Final Outcomes Report. Sherry Van Blyderveen, M.A. 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, M.A. 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. 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. 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) and tended to experience symptoms of anxiety and depression, in addition to their eating disorder. This suggests that it is important that interventions provided to address eating disorders also address other mental health concerns, and thus treatment should not exclusively be targeted towards eating disorder symptomology. It will also be important for future research to explore outcomes related to comorbid conditions such as anxiety and depression. 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. This demonstrates that the present treatment program is effective in treating the physical symptoms of eating disorders during childhood and adolescence. Future research is needed in order to consider outcomes related to additional symptoms of eating disorders such as preoccupation with weight and shape. Table of Contents Executive Summary 2 Table of Contents 2 Introduction. 2 Methodology 5 Results. 6 Conclusions and Recommendations 7 Knowledge Exchange Plan.. 8 References 8 Accounting Summary of Expenditures. 10 Introduction The goal of this program evaluation project was to better understand the patients treated by the Pediatric Eating Disorders Program and the nature and effects of the treatment provided. 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 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. Document and track the specific services provided to patients (e.g. medical appointments, family therapy, individual therapy, group therapy, nutritional counseling, workshops, hospitalization)

3 3. Determine whether patients experience improvement in symptoms of disordered eating, as well as comorbid conditions such as anxiety and depression. 4. Determine whether patients experience improved relationships with family members. 5. Assess patients and their families satisfaction with service delivery. 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 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 - 3 -

4 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). 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). Treatment. Treatment for eating disorders can take many approaches but none guarantee recovery. A recent meta-analysis found that current psychopharmacological treatment of Bulimia Nervosa with antidepressants has not led to significant remission of symptoms and behaviours; with patients often relapsing after drug treatment is discontinued (Mitchel, Stewart, & Wonderlich 2007). Cognitive Behavioural 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). Treatment Satisfaction. Research regarding patient and parental satisfaction with treatment is limited. Some researchers have found that parents tend to be more satisfied with family-based therapy than are the patients (Paulson-Karlsson, Nevonen, Engstrom, 2006). Unsatisfied patients have been shown to be less prepared to change their eating habits prior to the onset of treatment (Clinton, Bjorck, Sohlberg, & Norring, 2004)

5 Outcomes. Individuals with Anorexia Nervosa show variations in the course and outcome of their illness (APA, 1994). Within the first 5 years a significant proportion develop binge-eating behaviours 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). Psychosocial functioning at follow-up has been examined and found to generally be good across all age groups (Bryant-Waugh et al., 1996). Relationships with family members and those outside the family show more variability and researchers have claimed that psychosocial, especially family relationships, are the most diverse and elusive outcome parameters to study (Steinhausen et al., 1991). Comorbid psychopathologies have been found to significantly influence outcome of patients with eating disorders. A 10-year follow-up study showed that there was a significant relationship between the persistence of eating disorders and comorbid psychological disorders (Herpetz-Dahlmann, Muller, Herpetz, Heussen, Hebebrand, & Remschmidt, 2001). Methodology Participants. Participants included patients who received a consultation and/or treatment from the Pediatric Eating Disorders program. The program had seen 419 youth since it was created approximately 6 years ago. 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, 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. Measures. Patients complete a number of self-report questionnaires including the Eating Disorders Inventory-3, the Multidimensional Anxiety Scale for Children, the Children s Depression Inventory, and the Behavioral and Emotional Rating Scale-2nd Edition. Younger patients complete the Children s Eating Attitude Test and the Beck Inventories for Children and Youth (Depression, Anxiety, Anger and Self-Concept Inventories). Parents complete a demographic questionnaire and the Behavioral and Emotional Rating Scale-2nd Edition. Medical Information. Medical information has been 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

6 File Review. Descriptive information regarding the course of each patient s treatment will be obtained through a review of patient files. This task has not yet been completed as it has proved time consuming and difficulties confirming the accuracy of information have arose. 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. 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 selfreport. 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 Preliminary data analyses have been conducted and are presented below. Analyses in progress are also described. Descriptive statistics (e.g. means, percentages) were first generated in order to describe the patient population seen by the Pediatric Eating Disorders Program and the treatment provided. Main effects were then considered. 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=419). At intake patients with Anorexia Nervosa-Restricting or Anorexia Nervosa-Binge-Purge showed a mean age of 14.6 years, those with Bulimia Nervosa showed a mean age of 15.7 years, and those with an Eating Disorder Not Otherwise Specified-Restricting showed a mean age of 14.9 years. Diagnoses received at intake varied as follows: 34.8% Anorexia Nervosa-Restricting, 4.1% Anorexia Nervosa-Binge-Purge, 13.8% Bulimia Nervosa, 8.4% Eating Disorder Not Otherwise Specified- Restricting, 6.4% Eating Disorder Not Otherwise Specified-Binge-Purge, 4.1% Binge Eating Disorder, and 13.1% with no eating disorder. Gender. 89% 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. 39.1% of patients reported levels of depression in the clinical range and 30.3% of patients reported levels of anxiety in the clinical range. Treatment Provided. As data has not yet been compiled regarding the specific details as to the components of treatment provided to each patient, descriptives regarding the specific services provided to patients (e.g. medical appointments, family therapy, individual therapy, group therapy, nutritional counseling, workshops, hospitalization) are not available. Treatment Satisfaction. Data has not yet been collected to allow for the consideration of patient satisfaction with the treatment program

7 Outcomes. Over the course of six years, hospitalization was required for 103 patients seen by the Pediatric Eating Disorders Program. Of those who were admitted, 43% had been diagnosed with Anorexia Nervosa-Restricting subtype, 42% had been diagnosed with Anorexia Nervosa-Binge-Purge subtype, and 11% had been diagnosed with an Eating Disorder Not Otherwise Specified-Restricting subtype. 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 79.3% of their ideal body weight, while patients who had been diagnosed with Bulimia Nervosa were at 92.8% of their ideal body weight. At 6 and 12 months into treatment, patients diagnosed with Anorexia Nervosa had reached on average approximately 90% of their ideal body weight, while patients diagnosed with Bulimia Nervosa had reached on averaged approximately 100% of their ideal body weight. Currently 237 patients have left the Pediatric Eating Disorders Program for a variety of reasons. Of these patients who have discontinued treatment with the program, 30.5% have recovered from their eating disorder, 26.9% quit treatment prematurely, 9.1% were transferred out of the program to another facility, and 5.1% reached the maximum age for treatment within the Program and thus were referred to another facility for continued treatment. As only five patients had completed psychological questionnaires at discharge, further analyses were not presently possible at this time. When sufficient data has been collected, outcomes related to psychological questionnaires, such as anxiety and depression, shall be considered. Future analyses shall compare the outcomes of different groups of patients (e.g. patients receiving different diagnoses, patients in different age groups) and shall consider prognosis (e.g. predictors of recovery, predictors of prematurely leaving treatment). The number and breadth of questions proposed at the outset of this program evaluation project appears to have been overly inclusive and ambitious given the time constraints. As a result, measures relating to all questions posed have not yet been added to questionnaire packages completed by families (e.g. surveys regarding patient satisfaction have not been administered). Further, although the methodology of the proposed program evaluation project has been successfully implemented, sufficient time has not passed to allow for an adequate sample of psychological follow-up data to have been collected (e.g. only five patients had been discharged from the program since discharge data had begun to be collected). As data collection is an ongoing process, and given the momentum that this project has gained, it is hoped that sufficient data will be collected to allow for further consideration of the questions posed in the future. 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

8 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 treating eating disorders during childhood and adolescence. However, sufficient data had not been collected to allow for a consideration of outcomes related to the psychological aspects of eating disorders, such as preoccupation with weight and shape, which are considered to be more resistant to change. This will be an important consideration once sufficient data has been collected. It will also be important for future research to explore outcomes related to comorbid conditions such as anxiety and depression. 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. 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 established a process of program evaluation and set up appropriate means to continue with this project. Data will continue to be collected and compiled regarding outcomes, and when sufficient outcome data has been collected regarding psychological variables at multiple time points, further analyses will be conducted. In particular, the outcomes of a variety of comorbid mental health issues will be considered. For example, it is expected that symptoms of both anxiety and depression will improve during the course of treatment with the Pediatric Eating Disorders Program. A consideration of prognosis will also be considered. It is hoped that a better understanding of the correlates of premature termination of therapy will be gained from this process. 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 medical outcomes) and weaknesses (e.g. proportion of patients leaving treatment prematurely) 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. In the future, a formal presentation describing the - 8 -

9 outcome data will be given to the staff of the Pediatric Eating Disorders Program at their annual staff retreat in the fall. Acquired knowledge and skills, related to program evaluation generally, and of the program specifically, will be presented to the larger hospital community through a Grand Rounds offered by Pediatrics at McMaster Children s Hospital s. Poster presentations will be submitted to upcoming conferences (e.g. Eating Disorders Outreach Annual Meeting, Society for Research in Adolescence). Findings will also be presented in written documents for The Centre s required Final Report and Plain Language Summary of project outcomes, to be disseminated through its website. The possibility of submitting results of the project for publication in scholarly journals will be explored. 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, 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 - 9 -

10 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,

11 Schedule 2-B: Accounting Summary of Expenditures Eligible Budget Items Cost per Item ($) Total Cost ($) Personnel Costs Research Assistants $12,525 $12,525 (4 Research Assistants for a total of 666 hours, $16.97/hr plus pay in lieu of vacation and benefits) Consultation Costs Consultation re: Program Evaluation Process and Data Analyses $4,767 $4,767 Computer Costs Computer and Equipment $2,690 $2,690 Training Tools/Questionnaires Administrative Costs Office Supplies Knowledge Exchange Activities Travel Total Cost of All Expenses (Max $20,000) $19,982 $19,982 * Please note that the Accounting Summary of Expenditures has yet to be verified by our Finance Department as we are still waiting for items to be posted