Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa.

OBJECTIVE: This study provides data on the psychometric properties of a newly developed measure of treatment fidelity in Family-Based Treatment (FBT) for adolescent anorexia nervosa (AN). The Family Therapy Fidelity and Adherence Check (FBT-FACT) was created to evaluate therapist adherence and competency on the core interventions in FBT. METHOD: Participants were 45 adolescents and their families sampled from three randomized clinical trials evaluating treatment for AN. Trained fidelity raters evaluated 19 therapists across 90 early session recordings using the FBT-FACT. They also rated an additional 15 session 1 recordings of an alternate form of family therapy-Systemic Family Therapy for the purpose of evaluating discriminant validity of the FBT-FACT. The process of development and the psychometric properties of the FBT-FACT are presented. RESULTS: Overall fidelity ratings for each session demonstrated moderate to strong inter-rater agreement. Internal consistency of the measure was strong for sessions 1 and 2 and poor for session 3. Principal components analysis suggests sessions 1 and 2 are distinct interventions. DISCUSSION: The FBT-FACT demonstrates good reliability and validity as a measure of treatment fidelity in the early phase of FBT.

Central coherence in adolescents with bulimia nervosa spectrum eating disorders.

BACKGROUND: Weak central coherence-a tendency to process details at the expense of the gestalt-has been observed among adults with bulimia nervosa (BN) and is a potential candidate endophenotype for eating disorders (EDs). However, as BN behaviors typically onset during adolescence it is important to assess central coherence in this younger age group to determine whether the findings in adults are likely a result of BN or present earlier in the evolution of the disorder. This study examines whether the detail-oriented and fragmented cognitive inefficiency observed among adults with BN is observable among adolescents with shorter illness duration, relative to healthy controls. METHOD: The Rey-Osterrieth Complex Figure Test (RCFT) was administered to a total of 47 adolescents with DSM5 BN, 42 with purging disorder (PD), and 25 healthy controls (HC). Performance on this measure was compared across the three groups. RESULTS: Those with BN and PD demonstrated significantly worse accuracy scores compared to controls in the copy and delayed recall condition with a moderate effect size. These findings were exacerbated when symptoms of BN increased. DISCUSSION: Poorer accuracy scores reflect a fragmented and piecemeal strategy that interferes with visual-spatial integration in BN spectrum disorders. This cognitive inefficiency likely contributes to broad difficulties in executive functioning in this population especially in the context of worsening bulimic symptoms. The findings of this study support the hypothesis that poor global integration may constitute a cognitive endophenotype for BN.

What constitutes clinically significant binge eating? Association between binge features and clinical validators in college-age women.

OBJECTIVE: To investigate the association between binge features and clinical validators. METHOD: The Eating Disorder Examination assessed binge features in a sample of 549 college-age women: loss of control (LOC) presence, binge frequency, binge size, indicators of impaired control, and LOC severity. Clinical validators were self-reported clinical impairment and current psychiatric comorbidity, as determined via a semistructured interview. RESULTS: Compared with women without LOC, those with LOC had significantly greater odds of reporting clinical impairment and comorbidity (ps < 0.001). Among women with LOC (n = 252), the indicators of impaired control and LOC severity, but not binge size or frequency, were associated with greater odds of reporting clinical impairment and/or comorbidity (ps < 0.05). DICUSSION: Findings confirm that the presence of LOC may be the hallmark feature of binge eating. Further, dimensional ratings about the LOC experience--and possibly the indicators of impaired control--may improve reliable identification of clinically significant binge eating.

A review of attention biases in women with eating disorders.

There is robust evidence that women with eating disorders (EDs) display an attention bias (AB) for disorder-salient stimuli. Emerging data suggest that the presence of these biases may be due, in part, to neurological deficits, such as poor set shifting and weak central coherence. While some have argued that these biases function to predispose and/or act to maintain disordered eating behaviours, evidence supporting this view has rarely been examined. This report summarises and integrates the existing literature on AB in EDs and other related psychiatric disorders to better understand its potential role in the development and maintenance of an ED. The domains reviewed include experimental data using the dot-probe and modified Stroop task and neurobiological findings on AB in women with EDs as well as the role of AB in current theoretical models. We conclude by proposing an integrated model on the role of AB in EDs and discuss treatment approaches aimed at modifying these biases.

Set-shifting among adolescents with bulimic spectrum eating disorders.

OBJECTIVE: Set-shifting difficulties are observed among adults with bulimia nervosa (BN). This study aimed to assess whether adolescents with BN and BN spectrum eating disorders exhibit set-shifting problems relative to healthy controls. METHODS: Neurocognitive data from 23 adolescents with BN were compared with those from 31 adolescents with BN-type eating disorder not otherwise specified and 22 healthy controls on various measures of set-shifting (Trail Making Task [shift task], Color-Word Interference, Wisconsin Card Sorting Test, and Brixton Spatial Anticipation Task). RESULTS: No significant differences in set-shifting tasks were found among groups (p >.35), and effect sizes were small (Cohen f < 0.17). CONCLUSIONS: Cognitive inflexibility may develop over time because of the eating disorder, although it is possible that there is a subset of individuals in whom early neurocognitive difficulty may result in a longer illness trajectory. Future research should investigate the existence of neurocognitive taxons in larger samples and use longitudinal designs to fully explore biomarkers and illness effects. TRIAL REGISTRATION: clinicaltrials.gov NCT00879151.

An exploration of salivation patterns in normal weight and obese children.

We examined whether children's changes in salivary habituation to food vary based on weight status and/or allocating attention to a task. Children (31 non-overweight and 26 obese, ages 9-12 year) were presented with nine trials of a food stimulus and either listened to an audiobook (attention-demanding) or white noise (no-attention control). The salivary pattern differed significantly by weight status but not by condition or a condition by weight status interaction. This is the first study of salivary habituation in obese children; findings dovetail with an emerging set of evidence that obese individuals display distinctive biological responses to food.

Psychosocial correlates of shape and weight concerns in overweight pre-adolescents.

Shape and weight concerns among overweight pre-adolescents heighten risk for eating disorders and weight gain. Treatment and prevention efforts require consideration of psychosocial factors that co-occur with these concerns. This study involved 200 overweight pre-adolescents, aged 7-12 years (M age = 9.8; SD = 1.4), presenting for family-based weight control treatment. Hierarchical regression was used to examine the influence of pre-adolescents' individual characteristics and social experiences, and their parents' psychological symptoms, on shape and weight concerns as assessed by the Child Eating Disorder Examination. Findings revealed that higher levels of dietary restraint, greater feelings of loneliness, elevated experiences with weight-related teasing, and higher levels of parents' eating disorder symptoms predicted higher shape and weight concerns among overweight pre-adolescents. Interventions addressing overweight pre-adolescents' disordered eating behaviors and social functioning, as well as their parents' disordered eating behaviors and attitudes, may be indicated for those endorsing shape and weight concerns.

Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial.

OBJECTIVE: Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated. METHOD: 206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II. RESULTS: ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4). CONCLUSIONS: An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research.

Decreasing body dissatisfaction using a brief conditioning intervention.

OBJECTIVE: Body dissatisfaction in females is common and a risk factor for the development of an eating disorder. This study tested whether body dissatisfaction could be improved using a brief conditioning intervention in which photographs of participants' bodies were selectively paired with positive social stimuli (smiling faces) and photographs of other bodies were paired with neutral or negative social stimuli (neutral and frowning faces). METHOD: 39 women (mean age = 22.46; 64.1% Caucasian) with high body dissatisfaction were randomized to either the evaluative conditioning intervention (n = 22) or to a delayed waitlist control condition (n = 17). Body dissatisfaction (specifically, shape and weight concern), restraint, eating concern, and self-esteem were assessed at baseline, post treatment and again after four and 12 weeks. RESULTS: Compared to women in the delayed waitlist control condition, women in the treatment condition demonstrated a significant decrease in shape and weight concern, and a significant increase in self-esteem. Similar trends were found for the control condition after they completed the intervention. Changes at post treatment related to body dissatisfaction were maintained at 12-week follow-up. CONCLUSIONS: Repeatedly pairing photographs of an individual's body with positive social feedback may lead to improved body image and self-esteem.

Psychiatric co-morbidity in women presenting across the continuum of disordered eating.

OBJECTIVE: To compare the prevalence and correlates of psychiatric co-morbidity across a large sample of college women without an eating disorder, those at high risk for an eating disorder and women diagnosed using DSM-5 criteria for an eating disorder. PARTICIPANTS: 549 college women aged 18-25. METHODS: Data from the Eating Disorder Examination, the Structured Clinical Interview for DSM-IV Axis I disorders and self-report questionnaires were analyzed using logistic regression for categorical data and ANCOVA for continuous measures. RESULTS: Eating disordered symptomatology was strongly associated with anxiety disorders, mood disorders and insomnia. These co-morbidities (type and severity) tend to increase with eating disorder symptom severity. CONCLUSIONS: Prevention and treatment programs for eating disorders need to address the high levels of mood, anxiety and sleep problems in this population. The findings on insomnia are novel and suggest that sleep disturbance may play an integral role in eating-related difficulties.

An examination of the Clinical Impairment Assessment among women at high risk for eating disorder onset.

Identifying measures that reliably and validly assess clinical impairment has important implications for eating disorder (ED) diagnosis and treatment. The current study examined the psychometric properties of the Clinical Impairment Assessment (CIA) in women at high risk for ED onset. Participants were 543 women (20.6 ± 2.0 years) who were classified into one of three ED categories: clinical ED, high risk for ED onset, and low risk control. Among high risk women, the CIA demonstrated high internal consistency (α = 0.93) and good convergent validity with disordered eating attitudes (rs = 0.27-0.68, ps < 0.001). Examination of the CIA's discriminant validity revealed that CIA global scores were highest among women with a clinical ED (17.7 ± 10.7) followed by high risk women (10.6 ± 8.5) and low risk controls (3.0 ± 3.3), respectively (p < 0.001). High risk women reporting behavioral indices of ED psychopathology (objective and/or subjective binge episodes, purging behaviors, driven exercise, and ED treatment history) had higher CIA global scores than those without such indices (ps < 0.05), suggesting good criterion validity. These data establish the first norms for the CIA in a United States sample. The CIA is psychometrically sound among high risk women, and heightened levels of impairment among these individuals as compared to low risk women verify the relevance of early intervention efforts.

Psychosocial and familial impairment among overweight youth with social problems.

OBJECTIVE: Emerging research indicates that overweight children with social impairments are less responsive to weight control interventions over the long term. A better understanding of the breadth and psychosocial correlates of social problems among overweight youth is needed to optimize long-term weight outcomes. METHODS: A total of 201 overweight children, aged 7-12 years, participated in a randomized controlled trial of two weight maintenance interventions following family-based behavioral weight loss treatment. Children with HIGH (T ≥ 65) versus LOW (T<65) scores on the Child Behavior Checklist Social Problems subscale were compared on their own and their parents' pre-treatment levels of psychosocial impairment using multivariate analysis of variance. Hierarchical regression was used to identify parent and child predictors of social problems in the overall sample. RESULTS: HIGH (n = 71) children evidenced greater eating disorder psychopathology and lower self-worth, as well as a range of interpersonal difficulties, compared with LOW children (n = 130; ps<0.05). Compared with parents of LOW children, parents of HIGH children reported greater levels of their own general psychopathology (p<0.05). Parent psychopathology significantly added to the prediction of social problems in the full sample beyond child sex and z-BMI (ps<0.01). CONCLUSION: A substantial minority of overweight youth experience deficits across the social domain, and such deficits appear to be associated with impairment in a broad range of other psychosocial domains. Augmenting weight loss interventions with specialized treatment components to address child and parent psychosocial problems could enhance socially-impaired children's long-term weight outcomes and decrease risk for later development of psychiatric disturbances.

Disordered eating attitudes and behaviors in overweight youth.

Disordered eating attitudes and behaviors appear to be quite common in youth, and overweight youth have been identified as a subset of the population at particularly high risk for endorsing such symptoms. Overweight and eating disorder (ED) symptomatology independently confer significant threats to one's physical and psychosocial health, showing strong links with body weight gain and risk for ED development. When concurrent, the risk for negative health outcomes may be compounded. The purpose of this article is to review the current state of the literature as it concerns disordered eating and its correlates in overweight children and adolescents. Extant literature on the prevalence, distribution, correlates, and etiology of disordered eating attitudes and behaviors (i.e., negative attitudes toward shape and weight, unhealthy weight control behaviors, and binge eating) in overweight youth is reviewed and consolidated in order to make assessment and treatment recommendations for healthcare providers. The current literature suggests that early detection of disordered eating in overweight youth should be a priority to provide appropriate intervention, thereby helping to slow the trajectory of weight gain and prevent or reduce the long-term negative consequences associated with both conditions. Future research should focus on explicating developmental pathways, and on developing novel prevention and treatment interventions for overweight youth exhibiting disordered eating patterns.