Examining clinicians' perceptions and experiences working with diverse families in family-based treatment: Common adaptations and considerations for treatment engagement.

OBJECTIVE: Family-Based Treatment (FBT) is the leading manualized treatment for adolescent eating disorders; however, there is limited research on the adaptation of FBT for diverse families (i.e., families belonging to identity groups subject to systemic barriers and prejudices). The purpose of this qualitative study was to address: (1) adaptations made to the FBT model (if any) by clinicians working with diverse youth and families; (2) the barriers/facilitators of maintaining adherence (fidelity) to the model for these families; and, (3) the barriers/facilitators to access and engagement in FBT for diverse families. METHOD: Forty-one FBT clinicians were recruited globally using purposive and snowball sampling, and listservs from eating disorder networks. Clinicians participated in individual interviews or focus groups, discussing their experiences delivering and adapting FBT for diverse families. Qualitative data was transcribed verbatim and analyzed using directed content analysis. RESULTS: Some participants reported making adaptations to every phase of the FBT model, while others did not, when working with diverse families. In Phase 1, participants cited adapting the family meal, length/number of sessions provided, and addressed systemic barriers. In Phase 2, participants adapted the length of the phase and rate/level of independence given back to the adolescent. In Phase 3, participants increased or decreased the number of sessions, or eliminated this phase to address barriers to engagement in FBT. DISCUSSION: This is the first study to qualitatively examine clinicians' experiences of implementing FBT with diverse families. Results may inform future FBT planning, clinician training, clinical decision-making tools, and opportunities for modifications to the foundational model. PUBLIC SIGNIFICANCE: This qualitative study examined clinicians' perceptions and experiences implementing FBT with diverse families, specifically what adaptations (if any) were made to the foundational model, and the barriers and facilitators to adhering to and engaging in the model. Results show that some participants reported making adaptations to every phase of FBT, while others did not, with diverse families. Findings may inform future treatment planning, clinician training, clinical decision-making tools, and potential modifications to FBT.

TransitionED: A protocol for Co-designing and implementing Canadian practice guidelines for transitions for youth with eating disorders.

OBJECTIVE: Limited guidelines inform the transition from paediatric to adult healthcare for youth and young adults (YYA) with eating disorders (EDs). This study will develop, implement, and evaluate Canadian Clinical Practice Guidelines for ED transition, including identifying the relevant measurement and evaluation tools for transition readiness and continuity of care. METHODS: This study consists of three phases. Phase 1 involves conducting a scoping review of the evidence on transition interventions, outcomes, and measurement tools for YYA with EDs, along with guideline development using the modified Delphi method. Phase 2 identifies the contextual/cultural factors relevant to guideline implementation and co-designing an implementation protocol with governance committees and research partners. Phase 3 involves the application and evaluation of the proposed guide lines using the implementation protocol, and assessing the acceptability and feasibility of a prototype transition intervention in two Canadian paediatric ED programs. CONCLUSIONS: Results will provide the knowledge needed to enhance the lives of YYA, improve the effectiveness of the ED care system, and support the scale of the transition guidelines across Canada. These guidelines will have international relevance by potentially informing the field on how to support young people with EDs transitioning in similar funding structures and systems of care.

Involuntary treatment: A qualitative study from the perspectives of individuals with anorexia nervosa.

OBJECTIVE: Involuntary treatment for anorexia nervosa (AN) is sometimes necessary and lifesaving but can be experienced negatively by some individuals. The purpose of this qualitative study was to better understand participants' perceptions about their experience with involuntary treatment for AN. METHOD: Thirty adult participants, who had been treated involuntarily for AN in the past, completed self-report measures and qualitative interviews. Interview transcripts were coded using thematic analysis. RESULTS: Three themes were identified: (1) mixed perceptions about involuntary treatment, (2) the impact of involuntary treatment on external factors, including relationships, education, and employment, and (3) lessons learned from the experience. Participants who endorsed a positive shift in perspective regarding the need for involuntary treatment also reported favorable changes in their eating disorder recovery, whereas individuals whose perspective about their involuntary treatment remained negative, showed no changes in their recovery post-treatment. CONCLUSIONS: Involuntary treatment for AN was recognized, in retrospect, as being beneficial by individuals with AN who were doing well, but individuals who continued to struggle with their eating disorder reported negative consequences.

Meta-analytic evidence that allelopathy may increase the success and impact of invasive grasses.

Background: In the grass family, a disproportionate number of species have been designated as being invasive. Various growth traits have been proposed to explain the invasiveness of grasses; however, the possibility that allelopathy gives invasive grasses a competitive advantage has attracted relatively little attention. Recent research has isolated plant allelochemicals that are mostly specific to the grass family that can breakdown into relatively stable, toxic byproducts. Methods: We conducted a meta-analysis of studies on grass allelopathy to test three prominent hypotheses from invasion biology and competition theory: (1) on native recipients, non-native grasses will have a significantly more negative effect compared to native grasses (Novel Weapons Hypothesis); (2) among native grasses, their effect on non-native recipients will be significantly more negative compared to their effect on native recipients (Biotic Resistance Hypothesis); and (3) allelopathic impacts will increase with phylogenetic distance (Phylogenetic Distance Hypothesis). From 23 studies, we gathered a dataset of 524 observed effect sizes (delta log response ratios) measuring the allelopathic impact of grasses on growth and germination of recipient species, and we used non-linear mixed-effects Bayesian modeling to test the hypotheses. Results: We found support for the Novel Weapons Hypothesis: on native recipients, non-native grasses were twice as suppressive as native grasses (22% vs 11%, respectively). The Phylogenetic Distance Hypothesis was supported by our finding of a significant correlation between phylogenetic distance and allelopathic impact. The Biotic Resistance Hypothesis was not supported. Overall, this meta-analysis adds to the evidence that allelochemicals may commonly contribute to successful or high impact invasions in the grass family. Increased awareness of the role of allelopathy in soil legacy effects associated with grass invasions may improve restoration outcomes through implementation of allelopathy-informed restoration practices. Examples of allelopathy-informed practices, and the knowledge needed to utilize them effectively, are discussed, including the use of activated carbon to neutralize allelochemicals and modify the soil microbial community.

Psychological characteristics and childhood adversity of adolescents with atypical anorexia nervosa versus anorexia nervosa.

The assessment and diagnosis of atypical anorexia nervosa (AAN) is an ongoing challenge for clinicians. This study aims to examine psychological morbidity and exposure to childhood adversity in adolescents with AAN compared to adolescents with anorexia nervosa, restricting type (AN-R). This registry-based study compared 42 adolescents with AAN to 79 adolescents with AN-R on a variety of psychosocial measures at the time of presentation to a specialized eating disorder program. In contrast to AN-R, adolescents with AAN had more severe drive for thinness (p =.011), body dissatisfaction (p =.038), and lower quality of life (p =.047), but had better global functioning (p =.032). Adolescents who had high Adverse Childhood Experiences (ACE) Questionnaire scores (ACE score ≥ 4) had over 5 times higher odds of having AAN than those who did not have high ACE scores (p =.008). There was no significant difference between groups on measures of low self-esteem and non-accidental self-injury. Adolescents with AAN presented with similar or more severe psychosocial distress compared to their peers with AN-R across a majority of the measures. The findings highlight the need to address trauma, body-related difficulties, and quality of life in the assessment and treatment of adolescents with AAN.

Case Presentations Combining Family-Based Treatment with the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents for Comorbid Avoidant Restrictive Food Intake Disorder and Autism Spectrum Disorder.

Avoidant Restrictive Food Intake Disorder (ARFID) is a Feeding and Eating Disorder newly added to the Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition, which presents with high prevalence rates in community and clinical settings. Given its recent diagnostic recognition, validated and standardized treatments for this population are lacking. In addition, given the complexity, heterogeneity of symptoms, and high rates of psychiatric comorbidities in the ARFID population, new models of care are required. The current therapy model combines two evidence-based treatments - Family Based Treatment (FBT) and the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A) - for young patients with ARFID plus Autism Spectrum Disorder (ASD), which allows clinicians to personalize care based on each patient's unique presenting needs. This paper presents two distinct cases which showcase the use of the FBT+UP for ARFID approach for treating comorbid ARFID and ASD in a clinical setting. Case 1 demonstrates the application and reliance on FBT, while Case 2 draws upon UP to facilitate behavioural change in the patient. Case backgrounds, presenting problems, and treatment approaches combining the two evidence-based treatments are presented and discussed. The cases demonstrate the unique challenges of treating young patients with comorbid ARFID and ASD, along with the proposed benefits of the combined approach with this population.

Le trouble évitant/restrictif de la prise alimentaire (TERPA) est un trouble alimentaire nouvellement ajouté au Manuel diagnostique et statistique des troubles mentaux, 5 e édition, qui présente des taux de prévalence élevés en milieu communautaire et clinique. Étant donné sa récente reconnaissance diagnostique, il manque de traitements validés et normalisés pour cette population. En outre, vu la complexité et l'hétérogénéité des symptômes, et les taux élevés de comorbidités psychiatriques dans la population TERPA, de nouveaux modèles de soins sont nécessaires. Le modèle de thérapie actuel combine deux traitements fondés sur les données probantes ­ le traitement basé sur la famille (TBF) et les protocoles unifiés pour le traitement transdiagnostique des troubles émotionnels chez les enfants et les adolescents (PU-E/A) ­ pour les jeunes patients souffrant de TERPA et de TSA qui permet aux cliniciens de personnaliser les soins, selon les besoins uniques présentés par chaque patient. Le présent article présente deux cas distincts qui démontrent le recours à TBF + PU pour l'approche du TERPA afin de traiter le TERPA et le TSA comorbides dans un cadre clinique. Le cas 1 démontre l'application et la confiance dans le TBF, tandis que le cas 2 puise aux PU pour faciliter le changement de comportement du patient. Les antécédents des cas, les problèmes présentés et les approches de traitement combinant les deux traitements fondés sur des données probantes sont présentés et discutés. Les cas démontrent les difficultés singulières de traiter de jeunes patients souffrant de TERPA et de TSA comorbides, de même que les avantages proposés d'une approche combinée avec cette population.

The Prevalence of Impulse Control Disorders and Behavioral Addictions in Eating Disorders: A Systematic Review and Meta-Analysis.

Aim: Individuals with eating disorders (EDs) may present with impulse control disorders (ICDs) and behavioral addictions (BAs), which may result in additional suffering and treatment resistance. However, the prevalence of ICDs and BAs in EDs has not been systematically examined. Therefore, this systematic review and meta-analysis aimed to assess the prevalence of ICDs and BAs in ED samples. Methods: A comprehensive electronic database search of the peer-reviewed literature was conducted in the following online databases: MEDLINE, PsycINFO, Embase, and CINAHL from their inception to May 2021. We restricted review eligibility to research studies reporting prevalence for ICDs or BAs in individuals with diagnosed EDs. The outcome for this review was the prevalence of ICDs or BAs in individuals with EDs. A series of random-effects meta-analyses were performed on eligible studies to estimate the pooled proportions and 95% confidence intervals (CIs). Results: Thirty-five studies met the inclusion criteria, including a total of 9,646 individuals identified as having an ED, 18 of these studies specifically examined ICDs/BAs in AN, BN, and BED. Random-effects pooled estimates demonstrated that the comorbid prevalence of any ICD was 22%. The prevalence of comorbid pathological/compulsive buying was highest (19%), followed by kleptomania (18%), pathological internet use (12%), intermittent explosive disorder (4%), trichotillomania (3%), and gambling disorder (2%). In addition, the prevalence of stealing/shoplifting behaviors was 30% in those with EDs. Conclusion: This is the first meta-analysis on the comorbid prevalence of EDs and ICDs/BAs. We found a moderate prevalence for these comorbid conditions, with approximately one out of five individuals with an ED also displaying a comorbid ICD/BA. Although causal inferences cannot be drawn, the numbers strongly suggest that clinical screening/monitoring of ICDs/BAs should be part of the clinical routine in cohorts with EDs. ED settings need either the capacity to manage these disorders or adequate access to relevant services. Further investigations are needed to reveal common underlying pathomechanisms. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020202044.

Stay the course: practitioner reflections on implementing family-based treatment with adolescents with atypical anorexia.

BACKGROUND: Atypical anorexia nervosa (AN) has received minimal empirical attention regarding effective diagnosis and treatment. Family-based treatment (FBT) might be a promising treatment for atypical AN, yet it is unclear as to what adaptations are needed to the current manualized FBT for AN model. The objective of the current study was to identify how FBT practitioners applied FBT for atypical AN for adolescents in their clinical practice, and if there were any implementation challenges and adaptations to the model for this population. METHODS: The current study employed fundamental qualitative description, with the aim of capturing practitioners' reflections on working with adolescents with atypical AN in clinical practice. A purposeful sample of practitioners with training in FBT were recruited and each participant completed an individual, semi-structured interview. Data was analyzed using conventional content analysis. RESULTS: A total of 23 practitioners participated in this study. The results indicate that practitioners maintained some fidelity to manualized FBT in treating atypical AN, but they differed in their discussions around target weights, what constitutes weight restoration, and the dosage for FBT phases. Salient practice challenges included operationalizing the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5) definition of atypical AN, identifying a 'goal weight' for adolescents and activating parents to take charge of the re-nourishment process. CONCLUSIONS: The results of this qualitative study demonstrate practitioner reflections on the delivery and adaptations of FBT for adolescents with atypical AN. These reflections highlight the need to establish the delivery of coherent and consistent treatment and messaging with patients and families. Further, practitioners' reflections highlight common strategies to increase the sense of urgency in parents to support their child with atypical AN.

Tackling mixed messages: Practitioner reflections on working with adolescents with atypical anorexia and their families.

The treatment of atypical anorexia nervosa (AN) poses new research and practice challenges for the field of eating disorders. The objective of this study was to describe frontline practitioners' perceptions of differences between adolescents living with atypical versus typical AN, as well as the intervention challenges they experience when working with these adolescents and their families. We followed the principles of fundamental qualitative description and recruited a purposeful sample of practitioners treating adolescent eating disorders to complete a one-on-one semi-structured interview. Conventional content analysis and the constant comparison technique were used for data analysis. A total of 23 practitioners from four countries participated in this study. Practitioners described that adolescents with atypical AN present with higher pre-morbid weights and rates of weight-based teasing compared to their AN peers. Clinical challenges perceived by practitioners to be specific to working with adolescents with atypical AN included: addressing conflicting messages about eating disorders and weight loss, empathizing with a justified fear of weight gain, and increased risk for parental and therapist collusion with the eating disorder. Findings have implications for delivering interventions to adolescents seeking care for atypical AN.

Concurrent Assessment of Penile Blood Flow and Circumference as Indicators of Male Sexual Arousal.

INTRODUCTION: The current study aims to validate a new imaging tool to assess men's sexual psychophysiological responding: laser Doppler imaging (LDI), which directly measures subcutaneous genital blood flow. In this study, we concurrently assessed genital sexual arousal in a sample of men using the LDI and the current gold standard of male sexual psychophysiology, the penile strain gauge (PSG). AIM: To (i) assess the validity of the LDI as a measure of male sexual arousal, (ii) evaluate the relationship between the LDI and PSG, and (iii) compare sexual concordance produced by the LDI and PSG. METHODS: A total of 25 male participants (Mage = 24.28 years, SD = 6.10, range 18-37) watched 4 experimental films (ie, anxiety-provoking, humorous, erotic, neutral nature content) while their sexual arousal was assessed. Genital sexual arousal was assessed using the LDI (blood perfusion) and PSG (penile tumescence) concurrently. Subjective sexual arousal was assessed using continuous and discrete self-reported measures. MAIN OUTCOME MEASURE: Results demonstrate the validity of the LDI as an imaging-based measure of male genital arousal, and one that is comparable to the PSG. RESULTS: Significant increases in genital blood flow assessed via the LDI were observed for erotic, but not anxiety-provoking, humorous, or neutral films (F[1.65, 39.57] = 18.23, P < .001, ηp2 = .43). A moderate, positive correlation between genital arousal measured via the LDI and PSG concurrently was observed (r = .40), despite considerable across-participant variability. In the current sample, the LDI and PSG both produced strong sexual concordance estimates (r = .51 and r = .46, respectively). When all LDI and PSG concordance estimates were correlated, a moderate relationship was revealed (r = .37). CLINICAL IMPLICATIONS: As a new imaging tool for male sexual psychophysiological arousal, the LDI holds promise for improving our understanding of issues related to men's sexual health. STRENGTH & LIMITATIONS: Movement artifacts produced by penile engorgement were a limitation to the LDI as an imaging technique. Further, the LDI used in the current study was a discrete measure of arousal, whereas the PSG was continuous; future research would benefit by using continuous measurement capabilities of contemporary LDI systems. CONCLUSION: As a valid measure of genital sexual arousal in men, the LDI holds promise as a tool that can be used to explore more nuanced questions about human sexuality, including cross-gender comparisons and real-time exploration of genital arousal patterns. Bossio JA, Singh M, Pukall CF. Concurrent assessment of penile blood flow and circumference as indicators of male sexual arousal. J Sex Med 2018;15:1570-1578.

A pilot evaluation of group-based programming offered at a Canadian outpatient adult eating disorders clinic.

Eating disorder clinics across Canada place heavy reliance on group-based programming. However, little work has examined whether this modality of treatment is well-received by patients and results in clinical improvements. The purpose of this pilot study was to evaluate patient satisfaction and outcomes for group-based programming offered through an adult eating disorders clinic. Participants were 81 adults who met DSM-5 criteria for an eating disorder and participated in the study as part of the clinic's program evaluation. Participants received medical monitoring, psychiatric follow-up, adjunct nutrition and pre-psychological treatment, and participated in the clinic's core cognitive behavioural therapy (CBT) group. Demographic information and weight were collected at intake. Participants also completed pre- and post-group programming measures of life satisfaction, depressive and anxiety symptoms, psychological symptoms of the eating disorder, and satisfaction with the programming. Participants' experienced a significant increase in satisfaction with life, and decreases in depressive symptoms and psychological symptoms of the eating disorder post-group. Adults endorsed feeling fairly satisfied with the group-based services provided. Results draw attention to the importance of program evaluation as an integral component of an adult outpatient eating disorder clinic by providing a voice for patients' views of the services received and program outcomes.