = 850) > or = 13 years and < 20 years.

RESULTS

Compared with older adolescents (mean 15.6 years, SD 1.4), younger patients (mean 11.6 years, SD 1.2) were more likely to be male (chi2 = 9.25, p < .005) or diagnosed with eating disorder not otherwise specified (EDNOS) (chi2 = 5.09, p < or = .05), and less likely to be diagnosed with bulimia nervosa (BN) (chi2 = 13.45, p < or = .001). There were no significant differences in anorexia nervosa (AN) diagnoses between groups. Young patients were less likely to report purging (chi2 = 26.21, p < .001), binge eating (chi2 = 26.53, p < .001), diet pill (chi2 = 13.31, p < .001) or laxative use (chi2 = 6.82, p < .001) when compared with older teens. Young patients weighed less in percentage ideal body weight (p < .05), had a shorter duration of disease (p < .001), and had lost weight more rapidly than older adolescent patients (p < or = .001).

CONCLUSIONS

There are important diagnostic and gender differences in younger patients. Young ED patients presented at a lower percentage of ideal body weight and had lost weight more rapidly, which may put them at higher risk for future growth sequelae than their older counterparts.

Is family therapy useful for treating children with anorexia nervosa? Results of a case series

OBJECTIVE

Research suggests that family-based treatment (FBT) is an effective treatment for adolescents with anorexia nervosa (AN). This retrospective case series was designed to examine its usefulness with younger children.

METHOD

Data were abstracted from medical records of 32 children with a mean age of 11.9 years (range 9.0-12.9) meeting diagnostic criteria for AN (n=29) and eating disorder not otherwise specified-restricting type (n=3) who were treated at two sites with FBT. Baseline characteristics, before and after weights, and Eating Disorder Examination (EDE) scores were compared with an adolescent cohort (N=78) with a mean age of 15.5 years (range 13.1-18.4) who were treated with FBT.

RESULTS

Children with AN share most disordered eating behaviors with their adolescent counterparts; however, their EDE scores are significantly lower than adolescents at both pre- and posttreatment assessments. Over the course of treatment with FBT, children showed statistically and clinically significant weight gain and improvements in eating disordered thinking as measured by the EDE.

CONCLUSION

FBT appears to be an acceptable and effective treatment for AN in children.

Reading the signs of starvation

Guidelines for managing malnutrition in adolescent eating disorders are based on limited evidence. Swenne and Engström's study explored the relationship between symptoms, signs and weight status in this patient group, towards refining clinical approaches to nutritional assessment in adolescents.

CONCLUSION

The need to compare findings across studies is crucial for research in nutritional assessment of adolescents

Binge eating in children and adolescents

OBJECTIVE

To establish what is known about binge eating in children and adolescents and to identify unresolved questions.

METHOD

We reviewed relevant studies to highlight and synthesize salient research findings.

DISCUSSION

Available research has suggested that loss of control over eating may be more important than consumption of an objectively large amount of food in the assessment of binge eating in children. In addition, dieting may not be associated consistently with binge eating in children. Behavioral correlates of binges may include eating in the absence of hunger, eating in response to strong emotions or external cues, and eating in secret. On the basis of available research, provisional research criteria for binge eating disorder (BED) in children are suggested to stimulate further study of pediatric samples. We emphasize the need for prospective studies on the relationships among aberrant eating, weight and mood, and the inclusion of boys and girls of different ethnicities.

Gastric electric activity assessed by electrogastrography and gastric emptying scintigraphy in adolescents with eating disorders

BACKGROUND

Patients with eating disorders can refer to a variety of gastrointestinal symptoms, sometimes to justify reduced food intake and vomiting. The authors investigated whether adolescent patients with eating disorders and dyspeptic symptoms have altered gastric electric activity and abnormal gastric emptying as assessed respectively by electrogastrography and scintigraphy.

METHODS

Twenty-eight patients (18 with anorexia and 10 with bulimia) and 16 healthy volunteers underwent electrogastrography; 20 of the 28 patients (14 with anorexia and 6 with bulimia) underwent gastric emptying scintigraphy. Electrogastrography with bipolar recording lasted 1 hour, 30 minutes before and after a standard meal. Before gastric emptying scintigraphy, patients fasted overnight; during testing, they ingested a solid meal labeled with technetium-99m sulfur colloid. The ratio of fasting to postprandial electrogastrographic variables was evaluated using the Wilcoxon matched-pair test. The Mann- Whitney test was used to compare absolute values for electrogastrographic data in each group. The Student paired t test was used to compare scintigraphic results expressed as percentage of gastric emptying at 60 minutes and as the gastric emptying time (T(1/2)).

RESULTS

Patients with bulimia significantly differed from those with anorexia and control subjects regarding the amount of normal gastric electric activity and bradygastria, and from patients with anorexia only regarding tachygastria. These electrogastrographic variables did not differ significantly between patients with anorexia and control subjects. Gastric emptying time (T(1/2)) was significantly longer in patients with bulimia than in those with anorexia.

CONCLUSIONS

Adolescent patients with bulimia who complain of dyspeptic symptoms have documentable abnormalities of gastric electric activity and emptying, whereas their counterparts with anorexia, probably owing to their shorter disease duration, do not.

Eating disorders in school-aged children

It is widely accepted that eating disorders do occur in children. There is a growing literature on childhood-onset AN, and it seems that the core behavioral, psychologic, and physical features are similar to those in adults. The differences between children and adults also must be taken into account, however. Because children have lower levels of body fat, they tend to become emaciated and suffer the effects of starvation for more quickly than adults, which must be taken into account when considering treatment. Although cases of childhood-onset BN have been reported, they are so rare that empirical research is difficult. Clinical features reported regarding the atypical childhood-onset eating disorders generally concur, although empirical testing of these features has yet to be developed. Theories as to why children develop these disorders need further development. The general consensus is that all childhood-onset eating disorders must be considered using a multidimensional model that takes into account physical, psychologic, social, and family factors in origin, assessment, and treatment.

Bulimic symptoms in the Virginia Twin Study of Adolescent Behavioral Development: correlates, comorbidity, and genetics

BACKGROUND

This paper addresses bulimia symptoms in a large community sample of twins aged 8 to 17 years. We aim to identify environmental correlates of bulimia symptoms and relationships with other psychiatric disorder symptoms. The twin design allows examination of the structure of genetic and environmental effects.

METHODS

DSM-IIIR bulimia symptoms and consequential impairment were measured by interview in the first wave of the Virginia Twin Study of Adolescent Behavioral Development. Comorbidity with other psychiatric symptoms and environmental correlates were examined and the relative contributions of genes and environment were assessed using structural equation modeling.

RESULTS

An item-response theory model indicated that the range of bulimic symptoms represented a single underlying trait. Bulimia symptoms were more common in postmenarche girls and positively associated with body-mass index. Subdiagnostic symptomatology was associated with impairment in psychosocial functioning. Bulimia symptoms were strongly associated with other psychiatric disorders symptoms including anxiety and depression. Genetic model fitting identified strong additive genetic effects on the symptom score. Accounting for a potential violation of the equal environment assumption for identical and fraternal twins slightly reduced estimated genetic variance.

CONCLUSIONS

The pattern of comorbidity suggests overlap between bulimia symptoms and those of internalizing disorders. Substantial genetic variance (44%) was evident in the most conservative model.

Differences of symptoms and standardized weight index between patients with early-onset and late-onset anorexia nervosa

OBJECTIVE

There have so far been no studies that directly compared clinical features between patients with early- and late-onset anorexia nervosa (AN).

METHOD

We identified 64 patients with DSM-III-R AN. We defined individuals as an early-onset group, who had an age of onset before 14 years (N = 31), and the remaining as a late-onset group (N = 33). The clinical symptoms, body weight and weight index, were compared between the two groups. Subjects were dichotomized into those with extremely low weight and those remaining. We compared the proportion of the patients with extremely low weight between the two groups.

RESULTS

The rates of 'self-induced vomiting' and 'purging' were significantly lower in a group of patients with early-onset AN than in those with late-onset AN. There were significantly fewer subjects with extremely low weight in early-onset than in late-onset AN group.

CONCLUSION

We found clear differences in clinical features between early- and late-onset AN groups.

Anorexia nervosa in Chinese adolescents-does culture make a difference?

The clinical and psychosocial characteristics of 16 Chinese adolescents from Hong Kong with anorexia nervosa are reported. In contrast to previous local reports of adult patients, over 80 per cent of these younger patients reported a fear of fatness. It appears that, against the background of increasing Westernization, the illness is taking on a Western pattern, in line with the suggestion that significant concern about weight in anorexia nervosa is a pathoplastic effect of Westernization. There was also a marked increase in the referral rate of patients in the younger age group, reflecting both an increase in the incidence and general awareness of the illness.

Analyzing the relation between self-esteem and eating disorders: differential effects of self-liking and self-competence

Research in the past has demonstrated an association between low self-esteem and eating disorders. Recent research on self-esteem has shown, however, that self-esteem is composed of two distinct factors--self-liking and self-competence. The present study examined the relation between these two self-esteem factors and both eating disorders and eating disturbed cognitions. A total of 51 female participants from a high-risk population were clinically interviewed to identify the eating disorder and administered a series of questionnaires that included a measure of self-liking and self-competence. A strong relationship was found between self-liking and eating disorders, but no relationship was found between self-competence and eating disorders.

The Incidence of Perfectionism in Honors and Regular College Students

Using the Multidimensional Perfectionism Scale (Frost, Martin, Lahart, & Rosenblate, 1990) measures of perfectionism in a group of 90 Honors College students and 95 more typical peers were compared. Honors College students received significantly higher scores with a moderate effect size on the subscales of Concern Over Mistakes, Personal Standards, Parental Expectations, and the total score of overall perfectionism. This result is in contrast to recent findings of no difference in perfectionism scores between gifted and typical younger students. It is unclear if the finding of elevated perfectionism among Honors College students is indicative of predisposition to maladjustment or is a healthy component of the pursuit of academic excellence among the highly able.

Characteristics of school children who are choosy eaters

Choosiness, manifested in refusal of foods, eating little, and disinterest in food, was studied with regard to prevalence, stability, sociodemographic characteristics, health problems, weight, and associated problem behaviors in a sample of 240 Swedish primary school children. Questionnaires were used, and data on sociodemographic variables, health problems, weight, and height were collected from child health-care and school health records. Choosiness was present in one third of the children, but only 8% showed choosy behavior both at home and in school. The choosy children had no more health problems than others, nor were they significantly thinner. Choosiness was not related to gender, social class, or ethnic background. The choosy children had modestly elevated levels of externalizing, hyperactive, and internalizing behavior. The choosy children with a history of refusal to eat in infancy or preschool age had more pronounced choosy behavior and had more problem behaviors than the other choosy children. Choosiness can not easily be categorized within an eating disorders or main problem syndromes of childhood frame of reference.

Case study: early-onset anorexia nervosa in a Chinese boy

In this case study of early-onset anorexia nervosa in a male patient from Hong Kong, clinical features are outlined and compared with those of their Western counterparts. Implications of being the only son in a traditional Chinese family and the process of acculturation and cultural conflicts of growing up in a Western-oriented society are put forward as significant psychodynamic factors in the etiology of his illness.