Clinical care for severe and persistent eating disorders in pediatric populations: Perspectives of health professionals.

OBJECTIVE: Models of treatment for adults with severe and enduring eating disorders focus on harm reduction and improving quality of life. However, there is a notable gap in the pediatric literature in this area. The current study set out to assess the perspectives of health professionals regarding clinical care for young people (e.g., ages 10-25 years) with severe and enduring eating disorders, and to explore perceptions about appropriate treatment options for these presentations. METHODS: Health professionals were invited to complete a two-stage online survey about their experiences with clinical care for pediatric eating disorders through Canadian and Australian professional eating disorder networks. Survey 1 included questions about their experiences in supporting individuals with severe and enduring presentations. Participants who completed Survey 2 reviewed clinical vignettes and shared their perspectives about treatment recommendations and models of care, including for a severe and enduring presentation. RESULTS: A total of 85 clinicians responded to questions on Survey 1 about severe and enduring eating disorder presentations. A portion of these respondents (n = 25) also participated in Survey 2. The majority of respondents to Survey 1 reported providing clinical care for pediatric severe and enduring eating disorder presentations. Amongst respondents to Survey 2, there was low consensus amongst respondents for the clinical care that would be most appropriate for young people with a severe and enduring eating disorder presentation. Numerous challenges in models of care for severe and enduring presentations in pediatric settings were raised in responses on Survey 2, with clinicians sharing their awareness of models focusing on quality of life, while also raising concerns about the appropriateness of these models for young people. CONCLUSIONS: The preliminary results of this study demonstrate that the majority of clinicians report that they have provided care to young people with severe and enduring presentations. There is a clear need for establishing guidance for clinicians working in pediatric eating disorder settings around models of care focused on quality of life. Engagement with interested parties, including those with lived experience, can clarify the development of terminology and clinical pathways for severe and enduring presentations of pediatric eating disorders.

Treatment models focusing on harm reduction and quality of life (as opposed to eating disorder recovery) are available for adults with severe and enduring eating disorders. However, these models are not widely available for young people. In fact, there is very limited research on severe and enduring eating disorder presentations in pediatric populations. We assessed the views of health professionals regarding clinical care for young people with severe and enduring eating disorder presentations, and asked professionals about what treatment options might be most appropriate for these presentations. Most participants reported providing clinical care for pediatric severe and enduring eating disorder presentations. However, clinicians had diverse views about the treatment that would be most appropriate for a severe and enduring eating disorder presentation in a young person. Further research and engagement with clinicians and those with lived experience is needed to clarify the terminology and clinical pathways for severe and enduring presentations of pediatric eating disorders.

Estimating additional health and social costs in eating disorder care for young people during the COVID-19 pandemic: implications for surveillance and system transformation.

BACKGROUND: The impact of the COVID-19 pandemic on young people with eating disorders (EDs) and their families was profound, with surging rates of hospitalizations and referrals reported internationally. This paper provides an account of the additional health and social costs of ED care for young people living in Canada incurred during the COVID-19 pandemic, drawing attention to the available data to inform these estimates while noting gaps in data capacities to account for a full view of the ED system of care. METHODS: Three methodologies were used to capture costs: (1) provincial administrative data holdings available at the Canadian Institute of Health Information (CIHI) were used by Deloitte Access Economics to conduct analyses on costs related to hospitalizations, emergency room visits, outpatient visits with physicians and loss of well-being from being on a waitlist. These were examined across three fiscal years (April 1 to March 31, 2019-2022) to compare costs from one year before to two years after the onset of the pandemic, (2) data collected on support-based community ED organizations and, (3) costs identified by young people, caregivers and health care professionals. RESULTS: Estimates of additional health care costs and social costs arising from ED care waitlists were estimated to have increased by 21% across the two years after the onset of the pandemic and is likely to represent an underestimate of costs. Costs related to some standard ED care services (e.g. day treatment programs) and support-based community ED organizations that saw a 118% increase in services during this time, are some examples of costs not captured in the current cost estimate. CONCLUSIONS: This paper provides a first account of the additional health and social ED care costs associated with the pandemic, which indicate at minimum, a 21% increase. The results invite discussion for more investments in ED services for young people in Canada, as it is unclear if needs are expected to remain elevated. We suggest a call for a national surveillance strategy to improve data holdings to aid in managing services and informing policy. A robust strategy could open the door for much-needed, data-informed, system transformation efforts that can improve ED care for youth, families and clinicians.

The impact of the COVID-19 pandemic on young people with eating disorders and their families was profound, incurring substantial costs to youth, families, health professionals, eating disorder systems of care, and society. This study looks to draw on available data in Canada to estimate the additional health and social costs experienced during the pandemic. Using available national data holdings on eating disorder health system use, survey and discussion groups with individuals who provided or received eating disorder care during the pandemic, and data from support-based community eating disorder organizations, we attempted to capture the fulsomeness of these costs and demonstrate gaps that are likely leading to an incomplete picture. Available data across Canada on hospitalizations, emergency room visits, outpatient visits and loss of wellbeing while on a waitlist were looked at across three fiscal years (April 2019 to March 2022). Overall, an average increase of 21% of additional health care and social costs was seen across the two years after the onset of the pandemic, although this is considered an underestimation. Additional costs such as those for other standard eating disorder treatment options (e.g. day treatment programs) were not captured in these estimates. Additionally, costs related to services received through support-based community eating disorder organizations that saw a 118% increase in services during the pandemic, and private services (e.g. psychologist, dietitian) are some further examples of costs not captured in the current cost estimate. The results of this study highlight that needs and costs related to ED care rose during the pandemic and provides the first account of by how much. Given data limitations, there is a need to revisit national surveillance strategies for eating disorders to help increase accuracy of these estimates and aid in managing services and informing policies related to eating disorder care.

The financial and social impacts of the COVID-19 pandemic on youth with eating disorders, their families, clinicians and the mental health system: a mixed methods cost analysis.

BACKGROUND: The onset of the COVID-19 pandemic has had an adverse impact on children, youth, and families with eating disorders (EDs). The COVID-19 pandemic exacerbated pre-existing personal and financial costs to youth, caregivers, and health professionals accessing or delivering ED services. The objectives of this mixed methods study were to (1) understand the indirect, direct medical and non-medical costs reported by youth, caregivers, and clinicians; (2) understand how the COVID-19 pandemic may have impacted these costs, and (3) explore implications of these costs with regards to barriers and resources to inform future decisions for the ED system of care. METHODS: Youth (aged 16-25 years) with lived/living experience, primary caregivers, clinicians, and decision-makers were recruited with support from various partners across Canada to complete group specific surveys. A total of 117 participants responded to the survey. From those respondents, 21 individuals volunteered to further participate in either a discussion group or individual interview to provide additional insights on costs. RESULTS: Youth and primary caregivers reported costs relating to private services, transportation and impacts of not attending school or work. Additionally, primary caregivers reported the top direct medical cost being special food or nutritional supplements (82.8%). In discussion groups, youth and caregivers elaborated further on the challenges with long waitlists and cancelled services, impact on siblings and effect on family dynamics. Clinicians and decision-makers reported increased work expectations (64.3%) and fear/isolation due to COVID-19 in the workplace (58.9%). Through discussion groups, clinicians expanded further on the toll these expectations took on their personal life. Approximately 1 in 3 health professionals reported contemplating leaving their position in 1-2 years, with greater than 60% of this group stating this is directly related to working during the pandemic. CONCLUSIONS: Findings demonstrate the need for increased support for youth and caregivers when accessing ED services both during crisis and non-crisis times. Additionally, attention must be given to acknowledging the experience of health professionals to support better retention and resource management as they continue to navigate challenges in the health care system.

The COVID-19 pandemic has had significant impacts for children, youth and families with eating disorders (EDs) and those who care for them. The objective of this study was to understand the impacts on financial and personal costs to youth, caregivers and clinicians when either accessing or delivering ED services during the pandemic. This study consisted of an online survey and discussion groups with youth (16-25 years old) with lived experience of an ED, primary caregivers, clinicians and decision-makers delivering ED services to understand the costs they experienced. Although many reported costs were financial, including direct medical costs (i.e. private therapy) and direct non-medical costs (i.e. transportation, accommodation costs), there were also significant personal costs to individuals and their families. Healthcare professionals also reported extensive challenges with resources and increased work expectations due to the pandemic context. Acknowledging the costs experienced by young people, families and healthcare professionals during the pandemic allows for the discussion of how we can better support those accessing or delivering ED services in times of crisis and non-crisis.

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.

Psychometric properties of the Parent Eating Disorder Examination Questionnaire.

OBJECTIVE: To examine the psychometric properties of the Parent Eating Disorder Examination Questionnaire (PEDE-Q), developed to improve eating disorder (ED) assessment among youth by including parents as informants. METHODS: A multi-site, transdiagnostic sample of 355 adolescents with EDs completed the Eating Disorder Examination Questionnaire (EDE-Q) and their parents completed the PEDE-Q. RESULTS: The internal consistencies of the PEDE-Q subscales were on par with established EDE-Q ranges (.73 to .90), both when examined using the original four-factor EDE-Q subscales and the seven-item, three-factor subscales of the brief EDE-Q. Statistically significant medium- to large-sized correlations and poor to moderate levels of agreement were found between the corresponding EDE-Q and PEDE-Q subscales. Receiver-operator characteristic (ROC) curves showed that the PEDE-Q had a statistically significant area under the curve (AUC) to maximize sensitivity and specificity in diagnosing full-syndrome AN, whereas the EDE-Q did not. Based on chi-square analyses, the PEDE-Q identified a statistically significantly greater number of AN cases than the EDE-Q. The EDE-Q yielded a BN diagnosis more frequently than the PEDE-Q, although this difference was not statistically significant. DISCUSSION: Results suggest that the PEDE-Q has good psychometric properties and provides incremental information that can aid in the assessment and diagnosis of adolescents with EDs, particularly those with AN. PUBLIC SIGNIFICANCE: There exist complex challenges to identifying clinically significant eating disorders among youth. The PEDE-Q is a questionnaire measure that improves eating disorder assessment among children and adolescents by asking parents to report on the symptoms and behaviors they have observed in their child and that youth may not fully disclose. The PEDE-Q can aid in the diagnosis of adolescents with eating disorders, particularly those with anorexia nervosa.

The economic impact of eating disorders in children and youth in Canada: a call to action to improve youth eating disorder research and care.

The COVID-19 pandemic has led to an unprecedented rise in rates and symptoms of eating disorders among Canadian youth. To date, there is a lack of national surveillance and costing data in Canada to inform policymakers and healthcare leaders on how to best address the surge in new and existing cases. This has resulted in the Canadian healthcare system being unprepared to adequately respond to the increased needs. Therefore, clinicians, researchers, policymakers, decision-makers, and community organizations across Canada are collaborating to compare pre-and post-pandemic costing data from national and province-level healthcare systems in an effort to address this gap. Results from this economic cost analysis will be an important first step in informing and guiding policy on possible adaptations to services to better fulfill the needs of youth with eating disorders in Canada. We highlight how gaps in surveillance and costing data can impact the field of eating disorders in an international context.

Prevalence of pediatric acute-onset neuropsychiatric syndrome (PANS) in children and adolescents with eating disorders.

BACKGROUND: Pediatric obsessive-compulsive disorder (OCD) and eating disorder symptoms frequently overlap, clouding diagnostic certainty and hypothesized etiologic factors. Pediatric acute-onset neuropsychiatric syndrome (PANS) is defined by abrupt emergence of core obsessive-compulsive behaviours and/or food restriction with concurrent, ancillary cognitive and behavioral symptoms. Inflammatory and immune processes have putative roles in both PANS and a related described condition with cardinal obsessive-compulsive or tic symptoms, known as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). While prevalence of PANS and PANDAS has been examined in tic, movement disorder and OCD populations, this has not yet been systematically examined in a pediatric eating disorder sample. OBJECTIVES: To identify the lifetime prevalence of those meeting PANS and/or PANDAS criteria within a pediatric eating disorder cohort. METHODS: Convenience sampling method was utilized to select consecutive youth (ages 8-18-years) presenting to an interdisciplinary pediatric eating disorder subspecialty program with a confirmed eating disorder and completed parent-report PANS/PANDAS questionnaire (n = 100). A parent-reported measure was used to establish lifetime prevalence rates for PANS and PANDAS. Descriptive and exploratory comparative analyses were conducted between PANS and non-PANS groups. Continuous measures were analyzed using two-tailed independent sample t-tests and categorical measures were analyzed using two-tailed Fisher's exact tests. RESULTS: Among participants, 52% (n = 52) met PANS criteria and 0% (n = 0) met PANDAS diagnostic criteria. Core, abrupt-onset PANS symptoms included both food restriction and obsessive-compulsive symptoms in 63.5% (n = 33), food restriction only in 25% (n = 13), and obsessive-compulsive symptoms only in 11.5% (n = 6) of participants. In comparison to those who did not meet PANS criteria, those in the PANS subgroup were less likely to be male and more commonly prescribed a selective serotonin reuptake inhibitor medication. Significant group differences did not emerge for onset age, body mass index, eating disorder type or comorbid psychiatric/medical/autoimmune illness. CONCLUSION: Lifetime prevalence of symptoms in keeping with PANS diagnostic criteria within a pediatric eating disorder cohort was notably higher than that previously reported in OCD or tic disorder cohorts. The overlap between starvation effects and ancillary PANS symptoms may challenge the practical utility of this putative syndrome within the eating disorder population.

The connections and overlap between eating disorders and obsessive­compulsive disorder (OCD) are complicated and not fully understood. A syndrome described in the past decade (pediatric acute-onset neuropsychiatric syndrome; PANS) is characterized by a sudden, dramatic onset of food restriction and/or obsessive­compulsive symptoms in combination with several other behavioural and cognitive changes; a related condition is associated with sudden onset obsessive­compulsive symptoms or tics after streptococcal infection (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection; PANDAS). Rates of PANS and PANDAS have been reported in OCD and tic populations but not in eating disorders. We set out to screen a group of youth at a pediatric eating disorders program for lifetime symptoms of PANS and PANDAS. Among 100 eating disorder affected-youth in this study, approximately half (52%) met criteria for PANS, and none met criteria for PANDAS. However, the overlap between several PANS diagnostic criteria items and effects of starvation on both cognition and behaviour clouds the potential utility of this putative subtype within eating disorders populations.

Treatment experiences of male and female youths with eating disorders.

OBJECTIVES: The current study was conducted to further understand the experiences of youths with an eating disorder with accessing services and receiving treatment. Participants' perceptions of the role of gender in eating disorder treatment was also assessed. DESIGN: A prospective mixed methods design was used, with the current report focusing on qualitative interviews. METHODS: Youths who were receiving services in a specialized paediatric eating disorder program completed a semi-structured interview in combination with a visual lifeline upon their discharge. A process of interpretative induction was employed to derive high-level concepts from the interviews. RESULTS: A total of 28 youths (15 males and 13 females) completed an interview. Four high-level concepts were identified: (1) unwanted/non-collaborative support, (2) conflicting views, (3) dynamics in relationships (with sub-concepts relating to peers and health professionals), and (4) changing mindset. Although many participants viewed treatment as universal, a subset of participants noted that treatment was tailored towards females. CONCLUSIONS: Youths shared several challenges that they encountered in their journey to accessing specialized eating disorders treatment, including disagreement with their parents/caregivers and health professionals about treatment plans. Interactions with peers and health professionals represented both a facilitator (e.g., feeling supported and inspired by peers) and a challenge (e.g., negative interactions with professionals). Some youths shared concerns about the female-centric nature of treatment. The results of this study highlight the importance of collaborative care for paediatric eating disorders, and consideration for gender inclusivity in eating disorders treatment.

Pediatric Avoidant-Restrictive Food Intake Disorder and gastrointestinal-related Somatic Symptom Disorders: Overlap in clinical presentation.

Certain presentations of Avoidant/Restrictive Food Intake Disorder (ARFID) and Somatic Symptom and Related Disorders (SSRDs) have conceptual overlap, namely, distress and impairment related to a physical symptom. This study compared characteristics of pediatric patients diagnosed with ARFID to those with gastrointestinal (GI)-related SSRD. A 5-year retrospective chart review at a tertiary care pediatric hospital comparing assessment data of patients with a diagnosis of ARFID (n = 62; 69% girls, Mage = 14.08 years) or a GI-related SSRD (n = 37; 68% girls, Mage = 14.25 years). Patients diagnosed with ARFID had a significantly lower percentage of median BMI than those with GI-related SSRD. Patients diagnosed with ARFID were most often assessed in the Eating Disorders Program, whereas patients diagnosed with an SSRD were most often assessed by Consultation-Liaison Psychiatry. Groups did not differ on demographics, psychiatric diagnoses, illness duration, or pre-assessment services/medications. GI symptoms were common across groups. Patients diagnosed with an SSRD had more co-occurring medical diagnoses. A subset (16%) of patients reported symptoms consistent with both diagnoses. Overlap is observed in the clinical presentation of pediatric patients diagnosed with ARFID or GI-related SSRD. Some group differences emerged, including anthropometric measurements and co-occurring medical conditions. Findings may inform diagnostic classification and treatment approach.

Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada.

Importance: The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown. Objective: To assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth before and during the first wave of the COVID-19 pandemic. Design, Setting, and Participants: This repeated cross-sectional study analyzed new eating disorder assessments that were conducted at 6 pediatric tertiary-care hospitals in Canada between January 1, 2015, and November 30, 2020. Patients aged 9 to 18 years with a new anorexia nervosa or atypical anorexia nervosa diagnosis at the index assessment were included. Exposures: COVID-19-associated public health confinement measures during the first wave of the pandemic (March 1 to November 30, 2020). Main Outcomes and Measures: Primary outcomes were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Event rate trends during the first wave were compared with trends in the 5-year prepandemic period (January 1, 2015, to February 28, 2020) using an interrupted time series with linear regression models. Demographic and clinical variables were compared using a χ2 test for categorical data and t tests for continuous data. Results: Overall, 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female patients [91.0%]) were included. Prepandemic anorexia nervosa or atypical anorexia nervosa diagnoses were stable over time (mean [SD], 24.5 [1.6] cases per month; ß coefficient, 0.043; P = .33). New diagnoses increased during the first wave of the pandemic to a mean (SD) of 40.6 (20.1) cases per month with a steep upward trend (ß coefficient, 5.97; P < .001). Similarly, hospitalizations for newly diagnosed patients increased from a mean (SD) of 7.5 (2.8) to 20.0 (9.8) cases per month, with a significant increase in linear trend (ß coefficient, -0.008 vs 3.23; P < .001). These trends were more pronounced in Canadian provinces with higher rates of COVID-19 infections. Markers of disease severity were worse among patients who were diagnosed during the first wave rather than before the pandemic, including more rapid progression (mean [SD], 7.0 [4.2] months vs 9.8 [7.4] months; P < .001), greater mean (SD) weight loss (19.2% [9.4%] vs 17.5% [9.6%]; P = .01), and more profound bradycardia (mean [SD] heart rate, 57 [15.8] beats per minute vs 63 [15.9] beats per minute; P < .001). Conclusions and Relevance: This cross-sectional study found a higher number of new diagnoses of and hospitalizations for anorexia nervosa or atypical anorexia nervosa in children and adolescents during the first wave of the COVID-19 pandemic in Canada. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

Gender differences in symptom presentation and treatment outcome in children and youths with eating disorders.

BACKGROUND: To address the gaps in the literature examining eating disorders among males and gender minority youths, a prospective study was designed to assess gender differences in eating disorder symptom presentation and outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, and were included in assessment of eating disorder symptom presentation. METHODS: All cisgender male youths who presented for specialized eating disorder treatment at one of two sites were invited to participate, along with a group of matched cisgender females, and all youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment. RESULTS: A total of 27 males, 28 females and 6 trans youths took part in the study. At baseline, Kruskal-Wallis tests demonstrated that trans youths reported higher scores than cisgender male and female youths on measures of eating pathology (Eating disorder examination-questionnaire (EDE-Q) and the body fat subscale of the male body attitudes scale (MBAS)). These analyses demonstrated that there were no differences between cisgender male and female youths on eating disorder symptoms at baseline. However, repeated measures ANOVA demonstrated that males had greater decreases in eating pathology at discharge than did females, based on self-reported scores on the EDE-Q, MBAS, and Body Change Inventory. CONCLUSIONS: Gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths, though no differences between cisgender males and females emerged at baseline for eating disorder symptom presentation. Contrary to expectations, there were no gender differences in measures of muscularity concerns. Males demonstrated greater eating disorder symptom improvements than females, suggesting that male adolescents may have better treatment outcomes than females in some domains.

Research in the field of eating disorders has focused on females, and less is known about the symptom presentation and treatment outcomes in males and gender minority youths. This prospective study set out to assess gender differences in eating pathology and treatment outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, yet there is limited research on gender differences in muscularity concerns in treatment-seeking youths with eating disorders. Participants include cisgender male youths, matched cisgender females, and gender diverse youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment. Some gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths. There were no differences between cisgender males and females in eating disorder symptom presentation at baseline, and contrary to expectations, there were no gender differences in measures of muscularity concerns. However, males demonstrated greater eating disorder symptom improvements than females.

Parental experiences with their child's eating disorder treatment journey.

BACKGROUND: Parents are integral in the treatment of pediatric eating disorders. The current study was conducted to further understand the barriers and facilitators that parents experience in accessing specialized, tertiary level eating disorder treatment for children and adolescents. The goals of the study were to understand the processes leading to diagnosis and treatment, perceived barriers and facilitators to accessing care, and parents' experiences over the course of their child's eating disorder treatment. METHODS: Ten parents whose children were admitted to a Canadian tertiary level specialized pediatric eating disorders program took part in an exit interview upon their child's completion of treatment in the program. In-depth semi-structured interviews were combined with a visual timeline. Interpretive induction was performed to generate high-level concepts that emerged from the interviews. RESULTS: Five high-level concepts were identified: (1) delays in identifying eating disorder symptoms, (2) challenges in accessing eating disorder services, (3) the right treatment at the right time, (4) emotional impact on parents, and (5) parental expertise and involvement. CONCLUSIONS: Several barriers were identified by parents that interfered with treatment, including system-related challenges when accessing specialized eating disorder treatment, concerns about a lack of appropriate mental health support for their child, and difficulties with transitioning between community and tertiary level care. Negative emotions, including guilt and self-blame, were common early in the treatment journey. Themes of parental involvement throughout treatment, and parents taking charge of their child's recovery, emerged across interviews. The results of this study suggest the importance of early identification of eating disorder symptoms, facilitating smoother transitions between levels of care (e.g., community services and hospital-based eating disorder care), and improving clinical decision-making to ensure children and adolescents with eating disorders receive the most appropriate treatment based on their clinical presentation.

Parents play a central role in pediatric eating disorder treatment. To further understand parents' experiences over the course of their child's eating disorder treatment, interviews were conducted with ten parents whose children were admitted to a specialized pediatric eating disorders program. Five major themes emerged across the interviews with parents: delays in identifying eating disorder symptoms, challenges with accessing eating disorders care, the right treatment at the right time, emotional impact on parents, and parental expertise and involvement. Parents shared several barriers that interfered with their child's treatment, including challenges with transitions between their home community and specialized eating disorder treatment. Parents also commonly spoke about guilt and self-blame when their child was first diagnosed with an eating disorder, though many parents felt relief and improved confidence after being connected with specialized eating disorder treatment. Research is needed to understand how to provide the right treatment at the right time for each child and adolescent with an eating disorder, to ultimately improve clinical care and reduce the barriers experienced by families.

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.

Health professionals' familiarity and experience with providing clinical care for pediatric avoidant/restrictive food intake disorder.

OBJECTIVE: The current study explored the experience and familiarity of pediatric health professionals with avoidant/restrictive food intake disorder (ARFID), and assessed the application of diagnostic criteria in a series of clinical vignettes. METHOD: Pediatric health professionals were invited to complete an online survey. Data from 93 health professionals from medical and allied health roles who completed the survey were analyzed. RESULTS: Respondents providing care for pediatric feeding/eating disorders were more likely to report familiarity with ARFID than those not typically providing care for feeding/eating disorders. Clinicians who had provided care for pediatric ARFID reported more confidence in clinical management of ARFID than did those who had not yet provided care for ARFID, though there were overall relatively low levels of confidence in providing care for ARFID. Respondents to the clinical vignettes were more likely to confer a diagnosis of ARFID when there were symptoms of both psychosocial impairment and weight loss than when there was psychosocial impairment alone. DISCUSSION: The results suggest variability in current application of diagnostic criteria for ARFID, low confidence in clinical management of ARFID, and ambiguity in clinicians' judgments regarding whether psychosocial impairment is sufficient to meet a diagnosis of ARFID.

Perceived Occupational Performance in Youth with Eating Disorders: Treatment-Related Changes.

BACKGROUND.: This study examined changes in performance and satisfaction with self-identified occupational performance goals during a specialized day treatment admission in children and adolescents with eating disorders. Weight-related outcomes for underweight youth were also examined. METHODS.: A total of 63 youth participated in the study, with admission and discharge data on ratings of self-identified occupational performance goals (measured with the Canadian Occupational Performance Measure) available for 42 participants. FINDINGS.: Significant improvements were found in ratings of satisfaction and performance with self-identified goals over the course of treatment. The program was also effective in supporting weight restoration for underweight youth, with a large effect size observed. IMPLICATIONS.: A symptom-focused day treatment program for paediatric eating disorders led to improvements in perceived occupational performance. Collaborating with youth to develop self-identified goals in the context of eating disorders treatment can foster autonomy and potentially improve treatment engagement.

A longitudinal examination of body-checking behaviors and eating disorder pathology in a community sample of adolescent males and females.

OBJECTIVE: Related to the cognitive-behavioral theory of eating disorders, body checking has gained increasing recognition as both a maintaining factor for eating disorders and an important target for treatment. However, it is unclear whether body-checking behaviors contribute to the development of disordered eating, or if these behaviors develop as a response to experiencing eating disorder thoughts and behaviors. This study aims to examine the relationships between body-checking behaviors and eating disordered thoughts and behaviors in adolescent females and males in the community over time. METHODS: Participants included 238 adolescents (n = 104 males, n = 134 females, Mage = 16.5 years) recruited from high schools in British Columbia, Canada, who completed the Eating Disorder Examination Questionnaire and Body Checking Questionnaire at baseline (T1) and again approximately 4 months later (T2). RESULTS: After controlling for baseline levels of eating pathology and body mass index (BMI), body checking at T1 predicted increases in eating pathology for both males and females. In contrast, after controlling for baseline levels of body checking and BMI, eating pathology at T1 did not predict changes in body checking for females, but it did for males. Findings suggest that, among adolescents, engaging in body-checking behaviors may increase risk for disordered eating. DISCUSSION: If supported by further research, targeting body-checking behaviors in prevention programs may be warranted.

Cognitive and behavioral correlates of depressive symptoms in a community sample of adolescents.

Research in adults demonstrates a positive association among obsessive-compulsive symptoms, eating pathology, cognitive distortions, and comorbid depressive symptoms. Given that adolescence is characterized by unique and rapid changes in biopsychosocial processes, it is imperative to elucidate the relationship between these variables in youth. In this cross-sectional study, we explored whether obsessive-compulsive symptoms, thought-action fusion, thought-shape fusion, and eating pathology would be positively associated with and predict depressive symptoms in a school-based community sample of adolescents (n = 86; Mage = 15.60). All study variables were positively correlated with depressive symptoms. Results indicated that obsessive-compulsive symptoms, thought-shape fusion, and eating pathology explained a significant proportion of variance in depressive symptoms, whereas thought-action fusion did not. In accordance with the cognitive behavioral model of psychopathology, these findings highlight the relationships between key interrelated correlates of depressive symptoms that may be pertinent targets for prevention and treatment efforts in adolescents.

Eating Disorder Diagnoses and Symptom Presentation in Transgender Youth: a Scoping Review.

PURPOSE OF REVIEW: This scoping review includes recent literature on eating disorder diagnoses and evaluation of eating disorder symptom presentation among transgender youth (ages 8-25). RECENT FINDINGS: A total of 20 publications from the previous 5 years were identified, including case reports, retrospective chart reviews, and surveys. Significantly higher rates of eating disorder symptoms were documented in transgender youth compared to cisgender youth. Similarly, some studies reported transgender youth were more likely to be diagnosed with an eating disorder than cisgender youth, though the proportion of youth with eating disorder diagnoses varied across studies. A consistent theme across case studies was engagement in food restriction and/or compensatory eating behaviors to prevent puberty onset or progression, suggesting that for some transgender youth, these behaviors may be understood as a means of coping with gender-related distress. Clinical care could be enhanced through establishment of best practices for screening in settings offering eating disorder treatment and gender-affirming care, as well as greater collaboration among these programs. Research is needed to validate eating disorder measures for use with transgender youth and evaluate the effects of eating disorder treatment and gender-affirming medical interventions on the well-being of transgender youth.

Kindness begins with yourself: The role of self-compassion in adolescent body satisfaction and eating pathology.

OBJECTIVE: A wealth of evidence indicates that self-compassion is linked with positive psychological outcomes; however, little is known about the process through which self-compassion exerts its effect. The primary purpose of this research was to investigate the direct and indirect impact of self-compassion on body satisfaction and eating pathology in adolescents. METHOD: Two hundred and thirty-eight students were recruited from three local high schools (Mage = 16.49, 43.7% boys). All participants completed the Self-Compassion Scale (SCS), Hopkins Symptom Checklist (SCL-5), Body Areas Satisfaction Scale (BASS), and Eating Disorder Examination Questionnaire - Adolescent Version (EDE-Q) at baseline. The SCL-5, BASS, and EDE-Q were completed 4 months later. RESULTS: Self-compassion was positively associated with body satisfaction and negatively associated with psychological distress and eating pathology in boys and girls at both time points. Longitudinal conditional process analyses revealed that self-compassion predicted changes in body satisfaction and eating pathology through changes in psychological distress for girls only. Notably, self-compassion was higher in boys than in girls. DISCUSSION: Results underscore how self-compassion may be an important factor to target in fostering a positive body image and preventing disordered eating in adolescents.