A study protocol for implementing Canadian Practice Guidelines for Treating Children and Adolescents with Eating Disorders

BACKGROUND

Eating disorders have one of the highest mortality rates among psychiatric illnesses. Timely intervention is crucial for effective treatment, as eating disorders tend to be chronic and difficult to manage if left untreated. Clinical practice guidelines play a vital role in improving healthcare delivery, aiming to minimize variations in care and bridge the gap between research and practice. However, research indicates an active guideline implementation approach is crucial to effective uptake.

METHODS

Mixed methods will be used to inform and evaluate our guideline implementation approach. Semi-structured focus groups will be conducted in each of the eight provinces in Canada. Each focus group will comprise 8-10 key stakeholders, including clinicians, program administrators, and individuals with lived experience or caregivers. Qualitative data will be analyzed using conventional content analysis and the constant comparison technique and the results will be used to inform our implementation strategy. The study will then evaluate the effectiveness of our implementation approach through pre- and post-surveys, comparing changes in awareness, use, and impact of the guidelines in various stakeholder groups.

DISCUSSION

Through a multifaceted implementation strategy, involving the co-creation of educational materials, tailored training, and context-specific strategies, this study intends to enhance guideline uptake and promote adherence to evidence-based practices. Our study will also contribute valuable information on the impact of our implementation strategies.

Development and Implementation of a Pilot Integrative Day Hospital Program for Youth with Severe Obesity and Mental Health Issues

Background: Adolescents with severe obesity and comorbid mental health issues are the most resistant to traditional weight management approaches and have poor treatment outcomes. Our objective was to implement and evaluate a pilot day hospital treatment program for adolescents with severe obesity, or risk for severe obesity, and significant mental health comorbidities. Methods: This was a prospective cohort study of adolescents 12-18 years of age with severe obesity (BMI >99th percentile), or at risk for severe obesity, and comorbid mental health issues. The intervention, focused on healthy lifestyle and mental health support, was implemented within an existing psychiatric day hospital at a pediatric quaternary care hospital. Anthropometric and mental health measures were analyzed pre- and postintervention. Results: Thirty-two adolescents with a mean age of 14.9 years [standard deviation (SD) 1.6] participated in the pilot integrative day hospital program for a mean duration of 5.2 months (SD 2.3). Eleven participants had primary severe obesity and comorbid mental health conditions (obesity subgroup) and 21 participants had primary mental illness and were at risk for obesity (psychiatry subgroup). We did not observe a significant difference between BMI pre- and postprogram among adolescents in both subgroups. In other words, adolescents in both subgroups achieved weight maintenance. Fear in losing control of overeating and/or being seen by others when eating decreased significantly in the obesity subgroup [mean difference (MD) 0.99; 95% confidence interval (CI): 0.27 to 1.71]. There was a significant decrease in participant-reported depression symptom severity, both overall and within program subgroups. Quality-of-life scores of study participants improved significantly within the obesity subgroup (MD -12.31; 95% CI: -21.69 to -2.93), but not within the psychiatry subgroup (MD -6.35; 95% CI: -13.37 to 0.67). Conclusions and Implications: A day hospital model of care may result in weight maintenance, decreased eating concerns, and improved mental health in adolescents with severe obesity or risk for severe obesity, and significant mental health comorbidities.

Incidence and Age- and Sex-Specific Differences in the Clinical Presentation of Children and Adolescents With Avoidant Restrictive Food Intake Disorder

IMPORTANCE

To our knowledge, this is the first pediatric surveillance study of children and adolescents with avoidant restrictive food intake disorder (ARFID).

OBJECTIVES

To examine the incidence and age- and sex-specific differences in the clinical presentation of ARFID in children and adolescents in Canada.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, patients with ARFID were identified through the Canadian Paediatric Surveillance Program by surveying 2700 Canadian pediatricians monthly from January 1, 2016, to December 31, 2017.

MAIN OUTCOMES AND MEASURES

The incidence of ARFID in Canadian children (5-18 years of age) and age- and sex-specific clinical characteristics at presentation.

RESULTS

In total, 207 children and adolescents (mean [SD] age, 13.1 [3.2] years; 127 [61.4%] female) were included in this study. The incidence of ARFID in children 5 to 18 years of age was 2.02 (95% CI, 1.76-2.31) per 100 000 patients. Older children and adolescents were more likely to endorse eating too little (5-9 years of age: 76.7%; 95% CI, 58%-88.6; 10-14 years of age: 90.9%; 95% CI, 84.6%-94.8%; 15-18 years of age: 95.6%; 95% CI, 83.6%-98.9%; P = .02), have a loss of appetite (5-9 years of age: 53.3%; 95% CI, 35.4%-70.4%; 10-14 years of age: 74.2%; 95% CI, 66.0%-81.0%; 15-18 years of age: 80.0%; 95% CI, 65.5%-89.4%; P = .03), be medically compromised (mean body mass index z score: 10-14 vs 5-9 years of age: -1.31; 95% CI, -2.0 to -0.6; 15-18 vs 5-9 years of age: -1.35; 95% CI, -2.2 to -0.5; 15-18 vs 10-14 years of age: -0.04; 95% CI, -0.6 to 0.5; P < .001; mean percentage of treatment goal weight: 10-14 vs 5-9 years of age: -8.6; 95% CI, -14.3 to -2.9; 15-18 vs 5-9 years of age: -9.8; 95% CI, -16.3 to -3.3; 15-18 vs 10-14 years of age: -1.2; 95% CI, -5.8 to 3.4; P < .001; mean heart rate (beats per min): 10-14 vs 5-9 years of age: -10; 95% CI, -21.9 to 1.9; 15-18 vs 5-9 years of age: -19.7; 95% CI, -33.1 to -6.2; 15-18 vs 10-14 years of age: -9.7; 95% CI, -18.7 to -0.7; P = .002), have higher rates of anxiety (5-9 years of age: 26.7%; 95% CI, 13.7-45.4; 10-14 years of age: 52.3%; 95% CI, 43.7%-60.7%; 15-18 years of age: 53.3%; 95% CI, 38.6%-67.5%; P = .03) and depression (5-9 years of age: 0%; 10-14 years of age: 6.8%; 95% CI, 3.6%-12.7%; 15-18 years of age: 26.7%; 95% CI, 15.7%-41.6%; P < .001), and be more likely to be hospitalized (5-9 years of age: 13.3%; 95% CI, 5.0%-31.1%; 10-14 years of age: 41.7%; 95% CI, 33.5%-50.3%; 15-18 years of age: 55.6%; 95% CI, 40.7%-69.5%; P = .001). Younger children were more likely to endorse lack of interest in food (5-9 years of age: 56.7%; 95% CI, 38.4%-73.2%; 10-14 years of age: 75.0%; 95% CI, 66.8%-81.7%; 15-18 years of age: 57.8%; 95% CI, 42.8%-71.4%; P = .03), avoidance of certain foods (5-9 years of age: 90.0%; 95% CI, 72.6%-96.8%; 10-14 years of age: 69.7%; 95% CI, 61.3%-77.0%; 15-18 years of age: 62.2%; 95% CI, 47.2%-75.3%; P = .03), and refusal based on sensory characteristics (5-9 years of age: 66.7%; 95% CI, 47.9%-81.3%; 10-14 years of age: 38.6%; 95% CI, 30.7%-47.3%; 15-18 years of age: 22.2%; 95% CI, 12.3%-36.9%; P < .001). Eating but not enough was more common in girls (75.0%; 95% CI, 64.1%-83.4%) vs boys (68.5%; 95% CI, 59.8%-76.1; P = .04), and boys had a higher rate of refusal based on sensory characteristics (51.2%; 95% CI, 40.2%-62.2%) compared with girls (31.5%; 95% CI, 23.9%-40.2%; P = .007).

CONCLUSIONS AND RELEVANCE

This study suggests that ARFID is a relatively common eating disorder and is associated with important age- and sex- specific clinical characteristics that may help in early recognition and timely treatment of the presenting symptoms.

The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond

OBJECTIVE

The COVID-19 pandemic has had detrimental effects on mental health. Literature on the impact on individuals with eating disorders is slowly emerging. While outpatient eating disorder services in Canada have attempted to transition to virtual care, guidelines related to optimal virtual care in this field are lacking. As such, the objective of our Canadian Consensus Panel was to develop clinical practice guidelines related to the provision of virtual care for children, adolescents, and emerging adults living with an eating disorder, as well as their caregivers, during the COVID-19 pandemic and beyond.

METHODS

Using scoping review methodology (with literature in databases from 2000 to 2020 and grey literature from 2010 to 2020), the Grading of Recommendations, Assessment, Development, and Evaluation system, the Appraisal of Guidelines, Research and Evaluation tool, and a panel of diverse stakeholders from across Canada, we developed high quality treatment guidelines that are focused on virtual interventions for children, adolescents, and emerging adults with eating disorders, and their caregivers.

RESULTS

Strong recommendations were supported specifically in favour of in-person medical evaluation when necessary for children, adolescents, and emerging adults, and that equity-seeking groups and marginalized youth should be provided equal access to treatment. For children and adolescents, weak recommendations were supported for telehealth family-based treatment (FBT) and online guided parental self-help FBT. For emerging adults, internet cognitive-behavioural therapy (CBT)-based guided self-help was strongly recommended. Weak recommendations for emerging adults included CBT-based group internet interventions as treatment adjuncts, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps as treatment adjuncts. For caregivers of children and adolescents, weak recommendations were supported for virtual parent meal support training, and moderated online caregiver forums and support groups. For caregivers of emerging adults, guided parental self-help CBT was strongly recommended, and unguided caregiver psychoeducation self-help was weakly recommended.

CONCLUSIONS

Several gaps for future work were identified including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents, and emerging adults with eating disorders, as well as research on more intensive services, such as virtual day hospitals.

"I am the embodiment of an anorexic patient's worst fear": Severe obesity and binge eating disorder on a restrictive eating disorder ward

Adolescents who have been diagnosed with an eating disorder commonly have comorbid mental health conditions which have a significant impact on illness trajectory and may even limit access to effective treatment. Current models of eating disorder care focus mainly on treatment for patients diagnosed with restrictive eating disorders with fewer options available for those with binge eating disorder. We describe a case of an adolescent living with severe, complex obesity and binge eating disorder, presenting in a mental health crisis, admitted to an in-patient unit primarily for patients being treated for restrictive eating disorders such as anorexia nervosa. This case report describes multiple challenges that arose in admitting such a patient on a ward specializing in the treatment of restrictive eating disorders and highlights the need for equitable and more accessible care for patients living with all types of eating disorders.

Talking About Weight With Families-Helping Health Care Professionals Start the Conversation: A Nonrandomized Controlled Trial

Health care professionals (HCPs) and trainees feel ill-equipped to discuss weight-related issues with children and their families. A whiteboard video for HCPs and trainees outlining strategies to communicate about weight was developed and evaluated. Seventy HCPs, including 15 trainees, participated in the baseline assessment and 39 repeated measures 4 to 6 months later. HCP self-efficacy for initiating conversations with overweight and underweight patients, measured immediately following the video, significantly improved from pre-video values (Z = -5.6, P ≤ .001, and Z= -3.3, P = .001, respectively). Although improvements were not sustained 4 to 6 months later (overweight: P = .143, and underweight: P = .846), no significant decline was observed, suggesting retention of the skill. A majority of HCP respondents would recommend the video to a colleague and feel it will affect their practice. Thus, the present study suggests educational videos may be an effective tool for facilitating healthy weight-related conversations between HCPs and their pediatric patients.

Careful conversations: an educational video to support parents in communicating about weight with their children

BACKGROUND

Parents may struggle to initiate healthy weight-related conversations with their children. Educational videos may be an effective tool for improving parents' knowledge and self-efficacy on this topic. The aim of this pilot study was to develop an educational video to assist parents in weight-related conversations with their child, and to assess changes in parents' self-efficacy on this topic.

METHODS

Video development was based on a scoping review and semi-structured interviews with parents. Respondent demographics and user satisfaction were assessed at pre- and post- video, and 4-6 months later. Self-efficacy scores were compared between parent groups based on weight concerns over time.

RESULTS

Fifty-seven parents participated in the video questionnaires, and 40 repeated measures 4-6 months later. Significant improvements in self-efficacy in "raising the issue of weight" and "answering questions or concerns" were found after watching the video (p ≤ 0.002) compared to baseline, and scores 4-6 months post baseline remained slightly elevated, but non-significant. Parents with concerns about their child being overweight had significantly lower perceived self-efficacy scores compared to parents with no concerns about their child's weight (p = 0.031). The video was found to be positively received and of relevance to parents across a number of different domains.

CONCLUSION(S)

Preliminary findings suggest an educational video about initiating weight-related conversations may be an effective tool for increasing parents' perceived self-efficacy in the short term. Further work is needed to validate findings in a randomized controlled trial, and with diverse parent populations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03664492 . Registered 10 September 2018 - Retrospectively registered.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation

BACKGROUND

Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment.

METHODS

The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN. The secondary aim was to determine if changes in parental self-efficacy and caregiver accommodation contributed to improvements in eating disorder behaviour and weight restoration in the transition age youth with AN. Twenty-six participants (ages 16-22) and 39 caregivers were recruited. Caregivers completed the Parents versus Anorexia Scale and Accommodation and Enabling Scale for Eating Disorders at baseline, end-of-treatment (EOT), and 3 months follow-up.

RESULTS

Unbalanced repeated measures designs for parental self-efficacy and caregiver accommodation towards illness behaviours were conducted using generalized estimation equations. Parental self-efficacy increased from baseline to EOT, although not significantly (p = .398). Parental self-efficacy significantly increased from baseline to 3 months post-treatment (p = .002). Caregiver accommodation towards the illness significantly decreased from baseline to EOT (p = 0.0001), but not from baseline to 3 months post-treatment (p = 1.000). Stepwise ordinary least squares regression estimates of eating disorder behaviour and weight restoration did not show that changes in parental-self efficacy and caregiver accommodation predict eating disorder behaviour or weight restoration at EOT or 3 months post-treatment.

CONCLUSIONS

Our findings demonstrate, albeit preliminary at this stage, that FBT-TAY promotes positive increases in parental self-efficacy and assists caregivers in decreasing their accommodation to illness behaviours for transition age youth with AN. However, changes in the parental factors did not influence changes in eating and weight in the transition age youth.

A qualitative study on the challenges associated with accepting familial support from the perspective of transition-age youth with eating disorders

The aim of this study was to identify types of family support desired by young adults with eating disorders during the transfer of care from paediatric to adult eating disorders programs. Using constant comparative analysis, two salient themes from qualitative interviews with 15 young adults were identified: (a) uncertainty about the role of parents in maintaining recovery during the transfer; and (b) the need for parental support, defined as assistance with eating and maintenance of recovery. Young adults voiced that parental emotional involvement and assistance with navigating adult care services is critical to their successful transfer between the two systems of care.

Cost analysis of inpatient treatment of anorexia nervosa in adolescents: hospital and caregiver perspectives

BACKGROUND

Admission to hospital is the treatment of choice for anorexia nervosa in adolescent patients who are medically unstable; however, stays are often prolonged and frequently disrupt normal adolescent development, family functioning, school and work productivity. We sought to determine the costs of inpatient treatment in this population from a hospital and caregiver perspective, and to identify determinants of such costs.

METHODS

We used micro-costing methods for this cohort study involving all adolescent patients (age 12-18 yr) admitted for treatment of anorexia nervosa at a tertiary care child and adolescent eating disorder program in Toronto, between Sept. 1, 2011, and Mar. 31, 2013. We used hospital administrative data and Canadian census data to calculate hospital and caregiver costs.

RESULTS

We included 73 adolescents in our cohort for cost-analysis. We determined a mean total hospital cost in 2013 Canadian dollars of $51 349 (standard deviation [SD] $26 598) and a mean total societal cost of $54 932 (SD $27 864) per admission, based on a mean length of stay of 37.9 days (SD 19.7 d). We found patient body mass index (BMI) to be the only significant negative predictor of hospital cost (p < 0.001). For every unit increase in BMI, we saw a 15.7% decrease in hospital cost. In addition, we found higher BMI (p < 0.001) and younger age (p < 0.05) to be significant negative predictors of caregiver costs.

INTERPRETATION

The economic burden of inpatient treatment for adolescents with anorexia nervosa on hospitals and caregivers is substantial, especially among younger patients and those with lower BMI. Recognizing the symptoms of eating disorders early may preclude the need for admission to hospital altogether or result in admissions at higher BMIs, thereby potentially reducing these costs.

A qualitative study on the experiences of young adults with eating disorders transferring from pediatric to adult care

The study's objective was to identify systemic facilitators and barriers of transferring young adults (ages 17-21) with eating disorders from pediatric to adult health and mental health services. Qualitative interviews were conducted and three themes emerged: (a) difficulties navigating care during the transfer period; (b) challenges achieving and maintaining recovery due to systemic barriers after the transfer of care;and (c) recommendations for facilitating the transfer between systems of care. From the perspective of young adults with eating disorders our study shows that the transition to adult care services may be improved with increased coordination, communication, and collaborative partnerships between pediatric and adult providers.

Factors associated with successful completion in an adolescent-only day hospital program for eating disorders

The purpose of this study was to examine factors associated with completion of an adolescent-only eating disorder day hospital program. A total of 65 adolescents were included. Completers were compared to non-completers on multiple variables including diagnosis, weight, and medication use. Adolescents who completed the program were more likely to have been prescribed antidepressants and less likely to purge. The two groups did not differ significantly on other variables. Few factors differentiated completers from non-completers of the eating disorder day hospital program. Further research is needed to determine the role medications or purging may play in completing treatment.

The Ontario experience of involuntary treatment of pediatric patients with eating disorders

In this paper, the authors (two clinicians with specialized practices in child and adolescent eating disorders and a lawyer who practices health law in Ontario, Canada) review pertinent aspects of clinical capacity assessment, with elaboration of the specific unique and complex issues which shape that assessment in children and adolescents with eating disorders. The relevant Ontario legislation and institutional framework governing consent and capacity in children and adolescents are reviewed. The literature on involuntary treatment and consent and capacity in patients with eating disorders is reviewed. Specific cases involving child and adolescent patients with eating disorders that have been heard by the Ontario Consent and Capacity Board (OCCB) in the past decade are discussed in order to elucidate the Board's views of consent and capacity in this vulnerable and challenging patient population. Strategies to support clinicians' therapeutic alliances with their patients while both are going through what can be a lengthy and potentially adversarial-seeming legal process are also discussed.