Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network.

OBJECTIVE: Few published studies have evaluated the clinical utility of new diagnostic criteria for avoidant/restrictive food intake disorder (ARFID), a DSM-5 reformulation of feeding and eating disorder of infancy or early childhood. We examined the prevalence of ARFID and inter-rater reliability of its diagnostic criteria in a pediatric gastrointestinal sample. METHOD: We conducted a retrospective chart review of 2,231 consecutive new referrals (ages 8-18 years) to 19 Boston-area pediatric gastroenterology clinics for evidence of DSM-5 ARFID. RESULTS: We identified 33 (1.5%) ARFID cases; 22 of whom (67%) were male. Most were characterized by insufficient intake/little interest in feeding (n = 19) or limited diet due to sensory features of the food (n = 7). An additional 54 cases (2.4%) met one or more ARFID criteria but there was insufficient information in the medical record to confer or exclude the diagnosis. Diagnostic agreement between coders was adequate (κ = 0.72). Common challenges were (i) distinguishing between diagnoses of ARFID and anorexia nervosa or anxiety disorders; (ii) determination of whether the severity of the eating/feeding disturbance was sufficient to warrant diagnosis in the presence of another medical or psychiatric disorder; and (iii) assessment of psychosocial impairment related to eating/feeding problems. DISCUSSION: In a pediatric treatment-seeking sample where ARFID features were common, cases meeting full criteria were rare, suggesting that the diagnosis is not over-inclusive even in a population where eating/feeding difficulties are expected.

Re-examining premature mortality in anorexia nervosa: a meta-analysis redux.

Anorexia nervosa (AN) is reported to have the highest premature mortality of any psychiatric disorder, but recent meta-analyses may have inflated estimates. We sought to re-estimate mortality after methodological corrections and to identify predictors of mortality. We included 41 cohorts from 40 peer-reviewed studies published between 1966 and 2010. Methods included double data extraction, log-linear regression with an over-dispersed Poisson model, and all-cause and suicide-specific standardized mortality ratios (SMRs), with 95% Poisson confidence intervals. Participants with AN were 5.2 [3.7-7.5] times more likely to die prematurely from any cause, and 18.1 [11.5-28.7] times more likely to die by suicide than 15-34 year old females in the general population. Our estimates were 10% and 49% lower, respectively, than previously reported SMRs. Risk of premature mortality was highest in studies with older participants, although confounding by treatment was present. Gender, ascertainment, and diagnostic criteria also impacted risk.

Attention-Deficit Hyperactivity Disorder, Disruptive Behaviors, and Drug Shortage.

CASE: Kyle is a 10-year-old boy with Down syndrome and intellectual disability who is being followed up by a developmental behavioral pediatrician for attention-deficit hyperactivity disorder (ADHD) and anxiety. Kyle was initially taking a long-acting liquid formulation of methylphenidate for ADHD and fluoxetine for anxiety. Several months ago, the liquid formulation was on back order, and the methylphenidate formulation was changed to an equal dose of a long-acting capsule. Kyle is not able to swallow pills; therefore, the contents of the capsule were sprinkled onto 1 bite of yogurt each morning. Over the course of the next month, Kyle's behaviors became increasingly difficult. He was not able to tolerate loud or crowded places, and despite a visual schedule and warnings, he would become aggressive toward adults when directed to transition away from preferred activities. Fluoxetine was increased from 0.4 to 0.6 mg/kg/day at that time.One month later, his parents reported that although there may have been slight improvement in Kyle's irritability since the increase in fluoxetine, they felt he was nonetheless more aggressive and less cooperative than his previous baseline. Kyle was returned to the long-acting liquid formulation of methylphenidate at that time, and a follow-up was scheduled 2 weeks later.On return to clinic, his parents reported that Kyle's behaviors had continued to become increasingly difficult. He was described as uncooperative and aggressive at home and school. Kyle was easily upset any time he was not given his way, his behavior was corrected, or he felt that he was not the center of attention. When upset, he would yell, bite, kick, spit, or throw his body to the ground and refuse to move. At 110 pounds, Kyle's parents were no longer able to physically move his body when he dropped to the ground. This was a safety concern for his parents because he had displayed this behavior in the parking lot of a busy shopping area. Because of Kyle's aggressive and unpredictable behavior, parents no longer felt comfortable taking him to public places. Family members who had previously been comfortable staying with Kyle while his parents were out for short periods would no longer stay with him. Overall, the behaviors resulted in parents being unable to go to dinner as a couple or provide individual attention to their other children. The parents described the family as "on edge." How would you approach Kyle's management?

Human health exposure factor estimates based upon a creel/angler survey of the lower Passaic River (part 3).

The results of an analysis of site-specific creel and angler information collected for the lower 6 miles of the Passaic River in Newark, NJ (Study Area), demonstrate that performing a site-specific creel/angler survey was essential to capture the unique characteristics of the anglers using the Study Area. The results presented were developed using a unique methodology for calculating site-specific, human exposure estimates from data collected in this unique urban/industrial setting. The site-specific human exposure factors calculated and presented include (1) size of angler population and fish-consuming population, (2) annual fish consumption rate, (3) duration of anglers' fishing careers, (4) cooking methods for the fish consumed, and (5) demographic information. Sensitivity and validation analyses were performed, and results were found to be useful for performing a site-specific, human health risk assessment. It was also concluded that site-specific exposure factor values are preferable to less representative "default values." The results of the analysis showed that the size of the angling population at the Study Area is estimated to range from 154 to 385 anglers, based on different methods of matching intercepts with anglers. Thirty-four anglers were estimated to have consumed fish; 37 people consumed fish from the river. The fish consumption rate for anglers using this area was best represented as 0.42 g/day for the central tendency and 1.8 g/day for the 95th percentile estimates. Anglers fishing at the river have relatively short fishing careers with a median of 0.9 yr, an average of 1.5 yr, and a 95th percentile of 4.8 yr. Consuming anglers tend to fry the fish they caught. The demographics of anglers who consume fish do not appear to differ substantially from those who do not, with no indication of a subsistence angling population.

A survey methodology for collecting fish consumption data in urban and industrial water bodies (part 1).

The potential human health risks associated with consuming fish containing hazardous substances are related to the frequency, duration, and magnitude of exposure. Because these risk factors are often site specific, they require site-specific data. In anticipation of performing a risk assessment of the lower 6 miles of the Passaic River in New Jersey (Study Area), a year-long creel/angler survey collected such site-specific data. The lower Passaic River is urbanized and industrialized, and its site conditions present unique survey design and sampling challenges. For example, the combined population of the municipalities surrounding the Study Area is nearly 330,000, but because the Study Area is tidal, state law does not require fishing licenses for anglers to fish or crab in the Study Area. The sampling challenges posed by the lack of licensing are exacerbated by the industrialization and lack of public access in the lower half of the Study Area. This article presents a survey methodology designed to overcome these challenges to provide data for accurately estimating the Study Area's angling population and the fish and crabs they catch, keep, and eat. In addition to addressing the challenges posed by an urban and industrial setting, the survey methodology also addresses the issues of coverage, avidity, and deterrence, issues necessary for collecting a representative sample of the Study Area's anglers. This article is a companion to two other articles. The first companion article describes the analytical methodology designed to process the data collected during the survey. The second presents, validates, and interprets the survey results relating to human exposure factors for the lower Passaic River.

Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up.

OBJECTIVE: The course of eating disorders is often protracted, with fewer than half of adults achieving recovery from anorexia nervosa or bulimia nervosa. Some argue for palliative management when duration exceeds a decade, yet outcomes beyond 20 years are rarely described. This study investigates early and long-term recovery in the Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa. METHODS: Females with DSM-III-R/DSM-IV anorexia nervosa or bulimia nervosa were assessed at 9 and at 20 to 25 years of follow-up (mean [SD] = 22.10 [1.10] years; study initiated in 1987, last follow-up conducted in 2013) via structured clinical interview (Longitudinal Interval Follow-Up Evaluation of Eating Disorders [LIFE-EAT-II]). Seventy-seven percent of the original cohort was re-interviewed, and multiple imputation was used to include all surviving participants from the original cohort (N = 228). Kaplan-Meier curves estimated recovery by 9-year follow-up, and McNemar test examined concordance between recovery at 9-year and 22-year follow-up. RESULTS: At 22-year follow-up, 62.8% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa recovered, compared to 31.4% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa by 9-year follow-up. Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery at 22 years. Early recovery was associated with increased likelihood of long-term recovery in anorexia nervosa (odds ratio [OR] = 10.5; 95% CI, 3.77-29.28; McNemar χ²1 = 31.39; P < .01) but not in bulimia nervosa (OR = 1.0; 95% CI, 0.49-2.05; McNemar χ²1 = 0; P = 1.0). CONCLUSION: At 22 years, approximately two-thirds of females with anorexia nervosa and bulimia nervosa were recovered. Recovery from bulimia nervosa happened earlier, but recovery from anorexia nervosa continued over the long term, arguing against the implementation of palliative care for most individuals with eating disorders.

Primary care physicians' knowledge of and confidence in their referrals for special education services in 3- to 5-year-old children.

BACKGROUND: Children 3 to 5 years old with developmental delays are eligible for special education services. OBJECTIVE: To assess primary care physicians' (PCPs) knowledge, attitudes, and practices regarding their referrals to the special education system on behalf of children 3 to 5 years old. DESIGN/METHODS: Mail survey of 400 office-based general pediatricians and 414 family physicians in Michigan, fielded in fall 2012 and winter 2013, with a response rate of 44%. The 4-page survey included knowledge questions about special education eligibility, PCPs' role in accessing school-based services, and self-confidence in ability to help patients access these services. RESULTS: PCPs neither fully understood requirements for special education services nor were they very confident in identifying 3- to 5-year-old children eligible for special education services. CONCLUSIONS: PCPs recognize interacting with special education as a relative weakness, and they may be accepting of interventions to improve their knowledge and skills.

Mindfulness training alters emotional memory recall compared to active controls: support for an emotional information processing model of mindfulness.

OBJECTIVES: While mindfulness-based interventions have received widespread application in both clinical and non-clinical populations, the mechanism by which mindfulness meditation improves well-being remains elusive. One possibility is that mindfulness training alters the processing of emotional information, similar to prevailing cognitive models of depression and anxiety. The aim of this study was to investigate the effects of mindfulness training on emotional information processing (i.e., memory) biases in relation to both clinical symptomatology and well-being in comparison to active control conditions. METHODS: Fifty-eight university students (28 female, age = 20.1 ± 2.7 years) participated in either a 12-week course containing a "meditation laboratory" or an active control course with similar content or experiential practice laboratory format (music). Participants completed an emotional word recall task and self-report questionnaires of well-being and clinical symptoms before and after the 12-week course. RESULTS: Meditators showed greater increases in positive word recall compared to controls [F(1, 56) = 6.6, p = 0.02]. The meditation group increased significantly more on measures of well-being [F(1, 56) = 6.6, p = 0.01], with a marginal decrease in depression and anxiety [F(1, 56) = 3.0, p = 0.09] compared to controls. Increased positive word recall was associated with increased psychological well-being (r = 0.31, p = 0.02) and decreased clinical symptoms (r = -0.29, p = 0.03). CONCLUSION: Mindfulness training was associated with greater improvements in processing efficiency for positively valenced stimuli than active control conditions. This change in emotional information processing was associated with improvements in psychological well-being and less depression and anxiety. These data suggest that mindfulness training may improve well-being via changes in emotional information processing. Future research with a fully randomized design will be needed to clarify the possible influence of self-selection.