Modification of an inpatient medical management protocol for pediatric Avoidant/Restrictive Food Intake Disorder: improving the standard of care.

BACKGROUND: No guidelines currently exist that represent a standardization of care for Avoidant/Restrictive Food Intake Disorder (ARFID) on an inpatient service. Unique features of this diagnosis (e.g., sensory sensitivity contributing to involuntary emesis) suggest that established protocols that were developed for anorexia nervosa might be less effective for adolescents with ARFID. To inform improved inpatient medical stabilization and care for these patients, we first provide an overview of clinical characteristics for patients with ARFID who presented to a pediatric hospital for inpatient eating disorder care. We use these descriptives to outline the rationale for, and executions of, modifications to an inpatient protocol designed to flexibly meet the needs of this clinical population. METHODS: Chart review with descriptive statistics were conducted for patients who had received an ARFID diagnosis from March 2019 to March 2023 (N = 32, aged 9-23). We then present a case series (n = 3) of adolescents who either transitioned to a novel adjusted protocol from an original standard of care on the inpatient service, or who received only the standard protocol. RESULTS: The sample was aged M(SD) = 15.6 (3.3) years, 53% male, and a majority (69%) presented with the ARFID presentation specific to fear of negative consequences. On average, patients had deviated from their growth curve for just over two years and presented with mean 76% of their estimated body weight. Of those requiring nasogastric tube insertion during admission (n = 8, 25%), average duration of tube placement was 15 days. From within this sample, case series data suggest that the adjusted protocol will continue to have a positive impact on care trajectory among adolescents admitted for ARFID including improved weight gain, reduction of emesis, and improved food intake. CONCLUSIONS: Findings demonstrate the likely need to tailor established medical inpatient protocols for those with ARFID given different symptom presentation and maintenance factors compared to patients with anorexia nervosa. Further research is warranted to explore the longer-term impact of protocol changes and to inform standardization of care for this high priority clinical population across care sites.

No current standard of care exists for pediatric patients with Avoidant/Restrictive Food Intake Disorder (ARFID) who are hospitalized for medical stabilization related to complications secondary to malnutrition. Clinical features of this diagnosis (e.g., sensory sensitivity) suggest that existing treatment protocols developed for patients with other restrictive eating disorders, like anorexia nervosa, may be less effective for patients with ARFID. This study first describes a pediatric sample of patients with ARFID upon admission to an inpatient service. Then, a case series is used to illustrate the potential benefits of using an adjusted protocol that was modified to better suit the needs of children and adolescents with ARFID. Findings support future study of the proposed adjusted protocol and may inform future standardization of improved care for this high priority clinical population.

An exploration of the association between premorbid weight status on patient and caregiver factors at pre and post-treatment among youth with anorexia nervosa/atypical anorexia nervosa.

Patients with atypical anorexia nervosa (AAN) or anorexia nervosa (AN) with premorbid history of higher weight (PHW; median BMI ≥ 85th %ile) may report greater eating disorder (ED) pathology, anxiety, and depression, than patients with premorbid history of lower weight (PLW; mBMI <85th %ile). Less is known about caregiver attitudes or treatment outcome related to premorbid weight history. The current study examined associations between premorbid weight history and patient/caregiver factors at presentation, during treatment, and end of treatment among adolescents (N = 138) diagnosed with AN/AAN and their caregivers who received interdisciplinary ED treatment. The sample comprised adolescents with PHW (n = 58, 40.6 %) or PLW (n = 82, 59.4 %). Adolescents with PHW did not differ with regard to patient- or caregiver-reported ED symptoms, comorbid psychopathology, rates of treatment completion, and attainment of estimated body weight compared to PLW (ps > .05). Adolescents with PHW (vs. PLW) were more likely to be diagnosed with AAN (67.9 %, p < .001), identify as cisgender male (p < .001) and to have lost more weight prior to presentation (p < .001). Perceived caregiver burden was lower among adolescents with PHW vs. PLW (p < .001). Further research should expand on this preliminary study exploring associations between premorbid weight history on patient and caregiver factors at treatment presentation and conclusion to enhance the efficacy of evidence-based treatment across the weight-spectrum.

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.

Predictors of Treatment Outcome in Eating Disorders: A Roadmap to Inform Future Research Efforts.

PURPOSE OF REVIEW: With the current review, we provide a brief summary of recent literature that tests clinically observable characteristics at baseline that may impact treatment response, across eating disorder diagnoses. We then provide a critical discussion regarding how researchers may shift their approach to this research to improve treatment implications and generalizability of these findings. RECENT FINDINGS: Recent work has broadly replicated prior findings suggesting a negative impact of lower weight status, poor emotion regulation, and early-life trauma on eating disorder treatment outcomes. Findings are more mixed for the relative contributions of illness duration, psychiatric comorbidity, and baseline symptom severity. Recent studies have begun to explore more specific domains of previously tested predictors (e.g., specific comorbidities) as well as previously neglected identity-related and systemic factors. However, recent research continues to use similar sampling techniques and approaches to analysis used in prior work. We propose that resolving remaining questions and illuminating predictors of treatment outcome in eating disorders requires a new approach to research sampling and study design. Suggested changes that can be applied within a traditional clinical trial framework may yield new insights with relevance across transdiagnostic eating disorder presentations.

Development of evidence-informed bridge programming to support an increased need for eating disorder services during the COVID-19 pandemic.

Over the course of the COVID-19 pandemic, rates of eating disorders have increased, further straining systems of care that were already overburdened. The current paper describes novel interventions, largely informed by Family-Based Treatment (FBT), that were implemented by a tertiary specialist adolescent eating disorders service. In response to the pandemic, programming was designed to bridge access to care while waiting for availability of evidence-based therapy. The Brief Psychology Consultation Clinic provides several sessions to patients and families, focused on psychoeducation and problem-solving informed by FBT and other evidence-based therapies. Two groups, the FBT Caregiver Workshop Series and FBT Caregiver Support Group, provide psychoeducation and support for caregivers of youth with eating disorders. Perceived strengths and benefits of these services, as well as barriers to implementation and future research directions are discussed.

A test of the DSM-5 severity specifier for bulimia nervosa in adolescents: Can we anticipate clinical treatment outcomes?

OBJECTIVE: This study tested clinical utility of the DSM-5 severity specifier for bulimia nervosa (BN) in predicting treatment response among adolescents (N = 110) within a randomized clinical trial of two psychosocial treatments. METHOD: Analyses grouped individuals meeting criteria for BN diagnosis by baseline severity, per DSM-5. Associations among baseline severity classification and BN behavior (i.e., binge eating and compensatory behavior) and eating disorder examination (EDE) Global scores at end-of-treatment (EOT), 6- and 12-month follow-up were examined. RESULTS: Associations between severity categories with BN symptoms were not significant at EOT, or follow-up. Test for linear trend in BN behavior was significant at EOT, F = 5.23, p = 0.02, without demonstrating a linear pattern. Relation between severity categories with EDE Global scores was significant at 6-month follow-up, F = 3.76, p = 0.01. Tests for linear trend in EDE Global scores were significant at EOT, F = 5.40, p = 0.02, and at 6 months, F = 10.73, p = 0.002, with the expected linear pattern. DISCUSSION: Findings suggest the DSM-5 BN severity specifier holds questionable utility in anticipating outpatient treatment response in adolescents with BN. The specifier may have improved ability to predict attitudinal rather than behavioral treatment outcomes.

Rituals and preoccupations associated with bulimia nervosa in adolescents: Does motivation to change matter?

This study evaluated the effects of two treatments for adolescent bulimia nervosa (BN), family-based treatment (FBT-BN), and cognitive behavioral therapy (CBT-A), on both attitudinal and behavioural outcomes at end-of-treatment. These associations were examined specifically relative to motivation for change in obsessive-compulsive (OC) features of eating disorder (ED) symptoms. Adolescents (N = 110) were randomly assigned to FBT-BN or CBT-A and completed assessments of eating pathology and OC-ED behaviour. Across both treatments, greater motivation for change in OC-ED behaviour was associated with improved attitudinal features of ED at end-of-treatment. Motivation for change did not demonstrate a direct or interaction effect on BN behavioural outcomes. Results suggest that adolescents with BN who are more motivated to change OC-ED behaviours at the start of treatment, FBT-BN or CBT-A, are more likely to demonstrate improvements in cognitions, but not behaviours associated with EDs, at treatment conclusion.

Family-Based Treatment for Anorexia Nervosa Symptoms in High-Risk Youth: A Partially-Randomized Preference-Design Study.

This pilot study adapted family-based treatment (FBT) for youth with potentially prodromal anorexia nervosa (AN). Fifty-nine youth with clinically significant AN symptom constellations, but who never met full Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (DSM-IV) criteria for AN, were enrolled in a partially randomized preference design study. Participants were offered randomization to FBT or supportive psychotherapy (SPT); those who declined to be randomized because of a strong treatment preference were entered into a parallel, non-randomized self-selected intervention study. Without accessing outcome data, an observational analysis with three diagnostic subclasses was designed based on AN symptom severity profiles, combining randomized and non-randomized participants, such that participants receiving FBT and SPT within each subclass were similar on key baseline characteristics. Outcomes of this pilot study were explored by calculating effect sizes for end-of-treatment values within each subclass, and also with a longitudinal mixed effect model that accounted for subclass. Weight trajectory was measured by percent expected body weight. Psychological outcomes were fear of weight gain, feeling fat, importance of weight, and importance of shape. Results show that the pattern of symptom observations over time was dependent on subclass of SAN (least symptomatic, moderately symptomatic, or most symptomatic) and on the target outcome variable category (weight or psychological). Results from this study, which should be considered in the context of the small sample sizes overall and within groups, can generate hypotheses for future, larger research trials on early treatment strategies. Feasibility findings illustrate how the innovative partially randomized preference design has potential broader application for AN intervention research. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT00418977.

Outcome parameters associated with perceived helpfulness of family-based treatment for adolescent eating disorders.

OBJECTIVE: Family-based treatment (FBT) is an efficacious treatment for adolescent eating disorders, yet it is not routinely implemented in clinical practice. Given that consumers play a role in treatment selection, this study sought to examine families' perspectives on FBT and remission markers associated with increased treatment satisfaction across families. METHOD: Participants were 40 adolescents and 43 caregivers who received outpatient FBT. FBT helpfulness was assessed using a treatment follow-up questionnaire, and eating disorder symptomatology was assessed using percent expected body weight (%EBW) and the eating disorder examination (EDE). Regression analyses were used to assess whether changes in symptoms from baseline to end-of-treatment (EOT) were significantly associated with helpfulness reports. RESULTS: On average, patients and their parents perceived FBT as "quite helpful" and "extremely helpful," respectively. Improvements in all EDE subscales, with the exception of restraint, were significantly associated with adolescent report of helpfulness (all p < .05); increase in %EBW was significantly associated with maternal report of helpfulness (p = .03). There were no significant findings for paternal report. DISCUSSION: Both patients and their parents perceived FBT as helpful, but patients seemed to prioritize cognitive improvements while mothers prioritized physical improvements in rating their satisfaction with FBT.

Bulimia nervosa in adolescents: prevalence and treatment challenges.

Bulimia nervosa (BN) is a serious psychiatric illness that typically develops during adolescence or young adulthood, rendering adolescents a target for early intervention. Despite the increasing research devoted to the treatment of youth with anorexia nervosa (AN) and adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there have been four published randomized controlled trials comparing psychosocial treatments, leaving significant room to improve treatment outcomes. Family-based treatment is the leading treatment for youth with AN, while cognitive-behavioral therapy is the leading intervention for adults with BN. Involving caregivers in treatment shows promising results, however, additional research is needed to investigate ways in which this treatment can be adapted further to achieve higher rates of recovery.

A pilot study of online feedback for adult drinkers 50 and older: Feasibility, efficacy, and preferences for intervention.

Normative (NF) and personalized feedback (PF) are moderately effective brief interventions for at-risk drinking middle-aged and older adults. This study tested the feasibility of online feedback for drinkers 50 and older. This study's aims were to identify whether there is differential effectiveness of PF over NF in prompting drinkers 50years old and older to plan for change and to determine potential preferences for intervention among adult drinkers 50 and older with practical knowledge about computers. METHOD: Using Amazon's Mechanical Turk, 138 male and female drinkers aged 50 to 75+ were recruited to complete an online survey that asked about their: perceptions of their drinking, quantity and frequency of drinking, and any comorbid health and/or mental health disorders/medications. They were then provided either NF or PF. NF provided information about how participants' drinking compared to their same age and gendered peers. PF provided information about level of risk to health and provided recommendations for safe levels of drinking. After feedback, participants were evaluated for their reactions (e.g., "How much does this worry you?") and their plan to change their drinking. Participants were asked about preferences for interventions. RESULTS: 80% of participants rated themselves a no or low-risk drinker, yet 52.2% were found to be at-risk drinkers. Overall, participants reported feedback was helpful, and 43.9% made some kind of plan to change. Participants in NF were significantly more likely to make a plan for change than those in PF. Participants reported that they most preferred an online (40.9%) or a brief in-person (31.8%) intervention. CONCLUSION: Findings revealed that brief online feedback was feasible, though limited to those who are computer knowledgeable. Unexpectedly, NF outperformed PF, suggesting that peer comparisons may be more motivating for adults 50 and older than previously thought. Finally, an online intervention appears to be a preferred intervention for alcohol use among this particular group of drinkers.

An exploratory pilot study of mechanisms of action within normative feedback for adult drinkers.

Background. Normative feedback (NF), or receiving information about one's drinking compared to peer drinking norms, is one of the most widely used brief interventions for prevention and intervention for hazardous alcohol use. NF has demonstrated predominantly small but significant effect sizes for intention to change and other drinking related outcomes. Identifying mechanisms of action may improve the effectiveness of NF; however, few studies have examined NF's mechanisms of action, particularly among adults. Objective. This study is an exploratory analysis of two theorized mechanisms of NF: discrepancy (specifically personal dissonance-the affective response to feedback) and belief in the accuracy of feedback. Method. Using Amazon's Mechanical Turk, 87 men (n = 56) and women (n = 31) completed an online survey during which they were asked about their perceptions about their drinking and actual drinking behaviors. Then participants were provided tailored NF and evaluated for their reactions. Severity of discrepancy was measured by the difference between one's estimated percentile ranking of drinking compared to peers and actual percentile ranking. Surprise and worry reported due to the discrepancy were proxies for personal dissonance. Participants were also asked if they believed the feedback and if they had any plans to change their drinking. Mediation analyses were implemented, exploring whether surprise, worry, or belief in the accuracy of feedback mediated severity of discrepancy's impact on plan for change. Results. Among this sample of adult drinkers, severity of discrepancy did not predict plan for change, and personal dissonance did not mediate severity of discrepancy. Severity of discrepancy was mediated by belief in the accuracy of feedback. In addition, viewing one's drinking as a problem prior to feedback and post-NF worry both predicted plan for change independently. Conclusions. Results revealed that NF may not work to create personal dissonance through discrepancy, but belief in the accuracy of feedback may be important. It appears the more one believes the feedback, the more one makes a plan for change, suggesting practitioners should be mindful of how information within feedback is presented. Findings also indicate NF may work by validating a preexisting perception that drinking is a problem instead of creating concern related to discrepancy where none existed. Limitations regarding generalizability are discussed.

Unpacking personalized feedback: an exploratory study of the impact of its components and the reactions it elicits among problem drinking men who have sex with men.

UNLABELLED: Personalized feedback (PF) has demonstrated effectiveness in reducing drinking. Few studies have examined its effectiveness with adult problem drinkers or its potential mediators or moderators, including developing discrepancy. This study aimed to identify potential mediators and moderators of PF provided to adult problem drinking men who have sex with men (PDMSM). METHOD: An exploratory analysis of PF provided to PDMSM in the context of modified behavioral self-control therapy (N = 90). The association of individual items of PF, severity of PF, and independently rated, in-session participant reactions to PF with drinking outcomes (mean drinks per drinking day, MDDD) were examined using correlations and logistic and linear regression. RESULTS: Significant pre-post differences in MDDD emerged. Other drug risk, family risk, and having an abnormal liver enzyme test result were significantly associated with proxies for developed discrepancy in expected directions; however, no PF item or reaction to PF predicted drinking outcomes. Severity of PF was not associated with participant reactions or drinking outcome. CONCLUSIONS: PF may be an effective intervention for PDMSM. Further research is needed to identify potential mediators and moderators of PF among adults.

Motivational interviewing: a pilot test of active ingredients and mechanisms of change.

Motivational interviewing (MI) is an effective treatment for substance use disorders (SUDs) that focuses on resolving ambivalence and increasing commitment to positive behavior change. Although MI has a well-developed clinical theory, research findings have been mixed in supporting its view of how change occurs. The primary aim of this pilot study was to test hypothesized MI active ingredients and mechanisms of change in reducing drinking during the initiation of a behavior change episode. Problem drinkers (N = 89) seeking treatment were randomly assigned to MI, relational MI without directive elements (spirit-only MI [SOMI]), or a self-change (SC) control condition. Participants were followed during an 8-week treatment period. The first 2 of 4 treatment sessions were videotaped and coded for fidelity, discriminability, and change talk. Overall, conditions demonstrated high fidelity. As predicted, change talk significantly increased in MI relative to the SOMI condition. Drinking was significantly reduced at end treatment, but the reduction was equivalent across conditions. Post hoc analyses found that MI reduced drinking more rapidly than SOMI and SC and that increased change talk mediated the effects of MI relative to SOMI during the week immediately following the first session. Findings are discussed in the context of the pilot nature of the study and the relative absence of experimental tests of mechanisms of behavior change in SUD treatment research.

Predictors of moderated drinking in a primarily alcohol-dependent sample of men who have sex with men.

Understanding for whom moderated drinking is a viable, achievable, and sustainable goal among those with a range of alcohol use disorders (AUD) remains an important public health question. Despite common acceptance as severe risk factors, there is little empirical evidence to conclude whether co-occurring mental health disorders or drug dependence contribute to an individual's inability to successfully moderate his drinking. Utilizing secondary data analysis, the purpose of this study was to identify predictors of moderation among both treatment-seeking and non-treatment-seeking, primarily alcohol-dependent, problem-drinking men who have sex with men (MSM), with an emphasis on the high risk factors psychiatric comorbidity and drug dependence. Problem drinkers (N=187) were assessed, provided feedback about their drinking, given the option to receive brief AUD treatment or change their drinking on their own, and then followed for 15 months. Findings revealed that neither psychiatric comorbidity or drug dependence predicted ability to achieve moderation when controlling for alcohol dependence severity. Those who were younger, more highly educated, and had more mild alcohol dependence were more likely to achieve moderated drinking. Impact of treatment on predictors is explored. Limitations of this study and arenas for future research are discussed.