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.

Dissemination and Implementation of Manualized Family-Based Treatment: A Systematic Review

The objective of this article was to systematically review the literature pertaining to the dissemination and implementation of manualized family-based treatment (FBT). Several studies were found looking at the dissemination of FBT to sites beyond those of the primary research, mainly focusing on patient outcomes. Alternatively, articles were found which focused primarily on implementation outcomes, such as the barriers and facilitating factors for FBT uptake, a knowledge transfer model that could be applied to improve uptake, and team decision-making processes. It remains important to study the implementation of FBT in clinical practice due to the barriers identified in the literature.

Do supplementary items on the eating disorder examination improve the assessment of adolescents with anorexia nervosa?

OBJECTIVE

Given that adolescents with anorexia nervosa (AN) typically have lower scores on the Eating Disorder Examination (EDE) than expected, the current study examined whether the inclusion of eight supplementary items developed by the authors of the EDE better captured the symptoms of adolescents with AN.

METHOD

A dataset consisting of EDEs from 86 adolescents was examined by 3 primary methods: (1) baseline subscale scores were compared before and after the addition of the supplementary items, (2) the internal consistency of the EDE with the addition of these items was examined, and (3) each of these items was compared before and after treatment.

RESULTS

After the addition of the supplementary items, the Eating Concern and Weight Concern subscales were significantly increased, whereas the Restraint subscale was significantly decreased, and the Shape Concern subscale was unchanged. Internal consistency was improved on the Eating Concern, Weight Concern, and Shape Concern subscales, and was decreased on the Restraint subscale. Three of eight items showed a significant decrease with treatment.

CONCLUSION

Although the addition of some of these eight supplementary items better captured the psychopathology of adolescents with AN, scores were still substantially below expected, indicating that the exploration of other methods of assessment is needed.

Denial and minimization in adolescents with anorexia nervosa

OBJECTIVES

This study examines symptoms of denial in 86 adolescents with anorexia nervosa (AN) using a dataset from a family therapy trial.

METHOD

Using the Restraint subscale of the Eating Disorders Examination (EDE) at baseline, participants were divided into deniers (n = 15), minimizers (n = 21), and admitters (n = 50). These subgroups were compared with analysis of variance (ANOVA; Tukey post-hoc analysis) on a variety of assessment and treatment variables at baseline and at 12 months.

RESULTS

Although body mass index (BMI) was not significantly different, all subscale scores of the EDE were lower in the deniers compared with the admitters (p = .0001 for all subscales) at baseline. Minimizers also scored lower than admitters on 3 of 4 subscales (p = .0001 for the Restraint, Weight Concern, and Shape Concern subscales of the EDE). At baseline and at 12 months, there were no significant differences on the Youth Self-Report or the Child Behavior Checklist. At 12 months, the only significant difference was in the Restraint subscale, with deniers still scoring lower than admitters (p = .015).

CONCLUSION

Denial and minimization appear to be common processes occurring in adolescents with AN and present difficulties in assessment.

Parental perception of sleep problems in children of normal intelligence with pervasive developmental disorders: prevalence, severity, and pattern

OBJECTIVE

This study compares parents' perceptions of the prevalence, severity, and pattern of sleep problems in children of normal intelligence with pervasive developmental disorders (PDDs) with a normative comparison group of children.

METHOD

A survey including the Children's Sleep Habits Questionnaire was mailed to a sample of parents of children (age range 5-12 years) with PDDs (diagnosed by the Autism Diagnostic Interview-Revised) obtained by chart review of the past 7 years and to parents of comparison children matched on age, gender, and postal code.

RESULTS

The response rate in the PDD group was 82.2% (37/45) and 55.8% (43/77) in the comparison group. By individually matching, 23 pairs were obtained. The prevalence of sleep problems in the PDD group was reported by parents as being significantly higher than in the comparison group (78% and 26%, respectively; p < .002), as was the severity (mean score 48.2 and 39.0, respectively; p < .001). Values for four of eight sleep subscales including sleep onset delay, sleep duration, sleep anxiety, and parasomnias were significantly higher in the PDD group.

CONCLUSIONS

Parents report that sleep problems are significantly more prevalent and severe in children of normal intelligence with PDDs compared with normally developing children, and the pattern appears diverse. Sleep problems in children with PDDs require further research and clinical attention.

Efficacy of rapid-rate repetitive transcranial magnetic stimulation in the treatment of depression: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature pertaining to rapid-rate repetitive transcranial magnetic stimulation (rTMS) compared with sham therapy for the treatment of a major depressive episode in order to arrive at qualitative and quantitative conclusions about the efficacy of rapid-rate rTMS.

METHODS

MEDLINE, the Cochrane Library, the metaRegister of Controlled Trials and abstracts from scientific meetings were searched for the years 1966 until July 2003. The search terms "transcranial magnetic stimulation" and "transcranial magnetic stimulation AND depression" were used. Eighty-seven randomized controlled trials investigating the efficacy of rTMS were referenced on MEDLINE. Nineteen of these involved treatment of a major depressive episode, and these were reviewed. Six met more specific inclusion criteria including the use of rapid-rate stimulation, application to the left dorsolateral prefrontal cortex, evaluation with the 21-item Hamilton Rating Scale for Depression (HAM-D) and use of an intent-to-treat analysis. Scores on the 21-item HAM-D after treatment and standard deviations were extracted from each article for treatment and control subjects. A random-effects model was chosen for the meta-analysis, and the weighted mean difference was used as a summary measure.

RESULTS

Six studies that met the inclusion criteria were identified and included in the meta-analysis. Two of these reported a significantly greater improvement in mood symptoms in the treatment versus the sham group. When combined in the meta-analysis, the overall weighted mean difference was -1.1 (95% confidence interval -4.5 to 2.3), and the results of a test for heterogeneity were not significant (chi2(5) = 5.81, p = 0.33).

CONCLUSIONS

This meta-analysis suggests that rapid-rate rTMS is no different from sham treatment in major depression; however, the power within these studies to detect a difference was generally low. Randomized controlled trials with sufficient power to detect a clinically meaningful difference are required.

A retrospective assessment of citalopram in children and adolescents with pervasive developmental disorders

Although selective serotonin reuptake inhibitors have been used to treat symptoms of aggression and anxiety in children and adolescents with pervasive developmental disorders (PDDs), there are no published reports of the use of citalopram in this population. The purpose of this study was to examine the benefits and adverse effects of citalopram in a group of children and adolescents with PDDs. Target behaviors included aggression, anxiety, stereotypies, and preoccupations. Seventeen patients with PDDs (14 with autistic disorder, three with Asperger's disorder) (mean age = 9.4 +/- 2.9 years; range 4-15 years) were treated with citalopram for at least 2 months (mean duration of treatment = 7.4 +/- 5.3 months; range 1-15 months). Treatment was initiated at a low dose (5 mg daily) and was increased by 5 mg weekly as tolerated and as necessary. The mean final dose was 19.7 +/- 7.8 mg (range 5-40 mg). Outcome was based on a consensus between clinician and parents, using the Improvement item of the Clinical Global Impressions Scale as a guide. Ten (59%) children were judged to be much improved or very much improved regarding target behaviors. Core symptoms of PDDs (social interactions, communication) did not show clinically significant improvement. Citalopram was generally well tolerated, although four patients developed treatment-limiting adverse effects: two with increased agitation, one with insomnia, and one with possible tics. The results of this case series suggest that citalopram has beneficial effects on some interfering behaviors associated with PDDs with few adverse effects. Controlled trials are warranted.