Deconstructing Planning Ability in Children and Adolescents with Anorexia Nervosa.

Weaknesses in planning by patients with anorexia nervosa (AN) have been noted (e.g., Zakzanis, Campbell, & Polsinelli, 2010 ) and are generally based on adults. This study explored D-KEFS Tower Test performance to better understand learning styles and strategies used by child and adolescent patients with AN compared to healthy controls. Overall, no significant differences were found in achievement; however, Item 5 predicted performance across harder items. The AN group was significantly faster to move their first disc suggesting patients with AN did not spend as much time planning their strategies for item completion. The findings of this study in conjunction with other studies investigating planning in AN may suggest the existence of subtle differences in learning style and strategy, such as faster initiation times, rather than gross planning differences. Further research is required to better understand the relationship between these subtle differences and clinical presentations.

The use of cognitive remediation therapy on a child adolescent eating disorder unit: Patients and therapist perspectives.

Cognitive remediation therapy (CRT) is an intervention for anorexia nervosa (AN) that focuses on ameliorating the neuropsychological inefficiencies that underlie the illness. The current literature has reported promising results regarding its efficacy as an intervention for AN. However, there is a scarcity of studies considering the implementation of CRT in a child and adolescent population. This article describes an individual CRT therapy programme for children and adolescents with AN delivered on an inpatient unit for eating disorders. It considers the therapeutic process including the differing viewpoints of the patients and the therapists. The article concludes that CRT can be viewed as an engaging therapeutic intervention that could be useful as an additional treatment for AN.

Similarities and Differences of Neuropsychological Profiles in Children and Adolescents with Anorexia Nervosa and Healthy Controls Using Cluster and Discriminant Function Analyses.

OBJECTIVE: This study aimed to identify discrete neuropsychological profiles and their relationship to clinical symptoms in 253 female children and adolescents with anorexia nervosa (AN) and 170 healthy controls (HCs) using a standardised neuropsychological assessment battery. METHOD: Hierarchical cluster analysis was used to identify the optimum number of clusters, and participants were assigned using K-means cluster analysis. Confirmatory discriminant function analysis determined which combination of neuropsychological variables best distinguished the clusters. RESULTS: Three distinct clusters in the AN sample emerged- AN cluster 1 (19%) - "neuropsychologically low average to average"; AN cluster 2 (33%) - "verbal/visuo-spatial discrepancy"; and AN cluster 3 (48%) - "verbally strong and neuropsychologically average to high average". Two distinct clusters in HCs were identified. HC cluster 1 (48%) demonstrated poor visuo-spatial memory scores and high verbal fluency scores, whilst HC cluster 2 (52%) scored within the average range on all neuropsychological tasks. Neuropsychological performance was associated with clinical symptoms of body mass index centile, Eating Disorder Examination subscale and global score, anxiety, depression and obsessions, and compulsions between the AN and HC groups. However, niether significant differences emerged between AN clusters only nor HC clusters only at the post-hoc level. DISCUSSION: An underlying neuropsychological heterogeneity may exist in AN. We encourage future studies to investigate whether the identified profiles and their association with clinical characteristics are replicable. We cautiously suggest that neuropsychological profiling may have potential to both inform future research and have possible clinical benefits through individually tailored treatment strategies.

Quality of friendships and motivation to change in adolescents with Anorexia Nervosa.

This study explored the relationship between quality of friendships, motivation to change and peer support among young people receiving inpatient treatment for Anorexia Nervosa (AN). Thirty participants were recruited from three inpatient wards. Questionnaires assessed motivational stage, friendship functions and characteristics of friendships specific to AN. Three friendship functions - Help, Intimacy and Self-Validation - were significantly and positively correlated with greater motivational stage. Describing friends on the ward as supportive of adherence to the treatment program was positively associated with greater motivational stage and higher quality friendships. The association between motivation, friendship quality and peer support in treatment identifies close and supportive friendships among young people with AN as a potential target to improve outcomes.

Metabolic Control and Illness Perceptions in Adolescents with Type 1 Diabetes.

BACKGROUND: Disturbed eating behavior and psychosocial variables have been found to influence metabolic control, but little is known about how these variables interact or how they influence metabolic control, separately and combined. OBJECTIVE: To explore associations between metabolic control (measured by HbA1c) and eating disorder psychopathology, coping strategies, illness perceptions, and insulin beliefs in adolescents with type 1 diabetes. METHODS: A total of 105 patients (41.9% males) with type 1 diabetes (12-20 years) were interviewed with the Child Eating Disorder Examination. In addition, self-report psychosocial questionnaires were completed. Clinical data, including HbA1c, was obtained from the Norwegian Childhood Diabetes Registry. RESULTS: Significant gender differences were demonstrated. Among females, HbA1c correlated significantly with eating restriction (.29, p < .05), the illness perception dimensions consequences, personal control, coherence, and concern (ranging from .33 to .48), and the coping strategy ventilating negative feelings (-.26, p < .05). Illness perception personal control contributed significantly to HbA1c in a regression model, explaining 23% of the variance among females (ß .48, p < .001). None of the variables were significantly associated with HbA1c among males. CONCLUSIONS: Illness perceptions appear to be important contributors to metabolic control in females, but not males, with type 1 diabetes.

Age-Related Performance on the Brixton Spatial Anticipation Test in Healthy Child and Adolescent Girls: A Preliminary Evaluation.

The Brixton Spatial Anticipation Test assesses individuals' cognitive flexibility in terms of rule detection and attainment. It has been used to assess executive functioning in both clinical and nonclinical adult samples. However, little is currently known about the suitability of this task for younger populations. The current study therefore aimed to provide an initial exploration of this task's suitability for young people. Brixton responses from a healthy sample of children and adolescents were presented to investigate performance in both rule detection and rule attainment, respectively. A convenience sample of 72 female participants (Mage = 14.95 years, SD = 1.53 years, range = 11-17 years; MIQ = 103.76, SD = 10.81) was studied. The sample was divided according to age into four groups (11-12 years, 13-14 years, 15 years, and 16-17 years) to allow for developmental trajectory. No significant age performance differences were found. Small effect sizes between age groups lend support to the null findings. The current study suggests that the Brixton task norms are suitable for use with individuals aged 11 to 17 years old. However, normative work is still needed in this area, incorporating an adult sample for comparison, to comment upon the developmental trajectory specific to this task.

Are poor set-shifting abilities associated with a higher frequency of body checking in anorexia nervosa?

BACKGROUND: The rigid and obsessional features of anorexia nervosa (AN) have led researchers to explore possible underlying neuropsychological difficulties. Numerous studies have demonstrated poorer set-shifting in patients with AN. However, due to a paucity of research on the connection between neuropsychological difficulties and the clinical features of AN, the link remains hypothetical. The main objective of this study was to explore the association between set-shifting and body checking. METHODS: The sample consisted of 30 females diagnosed with AN and 45 healthy females. Set-shifting was assessed using the Wisconsin Card Sorting Test (WCST) and frequency of body checking was assessed using the Body Checking Questionnaire (BCQ). RESULTS: The analysis showed no significant correlations between any of the WCST scores and the BCQ. CONCLUSION: The results suggest that there is no association between set-shifting difficulties and frequency of body checking among patients with AN. An alternative explanation could be that the neuropsychological measure included in this study is not sensitive to the set-shifting difficulties observed in clinical settings. We recommend that future studies include more ecologically valid measures of set-shifting in addition to standard neuropsychological tests.

Family cognitive remediation therapy for anorexia nervosa.

Anorexia nervosa (AN) in childhood and adolescence has a poor prognosis. It is possible that this may in part be due to the fact that cognitive weaknesses that appear to be risk factors for its development and maintenance are not being targeted in treatment. Through its focus on these deficits, cognitive remediation therapy (CRT) has been shown to be a promising intervention for AN. Furthermore, family interventions are widely recommended for this patient population, but to date no studies have reported the use of CRT in a family setting. This paper presents a case series in which family-based CRT was a significant component of the management. It was well received by patients and their families and previously treatment resistant patients became more engaged with the entire treatment process. In addition, all patients receiving family-based CRT went on to make progress towards recovery. These initial clinical observations suggest family-based CRT is likely to be a useful addition to treatment for child and adolescent AN and justifies formal evaluation.

Memory versus perception of body size in patients with anorexia nervosa and healthy controls.

The objective of this study was to compare body size estimation based on memory versus perception, in patients with anorexia nervosa (AN) and healthy controls, adjusting for possible confounders. Seventy-one women (AN: 37, controls: 35), aged 14-29 years, were assessed with a computerized body size estimation morphing program. Information was gathered on depression, anxiety, time since last meal, weight and height. Results showed that patients overestimated their body size significantly more than controls, both in the memory and perception condition. Further, patients overestimated their body size significantly more when estimation was based on perception than memory. When controlling for anxiety, the difference between patients and controls no longer reached significance. None of the other confounders contributed significantly to the model. The results suggest that anxiety plays a role in overestimation of body size in AN. This finding might inform treatment, suggesting that more focus should be aimed at the underlying anxiety.

In the parents' view: weight perception accuracy, disturbed eating patterns and mental health problems among young adolescents.

BACKGROUND: An accurate weight perception has been associated with motivation to change eating habits in the case of under- or overweight. However, recent studies have reported frequent misperceptions among parents and their offspring, both in the form of under- and overestimation of weight status. The aim of the present study was to investigate weight perception accuracy among parents of young adolescents in relation to reports on disturbed eating patterns and mental health problems. METHODS: Weight perception accuracy was assessed among parents of young adolescents (N = 5,781, aged 11 - 13 years) who participated in the ongoing Bergen Child Study (BCS). Parental weight perception was classified in overestimation, underestimation and accurate. Other measures included demographic variables, the parents' evaluations of disturbed eating patterns and mental health problems among their offspring as well as the adolescents' own weight perception accuracy. RESULTS: The parents accurately perceived more than 80% of normal weight adolescents, but nearly 60% of the underweight adolescents were overestimated, and a substantial proportion of overweight girls (34. 8%) and boys (12.8%) were underestimated. In general, parents who were aware of deviations from average weight in their child also reported higher levels of disturbed eating patterns, emotional problems, and behavioral problems. After controlling for demographic factors, the risk of parental over- and underestimation was significantly predicted by weight status, the adolescents' weight perception accuracy as well as disturbed eating patterns reported by the parents (p < .05). CONCLUSIONS: Adolescents with under- or overweight proved most likely to be misperceived by their parents in this study. The pattern of perceptually correcting deviations from normal weight was interpreted as a positivity bias among the parents. These results suggest that weight perception accuracy should be targeted in family-focused interventions in order to strengthen adequate weight control among young adolescents.

Developing and evaluating cognitive remediation therapy (CRT) for adolescents with anorexia nervosa: a feasibility study.

BACKGROUND: Cognitive Remediation Therapy (CRT) aims at improving neuropsychological weaknesses and associated thinking styles in patients with anorexia nervosa (AN). It has only recently been developed for adolescents with AN, and evidence of its applicability for this particular patient group is limited. This study aimed to test the feasibility of individually tailored and delivered CRT for young females with AN. METHODS: A sample of 20 in- and outpatients (13-18 years) with AN participated in once- or twice weekly individual CRT sessions. The CRT materials used were available in a "CRT Resource Pack." Feasibility was assessed with regards to the recruitment process, the delivery of the intervention, the materials used and clinical experiences. RESULTS: Overall results indicate that the intervention was feasible with regards to (a) the recruitment of both in- and outpatients, (b) individual tailoring and delivery, (c) the CRT materials adapted to suit young females with AN, and (d) the acceptability for clinicians involved in the study. There were no voluntary dropouts, with 19 of 20 patients completing the entire course of treatment. CONCLUSIONS: The findings have implications for the refinement of CRT for the youngest AN population, and strengthens our understanding of the core components in the development and evaluation of novel interventions targeting AN. This study will help inform the design of a subsequent randomized controlled trial.

Pervasive refusal syndrome (PRS) 21 years on: a re-conceptualisation and a renaming.

Twenty-one years ago, Lask and colleagues first described pervasive refusal syndrome (PRS) as a child's "dramatic social withdrawal and determined refusal to walk, talk, eat, drink, or care for themselves in any way for several months" in the absence of an organic explanation. PRS has been conceptualised in a variety of ways since then. These have included a form of post-traumatic stress disorder, learnt helplessness, 'lethal mothering', loss of the internal parent, apathy or the 'giving-up' syndrome, depressive devitalisation, primitive 'freeze', severe loss of activities of daily living and 'manipulative' illness, meaning the possibility that the children have been drugged to increase chances of asylum in asylum-seeking families. Others have insisted that PRS is simply depression, conversion disorder, catatonia or a factitious condition. This paper reviews these conceptualisations, explores some of the central complexities around PRS and proposes a neurobiological explanatory model, based upon autonomic system hyper-arousal. It touches upon the clinical implications and suggests a new name for the condition reflecting what we believe to be a more sophisticated understanding of the disorder than was available when it was first described.

Patient and parental self-reports of executive functioning in a sample of young female adolescents with anorexia nervosa before and after cognitive remediation therapy.

OBJECTIVE: Previous studies assessing the potency of cognitive remediation therapy (CRT) have largely focused on performance-based assessments and how these change during the course of the intervention. Little is known of behavioural manifestations of such changes, and no previous studies have studied parental reports before and after CRT. METHOD: Patient and parental self-reports of executive function using the Behaviour Rating Inventory of Executive Function (BRIEF) were obtained for 17 adolescent patients in treatment for anorexia nervosa before and after CRT. RESULTS: Results indicated that patients scored significantly lower on the BRIEF shift subscale after CRT, whereas parental reports revealed significantly lower scores on the shift and emotional control subscales, and on the two composite indices Behavioural Regulation Index and Global Executive Composite. Case-wise comparisons support variations in executive functions in adolescents with anorexia nervosa. DISCUSSION: Changes are evaluated in light of the relationship between patients and parents and with regard to the limitations of the study design.

Central coherence, organizational strategy, and visuospatial memory in children and adolescents with anorexia nervosa.

The vast majority of studies in anorexia nervosa that have investigated the domains of central coherence, organizational strategy, and visuospatial memory have focused on adult samples. In addition, studies investigating visuospatial memory have focused on free recall. No study to date has reported the association between recognition memory and central coherence or organizational strategy in younger people with this disorder, yet the capacity to recognize previously seen visual stimuli may contribute to overall visuospatial ability. Therefore, we investigate these domains in children and adolescents with anorexia nervosa compared to age- and gender-matched healthy controls. There were no significant group differences in immediate, delayed, or recognition memory, central coherence, or organization strategy. When compared with controls, patients with anorexia nervosa scored significantly higher on accuracy and took significantly longer when copying the Rey Complex Figure Task. Caution must be taken when interpreting these findings due to lower-than-expected scores in memory performance in the control group and because of a potential lack of sensitivity in the measures used when assessing this younger population. For neuropsychological functions where no normative data exist, we need a deeper, more thorough knowledge of the developmental trajectory and its assessment in young people in the general population before drawing conclusions in anorexia nervosa.

Neuropsychological functioning in adolescents with anorexia nervosa before and after cognitive remediation therapy: a feasibility trial.

OBJECTIVE: To investigate neuropsychological functioning in adolescents with anorexia nervosa (AN) before and after receiving cognitive remediation therapy (CRT). METHOD: Twenty young females with AN participated in an individually-delivered CRT treatment program. Neuropsychological and psychiatric assessments were administered before and after treatment. Weight, depression, anxiety, duration of illness, and level of eating disorder psychopathology were considered as covariates in statistical analyses. RESULTS: Significant changes in weight, depression, visio-spatial memory, perceptual disembedding abilities, and verbal fluency were observed. Changes in weight had a significant effect on improvements in visuo-spatial memory and verbal fluency. Results also revealed a significant effect of depressive symptoms on perceptual disembedding abilities. DISCUSSION: The results suggest improvements on a number of neuropsychological functions during the course of CRT. Future studies should explore the use of additional assessment instruments, and include control groups to assess the effectiveness of the intervention.

Verbal fluency in anorexia nervosa.

Verbal fluency performance is commonly evaluated in clinical neuropsychology, in particular for assessment of executive functioning. Fluency is usually assessed by the person's ability to produce as many words as possible from a given cue within a specific timeframe. The cues are typically phonemic, e.g. words beginning with a specific letter, or semantic, e.g. words within a given category. Important components underlying fluency performance include clustering (the production of words within subcategories) and switching (the switch between clusters). Previous studies have demonstrated good performance on verbal fluency tasks in patients with anorexia nervosa (AN), but have not investigated the underlying components of this performance. The aim of the present study was to compare phonemic fluency performance in patients with AN to healthy controls (HC) and to investigate the use of clustering and switching in the two groups. Fifty-two patients with AN were compared with 37 HC on a phonemic fluency task. The patient group produced more words in total but the results were not significantly different compared to the HC sample. There were no differences between the two groups with regard to clustering, but patients with AN performed significantly more switches. In addition, switching was significantly more related to total output score in the patient sample. In contrast with previous studies of other areas of cognitive flexibility in AN, patients with AN appear to have good verbal set-shifting skills.

Season of birth bias and bulimia nervosa--results from a multi-centre collaboration.

BACKGROUND: Season of birth bias has been observed for people with a number of disorders, including women with bulimia nervosa. However, inconsistent results and methodological weaknesses render previous conclusions about such bias uncertain. With an enhanced methodology, this study aims to test whether there is a season of birth bias for women with bulimia nervosa. METHOD: Women with bulimia nervosa at five secondary and tertiary services in Norway, born between 1966 and 1988 (n = 549), were compared with women in the general population in a chi-square test for contingency tables, with known population parameters testing monthly deviations. RESULTS: There was no statistically significant association between month of birth and the distribution of births in the two groups (Cramer's V = .09). CONCLUSION: There appears not to be any season of birth bias in women with bulimia nervosa in Norway.

Season of birth bias and anorexia nervosa: results from an international collaboration.

OBJECTIVE: Based on inconsistent findings in the literature, this study tested the hypothesis that "there is a season of birth bias for females with anorexia nervosa (AN)." METHOD: Females with AN, born in 1975 to 1996, were compared to females born in the same years and geographical regions by chi-square test for contingency tables with known population parameter testing for monthly deviations. Five groups were based on a priori power calculation and geographical location: Iceland, Norway and Sweden (N = 847), United Kingdom (N = 706), Oregon, USA (N = 394), Argentina and Brazil (N = 486), and Australia (N = 381). RESULTS: The hypothesis was not supported in any of the groups. The associations (Cramér's V) between month of birth and the differences in distributions of births ranged from 0.05 to 0.08, none of which were statistically significant. DISCUSSION: The main implication of these findings is that season of birth may not play a significant part in the aetiology of AN.

The neuropsychological profile of children, adolescents, and young adults with anorexia nervosa.

The neuropsychological profile of a sample of 155 patients with a clinical diagnosis of anorexia nervosa was assessed using a test battery specifically developed for such patients. The current findings suggest that the patients display a common neuropsychological profile including both strengths and weaknesses when compared with published norms. The patients displayed good verbal fluency skills, but performed poorly on tests of visuospatial memory, associated with relatively weak central coherence. They were within the average range on the assessment of executive functioning except for one measure of set-shifting. This study provides a valuable point of reference for clinicians when considering treatment options.

Anorexia nervosa--a noradrenergic dysregulation hypothesis.

Anorexia nervosa manifests a wide range of features which cannot fully be explained on the basis of socio-cultural pressures to be thin, nor by starvation, nor dehydration. Evidence is emerging of a significant neurobiological contribution to its aetiology. However there has to date been no explanation for its pathogenesis that integrates the previously identified genetic, neurobiological and socio-cultural contributing factors. In this paper we propose an empirically-based hypothesis that genetically determined noradrenergic dysregulation, interacting with epigenetic factors, leads to high levels of anxiety, impaired neuroplasticity and regional cerebral hypoperfusion. These, in combination, lead to insula dysfunction. The resulting impairment in insula homuncular representation explains the pathognomonic body image distortion. This distortion, combined with high levels of body-focused anxiety, gives rise to intense dieting, noradrenergic precursor depletion, and initial reduction in anxiety. The subsequent rebound exacerbation of anxiety leads to a vicious cycle of maintenance. Novel treatment implications based on this hypothesis are briefly considered.