Adolescent eating disorder treatment outcomes of an in-person partial hospital program versus a virtual intensive outpatient program.

OBJECTIVE: Though virtual outpatient psychotherapy for eating disorders is likely effective, less is known about virtual higher levels of care. The current study examined the clinical outcomes of a family-based virtual intensive outpatient program (vIOP) for youth with eating disorders which was developed in response to the COVID-19 pandemic, compared to the same institution's in-person partial hospital program (PHP). METHODS: Treatment outcomes were assessed via chart review in 102 patients between the ages of 9-23 (M = 15.2, SD = 2.5) who were predominantly cisgender female (84.3%) and primarily diagnosed with anorexia nervosa (64.7%) or atypical anorexia (23.5%). Participants were either treated in the in-person PHP before the pandemic (n = 49) or the vIOP during the pandemic (n = 53). Percent expected body weight (%EBW) was examined at baseline, end of treatment, 3-months post-treatment, and 6-months post-treatment, as well as the frequency of medical, psychiatric, and residential admissions before, during, and after vIOP or PHP participation. RESULTS: Linear mixed models demonstrated no effect of treatment modality (in-person versus virtual) on %EBW over time. The duration of the vIOP was, on average, 12 calendar days longer, though the amount billed for the vIOP was lower. Survival analyses and Cox regression models did not suggest differences in the frequency of hospital and residential treatment admissions during treatment (vIOP: 9.4%, PHP: 10.0%) or post-treatment (vIOP: 15.0%, PHP: 10.2%). DISCUSSION: Findings support virtual family-based programs as suitable alternatives to in-person treatment and underscore the potential cost-effectiveness of a family-based IOP versus PHP. PUBLIC SIGNIFICANCE: This study demonstrates that a virtual, family-based, intensive outpatient program for youth with eating disorders had similar treatment outcomes to an in-person partial hospitalization program. Specifically, the virtual and in-person programs had similar weight restoration outcomes and rates of medical, psychiatric, or residential treatment admissions during or after treatment initiation. Findings support the use of virtual treatment, even for youth requiring a high level of intervention.

Omega-3 fatty acids and autonomic function in adolescents with anorexia: A randomized trial.

OBJECTIVES: Patients with anorexia nervosa (AN) have autonomic nervous system (ANS) dysfunction as measured by heart rate variability (HRV). Omega-3 fatty acids may improve heart rate regulation. Our aim was to describe ANS response to a mid-day meal in adolescent females with AN in a 12-week treatment program, randomized to receive either omega-3 supplements or placebo. METHODS: This pilot study was a longitudinal, double-blind, randomized controlled trial. Each group was subdivided into an acutely ill cohort and a chronically ill cohort. Linear and non-linear measures of slope, mean, and pre/post-meal changes in HRV were measured at baseline, 6 weeks, and 12 weeks. RESULTS: Twenty-four women (n = 12 placebo; n = 12 omega-3) were enrolled. By program end, the acute omega-3 group alone showed no change in any pre-meal slope. Acute and chronic omega-3 groups, but not placebo groups, demonstrated physiologically expected post-meal heart rate increases at 12 weeks. For all measures at 6 and 12 weeks, the chronic placebo and omega-3 groups had smaller physiologic responses to the meal compared with the acute groups. CONCLUSIONS: Participation in a 12-week partial hospitalization program may improve autonomic function in response to mealtime, with possible additional benefit from omega-3 PUFA, particularly in those with acute illness. IMPACT: Autonomic function with meals improves with a 12-week partial hospitalization program in adolescent females with anorexia nervosa. Omega-3 polyunsaturated fatty acids may improve autonomic function, especially in adolescent females with acute forms of anorexia nervosa. Longer duration of illness in adolescent females with anorexia nervosa is associated with blunted autonomic response to meals.

A pilot randomized controlled trial of omega-3 fatty acid supplementation for the treatment of anxiety in adolescents with anorexia nervosa.

OBJECTIVE: To evaluate the effectiveness and tolerability of omega-3 polyunsaturated fatty acid (PUFA) supplementation for treatment of trait anxiety among adolescent females with restrictive anorexia nervosa (AN). METHOD: A pilot double-blind, placebo-controlled randomized trial of adolescent females with AN (N = 24) entering Partial Hospitalization Program (PHP) from January 2015 to February 2016. Participants were randomized to four daily PUFA (2,120 mg eicosapentaenoic acid/600 mg docosohexaenoic acid) or placebo capsules for 12 weeks. A 9-item questionnaire of side effect frequency assessed medication tolerability. The Beck Anxiety Inventory-Trait measured anxiety at baseline, 6, and 12 weeks. Linear mixed models evaluated associations between randomization group and study outcomes. Twenty-two and 18 participants completed 6 and 12 weeks of data collection, respectively. RESULTS: Medication side effect scores were low and were not significantly different between randomization groups at Week 6 (p = .20) or 12 (p = .41). Mean trait anxiety score significantly (p < .01) decreased from baseline to 12 weeks in both groups, and the rate of change over the course of time did not differ between omega-3 PUFA and placebo groups (p = .55). CONCLUSION: Omega-3 PUFA supplementation was well tolerated in adolescent females with AN. Although power to detect differences was limited, we found no evidence that omega-3 PUFA benefited anxiety beyond nutritional restoration.

Inpatient medical stabilization for adolescents with eating disorders: patient and parent perspectives.

PURPOSE: The serious physical complications of eating disorders in adolescents may necessitate inpatient medical stabilization, yet little is known about how patients and their parents perceive the hospitalization experience. METHODS: We identified 82 patients admitted to a large urban hospital for medical stabilization between January 1, 2010 and June 30, 2013. Twenty-three patients and 32 parents completed directed telephone interviews. Respondents rated components of the inpatient protocol using five-point Likert scales and answered open-ended questions regarding hospitalization. Quantitative and qualitative analyses were performed. RESULTS: The mean age of patients at admission was 14.9 years (range 9-21) and the average stay was 8.4 days (range 2-25). Patients rated "massage therapy" most helpful and "cell phone limits" least helpful. Parents rated "nursing staff" most helpful and "seeing other patients in the hospital" least helpful. Protocol components viewed differently by parents and patients included parents more strongly endorsing "staff supervision of meals" (4.34 vs 2.82, p < 0.001) and "limits on physical activity" (4.34 vs 3.23, p = 0.001). The two most common themes identified in open-ended questions were need for hospitalization as a signifier of eating disorder severity and desire for mental health services on the medical unit. Parents emphasized the value of dietician-directed meal planning. CONCLUSIONS: Inpatient medical stabilization for adolescent eating disorders may play an important role not only in addressing acute medical complications, but also in activating the patient and family regarding the need for ongoing treatment. Parents particularly appreciate staff supervision of meals and having a respite from meal planning.

Effect of nutritional rehabilitation on gastric motility and somatization in adolescents with anorexia.

OBJECTIVE: To examine gastric function, as well as the presence of somatic complaints, anxiety symptoms, and functional gastrointestinal disorders (FGIDs), in adolescents with anorexia nervosa (AN) before and after nutritional rehabilitation. STUDY DESIGN: Sixteen females with AN and 22 healthy controls with similar demographic profiles were included. Gastric emptying (measured as residual gastric volume) and gastric accommodation (measured as postprandial antral diameter) were assessed with abdominal ultrasonography. Participants completed the Children's Somatization Inventory (CSI), the Screen for Child Anxiety-Related Emotional Disorders, and the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III version. All testing was repeated 3-4 months later. RESULTS: Body mass index in the AN group improved over time (P = .012). Fasting gastric parameters were similar in the 2 groups. Maximum postprandial antral diameter was significantly greater in controls compared with the AN group (P = .008). Only adolescents with AN demonstrated a significant increase in maximum postprandial diameter at repeat testing (P = .009). There was no difference in residual gastric volume between the 2 groups. Initial CSI scores were higher in adolescents with AN (P < .0001), including higher scores for nausea and abdominal pain. CSI scores were significantly lower in adolescents with AN (P = .035). Initial scores on the Screen for Child Anxiety-Related Emotional Disorders were significantly higher in adolescents with AN (P = .0005), but did not change over time. Adolescents with AN met significantly more criteria for FGIDs (P = .003). CONCLUSION: Adolescents with AN have impaired gastric accommodation that improves after nutritional rehabilitation, have significantly more somatic complaints, and meet more criteria for anxiety disorders and FGIDs. After nutritional rehabilitation, somatization improves and FGIDs become less common, but symptoms of anxiety persist.

Prevalence of pain-predominant functional gastrointestinal disorders and somatic symptoms in patients with anxiety or depressive disorders.

OBJECTIVE: To determine whether children with symptoms of internalizing psychiatric disorders have a greater prevalence of pain-predominant functional gastrointestinal disorders (FGIDs) and migraine-like headaches. STUDY DESIGN: Children and adolescents aged 6-18 years were recruited from a behavioral health center (n = 31) and a primary care center (n = 36). Subjects completed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-based symptom inventory questionnaires to screen for internalizing psychiatric disorders, the Questionnaire on Pediatric Gastrointestinal Symptoms, and a somatic distress assessment interview. RESULTS: Thirty-three subjects (19 of 31 from the behavioral health center and 14 of 36 from the primary care center) screened positive for symptoms of anxiety or depressive disorders. The remainder screened negative and served as controls. Pain-predominant FGIDs were more common in the group with symptoms of anxiety or depression compared with controls (prevalence, 51.5% vs 8.8%; P = .0002). Migraine headaches occurred in 57.6% of the subjects with internalizing psychiatric disorders vs 23.5% of the control group (P = .006). The prevalence of functional constipation did not differ significantly between the 2 groups. The data remained essentially unchanged when analyzed within each center of recruitment. CONCLUSION: Youths with anxiety or depressive symptoms are more likely to suffer from pain-predominant FGIDs and migraine-like headaches, but not from functional constipation. The lack of an association between functional constipation and internalizing psychiatric symptoms suggests that FGIDs associated with pain may bear a specific relationship to emotional disorders.

A Survey of Healthcare Providers About Reproductive Healthcare for Adolescent Women With Epilepsy.

STUDY OBJECTIVE: To evaluate knowledge, attitudes, and practices about sexual and reproductive health (SRH) for adolescent and young adult (AYA) women with epilepsy among general pediatricians, adolescent medicine specialists, and pediatric gynecologists. DESIGN: Survey comprising previously validated and novel items that underwent content validity testing and was distributed through specialty listservs. Categorical variables analyzed with χ2 or Fisher exact tests, and continuous variables with Kruskal-Wallis tests. SETTING: Online. PARTICIPANTS: Physicians and Advanced practice providers. INTERVENTIONS: Online survey. MAIN OUTCOME MEASURE(S): Questions testing SRH knowledge, assessing confidence in SRH counseling practices and frequency of intended SRH counseling, and identifying barriers and facilitators to SRH provision for AYA women with epilepsy. RESULTS: Of 329 participants, 57% were general pediatricians, 27% were adolescent medicine specialists, and 16% were pediatric gynecologists. On 15 items assessing knowledge, general pediatricians scored significantly lower than respondents in the other specialties (P < .01). Among 11 items about confidence in SRH skills, general pediatricians were significantly less confident than respondents in the other specialties (P < .01). General pediatricians reported that they would perform annual counseling less often on 7 SRH counseling topics compared with respondents in the other specialties (P < .01). In all, 54% of the respondents reported that barriers to SRH provision include limited time during visits and lack of epilepsy knowledge. Respondents identified facilitators including guidelines/algorithms for managing SRH (83%), provider education (61%), and electronic health record alerts (60%). CONCLUSION: Responses suggest suboptimal knowledge, confidence, and care provision regarding SRH for AYA women with epilepsy, particularly among general pediatricians. Identified barriers and facilitators may serve as targets for interventions to improve SRH provision.

Medical Admissions Among Adolescents With Eating Disorders During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Emerging data suggest the coronavirus disease 2019 (COVID-19) pandemic has been associated with worsening symptoms of eating disorders (EDs) among both adults and adolescents. With this study, we sought to determine if medical admission patterns among adolescents admitted to our institution for restrictive EDs changed during the pandemic, relative to prepandemic counts of admissions per month. METHODS: We performed a chart review of patients aged 10 to 23 years admitted to our children's hospital for restrictive EDs from March 2017 through March 2021 and completed an interrupted time series analysis of admission counts per month. Demographic variables for admitted patients were compared by using χ2, Fisher's exact, and 2-sample t tests. RESULTS: ED-related medical admissions at our institution increased significantly during the COVID-19 pandemic. The total number of admissions during the first 12 months of the COVID-19 pandemic (April 1, 2020, through March 31, 2021, n = 125) was more than double the mean number of admissions per year for the same time frame (April 1 through March 31) for the previous 3 years (mean = 56). Patient demographics were similar before and during the pandemic, with the exception that patients admitted during the COVID-19 pandemic were less likely than those admitted before the pandemic to have public insurance. CONCLUSIONS: Medical admissions related to restrictive EDs among adolescents increased significantly during the COVID-19 pandemic. Pediatric providers in a variety of settings should be prepared to care for adolescents with restrictive EDs during the pandemic.

Feasibility of a clinic-delivered adolescent and pediatrician communication intervention on patient participatory behaviors and behavior change: TIC TAC pilot study.

OBJECTIVES: Pediatrician-adolescent communication can improve adolescent health. We conducted a two-arm design to pilot-test an intervention that randomized adolescents to receive a Feedback Guide to promote engaged conversations. We hypothesized that adolescents who received the Guide would be more participatory. METHODS: We recruited 12 pediatricians and 29 adolescents. Clinic staff enrolled adolescents using a tablet that enabled consenting, assessment of high-risk behaviors, and audio recording of encounters. We surveyed adolescents immediately and two months after the encounter. RESULTS: Adolescents who received the intervention were more participatory than adolescents who did not. Pediatricians counseled on 20 of 32 high-risk behaviors with no significant arm differences. At follow-up, adolescents changed 9 of 32 behaviors; 6 were among 4 of adolescents in the intervention arm. Adolescents in the intervention arm were also more likely to report that counseling would help them change their behavior; these encounters were slightly longer than control arm encounters. CONCLUSIONS: We confirmed feasibility of a streamlined approach to enrolling and audio recording encounters. The Feedback Guide improved adolescent participation and might have helped them adopt healthier behaviors. PRACTICE IMPLICATIONS: Adolescents can be primed to be participatory and can change their behaviors after a meaningful encounter with their pediatrician.

Confidentiality, consent, and caring for the adolescent patient.

PURPOSE OF REVIEW: This study reviews the healthcare-related rationale for providing confidential care to adolescents, as well as the legal framework for the provision of such care. RECENT FINDINGS: Physician assurances of confidentiality increase adolescents' willingness to disclose sensitive health information, but these assurances are rarely given. Physicians may not be aware of legal minor consent guidelines or may be concerned about parental reaction to such confidential discussions. Fortunately, many parents and teens understand the importance of confidential healthcare. Adolescent consent and confidentiality laws vary from state to state, but there are federal guidelines and common law concepts that are applicable throughout the United States. The Health Insurance Portability and Accountability Act Privacy Rule also provides guidelines for confidential care to minors. Future challenges for adolescent confidentiality include ease of access to electronic medical records as well as patient (and/or parent)-controlled health records. SUMMARY: Confidentiality for adolescents has important implications for the quality provision of healthcare for this vulnerable population. Physicians and other healthcare providers must be aware of these health implications, as well as federal policies, common law, and their individual state's laws pertaining to this important topic.

Risk factors associated with overweight and obesity in college students.

UNLABELLED: College obesity is increasing, but to the authors' knowledge, no researchers to date have evaluated risk factors in this population. OBJECTIVE: The authors assessed whether abnormal eating perceptions and behaviors were associated with overweight in college students. PARTICIPANTS AND METHODS: A sample of undergraduates (N = 4,201) completed an online survey containing demographic questions and the Eating Attitudes Test-26 (EAT-26) questionnaire. The authors stratified participants into normal-weight and overweight/obese groups and evaluated physical activity, EAT-26 score, purging behaviors, and answers to selected overweight screening questions on the basis of body mass index. A modified EAT-26 score of > or = 11 was associated with overweight (p = .016). RESULTS: Compared with normal-weight peers, overweight participants displayed an increased fear of bingeing, preoccupation with food, desire to be thinner, and engagement in dieting behavior. Mean body mass index also increased with age and physical inactivity (p < .001). CONCLUSIONS: Because physical inactivity, disordered eating perceptions, and disordered behaviors are associated with increased rates of overweight and obesity, identification of these risk factors in obese youths may increase understanding of weight loss barriers and facilitate the treatment of adolescent obesity.

School performance: the pediatrician's role.

When children begin having difficulties in school, the first stop for parents is often the pediatrician's office. Although school performance problems may seem outside the realm of routine primary health care, there are many important roles that the primary care provider may play. These include identifying medical issues that may impact performance, helping the family form an intervention team, and acting as the child's advocate when interacting with the school. In addition, it is important for pediatricians to be familiar with cognitive, emotional, and developmental problems that affect school performance and to assist parents in becoming active participants in their children's education.