A shift to placing parents in charge: Does it improve weight gain in youth with anorexia?

Family-based treatment (FBT) has emerged as a promising approach for medically stable youth with anorexia nervosa (AN). While there is evidence that therapists embrace the core principles of FBT, most face barriers in implementing the model with fidelity. Little research has been conducted to determine whether adhering to the core methods of placing parents in charge are sufficient in restoring weight in youth with AN. This study involved a chart review of youth under 16 years of age, treated by a Canadian tertiary care health centre-based eating disorders team (EDT). The purpose was to compare the weight gain of youth treated before and after the team was trained in FBT and shifted to empowering parents to be in charge of weight gain. As predicted, youth who participated in family sessions adhering to the 'parents in charge' approach (PIC, N=32) made greater gains in percentage of ideal body weight (%IBW) and were more likely to reach body weights within a healthy range as compared with youth (N=14) who participated in a 'non-specific therapy' (NST) involving expert driven psycho-educational family sessions. Youth whose parents were placed in charge of weight gain were also significantly less likely to be hospitalized on the psychiatry unit for weight restoration, had significantly shorter mean duration of stays on this unit, and required tube-feeding less frequently than youth who participated in NST. Collectively, the results suggest that placing parents in charge of refeeding promotes efficient weight gain, while decreasing the need for more intensive intervention.

The influence of carer fear and self-blame when supporting a loved one with an eating disorder.

Carers often feel disempowered and engage in behaviours that inadvertently enable their loved one's ED symptoms and yet little is known regarding these processes. This study examined the relationships among fear, self-blame, self-efficacy, and accommodating and enabling behaviours in 137 carers of adolescents and adults with ED. The results revealed that fear and self-blame predicted low carer self-efficacy in supporting their loved one's recovery as well as the extent to which carers reported engaging in recovery-interfering behaviours. The relevance of these findings are discussed in the context of family-oriented ED therapies and highlight the importance for clinicians to attend to and help to process strong emotions in carers, in order to improve their supportive efforts and, ultimately, ED outcomes.

A study protocol for implementing Canadian Practice Guidelines for Treating Children and Adolescents with Eating Disorders.

BACKGROUND: Eating disorders have one of the highest mortality rates among psychiatric illnesses. Timely intervention is crucial for effective treatment, as eating disorders tend to be chronic and difficult to manage if left untreated. Clinical practice guidelines play a vital role in improving healthcare delivery, aiming to minimize variations in care and bridge the gap between research and practice. However, research indicates an active guideline implementation approach is crucial to effective uptake. METHODS: Mixed methods will be used to inform and evaluate our guideline implementation approach. Semi-structured focus groups will be conducted in each of the eight provinces in Canada. Each focus group will comprise 8-10 key stakeholders, including clinicians, program administrators, and individuals with lived experience or caregivers. Qualitative data will be analyzed using conventional content analysis and the constant comparison technique and the results will be used to inform our implementation strategy. The study will then evaluate the effectiveness of our implementation approach through pre- and post-surveys, comparing changes in awareness, use, and impact of the guidelines in various stakeholder groups. DISCUSSION: Through a multifaceted implementation strategy, involving the co-creation of educational materials, tailored training, and context-specific strategies, this study intends to enhance guideline uptake and promote adherence to evidence-based practices. Our study will also contribute valuable information on the impact of our implementation strategies.

The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond.

OBJECTIVE: The COVID-19 pandemic has had detrimental effects on mental health. Literature on the impact on individuals with eating disorders is slowly emerging. While outpatient eating disorder services in Canada have attempted to transition to virtual care, guidelines related to optimal virtual care in this field are lacking. As such, the objective of our Canadian Consensus Panel was to develop clinical practice guidelines related to the provision of virtual care for children, adolescents, and emerging adults living with an eating disorder, as well as their caregivers, during the COVID-19 pandemic and beyond. METHODS: Using scoping review methodology (with literature in databases from 2000 to 2020 and grey literature from 2010 to 2020), the Grading of Recommendations, Assessment, Development, and Evaluation system, the Appraisal of Guidelines, Research and Evaluation tool, and a panel of diverse stakeholders from across Canada, we developed high quality treatment guidelines that are focused on virtual interventions for children, adolescents, and emerging adults with eating disorders, and their caregivers. RESULTS: Strong recommendations were supported specifically in favour of in-person medical evaluation when necessary for children, adolescents, and emerging adults, and that equity-seeking groups and marginalized youth should be provided equal access to treatment. For children and adolescents, weak recommendations were supported for telehealth family-based treatment (FBT) and online guided parental self-help FBT. For emerging adults, internet cognitive-behavioural therapy (CBT)-based guided self-help was strongly recommended. Weak recommendations for emerging adults included CBT-based group internet interventions as treatment adjuncts, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps as treatment adjuncts. For caregivers of children and adolescents, weak recommendations were supported for virtual parent meal support training, and moderated online caregiver forums and support groups. For caregivers of emerging adults, guided parental self-help CBT was strongly recommended, and unguided caregiver psychoeducation self-help was weakly recommended. CONCLUSIONS: Several gaps for future work were identified including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents, and emerging adults with eating disorders, as well as research on more intensive services, such as virtual day hospitals.

Responsiveness of the Eating Disorders Quality of Life Scale (EDQLS) in a longitudinal multi-site sample.

BACKGROUND: In eating disorders (EDs), treatment outcome measurement has traditionally focused on symptom reduction rather than functioning or quality of life (QoL). The Eating Disorders Quality of Life Scale (EDQLS) was recently developed to allow for measurement of broader outcomes. We examined responsiveness of the EDQLS in a longitudinal multi-site study. METHODS: The EDQLS and comparator generic QoL scales were collected in person at baseline, and 3 and 6 months from 130 participants (mean age 25.6 years; range 14-60) in 12 treatment programs in four Canadian provinces. Total score differences across the time points and responsiveness were examined using both anchor- and distribution-based methods. RESULTS: 98 (75%) and 85 (65%) responses were received at 3 and 6 months respectively. No statistically significant differences were found between the baseline sample and those lost to follow-up on any measured characteristic. Mean EDQLS total scores increased from 110 (SD = 24) to 124.5 (SD = 29) at 3 months and 129 (SD = 28) at 6 months, and the difference by time was tested using a general linear model (GLM) to account for repeated measurement (p < .001). Responsiveness was good overall (Cohen's d = .61 and .80), and confirmed using anchor methods across 5 levels of self-reported improvement in health status (p < .001). Effect sizes across time were moderate or large for for all age groups. Internal consistency (Chronbach's alpha=.96) held across measurement points and patterns of responsiveness held across subscales. EDQLS responsiveness exceeded that of the Quality of Life Inventory, the Short Form-12 (mental and physical subscales) and was similar to the 16-dimension quality of life scale. CONCLUSIONS: The EDQLS is responsive to change in geographically diverse and clinically heterogeneous programs over a relatively short time period in adolescents and adults. It shows promise as an outcome measure for both research and clinical practice.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders.

OBJECTIVES: Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline. METHODS: Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders. RESULTS: Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed. CONCLUSIONS: Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

A controlled evaluation of web-based training for teachers and public health practitioners on the prevention of eating disorders.

The effectiveness of a web-based prevention program designed for elementary school teachers was examined in 78 elementary school teachers and 89 local public health practitioners (who provide support to schools). Participants were assigned to either the intervention (n = 95) or comparison (n = 72) study groups. All participants completed self-report online measures prior to, and following, the 60-day study period assessing knowledge about various factors that influence body image in children and efficacy to fight weight bias in the school. Information was also solicited on the feasibility of, and on the perceived benefit of the web-based program as a knowledge translation tool, in terms of layout and content. The Student Body program was found to be successful in improving knowledge concerning facts about dieting among the teacher participants, and in increasing efficacy to fight weight bias among the public health participants. Overall, the feedback was very positive concerning the layout and content of the Student Body. Participants reported an overall improvement in their awareness about how weight bias can be present in their teaching practices, and how this can trigger body image concerns among their students. Findings have implications for using the web to engage teachers in the prevention of disordered eating among school age children.

'I want to lose weight': Early risk for disordered eating?

The present study examined the risk of disordered eating and its relation to attempts to lose weight by surveying a Maritime Canadian sample of 247 girls and boys in grades 6, 7 and 8. Current attempts to lose weight were highest in grade 8 girls (41% of girls and 9% of boys) compared with grade 6 (14% of girls and 24% of boys) and grade 7 (21% of girls and 13% of boys) children. Of those trying to lose weight, 71.4% were in the average range for weight and height, 12.2% were overweight and 16.3% were obese. The Children's version of the Eating Attitudes Test (ChEAT) was used to assess eating attitudes and behaviours, and the Rosenberg Self-Esteem Scale was used as a measure of self-esteem. The results showed that 8.5% of the children fell in the high-risk group for disordered eating (ChEAT score 20 or higher). Those in the high-risk group were significantly more likely to fear being overweight (90%), to have tried to lose weight in the past (81%), to be currently trying to lose weight (76%), and to have engaged in binge eating (38%) and self-induced vomiting (24%). The best predictor of membership in the high-risk group for girls was current attempts at weight loss and having lower self-esteem. Only two boys fell in the high-risk group. Body mass index and current weight category (underweight, average, overweight and obese) could not explain the differences between the low- and high-risk groups. Knowing that a child is trying to lose weight can aid in identifying youth at risk for disordered eating, and can provide an opportunity for preventive education.

Development and multi-site validation of a new condition-specific quality of life measure for eating disorders.

BACKGROUND: In eating disorders (EDs) treatment, outcome measurement has traditionally focused on symptom reduction rather than functioning or quality of life (QoL). Generic QoL measures lack sensitivity for some diagnoses and many not be responsive in eating disorder patients. This article describes the development and validation of a condition-specific QoL measure for adolescents and adults with eating disorders--the Eating Disorders Quality of Life Scale (EDQLS). METHODS: Multi-source and multi-stage methods were used to develop the EDQLS, with participation of patients with EDs, their family members and ED treatment providers. Sources for domain and item development included 39 articles, 12 patient and 10 treatment provider interviews, and 31 first person narratives from the internet. Four stages of validation and pre-testing involving 17 patients, 10 family members and 18 providers reduced 233 items to 40 items in 12 domains. These items were pilot tested in 41 ED patients. RESULTS: The final instrument was then validated in a 12 site sample of 171 individuals aged 14-60 with EDs. All items showed good dispersion. The total raw mean score was 110 out of 200 (SD 27.6) with higher scores indicating better QoL. Internal consistency was excellent (Cronbach's alpha = .96) and subscale internal consistency ranged from alpha .36 to .79 providing evidence for a strong overall construct and some multi-dimensionality. Validity was supported by significant differences in mean EDQLS according to severity levels on the EDI-2 (F = 95.3, p <.001) and the BSI (F = 86.9, p <.001). EDQLS scores were positively associated with time in treatment (F = 4.65, p = .01) suggesting responsiveness. A strong positive association was also found between EDQLS scores and stage of change (F = 15.1 p <.001). Pearson's correlations between the EDQLS and criterion instrument scores were .71 for the SF-12 mental subscale, .61 for the QoLI and .78 for the 16D, supporting construct validity. Exploratory principal components and item response theory analyses identified only a few poor fitting items. CONCLUSION: The EDQLS has promising psychometric characteristics and may be useful for evaluating ED treatment effectiveness.

The canadian eating disorder program survey - exploring intensive treatment programs for youth with eating disorders.

OBJECTIVE: To explore and describe philosophies and characteristics of intensive eating disorder (ED) treatment programs based in tertiary care institutions across Canada. METHOD: A ninety-item survey examining ED services for adolescents was developed, piloted, and completed by 11 programs across Canada. Information pertaining to program characteristics and components, governance, staffing, referrals, assessments, therapeutic modalities in place, nutritional practices, and treatment protocols were collected. RESULTS: The results highlight the diversity of programming available but also the lack of a unified approach to intensive eating disorder treatment in youth. CONCLUSIONS: This report provides important baseline data that offers a framework that programs can use to come together to establish assessment and treatment protocols as well as a process for outcome evaluation. Continued collaboration will be essential moving forward to ensure Canadian youth, regardless of geographic location, receive the necessary treatment required to attain and sustain recovery.

OBJECTIF: Explorer et décrire les philosophies et les caractéristiques des programmes de traitement intensif des troubles alimentaires (TA) menés dans des institutions de soins tertiaires au Canada. MÉTHODE: Un questionnaire en 90 items examinant les services de TA pour adolescents a été mis au point, piloté et rempli par 11 programmes pancanadiens. L'information concernant les caractéristiques et les composantes des programmes, la gouvernance, la dotation en personnel, l'aiguillage, les évaluations, les modalités thérapeutiques instaurées, les pratiques nutritionnelles et les protocoles thérapeutiques a été recueillie. RÉSULTATS: Les résultats mettent en évidence la diversité des programmes offerts mais également, l'absence d'une approche unifiée du traitement intensif des troubles alimentaires chez les adolescents. CONCLUSIONS: Ce rapport offre d'importantes données de départ constituant un cadre que peuvent utiliser les programmes pour s'assembler et établir des protocoles d'évaluation et de traitement ainsi qu'un processus d'évaluation des résultats. La collaboration continue sera essentielle dorénavant pour faire en sorte que les adolescents canadiens, peu importe l'emplacement géographique, reçoivent le traitement nécessaire pour atteindre et faire durer le rétablissement.

Amanda's gift.

Even though we know that anorexia nervosa carries the highest mortality rate of all mental disorders, it is easy to distance ourselves from this fact. Cold hard statistics did not help me to understand what I was likely to experience as a therapist with a dying patient. Putting a face to these statistics, brings the grim reality closer to home for all of us.

Food for thought: Will adolescent girls with eating disorders self-monitor in a CBT group?

This study of a Cognitive Behavior Therapy group examined the process of self-monitoring by adolescent females with eating disorders in group treatment. Five females, aged 17-18 with Anorexia Nervosa (n = 2) and Bulimia Nervosa (n = 3), participated in an 8-week treatment group. Self-monitoring occurred on 50% of the days and was highest during the first 3 weeks of treatment. Commitment to monitoring was related to the girls' self-reported readiness to change. Girls with Anorexia self-monitored as frequently as those with Bulimia. The clinical usefulness of self-monitoring with adolescents is discussed.