Pediatric Somatic Symptom and Related Disorders: Parent Acceptance Influences Recovery.

OBJECTIVES: To assess how clinicians discuss the diagnosis of somatic symptom and related disorders (SSRDs) in patients admitted to a children's hospital and explore the effect of parent and patient acceptance of the diagnosis on recovery. STUDY DESIGN: In this cross-sectional study, we reviewed the electronic medical records of pediatric admissions diagnosed with SSRD over 18 months. All diagnostic discussions with patients and families were analysed to identify concepts used by clinicians within these discussions and the extent of parent and patient acceptance of the diagnosis. Recovery status up to 12 months after diagnosis was also identified. Acceptance and recovery were categorized as "full," "partial," or "none." RESULTS: Ninety-five of 123 (77.2%) patients (median age 14.3 years, range 7.3-18.3) had at least 1 diagnostic discussion recorded. Clinical explanations within the diagnostic discussion spanned a variety of concepts, with the most common being a description of somatization (62%). Full parent acceptance of the diagnosis of SSRD was more likely when discussions involved two parents (P = .002). Full acceptance of the diagnosis by at least 1 parent was associated with complete functional recovery in their children (OR 8.94, 95% CI 2.24, 35.9, P = .002). In contrast, there was no significant association between full acceptance by patients and their recovery. CONCLUSION: The influence of parent acceptance of the diagnosis of SSRD reinforces the importance of therapeutic engagement with families, as well as with children and adolescents.

Family-based treatment for adolescent anorexia nervosa: Outcomes of a stepped-care model.

OBJECTIVE: Stepped-care models of treatment are underexplored in eating disorders. To enhance treatment outcomes, and informed by literature about adaptations to family-based treatment (FBT), we developed an FBT-based stepped-care model for adolescents with anorexia nervosa (AN) that was consistent with family preference (i.e., tailored) and responsive to adolescent needs (i.e., intensity). The aim of this study was to evaluate the effectiveness of this model in terms of remission at end-of-treatment. METHOD: Adolescents (N = 82), aged 12-18 years (M = 15.1, SD = 1.8) and meeting Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria for AN, were assessed at baseline, Weeks 24 and 48. FBT was tailored to family preference and clinical need, with 16-18 sessions by Week 24. This was followed by three FBT booster sessions or an extension of FBT plus booster sessions (Week 48). The primary outcome was defined as weight > 95% of %median body mass index plus within 1 SD of the Eating Disorder Examination (EDE) global score community norms. RESULTS: Remission rates were 45.1% and 52.4% at Weeks 24 and 48, respectively. Commensurable improvements were evident across secondary outcomes (e.g., EDE subscale scores). As a reference point, remission rates compared positively with results from a recent randomized clinical trial from the same center and at the same time points (Week 24:45.1% vs. 32.1% and Week 48:52.4% vs. 30.2%). Controlling for propensity score, no statistically significant differences were observed. DISCUSSION: This stepped-care model, designed to be responsive to the individual needs of adolescents and their families, achieved encouraging rates of remission. This study provides an important signal that supports future clinical trials of stepped-care models for adolescents with AN.

Somatic symptom and related disorders in a tertiary paediatric hospital: prevalence, reach and complexity.

Specialist paediatric services manage a variety of presentations of functional somatic symptoms. We aimed to describe the presentation and management of children and adolescents with somatic symptom and related disorders (SSRDs) requiring admission to a tertiary children's hospital with the objective of informing the development of a local clinical pathway. Patients admitted to any hospital department from May 2016 to November 2017 were identified through an electronic medical record (EMR)-linked diagnosis of SSRD. Each record was reviewed for demographic details and admission histories. The frequency of interspecialty consultations and multidisciplinary team (MDT) family meetings were recorded. One hundred twenty-three patients with SSRD were admitted on 203 occasions to 17 different departments. The median (range) age was 14.3 (7.3-18.3) years. Interspecialty consultations occurred in 84.6% of patients, and MDT family meetings occurred in 18.9% patients. SSRD was diagnosed as an inpatient in 79.9% patients, yet only 40.7% of patients, including those with multiple admissions, had SSRD recorded as a discharge diagnosis.Conclusion: Despite high rates of consultation with hospital teams, the frequency of MDT family meetings was low, and less than half the patients had SSRD documented at discharge. This affirms the value of developing a local clinical pathway. What is Known • Functional somatic symptoms are commonly seen in children and adolescents. • Few studies have explored the reach of functional somatic symptoms across a tertiary paediatric hospital; the majority of inpatient studies have focused on a limited set of disorders or cases referred to psychiatry departments. What is New • Symptoms that spanned multiple body systems were the most common presentation of SSRDs in admitted children and adolescents. • Somatic symptom disorders are less likely to be recorded as a discharge diagnosis compared with functional neurological symptom disorder.

A case series of family-based treatment for adolescents with atypical anorexia nervosa.

The aim of this case series was to examine engagement in and outcomes of family-based treatment (FBT) for adolescents with DSM-5 atypical AN, that is, adolescents who were not underweight at presentation. Consecutive referrals for FBT of adolescents with atypical AN to a specialist child and adolescent eating disorder program were examined. Engagement in treatment (i.e., dose of treatment, completion rate), and changes in psychological symptomatology (i.e., eating disorder symptoms, depressive symptoms, self-esteem, obsessive compulsiveness), weight, and menstrual function were examined. The need for additional interventions (i.e., hospitalization and medication), and estimated remission rates were also examined. The sample comprised 42 adolescents aged 12-18 years (88% female). Engagement in FBT was high, with 83% completing at least half the treatment dose. There were significant decreases in eating disorder and depressive symptoms during FBT (p < .05) but no improvement in self-esteem. There was no significant change in percent of median BMI for age and gender for the sample as a whole (105 vs. 106%, p = .128). However, adolescents who were not admitted to hospital prior to FBT gained some weight (M = 3.4 kg) while those who were admitted did not gain weight during FBT (M = 0.2 kg, p < .01). The overall remission rate ranged from 38 to 52% depending on the criteria applied. FBT appears to be an effective treatment for adolescents with atypical AN. However, more research is needed into systematic adaptations of FBT and other treatments that could improve overall remission rates.

Parent-focused treatment for adolescent anorexia nervosa: a study protocol of a randomised controlled trial.

BACKGROUND: Family-based treatment is an efficacious outpatient intervention for medically stable adolescents with anorexia nervosa. Previous research suggests family-based treatment may be more effective for some families when parents and adolescents attend separate therapy sessions compared to conjoint sessions. Our service developed a novel separated model of family-based treatment, parent-focused treatment, and is undertaking a randomised controlled trial to compare parent-focused treatment to conjoint family-based treatment. METHODS/DESIGN: This randomised controlled trial will recruit 100 adolescents aged 12-18 years with DSM-IV anorexia nervosa or eating disorder not otherwise specified (anorexia nervosa type). The trial commenced in 2010 and is expected to be completed in 2015. Participants are recruited from the Royal Children's Hospital Eating Disorders Program, Melbourne, Australia. Following a multidisciplinary intake assessment, eligible families who provide written informed consent are randomly allocated to either parent-focused treatment or conjoint family-based treatment. In parent-focused treatment, the adolescent sees a clinical nurse consultant and the parents see a trained mental health clinician. In conjoint family-based treatment, the whole family attends sessions with the mental health clinician. Both groups receive 18 treatment sessions over 6 months and regular medical monitoring by a paediatrician. The primary outcome is remission at end of treatment and 6 and 12 month follow up, with remission defined as being ≥ 95% expected body weight and having an eating disorder symptom score within one standard deviation of community norms. The secondary outcomes include partial remission and changes in eating pathology, depressive symptoms and self-esteem. Moderating and mediating factors will also be explored. DISCUSSION: This will be first randomised controlled trial of a parent-focused model of family-based treatment of adolescent anorexia nervosa. If found to be efficacious, parent-focused treatment will offer an alternative approach for clinicians who treat adolescents with anorexia nervosa. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610000216011.

What paediatricians should know about eating disorders in children and young people.

Any health professional working with children and young people may become involved in the care of a child or young person with an eating disorder. Morbidity and mortality can be high, and paediatricians have an important role to play. There are broadly two aspects of underweight that the paediatrician may face - acute medical instability and a more chronic underweight which can impact greatly upon growth and development. Ultimate weight restoration means an adequate nutritional status to allow appropriate growth and development. Key to success is a team approach with paediatric and mental health and dietetic expertise combined. This paper provides an overview of eating disorders and explores current best practice, written in collaboration by a paediatrician and child and adolescent psychiatrist.

Borderline personality disorder traits in adolescents with anorexia nervosa.

OBJECTIVE: To examine the correlation between eating disorder (ED) symptoms and borderline personality disorder (BPD) traits in a sample of adolescents with eating disorders. METHOD: There were 168 participants (Mage  = 16.0 years; SD = 1.16) with a diagnosis of anorexia nervosa (AN) or Eating Disorder Not Otherwise Specified-AN type. Eating Disorder Examination (EDE) and the Borderline Personality Questionnaire (BPQ) were used to assess ED symptoms and BPD traits. RESULTS: A total of 10 participants (6.6%) scored above the clinical cut-off for a likely diagnosis of BPD. A positive correlation was observed between BPQ total score and EDE global (rs  = 0.64, p < .001). There were also positive correlations between the BPQ self-image and emptiness subscales and all EDE subscales. Similarly, the EDE eating concern subscale was correlated with all BPQ subscales. DISCUSSION: Previous studies have demonstrated that some BPD traits (i.e., suicidality, impulsivity, anger) are co-morbid with ED but the link with other BPD traits has been poorly studied in adolescents and those with AN. These findings indicate that while the prevalence of BPD in adolescents with AN may be relatively low, ED symptom severity is closely related to severity of BPD traits, particularly identity disturbance and feelings of emptiness.

What is the scientific evidence for the use of antipsychotic medication in anorexia nervosa?

This systematic review assesses the effectiveness of antipsychotic medication for improving core psychopathology and behavioral symptoms of anorexia nervosa. The Cochrane Depression, Anxiety and Neurosis Group Trials Register, reference lists of retrieved studies and conference abstracts were searched. Four randomized controlled trials comparing typical or atypical antipsychotic medication to other interventions were included. Clinical heterogeneity precluded meta-analysis. Overall, there is insufficient evidence to either support or refute the use of antipsychotic medication in anorexia nervosa. Further trials may be justified but should be designed with a clear theoretical framework to guide use of antipsychotic medication.

Somatic Symptom Disorders in Adolescent Inpatients.

PURPOSE: There are only a few reports of adolescents with somatic disorders (SDs) whose symptoms are sufficiently severe to require hospital admission. The aim of this study was to describe the symptom profile, health service utilization, and outcome of adolescents with SDs admitted to a tertiary children's hospital. METHODS: A retrospective cohort study of all adolescents admitted to the Adolescent Medicine Unit of a tertiary children's hospital was undertaken from July 2013 to June 2014. In a two-stage process, medical records were examined to identify patients who met the diagnostic criteria for SD. Evidence of functional recovery was obtained for the period from 18 to 30 months after discharge and rated as completely recovered, partially recovered, or functionally disabled. RESULTS: A total of 60 admissions (53 patients, 79% female) were identified with SD, accounting for 12% of the unit's admissions and 2% of hospital admissions over 12 years old. Nearly half (45%) the presenting symptoms were neurological and 39% involved pain. In total, 20% of admissions were for complex symptoms involving multiple body systems. The majority (81%) of adolescents with follow-up documentation (n = 37) demonstrated complete or partial recovery. Patients whose families fully accepted the diagnosis were more likely to accept counseling following discharge (p < .001) and were almost 20 times more likely to have completely recovered compared to adolescents whose families partially accepted or rejected the diagnosis (odds ratio 17.36, p = .003). CONCLUSIONS: Hospitalized adolescents with SD utilize substantial resources due to the requirement for comprehensive assessment, including multidisciplinary communication. Recovery can be anticipated for the majority, especially if supported by parents.

Randomized Clinical Trial of Parent-Focused Treatment and Family-Based Treatment for Adolescent Anorexia Nervosa.

OBJECTIVE: There have been few randomized clinical trials (RCTs) for adolescents with anorexia nervosa (AN). Most of these posit that involving all family members in treatment supports favorable outcomes. However, at least 2 RCTs suggest that separate parent and adolescent sessions may be just as effective as conjoint treatment. This study compared the relative efficacy of family-based treatment (FBT) and parent-focused treatment (PFT). In PFT, the therapist meets with the parents only, while a nurse monitors the patient. METHOD: Participants (N = 107) aged 12 to 18 years and meeting DSM 4(th)Edition criteria for AN or partial AN were randomized to either FBT or PFT. Participants were assessed at baseline, end of treatment (EOT), and at 6 and 12 months posttreatment. Treatments comprised 18 outpatient sessions over 6 months. The primary outcome was remission, defined as ≥95% of median body mass index and Eating Disorder Examination Global Score within 1 SD of community norms. RESULTS: Remission was higher in PFT than in FBT at EOT (43% versus 22%; p = .016, odds ratio [OR] = 3.03, 95% CI = 1.23-7.46), but did not differ statistically at 6-month (PFT 39% versus FBT 22%; p = .053, OR = 2.48, CI = 0.989-6.22), or 12-month (PFT 37% versus FBT 29%; p = .444, OR = 1.39, 95% CI = 0.60-3.21) follow-up. Several treatment effect moderators of primary outcome were identified. CONCLUSION: At EOT, PFT was more efficacious than FBT in bringing about remission in adolescents with AN. However, differences in remission rates between PFT and FBT at follow-up were not statistically significant. CLINICAL TRIAL REGISTRATION INFORMATION: A Randomised Controlled Trial of Two Forms of Family-Based Treatment and the Effect on Percent Ideal Body Weight and Eating Disorders Symptoms in Adolescent Anorexia Nervosa; http://www.anzctr.org.au/; ACTRN12610000216011.

Implementation of family-based treatment for adolescents with anorexia nervosa.

Although the implementation of new treatment models can be a challenging process for health care services, the outcomes can be greatly beneficial to patients and service providers. This article describes the process of change experienced within our multidisciplinary specialist eating disorder service when we implemented a new evidence-based model of care focusing on outpatient family-based treatment (FBT). Clinical outcomes were positive, including a 56% decrease in admissions, a 75% decrease in readmissions, and a 51% decrease in total bed days. Of families referred to FBT, 83% completed treatment and 97% of completers achieved >90% of their expected body weight. Despite these gains, many challenges were experienced, including misgivings about the suitability of FBT and difficulties in adhering to changes in professional roles. We describe these challenges, describe how they were overcome, and review factors perceived to be critical to the program's success, including integration of medical and mental health services, communication, and training.

Investigating the effectiveness, safety and tolerability of quetiapine in the treatment of anorexia nervosa in young people: a pilot study.

To investigate the safety and tolerability of the atypical antipsychotic quetiapine in anorexia nervosa patients, and to determine the effect of quetiapine treatment on anorexic psychopathology and other key outcome measures including weight and body image, we conducted a naturalistic, open-label, 12-week randomized controlled trial of low-dose (100-400 mg/day) quetiapine treatment versus treatment as usual in 33 anorexia nervosa patients from our Eating Disorder Clinics. To monitor the effects of treatment over the medium term, the participants were then followed up with assessment visits at 6 and 12 months after the end of the treatment phase. Low-dose quetiapine treatment resulted in both psychological and physical improvements, with minimal associated side-effects. Given the overall trend toward improvement that we observed, quetiapine appears to be a promising candidate for the treatment of anorexia nervosa. Further large-scale placebo-controlled clinical trials will be necessary to fully evaluate the benefits of quetiapine treatment for this disorder.