Final Outcomes Report. Sherry Van Blyderveen, Ph.D. Pediatric Eating Disorders Program McMaster Children s Hospital. April 30,

Transcription

1 Understanding Pediatric Eating Disorders and their Treatment: Evaluating an Outpatient Treatment Program for Children and Youth Struggling with Eating Disorders Final Outcomes Report Sherry Van Blyderveen, Ph.D. Pediatric Eating Disorders Program McMaster Children s Hospital April 30,

2 Executive Summary The McMaster Children s Hospital s Pediatric Eating Disorders Program provides services to children and adolescents up to the age of 18 who struggle with eating disorders. Treatment is provided by a multidisciplinary team, including pediatricians, psychologists, social workers, and a nutritionist. The treatment provided is family oriented and based on the work of Lock and Le Grange (2005). The purpose of the present program evaluation project was to describe the patients seen by the program, particularly demographic characteristics and presenting symptoms, including a consideration of comorbidity. The goal of the present project was also to consider treatment outcomes, specifically in relation to symptoms of disordered eating, anxiety, and depression. A pretest-posttest design was used, and information was collected at intake and discharge, as well as yearly while the youth was receiving treatment. Both medical and psychological information was collected. Medical information was collected during medical appointments and psychological information was collected through the use of questionnaires. The patients seen by the Pediatric Eating Disorders Program were similar to those described in other research on a number of dimensions (e.g. age, gender, diagnosis) and tended to experience symptoms of anxiety and depression, in addition to their eating disorder. The results of the present study also demonstrated that youth who receive treatment from the Pediatric Eating Disorders Program tend to improve in regards to their physical health within six to twelve months of receiving treatment. Improvement was also found to occur in relation to the psychological symptoms associated with eating disorders, as well as the symptoms related to comorbid conditions, anxiety and depression in particular. These findings demonstrate that the present treatment program is effective in treating the physical and psychological symptoms of eating disorders during childhood and adolescence, as well as comorbid conditions such as anxiety and depression. These findings contribute to the literature by providing evidence for the family-based outpatient treatment program provided by the Pediatric Eating Disorders Program. It will be important for future research to consider additional outcome variables (e.g. interpersonal relationships, family functioning), improve our understanding of prognosis (e.g. which patients recover or drop-out of treatment), and detail treatment trajectories. Table of Contents Executive Summary 2 Table of Contents 2 Introduction. 2 Methods 5 Results. 6 Conclusions and Recommendations 8 Next Steps 9 Knowledge Exchange Plan.. 9 References 10 Accounting Summary of Expenditures. 12 Introduction The goals of this program evaluation project were to better understand the nature and effects of treatment provided to patients treated by the Pediatric Eating Disorders Program and the associated outcomes. It was hoped that the program evaluation process would inform decisions regarding program development and demonstrate treatment and program effectiveness. It was also hoped that the program evaluation project would contribute to the evidence-base supporting - 2 -

3 the treatment approach offered to young people struggling with eating disorders by our program. The specific objectives originally proposed for this program evaluation project included: 1. Document and track the demographic characteristics and presenting symptoms of the patients served by the program (e.g. age, gender, diagnosis, comorbidity). 2. Determine whether patients experience improvement in symptoms of disordered eating during treatment. 3. Determine whether patients experience improvement in comorbid conditions, such as anxiety and depression, during the course of treatment. The McMaster Children s Hospital s Pediatric Eating Disorders Program, located at McMaster University Medical Centre, provides services to children and adolescents up to the age of 18 who require multi-disciplinary assessment and treatment of an eating disorder (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, and more serious forms of selective eating). Services include medical management, assessment, consultation, family therapy, individual therapy, group therapy, and nutritional counseling. Team members include pediatricians, psychologists, social workers, and a registered dietician. Although the program is primarily an outpatient program some patients who are medically unstable must be admitted to a general pediatric ward in the hospital, where they are followed by the team. The typical treatment plan includes medical monitoring, family and/or individual therapy, and nutritional counseling. Additional components of treatment that are considered include hospitalization, multifamily group therapy workshops, relaxation therapy, group therapy, and psychiatric consultation. The program s treatment model is based on the work of Lock and Le Grange (2005). Parents are supported in the supervision of nutritional intake and therapy is provided in order to address related psychosocial difficulties. This program evaluation project directly evaluates a mental health program, the Pediatric Eating Disorders Program at McMaster Children s Hospital, which services children up to the age of 18 who struggle with eating disorders. The program primarily services children in the central south region, although it accepts referrals from other regions in the province of Ontario. These patients and their families are the primary stakeholders in regards to this program evaluation project. Additional stakeholders include the treatment team, the larger hospital, and individuals who struggle with eating disorders in the larger population. Eating disorders are a major concern in western society as evidence indicates that prevalence rates are increasing (Woodside, 1992) and the age of onset is becoming younger (Eagles, 1995). A recent review of the literature determined that the overall incidence of anorexia nervosa is at least 8 per 100,000 population per year and at least 12 per 100,000 population per year for bulimia nervosa. Furthermore, both figures constitute underestimates of the actual incidence rates due to the number of individuals who do not seek treatment (Hoek & Hoeken, 2003). Anorexia Nervosa and Bulimia Nervosa as listed in the Diagnostic and Statistics Manual 4 th Edition (DSM-IV) (American Psychiatric Association [APA], 1994) are the two types of eating disorders that occur most frequently. According to the DSM-IV (APA, 1994) the criteria to receive a diagnosis of Anorexia Nervosa is having a current body weight less than 85% of the normal weight for age and height, an intense fear of being over weight, disturbed experience of one s own body weight and shape, and amenorrhea (absence of menstrual period) for at least three consecutive months. Medical complications arising from starvation and weight loss associated with Anorexia Nervosa include cardiac muscle wasting, decreased bone density, cerebral atrophy and hypercholesterolemia (Becker, Grinspoon, Klibanski, & Herzog, 1999). First described in 1979 (Russell, 1979), Bulimia Nervosa is characterized in the DSM-IV by recurrent binge eating with compensatory behaviours to prevent weight gain, and self-evaluation - 3 -

4 overly dependent upon body weight and shape. A binge episode is defined by the consumption of a larger amount of food than most people would eat in a similar time frame often accompanied by feeling out of control. Compensatory behaviours can include any, or all of, excessive exercise, self-induced vomiting, excessive laxative use, diuretic or enema use, and fasting. An individual s weight differentiates Bulimia Nervosa from the similar behaviours of Anorexia Nervosa-Binge Purge type, with those diagnosed with Bulimia Nervosa weighing in excess of 85% of the normal weight for their age and height. Physical complications arising in individuals with Bulimia Nervosa include dental enamel erosion, renal failure, hypokalemia and vital sign abnormalities (Pomery & Mitchell, 2002). Demographic Characteristics and Presenting Symptoms Age of Onset. Anorexia Nervosa rarely begins before puberty, typically beginning in mid- to late adolescence (age years) (APA, 1994). Bulimia Nervosa usually begins in late adolescence or early adult life (APA, 1994). Adolescent females aged are at the highest risk and constitute approximately 40% of all identified cases of Anorexia Nervosa, while year old women are at the highest risk for Bulimia Nervosa (Hoek & Hoeken, 2003). Subclinical symptomology tends to occur earlier as a southern Ontario study found 29.3% of girls years old were trying to lose weight and 10.5% had scores beyond clinical threshold for disordered eating (McVey, Tweed, & Blackmore, 2004). Another study found that 61% of grade 7 and 8 girls were dieting to lose weight, with a significant proportion using extreme methods (McVey, Pepler, Davis, Flett, & Abdolell, 2002). Gender. More than 90% of individuals struggling with Anorexia Nervosa and Bulimia Nervosa occur in females (APA, 1994). Studies have reported ratios of between 1:29 (Pasberg & Wang, 1994) and 1:10 (Joergensen, 1992) for the incidence of eating disorders between males and females, however these figures do not refer specifically to children. In one study that looked at outcome differences between males and females, no significant differences were found (Burns & Crisp, 1984). Comorbidity. The most commonly observed psychological problems in patients with eating disorders, or those who have recovered, include depression, anxiety disorders, obsessivecompulsive disorder, and drug and alcohol abuse (Steinhausen, Rauss-Mason, & Seidel, 1991; Theander, 1985). Individuals with Anorexia Nervosa who are severely underweight may manifest depressive symptoms secondary to the physiological semi starvation (APA, 1994). For many individuals with Bulimia Nervosa, mood disturbances begin at the same time or following the development of the eating disorders. Lifetime comorbidity with at least one anxiety disorders was found in 71% of individuals with Anorexia Nervosa and Bulimia Nervosa (Godart et al., 2003). Concurrent diagnoses of depression and anxiety in youth struggling with eating disorders are observed in staggering numbers (Calles, 2007). In a study of 80 adolescents enrolled in a RCT for bulimia nervosa, the majority of the sample (62.5%) presented with a comorbid psychiatric disorder; mood disorder (47.5%), anxiety disorder (3.8%), subthreshold depressive or anxiety disorder (7.5%), or another condition (3.8%) (Fischer & le Grange, 2007). A Canadian psychometric evaluation of 120 adolescents (93% female) with a range of DSM-III-R eating disorders, 45% of participants had a concurrent major depressive disorder diagnoses (Geist, Davis, & Heinman, 1998). Blinder et al. (2006) found that from their sample, 94% of patients with eating disorders had comorbid mood disorders and 56% had comorbid anxiety disorders. Although there is some discrepancy in the rates of comorbid disorders, mood and anxiety disorders are common among youth with eating disorders (Biederman et al., 2007)

5 Treatment Outcomes Treatment. Treatment for eating disorders can take many approaches but none guarantee recovery. Cognitive Behavioral Therapy (CBT) is considered the best psychotherapy approach for eating disorders to date (Fairburn, Kirk, O Connor, & Copper, 1986), yet often results in low rates of completed remission (Mitchel, Stewart, & Wonderlich, 2007). Family therapy has been found to be a superior form of treatment for patients with an age of onset younger than 18 years (Russell, Szmukler, Dare, & Eisler, 1987). Disordered Eating Thoughts and Behaviors. Individuals with Anorexia Nervosa show variations in the course and outcome of their illness (APA, 1994). Within the first 5 years, a significant proportion of those struggling with Anorexia Nervosa develop binge-eating behaviors, thus eventually warranting a change in diagnosis to Bulimia Nervosa. Hospitalization may be required to restore weight and electrolyte imbalances. Of those admitted to hospitals, the mortality rate for Anorexia Nervosa is over 10% resulting most commonly from starvation, suicide, or electrolyte imbalance. Disturbed eating behaviour of individuals with Bulimia Nervosa is found to persist for several years, with a chronic or intermittent course alternating with periods of remission. Over the longer-term follow-up, the symptoms of many individuals appear to diminish. In terms of eating difficulties and concerns about weight, Garfinkel et al. (1977) found that one year after onset of Anorexia Nervosa, 71% of women had moderate or marked food fads, 50% had bulimic episodes, 20% vomited occasionally, and 10% abused laxatives. In a longer 20- year follow-up, half of the women with Anorexia Nervosa continued to be preoccupied with thoughts of food and weight. Researchers have suggested that persistent body dissatisfaction and preoccupation with food and eating are more resistant to change than some of the physical manifestations of these illnesses (Van der Ham, Van Strien, & Van Engeland, 1994). Comorbidity. Considering the treatment outcomes of anxiety and depression among patients being treated for eating disorders is an important undertaking as depression (Berkman, et al., 2007; Fitchter et al., 2006), anxiety (Fitchter et al., 2006), and obsessiveness or compulsions (Berkman, et al., 2007; Fitchter et al., 2006) have each been associated with worse treatment outcomes, and comorbidity has been associated with the long-term persistence of eating disorders (Herpetz-Dahlmann, Muller, Herpetz, Heussen, Hebebrand, & Remschmidt, 2001). Methods Participants. Participants included patients who received a consultation and/or treatment from the Pediatric Eating Disorders program. The program had seen 493 youth since it was created approximately 7 years ago. However, only youth who had completed the necessary questionnaires were included in the data analyses. Thus, although intake information was available for 242 patients, information at one-year follow-up was only available for 35 patients, and at discharge information was only available for 14 patients. Design. Outcomes associated with the program are evaluated using a pretest-posttest design. All youth and their parents are given a package of questionnaires at intake, once yearly during the course of treatment, and upon completion of the program (discharge), for both clinical and program evaluation purposes. Plans are also underway to follow-up with patients one year after their discharge. Medical information is obtained during regularly occurring medical appointments and from the medical records relating to these medical appointments

6 Measures. Patients complete a number of self-report questionnaires, including the Eating Disorders Inventory-3 (EDI), the Multidimensional Anxiety Scale for Children (MASC), and the Children s Depression Inventory (CDI). Parents also complete a series of questionnaires. The EDI is a self-report questionnaire related to the psychological symptoms associated with eating disorders. The measure contains a number of subscales, three of which relate specifically to the psychological symptoms associated with eating disorders. These subscales relate to a drive for thinness, symptoms associated with bulimia, and body dissatisfaction. The MASC is a self-report questionnaire related to symptoms of anxiety. It is comprised of a series of seven scales, three composite scores, a total score, and an index score related to the DSM criteria for anxiety disorders. The total score and index score were considered for the purposes of this program evaluation project. The CDI is a self-report questionnaire related to the symptoms of depression. The measure is comprised of five subscales. These subscales relate to negative mood, interpersonal problems, feeling ineffective, anhedonia, and negative self-esteem. A total score is usually also derived which is used as an indicator of the severity of the depressive symptoms experienced by the youth. As these measures are copyright protected and access to them is restricted, we are not able to include these measures as an appendix. It is of note that these measures are commonly used by both clinicians and researchers. Medical Information. Medical information was obtained during the course of routine medical appointments by each patient s pediatrician. In particular, the information obtained during such appointments has included weight, height, body mass index, and status of menstruation. Study Limitations. Although patients have completed psychological questionnaires at the time of intake for a number of years, the particular questionnaires completed have differed depending on the preference of clinicians. As a result, data collection has not been consistent and not all measures were completed by all patients. However, for the last year and a half, there has been consistency in this regard, and yearly follow-up and discharge measures have also been collected. Further improvement is needed in regards to the proportion of youth completing questionnaires, and incentives (e.g. movie passes) are being considered to encourage youth to complete discharge questionnaires. A second limitation of the present study is that a control group is not available. This is a common limitation of program evaluation research. However, a number of the psychological questionnaires used in this project have norms available. A third limitation lies in the fact that many of the psychological questionnaires rely on youth self-report. As youth often attend their first appointment somewhat unwillingly they may not be motivated to indicate the extent of their distress due to ambivalence regarding receiving treatment. As a result, the degree of distress experienced by youth may be underreported at the time of intake. Results Question #1: Demographics and Presenting Symptoms Age of Onset and Diagnosis. The mean age at intake for all current and past patients seen by the Pediatric Eating Disorders Program was 14.6 years old (N=493). At intake patients with Anorexia Nervosa-Restricting or Anorexia Nervosa-Binge-Purge showed a mean age of 14.5 years, those with Bulimia Nervosa showed a mean age of 14.9 years, and those with an Eating Disorder Not Otherwise Specified-Restricting showed a mean age of 12.6 years. Diagnoses received at intake varied as follows: 33.1% Anorexia Nervosa-Restricting, 3.5% Anorexia Nervosa-Binge-Purge, 13.1% Bulimia Nervosa, 9.8% Eating Disorder Not Otherwise Specified

7 Restricting, 7.1% Eating Disorder Not Otherwise Specified-Binge-Purge, 3.9% Binge Eating Disorder, and 13.3% with no eating disorder. Gender. 89.8% of patients seen by the Pediatric Eating Disorders Program were female. Comorbidity. Patients treated by the Pediatric Eating Disorders program were found to have elevated levels of depression and anxiety relative to norms. 37.5% of patients reported levels of depression in the clinical range and 27.7% of patients reported levels of anxiety in the clinical range relative to norms on self-report questionnaires. Question #2: Treatment Outcomes Related to Eating Disorder Symptoms Weight Restoration. Patients showed the greatest improvement in regards to attaining their ideal body weight between 6 to 12 months into treatment. At intake, patients who had been diagnosed with Anorexia Nervosa were at an average of 77.6% of their ideal body weight, while patients who had been diagnosed with Bulimia Nervosa were at 97% of their ideal body weight. At 6 and 12 months into treatment, patients diagnosed with Anorexia Nervosa had reached on average approximately 98.6% of their ideal body weight, while patients diagnosed with Bulimia Nervosa had reached on averaged approximately 98.2% of their ideal body weight. Psychological Symptoms of Eating Disorders. At one year follow-up in the program (N=35); Results indicate a significant improvement for Drive for Thinness after one of year treatment (M = 11.59, SD = 1.57) relative to measures at intake (M = 15.62, SD = 1.55), p =.022. Results indicate a significant improvement for Bulimic Symptoms after one year of treatment (M = 4.00, SD = 1.06) relative to measures at intake (M = 5.76, SD = 1.34), p =.039. Results indicate a non-significant improvement for Body dissatisfaction after one year treatment (M = 17.24, SD = 2.22) relative to measures at intake (M = 20.41, SD = 2.08), p =.148. At discharge from the program (N=14); Results indicate a significant improvement for Drive for Thinness at discharge (M = 5.36, SD = 1.22) relative to measures at intake (M = 15.93, SD = 1.62), p =.013. Results indicate a non-significant improvement for Bulimic Symptoms at discharge (M = 2.58, SD = 0.74) relative to measures at intake (M = 7.67, SD = 3.05), p =.122. Results indicate a significant improvement for Body dissatisfaction at discharge (M = 8.64, SD = 1.93) relative to measures at intake (M = 16.64, SD = 2.898), p =.026. Question #3: Treatment Outcomes Related to Comorbidity Anxiety. Results indicate a significant improvement for anxiety symptoms, as indicated by the MASC Total Score, after one of year treatment (M = 47.17, SD = 3.79) relative to measures at intake (M = 55.37, SD = 3.40), p =.013 (N=35). In addition, results indicate a significant improvement on the Anxiety Disorders Index at one year follow-up (M = 14.27, SD = 1.09) relative to measures at intake (M = 16.07, SD = 0.93), p = (N=35)

8 Results indicate a non-significant improvement for anxiety symptoms, as indicated by the MASC Total Score, at discharge (M = 59.00, SD = 10.72) relative to measures at intake (M = 73.75, SD = 5.36), p =.0301 (N=14). Results indicate a non-significant improvement on the Anxiety Disorders Index at discharge (M = 17.75, SD = 2.75) relative to measures at intake (M = 21.75, SD = 1.65), p = (N=14). Depression. Results indicate a significant improvement in depressive symptoms as indicated by the CDI total score for depression after one year treatment (M = 11.49, SD = 1.89) relative to measures at intake (M = 16.29, SD = 1.47), p =.003 (N=35). Similarly, results indicate a significant improvement for depression at discharge (M = 7.75, SD = 1.88) relative to measures at intake (M = 16.92, SD = 3.27), p =.007 (N=14). Conclusions and Recommendations The demographic characteristics of children and adolescents seen by the Pediatric Eating Disorders Program are similar to those described in other research. The age of onset often reported in the literature is similar to the average age of initial referral to the Pediatric Eating Disorders Program. The gender differences often found in adult populations are similar to the gender differences found among the patients receiving treatment with the Pediatric Eating Disorders Program, with the majority of patients being female. Also, a considerable portion of the patients seen by the Pediatric Eating Disorders Program reported symptoms of anxiety and depression in the clinical range on psychological questionnaires. It is thus important that interventions provided to address eating disorders also address other mental health concerns, and thus should not exclusively be targeted towards eating disorder symptomology. In order to address the needs of youth it will be important that intervention for eating disorders also address symptoms of anxiety and depression. The results of the present study demonstrate that youth who receive treatment from the Pediatric Eating Disorders Program tend to improve in regards to their physical health within six to twelve months of receiving treatment. This demonstrates that the present treatment program is effective in restoring both the physical health of children and adolescents struggling with eating disorders. The results of the present study demonstrate that youth who receive treatment from the Pediatric Eating Disorders Program also tend to improve in regards to their psychological health. Within one year of treatment and/or at discharge from the program, youth reported less of a drive to be thin, fewer symptoms related to bulimia, and greater satisfaction with their body. However, these improvements were not always at the significant level for symptoms related to bulimia and body dissatisfaction. This inconsistency is consistent with previous findings that suggest that persistent body dissatisfaction and preoccupation with food and eating are more resistant to change than some of the physical manifestations of these illnesses (Van der Ham, Van Strien, & Van Engeland, 1994). Youth receiving treatment for their eating disorder also experienced an improvement in comorbid symptoms associated with anxiety and depression, within one year of treatment and/or at discharge from the program. A great deal has been learned from the evaluation activities that have been possible given the funding provided by this program evaluation grant. Staff have gained a better understanding of the research process, including a better understanding of the logistics of conducting a research project (e.g. hiring and training research assistants, coordinating those contributing to the project) and methodological design given the constraints of a clinical setting and population (e.g. measurement appropriateness and timing, missing measures). Staff expertise regarding methodological design and statistical analyses has improved a great deal as a result of this project

9 Further, this evaluation project has allowed staff to present research at conferences, and in the process has laid the foundations for future partnerships in program evaluation. This program evaluation project has had an impact on patients, staff and the organization as a whole. Primarily, the evidence supporting the effectiveness of this program has reaffirmed staffs beliefs that the treatment they provide is effective, and has contributed to the general morale of the team. Further, the descriptions provided regarding the patients served and their outcomes has generated interest in the program evaluation activities. Knowledge and skills gained as a result of the proposed program evaluation project will be used to inform improvements and guide decisions related to the treatment provided by the Pediatric Eating Disorders Program. This research will also contribute to our understanding of eating disorders and their treatment. This will lead to improvements in the treatment provided to patients who have eating disorders both by our program, and by other programs. As a result of the initiation of this program evaluation project, made possible by this grant, the Pediatric Eating Disorders Program has been able to refine the program evaluation activities and set up appropriate means to continue with this project. Data will continue to be collected and compiled regarding outcomes, and outcome questions and associated results will continue to be generated and refined. For example, the outcomes of a variety of comorbid mental health issues (other than anxiety and depression) will be considered. It is also hoped that a consideration of prognosis will improve our understanding of the correlates of premature termination of therapy. Next Steps This program evaluation project has allowed for a description of the patients seen by the Pediatric Eating Disorders Program and a consideration of treatment outcomes (e.g. medical and psychological symptoms related to eating disorders, anxiety, and depression). There are a number of next steps, which will extend the program evaluation work completed to date. Specifically, there are three research questions/directions that are presently felt worthy of consideration. Firstly, further outcome variables will be important to consider, specifically those relating to interpersonal relationships, particularly family and peer relationships. It is also felt that a consideration of prognosis will be an important extension of the present project. It is felt that an improved understanding of prognosis will allow our program to make modifications and changes to target patients for whom prognosis is poor. Predictors of recovery (when patients no longer meet diagnostic criteria for an eating disorder), drop-out (patients leaving treatment against the recommendations of their treatment providers), and improvement of specific symptoms related to eating disorders and comorbid conditions are felt worthy of consideration. An examination of treatment trajectories, as they relate to both symptoms of eating disorders and comorbid conditions, is also of interest. From their clinical experiences, members of the Pediatric Eating Disorders Program feel that there are different courses of the illness during treatment. Whereas the course of some patient s illness is variable (e.g. with improvements and declines throughout the course of the illness), for others a more consistent pattern is apparent (e.g. slow but gradual improvements). Knowledge Exchange Plan As a result of this described program evaluation work to date, the Pediatric Eating Disorders Program has been able to demonstrate the effectiveness of, and provide evidence for, the treatment program offered to young people struggling with eating disorders. This program evaluation work has highlighted both strengths (e.g. success rate in regards to physical and - 9 -

10 psychological outcomes) and weaknesses (e.g. inconsistent results regarding body dissatisfaction and bulimic symptoms than would be hoped) of the present treatment program. To date, knowledge obtained from this project has been shared with program staff informally at program rounds and research meetings. A formal presentation of a portion of this data has also been made to the team. Also, each year at the Annual Pediatric Eating Disorders Program Staff Retreat held in the fall, a formal presentation describing the status of the program evaluation project and associated outcome findings is given. Acquired knowledge and skills, related to program evaluation generally, and of the program specifically, have been shared with colleagues within the hospital and undergraduate students. For example, staff members of the Pediatric Eating Disorders Program have been, and will continue to, provide consultation and support to a program evaluation project being developed in relation to a newly implemented Diabetes Transition Clinic, where the medical and mental health of youth with diabetes who are transitioning to adult care will be followed. A number of undergraduate students have been involved in this project as both volunteers and thesis students, and have received mentoring from the Pediatric Eating Disorders Program and teaching through regular research meetings (at which the literature, design issues, and findings are discussed). An honours thesis student, a practica student, and a number of volunteers have been accepted to assist with program evaluation research for the fall, each of whom will receive mentorship and training while with the program. A paper and two poster presentations have been made at the Society for Research in Adolescence Biennial Conference. The paper presentation was made in collaboration with staff from the Pediatric Eating Disorders Program located at the Children s Hospital of Easter Ontario. A paper presentation will also be made at the Academy for Eating Disorders Annual Conference in May this year. A first draft of a paper summarizing a portion of the findings of this program evaluation project is presently underway, and it is expected that a second paper will be produced before the end of the year, both of which shall be submitted for publication in a scholarly journal. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4 th ed.). Washington, DC: Author. Becker, A. E., Grinspoon, S. K., Klibanski, A., & Herzog, D. B. (1999). Current concepts - Eating disorders. New England Journal of Medicine, 340, Burns, T., & Crisp, A. H. (1984). Outcome of anorexia nervosa in males. British Journal of Psychiatry, 145, Clinton, D., Bjorck, C., Sohlberg, S., & Norring, C. (2004). Patient satisfaction with treatment in eating disorders: Cause for complacency or concern? European Eating Disorders Review, 12, Eagles, J. M., Johnson, M. I., Hunter, D., Lobban, M., & Millar, A. H. (1995). Increasing incidence of anorexia-nervosa in the female population of northeast Scotland. American Journal of Psychiatry, 152, Fairburn, C. G., Kirk, J., O Connor, M., & Cooper, P. J. (1986). A comparison of two psychological treatments of bulimia nervosa. Behaviour Research and Therapy, 24, Garfinkel, P. E., Moldofsky, H., & Garner, D. M. (1977). The outcome of anorexia nervosa: Significance of clinical features, body image, and behavior modification. In R. A. Vigersky (Ed.), Anorexia nervosa (pp ). New York: Raven Press. Godart, N. T., Flament, M. F., Curt, F., Perdereau, F., Lang, F., Venisse, J. L., Halfon, O., Bizouard, P., Loas, G., Corcos, M., Jeammet, P., & Fermanian, J. (2003). Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study. Psychiatry Research, 117,

11 Herpertz-Dahlmann, B., Muller, B., Herpertz, S., Heussen, N., Hebebrand, J., & Remschmidt, H. (2001). Prospective 10-year follow-up in adolescent anorexia nervosa course, outcome, psychiatric comorbidity, and psychosocial adaptation. Journal of Child Psychology and Psychiatry, 42, Hoek, H. W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34, Joergensen, J. (1992). The epidemiology of eating disorder in Fyn County, Denmark, Acta Psychiatrica Scandinavica, 85, McVey, G. L., Pepler, D., Davis, R., Flett, G. L., & Abdolell, M. (2002). Risk and protective factors associated with disordered eating during early adolescence. Journal of Early Adolescence, 22, McVey, G., Tweed, S., & Blackmore, E. (2004). Dieting among preadolescent and young female adolescents. Canadian Medical Association Journal, 170, Mitchell, J. E., Agras, S., & Wonderlich, S. (2007). Treatment of bulimia nervosa: Where are we and where are we going? International Journal of Eating Disorders, 40, Palsberg, A., & Wang, A. (1994). Epidemiology of anorexia nervosa and bulimia nervosa in Bornholm County, Denmark, Acta Psychiatrica Scandinavica, 81, Paulson-Karlsson, G., Nevonen, L., & Engstrom, I. (2006). Anorexia nervosa: treatment satisfaction. Journal of Family Therapy, 28, Pomeroy, C., & Mitchell, J. E. (2002). Medical complications of Anorexia Nervosa and Bulimia Nervosa. In C. G. Fairburn, & K. D. Brownell, Eating Disorders and Obesity (2nd ed.): A comprehensive handbook. New York: Guilford Press. Russell, G. (1979) Bulimia nervosa: An ominous variant of anorexia nervosa. Psychological Medicine, 9, Russell, G. F. M., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44, Steinhausen, H. C., Rauss-Mason, C., & Seidel, R. (1991). The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over years in a prospective study. International Journal of Eating Disorders, 22, Theander, S. (1985). Outcome and prognosis of anorexia nervosa and bulimia: Some results of previous investigations, compared with those of a Swedish long-term study. Journal of Psychiatric Research, 19, Van der Ham, T., Van Strien, D. C., & Van Engeland, H. (1994). A four-year prospective follow-up study of 49 eating-disordered adolescents: Differences in course of illness. Acta Psychiatrica Scandinavica, 90, Woodside, D. B., & Garfinkel, P. E. (1992). Age of onset in eating disorders. International Journal of Eating Disorders, 12,

12 Eligible Budget Items Schedule 3: Accounting Summary of Expenditures Approved Budget ($) Actual Expenditures ($) Personnel Costs Research Assistants $10,800 $10,800 (2 Part-Time Research Assistants) Consultation Costs Data Analysis Consultation and Statistical Support $1,000 $1,000 (10 hours from the Institute for Social Research at York University) Computer Costs Training Tools/Questionnaires Administrative Costs Office Supplies Knowledge Exchange Activities Travel Total Cost of All Expenses $11,800 $11,