Children in Need-Diagnostics, Epidemiology, Treatment and Outcome of Early Onset Anorexia Nervosa

Early-onset restrictive food intake disorders in children: a latent class analysis

The two most frequent early-onset restrictive food intake disorders are early-onset anorexia nervosa (EOAN) and avoidant/restrictive food intake disorders (ARFID). Although the core symptoms of EOAN (i.e., fear of gaining weight and disturbed body image) are not present in ARFID, these symptoms are difficult to assess during the initial phase of hospitalisation. Our aim was  to identify restrictive food intake disorder subtypes in children using latent class analysis (LCA) based on the information available at admission to hospital, and to determine the agreement between the subtypes identified using LCA and the final diagnosis: EOAN or ARFID. We retrospectively included 97 children under 13 years old with severe eating disorders (DSM-5) at their first hospitalisation in a specialised French paediatric unit. LCA was based on clinical information, growth chart analyses and socio-demographic parameters available at admission. We then compared the probabilities of latent class membership with the diagnosis (EOAN or ARFID) made at the end of the hospitalisation. The most parsimonious LCA model was a 2-class solution. Children diagnosed with EOAN at the end of hospitalisation had a 100% probability of belonging to class 1 while children diagnosed with ARFID had an 8% probability of belonging to class 1 based on parameters available at admission. Our results indicate that clinical and socio-demographic characteristics other than the core symptoms of EOAN may be discriminating for a differential diagnosis.

Body Mass Index Distribution in Female Child, Adolescent and Adult Inpatients with Anorexia Nervosa-A Retrospective Chart Review

BACKGROUND

The variation in body mass index (BMI) of inpatients with anorexia nervosa has not been analyzed across the age span. A positive correlation between BMI and age has been reported in adolescent inpatients aged 15 years and younger that levels off at 15 to 18 years. BMIs standardized for age and sex (standard deviation scores, SDSs) were negatively correlated with age in these inpatients aged 8 to 18 years.

METHODS

The aims of the current retrospective study were threefold: first, to confirm the relationships of BMI, BMI-SDS and age in adolescent inpatients in a larger sample; second, to systematically assess the relationship of BMI, BMI-SDS, body height-SDS and age in adult inpatients at the time of referral; and third, to assess body height-SDSs and age to evaluate stunting.

RESULTS

We included 1001 girls (aged 12-17.9 years) and 1371 women (aged 18-73 years) admitted to inpatient treatment between 2014 and 2021. Mean BMI at admission was 14.95 kg/m2 (SD = 1.43; range 10.67-18.47) in adolescents and 14.63 kg/m2 (SD = 2.02; range 8.28-18.47) in adults. None of the adolescent patients but 20 adults had very low BMI values below 10 kg/m2. Adolescents showed a small but significant positive correlation between age and BMI (r = 0.12; p = 2.4 × 10-4). In adults, BMI was not correlated with age (r = -0.03; p = 0.3). BMI-SDSs was negatively correlated with age in adolescents and less so in adults (r = -0.35; p < 0.001 and r = -0.09; p = 0.001). Curve fit analyses for all patients indicated that there was a quadratic (age × age) relationship between age and BMI-SDS. Height correlated positively with BMI in adult (r = 0.1; p < 0.001) and adolescent (r = 0.09 p = 0.005) patients and we detected no evidence for stunting.

CONCLUSIONS

In conclusion, the BMI of inpatients seems to be relatively stable across the age span with mean values between 14 and 15 kg/m2. BMI values initially increase with age in younger patients, drop between ages 18 and 23 and then slowly decline with age.

Analysis of feeding and eating disorders in 191 children according to psychiatric or gastroenterological recruitment: The PEDIAFED cohort study

OBJECTIVE

The DSM-5 classification introduced new Feeding and Eating Disorders (FED) diagnostic categories, notably Avoidant and Restrictive Food Intake Disorder (ARFID), which, like other FED, can present psychiatric and gastrointestinal symptoms. However, paediatric clinical research that focuses on children below the age of 12 years remains scarce. The aim of this study was first to investigate the clinical features of FED in a cohort of children, second to compare them according to their recruitment (gastroenterology or psychiatry unit).

METHOD

This non-interventional retrospective cohort study analysed 191 patients in a French paediatric tertiary care centre (gastroenterology n = 100, psychiatry n = 91). The main outcome variables were clinical data (type of FED, BMI, nutritional support, chronic diseases, psychiatric comorbidities, sensory, sleep, language disorders, gastrointestinal complaints, adverse life events, family history). The outcome was defined by a Clinical Global Impression of Change-score.

RESULTS

FED diagnoses were ARFID (n = 100), Unspecified FED (UFED, n = 57), anorexia nervosa (AN, n = 33) and one pica/rumination. Mean follow-up was 3.28 years (SD 1.91). ARFID was associated with selective and sensory disorders (p < 0.001); they had more anxiety disorders than patients with UFED (p < 0.001). Patients with UFED had more chewing difficulties, language disorder (p < 0.001), and more FED related to chronic disease (p < 0.05) than patients with ARFID and AN. Patients with AN were female, underweight, referred exclusively to the psychiatrist, and had more depression than patients with ARFID and UFED (p < 0.001). The gastroenterology cohort included more UFED, while the psychiatry cohort included more psychiatric comorbidities (p < 0.001). A worse clinical outcome was associated with ARFID, a younger age at onset (p < 0.001), selective/sensory disorders and nutritional support (p < 0.05).

CONCLUSION

ARFID and UFED children were diagnosed either by gastroenterologists or psychiatrists. Due to frequently associated somatic and psychiatric comorbidities, children with FED should benefit from a multidisciplinary assessment and care.

Pediatric early-phase anorexia nervosa without hypokalemia exhibiting acute tubular injury: a case report

Anorexia nervosa can lead to kidney complications. Few studies reported kidney biopsy results in young adults, most of whom had chronic anorexia nervosa, and kidney biopsy findings in pediatric patients with early-phase anorexia nervosa are rarely reported. A 14-year-old girl who lost weight due to excessive exercise and reduced diet was admitted for kidney dysfunction. She was 147 cm tall and weighed 32.9 kg, with a body mass index of 15.2 kg/m2. She was 39 kg about a year earlier. Her heart rate and blood pressure were 30-40 beats/min and 108/68 mmHg, respectively. She had kidney dysfunction (estimated glomerular filtration rate, 56.6 mL/min/1.73 m2). Urine β2-microglobulin was slightly elevated (393 μg/L), and percent tubular phosphate reabsorption was low (75.2%), suggesting tubular damage; however, hypokalemia was absent. Kidney dysfunction did not improve with fluid loading. Kidney biopsy revealed that all glomeruli were intact, with no vasculitis, interstitial inflammation or fibrosis on light microscopy. However, proximal tubular epithelial walls were flattened and the brush border was absent, suggesting acute tubular injury. Immunofluorescent staining was negative for immunoglobulins and complement proteins, and electron microscopy showed no significant electron-dense deposition. The patient's serum creatinine gradually declined, normalizing on the 17th day of admission. Unlike previous reports in young adults, kidney dysfunction was observed even in the absence of hypokalemia in the current pediatric patient with early-phase anorexia nervosa. Proximal tubular injury in early-phase anorexia nervosa may be caused by bradycardia without hypokalemia, leading to subsequent kidney dysfunction.

The Diagnosis and Treatment of Anorexia Nervosa in Childhood and Adolescence

BACKGROUND

Anorexia nervosa (AN) is a serious disease with a lifetime prevalence of up to 3.6% in women and 0.3% in men. Abnormally low weight and the associated starvation partly account for its somatic and mental manifestations.

METHODS

This review is based on publications retrieved by a selective search concerning AN in childhood and adolescence.

RESULTS

The peak age of onset of AN is 15.5 years. The frequency of inpatient treatment for AN rose by 40% during the COVID pandemic, indicating the importance of environmental factors; the heritability of AN is estimated at 0.5. The ICD-11 sets the threshold for AN-associated underweight at the fifth percentile for age of the body mass index, as long as the remaining diagnostic criteria are met. The main goal of the multiprofessional treatment of AN is the return to normal body weight, which is a central prerequisite for regaining somatic and mental health. The mean duration of AN is 3.4 years, and approximately twothirds of patients recover from the disease over the long term.

CONCLUSION

Marked weight loss in childhood and adolescence can trigger AN in the presence of a predisposition to this disease. Patients and their families should receive psychoeducation regarding the symptoms of starvation and their overlap with those of AN. Important objectives are to shorten the duration of the illness, minimize mortality and the risk of chronic illness, and to identify pharmacological approaches to treatment.

Processing of food stimuli in anorexia nervosa: An ERP-study comparing adolescents and adults

BACKGROUND

Anorexia nervosa (AN) is associated with altered processing of disorder-relevant stimuli. Event-related potentials (ERP) - such as the Late Positive Potential (LPP) - give information about the underlying mechanisms of central nervous stimulus processing.

METHODS

Patients with AN (22 adolescents, 23 adults) and healthy controls (HCs; 17 adolescents, 24 adults) were included. Neutral, low, and high calorie food-images were rated for valence and arousal; EEG activity was recorded and LPPs (early: 350-700 ms; late: 800-1200 ms) were extracted. Effects of patient status, age group, and stimulus category were analyzed via mixed 2 × 2 × 3-AN(C)OVAs.

RESULTS

Patients with AN rated high calorie stimuli lower in valence and higher in arousal than HCs. Controlling for hunger, food stimuli elicited higher early LPPs than neutral ones in patients and HCs. For the late LPP, patients with AN showed larger amplitudes.

CONCLUSION

Results suggest a highly automatic attentional bias towards low-calorie foods. Patients with AN seem to have more intense cognitive processing independent of stimulus material. More research is needed to validate and clarify differences between early and late LPP measures as well as the operationalization and relevance of hunger status.

Eating disorder hospitalizations among children and youth in Canada from 2010 to 2022: a population-based surveillance study using administrative data

BACKGROUND

Eating disorders (EDs) are severe mental illnesses associated with significant morbidity and mortality. EDs are more prevalent among females and adolescents. Limited research has investigated Canadian trends of ED hospitalizations prior to the COVID-19 pandemic, however during the pandemic, rates of ED hospitalizations have increased. This study examined rates of ED hospitalizations among children and youth in Canada from 2010 to 2022, by sex, age, province/territory, length of stay, discharge disposition and ED diagnosis.

METHODS

Cases of ED hospitalizations among children and youth, ages 5 to 17 years, were identified using available ICD-10 codes in the Discharge Abstract Database from the 2010/11 to 2022/23 fiscal years. The EDs examined in this study were anorexia nervosa (F50.0), atypical anorexia nervosa (F50.1), bulimia nervosa (F50.2), other EDs (F50.3, F50.8) and unspecified EDs (F50.9). Both cases of total and first-time ED hospitalizations were examined. Descriptive statistics and trend analyses were performed.

RESULTS

Between 2010/11 and 2022/23, 18,740 children and youth were hospitalized for an ED, 65.9% of which were first-time hospitalizations. The most frequent diagnosis was anorexia nervosa (51.3%). Females had significantly higher rates of ED hospitalization compared to males (66.7/100,000 vs. 5.9/100,000). Youth had significantly higher rates compared to children. The average age of ED hospitalization was 14.7 years. Rates of ED hospitalizations were relatively stable pre-pandemic, however during the pandemic (2020-2021), rates increased.

INTERPRETATION

Rates of pediatric ED hospitalizations in Canada increased significantly during the pandemic, suggesting that there may have been limited access to alternative care for EDs or that ED cases became more severe and required hospitalization. This emphasizes the need for continued surveillance to monitor how rates of ED hospitalizations evolve post-pandemic.

The Impact of Chronic Stress Related to COVID-19 on Eating Behaviors and the Risk of Obesity in Children and Adolescents

During the COVID-19 pandemic, an increase in the incidence of overweight and obesity in children was observed. It appears that unhealthy food choices, an unbalanced diet, and a sedentary lifestyle, as well as experiencing stress related to the pandemic, may be contributing to this disturbing trend. Chronic stress is a significant factor contributing to eating disorders and obesity in youngsters, involving medical, molecular, and psychological elements. Individuals under chronic stress often focus on appearance and weight, leading to negative body image and disrupted relationships with food, resulting in unhealthy eating behaviors. Chronic stress also impacts hormonal balance, reducing the satiety hormone leptin and elevating the appetite-stimulating hormone ghrelin, fostering increased hunger and uncontrolled snacking. Two systems, the hypothalamic-pituitary-adrenal axis and the sympathetic system with the adrenal medulla, are activated in response to stress, causing impaired secretion of noradrenaline and cortisol. Stress-related obesity mechanisms encompass oxidative stress, neuroinflammation, insulin resistance, and neurohormonal and neurotransmission disorders. Stress induces insulin resistance, elevating obesity risk by disrupting blood sugar regulation and fat storage. Stress also affects the gut microbiome, potentially influencing chronic inflammation and metabolic processes linked to obesity. In conclusion, chronic stress is a multifaceted risk factor for eating disorders and obesity in children, necessitating a comprehensive understanding of effective preventive and intervention strategies amid the escalating prevalence of childhood overweight and obesity.

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Day hospital program for anorexia nervosa in children and adolescents: Assessment, management and specific focus on early onset anorexia nervosa

INTRODUCTION

The French day hospital program specialized in eating disorders (ED) opened in January 2018. Our study presents preliminary data on clinical profiles of patients with anorexia nervosa (AN). We describe more specifically clinical characteristics of patients with early onset AN and according to their therapeutics orientations. Then, we compare the weight gain of patients managed only in day-patient (DP) treatment with those managed initially inpatient (IP) treatment and relays in DP.

METHODS

Ninety-two patients with AN, aged between 8 and 18 years, were evaluated with several questionnaires (EDI-2, EDE-Q, BSQ, EDS-R, CDI, STAI-Y, VSP-A, EPN-13).

RESULTS

Patients with early onset AN, n = 23 (25.3%), presented more restrictive behaviors, less marked dietary symptomatology, a lower degree of clinical perfectionism and a less marked feeling of ineffectiveness than adolescent patients with AN. Regarding the choice of hospitalization modality (DP alone or IP-DP), the only difference highlighted was the severity of patient undernutrition. Among the patients who were treated (IP-DP n = 27 vs DP alone n = 25), the weight evolution after one month and at discharge was favorable for both groups.

CONCLUSION

These preliminary data suggest the effectiveness of DP in the care of AN in children and adolescents.

Admission rates and clinical profiles of children and youth with eating disorders treated as inpatients before and during the COVID-19 pandemic in a German university hospital

Introduction

Children and youth at risk for mental health disorders, such as eating disorders (ED), were particularly affected by the COVID-19 pandemic, yet evidence for the most seriously affected and thus hospitalized youth in Germany is scarce.

Methods

This crosssectional study investigated anonymized routine hospital data (demographic information, diagnoses, treatment modalities) of patients admitted (n = 2,849) to the Department of Child and Adolescence Psychiatry, Psychosomatics and Psychotherapy (DCAPPP) of a German University Hospital between 01/2016 and 02/2022. Absolute and relative number of inpatients with or without ED prior to (01/2016-02/2020) and during the COVID-19 pandemic (03/2020-02/2022) were compared. The effect of school closures as part of social lockdown measures for COVID-19 mitigation on inpatient admission rate was explored as it has been discussed as a potential risk factor for mental health problems in youth.

Results

During the COVID-19 pandemic, ED inpatient admission rate increased from 10.5 to 16.7%, primarily driven by Anorexia Nervosa (AN). In contrast to previous reports, we found no change in somatic and mental disorder comorbidity, age or sexratio for hospitalized youth with ED. However, we did observe a shortened length of hospital stay (LOS) for hospitalized youth with and without ED. In addition, non-ED admissions presented with an increased number of mental disorder comorbidities. In contrast to our hypothesis, school closures were not related to the observed increase in ED.

Discussion

In summary, the COVID-19 pandemic was associated with an increased rate of inpatient treatment for youth suffering from AN, and of youth affected by multiple mental disorders. Accordingly, we assume that inpatient admission was prioritized for individuals with a higher burden of disease during the COVID-19 pandemic. Our findings pinpoint the need for adequate inpatient mental health treatment capacities during environmental crises, and a further strengthening of child and adolescence psychiatry services in Germany.

Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review

PURPOSE

To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN).

METHODS

This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS).

RESULTS

Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies.

CONCLUSION

All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.

Comparison between continued inpatient treatment versus day patient treatment after short inpatient care in early onset anorexia nervosa (COTIDEA trial): a study protocol for a non-inferiority randomised controlled trial

BACKGROUND

In children with early-onset anorexia nervosa (first symptoms before 13 years old, EO-AN), experts recommend initial outpatient treatment but in-patient treatment (IP) is frequently indicated due to acute medical instability or for those who have not improved with outpatient treatment. This IP can target either a partial weight restauration or a total weight normalization (return to the previous BMI growth trajectory). There are no evidence in the literature on which is the better therapeutic option in EOAN. But as long length of stay induce social isolation, with elevated costs, we wonder if a stepped-care model of daypatient treatment (DP) after short IP stabilisation may be a treatment option as effective as full-time IP to target weight normalization. We designed a two-arm randomised controlled trial testing the non-inferiority of a stepped-care model of DP after short IP stabilisation versus full-time IP.

METHODS

Eighty-eight children aged 8 to 13 years suffering from EOAN with initial severe undernutrition will be randomly allocated to either IP treatment as usual or a stepped care DP model both targeting weight normalization. Assessments will be conducted at inclusion, somatic stabilization, weight normalization, 6 months and 12 months post randomisation. The primary outcome will be BMI at 12 months post-randomisation. Secondaries outcomes will included clinical (tanner stage), biological (prealbumin, leptin, total ghrelin and IGF1) and radiological (bone mineralization and maturation) outcomes, eating symptomatology and psychiatric assessments, motivation to change, treatment acceptability and quality of life assessments, cost-utility and cost-effectiveness analyses.

DISCUSSION

COTIDEA will provide rigorous evaluation of treatment alternative to full-time inpatient treatment to allow a reduction of social iatrogenic link to hospital length of stay and associated costs.

TRIAL REGISTRATION

Trial is registered on ClinicalTrials.gov (NCT04479683).

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.

Thyroid dysfunction in children and adolescents affected by undernourished and overnourished eating disorders

Eating disorders (ED) are one of the most prevalent chronic disorders in adolescents and young adults, with a significantly increasing prevalence in younger children, particularly in girls. Even if obesity in essence is not framed as an eating disorder and has always been considered a separate pathology, ED and obesity could be considered part of a continuum. It has become evident that one condition can lead to another, such as binge eating disorder (BED) and bulimia nervosa, and that they share the same repercussions in terms of psychosocial, metabolic, and nutritional health. This narrative review aims to investigate the hypothalamic-pituitary-thyroid axis in undernourished and overnourished patients with ED, including obesity, in order to highlight the relationship between weight control and thyroid function and its effects and to consider therapeutic and preventive strategies in children and adolescents. Literature data report that thyroid alterations occur in patients with ED, both underweight and overweight, and represent a continuum of changes depending on the severity and time course of the disease involving the endocrine system. Considering the relevant role thyroid hormones (TH) play not only in energy expenditure (EE) but also in metabolic control and cardiovascular risks related to dysmetabolism and mood regulation, continuous monitoring of thyroid homeostasis in patients with ED is mandatory to prevent severe complications and to start early treatment when necessary.

Iatrogenic triggers for anorexia nervosa and bulimia nervosa: A WHO safety database disproportionality analysis

Eating disorders, characterized by abnormal eating, weight control behaviors or both include anorexia nervosa (AN) and bulimia nervosa (BN). We investigated their potential iatrogenic triggers, using real-world data from the WHO safety database (VigiBase®). VigiBase® was queried for all AN and BN reports. The reports were classified as `pediatric' or `adult' according to age. Disproportionality analyses relied on the Information Component (IC), in which a 95% confidence interval lower-end positivity was required to suspect a signal. Our queries yielded 309 AN and 499 BN reports. Isotretinoin was disproportionately reported in pediatric AN (IC 3.6; [2.6-4.3]), adult AN (IC 3.1; [1.7-4.0]), and pediatric BN (IC 3.9; [3.0-4.7]). Lamivudine (IC 4.2; [3.2-4.9]), nevirapine (IC 3.7; [2.6-4.6]), and zidovudine (IC 3.4; [2.0-4.3]) had the highest ICs in adult AN. AN was associated with isotretinoin, anticonvulsants in minors, and antiretroviral drugs in adults. In adults, BN was related to psychotropic and hormonally active drugs. Before treatment initiation, an anamnesis should seek out mental health conditions, allowing the identification of patients at risk of developing or relapsing into AN or BN. In addition to misuse, the hypothesis of iatrogenic triggers for AN and BN should also be considered.

The efficacy of non-invasive brain stimulation in the treatment of children and adolescents with Anorexia Nervosa: study protocol of a randomized, double blind, placebo-controlled trial

BACKGROUND

Current psychological and pharmacological treatments for Anorexia Nervosa (AN) provide only moderate effective support, and there is an urgent need for research to improve therapies, especially in developing age. Non-invasive brain stimulation has suggested to have the potential to reducing AN symptomatology, via targeting brain alterations, such as hyperactivity of right prefrontal cortex (PFC). We suppose that transcranial direct current stimulation (tDCS) to the PFC may be effective in children and adolescents with AN.

METHODS

We will conduct a randomized, double blind, add-on, placebo-controlled trial to investigate the efficacy of tDCS treatment on clinical improvement. We will also investigate brain mechanisms and biomarkers changes acting in AN after tDCS treatment. Eighty children or adolescent with AN (age range 10-18 years) will undergo treatment-as-usual including psychiatric, nutritional and psychological support, plus tDCS treatment (active or sham) to PFC (F3 anode/F4 cathode), for six weeks, delivered three times a week. Psychological, neurophysiological and physiological measures will be collected at baseline and at the end of treatment. Participants will be followed-up one, three, six months and one year after the end of treatment. Psychological measures will include parent- and self-report questionnaires on AN symptomatology and other psychopathological symptoms. Neurophysiological measures will include transcranial magnetic stimulation (TMS) with electroencephalography and paired pulse TMS and repetitive TMS to investigate changes in PFC connectivity, reactivity and plasticity after treatment. Physiological measures will include changes in the functioning of the endogenous stress response system, body mass index (BMI) and nutritional state.

DISCUSSION

We expect that tDCS treatment to improve clinical outcome by reducing the symptoms of AN assessed as changes in Eating Disorder Risk composite score of the Eating Disorder Inventory-3. We also expect that at baseline there will be differences between the right and left hemisphere in some electrophysiological measures and that such differences will be reduced after tDCS treatment. Finally, we expect a reduction of endogenous stress response and an improvement in BMI and nutritional status after tDCS treatment. This project would provide scientific foundation for new treatment perspectives in AN in developmental age, as well as insight into brain mechanisms acting in AN and its recovery. Trial registration The study was registered at ClinicalTrials.gov (ID: NCT05674266) and ethical approval for the study was granted by the local research ethics committee (process number 763_OPBG_2014).

Examining the feasibility of a brief parent intervention designed to promote positive food communication with infants

BACKGROUND

Few prevention interventions exist focusing on supporting parents to use positive food communication at mealtimes, for the prevention of disordered eating. "Mealtime chatter matters (MCM)" is a brief intervention designed for parents of infants. The intervention was designed in collaboration with child health nurses (CHNs) to be embedded into usual care. The overall aim of this study was to test the feasibility of the intervention through examining the acceptability of the MCM content and resources and the potential impact of the intervention on parents.

METHODS

This pilot study utilised a mixed methods approach and took place within a regional child health service in Queensland, Australia (October 2021 to June 2022). Participants were parents of infants attending child health education groups and CHNs. The intervention consisted of a brief education session (including accompanying resources), facilitated by a Paediatric Dietitian. The acceptability of MCM content and resources was assessed by both parents and CHNs via self-reported questionnaires and the potential impact on parents assessed via pre-/post-self-reported questionnaires.

RESULTS

Forty-six parents of infants (aged < 8 months) and six CHNs who hosted the intervention and observed the program's delivery participated in the study. MCM content and resources were highly acceptable to parents and CHNs, as both qualitative and quantitative data concurred. How the program may have potentially impacted parenting practices was unclear from the survey results and further investigation is required to better understand these. Tangible lessons and opportunities to further test this intervention were clear from current results.

CONCLUSION

Overall, MCM was acceptable to both parents and CHNs, with the content and resources both being highly valued. Parents reported the content to be informative and engaging and CHNs were keen to have such an intervention available in the future. However, further modification and testing is required of MCM. This feasibility study is an essential first step in supporting parents and CHNs to access an evidence-based intervention with the aim of preventing disordered eating.

TRIAL REGISTRATION

Griffith University Human Research Ethics Committee (2021/577) and Gold Coast Hospital and Health Service Human Research Ethics Committee (QGC/76618).

Premenarchal anorexia nervosa: clinical features, psychopharmacological interventions, and rehospitalization analysis in a 1-year follow-up, controlled study

Premenarchal anorexia nervosa (AN) represents a specific subtype of AN, defined by an onset before the menarche in females, involving unique endocrine and prognostic features. The scarce data on this condition lack case-control and follow-up studies. This is a case-control, observational, naturalistic study, involving participants with premenarchal AN (premenarchal girls presenting to the study center newly diagnosed with AN) treated with a multidisciplinary hospital intervention, compared to postmenarchal AN individuals on clinical, endocrine, psychopathological, and treatment variables. The rate of rehospitalizations on a 1-year follow-up after discharge and respective prognostic factors were assessed with a Kaplan-Meier analysis and Cox regression model. The sample included 234 AN participants (43, 18.4% with premenarchal and 191, 81.6% with postmenarchal AN). When compared to postmenarchal, premenarchal AN individuals presented with lower depressive scores (Self-Administered Psychiatric Scales for Children and Adolescents (SAFA)) (U = 1387.0, p = 0.010) and lower luteinizing hormone (LH) levels (U = 3056.0, p = 0.009) and were less frequently treated with antidepressants (X² = 5.927, p = 0.015). A significant predictive model of the risk of rehospitalization (X² = 19.192, p = 0.004) identified a higher age at admission (B = 0.522, p = 0.020) and a day-hospital (vs inpatient) treatment (B = 3957, p = 0.007) as predictive factors for rehospitalization at 1-year, independent from the menarchal status.   Conclusion: This study reports the clinical and treatment characteristics of premenarchal AN in one of the largest samples available in the current literature. Specific clinical features and prognostic factors for rehospitalization at 1-year follow-up were identified. Future studies should longitudinally investigate treatment-dependent modifications in endocrine and psychopathological measures in this population. What is Known: • Premenarchal Anorexia Nervosa (AN) is a subtype of AN characterized by its onset before menarche in females and is associated with unique endocrine and prognostic features. What is New: • Individuals with premenarchal AN may display specific clinical profiles, with lower depressive symptoms and luteinizing hormone levels than postmenarchal controls.

Evaluation of visual food stimuli paradigms on healthy adolescents for future use in fMRI studies in anorexia nervosa

BACKGROUND

Mostly, visual food stimuli paradigms for functional Magnetic Resonance Imaging are used in studies of eating disorders. However, the optimal contrasts and presentation modes are still under discussion. Therefore, we aimed to create and analyse a visual stimulation paradigm with defined contrast.

METHODS

In this prospective study, a block-design fMRI paradigm with conditions of randomly altering blocks of high- and low-calorie food images and images of fixation cross was established. Food pictures were rated in advance by a group of patients diagnosed with anorexia nervosa to address the dedicated perception of patients with eating disorders. To optimize the scanning procedure and fMRI contrasts we have analysed neural activity differences between high-calorie stimuli versus baseline (H vs. X), low-calorie stimuli versus baseline (L vs. X) and high- versus low-calorie stimuli (H vs. L).

RESULTS

By employing the developed paradigm, we were able to obtain results comparable to other studies and analysed them with different contrasts. Implementation of the contrast H versus X led to increased blood-oxygen-level-dependent signal (BOLD) mainly in unspecific areas, such as the visual cortex, the Broca´s area, bilaterally in the premotor cortex and the supplementary motor area, but also in thalami, insulae, the right dorsolateral prefrontal cortex, the left amygdala, the left putamen (p < .05). When applying the contrast L versus X, an enhancement of the BOLD signal was detected similarly within the visual area, the right temporal pole, the right precentral gyrus, Broca´s area, left insula, left hippocampus, the left parahippocampal gyrus, bilaterally premotor cortex and thalami (p < .05). Comparison of brain reactions regarding visual stimuli (high- versus low-calorie food), assumed to be more relevant in eating disorders, resulted in bilateral enhancement of the BOLD signal in primary, secondary and associative visual cortex (including fusiform gyri), as well as angular gyri (p < .05).

CONCLUSIONS

A carefully designed paradigm, based on the subject's characteristics, can increase the reliability of the fMRI study, and may reveal specific brain activations elicited by this custom-built stimuli. However, a putative disadvantage of implementing the contrast of high- versus low-calorie stimuli might be the omission of some interesting outcomes due to lower statistical power. Trial registration NCT02980120.

"What Made My Eating Disorder Worse?" The Impact of the COVID-19 Pandemic from the Perspective of Adolescents with Anorexia Nervosa

(1) Background: the COVID-19 pandemic and subsequent confinements have led to a dramatic increase in anorexia nervosa (AN) in adolescent patients, whereas the effect on symptom severity and the influencing factors are not yet clear, especially not from the adolescents' perspective. (2) Methods: from February to October 2021, 38 adolescent patients with AN completed an adjusted version of the COVID Isolation Eating Scale (CIES), a self-report questionnaire asking for ED symptomatology before and during the COVID-19 pandemic and for their experiences with remote treatment. (3) Results: patients reported a significant negative impact of confinement on ED symptoms, depression, anxiety, and emotional regulation. During the pandemic, engagement with weight and body image was related to social media, and mirror checking increased. The patients were more preoccupied with cooking recipes and had more eating-related conflicts with their parents. However, the differences in the amount of engagement with social media actively glorifying AN before and during the pandemic did not remain significant after correction for multiple comparisons. The minority of patients who received remote treatment found it to be only limitedly helpful. (4) Conclusions: from the patients' perspective, the COVID-19 pandemic-associated confinement had a detrimental effect on the symptoms of adolescent patients with AN.

'It stopped you thinking about food' - The experiences of mealtimes and attending a post-meal support group for young people with anorexia nervosa

Anorexia nervosa presents as an international public health concern as it is the mental health problem with the greatest risk of mortality, and the average age of onset is decreasing. For those experiencing anorexia nervosa, mealtimes have long been recognized as a difficult and distressing time when young people need additional support. However, the post mealtime period can be associated with even greater distress, yet there is little research on interventions to support young people in this vulnerable time, and even less on how young people experience these interventions. This study, therefore, explores young peoples' perceptions of mealtimes and a post mealtime support group. Using a qualitative descriptive design, telephone interviews were conducted with a purposive sample of six young people who participated in a post-meal support group while an inpatient in a Child and Adolescent Mental Health Unit. Using a semi-structured interview guide, participants were asked about their experiences of this support group and their perceptions of how to improve this intervention. Content analysis resulted in the development of three themes: 'The Challenges of Mealtimes and Post Mealtimes', 'The Benefits of Post-meal Support Groups', and 'Improving Unhelpful Aspects of Post-meal Support Groups'. Findings are reported in accordance with COREQ guidelines and suggest that for young people experiencing anorexia nervosa, post mealtimes are often more distressing than the meal itself and that participants found post-meal support groups to be a helpful intervention in reducing post-mealtime distress. Post-meal support groups can be improved by ensuring a consistent approach from staff and providing staff with the training and knowledge required to support those affected by eating disorders.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Early-onset eating disorders in Australian children: A national surveillance study showing increased incidence

OBJECTIVE

The aim of this study was to collect prospective national data on early-onset eating disorders (EOEDs) in children in Australia to document changes in clinical presentations, medical complications, management, and incidence since initially described in 2002-2005.

METHOD

Each month pediatricians reported children aged 5-13 years newly diagnosed with an eating disorder to the Australian Paediatric Surveillance Unit and provided de-identified clinical data.

RESULTS

Between 2016 and 2018, 184 children were confirmed with EOED with a minimum estimated national incidence of 2.79 per 100,000 children aged 5-13 years (95% confidence interval [CI] 2.40-3.23), nearly double the previously recorded incidence. The mean age at diagnosis was 12.2 years; 43(24%) were boys who were younger than girls (11.85 vs. 12.33 years; p = .03). All had food avoidance. Common symptoms included fear of weight gain 140 (76%), preoccupation with body weight 134 (73%), and misperception of body size 116 (63%). Bradycardia was present in 83 (45%) and 117 (64%) who required hospital admission. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5) criteria for anorexia nervosa were met for 144 (78%).

DISCUSSION

Children with eating disorders continue to present with severe illness. Near doubling in incidence in just over a 10-year period highlights the need for increased clinical resourcing and comparable international data.

PUBLIC SIGNIFICANCE

The incidence of new presentations of eating disorders in children aged 5-13 years has nearly doubled since a similar study was conducted over 10 years ago. Children were unwell for an average of 8 months before diagnosis; approximately 80% had a clear diagnosis of anorexia nervosa and 64% needed hospital admission due to medical complications. This highlights the need for improvements in education and clinical resources for this age group.

Epidemiology of eating disorders among US adults

PURPOSE OF REVIEW

Public policy efforts for prevention of and intervention upon eating disorders is severely limited in the United States due to the paucity of population-based data. This review article summarizes findings regarding eating disorders based on the National Epidemiological Studies on Alcohol and Related Conditions, Third Wave. The studies reviewed provide the most recent epidemiological indicators of anorexia nervosa, bulimia nervosa, and binge-eating disorder (BED) in the United States and demonstrate the utility of population-based data for validating the generalizability of findings from clinical samples.

RECENT FINDINGS

Anorexia nervosa, bulimia nervosa, and BED are widely distributed across sociodemographic characteristics, with substantially elevated risks for a variety of serious psychiatric, medical, and functional impairments, including heighted suicidality over the lifespan. Sexual minorities and individuals with adverse childhood experiences may be particularly vulnerable. Yet, many adults with eating disorders do not seek help, particularly professional help. National Epidemiological Studies on Alcohol and Related Conditions, Third Wave studies also validated some important clinical observations (e.g., overvaluation of shape/weight and physical inactivity in BED, more severe anorexia nervosa with onset prior to 14 years old).

SUMMARY

More rigorous population-based studies are needed to further advocate for appropriate resources and policies for eating disorders in the United States.

Early Course of Symptom Development in Anorexia Nervosa

PURPOSE

Anorexia nervosa (AN) commonly begins in adolescence; however, detailed knowledge of symptom trajectories, including their temporal sequence, is less well elucidated. The purpose of the present study is to describe the onset and duration of disordered eating behaviors prior to a diagnosis of AN, examine concordance between child and parent report, and examine the relationships between timing of symptom onset and illness severity.

METHODS

Seventy-one adolescents (ages 12-18 years) and their parents were interviewed about dieting, restriction, loss of control/binge eating, purging, excessive/compulsive exercise, weight history, and amenorrhea. Body mass index percentiles were calculated, and adolescents completed the Eating Disorder Examination-Questionnaire.

RESULTS

Restriction, being underweight, dieting, and excessive exercise were reported by most of the sample; purging, loss-of-control eating, and having been overweight were reported by less than a third. Dieting typically emerged first, on average around age 14; the remainder of behaviors tended to emerge between ages 14 and 14½; and average age of formal diagnosis was slightly over 15 years. Dyads had good agreement regarding presence and timing of all behaviors except for dieting, for which children reported about 6 months earlier onset/longer duration, compared to parents. Although older age at interview was associated with lower body mass index percentile and higher EDE-Q score, neither age of onset nor duration was associated with severity when controlling for current age.

DISCUSSION

Teens and parents describe a similar sequence of behavior changes leading up to a diagnosis of AN that typically begins with dieting and occurs over an approximate 1- to 1½-year period. Querying teens and parents about eating behavior changes may aid in identification and early intervention in AN; adolescents with normal weight who engage in persistent dieting or restrictive eating may warrant more frequent weight monitoring.

Gut Microbiota Profiles in Children and Adolescents with Psychiatric Disorders

The aim of our work is to summarize the current state of knowledge on gut microbiota differences in children and adolescents with psychiatric disorders. To find the relevant articles, the PubMed, Web of Science, and Google Scholar databases were searched. Articles in English presenting original data and comparing the composition of gut microbiota in child psychiatric patients with gut microbiota in healthy children and adolescents were selected. Finally, we identified 55 articles eligible for our purpose. The majority of patients with autism spectrum disorders (ASD) were investigated. A smaller number of studies evaluating the gut microbiota in children and adolescents with attention-deficit/hyperactivity disorder (ADHD), Rett syndrome, anorexia nervosa, depressive disorder (DD), and tic disorders were found. The main findings of this research are discussed in our review, focusing on the age-related gut microbiota specificity for psychiatric disorders and the differences between individual diagnosis. To conclude, the gut microbiota in children and adolescents with psychiatric disorders is evidently different from that in controls. The most pronounced differences are seen in children with ASD, less in ADHD. Moreover, the changes are not identical to those in adult psychiatric patients, as Ruminococcus, Turicibacter, and Bilophila were increased in adults, and decreased in children with ASD, and Parabacteroides and Alistipes were more frequently represented in adults, but less frequently represented in children with depression. The available data suggest some genera have a different abundance in individual psychiatric disorders (e.g., Bilophila, Bifidobacterium, Clostridium, Coprococcus, Faecalibacterium, and Ruminococcus), suggesting their importance for the gut-brain axis. Other bacterial genera might be more important for the pathophysiology of specific disorder in children and adolescents, as Akkermansia and Desulfovibrio for ASD, or Romboutsia for DD. Based on the research findings, we assume that gut microbiota corrections have the potential to improve clinical symptoms in psychiatric patients.

When anorexia nervosa symptoms mask Kallmann syndrome

BACKGROUND

Although anorexia nervosa might delay puberty, a structured assessment at its onset remains crucial in excluding congenital delayed puberty diseases.

CASE PRESENTATION

During the follow-up of a 15-year-old girl suffering from anorexia nervosa, a change of treatment has led to a thorough medical history revealing the absence of the olfactory bulb. Kallmann syndrome diagnosis was made on a blood analysis and the patient was treated with a multidisciplinary approach.

CONCLUSION

After the diagnosis, our patient was relieved as it has clarified some of her symptoms including anosmia, poor height and maturational delay. Too often a delayed puberty is attributed to anorexia nervosa itself without considering medical history. This case definitely shows the importance of performing a case history and early diagnosis in pre-pubertal AN to rule out other rare diseases and avoid mid- and long-term sequelae.

LEVEL OF EVIDENCE

IV (case study).

Linguistic feature of anorexia nervosa: a prospective case-control pilot study

PURPOSE

Attention has recently been paid to Clinical Linguistics for the detection and support of clinical conditions. Many works have been published on the "linguistic profile" of various clinical populations, but very few papers have been devoted to linguistic changes in patients with eating disorders. Patients with Anorexia Nervosa (AN) share similar psychological features such as disturbances in self-perceived body image, inflexible and obsessive thinking and anxious or depressive traits. We hypothesize that these characteristics can result in altered linguistic patterns and be detected using the Natural Language Processing tools.

METHODS

We enrolled 51 young participants from December 2019 to February 2020 (age range: 14-18): 17 girls with a clinical diagnosis of AN, and 34 normal-weighted peers, matched by gender, age and educational level. Participants in each group were asked to produce three written texts (around 10-15 lines long). A rich set of linguistic features was extracted from the text samples and the statistical significance in pinpointing the pathological process was measured.

RESULTS

Comparison between the two groups showed several linguistics indexes as statistically significant, with syntactic reduction as the most relevant trait of AN productions. In particular, the following features emerge as statistically significant in distinguishing AN girls and their normal-weighted peers: the length of the sentences, the complexity of the noun phrase, and the global syntactic complexity. This peculiar pattern of linguistic erosion may be due to the severe metabolic impairment also affecting the central nervous system in AN.

CONCLUSION

These preliminary data showed the existence of linguistic parameters as probable linguistic markers of AN. However, the analysis of a bigger cohort, still ongoing, is needed to consolidate this assumption.

LEVEL OF EVIDENCE III

Evidence obtained from case-control analytic studies.

Long-term outcome in males with anorexia nervosa: A prospective, sex-matched study

OBJECTIVE

The objective of this study is to report on the 5.5-years outcome of anorexia nervosa (AN) in male adolescent inpatients and compare it to the outcome of female adolescent inpatients with AN.

METHOD

Diagnostic eating disorder outcome was assessed by the Structured Inventory of Anorexic and Bulimic Syndromes (DSM-IV) in 20 males and 20 females matched for AN diagnosis, age at treatment, and length of follow-up. For documentation, follow-up scores of the Eating Disorder Inventory and the Brief Symptom Inventory are reported.

RESULTS

Diagnostic outcome did not differ between sexes. Four male and six female participants had AN at follow-up. One male and four females had crossed to bulimia nervosa, and five males and three females to eating disorder not otherwise specified. Remission was found in 10 males and 7 females. Effect sizes were mostly small. At follow-up females had higher scores than males with large effect sizes for drive for thinness (Cohen's d = 0.86) and body dissatisfaction (d = 1.07).

DISCUSSION

Few significant sex differences were found. Additional research involving larger samples of males and a broader range of assessed outcomes (e.g., drive for muscularity) in both sexes is urgently needed.

Lifetime prevalence and clinical correlates of nonsuicidal self-injury in youth inpatients with eating disorders: a retrospective chart review

BACKGROUND

Youths with eating disorders (EDs) engaging in nonsuicidal self-injury (NSSI) are at higher suicide risk because EDs and NSSI are associated with suicidality. However, epidemiologic data on NSSI lacks in the vulnerable group of youth ED inpatients.

METHODS

This retrospective chart review included patients up to 18 years of age with an ICD-10 diagnosis of anorexia nervosa, restricting type (AN-R), anorexia nervosa, binge-purge type (AN-BP), and bulimia nervosa (BN), treated at the child and adolescent inpatient department of the University Hospital in Berlin, Germany, between 1990 and 2015. Across and within ED subgroups, lifetime NSSI prevalence, methods of self-harm, and clinical correlates were evaluated. Independent correlations of demographic and clinical factors with NSSI were identified via multivariable regression models.

RESULTS

Of 382 inpatients (median = 15.6 (range = 9-18) years, females = 97.1%), 21.5% reported lifetime NSSI, consisting of cutting = 86.6%, scratching = 12.2%, and hitting = 8.5%. NSSI was more frequent in BN (47.6%) and AN-BP (39.3%) than AN-R (8.3%) (Φ = 0.43). Across ED subgroups, NSSI was associated with a higher prevalence of psychiatric comorbidities (AN-R: Φ = 0.55; AN-BP: Φ = 0.69; BN: Φ = 0.78), suicidal ideation (AN-R: Φ = 0.30; AN-BP: Φ = 0.38; BN: Φ = 0.29), and psychiatric medication use (AN-R: Φ = 0.23; AN-BP: Φ = 0.64; BN: Φ = 0.60). In multivariable regression analyses, NSSI was independently associated with a higher prevalence of psychiatric comorbidities (AN-R: OR = 2.93 [1.42, 6.04]; AN-BP: OR = 2.67 [1.13, 6.31]; BN: OR = 3.75 [1.71, 8.23]). Additionally, independent correlates with NSSI in AN-R included a higher prevalence of suicidal ideation (OR = 0.21 [0.72, 0.64]) and less weekly weight gain (OR = 0.03 [0.02, 0.43]), while in BN, NSSI was correlated with longer inpatient treatment duration (OR = 1.01 [1.00, 1.02]).

CONCLUSIONS

There is a high lifetime prevalence of NSSI among youth with AN and BN requiring inpatient treatment, especially those with binge-purge behaviors. Treatment programs must be tailored to address psychiatric comorbidities and suicidality to improve patient care and suicide prevention.

TRIAL REGISTRATION

This study was not considered a clinical trial but a retrospective chart review based on routinely assessed clinical parameters. The study includes data from human participants, however: (1) no intervention and no prospective assignment to interventions were performed, and (2) no evaluation of an intervention on participants was accomplished.

Eating disorder onset during childhood is associated with higher trauma dose, provisional PTSD, and severity of illness in residential treatment

OBJECTIVE

Age of eating disorder (ED) onset has been of significant interest to both researchers and clinicians. The identification of factors associated with early or child onset has important prevention and treatment implications. The presence of prior trauma, resultant posttraumatic stress disorder (PTSD), ED severity, and comorbid psychopathology are of particular relevance to age of ED onset, but data are limited.

METHODS

Adults (≥18 years, 93% female, total n = 1283) admitted to residential ED treatment self-reported age of ED onset. Patients were divided into child onset (ages 5-10 years), adolescent onset (11-17 years), and adult onset (≥18 years) groups and compared on a number of clinical features and assessment measures.

RESULTS

The child onset group had significantly higher rates and doses of traumatic life events; higher current PTSD prevalence; higher BMIs, higher severity of ED, depression and state-trait anxiety symptoms; worse quality of life; and more prior inpatient and residential admissions for ED treatment, in comparison to both the adolescent and adult onset groups. Similarly, the adolescent onset group had significantly higher rates than the adult onset group.

CONCLUSIONS

These results have important implications for prevention, treatment and long-term follow-up and highlight the need for early trauma-focussed treatment of ED patients.

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).

Expression of CXCR4 on CD4+ T cells predicts body composition parameters in female adolescents with anorexia nervosa

Anorexia nervosa (AN) is a severe eating disorder characterized by excessive weight loss and lack of recognition of the seriousness of the current low body weight. Individuals with AN frequently exhibit an enhanced inflammatory state and altered blood levels of cytokines and chemokines. However, the expression of chemokine receptors in AN and the association with body composition parameters and treatment effects are still unknown. In this study, we examined the expression of CCR4, CCR6, CXCR3, and CXCR4 on peripheral blood T cells in female adolescents with AN before (T0, n = 24) and after 6 weeks of multimodal therapy (T1, n = 20). We also investigated their value to predict body mass index (BMI) and fat mass index (FMI) at baseline. Using multi-parameter flow cytometry, we found increased expression of CCR4, CXCR3, and CXCR4, but not CCR6, on CD4⁺ T cells in AN at T0 when compared to healthy controls (HC, n = 20). At T1, CXCR3 and CXCR4 expression decreased in AN. We found a close link between CCR4, CCR6 and CXCR4 expression and the adolescent mental health status in the study cohort as determined by the Strengths and Difficulties Questionnaire (SDQ). Specifically, CXCR4 expression correlated positively with emotional symptoms and peer relationship problems, as well as with the total sum score of the SDQ. In addition, CXCR4 expression on CD4⁺ T cells was a significant predictor of BMI and FMI in female adolescents. Our findings that CXCR4 expression on T cells is altered in adolescents with AN and predicts body composition parameters in adolescents suggest an impact of this chemokine receptor in the pathogenesis of AN.

Eater profile and associated factors in pediatric patients of the PEDIANUT cohort

Appetite traits have multifactorial origins. In association with environmental and genetic factors, they could become problematic and lead to Feeding or Eating Disorders (FED). As the DSM-5 classification is not suitable for pediatric FED, another way to describe eating behavior is to distinguish the clinical profiles of "small eater" and "big eater". The aim of this study was to identify socio-demographic and medical factors associated with these profiles, and to compare problematic and non-problematic profiles. From the Pedianut study, we analyzed socio-demographic, medical and family history data among 401 children according to 4 age groups (<1 year n = 101, 1-6 years n = 99, 6-12 years n = 100, 12-18 years n = 101). The information collected on eating behavior made it possible to define small eater profile (SEP) and big eater profile (BEP) using predefined grids. BEP was more frequent in adolescents (35.6%), and SEP was more frequent in children aged 1-6 years (34.3%). BEP was associated with having separated parents, being male and the oldest sibling (p < 0.05). Problematic BEP was associated with eating while watching television, being a girl, and having sensory disorders (p < 0.05). SEP was associated, whatever age, with non-breastfeeding, chronic illness, psychological history, sensory disorders, language delays (in the 1-6 year age group), and family history of FED (in the adolescent group) (p < 0.05). This analysis of factors associated with eater profile opens new perspectives for research on risk factors associated with eating traits, which warrants further study in larger populations to delineate transition from healthy to problematic eating.

Examining the significance of age of onset in persons with lifetime anorexia nervosa: Comparing child, adolescent, and emerging adult onsets in nationally representative U.S. study

OBJECTIVE

This study compared sociodemographic and clinical profiles of adult patients with lifetime DSM-5-defined anorexia nervosa (AN) categorized by age-of-onset using data from U.S. national sample of adults.

METHOD

Study included 216 participants from Third National Epidemiological Survey Alcohol and Related Conditions (NESARC-III) who met criteria for lifetime AN based on structured diagnostic interviews (AUDADIS-5) with age-of-onset prior to age 25. Of the 216 participants, 30 were categorized as child-onset (<15 years old), 104 adolescent-onset (15-18 years of age), and 82 "emerging-adult" (19-24 years of age); the three groups were compared on their clinical characteristics.

RESULTS

Among participants with lifetime diagnoses of AN with onsets earlier than 25 years, adjusted prevalence rates for the three groups were: 11.8% (SE = 2.04; child-onset), 39.6% (SE = 2.69; adolescent-onset), and 48.6% (SE = 2.67; emerging-adult). Child-onset group reported more frequent adverse childhood experiences (ACEs), lowest BMI, longest episode-duration, was least likely to attend college, and had highest rate of lifetime psychiatric comorbidity. Child-onset group had earliest age of help-seeking and were most likely to have been hospitalized. Group differences persisted in analyses adjusting for sociodemographic characteristics and duration of AN episode.

DISCUSSION

Our findings, based on a nationally representative sample of U.S. adults with lifetime diagnoses of AN, suggest that those with child-onset had more severe AN, greater life difficulties, and greater lifetime psychiatric comorbidity. Findings emphasize the importance of earlier recognition and rapid referral to effective treatments.

Short-Term Outcome of Inpatient Treatment for Adolescents with Anorexia Nervosa Using DSM-5 Remission Criteria

This study evaluated the short-term outcome of a multimodal inpatient treatment concept for adolescents with anorexia nervosa (AN). In this prospective observational study, a cohort of 126 female adolescents with AN (age range: 11–17, mean age: 14.83) was longitudinally followed from admission to discharge (average duration of stay: 77 days). We used gold-standard clinical interviews and self-report data, as well as DSM-5 remission criteria, to evaluate the treatment outcome. From admission to discharge, body-mass-index (BMI) significantly improved by 2.6 kg/m². Data from clinical interviews and self-reports yielded similar improvements in restraint eating and eating concerns (large effects). Lower effects were observed for variables assessing weight/shape concerns and drive for thinness. At discharge, 23.2% of patients showed full remission of AN, 31.3% partial remission, and 45.5% no remission according to DSM-5 criteria. Differences in remission groups were found regarding AN severity, age at admission, and use of antidepressant medication. Living with both parents, longer duration of inpatient treatment and the use of antipsychotic medication were significantly associated with higher BMI change. The findings provide evidence for the short-term effectiveness of our inpatient treatment concept. We recommend using DSM-5 based remission criteria to evaluate the treatment outcome to improve the comparability of studies.

Music and art therapy combined with cognitive behavioral therapy to treat adolescent anorexia patients

OBJECTIVE

To investigate the efficacy and feasibility of music and art therapy combined with cognitive behavioral therapy (CBT) in the treatment of adolescent patients with anorexia.

METHODS

A total of 77 patients admitted to our hospital from August 2018 to October 2019 were recruited as the study cohort, but 11 patients who dropped out of the study were excluded. The data from the 66 patients were collected for a statistical analysis. There were 31 patients in the control group and 35 patients in the treatment group. After the intervention, the body weight, cognitive and behavioral ability, emotional reaction, and treatment satisfaction changes were compared and analyzed in the two groups.

RESULTS

The treatment group had a significantly lower dropout rate and higher overall treatment satisfaction than the control group. After the intervention, the body weights, body mass indexes (BMI), and abdominal subcutaneous fat thicknesses were increased in the two groups, and the increase in the treatment group was significantly higher than it was in the control group (P < 0.05). After the intervention, the Eating Disorder Examination Questionnaire 6.0 (EDE-Q-6.0), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI) scores were significantly lower than they were before the intervention, and the scores in the treatment group were significantly lower than they were in the control group (P < 0.05).

CONCLUSION

Music and art therapy combined with CBT can effectively improve patients' recognition and acceptance of the treatment, the therapeutic effects, and the adverse emotional reactions (e.g., depression and anxiety), and help patients establish the correct cognition regarding food, body shape, and weight.

Psychometric evaluation of the Eating Disorders in Youth-Questionnaire when used in adults: Prevalence estimates for symptoms of avoidant/restrictive food intake disorder and population norms

OBJECTIVE

Restrictive eating behaviors occur across ages, but little is known about symptoms of avoidant/restrictive food intake disorder (ARFID), especially in adults. This study sought to examine the prevalence of symptoms of ARFID in the adult population, providing a psychometric evaluation of the Eating Disorders in Youth-Questionnaire (EDY-Q) and population norms.

METHOD

In a representative survey of the German population, N = 2,424 adults (1,297 women, 1,127 men; age 49.5 ± 17.5 years) were assessed with the EDY-Q and measures of eating disorder and general psychopathology for divergent validation.

RESULTS

The point prevalence of self-reported symptoms of ARFID amounted to 0.8% (20/2,424), with 0.8% of women (10/1,297) and 0.9% of men (10/1,127) being affected. Adults with symptoms of ARFID were significantly more likely to have underweight or normal weight, were more likely to report restrictive behaviors and lower levels of eating disorder psychopathology and binge eating than noneating-disordered controls and adults with symptoms of an eating disorder, but did not significantly differ in levels of compensatory behaviors, or depression and anxiety. The EDY-Q revealed favorable item statistics, heterogeneity, and satisfactory construct validity, including factorial, discriminant, and divergent validity. Weight-status specific norms were provided.

DISCUSSION

Both women and men from the population reported symptoms of ARFID with an anthropometric and psychopathological profile similar to that seen in youth with symptoms of ARFID, however, with lower prevalence estimates, and distinctive from that in other eating disorders. Interview-based assessment of this symptomatology is required to confirm the prevalence of ARFID diagnosis.

Can you find the right support for children, adolescents and young adults with anorexia nervosa: Access to age-appropriate care systems in various healthcare systems

OBJECTIVE

Anorexia nervosa (AN) often has its onset in childhood or adolescence. However, there is insufficient knowledge regarding access to and utilisation of age-specific clinical diagnostics and treatment.

METHODS

A literature review covering the last 10 years was conducted to provide a narrative review of the current state of research on the detection and treatment of young patients with AN in primary and secondary care.

RESULTS

Most articles were of Western European or US origin. Timely diagnosis of the eating disorder (ED) and treatment options more often depend on the structure and quality of the national health care system than on scientific evidence. Regular paediatric health check-ups and age-appropriate eating disorder services appear to facilitate early diagnosis. Age-specific treatment that also involves the carers is often associated with a higher continuity of care and a better outcome. Although many adolescents require an extension of treatment into young adulthood, individual and health care system-related obstacles in many countries prevent a smooth transition.

CONCLUSION

To improve outcomes in childhood and adolescent AN, age-specific and timely diagnostic and therapeutic procedures are urgently needed.

Psychopathological Risk Factors Associated with Body Image, Body Dissatisfaction and Weight-Loss Dieting in School-Age Adolescents

Determining the comorbidity patterns leading to suffering behavioural eating disorders (BED) that are identifiable in the early stages of life, can help prevent their becoming chronic, as well as preventing the consequences deriving from the cost and effectiveness of intervention programs. The paper focuses mainly on analysing the association between behavioural/emotional risk factors and body image, body satisfaction and diet in school children, as well as confirming whether there are differences based on sex. Several questionnaires (Strengths and Difficulties Questionnaire and several items of Health Behaviour in School-age Children) including these variables were distributed and completed by the 647 adolescents (16 year olds on average) who took part in the research project. The findings confirmed a differentiated risk profile in adolescent girls in that they had greater prevalence of emotional symptoms as a general psychopathological trait, although this was offset with their prosocial behaviour. Additionally, the findings also allowed us to conclude that the factors that predict vulnerability to BEDs are sex, the presence of emotional symptoms and social and behavioural issues. At the end of this paper, we discuss some implications and consequences that should be taken into account for future work.

The validity of the fifth and the 10th Body Mass Index percentile as weight cut-offs for anorexia nervosa in adolescence: No evidence from quantitative and network investigation of psychopathology

OBJECTIVE

Although the fifth Body Mass Index (BMI) percentile is the Diagnostic and Statistic Manual of Mental Disorders -5 weight cut-off criterion to diagnose anorexia nervosa (AN) in children and adolescents, its validity has not been proved, and the 10th percentile value is often applied. We aimed to investigate the diagnostic validity of these weight cut-offs.

METHOD

We compared general and eating-disorder (ED) specific psychopathology in 380 adolescents with AN or atypical AN. They were grouped first with respect to the fifth BMI percentile and then with respect to the 10th BMI percentile and differences between groups were analysed. Network analyses on psychopathological symptoms were also conducted.

RESULTS

Adolescents with BMI above the fifth and the 10th percentile reported more severe ED specific symptomatology compared to those with BMI below these cut-offs. No significant differences emerged between groups neither in general psychopathology nor in the network structure of psychopathology.

CONCLUSIONS

The fifth BMI percentile does not discriminate psychopathology severity in adolescents with AN. From the psychopathology perspective, our findings suggest that adolescents with atypical AN deserve the same clinical and research attention as those with full AN. Future studies are needed to identify a more accurate definition of underweight in adolescents.

[Feeding and eating disorders in ICD-11]

Feeding and eating disorders in ICD-11 Abstract. Innovations in ICD-11 include the adoption of a lifespan approach and culture-related guidance for each disorder. We describe the changes made to the chapter Feeding and Eating Disorders and compared them to the ICD-10. In addition to illustrating the revision of the guidelines for each disorder, we also comment on the inclusion of a new set of diagnoses, avoidant/restrictive food intake disorder (ARFID) and binge-eating disorder (BED).

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

Childhood Eating and Feeding Disturbances

Eating and feeding disturbances are prevalent yet understudied health conditions in youth. They are characterized by aberrant eating behaviors, cognitive and emotional dysfunctions, and dysregulated body weight. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition defines several feeding and eating disorders with a common onset in youth; however, data on their clinical validity at young ages are lacking. Further non-normative eating behaviors exist, but their clinical relevance needs elucidation. This Special Issue compiles state-of-the-art reviews and empirical research on the presentation, development, course, and maintenance of diverse eating and feeding disturbances as a prerequisite for delineating evidence-based interventions for treatment and prevention.

Psychopathology, Body Image and Quality of Life in Female Children and Adolescents With Anorexia Nervosa: A Pilot Study on the Acceptability of a Pilates Program

Background: Anorexia nervosa (AN) is a psychiatric illness that without early effective treatment becomes chronic with high physical, psychological and social morbidity and high mortality. Pilates exercises can improve quality of life and increase body awareness in different clinical and healthy populations. The aim of this pilot study was to examine the acceptability of a Pilates program in a sample of female children and adolescents with AN by evaluating the psychopathological status, alterations in the perception of body image and health-related quality of life after 10 weeks. Methods: A total of 12 female patients (age: 14.6 ± 1.7 years) completed the 10-week Pilates program. Psychopathology (EDI-3), body image disturbance (CDRS) and quality of life (KIDSCREEN-27) were evaluated before and after the intervention. A satisfaction questionnaire was also provided. Results: Regarding psychopathology, although there were standardized reductions in seven parameters of those that form EDI-3, none of them reached significance. In relation to body image, significant, moderately standardized and substantial decreases were observed in the body dissatisfaction (p = 0.046, Cohen's d = -0.69). There were significant, large standardized and substantial increases in physical well-being (p = 0.008, Cohen's d = 1.37) and significant, moderately standardized and substantial decreases in autonomy and parent relation (p = 0.021, Cohen's d = -0.60). Satisfaction data was positive. Conclusion: A Pilates program could help to improve perceived health outcomes by decreasing body dissatisfaction and increasing physical well-being in female children and adolescents with AN, so Pilates seems to be a beneficial complementary treatment in children and adolescents with AN. These findings from our pilot study are encouraging for future research with a substantially larger sample size, representing the first phase of a longer process.

Clinical Characteristics of Inpatients with Childhood vs. Adolescent Anorexia Nervosa

We aimed to compare the clinical data at first presentation to inpatient treatment of children (<14 years) vs. adolescents (≥14 years) with anorexia nervosa (AN), focusing on duration of illness before hospital admission and body mass index (BMI) at admission and discharge, proven predictors of the outcomes of adolescent AN. Clinical data at first admission and at discharge in 289 inpatients with AN (children: n = 72; adolescents: n = 217) from a German multicenter, web-based registry for consecutively enrolled patients with childhood and adolescent AN were analyzed. Inclusion criteria were a maximum age of 18 years, first inpatient treatment due to AN, and a BMI <10th BMI percentile at admission. Compared to adolescents, children with AN had a shorter duration of illness before admission (median: 6.0 months vs. 8.0 months, p = 0.004) and higher BMI percentiles at admission (median: 0.7 vs. 0.2, p = 0.004) as well as at discharge (median: 19.3 vs. 15.1, p = 0.011). Thus, in our study, children with AN exhibited clinical characteristics that have been associated with better outcomes, including higher admission and discharge BMI percentile. Future studies should examine whether these factors are actually associated with positive long-term outcomes in children.