Objective Caregivers often experience elevated stress while supporting a loved one with an eating disorder. This study was a secondary analysis exploring changes in caregiver burden (EDSIS), distress tolerance (DTS), and emotion regulation (ERQ) during family-based treatment (FBT) among caregivers high in expressed emotion (EE) participating in an emotion coaching or control intervention.Method Forty-one adolescents with anorexia nervosa (AN) or atypical AN (Mage = 14.88, SD = 1.63) and a caregiver scoring high in EE participated in FBT and were randomized to an emotion coaching or caregiver support group. Structural equation modeling was used to examine changes in the EDSIS, DTS, and ERQ from the start and end of FBT and at three-month follow-up.Results In the full sample, EDSIS decreased from baseline to end of treatment (p = 0.008) and end of treatment to 3-month follow up (p = 0.014). However, caregivers in the emotion coaching group experienced greater reductions in EDSIS (beta = -0.46 vs. -0.14, p = 0.042) and improvements in DTS (beta = 0.25 vs. -0.06, p = 0.042) from baseline to end of treatment than caregivers in the support group. Caregivers did not report significant changes on the ERQ.Discussion This is among the first studies to demonstrate reductions in caregiver burden during FBT, especially among caregivers who participated in an emotion coaching group focused on validation and communication skills. Emotion coaching interventions may support FBT outcomes among caregivers high in EE while reducing caregiver burden and distress.

OBJECTIVE:Telehealth services have become part of many eating disorder (ED) treatment settings; yet, few studies have examined the effectiveness of family-based treatment (FBT) delivered via telehealth. This study compared in-person and telehealth FBT in rates of weight restoration, treatment completion, and metrics of treatment progress, and explored potential moderators of these outcomes. METHOD:Retrospective chart review identified 169 adolescents (10-18 years) with restrictive EDs who received FBT in person before the COVID-19 pandemic (n = 92) or via telehealth during the pandemic (n = 77). Regression models examined the effect of FBT format, controlling for baseline percent of expected body weight (%EBW). Zip code-based geospatial analyses compared the distance each format reached. RESULTS:Treatment format (in-person versus telehealth) did not predict whether patients were weight restored to ≥ 95% of EBW at the end of treatment (OR = 0.74) or completed treatment (ORs = 0.53-1.74). Older age predicted lower odds of treatment completion among in-person but not telehealth patients; there was no moderating effect of age on weight restoration or of baseline %EBW on either outcome. Patients who received FBT via telehealth were less likely to be early responders (i.e., gained 2.3 kg by session four; OR = 0.33). FBT format did not predict the number of sessions to 95% EBW (f 2 = 0.01), hospitalization frequency, or distance reached (d = 0.27). DISCUSSION:Results suggest no significant differences between telehealth and in-person FBT in restoring weight or preventing hospitalization for adolescents with restrictive EDs, and support continued use of telehealth FBT to improve treatment accessibility and scalability. Additional research using a randomized design and ED psychopathology measures is needed.

Compared to cisgender peers, transgender and gender diverse (TGD) youth and adults report elevated eating disorder (ED) symptoms likely related to gender dysphoria and attempts to modify their bodies accordingly. Less is known about the impact on gender-affirming care and ED symptoms. This study aimed to expand on extant research and describe ED symptoms in TGD youth seeking gender-affirming care while exploring potential associations between gender-affirming hormone use and ED symptoms. A total of 251 TGD youth completed the Eating Disorders Examination-Questionnaire (EDE-Q) as part of routine clinical care. ANCOVAs and negative binomial regressions examined differences in ED symptoms among transgender females (identifying as female but assigned male at birth) and transgender males (identifying as male but assigned female at birth). ED severity was not significantly different among transgender females versus transgender males, (p = .09), or associated with gender-affirming hormone use (p = .07). Transgender females receiving gender-affirming hormones reported a greater proportion of objective binge eating episodes compared to those who were not (p = .03). Over a quarter of TGD youth reported engagement in ED behaviors suggesting assessment and intervention related to ED behaviors among TGD youth is imperative since adolescence is a particularly vulnerable period for adolescents and engagement in ED behaviors could lead to full ED development and medical risk.

Weight-centric health practices are based on the principle that excess weight predicts chronic disease, informing a growing sociopolitical movement to address an “obesity epidemic.” This hyper-focus on preventing obesity may contribute to weight stigma (i.e., the devaluation and discrimination of individuals based on body size) and other iatrogenic outcomes for youth, including the development and maintenance of eating disorders (EDs). Current evidence-based treatments for EDs include language and practices that may reinforce fears of fatness, body shame, and unhealthy dietary restriction without guidance on addressing weight stigma. Here, we present case examples from three adolescent patients across ED presentations and body sizes to (1) elucidate the role of weight stigma in ED development, (2) highlight the ubiquity and harms of weight stigma within ED treatments, and (3) outline thoughtful protocol adaptations to avoid further harm and facilitate recovery. We conclude with a call for immediate action to advance research characterizing the harms of weight-centric approaches in existing ED interventions to reduce the risk of iatrogenic effects on youth with EDs and advance weight-inclusive approaches to ED treatment.

Many behavior analysts, like professionals in other health-related fields, are not trained to promote themselves, affect public policy, or disseminate information to individuals outside of their field, including to lawmakers. One of the reasons professionals can be experts in their own professions is because they devote their time to advancing their knowledge in their field; thus, they have limited time to spend becoming proficient in public relations, advocacy, and public policy. However, it is precisely these skills that behavior analysts need to hone and utilize effectively if the profession is to be sustainable. This article gives a brief history of the professionalization of behavior analysis, discusses the pitfalls of sometimes only being recognized as a single-disability industry (i.e. autism), explores the behavior of other professions that serve as models for advocacy, and provides recommendations for advocacy at different levels. The intent is to guide the profession and professionals of applied behavior analysis to a sustainable future based on the experiences of leaders of three U.S. state organizations.

Patients with atypical anorexia nervosa (AAN) or anorexia nervosa (AN) with premorbid history of higher weight (PHW; median BMI ≥ 85th %ile) may report greater eating disorder (ED) pathology, anxiety, and depression, than patients with premorbid history of lower weight (PLW; mBMI <85th %ile). Less is known about caregiver attitudes or treatment outcome related to premorbid weight history. The current study examined associations between premorbid weight history and patient/caregiver factors at presentation, during treatment, and end of treatment among adolescents (N = 138) diagnosed with AN/AAN and their caregivers who received interdisciplinary ED treatment. The sample comprised adolescents with PHW (n = 58, 40.6 %) or PLW (n = 82, 59.4 %). Adolescents with PHW did not differ with regard to patient- or caregiver-reported ED symptoms, comorbid psychopathology, rates of treatment completion, and attainment of estimated body weight compared to PLW (ps > .05). Adolescents with PHW (vs. PLW) were more likely to be diagnosed with AAN (67.9 %, p < .001), identify as cisgender male (p < .001) and to have lost more weight prior to presentation (p < .001). Perceived caregiver burden was lower among adolescents with PHW vs. PLW (p < .001). Further research should expand on this preliminary study exploring associations between premorbid weight history on patient and caregiver factors at treatment presentation and conclusion to enhance the efficacy of evidence-based treatment across the weight-spectrum.

Youth with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) and premorbid overweight/obesity are particularly vulnerable to diagnostic delays, yet research about this patient subset is lacking. This study aimed to compare mental health and demographic characteristics of patients with AN/AAN and premorbid overweight/obesity to patients with premorbid normal weight. Retrospective chart review identified 253 patients (aged 10-22) hospitalized for medical complications of AN/AAN between 2013 and 2020, including 29.6% (n = 75) with and 70.4% (n = 178) without premorbid overweight/obesity. Analyses revealed that patients with AN/AAN and premorbid overweight/obesity were more often cisgender male (24% vs. 8.4%), diagnosed with AAN (62.7% vs. 32%), and had lost a greater percent of body weight (29% vs. 16.4%) than premorbid normal weight counterparts. No significant differences were found for illness duration (10.1 months vs 9.3 months), psychiatric comorbidities (42.7% vs. 32.2%) or psychotropic medication use (25.3% vs. 19.2%), past mental health treatment (44.6% vs. 37.5%), or family history of eating disorders (22.7% vs. 20.8%). Our findings suggest that when relying on historical records, patients hospitalized for medical complications of AN/AAN have similar characteristics across the weight spectrum.

BackgroundNo guidelines currently exist that represent a standardization of care for Avoidant/Restrictive Food Intake Disorder (ARFID) on an inpatient service. Unique features of this diagnosis (e.g., sensory sensitivity contributing to involuntary emesis) suggest that established protocols that were developed for anorexia nervosa might be less effective for adolescents with ARFID. To inform improved inpatient medical stabilization and care for these patients, we first provide an overview of clinical characteristics for patients with ARFID who presented to a pediatric hospital for inpatient eating disorder care. We use these descriptives to outline the rationale for, and executions of, modifications to an inpatient protocol designed to flexibly meet the needs of this clinical population.MethodsChart review with descriptive statistics were conducted for patients who had received an ARFID diagnosis from March 2019 to March 2023 (N = 32, aged 9-23). We then present a case series (n = 3) of adolescents who either transitioned to a novel adjusted protocol from an original standard of care on the inpatient service, or who received only the standard protocol.ResultsThe sample was aged M(SD) = 15.6 (3.3) years, 53% male, and a majority (69%) presented with the ARFID presentation specific to fear of negative consequences. On average, patients had deviated from their growth curve for just over two years and presented with mean 76% of their estimated body weight. Of those requiring nasogastric tube insertion during admission (n = 8, 25%), average duration of tube placement was 15 days. From within this sample, case series data suggest that the adjusted protocol will continue to have a positive impact on care trajectory among adolescents admitted for ARFID including improved weight gain, reduction of emesis, and improved food intake.ConclusionsFindings demonstrate the likely need to tailor established medical inpatient protocols for those with ARFID given different symptom presentation and maintenance factors compared to patients with anorexia nervosa. Further research is warranted to explore the longer-term impact of protocol changes and to inform standardization of care for this high priority clinical population across care sites. No current standard of care exists for pediatric patients with Avoidant/Restrictive Food Intake Disorder (ARFID) who are hospitalized for medical stabilization related to complications secondary to malnutrition. Clinical features of this diagnosis (e.g., sensory sensitivity) suggest that existing treatment protocols developed for patients with other restrictive eating disorders, like anorexia nervosa, may be less effective for patients with ARFID. This study first describes a pediatric sample of patients with ARFID upon admission to an inpatient service. Then, a case series is used to illustrate the potential benefits of using an adjusted protocol that was modified to better suit the needs of children and adolescents with ARFID. Findings support future study of the proposed adjusted protocol and may inform future standardization of improved care for this high priority clinical population.

Caregivers play a pivotal role in the success of family-based treatment (FBT) for anorexia nervosa (AN). Caregiver burden is frequently demonstrated in eating disorders (EDs) and may impact FBT outcomes. This study examined factors associated with caregiver burden before starting FBT and whether pre-treatment caregiver burden was associated with weight gain during FBT. Participants included 114 adolescents with AN or atypical AN (mean age = 15.6 years, SD = 1.4) and a primary caregiver (87.6

There is emerging evidence suggesting atypical anorexia nervosa (AAN), an eating disorder (ED) introduced in the DSM-5, is as serious an ED as anorexia nervosa (AN) in terms of medical risk and ED pathology. Medical hospitalizations among individuals with AAN have significantly increased over the years and individuals with AAN are noted to have longer illness durations and greater weight loss prior to receiving care than individuals with AN. Additionally, AAN is noted to be two to three times more common than AN in community samples of adolescents. Given that AAN is a newer diagnosis, research knowledge and evidence-based treatment guidelines are emerging, yet pivotal. Thus, this article discusses specific considerations during assessment and treatment using Family Based Treatment (FBT) among adolescents diagnosed with AAN and clinical and ethical concerns involved while providing effective care and mitigating any weight bias or stigma related to historical and current weight status.

Intermittent fasting (IF) is an emerging dietary trend that remains understudied. This study aimed to describe the implementation and eating disorder (ED) symptomatology, relevant to engagement in IF among both men and women. Intermittent fasters (N = 44 women, N = 20 men) recruited from Amazon Mechanical Turk, Reddit, and a Midwestern University were administered a demographic questionnaire, an assessment of ED symptomatology (Eating Disorder Examination Questionnaire; EDE-Q), and asked about their IF use. To assess the level of ED symptomatology among individuals using IF community and clinical norms were used for comparison. We hypothesized a) men and women engaging IF would score higher on the EDE-Q and b) more individuals engaging in IF would endorse ED behaviors (e.g., self-induced vomiting) than community norms. Intermittent fasters reported fasting for approximately 16 hours daily and for weight loss purposes. Men and women engaging in IF scored significantly higher than community norms on all subscales of the EDE-Q, with 31.25% of participants' EDE-Q scores being at or above the clinical EDE-Q cut-off. Men and women engaging in IF reported engaging in ED behaviors. Results suggest that IF is associated with ED symptomatology. Further research on psychological characteristics and temporal order of the association between IF and ED symptomatology is warranted.

The COVID-19 pandemic has had sweeping and deleterious effects on the well-being of individuals worldwide. Eating disorders (EDs) are no exception, with incidence and prevalence of EDs rising since COVID-19 onset. The current study examined inpatient census and readmission rates among youth (aged 8-18) hospitalized for medical complications of anorexia nervosa (AN) or atypical anorexia nervosa (AAN) throughout distinct periods of the COVID-19 pandemic, including pre-COVID-19 (n = 136), COVID-19 lockdown (n = 3), and post COVID-19 lockdown (n = 24). Data from the COVID-19 lockdown period was excluded from analyses due to low sample size. Youth hospitalized during post COVID-19 lockdown were over 8-times more likely to be readmitted within 30-days of discharge compared to patients hospitalized before the pandemic (p = .002). Further, the inpatient census of youth with AN/AAN was significantly higher during post COVID-19 lockdown compared to pre-COVID19 (p = .04). One-third of patients hospitalized since the pandemic identified COVID-19 consequences as a primary correlate of their ED. Our findings, although not causal, suggest an association between COVID-19 and AN/AAN development and exacerbation in youth, thus prompting more medical admissions and rapid readmissions among this demographic. This study has important implications for understanding how AN/AAN onset and exacerbation in youth has been affected by the COVID-19 pandemic and can inform new efforts to support individuals navigating treatment during a global crisis.

Yoga practice is associated with improvements in eating disorder (ED) symptoms and body dissatisfaction. This study continued to evaluate this relationship while also assessing changes in variables negatively associated with ED symptoms (self-compassion, mindfulness, body appreciation, self-efficacy) that are emphasized throughout yoga. Men were also included in this study given studies have predominantly focused on women. Participants (N = 99, 77.8% women) were recruited from a university-implemented yoga course and completed assessments at the beginning (Time 1 (T1)) and end (Time 2 (T2)) of an eight-week yoga course meeting three times a week for fifty minutes. Body dissatisfaction (ps <.05) and ED pathology (p = .02) were lower at T2. Body appreciation (p < .001), self-compassion (p = .01), yoga self-efficacy (p = .004) were higher at T2. Some gender differences emerged. Men reported greater reductions in concern with being overweight, (Overweight Preoccupation) from T1 (M = 2.46, SD = 0.61) to T2 (M = 2.13, SD = 0.61) compared to women, T1 (M = 2.75, SD = 0.98) to T2 (M = 2.69, SD = 0.97) associated with yoga practice. Men also reported greater improvements in body satisfaction (Appearance Evaluation) from T1 (M = 3.60, SD = 0.49) to T2 (M = 3.90, SD = 0.34) compared with women, T1 (M = 3.48, SD = 0.58) to T2 (M = 3.39, SD = 0.52) associated with yoga practice. Results suggest yoga may be associated with concurrent changes in protective and risk factors for ED in a college population.

Though debated, it has been argued that self-face recognition is an indicator of consciousness of self typically called self-awareness. Evidence from behavioral and neuronal studies suggests that self-recognition is associated with activation in the right prefrontal cortex (PFC). Although previous studies have examined neurological correlates of deficits in self-recognition (e.g., autism, schizophrenia), the current study attempted to examine neurological correlates of inflated self-focus. Thus, this study used transcranial magnetic stimulation to assess neurological correlates of self-recognition in different regions of the PFC and to assess whether narcissistic personality traits would be correlated with reaction time (RT) among 11 healthy participants. It was found that RT for self-face identification was positively correlated with narcissistic personality traits (p = .034). It was also found that the interaction between brain region and RT for self-faces was significant after narcissism was controlled for, demonstrating an association between narcissistic traits and self-recognition (p = .036). The results support previous research indicating the right PFC is necessary for self-face recognition. Furthermore, increases in narcissistic traits decreased self-recognition RT, and self-recognition appeared to be mediated via right PFC regions.

The Medial Prefrontal Cortex (MPFC) is crucial for normal social functioning in humans. Because of its involvement in social monitoring, self-awareness, and self-enhancement, the MPFC may be critical to buffering negative affect and establishing a positive self-esteem. For example, we have previously found that disruption of the MPFC leads to more honest responses, which implies that the MPFC may be critically involved in self-deception. We therefore hypothesized that disrupting the MPFC would lead to a decrease in affect. Employing a virtual lesion TMS (Transcranial Magnetic Stimulation) technique, we disrupted the MPFC while participants rated their mood based on two anchor affect terms. During TMS, the participants rated their current emotional mental state. Compared to sham TMS, it was found that mood was reduced immediately following single-pulse MPFC stimulation. The results supported the hypothesis the MPFC mood reduction occurs when the MPFC is disrupted. Because this study replicated the conditions employed in previous self-deception studies, we suggest that the results may indicate that lack of self-enhancement may lead to a decrease in mood. Further studies should examine this possibility.

We applied Brinley (1965) plot analysis to the eating disorders field. Across 23 studies and 165 experimental conditions [experienced by a total of 773 eating disorder (ED) participants, including anorexia nervosa (AN), binge eating (BE), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS) and 995 controls], the best-fit regression equation was Y (ED) = 1.08 X (CONTROL) - 31. This equation accounted for 98.2% of the variance. Thus, the ED subjects were only 1.08times slower than the control subjects, suggesting little processing speed slowing in ED. We also examined simple reaction time [SRT; Y (ED) = .91 X (CONTROL) + 63; variance accounted for = 93.6%] and choice reaction time (CRT; Y (ED) = 1.12X (CONTROL) - 43, variance accounted for = 99.7%). These slopes are significantly different. ED subjects are more impacted when the task involves a decision component (CRT) than when it does not (SRT).

Difficulties with emotions are common across mood and anxiety disorders. Dialectical behavior therapy skills training (DBT-ST) reduces emotion dysregulation in borderline personality disorder (BPD). Preliminary evidence suggests that use of DBT skills mediates changes seen in BPD treatments. Therefore, we assessed DBT-ST as a stand-alone, transdiagnostic treatment for emotion dysregulation and DBT skills use as a mediator of outcome. Forty-four anxious and/or depressed, non-BPD adults with high emotion dysregulation were randomized to 16 weeks of either DBT-ST or an activities-based support group (ASG). Participants completed measures of emotion dysregulation, DBT skills use, and psychopathology every 2 months through 2 months posttreatment. Longitudinal analyses indicated that DBT-ST was superior to ASG in decreasing emotion dysregulation (d = 1.86), increasing skills use (d = 1.02), and decreasing anxiety (d = 1.37) but not depression (d = 0.73). Skills use mediated these differential changes. Participants found DBT-ST acceptable. Thirty-two percent of DBT-ST and 59% of ASG participants dropped treatment. Fifty-nine percent of DBT-ST and 50% of ASG participants complied with the research protocol of avoiding ancillary psychotherapy and/or medication changes. In summary, DBT-ST is a promising treatment for emotion dysregulation for depressed and anxious transdiagnostic adults, although more assessment of feasibility is needed.

Studies of posttraumatic stress disorder (PTSD) in adolescence published from 2000 to 2011 indicate that adolescents are at greater risk of experiencing trauma than either adults or children, and that the prevalence of PTSD among adolescents is 3–57%. Age, gender, type of trauma, and repeated trauma are discussed as factors related to the increased rates of adolescent PTSD. PTSD in adolescence is also associated with suicide, substance abuse, poor social support, academic problems, and poor physical health. PTSD may disrupt biological maturational processes and contribute to the long-term emotion and behavior regulation problems that are often evident in adolescents with the disorder. Recommendations are presented for practice and research regarding the promotion of targeted prevention and intervention services to maximize adolescents’ strengths and minimize vulnerabilities. Public policy implications are discussed.