Feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program for adolescents with anorexia nervosa and atypical anorexia nervosa at six- and twelve-month follow-up.

This study examined the feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program (PHP) for adolescents with anorexia nervosa (AN) and atypical AN (AAN), and described the outpatient services received following discharge. Participants (N = 31) completed anthropometric and self-report assessments at admission, discharge, and six and twelve months after discharge from the PHP. Descriptive statistics explored markers of feasibility. Paired samples t-tests evaluated changes in weight and eating disorder (ED) symptomatology from admission to discharge, admission to six-month follow-up, and admission to twelve-month follow-up. Descriptive statistics and effect sizes compared symptoms at each timepoint between participants with AN and AAN. Results indicated that we were successful at recruiting greater than 50% of adolescents approached for this study. We collected follow-up data from more than 70% of participants at discharge, but did not meet this retention benchmark at six-month and twelve-month follow-ups. The entire sample demonstrated significant improvements in weight and ED symptomatology from admission to discharge, and generally maintained these improvements at six- and twelve-month follow-up. While descriptive statistics suggested that participants with AN and AAN received similar outpatient services following discharge from the PHP, those with AN experienced greater improvement in self-reported ED symptomatology than those with AAN at six- and twelve-month follow-up. These findings provide preliminary support for the efficacy of PHPs in treating adolescents with AN and AAN. Further research with larger sample sizes should investigate whether adolescents with AAN experience poorer outcomes than those with AN following discharge from a PHP.

Validation of the youth-nine item avoidant/restrictive food intake disorder screen.

OBJECTIVE: This study assessed the factorial, divergent, and criterion-related validity of the Youth-Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (Y-NIAS) in a paediatric clinical sample at initial evaluation for an eating disorder (ED). METHOD: Participants included 310 patients (82.9% female, 77.4% White, Age M = 14.65) from a tertiary ED clinic. Confirmatory factor analysis (CFA) evaluated the three-factor of the Y-NIAS. One-way analysis of variance compared Y-NIAS scores across diagnoses. A receiver operating curve analysis assessed the ability of each subscale to identify ARFID presentations from the full sample. Two logistic regressions assessed the criterion-related validity of the obtained Y-NIAS cut-scores. RESULTS: CFA supported the original three-factor structure of the Y-NIAS. Clinically-elevated scores were observed in all diagnostic groups except for binge-eating disorder. Subscales were unable to discriminate ARFID cases from other ED diagnoses. Cut scores were identified for picky eating subscale (10) and Fear subscale (9), but not for Appetite subscale. In combination with the ED Examination Questionnaire (EDE-Q), classification accuracy was moderate for ARFID (62.7%) and other EDs (89.4%). DISCUSSION: The Y-NIAS demonstrated excellent factorial validity and internal consistency. Findings were mixed regarding the utility of the Y-NIAS for identifying clinically-significant ARFID presentations from other ED diagnoses.

Preliminary Validation of The Eating Disorders Examination Questionnaire-Short Parent Version (EDE-QS-P).

OBJECTIVE: There is a lack of reliable and valid parent-report measures assessing eating disorder (ED) pathology in children and adolescents. This study aimed to develop and provide preliminary validation of a new parent-report measure, the 12-item Eating Disorder Examination Questionnaire-Short Parent Version (EDE-QS-P). METHOD: The EDE-QS-P was completed by 296 parents seeking treatment for their child at an ED clinic. Children (ages 6-18, N = 296) completed the Eating Disorder Examination-Questionnaire (EDE-Q), the seven-item Generalized Anxiety Disorder Questionnaire (GAD-7), and the nine-item Patient Health Questionnaire (PHQ-9). RESULTS: After removing item 10, the 11-item version of the EDE-QS-P showed borderline adequate fit to the one factor solution and strong internal consistency (α = 0.91). This measure also demonstrated strong convergent validity with child scores on the EDE-Q (r = .69), and moderate convergent validity with child scores on the GAD-7 (r = .37) and PHQ-9 (r = .46). The EDE-QS-P was able to differentiate children with EDs characterized by body image disturbances (e.g. anorexia nervosa) from those with avoidant/restrictive food intake disorder, who do not experience shape or weight concerns. DISCUSSION: The 11-item EDE-QS-P may be a promising parent-report measure of ED pathology in children and adolescents.

The impact of between-session habituation, within-session habituation, and weight gain on response to food exposure for adolescents with eating disorders.

OBJECTIVE: Exposure therapy is a promising treatment for eating disorders (EDs). However, questions remain about the effectiveness of exposure to feared foods during the weight restoration phase of treatment, and the importance of between-session and within-session habituation. METHOD: We recruited 54 adolescents from a partial hospitalization program (PHP) for EDs which included daily food exposure. Throughout treatment, participants provided subjective units of distress (SUDS) ratings before and after eating a feared food, and completed measures of ED symptomatology. RESULTS: Multilevel models found that pre-exposure SUDS decreased over time, providing some evidence that between-session habituation occurred. In contrast, the difference between pre-exposure and post-exposure SUDS did not decrease over time, indicating that within-session habituation did not occur. Weight gain predicted greater between-session habituation to feared foods, but did not predict within-session habituation. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes, including weight gain and improvements on the Children's Eating Attitudes Test and Fear of Food Measure. DISCUSSION: Partial hospitalization programs that include daily exposure to feared foods may be effective at decreasing anxiety about foods for adolescents with EDs who are experiencing weight restoration. Further research is warranted to replicate our findings challenging the importance of within-session habituation, and to better understand between-session habituation and inhibitory learning as mechanisms of change when conducting food exposure for EDs. PUBLIC SIGNIFICANCE: This study provides some evidence that PHPs that include food exposure may be useful for adolescents with EDs who are experiencing weight restoration. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes. Further research is needed to determine whether clinicians can disregard within-session habituation when conducting food exposure for EDs, and understand the importance of between-session habituation as a potential mechanism of food exposure.

An experimental protocol for a double-blind placebo-controlled evaluation of the effectiveness of oral naltrexone in management of adolescent eating disorders.

BACKGROUND: This double-blind, placebo-controlled study evaluates the effectiveness of oral naltrexone in adolescents and young adults with eating disorders (EDs) characterized by purging with or without binge-eating behaviors. We hypothesize that participants receiving oral naltrexone will demonstrate greater improvements in body mass index in underweight participants and self-reported ED symptomatology compared to placebo. METHODS: Thirty individuals receiving treatment in a partial hospitalization program for EDs with diagnoses of anorexia nervosa binge-eating/purging type, bulimia nervosa, or purging disorder will receive six weeks of either placebo or oral naltrexone. Participants will complete a battery of self-report measures and laboratory safety monitoring every three weeks in addition to standard of medical care for treatment environment. RESULTS: Analysis will compare outcomes at weeks three and six, and follow-up at nine weeks and six-months across the oral naltrexone and placebo groups. Main effects for time will examine improvements over the course of treatment for all participants, while group × time interactions will examine differences in the rate of change over time between study arms. CONCLUSIONS: We hypothesize that participants receiving oral naltrexone will experience more rapid improvements in symptom severity and weight restoration compared to placebo across study time points. There are very few medications with high-quality data demonstrating both safety and efficacy in the treatment of eating disorders. The authors theorize this study will demonstrate a clinically significant effect of oral naltrexone on impulsive-type EDs and support its use as an effective option for treatment augmentation.

Preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program for children and adolescents with avoidant/restrictive food intake disorder.

OBJECTIVE: This study explored the preliminary effectiveness of a partial hospitalization program (PHP) for children/adolescents with avoidant/restrictive food intake disorder (ARFID). We evaluated how ARFID symptoms changed from admission to discharge, and collected follow-up data on symptoms and outpatient care following PHP discharge. METHOD: Twenty-two children/adolescents with ARFID (77.3% White, 63.6% female) completed measures assessing ARFID symptomatology at admission and discharge from a PHP for eating disorders. Six months and twelve months following their discharge, participants were contacted to complete study measures again and take part in an interview assessing follow-up care. RESULTS: Paired samples t tests indicated that participants demonstrated increases in weight and decreases in ARFID symptomatology from admission to discharge with medium to large effects. All participants reported receiving some form of outpatient treatment following discharge, with the type of outpatient services varying across participants. Data from the 86% of participants who completed the six-month follow-up and 50% who completed the twelve-month follow-up suggest that participants generally maintained treatment gains following PHP discharge. DISCUSSION: Participants experienced symptom improvements from admission to discharge and appeared to maintain these gains after discharge. These results provide preliminary evidence that PHPs are an effective treatment option for children and adolescents with ARFID. PUBLIC SIGNIFICANCE STATEMENT: This study provides preliminary evidence that intensive, evidence-based PHPs are effective in treating ARFID. Our findings suggest that children and adolescents with ARFID who receive flexible, cognitive-behavioral, family-centered treatment in a PHP for EDs experience improvements in weight and ARFID symptomatology from admission to discharge. Despite receiving variable and nonstandardized outpatient treatment, individuals with ARFID appear to maintain treatment gains 6 and 12 months after discharge in a PHP.

Sleep and Avoidant Restrictive Food Intake Disorder (ARFID): Correlation With Psychopathology, Gender, and Academic Performance.

Objective No studies have investigated sleep disturbance in avoidant/restrictive food intake disorder (ARFID). We examined sleep disturbance in ARFID and its association with eating problems, body mass index (BMI), gender, internalizing and externalizing symptoms, cognitive performance, and academic difficulties. Methods Data from 71 ARFID patients from our partial hospitalization program (PHP) for children and adolescents were examined. Sleep data were extracted from measures administered at admission including Achenbach Child Behavior Checklist (CBCL), Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS). Correlational analyses were conducted to evaluate the convergent validity of parent-reported and participant-reported sleep problems. Association with the severity of eating problems, BMI, percentage of median body weight (% MBW), age, gender, psychotropic medication, psychopathology, and academic difficulties was examined using analysis of variance (ANOVA) and Pearson's correlation.  Results Fifty-two percent of parents and 74% of participants reported two or more sleep symptoms. Trouble sleeping was reported by 46.48% and nightmares by 35.21% of parents. Parent-reported trouble sleeping highly correlated with internalizing disorders. Parent-reported trouble sleeping and participant-reported difficulty sleeping positively correlated with attention and attention-deficit/hyperactivity disorder (ADHD) problems. Parent-reported less sleep and feeling tired correlated with sluggish cognitive tempo, while walking/talking in sleep negatively correlated with school performance. Gender differences were noted in parent-reported sleep problems. Sleep disturbances were not associated with lower BMI or median body weight at intake. Parent-reported talking/walking in sleep and participant-reported bad dreams and bedtime worries positively correlated with Children's Eating Attitudes Test (ChEAT) scores at intake and discharge. Discussion Our results provide compelling evidence to screen for sleep disturbance in ARFID patients regardless of median body weight and BMI. Exploration of sleep disturbances in ARFID using objective measures is warranted.

Selective Serotonin Reuptake Inhibitors and Hydroxyzine in the Treatment of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: Rationale and Evidence.

Objective: Despite lack of evidence, various pharmacological agents are judiciously used to manage anxiety in avoidant restrictive food intake disorder (ARFID). We aimed to explore the effectiveness of selective serotonin reuptake inhibitors (SSRIs), either alone or in combination with hydroxyzine, in a well-defined cohort of children and adolescents with ARFID receiving treatment in a partial hospitalization program for eating disorders. Methods: We conducted a retrospective chart review of 53 patients with ARFID who were prescribed an SSRI (n = 39) or SSRI with hydroxyzine (n = 14). We investigated changes from admission to discharge in these two medication groups on various outcome measures assessing weight, eating behaviors, mood, anxiety, and fears about food. Results: Participants in the SSRI+hydroxyzine group were significantly older than those in the SSRI only group. The majority of participants in both groups exhibited the fear presentation of ARFID. Repeated-measures analysis of variance yielded a significant main effect for treatment for all outcome measures, indicating that patients in both groups experienced improvements in weight, eating behaviors, mood, anxiety, and fears of food. A significant main effect for medication group emerged on the Children's Depression Inventory, suggesting that the group receiving SSRI+hydroxyzine experienced greater depressive symptomatology than the SSRI-only group. We did not find any significant interactions, indicating that participants in both medication groups experienced similar improvements over the course of treatment. Conclusion: These results provide preliminary evidence that SSRIs and hydroxyzine may be helpful in the treatment of children and adolescents with ARFID. Given that hydroxyzine was prescribed to patients who experienced high pre- and/or postmeal anxiety, it possibly contributed to similar decreases in anxiety and fear of food in a more challenging subset of patients. Randomized, placebo-controlled studies for children and adolescents with ARFID are warranted to better evaluate and understand the efficacy of SSRIs and hydroxyzine in this clinical population.

Patient perceptions of blind and open weighing in treatment for eating disorders.

Little is known about patients' perceptions toward open and blind weighing for eating disorders. Upon admission to a partial hospitalization program, 35 child/adolescent patients, 55 adult patients, and 36 parents of child/adolescent patients completed questionnaires assessing attitudes toward open and blind weighing. Participants perceived blind weighing as more effective in the short term. No differences emerged on measures assessing preference, credibility, or long-term effectiveness. Relative to adults, parents preferred blind weighing, and child/adolescents perceived blind weighing as more credible. On a forced-choice question, a majority of adults, about half of children/adolescents, and a minority of parents preferred open weighing over blind weighing. There was a positive association between past treatment experience and current attitudes about weighing. Results suggest that individuals enter treatment with variable attitudes about weighing procedures for eating disorders, and may develop more favorable attitudes toward the practice they receive in treatment.

Do individuals with eating disorders dislike exposure therapy? Attitudes from children, adults, and parents toward exposure therapy and other treatments for eating disorders.

OBJECTIVE: Exposure therapy appears underutilized in the treatment of eating disorders (EDs), perhaps due to clinicians' concerns that patients will dislike exposure therapy. The present study aims to investigate the attitudes of child patients, adult patients, and parents of child patients with EDs toward exposure therapy relative to four other treatments for EDs. METHOD: A questionnaire was administered to patients and parents (N = 126) upon admission to a partial hospitalization program for EDs. Participants read vignettes describing five different treatments for EDs, and answered questions assessing attitudes about each treatment. RESULTS: At admission, participants reported the most favorable attitudes toward cognitive therapy, and the least favorable attitudes toward psychiatric medication. Exposure therapy generally received similar scores as interpersonal and expressive art therapy, and was perceived as significantly more preferable and effective in the long-term than psychiatric medication. Relative to child and adult patients, parents reported greater preferences for all treatments except medication, and perceived all treatments as more credible except medication and art therapy. Preliminary findings from a subset of participants who also completed the questionnaire at discharge indicated that positive attitudes toward exposure therapy increased over the course of treatment. DISCUSSION: Individuals with EDs and their parents may enter treatment with particularly favorable views toward cognitive therapy, and do not appear to have strong attitudes toward exposure therapy one way or the other. Clinicians' concerns that patients with EDs will dislike exposure therapy may be largely unfounded.

Caregiver accommodation in adolescents with avoidant/restrictive food intake disorder and anorexia nervosa: Relationships with distress, eating disorder psychopathology, and symptom change.

OBJECTIVE: The role of family and caregiver accommodation is a well-defined maintenance factor for anxiety disorders and OCD. Family accommodation for patients with eating disorders is beginning to be described and characterized, but gaps in the literature remain. The current project compares levels of accommodation in families of those with anorexia nervosa (AN) to those with avoidant/restrictive food intake disorder (ARFID). It additionally establishes whether accommodation changes over the course of treatment and the extent to which these changes are related to changes in eating disorder pathology. METHODS: A total of 39 adolescents with ARFID and 59 with AN presenting to a partial hospitalization program were included, with measures completed at intake and discharge. RESULTS: Caregivers of adolescents with AN and those with ARFID reported similar levels of accommodation, with the exception of the Reassurance Seeking subscale of the Accommodation and Enabling Scale for Eating Disorders (AESED). Additionally, accommodation decreased significantly from intake to discharge for both patient groups. Intake AESED scores were also significantly related to caregiver distress, and changes in AESED scores were related to decreases in relevant eating disorder psychopathology for both groups. CONCLUSIONS: The results of the current study highlight the importance of considering family accommodation for ARFID patients and point to the need for future research to capture changes in accommodation over the course of treatment in relation to the delivery of evidence-based interventions and subsequent changes in ED symptoms.

Further support for diagnostically meaningful ARFID symptom presentations in an adolescent medicine partial hospitalization program.

OBJECTIVE: To identify potential presentations of avoidant/restrictive food intake disorder (ARFID) in a pediatric eating disorder partial hospitalization program (PHP) based on the nature of the eating restriction leading to core symptoms of ARFID. METHOD: A retrospective chart review of 83 patients ages 8-17 admitted to a PHP and diagnosed with ARFID. Charts were independently reviewed by two coders, with high inter-rater agreement (κ = 0.77). Distinct categories were identified and groups were compared on demographics, anthropometrics, comorbid psychopathology, and core ARFID symptoms. RESULTS: We identified cases characterized by predominantly selective eating based on aversions to the sensory properties of foods, lack of interest in eating/low appetite, and fear of aversive consequences from eating. We also distinguished a subset of patients with eating restrictions consistent with both selectivity and limited interest/appetite. The four primary ARFID presentation groups differed on core ARFID criteria, symptom trajectory and illness duration, mood and medical comorbidities, age, gender, and parent-reported symptoms of psychopathology. DISCUSSION: The present findings suggest that there are diagnostically meaningful ARFID subtypes that can be differentiated based on the nature of their eating restrictions, as well as other demographic, illness history features, and psychiatric comorbidity. As treatments for youth with ARFID are developed and refined, it will be important to take into consideration not only demographic differences, but also the variability in symptoms, as this might require distinct interventions and levels of care. Additionally, differing mechanisms that maintain different types of eating restrictions might necessitate unique psychological and psychiatric interventions.

Assessment of Parental Knowledge and Understanding of Eating Disorders.

Recommended treatment of adolescent eating disorders includes active parental involvement. The purpose of this study was to assess baseline parental knowledge and understanding of eating disorders and how it is affected by participation in treatment. A cross-sectional and prospective cohort study comparing the parents of children ages 8 to 18 years seeking initial evaluation for an eating disorder at an adolescent medicine clinic (ED) to those attending appointments at a general pediatrics clinic (GP) was performed utilizing a 20-item questionnaire. There was no difference in mean scores at baseline, however after 2 months, the mean score of the ED group was significantly higher, while that of the GP group was not. The change in mean score from the first to second survey was significantly greater for the ED group than the GP group. Increased knowledge may improve self-efficacy, which plays a critical role in parents' ability to adopt eating disorder treatments.

Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders.

OBJECTIVE: Avoidant/restrictive food intake disorder (ARFID) is a recently named condition to classify patients who present with restricted nutritional intake without body image distortion or fear of weight gain. We sought to compare treatment outcomes of patients with ARFID in a family-centered partial hospital program (PHP) to those with other eating disorders (ED). METHOD: A retrospective chart review of 130 patients 7-17 years of age admitted to the program from 2008 to 2012 was performed. Intake and discharge data included: length of stay; percentage median body mass index (%MBMI); and scores on the Children's Eating Attitudes Test (ChEAT) and Revised Children's Manifest Anxiety Scale (RCMAS). Between and within group effects were measured for intake and discharge data. RESULTS: Patients with ARFID spent significantly fewer weeks in program than those with anorexia nervosa (AN) and experienced a similar increase in %MBMI as patients with AN and other specified/unspecified feeding and eating disorders. All patients exhibited significant improvements in psychopathology over the course of treatment as measured by scores on the ChEAT and RCMAS. DISCUSSION: Our findings suggest that patients with ARFID can be successfully treated in the same PHP as patients with other ED, with comparable improvements in weight and psychopathology over a shorter time period. Results are limited to patients with ARFID who exhibit an acute onset of severe food restriction. Future research should incorporate measures relevant to the diagnosis of ARFID and explore how patients with different ARFID subtypes may respond to various treatments.

Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders.

BACKGROUND: Avoidant/Restrictive Food Intake Disorder (ARFID) is a "new" diagnosis in the recently published DSM-5, but there is very little literature on patients with ARFID. Our objectives were to determine the prevalence of ARFID in children and adolescents undergoing day treatment for an eating disorder, and to compare ARFID patients to other eating disorder patients in the same cohort. METHODS: A retrospective chart review of 7-17 year olds admitted to a day program for younger patients with eating disorders between 2008 and 2012 was performed. Patients with ARFID were compared to those with anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorder/unspecified feeding or eating disorder with respect to demographics, anthropometrics, clinical symptoms, and psychometric testing, using Chi-square, ANOVA, and post-hoc analysis. RESULTS: 39/173 (22.5%) patients met ARFID criteria. The ARFID group was younger than the non-ARFID group and had a greater proportion of males. Similar degrees of weight loss and malnutrition were found between groups. Patients with ARFID reported greater fears of vomiting and/or choking and food texture issues than those with other eating disorders, as well as greater dependency on nutritional supplements at intake. Children's Eating Attitudes Test scores were lower for children with than without ARFID. A higher comorbidity of anxiety disorders, pervasive developmental disorder, and learning disorders, and a lower comorbidity of depression, were found in those with ARFID. CONCLUSIONS: This study demonstrates that there are significant demographic and clinical characteristics that differentiate children with ARFID from those with other eating disorders in a day treatment program, and helps substantiate the recognition of ARFID as a distinct eating disorder diagnosis in the DSM-5.

Effects and linguistic analysis of written traumatic emotional disclosure in an eating-disordered population.

CONTEXT: In previous studies, writing about traumatic life events produced positive physical and psychological outcomes in various populations. Specific linguistic trends, such as increasing insight and cognitive words, have paralleled health benefits. OBJECTIVE: This study explored the effects of written traumatic emotional disclosure on eating disorder behavior and cognitions as well as linguistic dimensions of the disclosure writings completed by eating-disordered patients. DESIGN: Twenty-nine female patients, aged 16 to 39 years, from the Penn State Hershey Eating Disorders partial-hospitalization program participated. Twenty-five subjects completed a traumatic disclosure or control writing task, and 21 completed all writings and baseline and follow-up questionnaires to assess eating-disorder symptoms, emotional regulation strategies, self-efficacy, and motivation to change eating-disorder behaviors. The handwritten essays were transcribed into a word-processed document and analyzed on numerous dimensions using the Linguistic Inquiry and Word Count software. RESULTS: Individuals completing the disclosure writing did not differ from those in the control task group on any of the questionnaires at follow-up. However, the disclosure group did use more negative emotion, insight, cognitive, function, and filler words on all writing days along with decrease of tentative words. These changes in word use correlated with previous study findings. CONCLUSIONS: Whereas the expected linguistic trends were evident in the disclosure group writings, no correlating health benefits could be found between the disclosure and control groups. Eating-disordered populations, often alexithymic, may have difficulty engaging with the disclosure task and could potentially benefit from guidance in processing traumatic events and their affective states.

Motivational stage of change in young patients undergoing day treatment for eating disorders.

BACKGROUND: The objective was to determine whether motivation to change is significantly altered over the course of partial hospitalization in children and adolescents with eating disorders (EDs). METHOD: This study was a retrospective chart review of 30 sets of adolescents and their parents who completed the Motivational Stage of Change for Adolescents Recovering from an Eating Disorder (MSCARED) at both intake and discharge from partial hospitalization. The main outcome variables included change in stage of change (SOC) for patients and their parents. Secondary outcomes included correlations between SOC and other baseline variables, as well as changes in SOC and psychological test scores. RESULTS: The SOC was significantly higher at discharge than at intake in both the patients and parents, but the two groups were not in agreement at discharge. The change in the SOC was correlated with change in Children's Eating Attitudes Test scores. Assessment of decisional balance showed correlations with SOC. Age, change in weight, and psychiatric diagnoses did not correlate with initial SOC. CONCLUSION: The MSCARED may be a useful tool for monitoring young ED patients' psychological improvements with day treatment. Initial SOC is not predictive of treatment outcomes.