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Keywords:

  • Assessment measures;
  • eating disorders;
  • children and adolescents

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References

Background:  Several diagnostic and screening instruments are available for child and adolescent eating disorders. However, limitations have been identified in many of these.

Method:  We review the most frequently used assessment measures for eating disorders in children and adolescents.

Results:  Several of the available instruments have significant limitations, although relevant strengths are identified.

Conclusions:  Limitations in the current available instruments for child and adolescent eating disorders should be addressed in order to improve recognition and treatment.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References

Eating disorders such as anorexia nervosa, bulimia nervosa, binge-eating disorder and eating disorders not otherwise specified (EDNOS) are common in developed countries. Average prevalence rates for anorexia nervosa and bulimia nervosa are 0.3% and 1% respectively in young Western women (Van Hoeken, Seidell, & Hoek, 2003), but are higher – up to 5-7% of young women – if partial syndromes are included. The incidence of anorexia nervosa has been reported as 8 cases per 100,000 of the population per year, while the annual incidence of bulimia nervosa is reported to be around 12 per 100,000 (Hoek & van Hoeken, 2003).

There continues to be debate about whether incidence rates of eating disorders have increased during the 20th century. While there is recent evidence from the Netherlands of an increase in the incidence of anorexia nervosa in younger women, aged 15-19 years (van Son et al., 2006), evidence suggests that the overall incidence of anorexia nervosa has increased only slightly in the past century (Keel & Klump, 2003). There is some evidence that incidence rates of bulimia nervosa have fluctuated and risen since 1988. However, factors such as changes in symptom recognition and service use might explain this differential pattern of presentation (Currin et al., 2005; Turnbull, 1996).

Cases of eating disorders not otherwise specified (EDNOS) are common. However, difficulties in common definitions of this category have hampered establishing prevalence or incidence rates. Recent literature has recognised the need to investigate partial syndromes, given that they account for about 60% of cases in outpatient settings, and have a significant impact on functioning and well-being (Fairburn & Bohn, 2005).

While the clinical picture of eating disorders appears to be similar for males and females (Woodside et al., 2001; Bramon-Bosch, Troop, & Treasure, 2000), both anorexia nervosa and bulimia nervosa are disproportionately distributed between the sexes, with a ratio of 10:1 for females vs. males (Hoek & van Hoeken, 2003). Onset of eating disorders is typically in adolescence or young adulthood. Hazard rates increase from the age of 10 years (Lewinsohn, Striegel-Moore, & Seeley, 2000), with the highest reported incidence rates of anorexia nervosa in females occurring between 15 and 19 years, and the highest reported incidence rates of bulimia nervosa in females occurring between 20 and 24 years (Hoek & van Hoeken, 2003).

Child and adolescent eating disorders are a significant cause of morbidity and mortality (Gowers & Bryant-Waugh, 2004) and are linked to serious mental and physical health problems and impaired social functioning in adulthood (Lewinsohn et al., 2000; Johnson et al., 2002; Striegel-Moore, Seeley, & Lewinsohn, 2003). They have been rated 10th for females under 14 years of age and 4th for females aged 15-24 years as leading causes of burden of disease and injury (Mathers, Vos, & Stevenson, 1999).

Eating disorders are not self-limiting and many have a chronic course with notable psychiatric and medical co-morbidities and sequelae. Children and adolescents often have a wide range of physical problems secondary to eating disorders. These are compounded by the timing of onset, which can be at a crucial developmental stage for accruing adequate bone density and target height.

Problems with diagnosing child and adolescent eating disorders: classification systems

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References

The most widely used diagnostic systems for eating disorders, i.e. those produced by the American Psychiatric Association (Diagnostic and statistical manual of mental disorders, 4thedn.;APA, 1994) and the World Health Organisation (International statistical classification of diseases and related health problems, 10th rev.;WHO, 1992) do not include age-specific criteria. Both diagnostic systems, however, give some guidance in relation to pre-pubertal onset, but this mainly relates to hormonal dysfunction. Several authors have noted the different psychopathological and behavioural presentation of children and adolescents with eating disorders compared to adults (Overas, Winje, & Lask, 2008; Ackard, Fulkerson, & Neumark-Sztainer, 2007).

In relation to anorexia nervosa, for example, cognitive appraisals of current body weight or fear of fatness are often not reported by adolescents despite clear evidence of failure to adequately increase food intake or body weight (Couturier & Lock, 2006a). This may potentially be secondary to the different cognitive abilities of adolescents and to the specific developmental context. There are also issues with using the same physical criteria for diagnosing eating disorders in people of different ages. For example, although the core symptoms of weight loss and failure to be at age- and sex-appropriate weight are present both in adults and in adolescents, the use of Body Mass Index to assess proportion of ideal weight in children and adolescents is not considered appropriate (Cole et al., 2007).

There are also suggestions that bulimia nervosa has different cognitive aspects in children and adolescents than in adults. In particular, the subjective feeling of loss of control in relation to binge-eating is often not expressed by children and adolescents (Marcus & Kalarchian, 2003). Adolescents often have difficulty in describing the amount of food eaten (required to identify episodes of bingeing) and might report levels of behaviours below the thresholds required for a diagnosis. However, there is evidence that sub-threshold forms of bulimia nervosa have an important overlap with full syndrome bulimia nervosa in terms of comorbidity, physical complications, and impairment (le Grange et al., 2004; Binford & le Grange, 2005).

In light of these differences in presentation, and in the context of the current review of DSM criteria ahead of the publication of the DSM-V, there have been calls to change or refine the diagnostic criteria for eating disorders in children and adolescents, adapting them to be more developmentally sensitive and to reflect differences between young people and adults in terms of psychopathology, clinical presentation, and risk due to physical and nutritional sequelae (Workgroup for the Classification of Eating Disorders in Children and Adolescents, 2007).

Lask and Bryant-Waugh (2000) compiled a set of guidelines specifically for identifying eating difficulties, including anorexia nervosa and bulimia nervosa, in children. These guidelines are known as the Great Ormond Street criteria and have been found to be more reliable in young populations than the DSM and ICD criteria (Nicholls, Chater, & Lask, 2000). These guidelines, however, are not currently widely used with adolescents.

Other problems with assessing child and adolescent eating disorders

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References

Aside from the issue of the suitability of current classification systems, assessing children and adolescents for the presence of eating disorders can be difficult for a number of other reasons. For example, denial of the symptoms of anorexia nervosa is common, perhaps even more so among young people than among adults (Couturier & Lock, 2006a; Fisher et al., 2001). The absence of this can be interpreted in different ways: one hypothesis is that ‘denial’ requires an adequate cognitive component and therefore just reflects the young person’s developmental level; a second hypothesis is that the young person does not actually experience the cognitive symptoms of AN in the same way an adult might and therefore the denial is actually an absence of the cognitive component of AN.

In addition, information about certain constructs that are required for a diagnosis to be made can be difficult to elicit. For example, to assess whether someone meets the DSM-IV criteria for anorexia nervosa or bulimia nervosa, it should be determined whether their self-evaluation is unduly influenced by their weight or body shape. This is a complex notion that requires a sound grasp of the concept of self-definition (Peterson & Miller, 2005), something a child or younger adolescent may not possess. Other constructs can be difficult to quantify consistently. For example, the amount of food that would be considered large enough to meet one of the criteria for an episode of binge eating is likely to vary depending on the perspective of the person making the judgement (Peterson & Miller, 2005).

Assessment measures for child and adolescent eating disorders

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References

There are a number of widely used assessment measures for child and adolescent eating disorders, most of which have been adapted from instruments designed for use with adult populations. These measures include self-report questionnaires, such as the Children’s Eating Attitudes Test (ChEAT; Maloney, McGuire, & Daniels, 1988), the Children’s Eating Disorders Inventory (EDI-C; Garner, 1991a) and the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994); semi-structured interviews, such as the Children’s Eating Disorder Examination (ChEDE; Bryant-Waugh et al., 1996); and online measures, such as the Development and Well-Being Assessment (DAWBA; Goodman et al., 2000; Moya et al., 2005). These measures are described in more detail below, and see Table 1.

Table 1.   Assessment measures for child and adolescent eating disorders
MeasureAge groupFormatTimeDiagnostic
EAT ChEAT13+ years 8-13 yearsSelf-report questionnaire10-15 minutesNo
EDI-2 EDI-C12+ years Not definedSelf-report questionnaire20 minutesNo
EDE-QAdults and adolescents (not defined)Self-report questionnaire<15 minutesNo
EDE ChEDE14+ years 8-14 yearsFace-to-face interview60 minutesYes
DAWBA7-17 yearsFace-to-face or computerised10-20 minutes (eating disorder section)Yes

The Children’s Eating Attitudes Test

The Eating Attitudes Test (EAT; Garner & Garfinkel, 1979; Garner et al., 1982) is a self-report screening questionnaire, designed to detect eating disorder psychopathology in adults. The most commonly used version of the measure (the EAT-26; Garner et al., 1982) has 26 individual items that can be used to calculate a total score and three subscale scores (Dieting, Bulimia, and Oral Control). The EAT was developed as a screening tool and has been used in research studies; it has been found to reliably identify potential cases of eating disorders in non-clinical populations (Wood et al., 1992). Normal EAT scores for adolescent females in the UK have been determined, and levels of reliability of the subscales have been shown to be similar to those found in adult populations (Wood et al., 1992). The adult version of the measure has been used with older adolescents but is not suitable for use with younger children (Maloney et al., 1988).

A simplified version of the questionnaire has been developed specifically for use with young people aged 8-13 years (the ChEAT; Maloney et al., 1988). The basic psychometric properties of the ChEAT are similar to those of the adult EAT, making it a potentially valuable measure for capturing children’s eating behaviours and attitudes (Nathan & Allison, 1998). The usefulness of the EAT, however, is limited by high rates of false positives and false negatives (Wood et al., 1992), and its inability to distinguish between cases of anorexia nervosa and bulimia nervosa (Nathan & Allison, 1998), making it unsuitable for use as a diagnostic tool in clinical settings. In fact the ChEAT is mainly used in general population settings.

The Children’s Eating Disorder Inventory

The Eating Disorder Inventory (EDI; Garner, Olmstead, & Polivy, 1983) is a self-report questionnaire that measures eating disorder psychopathology and has psychometric properties that make it suitable for use as a screening instrument for eating disorders in non-clinical populations (Pike, 2005). There are three versions of the measure, the most commonly used to date being the EDI-2 (Garner, 1991b). This version consists of 91 items, mapping onto 11 scales: Body Dissatisfaction, Bulimia, Asceticism, Drive for Thinness, Ineffectiveness, Social Insecurity, Interpersonal Distrust, Perfectionism, Interoceptive Awareness, Impulse Regulation, and Maturity Fears.

The children’s version of the EDI (the EDI-C; Garner, 1991a) was developed by modifying the wording of some of the items of the EDI-2, making it more accessible for younger respondents. While some authors have found the EDI-C to have acceptable psychometric properties, similar to those of the EDI-2 (Thurfjell et al., 2003), research with non-clinical samples has cast doubt over the reliability of some of the subscales when the measure is used with young people and some authors have suggested that a different structure to the original EDI-2 might be more appropriate for children and adolescents (Eklund, Paavonen, & Almqvist, 2005). Like the EAT, the EDI can be useful as a screening instrument and for gathering information about eating behaviours and attitudes, but it is not a diagnostic tool (Pike, 2005).

The Children’s Eating Disorder Examination

The Eating Disorder Examination (EDE; Fairburn & Cooper, 1993) is a standardised, semi-structured, investigator-led interview that is widely used for the assessment of eating disorder psychopathology in adult populations. Frequently referred to as the ‘gold standard’ eating disorder assessment measure (e.g. Wilson, 1993), the EDE has been shown to have good psychometric properties when used with adults (Fairburn & Cooper, 1993; Rizvi et al., 2000; Cooper, Cooper, & Fairburn, 1989; Rosen et al., 1990).

The individual items of the EDE interview schedule assess the frequency and severity of eating disordered attitudes and behaviours over the 4 weeks prior to the interview taking place. Scores on these items can be used to generate subscale scores (the four subscales are Restraint, Eating Concern, Weight Concern, and Shape Concern) and a global score. The interview is also used to gather information about episodes of binge eating, self-induced vomiting, laxative misuse, diuretic misuse, and physical exercise used as a means of controlling weight or body shape. Diagnostic items in the schedule refer to thoughts, behaviours and physical symptoms during the 12 weeks prior to the interview. Responses to these items can be used to generate eating disorder diagnoses based on DSM-IV criteria.

The EDE has been adapted specifically for use with children and adolescents. This version of the interview (the ChEDE; Bryant-Waugh et al., 1996) has the same subscales, global score and diagnostic system as the adult version, but differs slightly in the way the questions are posed and the way in which some items are rated. For example, the rating takes into account the intention to behave in a certain way rather than the actual carrying out of the behaviour (Bryant-Waugh et al., 1996).

Findings from studies that have assessed the performance of the ChEDE in clinical samples have been mixed. The basic psychometric properties of the ChEDE were found to be good in a preliminary investigation by Watkins et al. (2005). However, Bryant-Waugh et al. (1996) found that 4 out of 11 participants (36.4%) with a clinical diagnosis of anorexia nervosa scored below the cut-off for clinical significance on key diagnostic items of the ChEDE. Other studies that assessed clinical samples using the ChEDE found that adolescents with anorexia nervosa received lower scores during the interview than adults with anorexia nervosa and adults and adolescents with bulimia nervosa (Binford, le Grange, & Jellar, 2005; Couturier & Lock, 2006). House et al. (2008) found that the ChEDE failed to identify an eating disorder in 35% of adolescents who were given a clinical diagnosis of either anorexia nervosa or EDNOS.

Couturier and Lock (2006b) modified the EDE in an attempt to make it better suited to the assessment of young people with anorexia nervosa. Use of this modified version did result in higher scores, but some participants denied behaviours that parents or clinicians reported were definitely occurring, and scores were still not as high as those seen in adult populations. Taken together, these findings imply that the ChEDE may have limitations when assessing young people with anorexia nervosa or related EDNOS (House et al., 2008).

In light of this, and in light of the length of time needed to complete the interview (approximately 60 minutes), alternatives to the standard ChEDE have been investigated for the assessment of children and adolescents. Couturier et al. (2007) developed parental and clinician interviews, to be completed in addition to the standard schedule. When they trialled these interviews they found that young people with bulimia nervosa reported more eating disorder symptoms than their parents, while young people with anorexia nervosa and related disorders received significantly lower subscale scores than their parents and clinicians (Couturier et al., 2007). While conducting multiple interviews is a potentially useful way of gathering as much information as possible about eating disorder symptoms, it is time consuming, requiring an hour of interviewing time per informant. In busy clinical settings this may not be a viable option.

A self-report questionnaire version of the EDE (the EDE-Q; Fairburn & Beglin, 1994) has been developed and a number of studies have aimed to determine the psychometric properties of this measure and to assess how useful it might be as an alternative to conducting the EDE interview (Olmstead et al., 2007). The EDE-Q is similar in structure to the EDE, allowing comparisons to be made between the two measures (Fairburn & Beglin, 1994), but the EDE-Q has the advantage of taking less than 15 minutes to complete (Fairburn & Beglin, 1994). A number of studies have compared the two measures with clinical and community samples of adults and have found discrepancies between subscale scores and reports of binge eating (e.g. Fairburn & Beglin, 1994; Black & Wilson, 1996).

Passi, Bryson and Lock (2003) conducted the first study to directly compare the EDE and the EDE-Q in a group of adolescent females with a clinical diagnosis of anorexia nervosa. They found that scores on the four subscales were consistently higher on the EDE-Q than on the EDE interview and that while all subscales were highly correlated across the two measures, scores on three of the four subscales differed significantly from each other across the measures. Binford et al. (2005) compared the EDE and the EDE-Q in a sample of adolescents with bulimia nervosa, partial-syndrome bulimia nervosa and anorexia nervosa. They found the greatest discrepancy between scores on the measures in the bulimia nervosa group.

The authors of these studies suggest that discrepancies between the measures may in part be due to informants being asked to complete the EDE-Q without the detailed instructions that are available to an EDE interviewer. When informants are given additional information prior to completing the EDE-Q, differences between EDE-Q and EDE scores are reduced (Passi et al., 2003; Carter, Aime, & Mills, 2001). Following direct comparisons of the EDE and the EDE-Q, most authors have concluded the EDE interview is superior for the assessment of clinical populations of adolescents with eating disorders. While the EDE-Q can be a useful screening tool and measure of eating disorder psychopathology, unlike the EDE it is not a diagnostic measure.

The Development and Well-Being Assessment

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References

The Development and Well-Being Assessment (DAWBA; Goodman et al., 2000) is a diagnostic instrument for child and adolescent psychiatric disorders. It can be administered in a face-to-face or online format. The DAWBA consists of a number of questionnaires, interviews and rating techniques designed to identify psychiatric problems based on the diagnostic systems of the DSM-IV and ICD-10. It is completed by the young person (aged 11+ years), a parent or carer and, in some cases, a teacher.

Each of the sections of the DAWBA begins with a set of screening questions. The responses to these questions determine whether the remainder of the section is disregarded or whether the respondent goes on to answer more detailed questions (if the answers to the screeners suggest they have some symptoms of a disorder). The different sections of the DAWBA contain open and closed questions about physical symptoms, thoughts and behaviours associated with different disorders. The closed questions map onto DSM-IV and ICD-10 diagnostic criteria, while responses to the open questions provide the interviewer with additional details about symptoms. In the online version of the DAWBA, the respondent completes the questions and submits their answers online. A computer algorithm then produces a diagnosis based on the closed questions. The diagnosis can then be reviewed by a trained clinical rater, who also considers the responses to the open questions.

The DAWBA has a dedicated eating disorders section, designed for use in epidemiological studies (Moya et al., 2005). This is similar in structure to the other sections, with screeners that lead on to more questions if an eating disorder is implied. Both the young person and parent/carer complete this section. Questions cover key eating disorder symptoms, such as dietary restriction, body image disturbance, binge eating and compensatory behaviours such as self-induced vomiting and laxative misuse.

This section of the DAWBA has been shown to have good basic psychometric properties (Moya et al., 2005). In a direct comparison of the diagnostic properties of the online DAWBA and the ChEDE, House et al. (2008) found that the DAWBA showed better agreement with diagnoses made by a multi-disciplinary clinical team than did the ChEDE. The generalisability of this study was limited, however, as it was conducted with a relatively small clinical sample of adolescents with anorexia nervosa, EDNOS or no definite eating disorder (and no cases of bulimia nervosa).

The face-to-face interview version of the eating disorder section of the DAWBA has the advantage of being faster to administer than other semi-structured interviews (taking approximately 15-20 minutes). The DAWBA also has the advantage of being available in a computerised, online format, and of being designed to obtain information from multiple informants (parents/carers as well as the young person). However, few studies have tested the reliability of the DAWBA in relation to eating disorders. Moreover, due to its structure, with skip rules at the beginning of the section, atypical cases might be missed.

Conclusions and future directions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References

Child and adolescent eating disorders are relatively common, and impact on social, physical and cognitive development. Valid and reliable assessment and screening measures are therefore very important. This applies not only to anorexia nervosa and bulimia nervosa, but also to the not otherwise specified category (EDNOS) and to sub-threshold symptoms that might have a significant impact on the sufferer.

The debate is still open in the eating disorders literature about the superiority of self-report questionnaires vs. interviews. In general, studies seem to suggest that self-report measures might be a viable alternative to interviewer-led measures when assessing eating disorders symptoms, so long as respondents are provided with comprehensive instructions. This debate also applies to computerised instruments. Some research findings in fact raise the question of whether computerised measures, such as the DAWBA, might be more useful than face-to-face interviews for diagnosing restrictive eating disorders in adolescents, perhaps due to the less stigmatising and less ‘confrontational’ approach.

The importance of including additional informants has also been highlighted and the use of parental reports has been shown to increase the reliability of available measures in children and adolescents. The issue of self-report instruments and additional parental report might be particularly important for restrictive eating disorders like anorexia nervosa, where denial of symptoms by the sufferer is common, rather than bulimia nervosa, where research has shown that young people in clinical settings report more of their symptoms.

Lastly, most measures used to assess child and adolescent eating disorders are derived from adult measures. Of the measures described above, the DAWBA is the only one to be designed originally for the younger age group. In view of the recent debate about differences in psychopathology and ability to report symptoms at younger ages, more research is needed to determine whether adult measures can be usefully adapted or whether assessment tools for children and adolescents should be conceptually different.

The continuing debate about assessment measures is important in view of the poor reliability of the most widely used diagnostic criteria for eating disorders in children and adolescents (Nicholls et al., 2000; Workgroup for the Classification of Eating Disorders in Children and Adolescents, 2007) and the current re-evaluation of these criteria (i.e. for the development of DSM-V and ICD-11).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Problems with diagnosing child and adolescent eating disorders: classification systems
  5. Other problems with assessing child and adolescent eating disorders
  6. Assessment measures for child and adolescent eating disorders
  7. The Development and Well-Being Assessment
  8. Conclusions and future directions
  9. References
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