Rachel Bryant-Waugh

Feeding and eating disorders in childhood

OBJECTIVEnTo review the literature related to the current DSM-IV-TR diagnostic criteria for feeding disorder of infancy or early childhood; pica; rumination disorder; and other childhood presentations that are characterized by avoidance of food or restricted food intake, with the purpose of informing options for DSM-V.nnnMETHODnArticles were identified by computerized and manual searches and reviewed to evaluate the evidence supporting possible options for revision of criteria.nnnRESULTSnThe study of childhood feeding and eating disturbances has been hampered by inconsistencies in classification and use of terminology. Greater clarity around subtypes of feeding and eating problems in children would benefit clinicians and patients alike.nnnDISCUSSIONnA number of suggestions supported by existing evidence are made that provide clearer descriptions of subtypes to improve clinical utility and to promote research.

Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network

OBJECTIVEnFew published studies have evaluated the clinical utility of new diagnostic criteria for avoidant/restrictive food intake disorder (ARFID), a DSM-5 reformulation of feeding and eating disorder of infancy or early childhood. We examined the prevalence of ARFID and inter-rater reliability of its diagnostic criteria in a pediatric gastrointestinal sample.nnnMETHODnWe conducted a retrospective chart review of 2,231 consecutive new referrals (ages 8-18 years) to 19 Boston-area pediatric gastroenterology clinics for evidence of DSM-5 ARFID.nnnRESULTSnWe identified 33 (1.5%) ARFID cases; 22 of whom (67%) were male. Most were characterized by insufficient intake/little interest in feeding (nu2009=u200919) or limited diet due to sensory features of the food (nu2009=u20097). An additional 54 cases (2.4%) met one or more ARFID criteria but there was insufficient information in the medical record to confer or exclude the diagnosis. Diagnostic agreement between coders was adequate (κu2009=u20090.72). Common challenges were (i) distinguishing between diagnoses of ARFID and anorexia nervosa or anxiety disorders; (ii) determination of whether the severity of the eating/feeding disturbance was sufficient to warrant diagnosis in the presence of another medical or psychiatric disorder; and (iii) assessment of psychosocial impairment related to eating/feeding problems.nnnDISCUSSIONnIn a pediatric treatment-seeking sample where ARFID features were common, cases meeting full criteria were rare, suggesting that the diagnosis is not over-inclusive even in a population where eating/feeding difficulties are expected.

Revision of ICD – status update on feeding and eating disorders

The World Health Organization is currently revising the International Classification of Diseases and Related Health Problems (ICD-10). A central goal for the revision of the ICD classification of mental and behavioural disorders is to improve its clinical utility. Global representation and cultural sensitivity and relevance are important across all mental disorders, but are especially critical to advancing our understanding, diagnosis and treatment of feeding and eating disorders (FED). This paper summarises the current status of the Eating Disorders Consultation Group (EDCG) considerations regarding diagnostic categories for FEDs in ICD-11 and represents work in progress. The recommendations of the EDCG are informed by relevant research evidence, and the consultation group is striving to find a balance between clinical utility and diagnostic purity. Provisional recommendations of the EDCG include: (1) merger of previous FEDs categories in one group; (2) inclusion of six main FED categories that include anorexia nervosa (AN), bulimia nervosa (BN), pica, regurgitation disorder, binge-eating disorder (BED) and avoidant/restrictive food intake disorder, the last two representing new categories; (3) broadening of categories with the aim of reducing the use of the unspecified ED category (e.g. dropping the amenorrhea requirement, increasing the body mass index cut-off for low weight and rewording the cognitive and behavioural features of AN to be more culturally-sensitive). In line with this last recommendation, one point that require further analysis pertain to frequency and severity of the binge-eating and purging behaviours in BN and BED, as the EDCG is considering reducing or eliminating the frequency criterion and broadening the binge-eating criterion to include ‘subjective’ binge episodes.

The impact of early symptom change and therapeutic alliance on treatment outcome in cognitive-behavioural therapy for eating disorders

The present study explored the impact of early symptom change (cognitive and behavioural) and the early therapeutic alliance on treatment outcome in cognitive-behavioural therapy (CBT) for the eating disorders. Participants were 94 adults with diagnosed eating disorders who completed a course of CBT in an out-patient community eating disorders service in the UK. Patients completed a measure of eating disorder psychopathology at the start of treatment, following the 6th session and at the end of treatment. They also completed a measure of therapeutic alliance following the 6th session. Greater early reduction in dietary restraint and eating concerns, and smaller levels of change in shape concern, significantly predicted later reduction in global eating pathology. The early therapeutic alliance was strong across the three domains of tasks, goals and bond. Early symptom reduction was a stronger predictor of later reduction in eating pathology than early therapeutic alliance. The early therapeutic alliance did not mediate the relationship between early symptom reduction and later reduction in global eating pathology. Instead, greater early symptom reduction predicted a strong early therapeutic alliance. Early clinical change was the strongest predictor of treatment outcome and this also facilitated the development of a strong early alliance. Clinicians should be encouraged to deliver all aspects of evidence-based CBT, including behavioural change. The findings suggest that this will have a positive impact on both the early therapeutic alliance and later change in eating pathology.

Pica and Rumination Disorder in DSM-5

The major proposed change for both pica and rumination disorder in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition is their relocation from their current section, titled “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,”1 to the newly proposed section, “Feeding and Eating Disorders.”2 This change emphasizes that these disorders occur across the age range, including adulthood. Also, specifiers for severity and course have been suggested for each of these disorders, in keeping with DSM-5 format. Additional minor, but noteworthy, changes in phrasing that clarify ascertainment of diagnostic criteria are summarized in this paper.

Parental perceptions of childhood feeding problems

Previous research suggests that parental report of children’s feeding corresponds with their child’s nutritional intake (Cooke et al., 2006; Ekstein et al., 2010). The current study aimed to determine whether there is a relationship between parental report of children’s feeding problems and their child’s nutritional intake in a non-clinical population and, in addition, to establish whether parental anxiety (Cooke et al., 2003) can predict whether parental report of feeding problems correspond with the child’s intake. Sixty-one parents of children aged two to seven years completed the parent report measure; the Behavioural Paediatric Feeding Assessment Scale as well as a food diary detailing their child’s intake, which was analysed using CompEAT nutritional software. They also completed the anxiety subscale of the Hospital Anxiety and Depression Scale. Previous findings of an association between parent report of feeding problems and child’s intake (Cooke et al., 2006) were not replicated. However, an association was found between parents’ anxiety and their reports of feeding problems. Parental anxiety was also found to independently predict whether parent report of feeding problems matched the child’s intake. Findings highlight the importance of a multifactorial approach to understanding childhood feeding difficulties. This requires replication with a clinical sample.

Advances in eating disorders

I recently received an email from a young professional who had been treated in our hospital for an eating disorder nearly 20 years ago. Around the same time as she was under our care, founding editor of Advances in Eating Disorders, Bryan Lask and I, together with Bryan’s friend and colleague Isky Gordon and some other colleagues, published a paper entitled ‘Childhood onset anorexia nervosa in children – towards identifying a biological substrate’ (Gordon, Lask, Bryant-Waugh, Christie, & Tamimi, 1997). In 1997, our in-patient unit was busy and we were working with families experiencing extremely challenging times as they and their children struggled with anorexia nervosa. We recognised that our attempts to assist in this process, although well-intentioned and as far as possible guided by what we knew from reading and experience worked best, were hampered by woefully inadequate understanding of the aetiology of this destructive condition. By then, a good 10 years into running a specialist eating disorders service for children and young adolescents, we had built up a modest but respectable publication record. Our papers had discussed recognising eating disorders in the younger population; we had outlined tools to assess and describe psychopathology in an age-appropriate manner; we had explored correlates and conducted follow-up and outcome studies; we had commented on the seriousness of anorexia nervosa in this age group and we had advised about monitoring of progress. We had not, however, published anything of substance relating to the central issue of aetiology; targeting treatment to known causes remained elusive. Our 1997 article was based on a small study involving 15 young people between the ages of 8 and 16 years treated on our unit for anorexia nervosa. All consented, with parental agreement, to undergo regional cerebral blood flow radioisotope scans, and three of them agreed to a follow-up scan when their weight had returned to normal. The findings of the study revealed that 87% (13 of the 15) were identified as having unilateral temporal lobe hypoperfusion, which was also seen in the 3 girls who had a follow-up scan after weight restoration. We commented that the study was the first to report on reduced regional cerebral blood flow in childhood-onset anorexia nervosa, and suggested that this may point to an underlying primary functional abnormality (Gordon et al., 1997). We cautiously stated that ‘The etiology of anorexia nervosa is not fully understood, but is probably multifactorial, including a biological substrate’. Meanwhile, we were treating our patients with a combination of experienced nursing care and milieu type therapy on the in-patient unit, with concurrent family therapy and individual work. The young professional who recently contacted me wrote that she had wanted to contact Bryan Lask for some time to let him know how much she appreciated, and continues to appreciate, the support he gave 20 years ago at the most difficult times. She recalled family therapy sessions with Bryan and myself and said that she was ‘so entrenched in the struggle at the time’ that thanks were not forthcoming. It is a strange thing – we do not do our work in order to receive expressions of gratitude, indeed, most of us are very familiar with the sheer awfulness of day-to-day existence for people suffering from eating disorders and for their loved ones. Why would anyone say