Clinical Characteristics of Inpatients with Childhood vs. Adolescent Anorexia Nervosa

Early-onset anorexia nervosa: a scoping review and management guidelines

BACKGROUND

Anorexia nervosa (AN) is a serious multifactorial eating disorder characterized by insufficient nutritional intake to maintain a minimum normal weight for one's age and height, a fear of gaining weight and a distorted body image. It affects mainly adolescents, but a decreased age at diagnosis has been reported, leading to the definition of a rare form of AN called early-onset or prepubertal anorexia nervosa (EOAN; ORPHA 525738), with reported epidemiological and clinical specificity. Current knowledge and specific treatments for this particular condition remain scarce. We aim to summarize the literature review and synthesize actual knowledge on EOAN for preliminary guidelines to harmonize the diagnosis, treatment and follow-up.

METHODS

A scoping literature review was performed from 2010-2021 using PubMed, Web of Science, PsycInfo and Cochrane via the following search terms: (anorexia nervosa) AND (early-onset OR premenarchal OR prepubertal OR childhood). International guidelines were screened for additional hits. Data extraction was limited to findings relevant to the key topic questions: epidemiology and clinical specificities section, diagnosis and initial evaluation section, treatment section, and follow-up and prognosis section.

RESULTS

A total of 1257 titles were retrieved via the initial search strategy. Finally, 42 records were included in the present article (30 articles and 11 international guidelines and 1 literature review). We identified 15 articles relevant for the epidemiology and clinical specificities section, 11 for the diagnosis and initial evaluation section, 3 for the treatment section, and 1 for the follow-up and prognosis section. Despite the growing literature on the epidemiological and clinical features of EOAN, knowledge of specific treatments and prognoses remains scarce in the absence of extensive standardized data collection and few age-specific clinical research protocols. Current international guidelines generally extrapolate strategies proposed for adolescents and young adults to children with a low level of evidence.

CONCLUSIONS

Continuing research efforts in this specific younger population is needed to validate child-specific care strategies, enabling the establishment of age-appropriate recommendations with a higher level of evidence targeting specific determinants and clinical specificities of EOAN.

Anorexia nervosa-specific home treatment in children and adolescents and their families (the HoT study): a study protocol of a randomized, controlled, multicenter, open-label, parallel group superiority trial

BACKGROUND

New treatment approaches are urgently needed to improve the prognosis of children and adolescents with anorexia nervosa (AN). Recently, the feasibility of multidisciplinary home treatment that strongly involves the patients' parents/caregivers has been investigated. However, no RCT has yet been performed to test the efficacy and safety of this approach compared to standard treatment approaches, such as inpatient treatment.

METHODS

In this multicenter randomized-controlled trial, home treatment for children and adolescents with AN aged 12 to 18 years is established at 5 major treatment centers for AN in Germany. Approximately 240 patients who are admitted to the hospital for AN will be included in the trial. After a short inpatient somatic stabilization phase (5-8 weeks), patients are randomized to receive either treatment as usual (TAU), in the form of continued inpatient or day patient treatment, or the newly developed home treatment (HoT) (n = 82/arm, n = 164 in total). There are three assessments throughout treatment (admission, randomization, and discharge), as well as follow-up assessments at 9 and 12 months after admission. The BMI at 12 months after admission (primary outcome) is compared between groups (adjusted for premorbid BMI and admission BMI); secondary outcomes include eating disorder and general psychopathology, the number and duration of psychiatric rehospitalizations, quality of life, motivation for treatment and treatment satisfaction. Other secondary outcomes include the primary caregivers' burden and skills in handling the child's illness and direct treatment costs. Statistical analysis will be based on intention-to-treat principles, using mixed models for repeated measures. (Serious) adverse events are assessed throughout treatment. In addition, the feasibility and implementation of HoT as well as the satisfaction and workload of the members of the multidisciplinary treatment teams in both arms will be assessed.

DISCUSSION

In the case of a positive evaluation, HoT can be considered an effective treatment method to replace or complete established treatment methods, such as IP, for treating AN in children and adolescents. The home treatment setting might shorten inpatient stays in this patient group, increase treatment satisfaction, and help to reduce the risk of rehospitalization, which is associated with a better outcome in this vulnerable patient group.

TRIAL REGISTRATION

The trial was registered with the German Clinical Trial Register (DRKS) under the ID DRKS00025925 on November 26, 2021 (prospectively registered): https://drks.de/search/de/trial/DRKS00025925 .

Anorexia Nervosa Across the Lifespan: A Review of Recent Literature

In this review, the authors provide an update on the understanding of anorexia nervosa (AN) across the lifespan. Focusing on key pieces of literature from the past 5 years, this review summarizes recent updates to DSM-5 within the domain of AN, including the addition of a new AN diagnosis: atypical anorexia. Additional sections covered in this review include improvements in the epidemiological understanding of AN across the developmental spectrum, treatment approaches that have been established as gold standard as well as new directions recently explored in treatment, and recent advancements in the biopsychosocial underpinnings of AN. Altogether, although this review captures several advancements in the field's overall conceptualization of AN, several key areas of treatment and diagnostic capacity continue to require additional focus and research.

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.

Nutritional Assessment of Children and Adolescents with Atypical Anorexia Nervosa: A Preliminary Longitudinal Investigation Using the 24-h Dietary Recall

BACKGROUND

Atypical Anorexia Nervosa (AAN) is a Feeding and Eating Disorder characterized by fear of gaining weight and body image disturbance, in the absence of significantly low body weight. AAN may present specific clinical and psychopathological features. Nonetheless, the literature lacks data concerning the nutritional characteristics and body composition of children and adolescents with AAN and their variation over time.

METHODS

Case series, including 17 children and adolescents with AAN. All the patients were assessed at the first evaluation (T0) with a standardized dietary assessment (24 h Dietary Recall, 24 hDR). Nutritional data were compared with European dietary reference values (DRVs). Body composition parameters (weight, fat mass, fat-free mass) and their changes over time at two (T1) and six (T2) months were collected as well, using a Bioelectrical impedance analysis (Wunder WBA300 with four poles and foot contact; impedance frequency 50 kHz 500 μA; impedance measurement range 200~1000 Ω/0.1 Ω).

RESULTS

The included individuals presented eating behaviors oriented towards significantly low daily energy intake (p < 0.001) compared with DRVs set by the European Food Safety Authority (EFSA) (with low carbohydrates and fats), and increased proteins (p < 0.001). A longer latency before observation (illness duration before observation) correlated with a negative change in weight. Body composition parameters were described, with no significant changes across the six-month outpatient assessment.

DISCUSSION

This is the first research to systematically assess the body composition and nutritional features of a group of individuals with AAN in the developmental age. Further research should assess the effect of targeted treatment interventions on body composition and nutritional features.

[New aspects in etiology and treatment of adolescent anorexia nervosa-a postulated bio-psycho-social model and the impact of the COVID-19 pandemic]

Anorexia nervosa is one of the most frequent chronic disorders of adolescence associated with a high mortality. During the COVID-19-pandemic, the number of hospitalized children and adolescents with anorexia nervosa significantly increased. This article outlines new research findings to decode the etiology of this serious disorder, especially a genetic disposition and changes of metabolism. Against the background of increasing rates during the COVID-19 pandemic, the importance of the gene-environment interaction is discussed, and new treatment forms are described. Besides the development of new biological treatment strategies, there is also some important progress in psychotherapeutic interventions. Carers should always be integrated when treating children and adolescents with anorexia nervosa, which is especially emphasized in the new "home treatment" setting. The new concept of anorexia nervosa as a metabo-psychiatric disorder gives us hope for new research ideas and treatment strategies in this often-debilitating disorder of childhood and adolescence.

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.

Cardiac involvement and its clinical significance in patients with anorexia nervosa

Cardiac complications are a major concern in patients with anorexia nervosa (AN) which contribute to morbidity and mortality. However, limited information exists regarding risk factors for the development of these complications. Our objective was to investigate the prevalence and associated risk factors of cardiac involvement among children and adolescents with AN admitted to a tertiary pediatric hospital. We collected demographic, clinical, and laboratory data from individuals with AN hospitalized between 2011 and 2020 in Schneider Children's Medical Center in Israel. Diagnosis was based on established criteria (DSM-5). Patients with other co-morbidities were excluded. Cardiac investigations included electrocardiograms (ECG) and echocardiograms. We conducted correlation tests between cardiac findings and clinical and laboratory indicators. A total of 403 AN patients (81.4% were females) with a median age of 15 ± 2 years were included in the study. Sinus bradycardia was the most common abnormality, observed in 155 (38%) participants. Echocardiogram was performed in 170 (42.2%) patients, of whom 37 (22%) demonstrated mild cardiac aberrations. Among those aberrations, 94.6% could be attributed to the current metabolic state, including pericardial effusion (15.3%) and valve dysfunction (8.8%). Systolic or diastolic cardiac dysfunction, tachyarrhythmias, or conduction disorders were not observed. Patients with new echocardiographic aberration had significantly lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension was higher in this group.

CONCLUSIONS

The prevalence of cardiac involvement, except for sinus bradycardia, was notably low in our cohort. The presence of cardiac aberrations is correlated with several clinical variables: lower body mass index (BMI) and the presence of amenorrhea and hypotension at admission. Patients presenting with these variables may be at high risk for cardiac findings per echocardiography. Dividing the patients into high and low risk groups may enable targeted evaluation, while avoiding unnecessary cardiac investigations in low-risk patients.

WHAT IS KNOWN

• Cardiac involvement in anorexia nervosa (AN) patients is a major concern, which contributes to morbidity and mortality. • It is unknown which patients are prone to develop this complication.

WHAT IS NEW

• Cardiac complications in our cohort are less frequent compared to previous studies, and it is correlated with lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension.

Inpatient Treatment Outcome in a Large Sample of Adolescents with Anorexia Nervosa

Anorexia nervosa is an illness affecting primarily adolescent girls and young women. Clinical guidelines recommend early intervention, with inpatient treatment for more severe cases. We present an evaluation of a multi-modal cognitive-behavioral inpatient treatment (CBT-E) involving carers in specialized units for adolescents. Routine data of 962 adolescent inpatients (26 boys) (mean age 15.48 [1.26]; range 12-17 years) were analyzed. Predictors of good body weight outcome (achieving a discharge BMI of at least 18.5 kg/m2) were identified by logistic regression analysis. Mean inpatient treatment lasted 96.69 (45.96) days. The BMI increased significantly from 14.93 (1.38) kg/m2 at admission to 17.53 (1.58) kg/m2 at discharge (z = 26.41; p < 0.001; d = 1.708). Drive for thinness decreased from 29.08 (9.87) to 22.63 (9.77; z = 18.41; p < 0.001; d = 0.787). All other subscores of the Eating Disorder Inventory also decreased significantly, with small to medium effect sizes. General psychopathology also showed significant decreases. The Beck Depression Inventory-II score decreased from 26.06 (11.74) to 16.35 (12.51; z = 18.41; p < 0.001; d = 0.883). A good body weight outcome was predicted by a higher BMI at admission (OR = 1.828), age at onset at 15 years or higher (OR = 1.722), and higher Somatization (OR = 1.436), Anxiety (OR = 1.320), and Bulimia (OR = 1.029) scores. CBT-E involving carers is an efficient intervention for adolescents with anorexia nervosa.

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.

The clinical presentation of avoidant restrictive food intake disorder in children and adolescents is largely independent of sex, autism spectrum disorder and anxiety traits

Background

Avoidant restrictive food intake disorder (ARFID) is a new eating disorder with a heterogeneous clinical presentation. It is unclear which patient characteristics contribute to its heterogeneity.

Methods

To identify these patient characteristics, we performed symptom-level correlation and driver-level regression analyses in our cross-sectional study in up to 261 ARFID patients (51% female; median age = 12.7 years) who were assessed at the Maudsley Centre for Child and Adolescent Eating Disorders, London between November 2019 and July 2022.

Findings

Symptoms across the three drivers 1) avoidance based on sensory characteristics of food; 2) apparent lack of interest in eating; and 3) concern about aversive consequences positively correlated with each other. Patients' anxiety traits showed the greatest positive correlations with symptoms of concern about aversive consequences of eating. Patient sex was not significantly associated with any of the three ARFID drivers. Patients with comorbid autism spectrum disorder (ASD; 28%) showed more food-related sensory sensitivities (RR = 1.26) and greater lack of interest in eating (RR = 1.18) than those of patients without ASD (49%).

Interpretation

In our clinical sample, the ARFID drivers occurred together and did not show clinically meaningful differences between the sexes. ASD may accentuate food-related sensory sensitivities and lack of interest, but may not drive a completely different symptom presentation. ARFID is multi-faceted and heterogenous, requiring a comprehensive multidisciplinary assessment to sufficiently understand the drivers of the restrictive eating behaviour. Results need replication in larger samples with more statistical power.

Funding

None.

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.

Antipsychotics in the Treatment of Children and Adolescents with Anorexia Nervosa: A Systematic Review

Evidence about the use of pharmacologic agents in the treatment of Anorexia Nervosa (AN) is lacking, especially in childhood and adolescence. A systematic scoping review was conducted to outline current literature evidence about the use of antipsychotics in this population. A total of 499 studies were identified with the initial search, and 28 of these studies were selected regarding the use of olanzapine (n = 13), risperidone (n = 4), aripiprazole (n = 3), chlorpromazine (n = 3), pimozide (n = 1) clotiapine (n = 1) and multiple antipsychotics (n = 3) in these patients. Overall, major side effects were reported infrequently; improvements in psychopathology and weight measures have been suggested in the majority of the considered studies. Nonetheless, the lack of RCT or good-quality studies strongly limits the generalizability of results in clinical practice.

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.

Treatment response in children and adolescents with anorexia nervosa: a naturalistic, case-control study

PURPOSE

Although a few recent articles describe adults with treatment-resistant anorexia nervosa (TR-AN), no study addresses the specific features of subjects not responding to treatment in the developmental age. This study reports on the clinical and psychopathological variables that distinguish children and adolescents who did not respond to treatment (here "TR-AN") from good-outcome controls, in a multidisciplinary hospital treatment setting.

METHODS

Naturalistic, case-control study conducted on individuals showing lack of response to treatment and good-outcome controls. TR-AN was defined as two or more incomplete admissions and no complete admissions, consistently with studies in adults. Good-outcome was defined as complete first admission, availability for follow-up visit after 6 months, and maintaining at follow-up a %BMI > 70% in the absence of binging or purging in the preceding 3 months. Psychopathological (Eating Disorders Inventory-3 EDI-3; Beck Depression Inventory-II), clinical, and treatment variables at admission were compared. Significant differences in the univariate analyses were included in an exploratory binary logistic regression.

RESULTS

Seventy-six patients (30 TR-AN, 46 good-outcome AN controls) were enrolled (mean age 14.9 ± 1.9 years, F = 94.7%). TR-AN individuals had a higher age at admission and higher EDI-3 Eating Disorder Risk (EDRC) scores, were treated less frequently with a nasogastric tube (NGT), and achieved a lower BMI improvement at discharge than good-outcome controls. A predictive model for TR-AN status was found (X² = 19.116; Nagelkerke-R² = 0.478, p < 0.001), and age at admission (OR = 0.460, p = 0.019), EDI-3 EDRC (OR = 0.938, p = 0.043), and NGT (OR = 8.003, p = 0.019) were associated with a TR-AN status.

CONCLUSIONS

This is the first report on the psychopathological and clinical characteristics of children and adolescents not responding to treatment. These patients showed higher age and eating disorder scores, and were less frequently fed with NGT than controls. Despite the multiple incomplete admissions of our subjects, the short included follow-up limits the possibility for direct comparisons with adult samples of treatment-resistant patients. Thus, the specific features of children and adolescents with TR-AN should be assessed in longitudinal studies.

LEVEL OF EVIDENCE

III, Observational, case-control study.

Adolescent inpatients with anorexia nervosa can roughly predict their own weight trajectories after discharge

Most adolescents with anorexia nervosa (AN) gain a substantial amount of weight during inpatient treatment, but many relapse after discharge. Therefore, there is a need to identify variables that predict weight changes after treatment. The current study tested whether such a variable may be patients' own predictions about their future weight. Data of 120 female adolescent inpatients with AN were available at discharge and one-year follow-up. Patients' own predictions about their future weight trajectories predicted their actual weight change after discharge: those who indicated that they would gain weight, gained weight, those who indicated that they would lose weight, lost weight, and those who indicated to maintain their weight, had no weight change on average. Similarly, expected weight change in kilograms correlated positively with actual weight change after discharge. Thus, patients who expect that they will lose weight again should receive intensified aftercare that fosters motivation to change.

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.

Intensive Treatments in Adolescent Anorexia Nervosa

Approximately one-fifth to one-third of patients with adolescent anorexia nervosa (AN) need intensive care in the course of their illness. This article provides an update and discussion on different levels of intensive care (inpatient treatment (IP), day patient treatment (DP) and home treatment (HoT)) in different health care systems based on recently published literature. Important issues discussed in this article are new recommendations for the refeeding process and the definition of target weight as well as principles of medical stabilization and psychotherapeutic approaches. The pros and cons of longer or shorter hospitalization times are discussed, and the advantages of stepped care and day patient treatment are described. A new promising intensive treatment method involving the patient, their caregivers and the direct home environment is introduced. Parents and caregivers should be included in treatment research to foster collaborative work with the attending clinicians. There is an urgent need to evaluate the mid- to long-term outcomes of various intensive treatment programs to compare their effectiveness and costs across different health care systems. This could help policy makers and other stakeholders, such as public and private insurances, to enhance the quality of eating disorder care.

Inpatient treatment of anorexia nervosa in adolescents: A 1-year follow-up study

OBJECTIVE

Inpatient treatment effectively increases body weight and decreases eating disorder symptoms in adolescents with anorexia nervosa (AN). However, there is a high risk of relapse within the first year after discharge, which calls for investigating long-term treatment success and its moderators.

METHOD

Female adolescent inpatients with AN (N = 142) were assessed, of which 85% participated at 1-year follow-up. Dependent variables were body mass index percentiles, eating disorder symptoms, depressive symptoms, compulsive exercise and life satisfaction.

RESULTS

On average, body weight increased and eating disorder symptoms and depressive symptoms decreased from admission to discharge and remained stable at follow-up. Compulsive exercise decreased and life satisfaction increased from admission to discharge and even improved further at follow-up. Age, duration of illness, previous inpatient treatments, length of stay and readmission after discharge moderated changes in several outcome variables.

CONCLUSIONS

This study confirms the high effectiveness of inpatient treatment for adolescents with AN and demonstrates that treatment effects remain stable or even improve further within the first year after discharge. However, subgroups of patients (e.g., those with an older age, longer duration of illness, and previous inpatient treatments) require special attention during inpatient treatment and aftercare to prevent relapse.

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.

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.

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.

'Therapists in action'-Home treatment in adolescent anorexia nervosa: A stepped care approach to shorten inpatient treatment

OBJECTIVE

It was the aim of this pilot study to apply a novel eating disorder (ED)-specific home treatment (HoT) to adolescents with anorexia nervosa (AN) and to investigate its feasibility, effects and safety.

METHOD

Twenty-two patients consecutively admitted to the hospital and fulfilling DSM-5 criteria for typical or atypical AN received HoT after 4-8 weeks of inpatient treatment. During the first two months of HoT, the patient and her family were visited on average three to four times per week, during the third and fourth months of HoT once or twice a week by a multi-professional team. Body mass index, ED and general psychopathology, quality of life and treatment satisfaction were assessed in the patients at admission, start and end of HoT and the 1-year follow-up as well as carers' skills and burden.

RESULTS

The majority of patients successfully achieved target weight within HoT and maintained it successfully at the 1-year follow-up. ED and general psychopathology in the patients and carers' skills improved significantly associated with a high treatment satisfaction.

CONCLUSIONS

HoT seems to be a promising new tool to improve outcome in adolescent AN and to reduce time of hospitalisation. Larger randomised controlled trials are needed to generalise these results.

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.