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Can collaboration between education and health professionals improve the identification and referral of young people with eating disorders in schools? A pilot study

Can collaboration between education and health professionals improve the identification and referral of young people with eating disorders in schools? A pilot study

ARTICLE IN PRESS Journal of Adolescence Journal of Adolescence 29 (2006) 137–151 www.elsevier.com/locate/jado Can collaboration between education an...

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ARTICLE IN PRESS

Journal of Adolescence Journal of Adolescence 29 (2006) 137–151 www.elsevier.com/locate/jado

Can collaboration between education and health professionals improve the identification and referral of young people with eating disorders in schools? A pilot study Liz Reesa,, Sam Clark-Stoneb a

CAMHS, Bowbridge Lane Stroud, Gloucestershire Partnership Trust, UK Eating Disorders Project, 36, Stroud Rd, Gloucestershire, GL1 5JR. UK

b

Abstract In this pilot study, a number of different methods of identifying young people with eating disorders in schools were compared. Pupils aged 16–18 years from 3 schools in the South West of the UK participated (389 boys and 374 girls in total). A self-report questionnaire (EDE-Q) was found to be the most effective method of case identification. However, very few of these cases accepted the offer of help and it was strongly suspected that other cases went undetected despite teacher, parent and school nurse guidance. Implications for future early intervention studies are discussed. r 2005 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Introduction Anorexia Nervosa, Bulimia Nervosa and Eating Disorders Not Otherwise Specified (EDNOS) are the three categories of eating disorders in the Fourth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV, American Psychiatric Association (APA), 1994). Binge eating disorder is subsumed within this latter category. Corresponding author.

E-mail addresses: [email protected] (L. Rees), [email protected] (S. Clark-Stone). 0140-1971/$30.00 r 2005 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.adolescence.2005.08.017

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Females account for the majority of cases, possibly due to the cultural ideal of slimness (Weiss, 1995) and the pervasive dieting that occurs in this population (Mickalide, 1990) which increases eight fold the risk of developing an eating disorder (Patton, Johnson-Sabine, Wood, Mann, & Wakeling, 1990). Due to their frequent exclusion from empirical investigations, less is known about eating behaviour in males. Those who do develop an eating disorder often have a history of obesity which may have led them to diet (Carlat & Camargo, 1991). However, they have the same symptoms, clinical correlates and core behaviours as females with eating disorders (Braun, Sunday, Huang, & Halmi, 1999; Ricciardelli, Williams, & Kiernan, 1999). Anorexia Nervosa is the least common eating disorder; it affects up to 1% of females (Rastam, Gillberg, & Garton, 1989) and 5–10% of sufferers are male, however, it is the third most common chronic adolescent illness (Lucas, Beard, O’Fallon, & Kurland, 1991). Bulimia affects between 0.5% (Santanastaso et al., 1996) and 3% of females (Fairburn & Beglin, 1990) and between 0.1% and 0.7% of males (Carlat & Camargo, 1991; Garfinkel et al., 1995) and has been described as a major public health problem (Fairburn, 1991). Binge Eating Disorder is thought to affect between 1.8% and 4.6% of women (Castonguay, Eldredge, & Agras, 1995) and 40% of cases are male (DSM-IV, American Psychiatric Association (APA), 1994). However, other partial syndromes (EDNOS) occur at much higher rates in the general population (Fairburn & Beglin, 1990; Schotte & Stunkard, 1987). The peak age of onset is adolescence to early adulthood in both females (Hoek, 1993; Joergensen, 1992; Steinhausen, Boydjieva, Grigoroiv-Serbanescu, Seidel, & Winkler Metake, 2000) and males (Braun et al., 1999; Carlat & Camargo, 1991) and the prevalence in both sexes appears to be increasing (Braun et al., 1999; Bushnell, Wells, Hormblow, Oakley-Browne, & Joyce, 1990; Eagles, Johnston, Hunter, Lobban, & Millar, 1995; Kendler et al., 1991). Eating disorders commonly persist for years (Slade, 1995) and seriously affect the physical and psychological health of the sufferer. However, many people with eating disorders do not seek treatment (Carlat & Camargo, 1991; Fairburn, 1983; Huon, 1985; Lucas et al., 1991). Adolescents in general, and males especially, often fail to seek help for mental health problems (Garland, 1995). However, the social stigma and secretiveness associated with eating disorders (Russell, 1992), failure to recognise the seriousness of the condition (Noordenbos, 1998) or a belief that intervention will lead to weight gain (Noordenbos, 1992) may act as further treatment deterrents. When it comes to treatment, early intervention improves the prognosis (Herzog, Rathner, & Vandereycken, 1992; Morgan & Russell, 1975; Steinhausen & Glanville, 1983) and provides a good rationale for early identification. A two stage, screening and interview method is often used to detect cases, however there is evidence that individuals with eating disorders often refuse to participate (Beglin & Fairburn, 1992; Johnson-Sabine, Wood, Patton, Mann, & Wakeling, 1988; King, 1989; Wade, Tiggemann, Martin, & Heath, 1997). Not announcing the day on which screening is to occur (Rathner, 1992) and face to face contact, rather than a postal screening (King, 1989) has been found to improve the response rate. Providing general practitioners (GP’s) with information and training has been shown to improve their detection rates (Hoek et al., 1995). However, GP’s often rely on self-report to make a diagnosis and many individuals with eating disorders often have difficulty telling their doctor directly about their eating behaviour (Noordenbos, 1992). There have been very few studies that have attempted to use methods of identification that bypass the need for self-report. Schools are perhaps a prime setting for early identification as they house a large, potentially at risk population (Neumark-Sztainer, 1996). Teachers can evaluate affective, cognitive and social difficulties, which are also commonly associated with eating

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disorders (Johnson & Larson, 1981). The school itself is a central point for communication between teachers and parents who can be easily accessed and informed about the available sources of help if their child is experiencing difficulties. Young people are often aware of each others difficulties (Cowie, 1999) and can provide an invaluable source of information about others who are in distress (Stewart, Troop, Todd, & Treasure, 1994) and the school nurse is able to make referrals to the health service. Teachers often come across young people with mental health problems (including eating disorders; (Stewart et al., 1994)), however, in the UK they are given very little mental health service support (Evans, 1999). A joint health and education approach would seem key, however, neither service has clear ownership in this area (Rosen & Neumark-Sztainer, 1998) and joint initiatives do not routinely occur. In the US however, there has been a national movement to augment the mental health services that are traditionally offered to schools. The preliminary reports about these Expanded School Mental Health (ESMH) services have been positive (Armbruster, Lichtman, & Koohyar, 1998; Illback, Kalafat, & Sanders, 1997). Research that encourages interest in a joint approach is needed in the UK to provide the groundwork for possible policy and systemic change. This study aimed to compare the effectiveness of different methods of identifying young people with eating disorders in schools. The interventions included: (1) Providing teachers and school nurses with written guidance about the identification and referral of young people with eating disorders. (2) Providing teachers and school nurses with a clinical consultation meeting. (3) Providing parents with a list of signs and symptoms of eating disorders and a contact number for the school nurse. (4) Using leaflets/posters to inform young people that teachers and/or the school nurse are available to help if they, or a friend have eating concerns. (5) Screening all of the young people for eating disorder symptoms using a self-report questionnaire. The inclusion of boys was thought to be important given the rising incidence in this population. Method Participants Three mixed sex state schools in one South West of the UK town participated. Two schools were allocated to the intervention status and one school was a control. The intervention school that could time-table a meeting with the head of the local NHS eating disorders clinic nearest to the start of the first term was allocated to the meeting and guidance group (school 1) and the other intervention school was allocated to the guidance only group (school 2). The control school will be referred to as school 3. School 1

Teachers and school nurses received guidance documents plus a consultation meeting with and expert on eating disorders

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School 2 School 3

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Teachers and school nurses received guidance documents only This control school did not receive any guidance or consultation.

Unlike schools 1 and 3, school 2 was a selective school that selects pupils on the basis of ability using an entrance examination. There is no evidence in the literature to suggest that there is a higher incidence of eating disorders in selective schools than in non-selective schools (Carter, Stewart, Dunn, & Fairburn, 1997). Although the socio-demographic status of the pupils’ families in each of the 3 schools was similar, it was possible that there was a slightly higher-class bias in school 2. There is some evidence in the literature of a higher incidence of eating disorders in the middle and upper classes (Askevold, 1992; Pope, Champonx, & Hudson, 1987; Szmukler, McCance, McCrone, & Hunter, 1986). Ethical issues relating to the study, in particular those of confidentiality, the stigma and secretiveness surrounding eating disorders were addressed with the assistance of the local research ethics committee. Parental involvement was also an issue and it was decided that only pupils over the age of 15, i.e. those in the 16–18 year old age group would be asked to participate in the study (as they could consent to participate for themselves). Pupils were given a research information sheet that enabled them to give full informed consent. They were also able to change their mind about participation at any stage in the study. Parents received information by post and were advised to talk to their child about any concerns that they had about involvement in the study but could not unilaterally withdraw their child from the study. The researcher was also mindful of the possible impact of the different gender of the two researchers and the context of the research on the data collection. Initially four schools agreed to participate in the study, but one school decided to withdraw. The study was suspended for a period of time by the local research ethics committee, until it could be established that proceeding with 3 schools would be scientifically and ethically appropriate. Table 1shows the number and percentage of boys and girls from each school who consented to participate in the study. In total there were 763 participants; 389 boys and 374 girls. Table 2 shows the number of staff within each school that were involved in the study, their gender, the mean number of contact hours (per week) that they had with the 16–18 year old pupils and the number of years that they had been in their profession. There were no significant differences in either the number of years that the teachers in the 3 schools had been in the teaching profession (Kruskal–Wallis, w22 ¼ 5.8, n.s.) or the number of contact hours that they had with the 16–18 year old pupils per week (w22 ¼ 2.6, n.s.). Table 1 The number and percentage of boys and girls from each school who consented to participate in the study School

1

2

3

Gender

Boys

Girls

Boys

Girls

Boys

Girls

Number consenting % of total consenting

85 94

108 99

123 95

127 95

181 96

139 96

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Table 2 Teacher and nurse information School

1

2

3

Male teachers Female teachers Mean contact hours (p/w)

7 7 11.1 (S.D. ¼ 6.3) 11.4 (S.D. ¼ 9.4) 1 Minimum 2 2.5

4 10 18.8 (S.D. ¼ 9.7) 8.2 (S.D. ¼ 3.4) 1 Minimum 2 11

3 7 9.2 (S.D. ¼ 7.8) 15 (S.D. ¼ 11.1) 1 Minimum 2 30

Years in profession Female school nurse Mean contact hours (p/w) Years in profession

Procedure Stage 1: Baseline knowledge, experience of eating disorders and referral rates To assess any baseline differences in knowledge and experience of eating disorders and confidence in case identification, the teachers and school nurse in each of the 3 schools completed a short questionnaire. The control school staff (school 3) were given this questionnaire at the end of the study. Stage 2: Teacher guidance document (available at www.edglos.org.uk) The school nurses and teachers in both intervention schools were given a guidance document about eating disorders which including signs and symptoms, their role in identification and referral and a contact phone number for the local eating disorders clinic. The staff in school 1 also attended a 50 min clinical consultation meeting with the head of the clinic who went through this information and answered questions. The staff in school 3 did not receive any guidance or attend a meeting. Stage 3: Screening for eating disorders The parents of the 16–18 year old pupils in all 3 schools received information (by post) about the study. During their registration period the pupils completed the Eating Disorders Examination Questionnaire (EDE-Q) and stated their height, weight and ideal weight. Pupils were also asked if they consented for a teacher or school nurse to forward their name to the researcher if there were concerns about his/her eating. The EDE-Q is a 38 item self report questionnaire which has been shown to be both reliable and valid in the assessment of eating disorders and allows a tentative diagnosis (Fairburn & Beglin, 1994; Luce & Crowther, 1999). Pupils whose responses on the EDE-Q met the criteria for an eating disorder that are printed below were invited for a clinical interview. These criteria are used in the Eating Disorders Examination and the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association (APA), 1994).

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Anorexia Nervosa. A body mass index (BMI) of less than 17.5 (one of the diagnostic criteria in the Tenth Edition of the International Classification of Diseases (ICD-10) (World Health Organisation, 1993) and intense fear of gaining weight (item scored as 4 or more) and feeling fat (item scored as 4 or more). Bulimia Nervosa. Episodes of binge eating with loss of control, eight or more times in the past month and use of inappropriate compensatory methods (self-induced vomiting, use of laxatives, diuretics or excessive exercise) eight or more times in the past month. Binge eating disorder. Eight or more episodes of binge eating with loss of control in the past month. EDNOS. Binges with loss of control that occurs at a frequency of less than 8 times a month (the criteria was set at 6, this criteria was set due to a natural break in the data). Inappropriate compensatory behaviour (such as vomiting) but no bingeing. Stage 4: Parent and pupil leaflets Pupils and their parents in the two intervention schools received a leaflet. The parents’ leaflet included a list of signs and symptoms of eating disorders and a contact number for the school nurse. The pupils’ leaflet stated that if they had concerns about their own or a friends’ eating, teachers and the school nurse could advise on how to receive help. The same information was displayed on posters in the pupils’ common rooms. Stage 5: Selection for a clinical interview After a period of 7 months (nearing the end of the academic year and before the examination period) pupils who had been identified by the EDE-Q or by a parent, peer, teacher, school nurse or had self identified to a member of staff and had consented for their name to be forwarded to the researcher were invited for a clinical interview. Stage 6: Clinical interview The Eating Disorders Examination (Fairburn & Cooper, 1993) is thought to be the gold standard clinical interview in the assessment of eating disorders (Wilson, 1993) and has also been shown to be valid and reliable with a good inter-rater reliability (Beglin, 1990; Cooper, Cooper, & Fairburn, 1989; Fairburn & Cooper, 1993; Rosen, Vara, Wendt, & Leitenberg, 1990; Wilson & Smith, 1989). Only the diagnostic items of the EDE were used as the purpose of the interview was purely to ascertain whether an individual met DSM-IV criteria for an eating disorder. Pupils were given the choice of attending the interview at school or on alternative premises. The interviews were conducted by the authors. In total, the research spanned a period of 7 months. Once the relevant questionnaires and information were disseminated, 4 months were allowed for pupils to be identified by peers/ parents/staff.

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Results Experience of eating disorders Overall, significantly more teachers knew of pupils with anorexia than bulimia (Kruskal–Wallis, w22 ¼ 3.9, po0:001) and many more teachers than school nurses knew of pupils with eating disorders. The teachers were also more confident in their ability to identify anorexia than bulimia (Mann–Whitney, U test, Z ¼ 4:35, po0:0001) and this was true for the teachers in each of the 3 schools (Z ¼ 2:7, po0:05, Z ¼ 2:7, po0:05 and Z ¼ 2:1, po0:05). There was one baseline difference between the 3 schools; the number of DSM-IV criteria for anorexia cited by the staff (Kruskal–Wallis, (w22 ¼ 7.6, po0:05) (1.8, 2.5 and 1, respectively). Interestingly, the teachers in school 1 agreed more with the statement ‘‘A school is an unsuitable place to identify young people with eating disorders’’ following the intervention (Z ¼ 2:0, po0:05). However, the teachers in both intervention schools were more confident in their ability to identify pupils with bulimia following the interventions (Z ¼ 2:00, po0:05 and Z ¼ 2:12, po0:05; respectively). Comparison of the different methods of identification None of the teachers from school 1 identified any pupils who they were concerned about. One teacher from school 2 mentioned a girl who she had concerns about (possible anorexia), however, she had not approached her because she felt that the concerns were not great enough. None of the parents of pupils in schools 1 or 2 rang the school nurse after receiving their leaflet. No pupils from school 1 saw the school nurse after receiving their leaflets. Three pupils from school 2 saw the school nurse; all three visits were made within 2 weeks of receiving the leaflet. Two of these females were concerned about their own eating and one other was concerned about another female in her year (possible anorexia). Unfortunately neither of the self-referring girls responded to attempts to contact them and the third girl had not been approached by the school nurse because she felt that the concerns were not great enough. Table 3 Boys in each school who were identified as having a possible eating disorder by the EDE-Q School number Total number of male participants (n)

1 85

2 123

3 181

BED Binge eating only

1

0

0

BN Binge eating and exercise

0

2

1

EDNOS Vomiting/laxatives/ diuretics Total number within each school (%)

0 1 1.1

2 4 3.2

1 2 1.1

Total number of possible male cases (%)

7 1.7

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Identification in school 3 The mothers of one male and one female pupil in school 3 contacted the researchers with concerns about their child after receiving the information about the study. Both young people were invited for an interview; however, the male pupil did not attend. The female pupil had also been identified on the EDE-Q as having possible bulimia. Although she no longer fitted the criteria for BN, her symptoms met the criteria for EDNOS. However, she did not consider herself to have an eating disorder and refused the offer of help. Identification using the EDE-Q Tables 3 and 4 show the boys and girls in each school who were identified as having a possible eating disorder by the EDE-Q. Tables 5 and 6 below show the number of male and female pupils who attended an interview, the number who did not attend (DNA) and the number of possible cases that were verified during the interview. In total, no male cases and eight female cases were identified by the EDE-Q and the interview, one of these female cases was also identified by her mother. Two of the girls accepted the offer of help and one had already sought help. The remaining six did not wish to receive help. Staff in school 2 suspected that one girl may have been anorexic, however, she had not been approached and it is unlikely that she participated in the study. Table 4 Girls in each school who were identified as having a possible eating disorder on the EDE-Q School number Total number of female participants (n)

1 108

2 127

3 139

Binge eating disorder Binge eating only

0

0

3

Bulimia nervosa Binge eating, vomiting and exercising Binge eating and laxatives Binge eating and exercise

0 0 0

0 0 1

1 1 1

Anorexia nervosa (non-purging) Low body weight and diet

1

0

1

Anorexia nervosa (purging) Low body weight, diet and diuretics

1

0

0

Eating disorders not otherwise specified Vomiting Sub-threshold binge eating Sub-threshold binge eating and exercising.

3 1 0

3 1 1

6 0 1

Total number in each school (%)

6 5.5

6 4.7

Total number of possible female cases (%)

26 6.9

14 10

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Table 5 Male cases who attended the interview and the number of verified cases Number attending interview

Number who did not attend the interview

Cases confirmed

School

1

2

3

1

2

3

1

2

3

BED Binge eating only BN Binge eating and exercise EDNOS Vomiting/laxatives/ diuretics Other method of identification Parent

1











0









1



2







0









2

1

















1







Table 6 Female cases who attended the interview and the number of verified cases. Number attending interview

Number who did not attend the interview

Cases confirmed

School

1

2

3

1

2

3

1

2

3

BED Binge eating only BN Binge eating, vomiting and exercise Binge eating and laxatives Binge eating and exercise AN purging Low body weight, diet and diuretics AN non purging Low body weight and diet EDNOS Vomiting Sub-threshold binge eating. Sub-threshold binge eating and Exercising





2





1





0





1











1

— — —

— 1 —

1 1 —

— — 1

— — —

— — —

— — —

— 1 —

1 0 —



1



1







0



2

2

5

1

1

1

1

2

2

1 —

1 1

— —

— —

— —

— 1

0 —

0 0

— —

— —

1 —

— —

— —

— 2

— —

— —

(1) —

Other method of identification : Parent — Self —

The case in brackets appears twice on this chart as she was identified both on the EDE-Q and by her mother.

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Discussion This study found that the EDE-Q screening questionnaire was more effective than the guidance document, training session and leaflets in identifying young people with eating disorders in the participant schools. The number of verified cases within each school was low however, and, for this reason, only small and tentative conclusions can be made from the study. Nevertheless, a number of interesting issues have been highlighted. The prevalence of bulimia is known to be higher than that of anorexia, nevertheless, perhaps due to the increased visibility of the disorder, the teachers and school nurses in the three participant schools knew of more pupils with anorexia than bulimia. The same trend was found in Stewart et al.’s (1994) study where 63% of matrons had come across pupils with anorexia and 45% had come across pupils with bulimia. Pre-intervention, the teachers in school 2 mentioned many more cases of anorexia than the other two schools and as a group, were more aware of the DSM-IV criteria for the disorder. This could be interpreted in one of two ways; an increased incidence of anorexia in this school or increased sensitivity (greater awareness) amongst the staff about the presence of pupils with the disorder. Either way, the trend seems to reflect Stewart et al.’s (1994) observation that once staff are alerted to the presence of anorexic pupils, they became more aware of bulimic pupils as the staff group in school 2 was the only one to mention bulimic pupils. The teachers knew of more pupils with eating disorders than the school nurses. Teachers have many more hours of direct contact with pupils and are perhaps more likely to be informed about those with an already diagnosed eating disorder than the school nurse. School nurses may be both unaware of the presence of pupils with eating difficulties and uninvolved in the referral process. The interventions with both schools 1 and 2 increased the teachers’ confidence in their ability to identify pupils with bulimia. However, it did not assist them to identify or approach pupils. The additional meeting that was held with the staff in school 1 did not lead to any additional benefits other than ensuring that the staff had read the guidance document. Interestingly, post intervention, the teachers in school 1 agreed more strongly with the statement that a ‘‘school is an un-suitable place to identify young people with eating disorders’’. This may reflect an un-easy attitude towards joint health and education initiatives that may be exacerbated following attempts to engage in collaboration. Despite the interventions, the majority of the teachers, neither school nurse nor none of the parents identified young people with eating disorders. Concerns were expressed about a female pupil in school 2 (with possible anorexia). However, neither the teacher nor the school nurse felt able to approach the girl. This possible case either did not participate in the study or did not fill out an EDE-Q truthfully and was not identified through screening. This was also the case in Meadows, Palmer, Newball, and Kenrick (1986) study where one anorexic female did not respond truthfully on her screening questionnaire. It was likely that peers were aware of each others difficulties but were either unwilling to break confidences or were engaging in eating disordered behaviour themselves. Eating disorders may be directly or indirectly supported by an individual’s peers as dieting is often highly endorsed (Meyer, 2001) and may reduce the likelihood that an individual will seek help (Beumont, Russell, & Touyz, 1995).

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Of all the methods of identification, the EDE-Q was the most effective in identifying young people with eating disorders, however, it is unlikely that it picked up all of the cases. The confirmed prevalence rate in the male group was 0%, and the confirmed rate in the female group was 0.5% for bulimia and 1.3% for EDNOS. Given the reported incidence rates in the literature, these rates are lower than expected. No cases of anorexia were picked up by the study which has also been the case in a number of other studies (e.g. Johnson-Sabine et al., 1988; Mann et al., 1983; Rathner & Messner, 1993; Santanastaso et al., 1996; Suzuki, Morita, & Kamoshita, 1990; Wlodarcyzk-Bisaga & Dolan, 1996); similarly, no cases of binge eating disorder were confirmed. It is possible that there were missed cases amongst the 18 males and 15 females who refused to participate from the beginning. It is likely that there were cases amongst the possible two bulimic and two males with EDNOS and the possible two bulimic cases and five females with EDNOS who refused to attend the interview. Missed cases were especially likely amongst those who reported vomiting, laxative or diuretic use on their screening questionnaire as the EDE-Q is thought to reliably assess these eating disorder symptoms (Luce & Crowther, 1999). However, three girls in school 3 who had reported vomiting on the EDE-Q did not report any episodes of vomiting during their interviews. This may reflect either an unwillingness to discuss this during the interview or the transient nature of some eating disorders. Reports of binge eating were perhaps less indicative of an eating disorder. Amongst the boys, the only two to attend the interview were the possible case of binge eating disorder and binge eating disorder with exercising (possible bulimia), neither were true cases. Amongst the girls, two of the three possible binge eating disorder cases attended the interview, neither were true cases and one of the two possible cases of binge eating and exercise (possible bulimia) was also disconfirmed. It is known that the more conceptually complex items on the EDE-Q may reduce its validity and this is especially true for the concept of ‘binge eating’ (Beglin, 1990; Fairburn & Beglin, 1994) as the clinical criteria do not match everyday notions of overeating, leading to false positive cases. Amongst the cases that were identified, two females accepted the offer of help and another female was already engaged with the eating disorders clinic. Neither of the cases of bulimia nor the three remaining cases of EDNOS believed that their symptoms were severe enough to accept help, despite the fact that they met DSM-IV criteria for an eating disorder. As dieting and weight control behaviours are fairly normative among adolescent females in many Western cultures (Griggs, Bowman, & Redman, 1996; Rodin, Silberstein, & Striegel-Moore, 1985) young people with eating disorder symptoms may see their behaviour as an extension of normal eating (Meyer, 2001). Non-compliance and denial of the disorder may also be strongest at the beginning when the recognisable physical effects are the smallest (Schoemaker, 1998). It is likely that this was the case for the young people in this study, furthermore, these screen detected cases had not sought treatment themselves and compliance may be expected to be lower (Schoemaker, 1998). The study was limited due to the small numbers of pupils with eating disorders in the three schools and the presence of only one school in each intervention group. Given these limitations, it was difficult to reliably compare the different methods of identification within each of the three schools. However, the methods of identification which were put in place to bypass the need for self-report were assessed to be largely unsuccessful. Parents were largely either unaware of their child’s disordered eating or were aware and chose not to utilise the school nurse. Education professionals were either unaware of pupils’ difficulties or were aware and did not feel confident

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enough to approach young people with suspected difficulties. The peers of young people on the whole may not have wished to break confidences or were involved in eating disordered behaviour themselves. Many of the young people with eating disorder symptoms avoided identification or denied that their symptoms were severe enough to warrant intervention. It may therefore be advisable for future early intervention projects to work proactively with the young people themselves, to educate them that eating disorder symptoms are not normal and to increase their motivation to seek help. A specialist mental health professional who can liase with staff, has sufficient time to use screening questionnaires, can work with young people individually or in a group and has an extensive enough training to use techniques such as motivational interviewing may be required. A model similar to the US Extended School programmes may be necessary if successful early identification of complex mental health problems such as eating disorders is to occur in schools.

References American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: Author. Armbruster, P., Lichtman, J., & Koohyar, P. (1998). Mental health treatment outcome in school based psychiatric settings. In C. Liberton, K. Kutash, & R. Friedman (Eds.), A system of care for children’s mental health: Expanding the research base. Tampa: Research and Training Centre for Children’s Mental Health. Askevold, F. (1992). Social class and psychosomatic illness. Psychotherapy and Psychosomatics, 38, 256–259. Beglin, S.J. (1990). Eating Disorders in young adult women. Unpublished masters thesis, University of Oxford, Oxford. Beglin, S. J., & Fairburn, C. G. (1992). Evaluation of a new instrument for the detection of eating disorders in community samples. Psychiatric Research, 44, 191–201. Braun, D. L., Sunday, S. R., Huang, A., & Halmi, K. A. (1999). More males seek treatment for eating disorders. International Journal of Eating Disorders, 25, 415–424. Bushnell, J. A., Wells, J. E., Hormblow, A. R., Oakley-Browne, M. A., & Joyce, P. (1990). Prevalence of three bulimia syndromes in the general population. Psychological Medicine, 20, 671–680. Carlat, D., & Camargo, C. (1991). Review of bulimia nervosa in males. American Journal of Psychiatry, 148, 831–843. Carter, J. C., Stewart, D. A., Dunn, V. I., & Fairburn, G. (1997). Primary prevention of eating disorders, might it do more harm than good? International Journal of Eating Disorders, 22, 167–172. Castonguay, L. G., Eldredge, K. L., & Agras, W. S. (1995). Binge eating disorders. Current state and future directions. Clinical Psychology Review, 15, 865–890. Cooper, Z., Cooper, P. J., & Fairburn, C. G. (1989). The validity of the Eating Disorders Examination and its subscales. British Journal of Psychiatry, 154, 807–812. Cowie, H. (1999). Peers helping peers: interventions, initiatives and insights. Journal of Adolescence, 22, 433–436. Eagles, J. M., Johnston, M. I., Hunter, D., Lobban, M., & Millar, H. R. (1995). Increasing incidence of anorexia nervosa in the female population of North East Scotland. American Journal of Psychiatry, 152, 1266–1271. Evans, S. W. (1999). Mental health services in schools: Utilisation, effectiveness and consent. Clinical Psychology Review, 19(2), 165–178 PII:S0272-7358(98)00069-5. Fairburn, C. G. (1983). Bulimia: Its epidemiology and management. Psychiatric Annals, 13, 953–961. Fairburn, C.G. (1991). Paper presented at the International Conference on Eating Disorders, Paris, 17–19th April. Fairburn, C. G., & Beglin, S. J. (1990). Studies of the epidemiology of Bulimia Nervosa. American Journal of Psychiatry, 147, 401–408. Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self report questionnaire? International Journal of Eating Disorders, 16, 363–370. Fairburn, C. G., & Cooper, Z. (1993). The Eating Disorders Examination. In C. G. Fairburn, & G. T. Wilson (Eds.), Binge eating: Nature, assessment and treatment, (12th Ed) (pp. 317–360). New York: Guilford.

ARTICLE IN PRESS L. Rees, S. Clark-Stone / Journal of Adolescence 29 (2006) 137–151

149

Garfinkel, P. E., Lin, E., Goering, P., Spegg, C., Goldbloom, D. S., Kennedy, S., Kaplan, A. S., & Woodside, D. B. (1995). Bulimia Nervosa in a Canadian Community sample: Prevalence and comparison of subgroups. American Journal of Psychiatry, 18, 1052–1058. Garland, A. F. (1995). Pathways to adolescent mental health services: Adolescent help seeking and teacher identification and referral. Dissertation Abstracts—International—Section B. The Sciences and Engineering, 55(7-B), 3013. Herzog, W., Rathner, G., & Vandereycken, W. (1992). Long term course of anorexia nervosa: A review of the literature. In W. Herzog, H. C. Deter, & W. Vandereycken (Eds.), The course of eating disorders (pp. 15–29). Berlin, New York: Springer. Hoek, H. W. (1993). Review of the epidemiological studies of eating disorders. International Review of Psychiatry, 5, 61–74. Hoek, H. W., Bartelds, A. I. M., Bosveld, J. F., Yolanda van der Graff, M. A., Veronique, E. L., Limpens, M. A., et al. (1995). Impact of Urbanization on Detection Rates of Eating Disorders. American Journal of Psychiatry, 152, 9. Huon, G. F. (1985). Therapy at a distance. In S. Touqz, & P. J. Beumont (Eds.), Eating Disorders: Prevalence and treatment. Syndney: Adis Health Science Press. Illback, R. J., Kalafat, J., & Sanders, D. (1997). Evaluating integrated service programs. In R. J. Illback, & H. M. Cobb (Eds.), Integrated services for children and families. Opportunities for psychological practice (pp. 323–346). Washington, DC: American Psychological Association. Joergensen, J. (1992). The epidemiology of eating disorders in Fyn County, Denmark, 1977–1986. Acta Psychiatrica Scandanavia, 85, 30–34. Johnson, C. L., & Larson, R. (1981). Bulimia: an analysis of moods and behaviour. Psychosomatic Medicine, 44, 341–353. Johnson-Sabine, E., Wood, K., Patton, G., Mann, A., & Wakeling, A. (1988). Abnormal eating attitudes in London school girls. A prospective epidemiological study. Factors associated with abnormal responses on screening questionnaires. Psychological Medicine, 18, 615–622. Kendler, K. S., MacLean, C., Neale, M., Kessler, R., Health, A., & Eaves, L. (1991). The genetic epidemiology of bulimia nervosa. American Journal of Psychiatry, 148, 1627–1637. King, M. B. (1989). Eating disorders in a general practice population: Prevalence, characteristics and follow up at 12–18 months. Psychological Medicine, 22, 951–959. Lucas, A. R., Beard, C. M., O’Fallon, W. M., & Kurland, L. T. (1991). 50 year trends in the incidence of anorexia nervosa in Rochester, Minnesota. A population based study. American Journal of Psychiatry, 148, 917–922. Luce, K. H., & Crowther, J. H. (1999). The reliability of the Eating Disorders Examination—Self report questionnaire version (EDE-Q). International Journal of Eating Disorders, 25, 349–351 PII:0276-3478/99030349-03. Mann, A. H., Wakeling, A., Wood, A., Monck, E., Dobbs, R., & Szmukler, G. (1983). Screening for abnormal eating attitudes and psychiatric morbidity in an unselected population of 15-year old school girls. Psychological Medicine, 13, 573–580. Meadows, G. N., Palmer, R. L., Newball, E. V. M., & Kenrick, J. M. T. (1986). Eating attitudes and disorders in young women: A general practice based survey. Psychological Medicine, 16, 351–357. Meyer, D. F. (2001). Help seeking for eating disorders in female adolescents. Journal of College Student Psychotherapy, 15(4), 23–26. Mickalide, A. D. (1990). Sociocultural factors influencing weight amongst males. In A. E. Andersen (Ed.), Males with eating disorders (pp. 30–39). New York: Brunner/Mazel. Morgan, H. G., & Russell, G. F. M. (1975). Value of family background and clinical features as predictors of long term outcome in anorexia nervosa: 4 year follow up of 41 patients. Psychological Medicine, 5, 255–371. Neumark-Sztainer, D. (1996). School based program for preventing eating disorders. Journal of school health, 66, 64–71. Noordenbos, G. (1992). Important factors in the process of recovery according to patients with anorexia nervosa. In W. Herzog, H. C. Deter, & W. Vandereycken (Eds.), The course of eating disorders. Long term follow-up studies of anorexia and bulimia nervosa (pp. 304–323). Berlin, Heidelberg: Springer. Noordenbos, G. (1998). Eating disorders in primary care: Early identification and intervention by GP’s. In W. Vandereycken, & G. Noordenbos (Eds.), The prevention of eating disorders. London: Athlone Press.

ARTICLE IN PRESS 150

L. Rees, S. Clark-Stone / Journal of Adolescence 29 (2006) 137–151

Patton, G., Johnson-Sabine, W., Wood, K., Mann, A., & Wakeling, A. (1990). Abnormal eating attitudes in London schoolgirls: A prospective epidemiological study. Psychological Medicine, 20, 3394–3883. Pope, H. G., Champonx, R. F., & Hudson, J. I. (1987). Eating disorders and socio-economic class: Anorexia nervosa and bulimia in nine communities. Journal of Nervous and Mental Disease, 175, 620–623. Rastam, M., Gillberg, C., & Garton, M. (1989). Anorexia nervosa in a Swedish urban region. A population based study. British Journal of Psychiatry, 155, 642–646. Rathner, G. (1992). Aspects of the natural history of normal and disordered eating and some methodological considerations. In W. Herzog, H. C. Deter, & W. Vandereycken (Eds.), The course of eating disorders (pp. 198–213). Berlin, NY: Springer. Rathner, G., & Messner, K. (1993). Detection of eating disorders in a small rural town: An epidemiological study. Psychological Medicine, 23, 175–184. Ricciardelli, L. A., Williams, R. J., & Kiernan, M. J. (1999). Bulimia symptoms in adolescent girls and boys. International Journal of Eating Disorders, 26, 217–221. Rosen, J. C., & Neumark-Sztainer, P. (1998). Review of options for primary prevention of eating disorders among adolescents. Journal of adolescent health, 23(6), 355–362. Rosen, J. C., Vara, L., Wendt, S., & Leitenberg, H. (1990). Validity studies of the Eating Disorders Examination. International Journal of Eating Disorders, 9, 519–528 PII:0276-3478/90/050519. Russell, G. F. M. (1992). The prognosis of eating disorders: A clinician’s approach. In W. Herzog, & H. C. Deter (Eds.), The course of eating disorders, long term follow up studies of anorexia and bulimia nervosa (pp. 198–213). London: Springer-Verlag, Athlone Press. Santanastaso, P., Zanetti, T., Sala, A., Favaretto, G., Vidotto, G., & Favaro, A. (1996). Prevalence of eating disorders in Italy: A survey on a sample of 16 year old female students. Psychotherapy and Psychosomatics, 65, 158–162 PII:0033-3190/96/0653. Schoemaker, C. (1998). The principles of screening for eating disorders. In W. Vandereycken & G. Noordenbos (Eds.), The prevention of eating disorders. Schotte, D. E., & Stunkard, A. J. (1987). Bulimia versus bulimic behaviours on a college campus. Journal of the American Medical Association, 258, 1213–1215. Slade, P. (1995). Prospects for prevention. In G. Szmukler, C. Dare, & J. Treasure (Eds.), Handbook of eating disorders. Theory, treatment and research (pp. 387–398). Chichester (1998): Wiley. Steinhausen, H. C., Boydjieva, S., Grigoroiv-Serbanescu, M., Seidel, R., & Winkler Metake, C. A. (2000). A transcultural outcome study of adolescent eating disorders. Acta Psychiatrica Scandanavia, 101, 60–66. Steinhausen, H. C., & Glanville, K. (Eds.). (1983). Editorial: Follow-up studies of anorexia nervosa: A review of the research findings. Psychological Medicine, 13, 239–249. Stewart, M., Troop, N., Todd, G., & Treasure, J. (1994). Eating disorders in boarding schools: A survey of school matrons. European Eating Disorders Review, 2, 106–111. Suzuki, M., Morita, H., & Kamoshita, S. (1990). Epidemiological survey of psychiatric disorders in Japanese school children. Part III: Prevalence of psychiatric disorders in junior high school children. Nippon Koshu Eisei Zasshi, 37, 991–1000. Szmukler, G., McCance, C., McCrone, L., & Hunter, D. (1986). Anorexia nervosa: A psychiatric case register study from Aberdeen. Psychological Medicine, 16, 49–58. Wade, T., Tiggemann, M., Martin, N. G., & Heath, A. C. (1997). Characteristics of interview refusers: Women who decline to participate in interviews related to eating. International Journal of Eating Disorders, 22, 95–99 PII:02763478/97/0100095-05. Weiss, M. G. (1995). Eating disorders and disordered eating in different cultures. Cultural Psychiatry, 18(3), 537–553. Wilson, G. T. (1993). Binge eating and addictive disorders. In C. G. Fairburn, & G. T. Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 97–122). New York: Guildford Press. Wilson, G. T., & Smith, D. (1989). Assessment of bulimia nervosa: An evaluation of the Eating Disorders Examination. International Journal of Eating Disorders, 8, 173–179. Wlodarcyzk- Bisaga, K., & Dolan, B. (1996). A two stage epidemological study of abnormal eating attitudes and their prospective risk factors in Polish school girls. Psychological Medicine, 26, 1021–1032.

ARTICLE IN PRESS L. Rees, S. Clark-Stone / Journal of Adolescence 29 (2006) 137–151

151

World Health Organisation. (1993). The ICD-10. Classification of mental and behavioural disorders: Diagnostic criteria for research. World Health Organisation: Geneva.

Further reading Crisp, A. H., Palmer, R. L., & Kalucy, R. S. (1976). How common is anorexia nervosa? A prevalence study. British Journal of Psychiatry, 128, 549–554. Moor, S., Shanock, G., Scott, J., McQueen, H., Wrate, R., Cowaan, J., et al. (2000). Journal of Adolescence, 23, 324–331.