There is nothing as inconsistent as the OSFED diagnostic criteria

Atypical anorexia nervosa (AAN), purging disorder (PD), night eating syndrome (NES), and subthreshold bulimia nervosa and binge-eating disorder (Sub-BN/BED) are the five categories that comprise the 'Other Specified Feeding or Eating Disorder' (OSFED) category in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). In this review, we examine problems with the diagnostic criteria that are currently proposed for the five OSFED types. We conclude that the existing diagnostic criteria for OSFED are deficient and fall short of accurately describing the complexity and individuality of those with these eating disorders (EDs). Therefore, to enhance the quality of life of people with OSFED, diagnostic criteria for the condition should be applied uniformly in clinical and research settings.

A new network analysis model in anorexia nervosa patients based on self-reported eating disorder symptoms, psychological distress, and cognitive flexibility

OBJECTIVES

Cognitive flexibility and psychological distress, such as depression and anxiety, have been implicated in the aetiology of Anorexia Nervosa (AN). Despite the known associations between eating disorder (ED) symptoms, depression, anxiety, and cognitive flexibility, the specific pathways that connect these constructs are unclear. We therefore used network analysis to examine the relationship between these symptoms in an AN sample.

METHODS

One hundred and ninety-three treatment-seeking individuals diagnosed with AN (95.6% female, M = 26.89 [SD = 9.45] years old) completed self-report measures assessing depression, anxiety, cognitive flexibility, and ED symptoms. To determine each symptom's influence in the network, we calculated the expected influence.

RESULTS

The two relationships with the greatest edges were those between (1) weight/shape concerns and eating/dietary restraint and (2) weight/shape concerns and psychological distress (a measure that combined depression and anxiety). Cognitive flexibility was not connected to weight/shape concerns but had negative partial associations with eating concerns/dietary restraint and psychological distress. There was also a slight, non-zero connection between eating concerns/dietary restraint and psychological distress.

CONCLUSIONS

The findings underscore the importance of weight/shape, eating/dietary concerns, and psychological distress in the AN network and suggest that addressing cognitive flexibility may be a useful target for eating concerns/dietary restraint and psychological distress. Future studies assessing the longitudinal course of psychopathology within the AN network structure may help in identifying whether specific symptoms function as risk factors or maintaining factors for this co-occurrence.

Validating and developing a shortened version of the detail and flexibility (DFlex) questionnaire for eating disorders, anxiety and depression

OBJECTIVE

To validate the original and a shortened version of the Detail and Flexibility (DFlex) Questionnaire.

METHOD

Confirmatory factor analyses, internal consistency, and discriminant validity estimates were conducted within individuals with a diagnosis of an eating disorder (ED) (n = 124), an anxiety disorder and/or depression (n = 219), and a community sample (n = 852) (Part 1). Convergent validity of the DFlex through comparisons with the Autism Spectrum Quotient, Wisconsin Card Sorting Task, and Group Embedded Figures Task was undertaken within a combined ED and community sample (N = 68). Test-retest reliability of the DFlex was also examined across 2 years in a community sample (N = 85) (Part 2).

RESULTS

The original factor structure of the DFlex was not supported. Hence, a shortened version, the DFlex-Revised, was developed. Good discriminant validity was obtained for the DFlex and DFlex-Revised, however, support for convergent validity was mixed. Finally, the 2-year test-retest reliability for the two DFlex versions was found to be low, suggesting potential malleability in construct over this timeframe.

CONCLUSIONS

Further research is needed to validate the DFlex in clinical and non-clinical populations using different neurocognitive tests. Test-retest, using varied time intervals, should also be assessed.

When eating disorder attitudes and cognitions persist after weight restoration: An exploratory examination of non-cognitive responders to family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Family-based treatment (FBT) is a well-established intervention for adolescent anorexia nervosa (AN). Although FBT is efficacious in promoting weight gain and improvements in psychological symptoms, for some adolescents, cognitive/attitudinal recovery lags behind weight gain. This study conducted an exploratory post hoc analysis of outcomes of adolescents who achieved weight gain by the end of FBT but continued to experience elevated psychological symptoms post-treatment.

METHODS

Data were drawn from two randomised controlled trials (RCTs) testing two forms of FBT (conjoint/whole family and parent-focussed). Descriptive statistics and generalised estimating equations were used to examine differences in treatment outcomes between non-cognitive responders (NCRs) (those who regained weight but continued to experience psychological symptoms) and full responders (FRs) (those who achieved both weight and cognitive restoration by the end of treatment) (n = 80; 83.7% female, Agemean [SD] = 14.66 [1.73]).

RESULTS

By 12 months post-treatment, there were no differences in weight between NCRs and FRs. However, NCRs had a slower trajectory of weight gain than FRs and continued to have elevated levels of psychological symptoms throughout the follow-up period.

CONCLUSIONS

A subset of adolescents appear to continue to experience clinically significant levels of eating pathology up to 12 months after FBT even when weight restoration is achieved.

Weight status and weight-control exercise in adolescents: A longitudinal population-based study

OBJECTIVE

Exercise is a transdiagnostic clinical feature of eating disorders, but consensus is lacking as to what constitutes, and gives rise to, excessive exercise motivated by weight control. Using a longitudinal cohort study, we aimed to describe population-level prevalence rates of varying levels of weight-control exercise and examine gender and weight status (overweight or obesity; OVOB) as cross-sectional determinants of weight-control exercise in 14-15-year-old adolescents. We then evaluated the association of OVOB at 10-11 years with weight-control exercise at 14-15 years.

METHODS

The sample comprised 6329 adolescents from the Longitudinal Study of Australian Children (LSAC). Weight and height were measured in early adolescence (aged 10-11) and in mid-adolescence (aged 14-15). Participants reported weight-control exercise using the Branched Eating Disorders Test at 14-15 years.

RESULTS

In mid-adolescence, the estimated population prevalence for any weight-control exercise was 49 % (55 % in females). For girls, moderate levels of exercise were most prevalent, and low levels for boys. For all levels except for the very lowest, boys with (vs. without) OVOB history (10-11 years) had about twice the odds of endorsing every level of weight-control exercise. Patterns among girls were similar, though lower in magnitude (∼1.5 times).

CONCLUSIONS

For both girls and boys, across most exercise levels, rates of weight-control exercise were greatest for those with OVOB; for the highest exercise level, effects were strongest for boys with OVOB. To accurately identify at-risk adolescents, our results provide preliminary support for a fluid definition of excessive weight-control exercise, dependent on gender and weight status.

Gender-based clinical differences in evidence-based treatment for adolescent anorexia nervosa: analysis of aggregated randomized controlled trials

PURPOSE

Boys represent a small proportion of samples in randomized clinical trials (RCT) investigating evidence-based treatment for adolescents with anorexia nervosa (AN). Consequently, knowledge of potential gender differences in clinical characteristics and treatment response in adolescents is considerably limited.

METHODS

Secondary analyses of aggregated data from two RCTs were used to characterize baseline and end-of-treatment clinical features in male and female adolescents with AN (n = 228, 10.53% male). Mixed analyses of variance were used to investigate potential gender differences in treatment response relative to weight outcomes (% median BMI) and eating disorder cognitions (Eating Disorder Examination Global scores; EDE).

RESULTS

There were no significant gender differences in prior inpatient care, illness duration, psychiatric comorbidity, or psychotropic medication use at baseline. Nor were there significant gender differences in binge eating, purging, or driven exercise at baseline or end-of-treatment. Girls reported elevated weight and shape concern compared to boys at baseline but overall reduction in EDE Global scores over the course of treatment did not differ according to gender. Boys gained more relative weight during treatment than girls, but this difference was statistically non-significant.

CONCLUSION

Overall findings do not suggest significant differences in treatment outcome relative to weight or ED cognitions, by gender. Current evidence suggests that, with the exception of shape and weight concerns, boys present with cognitive and behavioral symptoms as severe as their female counterparts which underscores the need for increased accuracy in assessment of these disorders in boys and young men.

LEVEL OF EVIDENCE

Level 1, secondary data analysis of randomized controlled trials.

Borderline personality disorder traits in adolescents with anorexia nervosa

OBJECTIVE

To examine the correlation between eating disorder (ED) symptoms and borderline personality disorder (BPD) traits in a sample of adolescents with eating disorders.

METHOD

There were 168 participants (M_age  = 16.0 years; SD = 1.16) with a diagnosis of anorexia nervosa (AN) or Eating Disorder Not Otherwise Specified-AN type. Eating Disorder Examination (EDE) and the Borderline Personality Questionnaire (BPQ) were used to assess ED symptoms and BPD traits.

RESULTS

A total of 10 participants (6.6%) scored above the clinical cut-off for a likely diagnosis of BPD. A positive correlation was observed between BPQ total score and EDE global (r_s  = 0.64, p < .001). There were also positive correlations between the BPQ self-image and emptiness subscales and all EDE subscales. Similarly, the EDE eating concern subscale was correlated with all BPQ subscales.

DISCUSSION

Previous studies have demonstrated that some BPD traits (i.e., suicidality, impulsivity, anger) are co-morbid with ED but the link with other BPD traits has been poorly studied in adolescents and those with AN. These findings indicate that while the prevalence of BPD in adolescents with AN may be relatively low, ED symptom severity is closely related to severity of BPD traits, particularly identity disturbance and feelings of emptiness.

Family-based treatment for adolescent anorexia nervosa: Outcomes of a stepped-care model

OBJECTIVE

Stepped-care models of treatment are underexplored in eating disorders. To enhance treatment outcomes, and informed by literature about adaptations to family-based treatment (FBT), we developed an FBT-based stepped-care model for adolescents with anorexia nervosa (AN) that was consistent with family preference (i.e., tailored) and responsive to adolescent needs (i.e., intensity). The aim of this study was to evaluate the effectiveness of this model in terms of remission at end-of-treatment.

METHOD

Adolescents (N = 82), aged 12-18 years (M = 15.1, SD = 1.8) and meeting Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria for AN, were assessed at baseline, Weeks 24 and 48. FBT was tailored to family preference and clinical need, with 16-18 sessions by Week 24. This was followed by three FBT booster sessions or an extension of FBT plus booster sessions (Week 48). The primary outcome was defined as weight > 95% of %median body mass index plus within 1 SD of the Eating Disorder Examination (EDE) global score community norms.

RESULTS

Remission rates were 45.1% and 52.4% at Weeks 24 and 48, respectively. Commensurable improvements were evident across secondary outcomes (e.g., EDE subscale scores). As a reference point, remission rates compared positively with results from a recent randomized clinical trial from the same center and at the same time points (Week 24:45.1% vs. 32.1% and Week 48:52.4% vs. 30.2%). Controlling for propensity score, no statistically significant differences were observed.

DISCUSSION

This stepped-care model, designed to be responsive to the individual needs of adolescents and their families, achieved encouraging rates of remission. This study provides an important signal that supports future clinical trials of stepped-care models for adolescents with AN.

Do orthorexia and intolerance of uncertainty mediate the relationship between autism spectrum traits and disordered eating symptoms?

PURPOSE

Autism spectrum disorder traits have been implicated in the psychopathology of eating disorders and may also be relevant for the development of orthorexia symptoms. Further, intolerance of uncertainty (IUS) may indirectly contribute to the development of disordered eating, as the displacement of anxiety onto food may help achieve a sense of control and maximise certainty. We examined a new cognitive model of eating pathology which assessed the role of IU and orthorexia symptoms as potential mediators of the relationship between autistic traits and disordered eating in a community sample.

METHODS

Three-hundred-and-ninety-six female participants (M = 20.07, SD = 4.52 years old) completed an online self-report questionnaire which assessed the variables of interest.

RESULTS

Despite finding significant bivariate correlations, our model results showed that autistic traits did not directly predict disordered eating or orthorexia symptoms. Significant indirect relationships were found between autistic traits and eating disorder symptoms through both IU and orthorexia symptoms.

CONCLUSION

The findings provide partial support for our proposed model suggesting that autistic traits may increase the vulnerability for disordered eating, not directly, but through their associations with mechanisms such as IU and the development of problematic eating behaviours typical of orthorexia. Future research should focus on whether targeting IU may assist in preventing the development of disordered eating.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Family-based treatment for adolescent anorexia nervosa: What happens to rates of comorbid diagnoses?

OBJECTIVE

Rates of psychiatric comorbidity are elevated in adolescents with anorexia nervosa, but little is known about how psychiatric comorbidity changes following family-based treatment (FBT).

METHODS

Adolescents with anorexia nervosa (N = 107) enrolled in a randomized controlled trial comparing two forms of FBT completed the Mini International Neuropsychiatric Interview for Children and Adolescents at baseline and end of treatment. Analyses tested whether baseline comorbid diagnoses predicted the presence of comorbid diagnoses at end of treatment and if baseline eating disorder psychopathology impacted this association.

RESULTS

Rates of comorbid diagnoses decreased from 54% at baseline to 26% at end of treatment. Logistic regression analyses indicated that individuals with multiple comorbid diagnoses at baseline were more likely to meet criteria for a comorbid condition at end of treatment (b = 2.00, p < .05). Individuals with reported psychotropic medication use were less likely to meet criteria for a comorbid condition at end of treatment (b = -1.63, p = .04). Diagnostic rates for major depressive disorder, generalized anxiety disorder, and panic disorder/agoraphobia decreased following FBT.

CONCLUSIONS

Findings suggest that FBT for adolescent anorexia nervosa may aid in the resolution of some co-occurring psychiatric diagnoses. Continued research is needed to understand factors contributing to comorbid symptom improvement throughout treatment.

Adolescent and Parent Experience of Care at a Family-Based Treatment Service for Eating Disorders

OBJECTIVE

Incorporating consumer perspectives is an important but often overlooked opportunity to optimize treatment engagement and outcomes for adolescents with eating disorders. This study explored the experience of care of adolescents and their parents at a multidisciplinary specialist eating disorders service providing family-based treatment (FBT) as first-line treatment.

METHOD

Eighty-five adolescents and 145 parents who completed FBT at the service between 2013 and 2015 were surveyed in 2017 about their experience of care. A study-designed survey asked respondents to rate on Likert scales their experience of service access, intake assessment, education, support, interactions with the treatment team, recovery, and the discharge process. Open-ended comments on helpful and unhelpful aspects of the service provided further context on the ratings.

RESULTS

Overall families were very positive about their experience, particularly in regard to assessment, education, interactions with the team, and achieving physical health. Although parents tended to be more satisfied, adolescents also held the service in high regard. Some areas were identified that could be improved, including treatment delays, carer support, therapeutic alliance, and preparation for discharge.

CONCLUSIONS

Surveying families about their experience of care provides an important opportunity to identify service strengths as well as services gaps. The results indicated several areas that specialist eating disorder services could focus on to ensure that the services provided, including FBT, fully meet the needs of families and optimize adolescents' treatment experiences.

Tackling mixed messages: Practitioner reflections on working with adolescents with atypical anorexia and their families

The treatment of atypical anorexia nervosa (AN) poses new research and practice challenges for the field of eating disorders. The objective of this study was to describe frontline practitioners' perceptions of differences between adolescents living with atypical versus typical AN, as well as the intervention challenges they experience when working with these adolescents and their families. We followed the principles of fundamental qualitative description and recruited a purposeful sample of practitioners treating adolescent eating disorders to complete a one-on-one semi-structured interview. Conventional content analysis and the constant comparison technique were used for data analysis. A total of 23 practitioners from four countries participated in this study. Practitioners described that adolescents with atypical AN present with higher pre-morbid weights and rates of weight-based teasing compared to their AN peers. Clinical challenges perceived by practitioners to be specific to working with adolescents with atypical AN included: addressing conflicting messages about eating disorders and weight loss, empathizing with a justified fear of weight gain, and increased risk for parental and therapist collusion with the eating disorder. Findings have implications for delivering interventions to adolescents seeking care for atypical AN.

Variability in remission in family therapy for anorexia nervosa

OBJECTIVE

The evolution toward more stringent conceptualizations of remission in family therapy for adolescent anorexia nervosa (AN) has, with time, introduced variability in outcomes across randomized controlled trials (RCTs). An examination of remission across the history of research on family therapy for AN shows that earlier studies adopted lenient definitions and generally yielded higher rates of remission than studies of the past decade that have used stricter definitions of remission. In this study, we investigate the reactivity of remission rates to the application of different definitions of remission used within the family therapy for AN literature, within a single RCT data set.

METHOD

We conducted a secondary analysis of data from a single-site RCT which compared the relative efficacy of two formats of family therapy in a sample of 106 Australian adolescents with AN. Using end-of-treatment data, we compared remission rates using 11 definitions of remission that have been used in studies of family therapy for AN spanning more than three decades.

RESULTS

We found wide variability in remission rates (21.7-87.7%; Cochran's Q χ² (10, N = 106) = 303.55, p = .000], depending on which definition of remission was applied. As expected, more lenient criteria produced higher remission rates than more stringent definitions.

DISCUSSION

Applying different criteria of remission to a single data set illustrates the impact of changing how remission is defined. Failure to consider the greater stringency of remission criteria in recent studies could result in false inferences concerning the efficacy of family therapy for AN over time.

Eating disorder symptoms across the weight spectrum in Australian adolescents

OBJECTIVE

Despite known associations between eating disorders and obesity, little is known about the current prevalence of symptoms of eating disorders across the weight spectrum. This study therefore aimed to estimate the population prevalence of eating disorder symptoms in relation to weight status in adolescents.

METHOD

The sample comprised 3,270 participants (14-15 years; 52% boys) drawn from Wave 6 of the Longitudinal Study of Australian Children. Symptoms of anorexia nervosa (AN) and bulimia nervosa (BN) were assessed using self-report on the Branched Eating Disorder Test. This measure identifies clinically significant symptoms in the past 3 months according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Using study-derived cross-sectional population weights, the prevalence of each symptom was estimated for the total population and by sex and weight status.

RESULTS

The estimated population prevalence was high (14.3-25.7%) for body image symptoms such as fear of weight gain and overvaluation of body weight but lower (0.5-3.7%) for behavioral symptoms such as binge eating and compensatory behaviors. Symptoms were more prevalent among adolescents with overweight or obesity. Although most symptoms tended to have higher prevalence among girls than boys, boys with obesity had higher prevalence of binge eating and excessive exercise than girls with obesity. The overall estimated population prevalence for AN and BN was 0.20% and 0.10%, respectively.

DISCUSSION

The study highlights a need for clinicians to be cognizant of disordered eating behaviors regardless of weight status and has implications for both eating disorder and obesity prevention and intervention.

Predictors of early response in conjoint and separated models of family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Early response, as indicated by early weight gain, in family-based treatment (FBT) for adolescent anorexia nervosa (AN) predicts remission at end of treatment. However, little is known about what factors contribute to early response. Further, no previous studies have examined early response to separated forms of FBT.

METHOD

Data from a randomised clinical trial of conjoint FBT and separated FBT (parent-focused treatment, PFT) were analysed to examine the timing and amount of early weight gain that predicted remission and identify factors associated with early response.

RESULTS

Weight gain of at least 2.80 kg in FBT (N = 55) and 2.28 kg in PFT (N = 51), by Session 5, were the best predictors of remission at end of treatment. Early response in FBT was predicted by greater paternal therapeutic alliance and lower paternal criticism. Early response in PFT was predicted by less severe eating-disorder symptoms and negative affect at baseline, lower maternal criticism, and greater adolescent therapeutic alliance.

CONCLUSIONS

The results confirm that early weight gain is an important prognostic indicator in both conjoint FBT and PFT and suggest that addressing negative emotion, parental criticism, and therapeutic alliance early in treatment could improve remission rates.

Reciprocal relations between dietary restraint and negative affect in adolescents receiving treatment for anorexia nervosa

Recent research has identified the important but overlooked role of negative affect in the maintenance of dietary restriction. However, understanding how fluctuations in negative affect relate to symptoms of anorexia nervosa (AN) during treatment is limited. In a longitudinal study, the reciprocal associations between higher and lower order dimensions of negative affect and dietary restraint were examined in adolescents undergoing treatment for AN. The sample consisted of 107 adolescents (Mage = 15.5, SD = 1.5 years) who underwent family-based treatment over the course of 6 months. Self-report data assessing negative affect and dietary restraint were collected at baseline, 6 times throughout treatment, and again at the end of treatment. Findings from lagged hierarchical linear models revealed reciprocal associations between higher order negative affect and dietary restraint but unidirectional associations among some dimensions of lower order affect. Specifically, dietary restraint predicted increased guilt and hostility, whereas fear predicted increased dietary restraint. These findings highlight the importance of examining the distinct dimensions of negative emotion and the temporal role of fear in precipitating dietary restraint, and guilt and hostility in proceeding dietary restraint. Collectively, these findings emphasize the functional nature of different emotions in the process of AN remission and provide preliminary evidence of affective mechanisms related to change in symptomatology during treatment for adolescent AN. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Delivery of Family-Based Treatment for Adolescent Anorexia Nervosa in a Public Health Care Setting: Research Versus Non-Research Specialty Care

Comparing evidence-based psychotherapy (EBP) to usual care typically demonstrates the superiority of EBPs, although this has not been studied for eating disorders EBPs such as family-based treatment (FBT). The current study set out to examine weight outcomes for adolescents with anorexia nervosa who received FBT through a randomized clinical research trial (RCT, n = 54) or non-research specialty care (n = 56) at the same specialist pediatric eating disorder service. Weight was recorded throughout outpatient treatment (up to 18 sessions over 6 months), as well as at 6- and 12-month follow-up. Survival curves were used to examine time to weight restoration [greater than 95% median body mass index (mBMI)] as predicted by type of care (RCT vs. non-research specialty care), baseline clinical and demographic characteristics, and their potential interaction. Results did not indicate a significant main effect for type of care, but there was a significant effect for baseline weight (p = .03), such that weight restoration was achieved faster across both treatment types for those with a higher initial %mBMI. These data suggest that weight restoration achieved in non-research specialty care FBT was largely similar to that achieved in a controlled research trial.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/, identifier ACTRN12610000216011.

Body Image Dissatisfaction and the Adrenarchal Transition

BACKGROUND

Puberty marks a transition in risk for body image disturbance and disordered eating. Yet few studies have examined these symptoms across puberty and none have examined links with adrenarche, the earliest phase in the pubertal hormonal cascade.

METHOD

Levels of adrenal androgens (dehydroepiandrosterone, dehydroepiandrosterone sulphate, and testosterone) were measured in a population-based study of 8- to 9-year-old children (516 males and 621 females). Body dissatisfaction was measured using the Kids' Eating Disorder Scale Silhouettes. Covariates included body mass index, age, and socioeconomic status.

RESULTS

There were significant associations between adrenal androgen levels and greater body dissatisfaction in both males and females. Specifically, females with more advanced levels of dehydroepiandrosterone and testosterone relative to peers, and males with more advanced levels of testosterone relative to peers, reported greater body dissatisfaction. However, after adjusting for covariates, hormones levels were no longer associated with body dissatisfaction, and only higher body mass index had a clear association with body dissatisfaction.

CONCLUSIONS

The adrenarchal transition brings a heightened risk for body dissatisfaction. Whether this arises from the neuroendocrine effects of adrenal androgens or as a reaction to the greater body mass that accompanies adrenarche requires further exploration.

"They don't really get heard": A qualitative study of sibling involvement across two forms of family-based treatment for adolescent anorexia nervosa

Little is known about the involvement of siblings in family-based treatment (FBT) for anorexia nervosa (AN). To explore the experience of families, adolescents who had completed FBT, their siblings, and parents were interviewed. Siblings reported that involvement in FBT enhanced their understanding of anorexia and that they supported their family in various ways. While siblings often wished they had attended more sessions, there was no consensus among parents and patients regarding sibling attendance and many were concerned about potential negative impacts on siblings. Clinicians should discuss sibling roles and expectations early in FBT and work actively with families to address concerns.

Feasibility of a parent education and skills workshop for improving response to family-based treatment of adolescent anorexia nervosa

OBJECTIVE

Early response to family-based treatment (FBT) is a robust predictor of positive outcomes for adolescents with anorexia nervosa (AN). We introduced a parent education and skills workshop in the first 4 weeks of treatment with the aim of improving changes in parent self-efficacy in FBT and, in turn, patient weight gain.

METHOD

Forty-five families who had at least one parent attend the workshop were compared to a matched control of families who did FBT before the workshop was introduced.

RESULTS

Among adolescents who were underweight at baseline, weight gain by Week 4 of treatment was higher for adolescents whose parents attended the workshop (M = 90.84% median BMI) than those who did not (M = 88.54% mBMI, p < .05). There was no significant difference in weight at Week 12 or at end of treatment, nor was there a difference in self-efficacy as measured by the Parent Versus Anorexia Scale. Participants reported a high level of satisfaction with the workshop and significant improvements in knowledge and confidence.

DISCUSSION

Overall, the workshop was a feasible adjunct for improving early response to FBT.

Body image diversity in the media: A content analysis of women's fashion magazines

ISSUE ADDRESSED

The narrow representation of body image in the media has been linked to body dissatisfaction, particularly among readers of women's fashion magazines. Some countries have made efforts to improve body image diversity in the media and the fashion industry. This has included attempts to regulate minimum body size of models (eg, Israel, France), and the development of codes of practices such as the Australian Industry Code of Conduct on Body Image. However, there is little evidence of whether these efforts have impacted media content.

METHOD

This study aimed to gauge the state of body image diversity in the print media 5 years after the introduction of the Australian Code of Conduct via a content analysis of 13 Australian women's fashion magazines published in 2015.

RESULTS

Results revealed low levels of diversity in body size, ethnicity and age among models depicted in fashion magazine images. Models were predominantly young, white and underweight.

CONCLUSION

The results suggest that efforts to improve body image diversity have had little impact on print media. Further research is needed to understand the barriers to increased diversity in the representation of body image in the media so that the industry and regulatory bodies can further address this important issue. This is increasingly pressing given the proliferation of content now enabled through online media platforms.

The modeled cost-effectiveness of family-based and adolescent-focused treatment for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a prevalent, serious mental disorder. We aimed to evaluate the cost-effectiveness of family-based treatment (FBT) compared to adolescent-focused individual therapy (AFT) or no intervention within the Australian healthcare system.

METHOD

A Markov model was developed to estimate the cost and disability-adjusted life-year (DALY) averted of FBT relative to comparators over 6 years from the health system perspective. The target population was 11-18 year olds with AN of relatively short duration. Uncertainty and sensitivity analyses were conducted to test model assumptions. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted.

RESULTS

FBT was less costly than AFT. Relative to no intervention, the mean ICER of FBT and AFT was $5,089 (95% uncertainty interval (UI): dominant to $16,659) and $51,897 ($21,591 to $1,712,491) per DALY averted. FBT and AFT are 100% and 45% likely to be cost-effective, respectively, at a threshold of AUD$50,000 per DALY averted. Sensitivity analyses indicated that excluding hospital costs led to increases in the ICERs but the conclusion of the study did not change.

CONCLUSION

FBT is the most cost-effective among treatment arms, whereas AFT was not cost-effective compared to no intervention. Further research is required to verify this result.

Parental Expressed Emotion During Two Forms of Family-Based Treatment for Adolescent Anorexia Nervosa

High parental expressed emotion (EE), reflected by criticism or emotional over-involvement, has been related to poorer outcome in family-based treatment (FBT) for adolescent anorexia nervosa. This study assessed EE in 89 mothers and 64 fathers at baseline and end of treatment in a randomised trial comparing conjoint FBT to parent-focused FBT (PFT). Compared with conjoint FBT, PFT was associated with a decrease in maternal criticism, regardless of adolescent remission. Furthermore, an increase in maternal criticism was more likely to be observed in conjoint FBT (80%) than PFT (20%, p = 0.001). Adolescents of mothers who demonstrated an increase in EE, or remained high in EE, were less likely to remit compared with adolescents for whom EE decreased or remained low (33% and 0% vs. 43% and 50%, p = 0.03). There were no significant effects for paternal EE. The results highlight the importance of considering EE when implementing FBT for adolescents with anorexia nervosa. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Symptom trajectories throughout two family therapy treatments for adolescent anorexia nervosa

OBJECTIVE

This study aimed to examine the trajectory of symptom remission and affective functioning throughout the course of two family-based treatments for adolescent anorexia nervosa (AN): conjoint family-based treatment (FBT) and parent-focused treatment (PFT).

METHOD

Participants were 107 adolescents (M_age  = 15.5 years, SD = 1.5) with a primary diagnosis of AN who participated in a randomized clinical trial comparing FBT (N = 55) and PFT (N = 51). Patient weight and self-reported assessments of dietary restraint and positive and negative affect were recorded at regular intervals throughout treatment.

RESULTS

Multilevel models revealed increases in weight (β = 0.33, p < .001) and positive affect (β = 0.03, p < .001), and decreases in dietary restraint (β = -0.03, p < .001) and negative affect (β = -0.04, p < .001) over the course of treatment. No significant effects emerged by treatment type.

DISCUSSION

These findings suggest that PFT may bring about comparable trajectories of weight gain and reduced dietary restraint as conjoint FBT, despite adolescents not being directly involved in treatment. These findings also highlight that the exclusively behavioral focus throughout both PFT and FBT is associated with significant increments in positive affect and significant reductions in negative affect.

The Participation of Mothers, Fathers, and Siblings in Family-Based Treatment for Adolescent Anorexia Nervosa

In family-based treatment (FBT) for adolescent anorexia nervosa, all family members are encouraged to attend sessions with the understanding that absences negatively impact treatment. There are, however, many obstacles to family members' attendance, and there is no research to indicate whether family member attendance improves treatment outcomes. We examined attendance patterns of 198 families who participated in FBT at a specialist pediatric eating disorders program and assessed the extent to which participation by mothers (n = 194), fathers (n = 175), and siblings (n = 165; 50% female) predicted outcome. All mothers attended at least one session, and 74% attended all sessions. By comparison, 95% of fathers and 73% of siblings attended at least one session, and 33% of fathers and 1% of siblings attended all sessions. The mean proportion of sessions attended was 94% for mothers, 72% for fathers, and 20% for siblings. Over 6 months of treatment, the proportion of mothers who attended each session was largely stable; fathers' attendance declined slowly, and siblings' attendance declined more rapidly. Greater attendance by fathers predicted higher weight and lower eating disorder symptoms in adolescents at end of treatment. Remission at end of treatment was associated with higher attendance by fathers (M = 81% vs. M = 69%). Achieving sustained engagement of the whole family system in FBT is a considerable challenge. However, this study demonstrates that implementing processes that encourage and enable family members to attend treatment sessions could have significant benefits for patient outcomes.

The Differential Effects of Mindfulness and Distraction on Affect and Body Satisfaction Following Food Consumption

This study investigated whether engaging in mindfulness following food consumption produced changes in affect and body satisfaction, as compared to a control distraction task. The moderating effects of eating pathology and neuroticism were also examined. A total of 110 female university students consumed food and water before engaging in either a mindfulness induction or a control distraction task. Participants completed trait measures of eating pathology and neuroticism at baseline, and measures of state affect and body satisfaction before and after food consumption, and after the induction. Results revealed that consuming food and water reduced positive affect. Unexpectedly, both the mindfulness group and distraction control group experienced similar improvements in negative affect and body satisfaction following the induction. Eating pathology and neuroticism did not moderate the observed changes. These findings suggest that both mindfulness and distraction may contribute to the effectiveness of treatments for disordered eating that incorporate both of these techniques, such as Dialectical Behavior Therapy.

The Anorexia Nervosa Genetics Initiative: Study description and sample characteristics of the Australian and New Zealand arm

OBJECTIVES

Anorexia nervosa is a severe psychiatric disorder with high mortality rates. While its aetiology is poorly understood, there is evidence of a significant genetic component. The Anorexia Nervosa Genetics Initiative is an international collaboration which aims to understand the genetic basis of the disorder. This paper describes the recruitment and characteristics of the Australasian Anorexia Nervosa Genetics Initiative sample, the largest sample of individuals with anorexia nervosa ever assembled across Australia and New Zealand.

METHODS

Participants completed an online questionnaire based on the Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) eating disorders section. Participants who met specified case criteria for lifetime anorexia nervosa were requested to provide a DNA sample for genetic analysis.

RESULTS

Overall, the study recruited 3414 Australians and 543 New Zealanders meeting the lifetime anorexia nervosa case criteria by using a variety of conventional and social media recruitment methods. At the time of questionnaire completion, 28% had a body mass index ⩽ 18.5 kg/m². Fasting and exercise were the most commonly employed methods of weight control, and were associated with the youngest reported ages of onset. At the time of the study, 32% of participants meeting lifetime anorexia nervosa case criteria were under the care of a medical practitioner; those with current body mass index < 18.5 kg/m² were more likely to be currently receiving medical care (56%) than those with current body mass index ⩾ 18.5 kg/m² (23%). Professional treatment for eating disorders was most likely to have been received from general practitioners (45% of study participants), dietitians (42%) and outpatient programmes (42%).

CONCLUSIONS

This study was effective in assembling the largest community sample of people with lifetime anorexia nervosa in Australia and New Zealand to date. The proportion of people with anorexia nervosa currently receiving medical care, and the most common sources of treatment accessed, indicates the importance of training for general practitioners and dietitians in treating anorexia nervosa.

A case series of family-based treatment for adolescents with atypical anorexia nervosa

The aim of this case series was to examine engagement in and outcomes of family-based treatment (FBT) for adolescents with DSM-5 atypical AN, that is, adolescents who were not underweight at presentation. Consecutive referrals for FBT of adolescents with atypical AN to a specialist child and adolescent eating disorder program were examined. Engagement in treatment (i.e., dose of treatment, completion rate), and changes in psychological symptomatology (i.e., eating disorder symptoms, depressive symptoms, self-esteem, obsessive compulsiveness), weight, and menstrual function were examined. The need for additional interventions (i.e., hospitalization and medication), and estimated remission rates were also examined. The sample comprised 42 adolescents aged 12-18 years (88% female). Engagement in FBT was high, with 83% completing at least half the treatment dose. There were significant decreases in eating disorder and depressive symptoms during FBT (p < .05) but no improvement in self-esteem. There was no significant change in percent of median BMI for age and gender for the sample as a whole (105 vs. 106%, p = .128). However, adolescents who were not admitted to hospital prior to FBT gained some weight (M = 3.4 kg) while those who were admitted did not gain weight during FBT (M = 0.2 kg, p < .01). The overall remission rate ranged from 38 to 52% depending on the criteria applied. FBT appears to be an effective treatment for adolescents with atypical AN. However, more research is needed into systematic adaptations of FBT and other treatments that could improve overall remission rates.

The effect of low parental warmth and low monitoring on disordered eating in mid-adolescence: Findings from the Australian Temperament Project

OBJECTIVE

To investigate the interactions between low parental warmth and monitoring at age 13-14 years and disordered eating attitudes and behaviours at age 15-16 years.

METHOD

Data on 1300 (667 females) adolescents and their parents were drawn from The Australian Temperament Project (ATP), a 30 year (15 wave) population based longitudinal study of social-emotional development. Parent participants completed surveys on parenting practices in late childhood, and adolescent participants reported disordered eating using the drive for thinness and bulimia subscales of the Eating Disorder Inventory (EDI) and an additional body dissatisfaction scale. Interaction was examined on the additive scale by estimating super-additive risk; i.e., risk in excess of the sum of individual risks.

RESULTS

For boys, neither parental warmth or monitoring, nor their interaction, was related to disordered eating. For girls, low parental warmth (alone) was associated with bulimic behaviours. In contrast, exposure to both low monitoring and warmth was associated with ∼3½-fold, ∼4-fold and ∼5-fold increases in the odds of reporting body dissatisfaction, drive for thinness and bulimia, respectively. For body dissatisfaction and drive for thinness, risk associated with joint exposure exceeded the sum of individual risks, suggesting an additive interaction between parenting styles.

CONCLUSION

Further investment in family-level interventions that focus on promoting parental monitoring behaviour and a warm parent-child relationship remain important strategies for preventing a range of disordered eating behaviours in adolescents.

Psychosocial Well-being of Siblings of Adolescents with Anorexia Nervosa

OBJECTIVE

Anorexia nervosa (AN) is often first diagnosed in the adolescent years. The treatment with the greatest evidence during this time is family-based treatment (FBT). In FBT, siblings are expected to attend treatment sessions; however, sibling well-being during this time has not been well researched. This study aimed to explore sibling well-being when the ill child was initially diagnosed with AN and after FBT had been completed.

METHOD

Eighty-five parents and 55 siblings of adolescents with AN completed the Strengths and Difficulties Questionnaire at diagnosis. In addition, 88 parents and 46 siblings completed the Strengths and Difficulties Questionnaire after finishing treatment.

RESULTS

Mothers and fathers reported siblings to have lower levels of conduct problems in comparison with population norms. Mothers also reported lower levels of prosocial behaviours. Siblings reported higher levels of emotional difficulties and hyperactivity in comparison with their peers. There were no differences in reported psychosocial well-being of siblings between diagnosis and following FBT.

CONCLUSIONS

Siblings of adolescents with AN have poorer psychosocial adjustment than their peers, both before and after FBT. Clinicians and parents are encouraged to be aware of sibling difficulties and seek additional support if required. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Randomized Clinical Trial of Parent-Focused Treatment and Family-Based Treatment for Adolescent Anorexia Nervosa

OBJECTIVE

There have been few randomized clinical trials (RCTs) for adolescents with anorexia nervosa (AN). Most of these posit that involving all family members in treatment supports favorable outcomes. However, at least 2 RCTs suggest that separate parent and adolescent sessions may be just as effective as conjoint treatment. This study compared the relative efficacy of family-based treatment (FBT) and parent-focused treatment (PFT). In PFT, the therapist meets with the parents only, while a nurse monitors the patient.

METHOD

Participants (N = 107) aged 12 to 18 years and meeting DSM 4(th)Edition criteria for AN or partial AN were randomized to either FBT or PFT. Participants were assessed at baseline, end of treatment (EOT), and at 6 and 12 months posttreatment. Treatments comprised 18 outpatient sessions over 6 months. The primary outcome was remission, defined as ≥95% of median body mass index and Eating Disorder Examination Global Score within 1 SD of community norms.

RESULTS

Remission was higher in PFT than in FBT at EOT (43% versus 22%; p = .016, odds ratio [OR] = 3.03, 95% CI = 1.23-7.46), but did not differ statistically at 6-month (PFT 39% versus FBT 22%; p = .053, OR = 2.48, CI = 0.989-6.22), or 12-month (PFT 37% versus FBT 29%; p = .444, OR = 1.39, 95% CI = 0.60-3.21) follow-up. Several treatment effect moderators of primary outcome were identified.

CONCLUSION

At EOT, PFT was more efficacious than FBT in bringing about remission in adolescents with AN. However, differences in remission rates between PFT and FBT at follow-up were not statistically significant.

CLINICAL TRIAL REGISTRATION INFORMATION

A Randomised Controlled Trial of Two Forms of Family-Based Treatment and the Effect on Percent Ideal Body Weight and Eating Disorders Symptoms in Adolescent Anorexia Nervosa; http://www.anzctr.org.au/; ACTRN12610000216011.

Physical and Psychological Morbidity in Adolescents With Atypical Anorexia Nervosa

BACKGROUND AND OBJECTIVE

Adolescents with atypical anorexia nervosa (AN) have lost significant weight but are not underweight. This study aimed to describe the physical and psychological morbidity of adolescents diagnosed with atypical AN, and to compare them with underweight adolescents with AN.

METHODS

All first presentations of atypical AN (n = 42) and full-threshold AN (n = 118) to a specialist pediatric eating disorder program between July 2010 and June 2014 were examined. Diagnosis was assessed by using the Eating Disorder Examination and anthropometric measurement. Psychological morbidity measures included eating and weight concerns, bingeing, purging, compulsive exercise, and psychiatric comorbidity.

RESULTS

Compared with AN, more adolescents with atypical AN were premorbidly overweight or obese (71% vs 12%). They had lost more weight (17.6 kg vs 11.0 kg) over a longer period (13.3 vs 10.2 months). There was no significant difference in the frequency of bradycardia (24% vs 33%;) or orthostatic instability (43% vs 38%). We found no evidence of a difference in frequency of psychiatric comorbidities (38% vs 45%) or suicidal ideation (43% vs 39%). Distress related to eating and body image was more severe in atypical AN.

CONCLUSIONS

Atypical AN considerably affects physical and psychological functioning, despite adolescents presenting within or above the normal weight range. There was little evidence that the morbidity of adolescents with atypical AN was any less severe than that of adolescents with full-threshold AN. The findings support the need for vigilance around weight loss in adolescents, regardless of body size.

Who's in the Room? A Parent-Focused Family Therapy for Adolescent Anorexia Nervosa

Family therapy is often assumed to involve the whole family; that is both parents and children attending the therapist's office together. In practice, however, which family members are included in family therapy, how often, and in what ways, is much more variable. In this article we provide an overview of the recent history of family therapy in regard to who is directly involved in therapy, and contrast changing practices in the eating disorders field with those in the family therapy field more widely. This overview leads into a discussion of current practices in family-based treatment for adolescent anorexia nervosa and the development of a new form of family therapy that is parent-focused.

Developmental antecedents of abnormal eating attitudes and behaviors in adolescence

OBJECTIVE

This study capitalizes on developmental data from an Australian population-based birth cohort to identify developmental markers of abnormal eating attitudes and behaviors in adolescence. The aims were twofold: (1) to develop a comprehensive path model identifying infant and childhood developmental correlates of Abnormal Eating Attitudes and Behaviors in adolescence, and (2) to explore potential gender differences.

METHOD

Data were drawn from a 30-year longitudinal study that has followed the health and development of a population based cohort across 15 waves of data collection from infancy since 1983: The Australian Temperament Project. Participants in this analysis were the 1,300 youth who completed the 11th survey at 15-16 years (1998) and who completed the eating disorder inventory at this time point.

RESULTS

Developmental correlates of Abnormal Eating Attitudes and Behaviors in mid-adolescence were temperamental persistence, early gestational age, persistent high weight, teen depression, stronger peer relationships, maternal dieting behavior, and pubertal timing. Overall, these factors accounted for 28% of the variance in Abnormal Eating Attitudes and Behaviors at 15-16 years of age. Depressive symptoms, maternal dieting behavior, and early puberty were more important factors for girls. Late puberty was a more important factor for boys.

DISCUSSION

Findings address an important gap in our understanding of the etiology of Abnormal Eating Attitudes and Behaviors in adolescence and suggest multiple targets for preventive intervention.

Implementation of family-based treatment for adolescents with anorexia nervosa

Although the implementation of new treatment models can be a challenging process for health care services, the outcomes can be greatly beneficial to patients and service providers. This article describes the process of change experienced within our multidisciplinary specialist eating disorder service when we implemented a new evidence-based model of care focusing on outpatient family-based treatment (FBT). Clinical outcomes were positive, including a 56% decrease in admissions, a 75% decrease in readmissions, and a 51% decrease in total bed days. Of families referred to FBT, 83% completed treatment and 97% of completers achieved >90% of their expected body weight. Despite these gains, many challenges were experienced, including misgivings about the suitability of FBT and difficulties in adhering to changes in professional roles. We describe these challenges, describe how they were overcome, and review factors perceived to be critical to the program's success, including integration of medical and mental health services, communication, and training.

Parent-focused treatment for adolescent anorexia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Family-based treatment is an efficacious outpatient intervention for medically stable adolescents with anorexia nervosa. Previous research suggests family-based treatment may be more effective for some families when parents and adolescents attend separate therapy sessions compared to conjoint sessions. Our service developed a novel separated model of family-based treatment, parent-focused treatment, and is undertaking a randomised controlled trial to compare parent-focused treatment to conjoint family-based treatment.

METHODS/DESIGN

This randomised controlled trial will recruit 100 adolescents aged 12-18 years with DSM-IV anorexia nervosa or eating disorder not otherwise specified (anorexia nervosa type). The trial commenced in 2010 and is expected to be completed in 2015. Participants are recruited from the Royal Children's Hospital Eating Disorders Program, Melbourne, Australia. Following a multidisciplinary intake assessment, eligible families who provide written informed consent are randomly allocated to either parent-focused treatment or conjoint family-based treatment. In parent-focused treatment, the adolescent sees a clinical nurse consultant and the parents see a trained mental health clinician. In conjoint family-based treatment, the whole family attends sessions with the mental health clinician. Both groups receive 18 treatment sessions over 6 months and regular medical monitoring by a paediatrician. The primary outcome is remission at end of treatment and 6 and 12 month follow up, with remission defined as being ≥ 95% expected body weight and having an eating disorder symptom score within one standard deviation of community norms. The secondary outcomes include partial remission and changes in eating pathology, depressive symptoms and self-esteem. Moderating and mediating factors will also be explored.

DISCUSSION

This will be first randomised controlled trial of a parent-focused model of family-based treatment of adolescent anorexia nervosa. If found to be efficacious, parent-focused treatment will offer an alternative approach for clinicians who treat adolescents with anorexia nervosa.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12610000216011.

NICU-only versus universal screening for newborn hearing loss: Population audit

AIM

Targeted newborn hearing screening for infants in neonatal intensive care units (NICUs) may be considered when resources preclude universal newborn hearing screening (UNHS). However, process outcomes have not been compared between stand-alone NICU hearing screening programs and NICU screening within a full UNHS program.

METHODS

Comparison of two consecutive hearing screening programs delivered under similar conditions in the four NICUs in Victoria, Australia. All NICU infants were eligible for pre-discharge automated auditory brainstem response (AABR) hearing screening. Capture, referral and diagnostic data were collected for all NICU infants during the NICU-only (April 2003-February 2005) and subsequent UNHS (April 2005-June 2006) programs.

RESULTS

4704 eligible infants were admitted during the 23-month NICU-only period, and 3160 during the 15-month UNHS period. Double AABR using ALGO 3i equipment was planned for both programs but, due to clinician concern about this high-risk clinical population, the NICU-only protocol was amended to single AABR using AccuScreen equipment. Capture rates were 71.1% (NICU-only) vs. 95.4% (UNHS) (P < 0.001), successful follow-up rates were 85.8% vs. 96% (P= 0.004), and mean corrected age at the first audiology appointment was 51.5 vs. 40.2 days (P= 0.05).

CONCLUSIONS

NICU screening offered within a larger UNHS program outperformed the stand-alone NICU hearing screening program on all measured parameters. Greater resourcing might address shortcomings of the stand-alone program but would also reduce its potential savings. The high loss to follow-up also argues against the often-advocated approach of referring all NICU infants for diagnostic audiologic testing, bypassing hearing screening altogether.

Emotion regulation moderates relationships between body image concerns and psychological symptomatology

The study investigated the moderating role of emotion regulation (ER) in relationships between body image concerns and psychological symptomatology. A community sample of 533 boys and girls (11-20 years) completed measures assessing body image thoughts and feelings, domain-specific and general ER strategies, drive for thinness, and bulimic, depressive and anxiety symptoms. Results indicated that ER moderated relationships between body image concerns and both bulimic and depressive symptoms, but not relationships between body image concerns and drive for thinness or anxiety symptoms. Adolescents who reported frequent body image concerns were more likely to have higher levels of bulimic symptoms if they tended to use avoidance and internal dysfunctional ER strategies. Furthermore, adolescents who reported frequent body image concerns were more likely to have higher levels of depressive symptoms if they used positive rational acceptance and internal functional strategies infrequently. Implications of the findings for prevention and intervention are discussed.

Discrepancies between adolescent, mother, and father reports of adolescent internalizing symptom levels and their association with parent symptoms

Discrepancies among informants on measures of internalizing symptoms in children and adolescents are common in the literature. One reason proposed for such discrepancies is that psychopathology may distort or bias third-party reports. In the present study, measures of adolescent internalizing symptom levels were completed by adolescents aged 13 to 18 years and their mothers and fathers. Parents also completed measures of their own depression, anxiety, and stress symptoms. Parent symptoms explained a small amount of variance in discrepancies between informants. Specifically, mothers' depression and stress symptoms were associated with discrepancies regarding sons' symptomatology and fathers' anxiety and stress symptoms were associated with discrepancies regarding daughters' symptomatology. Implications of informant discrepancies for both clinical practice and research are discussed.

The normative development of emotion regulation strategy use in children and adolescents: a 2-year follow-up study

BACKGROUND

Emotion regulation involves intrinsic and extrinsic processes responsible for managing one's emotions toward goal accomplishment. Research on emotion regulation has predominantly focused on early developmental periods and the majority of emotion regulation research examining the pre-adult years has lacked a comprehensive theoretical framework. The current study examined the use of two strategies of emotion regulation during childhood and adolescents, as conceptualised within Gross's (1998) process-oriented model.

METHODS

To determine the use, norms and development of the Expressive Suppression and Cognitive Reappraisal strategies, the Emotion Regulation Questionnaire for Children and Adolescents (ERQ-CA) was administered to 1,128 participants aged between 9 and 15 years. Three data collection phases, each one year apart, enabled investigation of developmental patterns in the use of the two strategies.

RESULTS

As predicted, Suppression use was found to be lower for older participants compared to their younger peers, and over time participants reported less use of this strategy. Older participants also scored lower on Reappraisal but stability over time was found. Also as expected, males reported more Suppression use compared to females.

CONCLUSIONS

By documenting the development and norms for Cognitive Reappraisal and Expressive Suppression in a community sample of children and adolescents, the current study makes a significant contribution to our understanding of these two ER strategies during these developmental periods.