Patient and clinician perspectives on supported mealtimes as part of anorexia nervosa treatment: A systematic review and qualitative synthesis

OBJECTIVE

To systematically review the literature on clinicians' and patients' experiences of supported mealtimes in the treatment of anorexia nervosa.

METHOD

This systematic review was conducted in accordance with PRISMA guidelines and registered on PROSPERO (CRD42022372565). PsycINFO, MEDLINE and Embase were searched up to the 20th of November 2023 for qualitative articles investigating the perspectives of healthcare professionals and patients on clinician-supported meals across all clinical settings. Data were analysed using thematic synthesis. The Critical Appraisal Skills Programme was used to evaluate the quality of selected studies.

RESULTS

This review comprised of 26 studies; eight concerned with the perspectives of clinicians only, 16 addressing patients' views, and two studies exploring the views of both groups. Experiences of both groups were generally negative, and three overlapping themes were identified: lack of consistency in care provided, high levels of negative emotions and an uncomfortable power dynamic.

CONCLUSIONS

This review suggests that supported mealtimes are experienced more positively by patients when rules are clear and consistently enforced, and when clinicians make informal conversation and supportive comments. Our findings highlight the need for best practice guidelines and clinician training to improve the delivery of supported mealtimes. Such guidelines and training should be coproduced in collaboration with patients and carers.

A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID)

OBJECTIVE

This scoping review identifies and describes psychological interventions for avoidant restrictive food intake disorder (ARFID) and summarizes how outcomes are measured across such interventions.

METHOD

Five databases (Cochrane, Embase, Medline, PsycInfo, Web of Science) were searched up to December 22, 2022. Studies were included if they reported on psychological interventions for ARFID. Studies were excluded if participants did not have an ARFID diagnosis and if psychological interventions were not delivered or detailed.

RESULTS

Fifty studies met inclusion criteria; almost half were single-case study designs (23 studies) and most studies reported on psychological interventions for children and adolescents with ARFID (42 studies). Behavioral interventions (16 studies), cognitive-behavioral therapy (10 studies), and family therapy (5 studies), or combinations of these therapeutic approaches (19 studies) were delivered to support patients with ARFID. Many studies lacked validated measures, with outcomes most commonly assessed via physical health metrics such as weight.

DISCUSSION

This review provides a comprehensive summary of psychological interventions for ARFID since its introduction to the DSM-5. Across a range of psychological interventions and modalities for ARFID, there were common treatment components such as food exposure, psychoeducation, anxiety management, and family involvement. Currently, studies reporting on psychological interventions for ARFID are characterized by small samples and high levels of heterogeneity, including in how outcomes are measured. Based on reviewed studies, we outline suggestions for clinical practice and future research.

PUBLIC SIGNIFICANCE

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by avoidance or restriction of food due to fear, sensory sensitivities, and/or a lack of interest in food. We reviewed the literature on psychological interventions for ARFID and the outcomes used to measure change. Several psychological interventions have been developed and applied to patients with ARFID. Outcome measurement varies widely and requires further development and greater consensus.

Early parenting interventions to prevent internalising problems in children and adolescents: a global systematic review and network meta-analysis

QUESTION

We compared the effectiveness of different types of parenting interventions based on an a priori taxonomy, and the impact of waitlists versus treatment as usual (TAU), in reducing child internalising problems.

STUDY SELECTION AND ANALYSIS

We conducted a systematic review and network meta-analysis of published and unpublished randomised controlled trials (RCTs) until 1 October 2022 that investigated parenting interventions with children younger than 4 years.

EXCLUSION CRITERIA

studies with children born preterm, with intellectual disabilities, or families receiving support for current abuse, neglect, and substance misuse. We assessed the certainty of evidence using the Confidence in Network Meta-Analysis framework. We used random-effects network meta-analysis to estimate standardised mean differences (SMDs) with 95% credible intervals (CrIs).

FINDINGS

Of 20 520 citations identified, 59 RCTs (18 349 participants) were eligible for the network meta-analysis. Parenting interventions focusing on the dyadic relationship (SMD: -0.26, 95% CrI: -0.43 to -0.08) and those with mixed focus (-0.09, -0.17 to -0.02) were more effective in reducing internalising problems than TAU at the first time point available. All interventions were more effective than waitlist, which increased the risk of internalising problems compared with TAU (0.36, 0.19 to 0.52). All effects attenuated at later follow-ups. Most studies were rated as with 'high risk' or 'some concerns' using the Risk of Bias Assessment Tool V.2. There was no strong evidence of effect modification by theoretically informed components or modifiers.

CONCLUSIONS

We found preliminary evidence that relationship-focused and mixed parenting interventions were effective in reducing child internalising problems, and the waitlist comparator increased internalising problems with implications for waiting times between referral and support. Considering the high risk of bias of most studies included, the findings from this meta-analysis should be interpreted with caution. PROSPERO registration number CRD42020172251.

Attachment in individuals with eating disorders compared to community controls: A systematic review and meta-analysis

OBJECTIVE

Individuals with eating disorders are known to have higher rates of insecure attachment compared to community controls, but the factors underlying this finding are poorly understood. We conducted the first meta-analysis comparing attachment in eating disorder samples compared to community controls that included quality assessment, publication bias and moderation analysis.

METHOD

We pre-registered our meta-analysis (CRD42019146799) and followed PRISMA guidelines. We searched PsychINFO, Embase, Medline, CINAHL, and Scopus for publications. Attachment scores were extracted, and Cohen's d calculated for each study using a random effects model.

RESULTS

In total, 35 studies were included in the meta-analysis and six studies were summarized in a narrative review. Eating disorder samples showed higher rates of insecure attachment compared to community controls, with a large effect size, across measurement methods and different attachment dimensions. Blinding of assessors moderated effect sizes for attachment interview studies, but no other moderators were significant.

DISCUSSION

Risk of insecure attachment is elevated in individuals with eating disorders, albeit heterogeneity is high and largely unexplained. Clinicians may need to take this into account in their work, particularly given the association between attachment insecurity and challenges to therapeutic alliance. Future studies comparing eating disorder samples with community samples should control for general psychopathology.

PUBLIC SIGNIFICANCE

Attachment is a broad concept referring to a person's thoughts, feelings and behaviors in relation to close others. This systematic review and meta-analysis found that individuals with eating disorders are lower in attachment security than community controls, regardless of attachment construct or measurement approach. Attachment may be relevant in influencing eating disorder recovery, the development of therapeutic alliance, and potentially clinical outcomes, although more research is needed.

Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa

Anorexia nervosa-focussed family therapy (FT-AN) is the first-line treatment for adolescent anorexia nervosa (AN), but the predictors of poor treatment response are not well understood. The main aim of this study was to investigate the role of attachment and mentalization in predicting treatment outcome. The secondary aims of the study were to investigate therapeutic alliance at 1 month as a predictor of outcome, and to test the associations between alliance and baseline attachment and mentalization. 192 adolescents with AN and their parents were recruited as they began family therapy in out-patient specialist eating disorder services. Self-report measures of attachment, mentalization, and emotion regulation were completed at the start of treatment by adolescent patients and one of their parents. Self-reported alliance scores were collected at one month. Higher scores on the Certainty Scale of the Reflective Functioning Questionnaire, completed by parents, which indicate over-certainty about mental states, were the strongest predictor of poor outcome (Odds Ratio: 0.42, CI: 0.20-0.87). Similarly, for adolescents, higher Lack of Clarity scores on the Difficulties in Emotion Regulation Scale, representing being unclear about one's feelings, were predictive of positive treatment outcome (OR: 1.10, CI: 1.00-1.21). Higher alliance scores at 1 month predicted positive outcome, and were associated with attachment security and mentalization. These novel findings suggest that, particularly in parents, a tendency towards excessive certainty about mental states in others may predict poor outcome in FT-AN. Further research is warranted to replicate the finding and characterise families at risk of poor outcome.

Recovery as a process: Exploring definitions of recovery in the context of eating-disorder-related social media forums

OBJECTIVE

Online forums related to eating disorders (EDs) represent sources of support for recovery, and comments on these platforms might therefore highlight aspects of recovery that have been previously neglected in research. Reddit, an online discussion platform, hosts several ED-related forums. Due to the unique benefits of examining ED-related social media comments, we aimed to use a qualitative approach to conduct an exploratory study to examine users' conceptualizations of recovery from an ED.

METHOD

We extracted public comments mentioning recovery that were posted on three ED-related online forums on Reddit between March 2017 and August 2017. We thematically analyzed the data corpus using an inductive approach to examine how recovery is defined in the context of ED-related online communities.

RESULTS

Two superordinate themes ("Recovery as a Process," "Psychosocial Factors") and three subordinate themes emerged (within the "Psychosocial Factors" theme: cognitive/affective, behavioral/physical, social).

DISCUSSION

The data support a definition of recovery that includes positive aspects of well-being and quality of life. Furthermore, the data highlight that recovery is experienced as an ongoing process that is unique to each individual.

Measuring Vitality

Subjective perceptions of mental and physical energy were measured by the use of visual analogue scales (VAS) over the course of a week in a group of normal volunteers. These variables were found to correlate, highly both with one another and with assessments of vigour and fatigue measured with a standard adjectival format. In addition, high correlations were found with a measure of positive affect. These five variables also displayed characteristic patterns of diurnal variation. Physical and mental energy, vigour and positive affect were highest in the morning, falling progressively and significantly over the day. In contrast, fatigue showed the opposite pattern. Extraversion showed positive correlations with physical and mental energy, vigour and positive affect, and negative correlations with fatigue and negative affect, most being significant (P less than 0.05). Conversely, neuroticism showed a negative correlation with the first four energy variables but was positively related to fatigue and negative affect, most correlations again being significant. Physical and mental energy, vigour and positive affect also showed a positive correlation (P less than 0.01) with a measure of happiness. It is concluded that VAS-derived ratings of physical and mental energy are reliable indicators of self-perceived vigour and fatigue. They are easy to record and show sufficient short-term stability to be used in more extensive studies both of well-being and of its physiological correlates.

Family Therapy for Child and Adolescent Eating Disorders: A Critical Review

Eating disorder-focused family therapy has emerged as the strongest evidence-based treatment for adolescent anorexia nervosa, supported by evidence from nine RCTs, and there is increasing evidence of its efficacy in treating adolescent bulimia nervosa (three RCTs). There is also emerging evidence for the efficacy of multifamily therapy formats of this treatment, with a recent RCT demonstrating the benefits of this approach in the treatment of adolescent anorexia nervosa. In this article, we critically review the evidence for eating disorder-focused family therapy through the lens of a moderate common factors paradigm. From this perspective, this treatment is likely to be effective as it provides a supportive and nonblaming context that: one, creates a safe, predictable environment that helps to contain anxiety generated by the eating disorder; two, promotes specific change early on in treatment in eating disorder-related behaviors; and three, provides a vehicle for the mobilization of common factors such as hope and expectancy reinforced by the eating disorder expertise of the multidisciplinary team. In order to improve outcomes for young people, there is a need to develop an improved understanding of the moderators and mediators involved in this treatment approach. Such an understanding could lead to the refining of the therapy, and inform adaptations for those families who do not currently benefit from treatment.

Attachment and mentalization and their association with child and adolescent eating pathology: A systematic review

OBJECTIVE

Insecure attachment and mentalizing difficulties have been associated with eating pathology in adulthood. However, it is unclear whether eating pathology is associated with attachment or mentalization in children. The aim of this study is to systematically review the literature in this emerging field.

METHOD

Electronic databases were used to search for articles.

RESULTS

Twenty-two studies were identified. In the 15 studies investigating attachment, an association with eating pathology was found in all studies. Mentalizing difficulties and eating pathology were found to be correlated in the seven studies which examined their association.

DISCUSSION

In keeping with the adult literature, cross-sectional studies of children and adolescents consistently report associations with eating pathology. There is some evidence from prospective studies that insecure attachment may be a risk factor for the development of eating pathology in adolescence. The literature on mentalization and eating pathology suggests that adolescents with anorexia nervosa may have difficulties in recognizing emotions. Further research using clinical samples and well-validated measures of attachment and mentalization are required to shed further light on this area.

Development of a children's version of the SCORE Index of Family Function and Change

The Systemic Clinical Outcome and Routine Evaluation (SCORE) Index of Family Function and Change is a recently developed outcome measure. It was designed to be acceptable to adults and children aged 12 and over. Thus far no research has been conducted using the SCORE in children under the age of 12. The aim of this study was to pilot a children's version of the SCORE. An existing 29-item version of the SCORE was completed by a sample of seven children aged 8-10. Time was allowed for group discussion with the children. Feedback from this stage of the study was used to develop a draft version of the SCORE for children. An expert panel of clinicians and researchers were also consulted. A pilot version of the Child SCORE was administered to 80 children aged 7-10 in an inner London primary school. Thirty-five children also completed the measure for a second time, 1 week later. Findings suggested that the Child SCORE was acceptable to children in the 8-11 age range. Values for internal reliability and test-retest reliability were good. The Child SCORE appears to be a promising instrument. Further research is required to confirm its acceptability to clinical populations, and to demonstrate sensitivity to change.

Public health in practice: the three domains of public health

This paper outlines a conceptual model for public health practice by proposing the three domains as a framework to organize and to deliver public health programmes. The model builds on the recognition that public health is everybody's business and therefore, needs a common definitional base. Different levels of skill and a wide range of contributions are needed if public health programmes are to make the most impact. The different domains of practice help to construct a basis for understanding the necessary elements of the public health system and their interactions.

Using teenage pregnancy as a case study of a public health programme highlights the characteristics of the model. It demonstrates not only the importance of the role of directors of public health in taking a population-based overview, but also the need for multisectoral, multidisciplinary working. The relevance of the public health approach not only to primary care but also to the hospital-based sector becomes apparent, as does its relevance to communities, voluntary sector and local government. Integration of the three domains, a common definition and the framework for the public health system will support effective delivery of health improvement.

Short-term variations in stature growth in Ethiopian and English children

Two groups of young children, one in Addis Ababa and one in Oxford, were measured every calendar month for 6 months. Changes in their stature variability, as evidenced by increasing measurement interval length, are here compared. There is evidence for substantially greater variability in the Addis Ababa children. When the variability is expressed as coefficients of variation both groups show a marked decline with interval length, presumably as constant and additive components of variation become proportionally less important as the mean increases. One constant element is identified in the Addis Ababa children, since a single subtraction from all interval coefficients greater than two months produces the same CV. It is concluded that this probably represents the homeostatic cycle of catch-up growth in this group of children.