Screening and Assessment
In terms of screening and assessment, surveyed clinicians reported including questions about eating behaviors during their clinical assessment “often”, “usually”, or “always” in greater than half of the cases (62%). Sixteen percent of clinicians reported “always” screening for ED in their clinics, an encouraging figure relative to the findings reported among primary physicians in the United Kingdom (
Bryant-Waugh et al., 1992). In terms of presenting complaints/symptoms, overall, infrequent-screening clinicians report encountering amenorrhea and low self-esteem less often than frequent-screening clinicians. In terms of disciplines, psychologists endorsed encountering psychological symptoms of ED most often, while physicians endorsed encountering the medical symptoms most often. In light of the fact that, in Ontario, medical doctors (family physicians, pediatricians, etc.) are sometimes the only discipline from whom referrals are accepted by treatment programs, this over-reliance on physical symptoms may suggest that at the time of referral, patients are more likely to be entrenched in psychological issues. Frequently occurring co-morbid psychiatric risk factors such as major depression are also likely to be missed. Similarly, the low frequency with which psychologists detect physical symptoms such as amenorrhea, may lead patients to become more medically compromised by the time the appropriate services are rendered, or a referral is made to a physician or specialist. In terms of family involvement, a high proportion of clinicians, psychologists and physicians alike, fail to routinely involve families in the assessment process. This is a serious problem given that patients with ED typically deny, or lack appreciation of the severity of symptoms. Parents, if included in interviews, can serve as important informants, which can lead to a more accurate diagnosis, or reduce the likelihood of a misdiagnosis.
Treatment
It has been established and accepted that behavior-based family therapy using a team approach is currently considered best practice in the treatment of ED in children and adolescents. However, according to the results of this study, only a third of the participants reported always involving families in treatment, and of these, it is unclear how this involvement translates into practice. For example, although psychologists reported inclusion of families in their treatment more often than did family physicians, the majority of them reported providing individual therapy rather than family therapy as a primary service rendered. While this approach may be useful with adult populations, it is not considered best practice when working with children and adolescents. As such, when the small proportion of clinicians does report including families in treatment, it may be in a less direct, more consultative role, as opposed to being directly active in the intervention. It is reassuring, however, that a large number of clinicians, physicians and psychologists alike, list referrals to specialists as a common service pathway.
Implications
In pediatric ED, the earlier the diagnosis and treatment, the better the outcome. Without a doubt, this study suggests that in Ontario, Canada, there seems to be a need to improve the training of, and support for primary care clinicians to whom patients with ED may present. In particular, physicians and psychologists may benefit from additional training around screening, multi-informant assessment methods, as well as evidence-based interventions. Improved screening, assessment and treatment practices could improve the quality of life of children with ED and their families, lead to shorter lengths of stays in specialized treatment centers, and, in turn, reduce overall health-care costs. With respect to screening and assessment specifically, it may also be worthwhile to promote inter-disciplinary collaborations to increase detection rates by both disciplines, by harnessing their respective strengths. Lastly, the results of the current study have implications for treatment centers who only accept referrals from a medical doctor (family physician, pediatrician, etc.) prior to conducting a multi-disciplinary assessment. It may be that, for eating disorders, as long as a medical assessment is conducted, referrals from caregivers, school personnel, etc., could also be considered.
Limitations
The response rate for this study was low, especially for family physicians. As such, it is possible that results may be biased if non-respondents differed from respondents in significant ways. It was not possible to obtain information about non-respondents in this study, so this potential bias cannot be evaluated. It was also not possible to track for duplicate survey submissions; however, given the low response rate, we do not believe this to be a likely event. In addition, the wording of the questions limited the information that could be gathered regarding family involvement. Additional information on the nature of discipline-specific family involvement will be useful to examine in future studies to further clarify clinical practices. Finally, future studies should also survey other medical specialists who may be referring to specialized centers, such as pediatricians, psychiatrists, gastroenterologists, etc.
