Eating Disorder Service Research Articles

Olanzapine for young PEople with aNorexia nervosa (OPEN): results of a feasibility study

BackgroundDespite the availability of evidence-based treatments for anorexia nervosa (AN), remission rates are moderate, and mortality is high. Olanzapine is used as adjunct therapy for AN in case of insufficient response to first-line treatments, even though the evidence is limited. Its effect on eating disorder (ED) psychopathology, its efficacy and tolerability, and its acceptability and adherence rate are unclear.MethodsWe assessed the feasibility of a future definitive trial on olanzapine in young people with AN in an open-label, one-armed feasibility study that aimed to include 55 patients with AN or atypical AN aged 12–24 who gained < 2 kg within at least one month of treatment as usual (TAU) during outpatient, inpatient, or day-care treatment. Time points for assessments were at baseline, 8 weeks, 16 weeks, and 6 or 12 months. We estimated the following planning parameters: Recruitment rate (number of patients who agreed to take olanzapine/number eligible), adherence rate (number adhering to treatment/number recruited) and attrition rate (number completing study assessments/number recruited). In addition, two exploratory effect size parameters were estimated: Mean change in body mass index (BMI) and mean change in ED psychopathology.ResultsFifty-two people were pre-screened (June 2022 to May 2023; 10 study sites in England). 13 were ineligible at pre-screening . Of the 39 approached, 4 were found ineligible at screening. Of the remaining 35 eligible, 10 declined and 5 did not take part for other reasons. Thus, 20 participants were recruited and started olanzapine (recruitment rate: 20/35 = 57%). 15 out of 20 (75%) continued olanzapine for ≥ 16 weeks, and 13 participants (65%) remained in the trial until follow-up (either 6 or 12 months). Participants experienced, on average, a decrease over time in their Eating Disorder Examination Questionnaire (EDE-Q) Global scores (0.07 per week, N = 20) and an increase in BMI (0.08 kg/m2 per week, N = 20) during treatment with olanzapine plus TAU.ConclusionsPossible reasons for the recruitment difficulties and low adherence rate include the high clinical workload of ED services during the COVID-19 pandemic and the reluctance of patients to agree to take olanzapine under the relatively restricted conditions of a clinical study.Trial registrationInternational standard randomised controlled trial register number: ISRCTN80075010. Registration date: 27/04/2022.

Eating disorder service transitions: integrated models, knowledge gaps and opportunities, Ragnhildstveit et al.

Eating disorder service transitions: integrated models, knowledge gaps and opportunities, Ragnhildstveit et al.

Mapping eating disorders in adolescents and young adults: an investigation of geographic distribution and access to care in Ontario, Canada

BackgroundThere is limited research on the spatial distribution of eating disorders and the proximity to available eating disorder services. Therefore, this study investigates the distribution of eating disorders among adolescents and young adults in Ontario, Canada, with a specific focus on geographic disparities and access to publicly-funded specialized eating disorder services.MethodsA community sample of 1,377 adolescents and young adults ages 16–30 across Ontario between November and December 2021 participated in this study and completed the Eating Disorder Examination Questionnaire. Utilizing Geographic Information System (GIS) technology, we mapped the geographic prevalence of eating disorders and examined proximity to specialized eating disorder services. Multiple linear and logistic regression analyses were utilized to determine the association between geographic region and eating disorder symptomatology. Additionally, t-tests were utilized to examine differences between time/distance to specialized services and clinical risk for eating disorders.ResultsApplying geospatial analysis techniques, we detected significant spatial clusters denoting higher eating disorder scores in rural areas and areas with fewer specialized services. Likewise, our findings report disparities between rural and urban areas, suggesting that rural regions exhibit elevated rates of eating disorders. There were no associations between distance/time to services and eating disorder symptomology.ConclusionsThe discrepancies in eating disorder symptomology between urban/rural may stem from stigma and unique socio-cultural contexts in rural communities. The study underscores the need for targeted intervention, including telehealth, in addressing the eating disorder challenges faced by adolescents and young adults in rural regions.

Investigating the utility of the AQ-10 in children and adolescents assessed in an outpatient ARFID clinic.

The high co-occurrence of autism and eating disorders is well established, including for those with Avoidant Restrictive Food Intake Disorder (ARFID). It is therefore important to consider autism and identify possible autism when people present to eating disorder services to ascertain whether further assessment is indicated, to support clinical formulation and to make appropriate adaptations during interventions. This paper explores the utility of a validated autism screening measure, the AQ-10, in a population of children and adolescents who presented to an outpatient eating disorders clinic for an assessment of possible ARFID. Over 19 months, 335 young people were assessed and 246 families with children aged between 4 and 17 years completed one of three versions of the AQ-10 (Child, Adolescent, and Adult), as part of a battery of routinely administered pre-assessment questionnaires. Results indicated that 80.2% (n = 69) of those with an existing autism diagnosis scored above clinical threshold of ≥6 (M = 7.2, SD = 1.9), 43.9% (n = 43) of those queried to be autistic scored above clinical threshold (M = 5.2, SD = 2.5), and 6.5% (n = 4) of non-autistic individuals scored above clinical threshold (M = 2.8, SD = 1.8). Additionally, the AQ-10 satisfactorily discriminated between those with a known autism diagnosis and those who are not autistic across all age groups and sex. We conclude that the AQ-10, alongside a comprehensive clinical assessment and clinical judgment, is a useful screening tool that can support clinicians to identify appropriate onward referrals for autism assessments, aid clinical formulation, and consider appropriate adaptations and reasonable adjustments during ARFID interventions.

Building research and evaluation within an Australian community eating disorder organisation through academic partnership: A pragmatic protocol

Eating disorders are complex mental health conditions with rising prevalence. Despite this, research and evaluation (R&amp;E) remain under-funded, hindering translation, policy, prevention and advances in care; an equitable and responsive ecosystem of research and knowledge-sharing across the sector is needed to enhance outcomes for people and systems affected by eating disorders. Community members engage with community eating disorder organisations/services to receive guidance and support, often through innovative co-designed programs and resources. Building R&amp;E capacity and capability within community settings is essential in capturing, leveraging and translating local knowledges, such as evaluation outcomes to research, policy, practice settings and the broader community to improve understandings, actions and outcomes. Partnerships between community service providers and academic researchers could be a way of establishing reciprocal knowledge- sharing pathways while simultaneously building internal R&amp;E capacity/capability. The current article presents a longitudinal participatory protocol to plan for, co-design and implement R&amp;E practices within an Australian community-based eating disorder service via an academic partnership. We present a four-stage methodological outline aiming to (a) identify the needs, experiences and feasibility of engaging in R&amp;E in a community eating disorder context; and (b) collaboratively plan for, develop and integrate R&amp;E practices through partnership. We will collect data through focus groups, meetings, interviews, researcher notes and questionnaires across several months. This pragmatic plan can guide future collaborative R&amp;E building efforts within a community mental health context in ways that inform the development and scalability of sustainable, effective and efficient R&amp;E praxis and partnerships across the eating disorder and broader mental health sector.

Suicide in individuals with eating disorders who had sought mental health treatment in England: a national retrospective cohort study

Although studies have suggested a high risk of suicide in people with eating disorders, most studies have focused on suicidal ideation and attempts. There is little research on the characteristics of people with eating disorders who died by suicide, nor investigation of trends over time. We aimed to compare the characteristics of patients with eating disorders who died by suicide versus patients with other mental health diagnoses who died by suicide in England and to examine the trends in rates. In this national retrospective cohort study, data on all people (aged ≥10 years) who died by suicide in England, UK, between Jan 1, 1997, and Dec 31, 2021, while under the care (within the previous 12 months) of mental health services were obtained from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), in which clinical information is collected via a questionnaire completed by the mental health professional responsible for the patient's care. Incidence of suicide in, and demographic, clinical, and treatment characteristics of, patients with a diagnosis of eating disorder (as recorded by the treating clinician) who died by suicide were compared with patients with other mental health diagnoses who died by suicide within the same timeframe using univariable logistic regression analysis. People with related lived experience were involved in the study design, implementation, interpretation, and writing of the manuscript. Of 119 446 people for whom NCISH were notified of dying by suicide in England, 30 795 were under the recent care of mental health services, of whom 30 246 had known diagnoses and were included in analyses. Of these individuals, 10 373 (34%) were female and 19 873 (66%) were male; 2236 (8%) were of minority ethnicity; 382 (1%) had a diagnosis of eating disorder and 29 864 (99%) had another mental health diagnosis. Compared with patients with other mental health diagnoses who died by suicide, patients with eating disorders were younger (median age 33 years [range 15-90] vs 45 years [10-100]), more often female (343 [90%] female and 39 [10%] male in the eating disorders group; 10 030 [34%] female and 19 834 [66%] male in the other diagnoses group), and less likely to have evidence of conventional risk factors for suicide such as living alone (odds ratio [OR] 0·68, 95% CI 0·55-0·84). 22 (6%) of 382 were from a minority ethnic group. Patients with an eating disorder were characterised by a greater clinical complexity (eg, self-harm [OR 2·31, 95% CI 1·78-3·00], comorbidity [9·79, 6·81-14·1], and longer duration of illness [1·95, 1·56-2·43]), and were more likely to have died following overdoses (2·00, 1·62-2·45) than patients with other diagnoses. Childhood abuse (52 [37%] of 140) and domestic violence (18 [20%] of 91) were common in patients with eating disorders. Similar to patients with other diagnoses, most (244 [75%] of 326) of those with eating disorders who died by suicide were rated as low risk by clinicians at last contact. The number of suicide deaths in patients with eating disorders rose between 1997 and 2021 (incidence rate ratio [IRR] 1·03, 95% CI 1·02-1·05; p<0·0001), but rates fell when accounting for the greater number of patients entering mental health services (IRR 0·97, 0·95-1·00; p=0·033). This study was focused on people who sought help from mental health services. It did not consider subtypes of eating disorders or include a control group, but it does highlight possible areas for intervention. The comprehensive provision of evidence-based treatment for eating disorders and underlying conditions to address the clinical complexity in these patients might help to reduce suicide. Recognising limitations in clinical risk assessment, addressing early life experiences and current adversities, and appropriate prescribing might also be of benefit. Suicide prevention must remain a priority for eating disorder services and mental health care more widely. The Healthcare Quality Improvement Partnership.

The clinical characteristics of autistic women with restrictive eating disorders.

Autistic women are at high risk of developing restrictive eating disorders (REDs), such as anorexia nervosa. This study provides an overview of the clinical characteristics of autistic women with REDs to (i) enhance understanding of increased risk, and (ii) support the identification of autistic women in eating disorder services. We compared self-reported autistic and disordered eating characteristics of: autistic participants with REDs (Autism + REDs; n = 57); autistic participants without REDs (Autism; n = 69); and women with REDs who are not autistic (REDs; n = 80). We also included a group of women with high autistic traits (HATs) and REDs, but no formal autism diagnosis (HATs + REDs; n = 38). Autism + REDs participants scored similarly to Autism participants in terms of autistic characteristics and to REDs participants in terms of experiencing traditional disordered eating symptoms. Autism + REDs participants were distinguished from both groups by having more restricted and repetitive behaviours and autism-specific eating behaviours related to sensory processing, flexibility and social differences. HATs + REDs participants showed a similar pattern of scores to Autism + REDs participants, and both also presented with high levels of co-occurring mental health difficulties, particularly social anxiety. The presentation of autistic women with REDs is complex, including both traditional disordered eating symptoms and autism-related needs, as well as high levels of co-occurring mental health difficulties. In eating disorder services, the REDs presentation of autistic women and those with HATs should be formulated with reference to autism-specific eating behaviours and co-occurring difficulties. Treatment adaptations should be offered to accommodate autistic characteristics and related needs.

Clinician perspectives on how change occurs in multi-family therapy for adolescent anorexia nervosa: a qualitative study

BackgroundMulti-family Therapy (MFT) is being increasingly used in specialist eating disorder services internationally. Despite evidence of its efficacy, little is understood about the treatment mechanisms and what specifically promotes change. This study aimed to understand clinician perspectives on how change occurs during MFT.MethodsClinicians with (a) 5 or more years’ experience facilitating MFT and (b) who had facilitated a minimum of two MFT groups were eligible for this study. Two individual interviews and four semi-structured focus groups were conducted online. Recordings were transcribed verbatim and analysed using reflexive thematic analysis.ResultsTwelve clinicians (five systemic/family psychotherapists, five clinical psychologists, and two consultant child and adolescent psychiatrists) from six different specialist services in the UK participated. Four main inter-connected themes describing how change is perceived to occur were generated; (1) Intensity and immediacy, (2) Flexibility, (3) New ideas and channels of learning and (4) Containment.ConclusionsCurrent data matches closely with young person and parent experiences of MFT and intensive day treatment and how they perceive change to occur. Quantitative data are now needed to evaluate the impact of these factors on outcome.Plain English SummaryMulti-family Therapy (MFT) is being increasingly used in specialist eating disorder services internationally. While there is evidence that it is helpful, little is understood about how the treatment works and what specifically promotes change. This study aimed to understand how clinician believe change to occur during MFT for young people and their family members. Clinicians with (a) five or more years’ experience facilitating MFT and (b) who had facilitated a minimum of two MFT groups were eligible for this study. Two individual interviews and four semi-structured focus groups were conducted online. Recordings were written out word-for-word and analysed using reflexive thematic analysis, a commonly used method for analysing this type of data. Twelve clinicians (five systemic/family psychotherapists, five clinical psychologists, and two consultant child and adolescent psychiatrists) from six different specialist services in the UK participated. Four related themes describing how change is perceived to occur were generated; (1) Intensity and immediacy, (2) Flexibility, (3) New ideas and channels of learning and (4) Containment. Current data matches closely with young person and parent experiences of MFT and intensive day treatment and how they perceive change to occur. These factors now need to be tested in future research.

"Don't talk to me like Iam an illness": exploring patients' needs using the communication passport in an eating disorder service.

Social challenges are common in patients with eating disorders (ED). The presence of autistic characteristics often exacerbates social difficulties within this group, potentially affecting treatment outcomes. This study investigates the communication preferences, challenges, dislikes, and support needs of patients with ED, both with and without autistic traits, using acommunication passport in anational inpatient ED service. An explorative qualitative analysis of 38 completed communication passports was conducted to investigate patients' communication preferences, sensory needs, struggles and dislikes, and areas of support required, paying particular attention to the distinct needs of patients with high levels of autistic traits. The communication passport provided valuable insights into patients' communication preferences, sensory sensitivities, challenges, and support needed. Patients also used the passports to share information about their strengths, personal identity, and life beyond the hospital. The communication passport fosters adeeper understanding of patients' needs and may support clinicians in care planning and communication strategies tailored to each patient's needs. Regular evaluation and updates are warranted to ensure its usability and accessibility by the wider care team.

A prospective observational study comparing rates of medical instability between adolescents with typical and atypical anorexia nervosa.

Recognition of atypical anorexia nervosa (AAN) has challenged underweight as a defining factor of illness severity in anorexia nervosa (AN). The present study aimed to compare rates of medical instability in adolescents with underweight (AN) and non-underweight (AAN) anorexia nervosa. The study examined assessment data from specialist eating disorder services in the UK between January and December 2022. Participants (n = 205) aged 11-18 years were recruited across eight eating disorder clinics and diagnosed with AN (n = 113) or AAN (n = 92) after clinical assessment. Parameters associated with risk of medical instability were compared between AN and AAN groups, using t tests and regression analysis. Rates of bradycardia and hypotension did not differ significantly between AN and AAN groups (p = 0.239 and p = 0.289). Although white blood cell counts were lower in the AN group, rates of leukopaenia could not be statistically compared as a result of there being too few counts in at least one group. No incidences of hypophosphataemia were found in the sample. A significant regression equation was found for percentage median body mass index, but not rate of weight loss, as a predictor of blood pressure, serum phosphorous and magnesium. Our findings indicate that medical instability occurs across a range of body weights in young people with AN and AAN. Although certain parameters of risk such as blood pressure, serum phosphorous and magnesium may be worsened at lower weight, both AN and AAN are serious mental health conditions that can lead to medical instability.

A Re-Audit of Physical Health Monitoring of Day-Care Patients in the Adult Eating Disorder Service at Surrey and Borders Partnership NHS Foundation Trust

A Re-Audit of Physical Health Monitoring of Day-Care Patients in the Adult Eating Disorder Service at Surrey and Borders Partnership NHS Foundation Trust

Reimagining care: effectiveness of modifying an adolescent eating disorder intensive service.

The COVID-19 pandemic prompted a surge in adolescent eating disorders and rapid changes in the delivery of intensive community treatments. This study investigates the modification from a group-based day programme to an intensive family treatment approach. A retrospective chart review was performed on data from 190 patients who accessed the intensive service for anorexia nervosa in the past 6 years. Outcomes from the traditional model were compared with the new intensive family model, namely length of admission, percentage median body mass index difference and transfers to in-patient services. There was a significant reduction in the length of intensive treatment (from 143.19 to 97.20 days). The number of transfers to specialist eating disorder in-patient services also significantly reduced, and is decreasing year on year. The findings hold particular relevance as intensive services for adolescent eating disorders continue to be established within health services, with no clear unified approach to treatment.

Estimating additional health and social costs in eating disorder care for young people during the COVID-19 pandemic: implications for surveillance and system transformation

BackgroundThe impact of the COVID-19 pandemic on young people with eating disorders (EDs) and their families was profound, with surging rates of hospitalizations and referrals reported internationally. This paper provides an account of the additional health and social costs of ED care for young people living in Canada incurred during the COVID-19 pandemic, drawing attention to the available data to inform these estimates while noting gaps in data capacities to account for a full view of the ED system of care.MethodsThree methodologies were used to capture costs: (1) provincial administrative data holdings available at the Canadian Institute of Health Information (CIHI) were used by Deloitte Access Economics to conduct analyses on costs related to hospitalizations, emergency room visits, outpatient visits with physicians and loss of well-being from being on a waitlist. These were examined across three fiscal years (April 1 to March 31, 2019–2022) to compare costs from one year before to two years after the onset of the pandemic, (2) data collected on support-based community ED organizations and, (3) costs identified by young people, caregivers and health care professionals.ResultsEstimates of additional health care costs and social costs arising from ED care waitlists were estimated to have increased by 21% across the two years after the onset of the pandemic and is likely to represent an underestimate of costs. Costs related to some standard ED care services (e.g. day treatment programs) and support-based community ED organizations that saw a 118% increase in services during this time, are some examples of costs not captured in the current cost estimate.ConclusionsThis paper provides a first account of the additional health and social ED care costs associated with the pandemic, which indicate at minimum, a 21% increase. The results invite discussion for more investments in ED services for young people in Canada, as it is unclear if needs are expected to remain elevated. We suggest a call for a national surveillance strategy to improve data holdings to aid in managing services and informing policy. A robust strategy could open the door for much-needed, data-informed, system transformation efforts that can improve ED care for youth, families and clinicians.

A novel whole-team training programme for adult eating disorder services in England: rationale, development and preliminary evaluation.

In response to recommendations for improving the quality and coordination of care delivered by eating disorder services, a whole-team training programme was commissioned by Health Education England in 2020. This paper describes the development and evaluation of the Eating Disorder Services for Adults (EDSA) whole-team training course, delivered to National Health Service adult eating disorder community teams in England. Course participants (n = 561) in the first two EDSA training cohorts (2021 and 2022) were asked to complete questionnaires at intake and after each session, asking about their views on the training. All course aspects were rated as highly enjoyable, meeting participants' training needs and fostering reflective practice. Thematic analysis identified themes relating to key innovative features of the course and suggestions for improvements. Preliminary evaluation suggests that EDSA is valued by clinicians to enhance their knowledge, skills and ability to improve eating disorder patient care.

The Cultural Formulation Interview as a clinical tool in the assessment of eating disorders: a pilot study.

The Cultural Formulation Interview (CFI) in the DSM-5 is a person-centered instrument for systematically appraising the impact of sociocultural factors in psychiatric assessment. The CFI has been shown to be feasible, acceptable, and useful in various clinical contexts. However, to this date there is only one published report describing the use of the CFI with patients with eating disorders. To explore the potential benefits and challenges of utilizing the CFI in the assessment of eating disorders. As an addendum to an ongoing qualitative study about barriers to treatment for eating disorders for individuals with a migration background in Sweden, we utilized the CFI in the assessment of adult patients (n=8) in specialist eating disorder treatment. Interview data were analyzed employing a thematic analysis framework. Participants provided feedback using a standard form for evaluation of the CFI. Certain CFI questions proved especially meaningful in this context. In response to the CFI question about patient explanatory models, previously unrecognized ideas about causation emerged. These included perfectionism-a known risk factor for eating disorders-based on immigrant parents' career expectations and experiences of strict family control over life choices. In response to the CFI questions on cultural identity and its impact, the participants provided rich descriptions including important themes such as religion, racism, and ambiguities associated with being a second-generation immigrant. The final CFI question, eliciting concern about the patient-clinician relationship, revealed numerous examples of prejudice and unfamiliarity with migrant groups among healthcare providers. The CFI can be useful in the assessment of patients with eating disorders and should be further explored as a standard tool in specialist eating disorder services.

The Zen Garden Virtual Reality App for eating disorders: description and preliminary results

IntroductionVirtual Reality (VR) represents an emerging and promising tool to enhance standard care for patients with eating disorders (EDs). Indeed, VR provides an immersive and interactive experience in a safe and controlled environment that can simulate real-life situations, showing encouraging findings on various components of psychological treatments such as exposure therapy, psychoeducation, and emotional regulation.ObjectivesThis study aims to evaluate the Zen Garden VR App in patients with anorexia nervosa (AN) in order to obtain pilot data regarding changes in mood, relaxation, anger, anxiety, and weight and shape concerns. A secondary aim was to receive feedback from participants about the VR experience, its components, and its possible application for people with AN.MethodsSelf-reported baseline and post-intervention data were collected from a sample of six female inpatients with AN recruited at the Eating Disorders Service at the Bethlem Royal Hospital of the South London and Maudsley NHS Foundation trust (SLaM). The technology used during the VR session consisted of an Oculus head-mounted display headset and two controllers which provided continuous rotational and positional tracking (Figures 1, 2 and 3).ResultsFindings showed a global improvement after the VR Zen Garden App session, mainly in reducing levels of anxiety (Cohen’s d= 1.07) and promoting relaxation (Cohen’s d= 0.95), with possible applications especially before and after meals when food fears are at their highest. In addition, the music that was played during the intervention had a particularly positive effect.Image:Image 2:Image 3:ConclusionsDespite limitations, such us the small sample size and the one time point measurement, positive clinical implications have been highlighted for the Zen Garden VR App in patients with AN, although further studies are needed to confirm these preliminary findings. It is possible that VR could usefully augment and personalize care for people with an EDs. A range of interventions might be used to target the most compromised symptoms such as designing interventions that can help with triggers to eating disorder psychopathology.Disclosure of InterestNone Declared

The financial and social impacts of the COVID-19 pandemic on youth with eating disorders, their families, clinicians and the mental health system: a mixed methods cost analysis

BackgroundThe onset of the COVID-19 pandemic has had an adverse impact on children, youth, and families with eating disorders (EDs). The COVID-19 pandemic exacerbated pre-existing personal and financial costs to youth, caregivers, and health professionals accessing or delivering ED services. The objectives of this mixed methods study were to (1) understand the indirect, direct medical and non-medical costs reported by youth, caregivers, and clinicians; (2) understand how the COVID-19 pandemic may have impacted these costs, and (3) explore implications of these costs with regards to barriers and resources to inform future decisions for the ED system of care.MethodsYouth (aged 16–25 years) with lived/living experience, primary caregivers, clinicians, and decision-makers were recruited with support from various partners across Canada to complete group specific surveys. A total of 117 participants responded to the survey. From those respondents, 21 individuals volunteered to further participate in either a discussion group or individual interview to provide additional insights on costs.ResultsYouth and primary caregivers reported costs relating to private services, transportation and impacts of not attending school or work. Additionally, primary caregivers reported the top direct medical cost being special food or nutritional supplements (82.8%). In discussion groups, youth and caregivers elaborated further on the challenges with long waitlists and cancelled services, impact on siblings and effect on family dynamics. Clinicians and decision-makers reported increased work expectations (64.3%) and fear/isolation due to COVID-19 in the workplace (58.9%). Through discussion groups, clinicians expanded further on the toll these expectations took on their personal life. Approximately 1 in 3 health professionals reported contemplating leaving their position in 1–2 years, with greater than 60% of this group stating this is directly related to working during the pandemic.ConclusionsFindings demonstrate the need for increased support for youth and caregivers when accessing ED services both during crisis and non-crisis times. Additionally, attention must be given to acknowledging the experience of health professionals to support better retention and resource management as they continue to navigate challenges in the health care system.

Eating disorders and COVID-19 - different or just more?

BackgroundCOVID-19 saw an increase in child mental health presentations internationally. Clinicians analogised the exponential increase in anorexia nervosa to a ‘tsunami’ or ‘outbreak’, raising parallel concerns regarding medical and psychological risks (Marsh in The Guardian, 2021; Leask in NZ Herald, 2021; Monteleone et al. in Eat Weight Disord 26(8):2443–2452, 2021) . It is unclear whether Ireland emulated this picture of increased referrals with increased medical compromise.AimsThis paper examines both rates and clinical profiles of child eating disorder presentations in the Republic of Ireland (ROI), across different clinical settings.MethodsFollowing ethical approval, retrospective chart reviews were conducted in a community eating disorder service and in two paediatric hospital settings. The time frame of the different studies ranged from January 2016 to December 2022.ResultsCommunity eating disorder services saw significantly higher referral rates post COVID-19 (3.78/month vs. 2.31/month, p = 0.02), with a shorter duration of illness (4.8 months vs. 7.4 months, p = 0.001), but no significant difference in ideal body weight % (IBW%) at referral (85.32% vs. 83.7%, p = 0.1). Both paediatric hospitals witnessed significantly increased referrals post-COVID-19 (hospital 1; 4.38/month vs. 1.93/month, p = 0.0001; hospital 2; 2.8/month vs. 0.92/month, p < 0.0001), but no significant difference in IBW% at assessment (hospital 1; 82.7% vs. 81.39%, p = 0.673; hospital 2; 81.5% vs. 83%, p = 0.563). There was no significant difference in clinical profile, management, or duration of hospital stay.ConclusionsThis study supports the growing consensus of a pandemic specific increase in eating disorder referrals to both medical and psychiatry services. However, there was little to indicate a change in clinical profile or severity. Ongoing monitoring of referrals is necessary to ensure adequate service availability and expertise.

The Role of the Dietitian within Family Therapy for Anorexia Nervosa (FT-AN): A Reflexive Thematic Analysis of Child and Adolescent Eating Disorder Clinician Perspectives.

Despite dietitians being important members of the multidisciplinary team delivering family therapy for anorexia nervosa (FT-AN), their specific responsibilities and roles are unclear and their involvement in the treatment can be a contentious issue. Clinicians (n = 20) experienced in the delivery of FT-AN who were working at a specialist child and adolescent eating disorder service responded to an online survey about their experience of including a dietitian in FT-AN and how they understand the role. Both categorical and open-ended questions were used. Reflexive thematic analysis was used to analyse the qualitative free-text responses of clinician perspectives on the role of the dietitian in FT-AN. All clinicians agreed that dietetics had a role within FT-AN and most frequently sought dietetic involvement in the early phases of FT-AN. Reflexive thematic analysis of responses identified three main themes. These were (1) collaboration is key, (2) confidence as a core consideration and (3) case-by-case approach. These themes evidenced the role of the dietitian within FT-AN and highlighted both the benefits and concerns of this involvement. This study demonstrated that dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counselling should be offered in joint sessions with the therapist rather than separately. The findings of the study were limited by the small sample size of participants recruited from a single centre and heterogeneity in the professional background of respondents. Although the integration of dietetics within the multidisciplinary team and the ability of dietitians to individualise patient care can enhance FT-AN treatment, potential benefits and disbenefits should be considered for each case.

What role should schools play in the prevention of disordered eating in children and young people?

Whilst clinical eating disorders are relatively uncommon in children and young people, a much larger proportion are thought to experience subclinical difficulties with eating, termed ‘disordered eating’. Given that the issue is so widespread and many young people experiencing disordered eating do not meet the criteria for specialist eating disorder services, schools have a responsibility to work systemically to reduce the prevalence of these difficulties. Educators may be able to use some of the risk factors for disordered eating, including body dissatisfaction, parental pressure to lose weight, peer influence and internalisation of food rules, to inform preventative strategies. These strategies may include, but not be limited to, implementing curriculum changes such as teaching about body image and nutrition education in developmentally appropriate ways, as well as considering whole-school policy changes such as specifying weight-related victimisation in the school’s anti-bullying policy and deliberating the school’s involvement in national child weighing schemes. Taken together, schools have the potential to play a critical role in reducing disordered eating in children and young people. Educational psychologists are well-positioned to raise educators’ awareness of disordered eating and support senior leadership teams implement these preventative strategies in an evidence-informed way as well as considering the role disordered eating might play in their own casework.