Rebecca Jaspan, MPH, RD, CDN, CDCES
Eating disorders are complex neurobiological and psychiatric illnesses that are difficult to identify and frequently overlooked. Identifying relevant medical and psychological symptoms and using the appropriate screening tools are imperative to addressing eating disorder concerns early. The American Academy of Pediatrics recommend that primary care providers routinely screen for eating disorders during annual well visits or sports physicals and ask surveillance questions about eating patterns and body image to all preteens and adolescents.1 Additionally, The American Academy of Child and Adolescent Psychiatry advise that mental health providers screen all child and adolescent patients for eating disorders.2 Early detection and intervention can significantly contribute to better outcomes and pediatricians are ideally placed to influence this.3
There are several eating disorder screening tools available and each can serve an important function in the appropriate time and place. Let’s review the different screens.
The SBIRT-ED, which stands for Screening, Brief Intervention, and Referral to Treatment for Eating Disorders, is an easy to access tool for primary providers. The tool contains a brief questionnaire followed by next steps for doctors to recommend based on the results and degree of severity of symptoms reported. Talking about these challenging topics with patients is not always easy, so the SBIRT-ED contains scripts to help doctors with the language to use with both patients and their parents. The SBIRT-ED also links to referral lists to help patients find a team of additional medical providers, dietitians, and therapists in their area who specialize in eating disorders.
The SCOFF Questionnaire is a short screen for eating disorders. It cannot be used to diagnose an eating disorder, but the results indicate whether further evaluation is necessary. In the primary care setting, it had a sensitivity of 84.6% and specificity of 89.6%, detecting all cases of anorexia nervosa, bulimia nervosa, and 77% of EDNOS. Because the SCOFF Questionnaire is a short 5-question measure, it is a recommended tool for primary care doctors to use to screen for eating disorders in their patients.4
The Eating Disorder Examination Questionnaire (EDE-Q) is a 28-item questionnaire designed to assess the range and severity of features associated with an eating disorder diagnosis using 4 subscales. These subscales include restraint, eating concern, shape concern, and weight concern. The EDE-Q is intended for anyone over age 14. There is an adolescent version, but the developers advise against using this particular tool with individuals below age 12. The EDE-Q is meant to be a self-report measure which can be completed in person or electronically.5 An individual can be given the questionnaire to complete on their own or it can be administered by a primary care doctor, psychiatrist, or psychiatric nurse practitioner.6
The EDE-QS is a 12-item shortened version of the EDE-Q. It includes response scales ranging from 0 to 3 and captures essential symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. A shortened version was developed to reduce the cognitive demand of a 28-item questionnaire and research showed that participants were not making full use of the 0-6 scale. The tool has a sensitivity of 83% and specificity of 85%. The EDE-QS also yielded a lower rate of ED cases compared to the EDE-Q and SCOFF. Despite this result, the EDE-QS demonstrates good discriminatory power and provides more information on specific ED behaviors and their severity, which could be more clinically useful. The EDE-QS can be used in the primary care setting administered by a doctor or given to a patient to complete on their own as a step toward further screening.7
The Eating Attitudes Test (EAT-26) is one of most widely used standardized measures of symptoms and concerns characteristic of eating disorders. This questionnaire was a redevelopment of the EAT-40 that was first published in 1979 and used to examine socio-cultural factors that contribute to the development and maintenance of eating disorders. It is designed to be administered by mental health professionals and primary care doctors as well as coaches and others with the interest in gathering information to determine if an individual should be referred toa specialist for further evaluation for an eating disorder. The EAT-26 is intended primarily for adolescents and adults.8
The Eating Disorder Diagnostic Scale (EDDS) is a 22-item self-report questionnaire designed to screen for anorexia nervosa, bulimia nervosa, and binge eating disorder symptoms that are aligned with the DSM-V diagnostic criteria. The first section assesses attitudinal symptoms of anorexia and bulimia within the past three months. This is followed by questions to measure the frequency of uncontrollable food consumption to assess for binge eating disorder. The EDDS also takes into account height, weight, menstrual cycle and birth control pill use. Research shows that this tool is sensitive to change over time, therefore, the EDDS is a useful screening tool at the beginning stages as well as for treatment monitoring. This tool can be used in adolescents and adults.9
The Compulsive Exercise Test
In a review study, it was found that up to 85% of individuals with eating disorders engage in compulsive exercise.10 Clients who engage in such behavior tend to have worse outcomes, therefore, it is essential that we adequately screen for excessive exercise in the context of eating disorders in all of our clients.11 The Compulsive Exercise Test addresses five subscales: avoidance and rule-driven behavior, weight control exercise, mood improvement, lack of exercise enjoyment, and exercise rigidity. The test is 24 questions that can be completed by a physician, therapist, or self-reported by the client. This screening tool is valid and effective in both adolescents and adults.12
At LCWNS, we collaborate as a team with the client’s medical doctor and therapist to ensure they are properly screened and diagnosed. The earlier eating disorder symptoms are identified and screened for, the faster the client can begin their treatment process, which results in better long-term outcomes.
- Hornberger LL, Lane MA; COMMITTEE ON ADOLESCENCE. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2021;147(1):e2020040279. doi:10.1542/peds.2020-040279
- Lock J, La Via MC; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015;54(5):412-425. doi:10.1016/j.jaac.2015.01.018
- Rowe E. Early detection of eating disorders in general practice. Aust Fam Physician. 2017;46(11):833-838.
- Kutz AM, Marsh AG, Gunderson CG, Maguen S, Masheb RM. Eating Disorder Screening: a Systematic Review and Meta-analysis of Diagnostic Test Characteristics of the SCOFF. J Gen Intern Med. 2020;35(3):885-893. doi:10.1007/s11606-019-05478-6
- Jennings KM, Phillips KE. Eating Disorder Examination-Questionnaire (EDE-Q): Norms for Clinical Sample of Female Adolescents with Anorexia Nervosa. Arch Psychiatr Nurs. 2017;31(6):578-581. doi:10.1016/j.apnu.2017.08.002
- Prnjak K, Mitchison D, Griffiths S, et al. Further development of the 12-item EDE-QS: identifying a cut-off for screening purposes. BMC Psychiatry. 2020;20(1):146. Published 2020 Apr 3. doi:10.1186/s12888-020-02565-5
- Fietz M, Touyz S, Hay P. A risk profile of compulsive exercise among adolescents with an eating disorder: A systematic review. Advances in Eating DIsorders: Theory, Research and Practice. 2014;2:241–263. doi: 10.1080/21662630.2014.894470
- Beumont PJ, Arthur B, Russell JD, Touyz SW. Excessive physical activity in dieting disorder patients: Proposals for a supported exercise programme. Int J Eat Disord. 1994;15:21–36. doi: 10.1002/1098-108X(199401)15:1<21::AID-EAT2260150104>3.0.CO;2-K
- Goodwin H, Haycraft E, Taranis L, Meyer C. Psychometric evaluation of the compulsive exercise test (CET) in an adolescent population: links with eating psychopathology. Eur Eat Disord Rev. 2011;19(3):269-279. doi:10.1002/erv.1109