Pediatric Screenings for Eating Disorders, Essay Example

Abstract

The purpose of this study was to investigate pediatric care providers’ perceptions of, and diagnosis of eating disorders in Southern West Virginia.  As evident in magazines everywhere, eating disorders are becoming a growing epidemic and major concern in the United States.

I have not yet begun my investigation, but my intent will be to survey a sample of pediatric and primary care facilities in Southern West Virginia.  I will distribute a brief survey to willing participants throughout Southern West Virginia whose patient population includes children and adolescents.  The questionnaire to be used was devised for a study conducted by the Kartini Foundation.  Also, blank copies of each facility’s health forms and health questionnaires will be collected in order to determine if questions that specifically screen for eating disorder symptoms are included.  The results will be coded and reported upon completion of the study.

Acknowledgements

This project was possible only with the help of numerous people.  First, I would like to thank the participants in the study, including the pediatric care administration and staff, as well as the members of the Kartini Foundation.  Their willingness to participate in this study is greatly appreciated.  I would like to thank my committee members for their support, encouragement, and guidance throughout this project. Finally, I would like to thank my family for being so patient with me during this process; I could not have done this without your love and support.

Chapter 1

Introduction

Pediatric eating is controlled by many factors including appetite, food availability, family, peers, cultural practices, and attempts at voluntary control.  Dieting to a weight leaner than needed for health is highly promoted by current fashion trends, sales of special foods, and in some activities and professions (National Institute of Mental Health, 2001). Due to these trends, there are multiple forms of eating disorders that have emerged that most notably include overeating and under eating.

Feeding issues may stem from oral-motor, sensory, emotional or other medical barriers to feeding progress. Difficulty obtaining nutritionally and developmentally appropriate nutrition can be compounded by increased nutrient needs stemming from the primary disorder and subsequent poor intake can lead to greater morbidity and risk. The inordinate focus on weight, can lead to lifelong disordered eating in children with chronic illness resulting in anorexia, bulimia and obesity. In teenagers, presence of anorexia nervosa is a typical eating disorder, and is classified as an ‘illness’ rather than genetic or motor disorder that usually occurs in teenage girls, but can also be found in teenage boys, with continuation into adulthood.

People with anorexia are preoccupied with being slim; they lose an unhealthy amount of weight and are terrified of gaining even a small amount for fear of being socially outcast. These individuals also typically believe they are overweight even though they are extremely lean. Although many people think anorexia is merely a problem with food and personal weight perceptions, research shows that it is an attempt to use food and weight to deal with many different emotional issues that arise during adolescence (“FamilyDoctor,org”, 2005).

Background

Eating disorders have a variety of physical, psychological, and social ramifications and are largely misunderstood and misdiagnosed.  According to the National Office on Women’s Health, “…people with eating disorders experience depression, anxiety, substance abuse, and childhood sexual abuse, and may be at risk for osteoporosis and heart problems.  Moreover, death rates are among the highest for any mental illness” (Office on Women’s Health, n.d.).  Due to the numerous severe complications associated with eating disorders, it is extremely important that such illnesses be caught as soon as possible after onset, if not before.  Therefore, routine checkups performed by medical professionals should include various screenings to determine at-risk patients so that additional help, if needed, can be offered before the problems escalate.  Several screening options include weight, height, and body mass index records, questionnaires, and oral health exams, among other methods.  Research on such screening tools is being conducted to determine their usefulness in pediatric care environments.

There is no single cause of eating disorders, but professionals agree that dieting precedes the onset of most eating disorders (Ohio State University, 2001).  Anorexia is characterized by a “refusal to maintain body weight at or above 85 percent of expected weight, as defined by body mass index charts” (Pritts & Susman, 2003, p. 298).  Social pressure and preoccupation with having a thin body are important risk factors for the development of eating disorders (The McKnight Investigators, 2003).  Research has shown that adolescents are at highest risk for an eating disorder (Vitiello & Lederhendler, 2000, p. 781).  It has been shown that family influences and school behaviors are possible risks for the development of eating disorders.  A particular study found that a “combination of generally higher levels of negative emotionality as a trait characteristic, relative lack of parental sensitivity to these feelings…and various socio-cultural attitudes may provide the foundation for the later development of an eating disorder” (Leon, Fulkerson, Perry, Keel, Klump,1999).

For more than 100 years the medical literature has recognized anorexia nervosa as a psychiatric syndrome.  The primary clinical feature of anorexia nervosa is extreme weight loss which can be life-threatening.  This weight loss has been shown to be caused by extremely restrictive eating and in most cases excessive exercise and/or purgative behavior (Assessment of Eating Disorders, 1990).  According to Williamson 1990, these actions are driven by an extreme fear of weight gain, strong preference for thinness, and body image disturbance (Wickman, 2000).  Each time an anorexic loses more weight, the obsession intensifies, driving even more extreme weight control methods.  The distortion of body size by a patient suffering from anorexia manifests itself as a perception of being fat despite being thin.  Some of the physical consequences of severe weight loss and restrictive eating are cessation of the menstrual cycle, loss of hair, lowered body temperature, dry skin secondary to dehydration, and erosion of tooth enamel (MayoClinic.com, 2008).

Research Problem

Anorexia nervosa is a disease which in its advanced stages is characterized by severe malnutrition, altered metabolism, and organ catabolism that can lead to organ failure.  Early identification and treatment is imperative.  Various screening tools are valid and available.  The extent to which they are deployed in pediatric care settings is unclear.  However, it is evident is that “general practitioners are key in recognizing and offering early intervention in cases of incipient eating disorders or problem dieting behavior” (Gonzalez, Kohn, Clarke, 2007, p. 614).

Research Purpose

The purpose of this study is to examine if adolescents are being assessed for eating disorders by pediatric care providers and which screening tools or methods are being used.

Research Questions

The research questions for this study are:

• Are adolescents being screened for eating disorders in hopes of early detection and prevention?
• Which screening tools and methodologies are being used?

Definitions

The following definitions were used in accordance with this study:

• Adolescents: a boy or a girl from puberty to adulthood; teenage person (YourDictionary.com).
• Anorexia Nervosa: Refusal to maintain body weight above 15% below that which is expected; extreme fear of weight gain despite being significantly underweight; disturbance of body image; amenorrhea for at least three consecutive menstrual cycles (“Danielle’s Place”, n.d.).
• Binge Eating Disorder: a serious eating disorder in which you frequently consume unusually large amounts of food (MayoClinic.com).
• Bulimia Nervosa: a type of eating disorder in which the individual is preoccupied with his or her weight and body shape, often judging one’s self severely and harshly for perceived flaws. With bulimia, the individual engages in episodes of bingeing and purging, where he or she may eat a large amount of food and then try to immediately rid the body of the extra calories by such unhealthy ways as self-induced vomiting or excessive exercise.
• Eating Disorders: Eating disorders are a broad group of serious conditions in which you’re so preoccupied with food and weight that you can often focus on little else. The main types of eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder, and there are also many subtypes (MayoClinic.com, 2008).
• Pediatric Care Provider: A physician, nurse practitioner or physician’s assistant who provides medical services to children and adolescents between ages 12 and 18 (MedTerms.com).

According to the National Institute of Mental Health (NIMH), the three main types of eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder, with U.S. national statistical reporting illustrated in the following indicators:

Theoretical Framework

The theoretical framework for this study is Lydia E. Hall’s Care, Core, and Cure Model.  This theory emphasizes a ‘total person’ approach and stresses the importance of viewing the three aspects of nursing as interrelated, not independent. The three aspects of nursing highlighted in this theory are: 1) Care, which represents the body; 2) Core, which represents the person; and, 3) Cure, which represents the disease. An integrated model of patient intervention, each aspect can be conceptualized as an interlocked circle which may change in size with the patient’s progress.

The circle of care symbolizes nurturing components inherent to nursing ethics and practices (George, 2002). Nurses offer bodily care for the patients and help them complete basic daily biological functions.  Objectives in nursing are underscored by a praxis of patient comfort and somatic sustainability. As the health of the body increases, so too do the other forms of health associated with the patient. Central to Hall’s theory, is the correspondence of the social sciences, [which involve] the therapeutic use of self, and is shared with other members of the health team” (George, 2002).  Nurses participate in informational feedback, and enable patients to participate in the own treatment through incorporation of their express feelings about the disease and its effects; a critical step in patient recovery. Contemporary research on patient care looks at the importance of patient dialogue toward improvement of overall mental and physical health that would otherwise be restricted without the holistic advancement of the healing process, and subsequent clinical treatment.

Finally, the Hall’s approach touches on potentialities of integrated care in the pathological and therapeutic sciences. Here, nurses assist patients and families with the “…medical, surgical, and rehabilitative prescriptions made by the physician” (George, 2002).  Hence, the nurse has become instrumental in the active advocacy of the patient throughout application of therapeutic intervention, and continues to serve as a source of support throughout the treatment and healing processes.

Significance

The extreme weight loss associated with anorexia nervosa can be life threatening.  During the 1980’s, professionals, scientists, and the general public started showing an interest in this particular eating disorder.  In the United States, the 1970’s and 1980’s were associated with a strong emphasis on thinness in young women.  Research has shown that 40% of 9- and 10-year-old girls are already trying to lose weight and women who were raised in foster care are 7 times more likely to develop bulimia nervosa (Sullivan 2007).  These statistics are striking and should be considered highly relevant for early screening.  Other data also shows that “…people with eating disorders experience depression, anxiety, substance abuse, and childhood sexual abuse, and may be at risk for osteoporosis and heart problems. Moreover, death rates are among the highest for any mental illness” (Office on Women’s Health, n.d.).

The aforementioned statistics are often a result of limited access to healthcare, therefore limiting the screening tools and tasks available.  The socio-cultural influence of this emphasis on thinness is generally credited as a major influence on the apparent increased incidence of anorexia nervosa in young women.  It also partially accounts for why so many overweight adolescents and adults have been so preoccupied with losing weight.  One day a person may be healthy at an obese weight, and shortly after, they are unhealthy at a life-threatening low weight.  Other factors which have raised our society’s consciousness about the dangers of obesity are studies which linked obesity with the increased risk of medical problems, and general societal emphasis upon improved health.

Summary

At present, eating disorders in the United States are at epidemic proportions in the adolescent population. In order to care for youth affected by those disorders, pediatric care providers’ offer service provisions ranging from assessment to follow-up treatment, and may include both hospital and alternative therapeutic clinics. Generally, a well-baby check on adolescents from age 12 up until the age of 18, is the initial step in evaluation of patients for recommendation to eating disorder treatment programs. Recognition of vitals is, however, the preliminary phase of care toward mitigation of eating disorders in adolescents, and a variety of attendant or resultant disorders may accompany a child’s condition, and ultimately overall wellness progress. The study proposes to verify that: 1) Nurse practitioners know when they are seeing an adolescent or child with an eating disorder; and, 2) Nurse practitioners must understand why they need to be concerned about the weight issue. The aforementioned are encompassed in the project in its directed study of eating disorder screenings of children in a pediatric care settings.

Chapter 2

The purpose of this chapter is to present a review of literature as it relates to the numerous effects that eating disorders have on a person.  This literature review also explores the concept of including screenings for eating disorders in routine checkups for adolescents.  A variety of professional journal articles and research documents have been studied in searching for pertinent information and statistical data.

Introduction

Eating disorders have a variety of physical, psychological, and social ramifications and are largely misunderstood and misdiagnosed.  As previously mentioned, individuals suffering from eating disorders experience advanced mental and physical health problems and are also at high risk of suicide and health-related death (Office on Women’s Health, n.d.).  Due to the numerous complications associated with eating disorders and their severity, it is extremely important that such illnesses be caught as soon as possible after onset, if not before.  Therefore, routine checkups performed by pediatricians should include various screenings to determine at-risk patients so that additional help, if needed, may be sought before the problems escalate.  Several screening options include weight, height, body mass index records, questionnaires, and oral health exams, among other methods.  Research on such screening tools is being conducted to determine their usefulness in primary care environments.

According to Genevieve W. Ressel’s report (2003), “Screening for eating disorders should be part of routine annual health care, including ongoing monitoring of weight and height and looking for signs and symptoms of an incipient eating disorder.”  Ressel suggests that early detection of eating disorders may prevent physical and psychological consequences of malnutrition that could possibly cause the illness to progress.  This particular researcher was a true advocate for the screening of eating disorders as a means of preventing the disorders as well as providing early intervention and support to minimize attendant deaths.  The author of this report provides evidence to support her statement on the detection policy and also suggests that professionals need to perform specific screening tasks in order for patients to get the most benefit from the annual check-ups (Ressel, 2003).

Screening Adolescents for Early Warning Signs

Eating disorders are on the rise in the United States, and the most common are anorexia nervosa, bulimia nervosa, and binge eating disorder (Office on Women’s Heath, n.d.).  To end the increasing numbers of eating disorder cases, research is being conducted on how to prevent the illnesses, as well as on how to catch them in their early stages to stop them before they worsen.  Pediatric clinics and family doctors now have options for screening patients to determine at-risk adolescents.

The researchers of the Detection, Evaluation, and Treatment of Eating Disorders: The Role of the Primary Care Physician feel very strongly about the necessity of screening patients to help prevent disordered eating from progressing into a full-fledged disease. There is no single cause of eating disorders, but “…professionals agree that dieting precedes the onset of most eating disorders” (Ohio State University, 2001).  The prevalence of extreme weight control behaviors (self-induced vomiting and use of laxatives, diet pills, or diuretics) increased from 14.5% to 23.9% during a 5-year period as female adolescence progressed from middle to late adolescence (Neumark-Sztainer 2008, p. 17).

Anorexia is characterized by a “refusal to maintain body weight at or above 85 percent of expected weight, as defined by body mass index charts”.  Bulimia however, is “…characterized by uncontrollable binge-eating episodes often followed by purging behaviors such as vomiting or the use of laxatives…Patients who have bulimia may be of normal weight, or they may be under- or overweight, whereas patients with binge-eating/purging-type anorexia are underweight” (Pritts & Susman, 2003, p. 298).  Maintaining notes on weight, height, and body mass index may possibly help doctors catch disordered eating before it turns into a full-blown disorder.

Oftentimes, additional information from family and friends is necessary because patients may have trouble explaining their behavior truthfully (Rome et al., 2003, p. e100).  Children and Adolescents With Eating Disorders: The State of the Art (Date) provides a list of questions that would be useful in screening patients for eating disorders.  The list is very thorough and well-organized to allow for a smoother, more complete interview.  This particular list of questions, along with a detailed screening tool such as the SCOFF questionnaire or the EDI-3, would provide physicians with sufficient data to determine the possibility of the development of an eating disorder. A study conducted at Children’s Hospital and Harvard School of Public Health in Boston, MA focused on the levels of prevention saying “reactive primary prevention can occur before or after the stressor” (Austin 2000, p 1251).  However, the results of 20 intervention/prevention cases were discouraging, only four showed any type of positive change, and four actually recorded worsening of symptoms (Austin 2000, p 1254).  As a result, future screening methods and tools have been altered to adjust specific needs of patients.

Monitoring Adolescents’ Growth Patterns

Keeping records of weight, height, and body mass index can help physicians monitor the eating habits of adolescents.  Charts of this information can show the medical professionals any patterns in eating that may be warning signs of an eating disorder.  Flow sheets are used by many physicians “to improve chart organization and facilitate consistent provision of longitudinal care” (Montalto, 1999).  Such charts may provide information that would catch the attention of professionals so that they could intervene and recommend treatment for the patient.  Dieting would definitely be reflected in the charts because weight loss since previous visits would be noted.  Anorexia nervosa and bulimia nervosa are usually preceded by “very strict dieting and weight loss.  Binge eating disorder can begin with occasional binging” (APA Help Center, 2004).  The likelihood of developing these disorders could be lessened through the use of the on-going chart assessments, especially if the charts are well-maintained and very organized.

Pritts and Susman’s article suggests that the patient’s “…medical history is the most powerful tool for diagnosing eating disorders” (Pritts & Susman, 2003, p. 299).  This is due to the fact that physical examinations and laboratory findings can be normal, especially in the early stages of the eating disorder.  The researchers of this study note however that although there are numerous comprehensive psychiatric interviews that could be used for diagnosing the disorders, they are rather impractical for use in the pediatric care environment (Pritts & Susman, 2003, p. 299).  This article also offers a table consisting of diagnostic criteria for bulimia nervosa.  The authors provide evidence to support their work and give readers enough detail to thoroughly understand the concepts being explored throughout the study.

Dental professionals also play a key role in the early detection of eating disorders due to the oral effects.  Telltale signs appear early in the mouth, so dentists may be the first to suspect the disease and should encourage the patient to seek immediate help.  Continual vomiting causes the strong acids from the digestive system to erode tooth enamel and weaken fillings, and the teeth may even become worn and translucent (Colorado Department of Public Health and Environment, n.d.).  Dental professionals should encourage patients with possible eating disorders to obtain professional assistance before the condition worsens.  This article offers suggestions to those with eating disorders on how to neutralize the effects of stomach acid in order to help protect the teeth until the disorder is under control.

Influence of Family, Peers and Environment

Children 0-3 years of age, with special health care conditions are at the highest risk for feeding problems. Between 12-18% of children in the United States have a special health care needs (American Dietetic Association, 2004)  Children with special heath care needs (CSHCN) are those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who require health and related services beyond those typically required by children This would include children with developmental disabilities, congenital deformities (cleft palate), chronic illness (renal disease, diabetes), metabolic disorders (PKU), sensory disorders (visual impairment) and children born prematurely. Within this group, feeding concerns are extensive. In a study involving almost 400 CSHCN, Sullivan (2000) reported that feeding problems were prevalent: 89% needed help with feeding and 56% choked with food; 20% of parents described feeding as stressful and un-enjoyable. In the most extreme cases, the use of alternative feeding routes such as a naso-gastric tube or gastrostomy tube is required (Sullivan 2000). Prolonged feeding times (3h/day) reported at 28%. Medication use and timing can interfere with naturalistic feeding patterns – up to 90% of children enrolled in an early intervention program had at least one indicator of nutritional risk (Ekvall 2000).

Placement of patients suffering from eating disorders can be challenging. For many, the process of feeding and related therapies prompts negative reactions to an institutional clinical setting, and hence, furthering detachment from those whom may already be attempting to provide nurturance that accompanies treatment (Campbell, 1988). A negative feeding relationship between mother and child can contribute to decreased interaction. Parent to child proximity and touch can become especially disturbed in feeding disorders, leading to fundamental relationship difficulties and poor growth (Feldman 2004). Poor feeding ultimately leads to decreased intake of key nutrients, inappropriate weight and linear gains and an inability to develop health promoting eating habits to prevent later in life morbidity. Often needed medical procedures must be delayed until a child reaches a specific weight, causing further disability and further pressure on the feeding interaction.  The inordinate focus on weight, can lead to lifelong disordered eating in children with chronic illness resulting in anorexia, bulimia and obesity (Anderson 2003, Colton 2007, Mouridian 2007).

Family of origin might also play a key role in the development of eating disorders in a different way: through genetics. First-degree biological relatives of individuals with an eating disorder have “an increased risk of Anorexia Nervosa” (DSM-IV-TR, 2000).  A “…child’s hardwiring may make at least an equal, and in some cases dominant contribution toward a predisposition for disordered eating in adolescence” (Eliot, 2004 p. 14+).  In fact, it is thought that “…50% of the incidence of anorexia nervosa may be genetic…” (Eliot, 2004 p. 14+).  While this article reiterates that weight is a result of factors such as inactivity, tastiness of foods, and lifestyle choices, it also points out that “…heredity is the major determinant of weight…” (Eliot, 2004 p. 14+).  Although the researcher touches on the possibility of eating disorders having a genetic link, she does not provide any information as to whether or not there is any interest in finding a way to test genes in adolescents to determine their predisposition for developing a disorder.

Feeding challenges may threaten parental orientations in regard to competency and connection with a child. Isolation can contribute to either over concern in toward a child’s personal care, medical and developmental interventions, or denial of the problem. The child’s high risk status may compound the isolation due to fear of exposure to illness. Inclusion of parental participation and perspective in a patient centered approach to feeding therapies can increase sensitivity to the limitations attendant to illness and exposure, assist to strengthen the social-emotional interaction between the patient and family members, while providing encouragement of the child/teens feeding development, growth and nutrition.  The Guidelines for Adolescent Preventive Services (GAPS) consist of 24 recommendations that include health care delivery, health guidance, screening, and immunizations.  The data derived from various studies show that health risks among 11-21 year old patients are more social than medical and that adolescent mortality and morbidity can be reduced if the unhealthy behaviors are recognized and interventions applied at an earlier age.   “The GAPS Health Service Record (GAPS-HSR) is an ideal method for recalling and applying GAPS recommendations to adolescent patients” (Montalto, 1999).  The author of this report also suggests strategies to help implement the recommendations; these include counseling, providing basic information, and scheduling follow-up visits or referrals.  Although this particular article advises the public of the necessity of screenings to allow for early intervention, it does not provide a very thorough explanation of the individual screening methods available.

Summary

“All patients with eating disorders should be screened for risk of suicide” (Rome et al., 2003, p. e100).  Earlier diagnoses of eating disorders resulting in appropriate professional intervention have shown improved prognoses and health implications for patients.  Therefore, “concern over a patients’ eating behavior should quickly lead to a coordinated plan that specifically addresses the problem” (Rome et al., 2003, p. e100).  Due to the potential risk of suicide, it is important that disordered eating be recognized before it escalates into a full-blown eating disorder.  To help with this task, researchers suggest that screenings be performed in pediatric care facilities to diagnose the disorders as early as possible.  There are a variety of screening tools being evaluated by researchers; some of these methods include maintaining records of weight, height, and body mass index, questionnaires regarding topics such as body image, eating habits, and dieting, and oral exams conducted by dental professionals.

Chapter 3

Introduction

According to The National Institute of Mental Health, between 5 and 10 percent of females (i.e. 5-10 million people) and 1 million males suffer from eating disorders, such as anorexia, bulimia, binge eating disorder, or other associated dietary conditions.  Of the female population, an estimated 10% of college students suffer from a clinical or sub-clinical (borderline) eating disorder(s); over half of which report bulimia nervosa.  Due to the number of deaths resulting from anorexia nervosa (0.5% of those affected), consideration of mortality is of primary importance within the somatic deterimnants indicated by psychiatric physicians.

Due to such high and increasing percentages of the population being affected by eating disorders, it is proposed that screening adolescents for such diseases be included in pediatric evaluations.  A committee consisting of Psychologist Dr. James Calpin PhD, Nancy Lynch RN, and Dr. Jessica Sharp PhD has been formed to assist in an investigation relating to the assessment of children to promote early detection of eating disorders.  Forthcoming data will be put into aggregate comparison with existing data on the topic, an contribute to the pediatric field of pediatric medicine toward emergent strategies in integrated care, and including hospital referral to private and nonprofit agencies dedicated to therapeutic feeding and nutrition programs toward long and short-term specialist intervention and follow-up. An examination of the relationship between those clinical settings and hospital information services will be investigated in order to determine the prevalence of those provisions in pediatric referrals, and the potential of those knowledge sharing networks in expansion of services.

One of the main purposes of this research is to assess the occurrence of eating disorder screenings in pediatric care facilities as a core criterion in diagnoses, and in relation to other disorders. The determination of ‘occurrence’ is understood to be based on clinical and self-reporting responses to targeted questions pertaining to symptoms of disordered eating within general health questionnaire rubrics presented to patients upon arrival.  Disclosure often includes descriptive data that will be used to substantiate qualitative information in the proposed study, and will also contribute to statistical correlation upon codified data assessment meant to test the ‘validity’ of the screening tools, and more importantly the instrumental use of those survey outcomes in provision of  recommendation to outside referral services and integrated patient care.

Assessment is based on medical and developmental history, dietary analysis, feeding history, anthropomorphic measurements and feeding observations. Occupational therapy (i.e., oral health & safety)  is also provided for children who may have oral-motor difficulties with chewing or swallowing, sensory aversion to touch, smell or taste of foods, and who may be underweight or overweight, have medical problems that affect hunger and digestion, and/or have behavioral challenges around eating. The primary goal of the program is to promote eating as a pleasurable experience for the child; using various feeding strategies embedded in a play-based interaction to support feeding. In addition, parent education and professional training of colleagues informs caregivers and colleagues directly engaged with client development, as well as serve to promote the efficacy of the agency’s mission as a lead organization in the field of developmental services in the area of nutrition education.

An initial individual nutrition screening prefaces eating disorder therapies. Nutritional content should be based on American Academy of Pediatrics (AAP) guidelines for age index feeding. Each patient should be assessed at the beginning of the program and at quarterly intervals. These sessions should also assist in the achievement of individual client goals. Initial nutrition screening includes the MCH Region ( no. ) Nutrition Screening Form, with information obtained at onset, and at quarterly stages in determination of frequency, weight, length, and head circumference measurements. Excessive or low body mass index (BMI), mid-arm circumference and tricep skinfold should provide the most immediate criterion. Where parents are involved, feeding development screening incorporates occupational therapy standards into observation of child, and parent review. The screenings are put into comparative analysis with “normative” data on body mass etc., with record retained for referral to physicians.

Traditional diagnoses do not allow for the time it requires to observe a feeding session where ‘red flags’ may arise.  Concerns such as poor or erratic weight / linear gains, delayed feeding skills, and dental caries may be completely opaque upon initial assessment. Many patients who have multiple medical needs are under the care of a pediatric specialist (neurologist, orthopedist, endocrinologist) see the specialist as their ‘primary physician,’ rather than a pediatrician due to frequency of relationship. The project serves to inform the field on recognition of these ‘red flags’ elicited by the Study’s pediatricians through researched educational materials and training, as well as provide easy access for referred patients and families.

The premise that the ‘whole child’ must be accounted for within early assessment and intervention, responds to potential environmental and complex chronic conditions within the treatment framework; concerns that often go unrecognized during a traditional pediatric visit. The cultural context of that family influences how and when a child is fed, what and when foods are introduced, who feeds the child, where the child is fed, and what types of equipment are acceptable (Olson 2004).  At times the cultural imperative is in conflict with the medical imperative.  Successful treatment of the feeding disorder seeks common ground between the two imperatives.

Comprehensive program outcomes, based on coordinated assessment of individual medical histories and feeding challenges (i.e., medical, sensory motor, and psychological) are a core challenge in clinical eating disorder observation programs. Adequacy of patient record and mutual condition recognition within service outcomes is critical to provide strong evidence that the data generated from patient programs offers patients, parents and caregivers positive reinforcement for their own behavior with information and the progress reporting. Patient-centered care also highlights the client’s own contribution to wellness strategies, and serves as an advocacy tool on their behalf. Two (2) evaluation instruments that assist in tracking individual progress: 1) Growth Charts indicate consistent or improved gains while in the program; and 2) Testing Parent-Child Early Relational Assessment (PCERA) and/or Nursing Child Assessment Satellite Testing (NCAST) may be utilized toward scoring of patient progress initially, and upon completion of care.

Despite the long-term challenges presented by pediatric feeding disorders, referral to feeding specialists for assessment or therapeutic treatment is rare. CSHCN often have inadequate medical insurance coverage for specialized services, or are not referred to those specialists that can provide adequate treatments (Davidoff 2004, Kuhlthau 2001, Kogan 2005). This lapse in care is most pervasive amongst minority children; as they are more likely to be without health insurance coverage, access to health resources, coupled with lack of parent education on where to obtain existing resources (Newacheck 2002).

Sample and Setting

The convenience sample for this study will consist of pediatric medical facilities.  The data will be collected from pediatric care sites chosen throughout Southern West Virginia.

Instrumentation and Data Collection

A brief questionnaire devised for a study by the Kartini Foundation will be distributed to area facilities along with self-addressed, stamped envelopes.  A letter discussing the purpose and importance of this study will also be included.  Participants will be asked to complete the short survey and return it with blank copies of their health forms and/or health questionnaires.  The questionnaires will be assessed for evidence of questions regarding eating habits, body image, and behavioral symptoms.  The face validity of the health questionnaires being used as the primary screening tool will be established upon completion of this study.  Other, more specialized screening tools being used will also be detected through the study’s survey.  Any recommendations the physicians have for the advancement of the future use of screening tools will also be noted.

Data Analysis

At this time, no data has been collected.  However, once data has been received, it will be analyzed and graphed, and a statistician will be consulted to assist with interpretations.

Participants’ Rights and Consent to Participate

After full approval by the Institutional Review Board at Mountain State University, the study will be conducted.  Agreement to participation will be based upon whether or not facilities choose to return the requested materials.

The investigator will collect the questionnaires in order to review the questions on each.  The investigator will not need to obtain any confidential information from patients’ medical records.

Assumptions

The participants will answer all questions fully and honestly.  Appropriate and authentic forms will be provided for assessment.

Summary

This chapter presented the methodologies to be employed in the proposed research, and in analysis toward dissemination of predictive correlation of the study. The sample will consist of pediatric care facilities throughout Southern West Virginia.  The instrument used will be a questionnaire designed for a study by the Kartini Foundation that consists of 3 questions regarding type of facility and utilization of screening tools.  Individual facility health forms will be assessed for questions pertaining to eating disorder issues and results will be coded for statistical rendering of the findings in SPSS (or alternative) for publication.

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