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Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20

Factors Associated With Successful Completion in an Adolescent-Only Day Hospital Program for Eating Disorders a

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Seena Grewal , Karin Jasper , Cathleen Steinegger , Evelyn Yu & Ahmed Boachie

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Hospital for Sick Children , Toronto , Ontario , Canada Published online: 09 Dec 2013.

To cite this article: Seena Grewal , Karin Jasper , Cathleen Steinegger , Evelyn Yu & Ahmed Boachie (2014) Factors Associated With Successful Completion in an Adolescent-Only Day Hospital Program for Eating Disorders, Eating Disorders: The Journal of Treatment & Prevention, 22:2, 152-162, DOI: 10.1080/10640266.2013.860848 To link to this article: http://dx.doi.org/10.1080/10640266.2013.860848

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Eating Disorders, 22:152–162, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2013.860848

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Factors Associated With Successful Completion in an Adolescent-Only Day Hospital Program for Eating Disorders SEENA GREWAL, KARIN JASPER, CATHLEEN STEINEGGER, EVELYN YU, and AHMED BOACHIE Hospital for Sick Children, Toronto, Ontario, Canada

The purpose of this study was to examine factors associated with completion of an adolescent-only eating disorder day hospital program. A total of 65 adolescents were included. Completers were compared to non-completers on multiple variables including diagnosis, weight, and medication use. Adolescents who completed the program were more likely to have been prescribed antidepressants and less likely to purge. The two groups did not differ significantly on other variables. Few factors differentiated completers from non-completers of the eating disorder day hospital program. Further research is needed to determine the role medications or purging may play in completing treatment.

Engaging adolescents and their families in the treatment of an eating disorder (ED) is important given the high drop-out rates often seen in mental health treatment (Mahon, 2000). Dropout rates in treatment studies of adolescents with eating disorders are approximately 10% (Hoste, Zaitsoff, Hewell, & le Grange, 2007; Lock, Agras, Bryson, & Kraemer, 2005). Our understanding of factors associated with successful completion of treatment for adolescents is limited. Lock et al. (2006) reported that families were more likely to drop out of treatment during a randomized study for family therapy for anorexia nervosa when there was a comorbid diagnosis and when families were randomized to the longer treatment arm (Lock, Couturier, Bryson, & Agras, 2006). Hoste et al. (2007) found that the only difference between treatment dropouts and completers in a study involving adolescents with bulimia

Address correspondence to Seena Grewal, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada. E-mail: [email protected] 152

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nervosa was duration of illness. There has been less focus on other treatment modalities for adolescents with eating disorders such as day hospital programs. Day hospital programs have features that make them effective treatment options for addressing serious symptoms of eating disorders, namely they promote significant weight gain in individuals with anorexia nervosa (AN) (Exterkate, Vriesendorp, & De Jong, 2009; Fittig, Jacobi, Backmund, Gerlinghoff, & Wittchen, 2008; Jones, Bamford, Ford, & Schreiber-Kounine, 2007; Piran, Langdon, Kaplan, & Garfinkel, 1989) and reduce binge eating and purging in individuals with bulimia nervosa (BN) or AN-binge/purge type (Fittig et al., 2008; Piran et al., 1989; Zeeck et al., 2009). Day hospitals can improve symptoms of depression (Fittig et al., 2008; Jones et al., 2007; Schaffner & Buchanan, 2008) and family functioning (Woodside, Lackstrom, Shekter-Wolfson, & Heinmaa, 1996). While these improvements can also occur with inpatient treatment for eating disorders (Lowe, Davis, Annunziato, & Lucks, 2003; Zeeck et al., 2009), day hospital programs have the advantages of allowing adolescents to remain connected to their home environment (Zipfel et al., 2002) and peers, and are cost-effective compared to inpatient treatment (Birchall, Palmer, Waine, Gadsby, & Gatward, 2002). To date, there have been no studies reported in the pediatric literature describing factors associated with successful completion in an adolescentonly day hospital setting, however studies involving programs with adults or adults and adolescents have been reported. Fittig et al. (2008) reported there were no baseline differences between “successful” and “unsuccessful” completers diagnosed with AN, but successful completion for BN patients was associated with lower scores on the EDI bulimia subscale. Franzen, Backmund, and Gerlinghoff (2004) reported that non-completers had more binging and vomiting episodes prior to admission to a day hospital, were less socially inhibited and had a higher tendency to aggressive and extrovert behavior than completers. Howard et al. (1999) reported on factors associated with the successful transition of adolescents and adults with AN from inpatients to a day hospital program: a length of illness greater than 6 years, amenorrhea of greater than 2.5 years and a lower body mass index at the time of transfer predicted non-completion of the program (Howard, Evans, Quintero-Howard, Bowers, & Andersen, 1999). Other studies have reported non-completion in individuals with longer duration of illness, lower initial body mass index (Jones et al., 2007), transfer directly from an inpatient unit, and higher phobic scores on the Fear Questionnaire (Piran et al., 1989). The current study is one of the few to examine a day treatment program exclusively for adolescents. The purpose of this study was to investigate factors associated with successful completion of a day hospital program for adolescents and their families and to investigate potential predictors of length of stay in the program.

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METHODS Participants

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Patients admitted between 2002 and 2008 to the Eating Disorders Day Hospital program (EDDH) at The Hospital for Sick Children (SickKids) were included in the study. All individuals met DSM-IV (American Psychiatric Association, 2000) criteria for an eating disorder and were younger than 18 years at time of admission to the program. For participants with multiple admissions, only data from the first admission were included. The study was approved by the research ethics board at SickKids.

Description of the EDDH The EDDH is part of a continuum of care for eating disorders provided at SickKids that also includes inpatient and outpatient programs. Staff consists of family therapists, a psychiatrist, an adolescent medicine specialist, a nurse, dietitian, and child and youth counselors. The program also has a classroom with a dedicated school board certified teacher. Up to eight participants between the ages of 13 and 18 can attend the EDDH at one time and they attend 5 days per week. Most participants come from the city of Toronto and surrounding suburbs. The program is publically funded and there are no fees charged to families. Participants must be over 80% of their individualized goal weight to start the program and must be medically stable. Referrals are typically for individuals who have been unable to progress using outpatient treatment only or who have had multiple inpatient admissions followed by relapses. The goal weight (GW) for each participant is calculated by the program dietitian based on an adolescent’s pre-eating disorder growth curve, menstrual threshold if available and percent body fat and is adjusted over time to account for growth and development. The EDDH uses a family-based therapy model (Maudsley approach) adapted for day treatment in a milieu setting (Girz, Robinson, Foroughe, Jasper, & Boachie, 2012; Robinson Strahan, Girz, Wilson, & Boachie, 2012). Parents are responsible for keeping their children in regular attendance at the program and for managing their children’s food intake and related symptoms on the weekends. Parents attend weekly individual family therapy sessions and a weekly 2-hour multi-family group. Because peer relations are a significant source of both difficulties and support for adolescents, the EDDH uses group therapy and the milieu, including the idea of “existing expertise” to support recovery. More senior participants take the lead in supporting and challenging others at meals and in groups. The start date, rate of progress through the program, and end date is individualized for each participant. A participant is not considered to have completed the program unless she or he has reached his or her GW and maintained it long enough

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to demonstrate an ability to proceed with life without relying on eating disordered behaviours to cope. When an individual is ready to be discharged from the program, the transition is gradual.

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Procedure Charts for all individuals who were admitted to the program were reviewed. Demographic information including age at admission, gender, and diagnosis was collected as was information pertaining to the illness and treatment, such as weight data at admission and discharge and length of stay. Data pertaining to weight are presented as a percent of GW (%GW) in the program.

Statistical Analyses The current study was exploratory in nature and designed to examine similarities and differences between individuals who completed the day hospital program and those who did not. Continuous variables were analyzed for potential significant differences using t-tests. Categorical variables were compared using the Chi-Square test or Fisher’s Exact Test as appropriate. An exploratory multiple regression analysis was also performed to examine potential predictors of completion of the day hospital program.

RESULTS Characteristics of the Overall Sample A total of 65 adolescents met criteria for the study. The majority of participants were female (n = 61, 94%). The mean age at admission to the program was 15.6 years (SD = 1.4) and the mean age at onset of illness was reported as 13.3 years (SD = 1.4). As Table 1 shows, the majority of individuals had a diagnosis of anorexia nervosa, restricting type. The EDDH does not admit individuals who are extremely low weight (defined as less than 80% GW) and the range of %GW at entry was 79.7–105.9% with a mean of 91.7% (SD = 6.1). Four individuals in the program did not have a GW set because they were attending the program for binge-eating or bulimia-related symptom interruption. Weight was expected to stabilize when symptoms subsided. Therefore, a total of 61 participants had information regarding %GW available. The mean %GW at discharge from the program was 101.8% (SD = 7.7) and the range was 83.9–117.6%. The %GW at 6 months post-discharge was available for 29 participants. The mean %GW at 6 months was 100.2% (SD = 9.4) All the participants had received treatment for the eating disorder prior to beginning the EDDH program. The average length of stay in the program was 200.4 days (SD = 109.8) and ranged from 42 days to 517 days.

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TABLE 1 Descriptive Statistics of Overall Sample

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Item Diagnosis Anorexia nervosa, restricting type Anorexia nervosa, binge/purge type Eating disorder NOS (subsyndromal AN) Eating disorder NOS (subsyndromal BN) Bulimia nervosa, purging type Bulimia nervosa, nonpurging type Binge eating disorder Psychiatric comorbidity Major depressive disorder Bipolar affective disorder Generalized anxiety disorder Social phobia Obsessive compulsive disorder Substance abuse Eating disorder symptoms History of exercise as weight loss method History of purging Exercise not managed prior to discharge Previous treatment for the eating disorder Pediatric medical inpatient unit Specialized ED inpatient program Specialized ED outpatient program General psychiatry outpatient program Other ED day hospital program Psychiatric medications On any psychiatric medication SSRI Antipsychotics Menstrual history at admission Premenarcheal Med-free menses Secondary amenorrhea On oral contraceptive Menstrual history at discharge Premenarcheal Med-free menses Secondary amenorrhea On oral contraceptives Family history of an eating disorder Adolescent lives in household with both parents

n

%

39 9 4 4 5 2 2

60.0 13.8 6.2 6.2 7.7 3.1 3.1

21 1 29 6 13 3

32.3 1.5 44.6 9.2 20.0 4.6

50 18 12

76.9 27.7 18.5

24 51 57 3 4

37.5 78.5 87.7 4.6 6.2

46 50 16

70.8 76.9 24.6

8 25 25 3

13.1 41.0 41.0 4.9

5 40 7 9 16 41

8.2 65.6 11.5 14.8 24.6 63.1

Comparison of Completers Versus Non-completers Of the total group of adolescents who participated in the program, 38 (58.5%) completed the program as recommended by the treatment team and 27 (41.5%) left before completing the full program. Of those who did not complete the program, 10 left with reduced symptoms, eight had parents who chose to take their child out of the program against medical advice, six were

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Successful Completion of an Adolescent-Only Day Hospital TABLE 2 Comparison of Completers Versus Non-Completers

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Item Females Males Comorbid MDD, GAD, or OCD History of exercise as weight loss method History of purging Previous inpatient eating disorder treatment On psychotropic meds at admission On psychotropic meds while in program On SSRI at admission Prescribed SSRI in program On neuroleptic at admission Prescribed neuroleptic in program Family history of eating disorder Patient lives with both parents

Completers (total n = 38) n (%)

Non-completers (total n = 27) n (%)

35 (92.1) 3 (7.9) 34 (89.4)

26 (96.3) 1 (3.7) 19 (70.4)

Factors associated with successful completion in an adolescent-only day hospital program for eating disorders.

The purpose of this study was to examine factors associated with completion of an adolescent-only eating disorder day hospital program. A total of 65 ...
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