Assessment and Treatment of Pediatric Eating Disorders: A Survey of Physicians and Psychologists

Abstract

Studies show that primary care clinicians struggle with the assessment and treatment of eating disorders in adults. There are no known studies examining current practices of clinicians with respect to eating disorders in children and adolescents. The following study describes the key practices of primary care clinicians in Ontario, Canada, around the screening, assessment, and treatment of eating disorders in children and adolescents.
A 24-item survey was developed to obtain information from family physicians and psychologists about presenting complaints and current practices related to the assessment and treatment of eating disorders.
Findings of this study suggest that despite discipline-specific differences, a large proportion of clinicians do not routinely screen for eating disorders, and when eating disorders are assessed and treatment is initiated, family members are not routinely involved in the process.
In Ontario, primary care clinicians may benefit from more training and support to better identify and treat children and adolescents with eating disorders. In particular, clinicians may require additional training around screening, multi-informant assessment methods, as well as appropriate therapy techniques.

Full text

J Can Acad Child Adolesc Psychiatry, 21:1, February 2012 45
rESEArCH ArTICLE..
Assessment and Treatment of Pediatric Eating Disorders:
A Survey of Physicians and Psychologists
Adèle Lafrance Robinson PhD, CPsych1; Ahmed Boachie MB ChB, MRCPsych, DCH,
FRCP(C)2,3; Glenys A. Lafrance PhD4
1Laurentian University, Sudbury, Ontario
2Southlake Regional Health Centre, Newmarket, Ontario
3University of Toronto, Toronto, Ontario
4Avanti Insight, London, Ontario
Corresponding email: acrobinson@laurentian.ca
Submitted: February 22, 2011; Accepted: May 27, 2011
█Abstract
Objective: Studies show that primary care clinicians struggle with the assessment and treatment of eating disorders in
adults. There are no known studies examining current practices of clinicians with respect to eating disorders in children
and adolescents. The following study describes the key practices of primary care clinicians in Ontario, Canada, around
the screening, assessment, and treatment of eating disorders in children and adolescents. Method: A 24-item survey
was developed to obtain information from family physicians and psychologists about presenting complaints and current
practices related to the assessment and treatment of eating disorders. Results: Findings of this study suggest that despite
discipline-specic differences, a large proportion of clinicians do not routinely screen for eating disorders, and when eating
disorders are assessed and treatment is initiated, family members are not routinely involved in the process. Conclusion:
In Ontario, primary care clinicians may benet from more training and support to better identify and treat children and
adolescents with eating disorders. In particular, clinicians may require additional training around screening, multi-informant
assessment methods, as well as appropriate therapy techniques.
Key words: eating disorders, children and adolescents, assessment and treatment, primary care
█Résumé
Objectifs: Les cliniciens chargés des soins primaires ont des difcultés à diagnostiquer et à traiter les troubles
alimentaires chez les adultes. À notre connaissance, aucune étude n’examine les pratiques actuelles des cliniciens qui
traitent les troubles alimentaires chez les enfants et les adolescents. Cet article expose les principales pratiques des
cliniciens responsables des soins primaires en Ontario, et plus particulièrement en ce qui a trait au triage, à l’évaluation
et au traitement des troubles alimentaires chez les enfants et les adolescents. Méthodologie: Des généralistes et des
psychologues ont répondu à 24 questions sur les symptômes des troubles alimentaires et sur leurs méthodes d’évaluation
et de traitement. Résultats: Malgré les différences propres à chaque discipline, la majorité des cliniciens ne fait pas
de triage en matière de troubles alimentaires. Lorsqu’ils diagnostiquent les troubles alimentaires et mettent en place
le traitement, les cliniciens n’impliquent généralement pas les membres de la famille. Conclusion: En Ontario, les
responsables des soins primaires gagneraient à suivre des formations complémentaires et à avoir davantage de soutien,
an de mieux dépister les troubles alimentaires chez enfants et les adolescents et d’améliorer le traitement de ces derniers.
Les cliniciens peuvent notamment demander à être formés aux techniques d’évaluation par plusieurs intervenants et aux
thérapies appropriées.
Mots clés: troubles alimentaires, enfants et adolescents, évaluation et traitement, soins primaires
Lafrance Robinson et al

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Lafrance Robinson et al
J Can Acad Child Adolesc Psychiatry, 21:1, February 2012
Eating disorders (ED) are the third most common chron-
ic disease among adolescent females after asthma and
obesity (Golden et al., 2003). Approximately 0.5% of the
population in Canada is suffering from anorexia nervosa
(AN), 1% from bulimia nervosa (BN), and 3% to 5% from
other disordered eating patterns severe enough to warrant
clinical attention (Garnkel et al., 1995, 1996). The annual
mortality rate of 15- to 24-year old females with anorexia
nervosa is 12 times that of the general population and can
be as high as 20% (National Institute of Mental Health
[NIMH], 2001). Up to 50% of adult ED patients are unre-
sponsive to standard treatment protocols, and progress on to
chronic medical and psychosocial impairments which not
only severely impair quality of life, but also lead to exorbi-
tant health care system costs (NIMH, 2001).
Diagnosis and Treatment of ED in
General and Adult Populations
Research suggests that physicians struggle with the assess-
ment and diagnosis of ED in general (Boulé & McSherry,
2002; Burnsten, Gabel, Brose & Monk, 1996; Clarke & Po-
limeni-Walker, 2004). This is a serious problem given that
ED patients visit their family physicians signicantly more
frequently than matched controls in the ve years prior to a
diagnosis (Ogg & Millar, 1997), and that early detection of
ED can be related to patient outcome (Hall, Slim, Hawker
& Salmond, 1984). For example, Bursten, Gabel, Brose,
and Monk (1996) surveyed family physicians on the assess-
ment and diagnosis of BN in the general population and
reported that, despite a general prevalence rate of 1% for
the disorder, almost one-third of physicians reported no cur-
rent or past ofce contact with bulimia, and more than half
(60%) reported having no bulimic patients on their caseload
at the time of the survey. When physicians did report see-
ing bulimic patients, the majority (86.9%) reported provid-
ing medical care only and chose to refer to specialists for
counseling. Only 3.4% of respondents reported managing
all aspects of these patients’ care.
Researchers in Canada also conducted a survey among fam-
ily physicians which yielded similar results with respect to
the assessment and diagnosis of ED in the general popu-
lation (Boulé & McSherry, 2002). The authors found that
nearly 20% of family physicians surveyed reported having
no patients with ED in their practice, and 3% of respondents
reported never having seen a patient with an ED. In addi-
tion, the authors reported that a mere 25.4% of respondents
admitted to routinely screening for ED. With respect to
treatment, the majority of physicians (87%) reported shar-
ing patient care with other health professionals including
psychiatrists, nutritionists and psychologists. Only 3.6%
of respondents indicated that they managed all aspects of
patient care, compared to 7.1% who reported referring all
aspects of care.
Diagnosis and Treatment of ED in
Child and Adolescent Populations
To date, there have been no studies examining the practices
of physicians with respect to the assessment and treatment
of ED in children and adolescents. The only known study
related to the assessment of pediatric ED was conducted
with pediatricians, general practitioners, and school medi-
cal ofcers using clinical vignettes of AN in children (Bry-
ant-Waugh, Lask, Shafran & Frosson, 1992). The results
of this study revealed that only 33% of pediatricians con-
sidered AN in their differential diagnosis, while only 2%
of primary care physicians did so. Those who did consider
ED in their differential diagnosis indicated that treatment
should include medical management (including blood and
urine analyses), as well as frequent appointments with the
child and/or referral to a mental health specialist.
The Current Study
Overall, it is clear that physicians struggle with the assess-
ment and treatment of ED in adult populations and in gener-
al. However, there are no known studies examining the cur-
rent practices of primary care physicians with respect to ED
in children and adolescents specically. In addition, despite
the fact that psychologists are qualied to assess, diagnose,
and treat mental disorders, including ED, there have been
no studies examining their practices. This is particularly rel-
evant given that more and more research is pointing to the
importance of family involvement in child and adolescent
mental health in general (Josephson & Diamond, 2005),
and more specically in the treatment of ED. For example,
behavior-based family therapy (family-based therapy or the
Maudsley approach) in conjunction with medical monitor-
ing is considered best practice in the treatment of ED in
children and adolescents (see Loeb & le Grange, 2009, for
a review of the research ndings). As a result, the following
study describes the key practices of primary care clinicians
in Ontario, Canada with respect to ED in children and ado-
lescents by identifying (a) common presenting complaints
and current practices related to assessment, as well as (b)
current practices related to treatment, including referral
pathways. These practices are explored in relation to clini-
cians’ (a) discipline (physician/psychologist); (b) clinic sta-
tus (the absence/presence of children and adolescents with
ED within an individual’s practice); and (c) family-focus
status (the degree to which ED clinicians reported using a
family-focused approach to assessment and treatment).

J Can Acad Child Adolesc Psychiatry, 21:1, February 2012 47
Assessment and Treatment of Pediatric Eating Disorders: A Survey of Physicians and Psychologists
Method
Materials
A 24-item survey informed by previously used survey in-
struments was developed (Boulé & McSherry, 2002; Clarke
& Polimeni-Walker, 2004). Several clinicians reviewed a
draft of the survey and revisions were made based on their
feedback. The study received approval from the institu-
tional research ethics board. Participants were advised in a
covering letter that surveys returned by mail, fax, or elec-
tronically would assume informed consent.
Although the scope of the survey was broader, this study fo-
cuses on the results associated with items pertaining to cli-
nicians’ assessment and treatment practices and pathways
when pediatric ED was suspected or identied.
Participants
Individuals eligible to participate in the study included
family physicians and psychologists/psychological associ-
ates whose practices included children and/or adolescents
in the province of Ontario, Canada. From here on, the term
psychologist is used to describe both psychologists and psy-
chological associates. Participants were recruited via (a) a
mail-in survey targeted to clinicians within a metropolitan
area, and (b) two electronic list-serves (Ontario Psycho-
logical Association and Ontario College of Family Physi-
cians). A list of potential participants was compiled using
web-based directories of The College of Physicians and
Surgeons of Ontario and The College of Psychologists of
Ontario.
A total of 783 potential participants were identied and con-
tacted at Stage 1 via mail-outs. Of these, 95 (12%) returned
surveys. At Stage 2, 73 online surveys were collected via
list-serves. Fifteen surveys were removed from the analyses
because respondents did not specify discipline, leaving a
valid sample of 153 respondents.
Statistical Procedures
Descriptive statistics included (a) the median for ordinal
and non-normal continuous variables, and (b) percentages
for categorical variables. Group differences were assessed
on the basis of primary grouping variables and, where war-
ranted, interactions among them were examined. The pri-
mary grouping variables were: (a) discipline (physicians/
psychologists), (b) clinic status (non-ED/ED), and (c)
family-focus status (non family-focused/family-focused).
Fisher’s Exact Test (chi-square, FET) and Mann-Whitney
(U) tests were used to detect group differences, if any.
Where multiple tests were conducted, a correction to alpha
was applied. In the presence of a signicant FET result,
the adjusted standardized residuals (ASR) produced with
contingency table analyses were examined to locate group
differences associated with individual response values. An
ASR value >2 was considered signicant.
Group effects from categorical data are reported using odds
ratios (condence intervals) and an r estimate was derived
(Z/sqrt(N)) for Mann-Whitney tests. All statistical tests
were two-tailed; the level of precision was a = 0.05, with
p-values < .05. Unless noted, non-signicant results were
omitted.
Results
Discipline and Clinic Status
The disciplines were equally represented across the sample,
with 76 physicians and 77 psychologists. Approximately
63% of the total sample reported seeing ED in their prac-
tice. Physicians were 4.3 (CI = 2.1, 8.7) times more likely
than psychologists to do so.
Family-focus Status
Assessment. Only clinicians who reported having children
and/or adolescents with identied or suspected ED in their
practice were asked to answer questions regarding family
involvement in assessment. Table 1 provides the response
frequencies to the question that asked, “How often do you
involve the family in identication and/or assessment of an
eating disorder?” Approximately 65% of ED clinicians re-
ported “usually” or “always” involving the family in the
assessment of ED in children or adolescents (N = 90, Mdn
= “usually”). Although the disciplines’ medians were the
same, there were signicant differences in the distributions
of the values. None of the ED physicians (n = 57) compared
to 12% of the ED psychologists (n = 33) reported “never”
involving the family in the assessment. On the other hand,
only 25% of the ED physicians, compared to 46% of the ED
psychologists, reported always involving the family.
Treatment. In terms of treatment, approximately 61% of
ED clinicians reported “usually” or “always” involving the
family in the treatment of ED (n = 90, Mdn = “usually”)
in response to the following question: “How often do you
involve the family in the treatment of an eating disorder?”
Distributions of the values did not vary signicantly by dis-
cipline (Table 1).
Family-focus status. In line with the literature on the im-
portance of family involvement, the sample was stratied
into two categories (using the median as a cut-off) to dis-
cern the clinicians involvement of the family with respect
to the assessment and treatment processes. The two values
associated with the new variable, family-focus status (FFS),
were (a) NFF = clinicians who did not usually/always in-
volve families in both assessment and treatment, and (b)

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Lafrance Robinson et al
J Can Acad Child Adolesc Psychiatry, 21:1, February 2012
FF = clinicians who usually/always did. Approximately half
of ED clinicians were categorized as “FF”, irrespective of
discipline.
To deepen our understanding of current ED practices and
pathways, the remaining assessment and treatment items
were analysed in the context of each of the attribute vari-
ables (discipline, clinic status and family-focus status).
Clinical Interview
When asked the following question: “During clinical as-
sessment or health examinations, how often does your clini-
cal interview or functional inquiry include questions about
eating behaviours?” overall, clinicians reported doing so
often or more (62%, Mdn = “often”). Only 5% of the par-
ticipants reported never screening, while only 16% claimed
that they always screen. Interestingly, this question had the
highest rate of missing entries. Table 2 reports response fre-
quencies and group comparisons.
Discipline Effect. Psychologists were 4.1 times (CI = 1.2,
18.8) more likely than physicians to report “always” ask-
ing questions related to eating; however, the FET result
was non-signicant once the multiple test correction was
applied. No signicant interaction was noted between dis-
cipline and clinic status.
Table 1. Family involvement in the assessment and treatment of pediatric eating
disorders
Discipline
Family-focus status item
Total
(N = 90)
ED Physician
(n = 57)
ED Psychologist
(n = 33)
Family involvement in assessment
Never 4% 0%* 12%*
Occasionally 12% 16% 6%
Often 19% 26%* 6%*
Usually 32% 33% 30%
Always 33% 25%* 46%*
Family involvement in treatment
Never 5% 3% 7%
Occasionally 10% 10% 10%
Often 24% 26% 21%
Usually 29% 29% 28%
Always 32% 32% 34%
Note. ED = pediatric eating disorder, N = sample size, n = sub-sample size.
* = signicant group differences, FET two-tailed p < .001/ASD > 2.0, comparator groups share symbols row-wise within grouping factors.
Table 2. Eating behaviours questions included in clinical interviews or functional
inquiries. Discipline by clinic status.
Clinic status
Non-ED ED
Clinical interview ED scope
Total
(N = 84)
Physician
(n = 12)
Psychologist
(n = 17)
Physician
(n = 38)
Psychologist
(n = 17)
Median*
3.0 2.5 3.0 3.0 3.0
Never
5% 8% 6% 3% 6%
Occasionally
33% 42% 24% 37% 29%
Often
27% 17% 29% 34% 18%
Usually
19% 25% 6% 18% 29%
Always
16% 8% 35% 8% 18%
Note: ED = pediatric eating disorder, N = sample size, n = sub-sample size,
* Median where 2 = “occasionally”, 3 = “often”.

J Can Acad Child Adolesc Psychiatry, 21:1, February 2012 49
Assessment and Treatment of Pediatric Eating Disorders: A Survey of Physicians and Psychologists
Presenting Complaints
ED clinicians were presented with a list of 14 common
presenting complaints related to pediatric ED. They were
asked to indicate those which they encounter. Of the 14
complaints, the majority of ED clinicians encountered 9 of
them. Table 3 shows the response rates by discipline.
Discipline Effect. With respect to the items selected most
often, ED physicians were more likely than ED psycholo-
gists to encounter amenorrhea (OR = 2.4, CI = 1.0, 5.6),
while ED psychologists were more likely than ED physi-
cians to be presented with depression, (OR = 5.7, CI = 1.6,
21.0). There were no differences attributable to discipline
for restriction of food intake, weight loss, anxiety, self-es-
teem, binge eating, self-induced vomiting, or over-exercise.
Among the ve least frequently encountered presenting
complaints, ED physicians were more likely than ED psy-
chologists to select fatigue/fainting (OR = 4.3, CI = 1.6,
11.3) and gastrointestinal complaints (OR = 3.5, CI = 1.3,
9.2). No group differences were detected for abdominal
pain, food intolerance, or abnormal blood work.
Presenting Complaints by Screening
Frequency
The presenting complaints’ frequencies were cross-tabu-
lated with dichotomized screening frequencies (usually/
always versus never/occasionally/often) to determine if
screening frequency might account for fewer opportunities
to receive presenting complaints (Table 3).
Screening Frequency Effect. Except for low self-esteem,
there were no signicant effects attributable to screening
frequency. The most frequent screeners were 5.7 (CI = 1.1,
28.7) times more likely than those who screened less fre-
quently to receive complaints related to self-esteem.
Screening Frequency within ED Physicians. When disci-
pline was accounted for, amenorrhea and low self-esteem
were more likely to be encountered by ED physicians
who screened frequently compared to ED physicians who
screened infrequently (OR = 9.0, CI = 1.0, 80.1; OR = inf);
all frequent screening ED physicians encountered low self-
esteem complaints compared to 50% of infrequent screen-
ing ED physicians.
Screening Frequency within ED Psychologists. No sig-
nicant differences were noted between ED psychologists
Table 3. Common presenting complaints/problems encountered
Screening frequency
Discipline Frequent Infrequent
Presenting
complaints
selected
Total
(N = 95)
ED Physician
(n = 60)
ED Psychologist
(n = 35)
ED Physician
(n = 10)
ED Psychologist
(n = 8)
ED Physician
(n = 28)
ED Psychologist
(n = 8)
Restriction
77% 72% 86% 90% 88% 71% 75%
Weight loss
76% 78% 71% 100% 88% 79% 50%
Depression
75% 65%* 91%* 70% 75% 54% 88%
Anxiety
75% 70% 83% 70% 75% 71% 75%
Low self-esteem
73% 67% 83% 100%* 75% 50%* 88%
Binge eating
62% 62% 63% 80% 75% 71% 50%
Self-induced
vomiting
58% 57% 60% 50% 63% 50% 50%
Over-exercise
56% 52% 63% 70% 50% 50% 50%
Amenorrhea
51% 58%* 37%* 90%*,** 13%* 50%** 25%
Fatigue/fainting
40% 52%* 20%* 60% 13% 46% 13%
Gastrointestinal
complaints
37% 47%* 20%* 50% 13% 43% 25%
Abdominal pain
25% 30% 17% 10% 0% 25% 0%
Food intolerance
17% 22% 9% 20% 0% 14% 13%
Abnormal blood
work
12% 17% 3% 20% 13% 18% 0%
Note. ED = pediatric eating disorder, N = sample size, n = sub-sample size.
*,** = signicant group differences, FET two-tailed p < .025/ASD > 2.0, comparator groups share symbols row-wise within grouping factors.

50
Lafrance Robinson et al
J Can Acad Child Adolesc Psychiatry, 21:1, February 2012
with different screening practices for any of the presenting
complaints.
Screening Frequency between ED Disciplines. The only
presenting complaint where a signicant screening effect
between disciplines was detected was amenorrhea. ED phy-
sicians who screened frequently were more likely than their
ED psychologist counterparts to encounter amenorrhea (OR
= 63, CI = 3.3, 1195).
Services Provided
Discipline Effect. The ED clinicians were asked to indicate
the services they provided to their pediatric ED patients.
Table 4, ranked by response rate, shows signicant group
differences by discipline for all items. When compared
with ED psychologists, the ED physicians reported provid-
ing signicantly more referrals to specialists, medical man-
agement, medications, nutrition counseling, and exercise
information. In contrast, the ED psychologists provided
signicantly more individual counseling/therapy and fam-
ily counseling/therapy than the ED physicians.
Given the polarity of responses across disciplines, ndings
are presented within disciplines without further reference to
overall ranking or between discipline effects.
Services Provided by ED Physicians. Within the ED physi-
cians group, the median number of services provided was
three, irrespective of family-focus status. The top three
Table 4. Services provided by ED clinicians by discipline by family-focus status
Family-focus status
Discipline Non-family-focused Family-focused
Services
Provided
Total
(N = 88)
ED Physician
(n = 56)
ED Psychologist
(n = 32)
ED Physician
(n = 27)
ED Psychologist
(n = 15)
ED Physician
(n = 29)
ED Psychologist
(n = 17)
Referral to
specialist
73% 82%* 56%* 74% 67% 90% 47%
Individual
counseling/
therapy
58% 45%* 81%* 37% 60%* 52% 100%*
Medical
management
58% 88%* 6%* 89% 7% 86% 6%
Medications
33% 50%* 3%* 52% 0% 48% 6%
Nutrition
counseling
27% 39%* 6%* 37% 0% 41% 12%
Family
counseling/
therapy
23% 7%* 50%* 7% 27%* 7% 71%*
Exercise
information
21% 30%* 3%* 19% 0% 41% 6%
Note: ED = pediatric eating disorder, N = sample size, n = sub-sample size.
* = signicant group differences, FET two-tailed p < .05, comparator groups share symbols row-wise within grouping factors.
Table 5. Referral Paths. Discipline by clinic status
Clinic status Family-focus status
Non-ED ED Non-family-focused Family-focused
Referral paths
selected
Total
(N = 117)
Phy
(n = 12)
Psy
(n = 31)
Phy
(n = 48)
Psy
(n = 26)
ED Phy
(n = 25)
ED Psy
(n = 16)
ED Phy
(n = 23)
ED Psy
(n = 10)
Psychiatrist
74% 75% 58% 81% 81% 80% 81% 83% 80%
Psychologist
66% 50%* 84%*,** 67% 50%** 64% 38% 70% 70%
Dietician
51% 42% 42% 56% 58% 60% 31%* 52% 100%*
Community mental
health worker
17% 33%* 7%* 23% 12% 8%* 13% 39%* 10%
Endocrinologist
10% 17% 7% 15% 4% 8% 0% 22% 10%
Internal medicine
9% 0% 10% 6% 15% 0% 6% 13% 30%
Public health nurse
7% 17% 3% 4% 12% 4% 19% 4% 0%
Note: ED = pediatric eating disorder, Phy = physician, Psy = psychologist, N = sample size, n = sub-sample size.
*,** = signicant group differences, FET two-tailed p < .05, comparator groups share symbols row-wise within grouping factors.

J Can Acad Child Adolesc Psychiatry, 21:1, February 2012 51
Assessment and Treatment of Pediatric Eating Disorders: A Survey of Physicians and Psychologists
services provided by physicians, in ranked order, were med-
ical management (88%), referrals to specialists (82%), and
medications (50%) while the lowest ranked item was family
counseling/therapy, by far (7%). There were no signicant
family-focus effects among any of these service items.
Services Provided by Psychologists. Within the ED psychol-
ogists group, the family-focused ED psychologists (Mdn =
2) offered more services than the non-family-focused group
(Mdn = 1), N = 32, U = 57.50, Z = 2.89, p < .01, r = .50.
The top three services provided by ED psychologists, in
ranked order, were individual counseling/therapy (81%),
referral to specialists (56%), and family counseling/therapy
(50%). Family-focused ED psychologists provided signi-
cantly more individual counseling/therapy services (OR =
innity) and family counseling/therapy services (OR = 6.6,
CI = 1.4, 31.1) than their non-family-focused counterparts.
Finally, it may be worth noting that, for 40% percent of the
non-family-focused ED psychologists, the only service re-
ported was that of referral to a specialist, while none of the
family-focused group reported referral as the only service
provided (OR = innity).
Referral Paths
All clinicians (non-ED and ED) were asked to identify to
whom they might refer patients with suspected ED (Table
5). Overall, clinicians indicated that they referred cases
most often to psychiatrists, psychologists and dietitians
(74%, 66%, 51%, Ns = 117).
Clinic Status Effect within Physicians. There were no sig-
nicant clinic status effects for any referral paths when
comparing ED to non-ED physicians. However, the family-
focused physicians were more likely than their non-family-
focused counterparts to refer to community health workers
(OR = 7.4, CI = 1.4, 39.3).
Clinic Status Effect within Psychologists. Within psycholo-
gists, non-ED psychologists were 5.2 (CI = 1.5, 17.9) times
more likely than ED psychologists to refer to psycholo-
gists. All of the family-focused psychologists referred to
dietitians compared to only 31% of non-family-focused
psychologists.
Discipline by Clinic Status Effect. Between disciplines,
non-ED psychologists were 5.2 (CI = 1.2, 22.9) times more
likely than non-ED physicians to refer to psychologists. As
well, although referral to community health workers was
not frequently selected (17%, N = 117), non-ED physicians
were 7.3 (CI = 1.1, 47.6) times more likely than non-ED
psychologists to make these referrals. It should be noted
that both of these results were non-signicant once the mul-
tiple test correction was applied.
Number of Referral Paths. There was no association be-
tween referral services and the number of referral paths
selected.
Conclusion
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 clini-
cians reported “always” screening for ED in their clinics, an
encouraging gure relative to the ndings 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 fac-
tors such as major depression are also likely to be missed.
Similarly, the low frequency with which psychologists de-
tect physical symptoms such as amenorrhea, may lead pa-
tients 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 physi-
cians alike, fail to routinely involve families in the assess-
ment 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 consid-
ered 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 treat-
ment 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

52
Lafrance Robinson et al
J Can Acad Child Adolesc Psychiatry, 21:1, February 2012
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 clini-
cians 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 psycholo-
gists 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, physi-
cians and psychologists may benet from additional train-
ing around screening, multi-informant assessment methods,
as well as evidence-based interventions. Improved screen-
ing, 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 specically, 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
signicant 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 re-
sponse rate, we do not believe this to be a likely event. In
addition, the wording of the questions limited the informa-
tion that could be gathered regarding family involvement.
Additional information on the nature of discipline-specic
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 pediatri-
cians, psychiatrists, gastroenterologists, etc.
Acknowledgements / Conicts of Interest
The authors have no nancial relationships to disclose.
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