Expressed emotion and early treatment response in family-based treatment for adolescent anorexia nervosa.

This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12-18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced.

Nonanaphylactic Variant of Alpha-Gal Syndrome as an Etiology for Chronic Gastrointestinal Symptoms in Children.

We report 3 pediatric patients who presented with only nonanaphylactic symptoms of alpha-gal syndrome. This report highlights the necessity of not discounting alpha-gal syndrome from a differential diagnosis for patients with recurrent gastrointestinal distress and emesis after consuming mammalian meat, even in the absence of an anaphylactic reaction.

Parent and clinician perspectives on virtual guided self-help family-based treatment (GSH-FBT) for adolescents with anorexia nervosa.

PURPOSE: Guided self-help (GSH) treatments have the capacity to expand access to care, decrease costs, and increase dissemination compared to traditional therapist-directed treatment approaches. However, little is known about parent and clinician perspectives about the acceptability of GSH for adolescents with eating disorders. METHODS: This study utilized a mixed methods approach to obtain qualitative and quantitative data regarding clinician and participants' experiences with GSH. Parent participants were enrolled in a randomized trial comparing GSH family-based treatment (GSH-FBT) to family-based treatment delivered via videoconferencing (FBT-V) for adolescents (12-18 years old) with a DSM-5 diagnosis of anorexia nervosa (AN). Parent participants provided qualitative feedback using the Helping Alliances Questionnaire about their experience of treatment. Clinician participants were six master's or PhD-level therapists. These clinicians were trained in and provided both treatments (GSH-FBT and FBT-V). They provided responses to questionnaires and participated in a 1-h focus group about their experience as treatment providers. RESULTS: Regardless of treatment condition, parents listed more improvement than worsening of symptoms in their child with AN. Clinicians reported lower scores on competency and comfort metrics with GSH-FBT compared to FBT-V. Qualitatively, clinicians reported both advantages and disadvantages of delivering GSH-FBT. CONCLUSION: Further studies are needed to better understand how GSH interventions can be disseminated to patients and families, particularly those with limited access to specialized eating disorder treatment centers. Level of evidence Level I, data collected as part of a randomized controlled trial.

Eating disorders early app use mediates treatment effect on clinical improvement.

OBJECTIVE: Eating disorders (EDs) contribute considerably to the global burden of disease. However, most affected individuals do not receive treatment. Mobile apps present an enormous opportunity to increase access to mental healthcare services. This study examined whether the degree of usage of a self-help app for EDs mediated the app's effects on the clinical response by individuals with EDs. METHOD: App usage measures included the total number of cognitive-behavioral meal logs, total number of days spent using the app, and the last day the app was used during the study period. Mediation analysis was performed using the MacArthur framework. RESULTS: All usage variables met the analytic requirements for testing mediation (group means (sd) for app and standard app, respectively: logs = 74 (108) vs. 51.4 (88.1), days spent = 14.3 (17.5) vs. 10.6 (15.0), p-values from Wilcox rank sum tests p < .01). Regression coefficients indicated mediation effects. The mediation effects demonstrated support that increased engagement (as measured by logs and time spent on the app) was related to an increased likelihood of achieving a significant clinical change by the end of the trial. DISCUSSION: Greater and longer engagement in an ED app mediates its efficacy in terms of ED remission.

Feasibility of conducting a randomized controlled trial comparing family-based treatment via videoconferencing and online guided self-help family-based treatment for adolescent anorexia nervosa.

OBJECTIVE: This report describes the feasibility, acceptability, and outcomes from a pilot randomized clinical trial (RCT) comparing an online guided self-help program version of family-based treatment (GSH-FBT) for parents with a child with DSM-5 anorexia nervosa (AN) to FBT delivered via videoconferencing (FBT-V). METHOD: Between August 2019 and October 2020, 40 adolescents ages 12-18 years with DSM-5 AN and their families were recruited at two sites and randomized to either twelve 20-min guided sessions of GSH-FBT for parents or fifteen 60-min sessions of FBT-V for the entire family. Recruitment, retention, and acceptability of treatment were the primary outcomes. Secondary outcomes were changes in weight, eating disorder examination (EDE), parental self-efficacy, weight remission, full remission, and outcome efficiency (therapist time needed to achieve treatment outcomes). RESULTS: Descriptive data are reported. Recruitment and retention rates are similar to RCTs using in-person treatments. Both treatments received similar acceptability rates. Medium and large effect sizes (ES) related to improvements in weight, EDE, parental self-efficacy, and remission were achieved in both treatments and were maintained at a 3-month follow-up. Clinical outcomes between groups were associated with a small ES. Differences in efficiency (outcome/therapist time) were associated with a large ES difference favoring GSH-FBT. DISCUSSION: These data support the feasibility of conducting an adequately powered RCT comparing online GSH-FBT to FBT-V to determine which approach is more efficient in achieving improvements in clinical outcomes in adolescents with AN.

Quadratic relations of BMI with depression and brain volume in children: Analysis of data from the ABCD study.

BACKGROUND: Weight-related health conditions and depression peak during adolescence and show relations with brain structure. Understanding how these conditions relate to each other prior to adolescence may guide research on the co-development of unhealthy weight conditions (both underweight and overweight) and depression, with a potential brain-based link. This study examines the cross-sectional relations between body mass index (BMI), depressive symptoms, and brain volume (total and regional) to determine whether BMI has a linear or quadratic relation with depressive symptoms and brain volume and how depressive symptoms and brain volume are related. METHODS: Cross-sectional study using structural magnetic resonance imaging, height and weight to calculate BMI z-scores, and Child Behavior Checklist withdrawn depression scores. Data were from the Adolescent Brain Cognitive Development Study, collected at 21 sites across the United States from 11,875 9- and 10-year-old children recruited as a national sample. Mixed models were used to examine the linear and quadratic effects of BMI z-score on both brain volume (total and regional) and withdrawn depression scores, as well as the relations between brain volume and depression scores. Intracranial volume, age, sex, race, site, and family were included in the models as covariates. RESULTS: Overall, BMI z-scores showed a quadratic relation with brain volumes and depressive symptoms. When including intracranial volume as a covariate, regional volumes investigated did not follow the same global pattern of effects except for right hippocampus and left lateral orbitofrontal cortex. Total brain volume was negatively related to depressive symptoms. CONCLUSIONS: Links between depressive symptoms and low or high weight could improve our understanding of brain structural differences in depression. These findings also emphasize the importance of including the full spectrum of BMI from underweight to overweight and testing for nonlinear effects in models.

Descriptive analysis of binge eating in adult and adolescent females.

PURPOSE: Provide qualitative descriptions of context and characteristics of binge eating in adults and adolescents to explore consistency in precipitating factors. METHOD: Open-ended, qualitative interviews were administered to an adult sample (n = 24) and an adolescent sample (n = 20) to collect details about the context in which two binge episodes occurred. RESULTS: Factors and context of the binge episodes were similar between adults and adolescents. In contrast, the two binge episodes described by each individual were not consistent. Binge episodes were not strongly affect-driven or food cue-driven. CONCLUSIONS: Binge eating appears similar between adults and adolescents, which may have treatment implications. Similar treatment approaches may be used with both age groups and would benefit from covering a broad range of binge triggers rather than attempting to match individuals into an approach focused on particular triggers. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Perfectionism, anorexia nervosa, and family treatment: How perfectionism changes throughout treatment and predicts outcomes.

OBJECTIVE: This study uses data from a multisite randomized clinical trial to study the role of perfectionism in family-based treatment (FBT) for adolescent anorexia nervosa (AN). The main aim is to examine the role of baseline perfectionism in treatment response. METHOD: Adolescents (N = 158; ages 12-18; 89.2% female) and their families were randomized to receive either FBT or systemic family treatment for AN. Eating disorder (ED) pathology, obsessive-compulsive symptoms, and perfectionism were assessed at baseline, end of treatment, and 6- and 12-month follow-up. Linear regression analyses were used to test whether perfectionism and obsessive-compulsive symptoms at baseline predict ED pathology at all timepoints. An independent samples t test was used to test whether there was a significant difference in the change in perfectionism in either treatment group. RESULTS: Baseline maladaptive perfectionism significantly predicted ED pathology but not ideal body weight at all timepoints. The model that included obsessive-compulsive symptoms also predicted ED pathology at all timepoints except 12-month follow-up. Perfectionism scores did not change during treatment regardless of treatment type. DISCUSSION: Baseline perfectionism predicted treatment response in this study. Interventions might target perfectionism to improve treatment response in AN.

Parent-based prevention after parental weight loss surgery: a pilot case-series trial.

BACKGROUND: Overeating and obesity are elevated in children of parents who have undergone weight loss surgery. Parents who have undergone weight loss surgery often report their personal history of obesity interferes with their knowledge, skills, and self-efficacy in developing their children's healthy habits, thus reducing the likelihood of addressing obesogenic environmental factors. OBJECTIVES: This study examines whether a 6-session parent-based prevention after bariatric surgery online intervention is feasible and acceptable for parents. The study also explores the program's signal of efficacy in improving short-term outcomes related to decreased long-term risks for obesity by examining short-term impact on targeted parental cognitions, feeding practices, and child eating behaviors and physical activity habits. SETTING: University Hospital, United States. METHODS: Parents were recruited using flyers, clinician referrals, and social media. Measures assessed parental feeding practices, children's eating behaviors, daily hours of screen time, and outdoor play. RESULTS: Ten families enrolled and 7 completed the study. Parents found the intervention relevant and suitable for addressing their parenting concerns. Parental feeding behaviors, such as restriction and pressure to eat, reduced while tracking of sweets and high-fat snacks increased. Children reduced both emotional overeating and undereating. Children's daily hours of screen time reduced as well as their outdoor play time. CONCLUSIONS: Parent-based prevention after bariatric surgery aimed at helping parents who have undergone weight loss surgery engineer healthier family lifestyles is feasible, acceptable, and associated with reduced obesogenic risk factors.

The offspring of parents undergoing a weight loss surgery: a systematic review.

The offspring of parents with obesity are at an increased risk of developing this condition themselves because of genetic and environmental factors. One subgroup that may be at particularly high risk of developing obesity is the offspring of parents who have undergone weight loss surgery (PWLS). To date, little research has focused on these offspring or their parents. This systematic review addresses this gap by integrating available literature and assessing the quality of the evidence. To be included, studies were required to have researched characteristics of the offspring of PWLS or parental feeding practices within this population. After review, 12 studies met inclusion criteria. Findings include evidence for heightened risk of obesity among children of PWLS. However, research suggests these children may experience positive, although time-limited, health outcomes after their parents' surgeries. Quality of the evidence was rated as low, primarily because of the lack of randomized controlled studies and information regarding available interventions specifically targeting this vulnerable population. This review underscores the need for research to improve understanding of PWLS families to better support them and capitalize on postbariatric surgery benefits.

Parenting after Weight Loss Surgery: A Conceptual Model and Two Case Reports.

The ways families approach eating, shape, and weight can result in stress for individual family members and challenge the overall functioning of the family. This is further complicated among families with a parent who has history of obesity or undergone weight loss surgery (WLS). Although WLS can positively impact other family members, it can also exacerbate conflicts regarding feeding and weight. Such conflicts can involve uncertainty regarding the extent to which the entire family should make the dietary changes recommended for the post-WLS parent. Conflict might also center on the appropriate level of concern regarding the children's risk of developing (or maintaining) obesity. This paper uses two case examples to describe the application of a specialized, time-limited intervention: Parent-Based Prevention following Bariatric Surgery (PBP-B). The program was developed to address the unique challenges and concerns that arise after, or are exacerbated by, WLS. Each detailed case example illustrates a common child-feeding challenge and the employment of key PBP-B strategies throughout the course of treatment. In the first case, the parent who had undergone WLS believed the family's current eating behaviors were the same as those that had led to her own overeating, obesity, and co-occurring psychiatric symptoms, while her husband disagreed. In the second case, both parents were concerned about their son's weight, yet due to their prior eating histories, they felt unable to construct boundaries around the feeding experience. Both cases follow families through the entire intervention and illustrate key points and challenges. These cases underscore the need for novel treatment modalities to support families following parental WLS.

Las maneras en las que las familias abordan la alimentación, la figura y el peso pueden causar estrés en los integrantes individuales de la familia y poner a prueba el funcionamiento general de la familia. Esto es aun más complicado entre las familias con un padre que tiene antecedentes de obesidad o que se sometió a una cirugía para adelgazar. Aunque la cirugía para adelgazar puede repercutir de manera positiva en otros miembros de la familia, también puede exacerbar conflictos con respecto a la alimentación y al peso. Dichos conflictos pueden consistir en la incertidumbre con respecto al grado en el cual toda la familia debería hacer los cambios alimentarios recomendados para el padre que se ha operado para adelgazar. El conflicto también podría centrarse en el nivel adecuado de preocupación en relación con el riesgo de los niños de desarrollar (o mantener) la obesidad. Este artículo utiliza dos ejemplos de casos para describir la aplicación de una intervención especializada y limitada temporalmente: "La prevención basada en los padres después de una cirugía bariátrica" (Parent-Based Prevention following Bariatric Surgery, PBP-B). El programa se desarrolló para abordar los desafíos y las preocupaciones particulares que surgen después de la cirugía para adelgazar o que son exacerbados por esta. Cada ejemplo de un caso detallado ilustra un desafío común con respecto a la alimentación de los niños y al empleo de estrategias fundamentales de la PBP-B a lo largo del transcurso del tratamiento. En el primer caso, la madre que se había sometido a la cirugía para adelgazar creía que los comportamientos alimentarios actuales de la familia eran los mismos que los que la habían conducido a su propia sobreingesta, obesidad, y síntomas psiquiátricos concomitantes, mientras que su esposo no estaba de acuerdo. En el segundo caso, ambos padres estaban preocupados acerca del peso de su hijo, sin embargo, debido a sus antecedentes alimentarios previos, se sentían incapaces de establecer límites en torno a la experiencia alimentaria. Ambos casos siguen a las familias durante toda la intervención e ilustran puntos clave y desafíos. Estos casos subrayan la necesidad de incorporar modalidades innovadoras de tratamiento orientadas a apoyar a las familias después de la cirugía para adelgazar de uno de los padres.

Comparing a Tailored Self-Help Mobile App With a Standard Self-Monitoring App for the Treatment of Eating Disorder Symptoms: Randomized Controlled Trial.

BACKGROUND: Eating disorders severely impact psychological, physical, and social functioning, and yet, the majority of individuals with eating disorders do not receive treatment. Mobile health apps have the potential to decrease access barriers to care and reach individuals who have been underserved by traditional treatment modalities. OBJECTIVE: The objective of this study was to evaluate the effectiveness of a tailored, fully automated self-help version of Recovery Record, an app developed for eating disorders management. We examined differences in eating disorder symptom change in app users that were randomized to receive either a standard, cognitive behavioral therapy-based version of the app or a tailored version that included algorithmically determined clinical content aligned with baseline and evolving user eating disorder symptom profiles. METHODS: Participants were people with eating disorder symptoms who did not have access to traditional treatment options and were recruited via the open-access Recovery Record app to participate in this randomized controlled trial. We examined both continuous and categorical clinical improvement outcomes (measured with the self-report Eating Disorder Examination Questionnaire [EDE-Q]) in both intervention groups. RESULTS: Between December 2016 and August 2018, 3294 Recovery Record app users were recruited into the study, out of which 959 were considered engaged, completed follow-up assessments, and were included in the analyses. Both study groups achieved significant overall outcome improvement, with 61.6% (180/292) of the tailored group and 55.4% (158/285) of the standard group achieving a clinically meaningful change in the EDE-Q, on average. There were no statistically significant differences between randomized groups for continuous outcomes, but a pattern of improvement being greater in the tailored group was evident. The rate of remission on the EDE-Q at 8 weeks was significantly greater in the group receiving the tailored version (d=0.22; P≤.001). CONCLUSIONS: This is the first report to compare the relative efficacy of two versions of a mobile app for eating disorders. The data suggest that underserved individuals with eating disorder symptoms may benefit clinically from a self-help app and that personalizing app content to specific clinical presentations may be more effective in promoting symptomatic remission on the EDE-Q than content that offers a generic approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT02503098; https://clinicaltrials.gov/ct2/show/NCT02503098.

Sex differences in total frontal plane knee movement and velocity during a functional single-leg landing.

OBJECTIVES: Females land with more knee valgus than males. While most studies have evaluated lower extremity mechanics during double leg landing, most sports require single-leg landing from a double or single leg takeoff. Further, knee movement occurs toward both varus and valgus during functional landing. The purpose of this study was to determine if differences exist between females and males in total frontal plane movement and velocity of the knee during single-leg landing. DESIGN: Experimental cohort. SETTING: Motion analysis laboratory. PARTICIPANTS: Forty healthy, physically-active females (n = 20) and males (n = 20). MAIN OUTCOME MEASURES: Three-dimensional motion analysis was completed on the lower extremities during double-leg jumping followed by a single-leg landing. Student's t-tests (p ≤ 0.05) were used to determine if differences exist in frontal plane knee angles (valgus and varus excursion) and angular velocities between females and males. RESULTS: Females demonstrated greater knee valgus and varus excursion, and valgus and varus velocities compared to males (p < 0.05). CONCLUSIONS: These findings suggest that total movement in the frontal plane at the knee may be an important factor in injury mechanics in females. Further, single-leg landing from a functional jump should be considered when comparing landing biomechanics between females and males.

Geographic variation in racial disparities in child maltreatment: The influence of county poverty and population density.

There are documented disparities in the rates at which black children come into contact with the child welfare system in the United States compared to white children. A great deal of research has proliferated aimed at understanding whether systematic biases or differential rates of risk among different groups drive these disparities (Drake et al., 2011). In the current study, county rates of maltreatment disparity are compared across the United States and examined in relation to rates of poverty disparity as well as population density. Specifically, using hierarchical linear modeling with a spatially lagged dependent variable, the current study examined data from the National Child Abuse and Neglect Data System (NCANDS) and found that poverty disparities were associated with rates of maltreatment disparities, and densely populated metropolitan counties tended to have the greatest levels of maltreatment disparity for both black and Hispanic children. A significant curvilinear relationship was also observed between these variables, such that in addition to the most densely populated counties, the most sparsely populated counties also tended to have higher rates of maltreatment disparity for black and Hispanic children.

A Nationally Representative Study of Early Childhood Home Visiting Service Use in the United States.

Early childhood home visiting (HV) services are expanding broadly across the United States. Supported by federal policy, HV is now an integral part of maternal and child health services. However, no nationally representative estimate of HV use is available and no research has compared HV use across states. The 2011/12 National Survey on Children's Health was used to estimate the national and state prevalence of HV use for children 0-3 years. Generalized linear mixed modeling was used to predict HV use. An estimated 2,137,044 US children and families received HV during pregnancy and up to child age of 3 years. State HV prevalence range was 3.7-30.6 %. Nationally, 19.1 % of children below the federal poverty line received HV services. Although family poverty increased the odds of receiving HV services, higher rates of child poverty at the state level predicted less use of HV services. Important predictors of HV use include infant/child need factors (health risk, adverse experiences), predisposing factors (family size), and enabling factors (insurance type). This study provides the first estimates of national and state HV service use. Although findings indicate HV services are targeted to children at elevated risk for poor physical or developmental outcomes, our estimates show the vast majority of at-risk children did not receive HV services, including more than 80 % of low-income children, 76 % of preterm infants, and 57 % of very low birth weight infants. Increasing HV service availability could decrease negative health outcomes for young children.