Julie McCormack

Prevention of eating disorders: A systematic review of randomized, controlled trials.

OBJECTIVE This systematic review evaluated the efficacy of universal, selective, and indicated eating disorder prevention. METHOD A systematic literature search was conducted in Medline, PsycINFO, Embase, Scopus, and the Cochrane Collaboration Library databases to January 2016. Studies were included if they were randomized, controlled trials (RCT) and tested an eating disorder prevention program. We retrieved 13 RCTs of universal prevention (N = 3,989 participants, 55% female, M age = 13.0 years), 85 RCTs of selective prevention (N = 11,949 participants, 99% female, M age = 17.6 years), and 8 RCTs of indicated prevention (N = 510 participants, 100% female, M age = 20.1 years). Meta-analysis was performed with selective prevention trials. As there were a limited number of universal and indicated trials, narrative synthesis was conducted. RESULTS Media literacy had the most support for universal prevention. Most universal approaches showed significant modest effects on risk factors. Dissonance-based was the best supported approach for selective prevention. Cognitive-behavior therapy (CBT), a healthy weight program, media literacy, and psychoeducation, were also effective for selective prevention and effects were maintained at follow-up. CBT was supported for indicated prevention and effects were maintained at follow-up. DISCUSSION The modest effects for universal prevention were likely due to floor effects. The evidence for selective prevention suggests that empirically supported approaches should be disseminated on a wider basis. Our findings suggest CBT should be offered for indicated populations. Overall, results suggest efficacy of several prevention programs for reducing risk for eating disorders, and that wider dissemination is required.

Comparative study of children and adolescents referred for eating disorder treatment at a specialist tertiary setting

OBJECTIVE To examine child and adolescent differences in the clinical presentation of eating disorders (EDs) at referral to a specialist pediatric program. METHOD This study compared cognitive, behavioral, and physical and medical features of children (≤ 12 years) and adolescents (13-18 years) with EDs presenting to a state-wide specialist pediatric ED service over two decades (N = 656; 8-18 years; 94% female). RESULTS Significant differences were found between the groups. Children were more commonly male (p < .001), had lower eating pathology scores (p < .001), were less likely to binge eat (p = .02), purge (p < .001) or exercise for shape and weight control (p < .001), and lost weight at a faster rate than adolescents (p = .009), whereas adolescents were more likely to present with bulimia nervosa spectrum disorders (p = .004). Children and adolescents did not differ significantly on mean body mass index z-score, percentage of body weight lost, or indicators of medical compromise (p > .05). DISCUSSION The clinical presentation of EDs differs among children and adolescents, with eating pathology and behavioral symptoms less prominent among children. Frontline health professionals require knowledge of these differences to assist with early detection, diagnosis, and prognosis.

Parent-Child Concordance in Reporting of Child Eating Disorder Pathology as Assessed by the Eating Disorder Examination

OBJECTIVE The aim of this study was to examine parent-youth concordance in reporting of eating disorder pathology, as assessed by the Eating Disorder Examination (EDE) in a clinical pediatric sample. METHOD The sample comprised 619 parent-youth dyads of youth (8-18 years) presenting for treatment at a specialist eating disorder clinic. A cross-sectional correlational design was used to examine the association between parent and youth symptom reports. RESULTS On the whole, parent-youth inter-rater agreement was poor to moderate. Agreement was acceptable for the presence of behavioral symptoms, with the exception of excessive exercise (PAK = 0.48-0.98). There was poor inter-rater agreement on frequency of behavioral symptoms, with parents providing lower estimates than youth (ICC = 0.07-0.52). Although we predicted that inter-rater agreement on cognitive symptoms would by higher with adolescents than children, both groups were discordant with parent reports. Younger children identified less severe eating disorder cognitions than parents and the opposite occurred for adolescents. An anorexia nervosa presentation and lower malnutrition were not associated with lower inter-rater agreement, as might have been expected through ego syntonicity. Youth with bulimia nervosa presentations reported significantly higher severity of cognitive symptoms and more frequent disordered eating behaviors compared with their parents. DISCUSSION Results support the utility of parent-youth assessment via the EDE to obtain a wider clinical picture of eating disorder psychopathology in children and adolescents, particularly for younger children. Clinical implications pertinent to administration of the EDE and parent literacy regarding eating disorder symptoms are discussed.

The Anorexia Nervosa Genetics Initiative: Study description and sample characteristics of the Australian and New Zealand arm:

Objectives: Anorexia nervosa is a severe psychiatric disorder with high mortality rates. While its aetiology is poorly understood, there is evidence of a significant genetic component. The Anorexia Nervosa Genetics Initiative is an international collaboration which aims to understand the genetic basis of the disorder. This paper describes the recruitment and characteristics of the Australasian Anorexia Nervosa Genetics Initiative sample, the largest sample of individuals with anorexia nervosa ever assembled across Australia and New Zealand. Methods: Participants completed an online questionnaire based on the Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) eating disorders section. Participants who met specified case criteria for lifetime anorexia nervosa were requested to provide a DNA sample for genetic analysis. Results: Overall, the study recruited 3414 Australians and 543 New Zealanders meeting the lifetime anorexia nervosa case criteria by using a variety of conventional and social media recruitment methods. At the time of questionnaire completion, 28% had a body mass index ⩽ 18.5 kg/m2. Fasting and exercise were the most commonly employed methods of weight control, and were associated with the youngest reported ages of onset. At the time of the study, 32% of participants meeting lifetime anorexia nervosa case criteria were under the care of a medical practitioner; those with current body mass index < 18.5 kg/m2 were more likely to be currently receiving medical care (56%) than those with current body mass index ⩾ 18.5 kg/m2 (23%). Professional treatment for eating disorders was most likely to have been received from general practitioners (45% of study participants), dietitians (42%) and outpatient programmes (42%). Conclusions: This study was effective in assembling the largest community sample of people with lifetime anorexia nervosa in Australia and New Zealand to date. The proportion of people with anorexia nervosa currently receiving medical care, and the most common sources of treatment accessed, indicates the importance of training for general practitioners and dietitians in treating anorexia nervosa.

A decade of data from a specialist statewide child and adolescent eating disorder service: does local service access correspond with the severity of medical and eating disorder symptoms at presentation?

BackgroundEating disorders affect up to 3% of children and adolescents, with recovery often requiring specialist treatment. A substantial literature has accrued suggesting that lower access to health care services, experienced by rural populations, has a staggering effect on health-related morbidity and mortality. The aim of this study was to evaluate whether lower service access foreshadowed a more severe medical and symptom presentation among children and adolescents presenting to a specialist eating disorders program.MethodThe data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N ~1000), a prospective ongoing registry study comprising consecutive paediatric tertiary eating disorder referrals. The sample consisted of 399 children and adolescents aged 8 to 16 years (M =14.49, 92% female) meeting criteria for a DSM-5 eating disorder.ResultsConsistent with the hypotheses, lower service access was associated with a lower body mass index z-score and a higher likelihood of medical complications at intake assessment. Contrary to our hypothesis, eating pathology assessed at intake was associated with higher service access. No relationship was observed between service access and duration of illness or percentage of body weight lost.ConclusionsLower service access is associated with more severe malnutrition and medical complications at referral to a specialist eating disorder program. These findings have implications for service planning and provision for rural communities to equalize health outcomes.

A hub and spokes approach to building community capacity for eating disorders in rural Western Australia

OBJECTIVE To determine whether an outreach community-based training program on eating disorders enhances perceived capacity of rural health and education professionals to respond to and manage eating disorders. DESIGN Survey conducted upon completion of outreach training. SETTING Rural Western Australia. PARTICIPANTS Health and education professionals working in rural Western Australia. MAIN OUTCOME MEASURES Questionnaire responses analysed via descriptive statistics and inferential tests. RESULTS There was a significant increase in perceived ability to identify, support and/or treat people with eating disorders among health and education professionals. CONCLUSIONS Outreach training up-skilled rural gatekeepers and introduced systemic health system benefits of increased consultation and liaison, a fine-tuning of referral processes, a reduction in hospital admissions and better uptake of local services by patients discharged from hospital.

Consensus-based perspectives of pediatric inpatient eating disorder services

OBJECTIVE There are few evidence-based guidelines for inpatient pediatric eating disorders. The aim was to gain perspectives from those providing and receiving inpatient pediatric eating disorder care on the essential components treatment. METHOD A modified Delphi technique was used to develop consensus-based opinions. Participants (N = 74) were recruited for three panels: clinicians (n = 24), carers (n = 31), and patients (n = 19), who endorsed three rounds of statements online. RESULTS A total of 167 statements were rated, 79 were accepted and reached a consensus level of at least 75% across all panels, and 87 were rejected. All agreed that families should be involved in treatment, and thatpsychological therapy be offered in specialist inpatient units. Areas of disagreement included that patients expressed a desire for autonomy in sessions being available without carers, and that weight gain should be gradual and admissions longer, in contrast to carers and clinicians. Carers endorsed that legal frameworks should be used to retain patients if required, and that inpatients are supervised at all times, in contrast to patients and clinicians. Clinicians endorsed that food access should be restricted outside meal times, in contrast to patients and carers. DISCUSSION The findings indicate areas of consensus in admission criteria, and that families should be involved in treatment, family involvement in treatment, while there was disagreement across groups on topics including weight goals and nutrition management. Perspectives from patients, carers, and clinicians may be useful to consider during future revisions of best practice guidelines.

Reaching out for hope - a peer support program

The value and need for consumer involvement in the delivery of mental health services is becoming increasingly recognised and acknowledged both throughout government and non-government organisations. The aim of consumer and carer involvement and engagement is, ultimately, to improve the quality of health care provided. The Child and Adolescent Mental Health Service (CAMHS) Eating Disorders Program (EDP), is a specialised service located at Princess Margaret Hospital. CAMHS has always had a strong investment in consumer focus and participation and have consistently included consumer input in to the current clinical services. In 2013, funding was obtained from a Capacity Building Grant which allowed for collaboration between CAMHS EDP and Women’s Healthworks (WHW), Body Esteem Program (BEP). From this collaboration a peer support program called “Reaching out for Hope,” was piloted. The “Reaching out for Hope” program was designed to allow young people attending the PMH EDP service to hear the experiences of others who once had an eating disorder, but now manage life without one. Delivery of the group program is based on peer support workers having a reciprocal and equal, non-clinical, non-expert relationship with participants. Developing this program has involved several steps including ethics and funding approval, integration of research, clinical services and consumer input. This presentation will detail the program from inception to delivery, including details from the final report focusing on identified strengths and limitations. The presentation will be delivered collaboratively by CAMHS EDP and WHW BEP staff. This abstract was presented in the Peer Support stream of the 2014 ANZAED Conference.

Selective eating: searching for clarity in complexity

Selective Eating (SE) refers to those children who significantly restrict their eating, but demonstrate no apparent concerns about weight or shape. Typically children with SE eat a very limited range of foods, usually over a number of years. In severe cases of SE there is anecdotal evidence that the childs growth is affected, but more commonly parents report that the childs eating patterns result in marked family distress and conflict as well as impairment in social functioning. This category of eating disorders is diagnostically unclear, with no formal criteria, and a paucity of empirical research. This research set out to understand more clearly the nature of SE starting with investigation of the level of concern about the problem and associated demographic factors. An objective measure of SE was developed based on analysis of food diaries, which was crucial in both ongoing research and assessing this ill-defined problem. Finally psychological aspects of the problem were investigated by comparing children with SE with a control group. Parents of SEs were more stressed and also more involved with their childs eating. The children themselves often had a history of developmental issues such as gagging or sensory aversion, but also had an anxious temperament and behavioural difficulties when younger, and features of anxiety and particularly OCD when older. These results highlight the complexity in assessing and treating this phenomenon. This abstract was presented in the Service Initiatives: Child and Adolescent stream of the 2014 ANZAED Conference.

Correlates of Psychiatric Inpatient Admission in a Paediatric Eating Disorder Cohort

Method The sample comprised patients aged 8 to 17 years (91% female), with DSM-5 eating disorder diagnosis, categorised as with (n = 38) or without (n = 247) impending psychiatric admission, assessed between 2006 and 2013. The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N ~ 1000), a prospective, ongoing registry study comprising consecutive paediatric tertiary eating disorder referrals.