Eating Disorders in Children and Adolescents. An Updated Review on Screening Methods

LEȚI Maria-Mădălina1, POP Anca Lucia 2, 3, GARNER David4, DOBRESCU Iuliana1, 3

1Clinical Hospital of Psychiatry “Prof. Dr. Alexandru Obregia”, Romania

2National Institute of Diabetes, Nutrition and Metabolic Diseases “Prof. Dr. N. Paulescu” Romania

3University of Medicine and Pharmacy “Carol Davila” Bucharest, Romania

4 President, Department of Psychology, River Centre Clinic, United States of America

*Corresponding author:ancapop@hotmail.com

Abstract 

This article aims to review the screening and diagnostic tools for eating disorders (ED). Eating disorders represent a complex pathology defined by an imbalance between hunger and satiety, installed in an emotional, traumatic or conflictive context. Recently, the emphasis regarding ED is focused on the link between genetics, the mental pathology and the somatic and metabolic phenotype and early detection. Early detection and intervention can assure a better recovery and can improve a lot the quality of life of these patients. Methods: we selected ten articles of central importance on the topic in a systematic search on eight databases, articles selected on the type of scales and size of the study. Results: We identified eight questionnaire scales used in large trials in ED disorders in the scanned literature, choose because we consider it the most accurate and the ones that evaluate best the pathology and the elements that are important as specific traits in ED. There are interview-type scales and self-administered scales. Interview scales are characterized by assessments of symptoms and diagnosis, while self-administered assess specific traits and the possibility of further development of eating disorders. The majority of the scales evaluated were described and used in adult populations. From all the scales evaluated and analyzed, only three are described at the child population – it is EAT-26 (> 16 years), EDI-3 (>13 years) and ANSOCQ (> 13 years). Conclusions: It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Early detection of ED in children implies a simple and accurate evaluation at the primary care level or in schools, as the course of disease can be subclinical for several years. Moreover the need for accurate scales and telemedicine testing and diagnose are of high importance during COVID-19 pandemic as youth are at special risk being psychologically affected due to disrupted education and social interactions – at critical time. 

Keywords: eating disorders, anorexia nervosa, bulimia nervosa, personality traits, screening tools, Covid-19

Introduction

The Eating Disorders represent a pathology which is among us since the beginning of the civilisation – in Ancient Greek woman from the high class society fasting themselves in order to be thinner and to be perceived well by the people [1]. Feeding is the most important initial step for connection between mum and child. According to DSM –V – The Diagnostic and Statistical Manual of Mental Disorders, the main eating disorders (EDs) described in the early years of life are pica, rumination, then in adolescence – anorexia nervosa (AN), bulimia nervosa (BN) and the newly introduced Night Eating Syndrome (ENS) [13,32]. Besides the somatic disturbances, the ED pathology spectre includes emotional instability and a nutritional imbalance. Even though with the appropriate therapeutic approach there are long periods of remission, 30-50% of cases relapse. The setting out can be in childhood, between 5 and 12 years; first is noticed by the close environment (family, friends, school, family doctor), but usually neglected or ignore the pathology due to insufficient knowledge about an adequate diet. During the COVID-19 pandemic children are at special risk due to disrupted education and social interactions – at critical time. [34]. The early detection implies a simple and accurate evaluation at the primary care level, in the early stages both in adults and more important, in children often undiagnosed for an average of 4 to 12 years. In this purpose several screening interview scales are available (not freely accessible), a few of them feasible for the paediatric population. 

Several types of scales are currently used – (a) self-report questionnaires –EDI-3, BSQ, TFEQ, MAC, BULIT-R, QEWP-R, EDE-Q, EAT, NEQ – and other; (b) semi-structured interviews – SCID-I, EDE – and other; (c) clinical interviews unstructured or observer based rating scales- Morgan Russel scale [33, ]. Less is known about the better selection of the

most sensitive and accurate scale for children, the implementation level and outcomes in our country and also worldwide. 

Aim of the study: to overview the available screening scales for ED (especially AN and BN) and use in clinical trials and identify research and practice gaps in screening AN and BN, the search was made especially to see which one applies on the paediatric populations. We screen the literature for the available screening tools in ED and studies applying the scales. Data sources: we made an accurate search in the main sources of Databases (PubMed, BMC Public Health, Global Health, Cross Ref, Scopus, Web of Science, Google Scholar and Medline) with the keywords: “screening eating disorders”, “intervention Anorexia Nervosa”, “intervention eating disorders”, “screening Bulimia Nervosa”. Binge-Purge subtype. Forty studies using AN and BN scales with a clinical eating disorder group with or without control group were identified. Of these, 8 were included in the present study (Table 1).

Scales reviewed in the current paper: 

  • EDE –useful for the clinician to observe the pathology and evaluate the main and specific characteristics regarding the present moment of disease. 
  • EDE-Q –semi-structured and administered by a qualified person, takes a long time for administration; a self-administered questionnaire that assesses the severity of symptoms and how somatic features are altered – weight, height, menstruation. For good accuracy, it is preferable to use it together with another questionnaire that better evaluates the specific symptoms [16].
  • EDI – over 13 years; evaluate the specific characteristics of AN and BN; Now is available the third version, with 91 item, 12 subscales that evaluate the specific characteristics; it also evaluate the weight.
  • EAT – 26 item – over 16 years; also evaluate somatic features-weight, height and the specific behaviours that determine eating disorders
  • SWEAA – self-reported questionnaire, administered to children with autism spectrum disorder and normal intellect, which have particularities of eating behaviour [18]
  • CIA 3.0 – self-reported questionnaire; evaluates the specific features of eating disorders and complete the clinical diagnosis [22]
  • SCOFF – the test include 5 simple questions addressed to patients in primary care units by clinicians to facilitate if there is a suspicion of a diagnosis of ED. It has a very high sensitivity. Not enough data to consider the validity and reliability and the possibility of using it to screen ED in general population. But it can still be used in primary medicine care for patients considered at risk for ED After application, the clinician evaluate the existence of ED diagnosis and the necessity of the referral to a specialist for a complex evaluation [7,20].
  • ANSOCQ – over 14 years; reliable and self-report questionnaire – assess the readiness for change and motivation, 20 items, it is used to evaluate the wish of change of the persons already diagnosed with AN. Lickert Scale CUT-OFF 2,5; As the scores on these scales are bigger, the person is more motivated to change (made after the stages of change model – DiClemente and Prochaska 1998 – pre-contemplation, contemplation, preparation, action, maintenance).

Results

Ten articles of central importance on the topic were identified in a systematic search on eight databases, articles selected on the type of scales and size of the study; we identified nine questionnaire scales used in large trials in ED disorders in the scanned literature for the most accurate scales (Table 1).

To observe the personality traits, the clinician may use SCID II Interview – a structured interview used in persons which has already the diagnostic and it helps to observe the specific traits. It also evaluate the personality disorder – used at the persons that already have a

diagnostic of AN, the most common types of personality were avoidant (13%), followed by borderline (9%), obsessive-compulsive (8%) and antisocial (7%)  [32].

It’s good to know that the devastating effects of eating disorders didn’t affect only the persons which have the pathology, but also the family and the people around it. Is well known that the Anorexia Nervosa has the highest rate of mortality from all eating disorders (up to 10% [6]) and it’s one of the most common pathologies in adolescents, over asthma or diabetes. There is a high risk of suicide, severe depression, alcohol abuse, substance dependence or major stress in this kind of persons [12, 15]. The rate of mortality rises if there are comorbidities like major depression or dependence [5].

In many cases, it was reported that there is a pre-existing cerebral dysfunction regard structural or neurochemical fields. Studies in recent years open new perspectives that support the existence of certain pre-existing genetic mutations in eating disorders (modified locus on chromosome 12 rs4622308) [1]. According to Rahkonen & al., in 2016 the eating disorders affected up to 4% of persons around the world; the most frequent being Anorexia Nervosa, followed by binge eating and less expanded is Bulimia Nervosa [3]. Unfortunately, less than 10% of people addresses to a doctor and up to 70% have a psychiatric comorbidity. Salbach-Andrae & al. discovered that 25-29% of Anorexia Nervosa cases associated Obsessive Compulsive Disorder (OCD) and up to 79% will develop an episode during the life [14]. 

It is obvious that in ED there is a genetic vulnerability. History of anxiety disorders, depression, alcoholism or “schizo” spectrum disorders are usually present in this kind of patients [13, 28].

The Global Burden of Disease Study published the results in 2015 states that AN and BN are responsible for 1.9 million people affected globally by burden –chronic and disabling diseases lasting over long periods of time measured by DALY (disability-adjusted life year). Unfortunately, there are not enough studies on large population groups to accurately characterize the profile of these disorders, but the inclusion in the Global Burden of Disease mark an important moment and increases the need for prevention and early detection, requiring the attention of Public Health Services [2]. 

It is important to know that obesity is treated by nutritionist or endocrinologist and it’s not considered a mental disease; It is considered a metabolic disease even though in many cases it has been demonstrated an overlap of specific personality traits and behaviours that aggravates and sustain the disease. In a group of diabetic patients from Romania, most of them obese, it has been proved that anxiety and depression is usually met [6, 7]. Also, we are not talking about the malnourishment or sub nutrition in these paper. These are really important Heath service problem and worldwide and it is due to poverty, but this can determine low school performance or other emotional imbalances. Unfortunately, during the Covid-19 pandemic billions of children didn’t receive anymore the food from theirs schools.

The psychological impact of the recent COVID-19 quarantine on ED patients are PTSD symptoms, confusion, boredom, anger, anxiety, increased risk of relapses. The period may amplify compulsive eating and favoured diets due to the fear of infection, sedentary lifestyle, social isolation, strict hygiene [33].

Regarding somatic impact of ED, AN is the most affected and presents a wide range of changes on various organs and systems; the most important are functional amenorrhea, dysfunction of hypothalamic-pituitary-ovarian axis, impaired fertility [27]. 

From studying the literature, in the present study we identified several types of issues linked to the ED: lack of public health programs, late diagnose, lack of information for teachers and parents in child ED aspects and risk factors, low access or addressability of the patients to the specialised clinicians (psychologists, psychiatrists), low access to screening for the behalf of primary healthcare professionals (GP’s, school doctors, nutritionists, school nurses, dentists, paediatricians), low capacity of management the ED disorders in quarantine situations.

The issues linked with ED questionnaires in ED and ED literature regarding early diagnose and screening scales studies: translation, validity, accuracy, reproducibility were taken into account in the analysed studies and met all the conditions for statistical validation.

The evaluation method is an important element – some questionnaires are self-administered, others are by clinical interview. We believe that a trained person is needed to apply these questionnaires and to explain leisurely what each item represents and how it should be best interpreted. 

Conclusions

There is more than ever important to know that by intervention in the field of teenagers, especially in their school and families, we have a chance to prevent the development of eating disorders and to stop unrealistic perceptions of the body image. Among the risk factors to develop eating disorders are the bullying phenomena due to body weight, the lack of physical activity in schools, inadequate meals, restrictive diets, social/online/family unrealistic beauty standards which are accessible from the period of childhood. An important number of preventing programs for ED risk factors have developed among the world [17].

A large topic about prevention and intervention will be the topic of our future research. In these study we only evaluate the screening and diagnostic. The auto-administered scales give liberty to the person to express how their feel, but has the disadvantages that can be misunderstood. It often happens that people with eating disorders, especially those with anorexia nervosa, avoid giving true answers about symptoms, hide many behaviours and consider their behaviour to be normal [30].

The majority of the scales used were described and used in adults populations. From all the scales evaluated and analysed, only three are described at the child population – it is EAT-26 (children above 16 years), EDI-3 (children above 13 years) and ANSOCQ (children above 13 years). One of the scales that we presented in this paper is used after the diagnostic is made (ANSOCQ) and help the clinician to evaluate the stage and to understand how much work he has to do and what levels need to be improved. 

The present study evaluates the actual scales used in screening and follow-up of the nutritional psychiatric pathologies.  The next step is the application of selected questionnaires or combination of during a future coordinated clinical trial in order to objectively evaluate the best form in screening the ED in youth. It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Moreover the urgent need for accurate scales and telemedicine testing and diagnose tools are of high importance during COVID-19 pandemic as youth are at special risk – at critical time.

Declaration of interests: the authors declare no conflict of interests. Funding: No funding to declare.

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