Nagamitsu et al. BioPsychoSocial Medicine
https://doi.org/10.1186/s13030-019-0162-3(2019) 13:21

RESEARCH

Open Access

Validation of a childhood eating disorderoutcome scale
Shinichiro Nagamitsu1* , Yoshimitsu Fukai2, So Uchida3, Michiko Matsuoka4, Toshiyuki Iguchi5, Ayumi Okada6,
Ryoichi Sakuta7, Takeshi Inoue7, Ryoko Otani7, Shinji Kitayama8, Kenshi Koyanagi9, Yuichi Suzuki10, Yuki Suzuki11,
Yoshino Sumi12,13, Shizuo Takamiya14,15, Chikako Fujii16, Yasuko Tsurumaru16, Ryuta Ishii1, Tatsuyuki Kakuma17 andYushiro Yamashita1

Abstract
We developed and validated a childhood eating disorder outcome scale based on outcomes associated with bodymass index standard deviation score (BMI-SDS). This prospective observational study included 131 children witheating disorders (aged 5–15 years). Participants’ outcomes scales were completed at the first visit and at 1, 3, 6, and12 months. The scale evaluated 12 outcomes: body weight change (BW), eating attitude (EA), fear of being fat (FF),body image distortion (BD), menstruation (ME), perceived physical condition (PC), attending school (AS), diseaserecognition by school (RS), family function (FA), disease recognition by parent (RP), social adaptation (SA), andrelationships with friends (RF). Responses to all items were on a four-point Likert scale. Exploratory factor analysis
was used to determine the number of factors based on the 12 outcomes. The relation between outcome scalescores and BMI-SDS over the 12-month follow-up period was analyzed. Two types of factors were extracted:
disease-specific factors (EA, FF, BD) and biopsychosocial factors (BW, PC, AS, FA, SA, RF). Three items (ME, RS, RP)
were excluded because they showed no significant loading effect. There was a significant negative correlation
between the outcome scale and BMI-SDS, and changes in outcome scale scores from baseline to 12 months weresignificantly associated with improvement in BMI-SDS. We developed a childhood eating disorder outcome scalecharacterized by disease-specific and biopsychosocial factors. Biopsychosocial management combined with atherapeutic approach for disease-specific symptoms may support body weight recovery for children with eating
disorders.
Keywords: Eating disorders, Anorexia nervosa, Outcome, Children

Introduction
Childhood eating disorders are serious psychiatric illnesses that confer substantial morbidity and mortality
and manifest as disturbances in eating habits, excessive
preoccupation with weight, restricted caloric intake, andbody image distortion. The prevalence of childhood eating disorder is 1% in adolescents, with one-third of theseadolescents classified as avoidant/restrictive food intake
disorder (ARFID) and more than half as anorexia nervosa(AN) [1–4]. Various short-term and longitudinal outcome
studies have reported 40–88% complete remission, 34–72%
recurrence, and 12–24% undesirable outcomes) [5–11].
* Correspondence: kaoru@med.kurume-u.ac.jp
1
Department of Pediatrics and Child Health, Kurume University School of
Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
Full list of author information is available at the end of the article

However, the results varied depending on the definition ofoutcome used in the study.
The Morgan-Russell Outcome Assessment Schedule
was developed to identify outcome predictors using datafrom clinical observation, premorbid personality, and thepatient’s family background at the time of first assessment[12]. It covers nutritional status, menstrual function, mental state, sexual adjustment, and socioeconomic status;
however, those scales are not standardized and each rating
scale is relatively subjective. Furthermore, some scales are
not specific to children, as they cover sexual relationships,
establishment of economic independence from the family,
and occupational records. Moreover, the Morgan-Russell
Outcome scale does not include core symptoms of eating
disorders, such as body image distortion and fear of being
fat. The Morgan-Russell Outcome Scale is widely used for© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Nagamitsu et al. BioPsychoSocial Medicine(2019) 13:21

eating disorders in adulthood [9, 13, 14]; however, manystudies used body weight and the presence of menstruation to evaluate prognosis. Similarly, the Diagnostic andStatistical Manual of Mental Disorders, fifth Edition(DSM-5) definition of eating disorders specifies disease severity using body mass index (BMI); for example, moderate (BMI 16–16.99 kg/m2), severe (BMI 15–15.99 kg/m2),
and extreme (BMI < 15 kg/m2) [15]. However, absolute
BMI values are not recommended as a measure for underweight in adolescence, as development-related variations
may bias results [16, 17]. In DSM-5, an age- and genderadjusted BMI percentile of 5 is suggested as a numeric
cut-off for low weight criterion in AN in children and adolescents, however, the evidence supporting this cut-off forunderweight is lacking [18]. As AN cases with extreme
low weight are in a BMI percentile near zero, it is difficult
to distinguish their severity of weight loss. Therefore, BMI
standard deviation scores (BMI-SDS), which are also ageand sex-standardized, may represent a more accurate
measure [16, 17]. Furthermore, recent increments in early
onset of childhood AN may affect onset of menarche,meaning the presence or absence of menstruation may
not be a suitable outcome measurement in child cases.
Therefore, an eating disorder outcome scale that is specific for children’s developmental physical condition isneeded.
In addition to consideration of physical developmental
condition, psychosocial factors (e.g., family function,
relationships with friends, and school adaptation) areoften considered for recovery in childhood eating disorder [19, 20]. Several studies have argued the importance of family functioning in the recovery process forchildren with AN [21, 22]. There is an association between an adolescent’s positive perception of family functioning and better outcomes. However, family distressand dysfunction, such as parental conflict or feelings ofdepression, predict poorer outcomes [23–27]. Relationships with friends and school achievement also have asignificant impact on recovery [28–30]. Westwood et al.
[30] reported that social difficulties may play a role inboth the development and maintenance of AN, especially where there is isolation from the friendship experience. Furthermore, positive friendship qualities, such as
good communication, trust, and peer acceptance were
not associated with eating disorder symptoms [28, 30]. A
national cohort study showed high achievement inschool was associated with an increased risk for eating
disorders [29], although the reason for this association
remained unknown. However, for example, if a childwith a perfectionist tendency has experienced less thanperfect school achievement, this characteristic may prohibit their recovery from AN. This indicates that a childhood eating disorder outcome scale should include
psychosocial assessment factors in addition to physicalPage 2 of 11

assessment, as both psychosocial and physical improvements are needed for complete recovery.
This study aimed to develop and validate a childhood
eating disorder outcome scale that reflects both physicaland psychosocial assessment, in addition to evaluatingcore eating disorder symptoms. We conducted a prospective observational study involving 131 children with eating
disorders. To ensure the outcome scale was reliable, weused BMI-SDS to reflect weight changes, performed factor
analysis to eliminate low loading items, and developed
distinct definitions for each item.

Methods
Study organization

The Japanese Pediatric Eating Disorders Outcome: aProspective Multicenter Cohort Study (J-PED study)group was established in 2014 to develop a childhood
eating disorder outcome scale. Eleven regional medical
institutions covering northern to southern Japan participated in this study. Participating medical institutions
employed pediatricians who were engaged in managing
treatment for children with eating disorders. Membersof the J-PED study team discussed several possible items
for the outcome scale, and decided on the definitions of
the clinical level for each outcome. All J-PED members
were also trained by a child psychiatrist on how to use
the Mini-International Neuropsychiatric Interview (MINI)[31] to assess comorbid psychiatric disorders.
Study protocol
Enrollment

The purpose of this study was to develop a childhood
eating disorder outcome scale associated with BMI-SDS.
Inclusion criteria were: aged under 16 years, having abnormal eating habits and unaccountable weight change.
The J-PED members ruled out medical causes for theeating habits and the weight change, and checked forany related complications. After patients had physicalexamination and laboratory tests, their eating habitswere assessed by the Japanese version of the ChEAT26[32]. If the J-PED members suspected that patients havesome type of eating disorder, they used the diagnostic
criteria for eating disorders in DSM-IV, Great OrmondStreet Criteria or DSM-5) [15, 33]. They also used MINI
to assess any comorbid psychiatric disorders. Untreatedfirst-visit patients and patients who were referred fromother hospitals were included. Patients who did not provide informed consent to participate in this study were
excluded. The enrollment period was from 2014 April to2016 March (2 years).
Participants

Patients with eating disorders who visited one of the JPED study group medical institutions for treatment

Nagamitsu et al. BioPsychoSocial Medicine(2019) 13:21

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received an explanation about the study protocol. Those
who understood the purpose of this study and provided
signed informed consent or assent were eligible to participate in this study. In total, 131 children with eating
disorders were enrolled between 2014 and 2016; 89 werediagnosed as AN, and 38 as ARFID. The remaining four
were diagnosed with functional dysphagia. There wereno cases with bulimia nervosa. The mean (standard deviation [SD]) onset age was 12.5 years (1.9 years). The
number of inpatient and outpatient cases were 82 and49, respectively. The mean and standard deviation of theduration between possible disease onset and first visit
was 262 days and 245 days, respectively.

regularity of menstruation and AS by the frequency ofattending school. Definitions of the EA, FA, RP, RS, RE,
and SA scores are described using examples (Table 1).
The total score for the childhood eating disorder outcome scale ranged from 0 to 36, with a score of 36 indicating the worst condition. Before this study started,
physicians self-trained in using the outcome scale by rating imaginary cases with eating disorders. After rating,they discussed the scores in each subscale that were suitable for the imaginary cases as a group. This aimed topreserve inter-rater reliability across institutions andwithin the whole study group.

Candidate items for the outcome scale

Assessment schedule and scales

We referred to several papers to select optimal candidate
items for the outcome scale [5, 34–37], and extracted
many items that manifest a multidimensional measure ofeating disorder pathology. After discussion among the JPED members, we classified these items into similar categories and selected 12 outcomes: 1) body weight change(BW), 2) eating attitudes (EA), 3) fear of being fat (FF),4) body image distortion (BD), 5) menstruation (ME), 6)
perception of physical condition (PC), 7) family function(FA), 8) disease recognition by parent (RP), 9) diseaserecognition by school (RS), 10) attending school (AS),11) relationships with friends (RF), and 12) social adaption (SA). There were four possible responses for eachoutcome (e.g., 0 = no problem, 1 = unclear, 2 = moderate
problem, and 3 = major problem). After discussion
among the J-PED members, detailed definitions for eachpoint on all outcomes were developed. For example, theBW outcome (evaluated at each visit) was categorized
into four levels of BMI-SDS change: >2SD decrease(scored as 3), 1SD–2SD decrease (scored as 2), between
1SD increase and < 1SD decrease (scored as 1), and a >1SD increase (scored as 0). The FF item was based on
three parameters: intense fear of becoming fat, preoccupation with thinness, and excessive exercise. If a patient
met all three parameters, the score was recorded as 3. If
a patient had none, one, or two of the three parameters,
the score was 0, 1, or 2, respectively. A patient’s score
for the outcome therefore depended on how many parameters that patient met. PC were assessed in samemanner. The scale definition of “body image distortion(BD)” was derived from criteria C for AN in the DSM-5.
Criteria C specifies: disturbance in the way in which
one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of current
low body weight. We applied the second and third
points of criteria C without any changes as parametersin this study; however, we represented the first point as“preoccupation with body image.” ME was assessed byParticipating patients were assessed using the childhood
eating disorder outcome scale at their first visit, and at
1, 3, 6, and 12 months after the first visit. Comorbidities(psychiatric disorders and other complications) wereassessed at the first visit. In addition, the Japanese version of the ChEAT26 [32] was administered and BMISDS calculated at each assessment. In each institution, asingle rater performed the evaluations at baseline and at
1, 3, 6, and 12 months.
Treatment

Participating patients were treated at either the inpatientor outpatient unit, according to the Childhood Eating
Disorder Treatment Protocol published by JapaneseSociety of Psychosomatic Pediatrics [38]. This guideline
includes total parental nutrition therapy, enteral feeding
through a nasogastric tube, psychotherapy, behavioral
therapy, and medications. A combination of these therapies was selected in each case.
Statistical analysis

To verify the validity of the childhood eating disorderoutcome scale, we performed a factor analysis for the
scale and correlation analysis between the modified
scale and BMI-SDS in 131 children with eating disorders at the first visit. We performed correlation analysis between the changes of the scale scores and
BMI-SDS from the first visit to the 12 month followup visit.
Exploratory factor analysis with varimax rotation was
performed to determine the number of factors. Eigenvalues and clinical consideration of factor structures
were used to decide the number of factors to beretained. After the number of factors was determined,
confirmatory factor analysis was performed to obtainfactor loadings. The relation between the outcome scalescores and BMI-SDS at first visit and at 12 months wasanalyzed with Pearson’s correlation coefficients.

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Table 1 Outcome scale candidate items and definition ofscoresTable 1 Outcome scale candidate items and definition ofscores (Continued)

1. Body weight change (BW)

8. Disease recognition by school (RS)score 0 increase 1SDscore 0 positively cooperativescore 1 change ±1SDscore 1 slightly cooperativescore 2 decrease >1SD − 2SDscore 2 unconcerned

score 3 decrease >2SDscore 3 critical or refusal

2. Eating attitude (EA)

9. Family function (FA)score 0 no problem

score 0 relationship always goodscore 1 unclear

score 1 sometimes good, sometimes badscore 2 moderate problem

score 2 tension at homescore 3 major problem
3. Fear of being fat (FF)
Parameters: 1) intense fear of becoming fatscore 3 impossible to be involved
10. Disease recognition by parent (RP)score 0 positively cooperative2) preoccupation with thinness

score 1 slightly cooperative

3) excessive exercisescore 2 unconcerned

score 0 none of the parametersscore 1 any one parameterscore 3 critical or refusal
11. Social adaptation (SA)score 2 any two parametersscore 0 assertive and cooperativescore 3 all of the parametersscore 1 unclear

4. Body image distortion (BD)
Parameters: 1) preoccupation with body image
2) undue influence of body weight or shapeon self-evaluation3) persistent lack of recognition of seriousness
score 0 none of the parametersscore 1 any one parameterscore 2 in conflictscore 3 isolated
12. Relationships with friends (RF)score 0 having friends that are trusted
score 1 having friends to talk withscore 2 no friends, but not isolated
score 3 no friends and isolated

score 2 any two parametersscore 3 all of the parameters
5. Menstruation (ME)score 0 regular menstruation
score 1 unclear
score 2 irregular menstruation
score 3 no menstruation
6. Perceived physical condition (PC)
Parameters: 1) no feeling of being tired
2) no feeling of being hungry
3) no feeling of fullness
score 0 none of the parametersscore 1 any one parameterscore 2 any two parametersscore 3 all of the parameters
7. Attending school (AS)score 0 going school every dayscore 1 going school a few times/weekscore 2 can go to substitutional schoolscore 3 cannot go to any school

Results
Rate of patient follow up and comorbid disorders

Before the 12-month follow-up visit, 17 patients stopped
visiting their medical institution. The timing of the participants who dropped out is described in Fig. 1. All
dropped out before recovering from their eating disorder
symptoms. Five patients were referred to a psychiatricclinic because of suicidal behaviors, major depression, orother behavioral problems: Three recovered before the
12-month follow-up visit.
Patient characteristics

The characteristics of 131 participating children (10boys) are summarized in Table 2. In total, 89 were diagnosed with AN (86 had restricting type and theremaining three had binge eating/purging type), 38 with
ARFID, and four with another form of eating disorder.
Of the 10 boys with eating disorders, three had AN andseven had ARFID. Age ranged from 5.5–15.5 years, witha mean age of 12.5 years. Twenty-two girls were younger
than 12 years; of these, 12 had AN, nine had ARFID, andNagamitsu et al. BioPsychoSocial Medicine(2019) 13:21

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child had a low potassium level (less than 3 mEq/L), 13
had hypotension (systolic blood pressure < 80 mmHg),
and 69 had bradycardia (heart rate < 60/min). Over the
study period, the mean BMI-SDS changed from − 3.5 to −1.6, and the mean childhood eating outcome score from
13.3 to 6.2. Among the 46 children with psychiatric comorbidity, data for the first visit showed the mean BMISDS was − 3.2 and the mean childhood eating outcome
score was 17.0. At the 12-month follow-up, the mean
BMI-SDS was − 0.8 and mean childhood eating outcome
score was 8.3. Total parental nutrition was reported for 14
children and enteral feeding through a nasogastric tube
was reported for seven children. Forty-three children received counseling, 15 received psychotherapy and eightreceived cognitive behavioral therapy. Eighteen children
were taking psychotropic medication, including risperidone (n = 6), aripiprazole (n = 4), sulpiride (n = 4), fluvoxamine (n = 2), and others.

Factor analysis of the childhood eating disorder outcome
scaleFig. 1 Flow diagram for this study

one had functional dysphagia. Overall, four children had
normal weight loss, five had moderate weight loss, 13
had severe weight loss, and 105 had extreme weight loss;
89% of the children with AN and 82% with ARFID
showed extreme weight loss. Forty-six children were diagnosed with psychiatric comorbidity, including anxiety disorder (n = 11), suicidal behaviors (n = 9), obsessive
compulsive disorder (n = 7), autistic spectrum disorders(n = 8), major depression (n = 5), and others (n = 6). Fourteen patients had a serious physical illness, such as superior mesenteric artery syndrome or severe infection. One

Initial exploratory factor analysis was performed to extract important factors. A two-factor solution explained
39.1% of the total variance and showed appropriate eigenvalues and clinically meaningful factor structures.
Based on the results of this analysis, we conducted confirmatory factor analysis (Tables 3 and 4). One factor included three outcomes (EA, FF, and BD) and the otherincluded six outcomes (BW, PC, AS, FA, SA, RF). The
first factor reflected core eating disorder symptoms (preoccupation with being thin, a fear of getting fat, and eating attitude), and was called the “disease-specific factor.”
The second factor comprised six items covering physicaland psychological domains, and was labeled the “biopsychosocial factor.” The outcomes FF and BD of thedisease-specific factor showed higher loading effects

Table 2 Patients’ characteristics
Total cases

AN

ARFID

At the first visit
N (M:F ratio)

131 (10:121)

89 (3:86)

38 (7:31)

Mean age, y (range)

12.5 (5.5–15.5)

12.9 (9.1–15.5)

11.6 (5.5–14.8)

Mean BMI-SDS (range)−3.5 (−8.7–0.1)−3.7 (−7.8–0.1)−3.3 (− 8.7−−1.1)

Mean outcome score (range)

13.3 (4–23)

14.6 (6–23)

10.4 (5–18)

Mean ChEAT26 (SD)21.4 (15.0)

25.6 (15.4)

11.6 (8.6)

At the 12-month follow-up
Mean BMI-SDS (range)−1.6 (−7.7–1.5)−1.5 (− 7.7–1.5)− 1.6 (−6.4–0.1)

Mean outcome score (range)

6.2 (0–21)

6.8 (0–21)

4.4 (0–14)

Mean ChEAT26 (SD)12.3 (12.3)

14.4 (13.3)

7.8 (8.9)

AN anorexia nervosa, ARFID avoidant/restrictive food intake disorder, y years, BMI-SDS body mass index-standard deviation score, ChEAT26 children’s version of theEating Attitude Test-26 items, SD standard deviation

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Table 3 Factor analysis of the childhood eating disorder outcome scaleleft). We further divided the correlation analysis by thedisease-specific and biopsychosocial factors) (Fig. 2, middle and right). The sum of the three outcome scores forthe disease specific factor showed no correlation with
BMI-SDS (Fig. 2, middle); however, the sum of the six
outcome scores for the biopsychosocial factor showeda significant negative correlation with the BMI-SDS(Fig. 2, right).

(Table 4). Three outcomes (ME, RS, RP) were excluded
because of low loading.
Correlation between the childhood eating disorderoutcome scale and BMI-SDS at the first visit

There was a significant negative correlation between thechildhood eating disorder outcome scale total score and
BMI-SDS at the first visit (r = − 0.204, p < 0.05) (Fig. 2,

Table 4 Confirmatory factor analysis
Score item

Coef.

Std. ErrZ

p-value

95%

CI

Cronbach’s alphas

Eating attitude (EA)

0.3114

0.5910

5.27

0.000

0.19560.42730.6310Fear of being fat (FF)0.95740.1028

9.32

0.000

0.75601.15890.6087

Body image distortion (BD)1.02580.9244

11.10

0.000

0.84451.20690.5919Disorder-specific factor

Biopsychosocial factor
Body weight change (BW)−0.2978

0.0960

−3.10

0.002

−0.4860−0.1097

0.6771

Perceived physical condition (PC)0.43530.0956

4.55

0.000

0.24790.6226

0.6064

Attending school (AS)0.32170.1493

2.15

0.031

0.02900.61430.6667

Family function (FA)0.32600.0785

4.15

0.000

0.17210.47990.6451Social adaptation (SA)0.45710.1000

4.55

0.000

0.26010.65410.6340Relationships with friends (RF)0.72790.1062

6.86

0.000

0.51980.93600.5995

CI confidence intervalNagamitsu et al. BioPsychoSocial Medicine(2019) 13:21

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Fig. 2 Correlation analysis between each outcome score and BMI-SDS at first visit. BMI-SDS, body mass index standard deviation score

Correlation between the changes in the childhood eating
disorder outcome scale scores and BMI-SDS from the first
visit to 12 months

between change in the outcome scale score and change
in BMI-SDS (r = − 0.562, p < 0.001) (Fig. 4).

Figure 3 describes consecutive outcome scale and BMISDS data from the first visit to the 12-month follow-up
visit. The changes in each outcome score and BMI-SDS
were calculated by subtracting each score at the 12month follow-up from those at the first visit. The mean
and range of changes of the scale score and BMI-SDS
were − 7.0 (range − 21 to 6) and 1.9 (range 8.1 to − 4.0),
respectively. There was a significant negative correlation

Discussion
Childhood eating disorder outcome studies have received
much interest from child psychiatrists and pediatricians,
especially as some childhood cases have revealed poor disease outcomes, with transition to an adult form of the eating disorder [5–7]; however, others have shown a good
prognosis [8, 9, 11]. Psychiatrists and pediatricians areinterested in the factors that are significant for better

Fig. 3 Consecutive outcome scale and BMI-SDS for 131 patients during the study. BMI-SDS, body mass index standard deviation score; mo, month/months

Nagamitsu et al. BioPsychoSocial Medicine(2019) 13:21

Fig. 4 Correlation between changes in outcome score and BMI-SDS
from the first visit to the 12-month follow-up evaluation. MI-SDS,
body mass index standard deviation score; Δ, Changes of outcome
score or BMI-SDS from the initial visit to the 12-month follow-up

prognosis. Therefore, we developed a childhood eating disorder outcome scale that was verified by factor analysis andconsecutive application over a 1-year period. Factor analysis
revealed a two-factor solution (disease-specific factor andbiopsychosocial factor), with appropriate eigenvalues. To
our knowledge, this scale is the first statistically analyzed
outcome scale for childhood eating disorders.
The disease-specific factor included three outcomes(EA, FF, and BD), which were drawn from the DSM-5
eating disorder criteria [15]. At the first visit assessment,
the subtotal for the disease-specific factor was not significantly correlated with BMI-SDS. This may indicatethat patients with early onset-type eating disorder (20%of cases were younger than age 10 years in the present
study) may find it hard to describe or express their fearof being fat or body image distortion precisely at the initial intervention. Alternatively, the proportion of eating
disorder types in the present study might have affected
the absence of significance. About one-third of participants in this study had ARFID; these patients may showless fear of being fat and body image distortion, whichmight account for the low scores for the disease-specificfactor. Furthermore, several psychometric studies haveshown that the patient’s emotional state or interpersonal
relationships were more relevant to pathophysiology
in children with ARFID than in children with typical
AN [39, 40].
The biopsychosocial factor included six outcomes(BW, PC, AS, FA, SA, and RF). This factor was characterized by inclusion of psychosocial assessments that mainly
covered relationships with parents, friends, and school. Although the Morgan-Russell Outcome Assessment Schedule

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has been widely used and includes psychosocial scales,
those scales are not specific to children as they covermarriage, sexual identity, and image of menstruation [12].
Given the increasing prevalence of early onset-type eating
disorders, such items may not be suitable for an outcome
scale for children. Both the biopsychosocial factor subtotal
and the total score were significantly correlated with BMISDS at the first visit, indicating that biopsychosocial assessment was more significant for the pathogenesis of eating
disorders in participating children. Several reports havesuggested that psychosocial and socioeconomic status arestrongly associated with onset or severity of childhood eating disorder, and family/social relationships and support
are critical for their remission [19, 23–27]. The childhood
eating disorder outcome scale placed emphasis on comprehensive psychosocial aspects; therefore, the scale may be
useful for assessing therapeutic components that need more
support for remission.
Furthermore, our procedure of factor analysis for theselected outcomes, with exclusion of three non-significant
items (ME, RS, and RP) made the childhood scale more reliable. The RS and RP items appeared to be important for apatient’s remission; however, a more detailed definition forthe categorization of these items may be necessary to exclude physician subjectivity. For example, disease recognition differed between mothers and fathers and between
class teachers and school nurses. Raters also often had difficulty in deciding scores; therefore, we excluded those two
scales. The exclusion of ME was based on agreement about
the consideration of younger cases, and was consistent with
DSM-5 criteria, from which amenorrhea was excluded [15].
In our study, 46 children had psychiatric comorbidity(e.g., autism spectrum disorder, depression, obsessive
compulsive disorder), which are considered to have significant adverse effects on the prognosis for eating disorders [9, 13, 41]. The mean outcome score in children
with psychiatric comorbidity was higher than that in
total cases (17.0 vs. 13.3); however, the mean BMI-SDS
did not differ between the two groups (− 3.2 vs. − 3.5).
At the 12-month follow-up, changes in mean BMI-SDS
did not differ between children with psychiatric comorbidity and total cases. This indicated that the presenceof psychiatric comorbidity had little effect on bodyweight changes. Similarly, the presence of physical illness
showed a slightly higher mean outcome score (15.1)
among those with comorbidities compared with total
cases; however, there was little effect on the mean BMISDS (− 2.9) in this group (data not shown).
As we planned to measure the childhood eating disorder outcome scale prospectively, it was consecutively
measured from the initial visit to 12 months. This qualitative prospective study design was suitable to assess patient
outcome and minimized research bias. The outcome
scores in the majority of cases showed improvement,

Nagamitsu et al. BioPsychoSocial Medicine(2019) 13:21

accompanied by recovering BMI-SDS, and the changes of
total scale score from the initial visit to 12 months significantly reflected the changes in BMI-SDS. These results
indicate that this outcome scale could be used for assessment of therapeutic effects during the course oftreatment.
There were several limitations to this study. First, although 46 patients had psychiatric comorbidity (e.g.,
autism spectrum disorders, depression, obsessive compulsive disorder), involvement of these comorbidities
was not included or considered as weighting elements
for the outcome score. Although those comorbidities
have been considered as having significant adverse effects on the prognosis for eating disorders [9, 13, 41],
the degree of severity of comorbidities may differ among
disorders, or among patients with each comorbid disorder. Therefore, we did not include the presence of comorbidity in the outcome scale. The presence ofcomorbidity could be assessed as factor predictive ofprognosis in future research. Second, it may be better todistinguish ARFID and AN at the initial assessment andconduct analyses separately for rating purposes. However, initial assessment for differential diagnosis of these
two types of childhood eating disorders may be difficult.
We did not consider the type of eating disorder, because
comparable improvements in weight and psychopathology have been reported as outcomes for patients with
ARFID and those with AN [42–44]. Furthermore, physicians sometimes have difficulty making a differential
diagnosis between ARFID and AN, as there are cases inwhich children with AN do not express fear of being fat
or body image distortion. After induction of nutritional
therapy, children with an eating disorder tended topresent with a fear of being fat or other characteristics
specific to AN. Further research is needed to develop
outcome scales that specify the type of eating disorder.
Third, although all initial visit data for 131 cases were
included in the factor analysis, 22 of the 131 children
dropped out or were referred to psychiatric care before
the 12-month evaluation. Fourth, each clinician completed the outcome scale ratings for their patients without a blinded double coding, which gives a possibility ofrater variability. Furthermore, types of treatment were
not evaluated for each case. The reasons for droppingout and type of treatment need to be further evaluatedto assess more global aspects of the outcome scale. Although this study had several methodological limitations,
including lack of physically meaningful aspects, an advantage of the new rating scale in the clinical context isthat it may make it possible for physicians to assess a patient’s entire condition and clinical process of disease
severity.
In conclusion, we developed a childhood eating disorder outcome scale that comprised disease-specific andPage 9 of 11

biopsychosocial factors. We showed that the biopsychosocial score was significantly associated with BMI-SDS
and that change in the total score through therapeuticintervention reflected improvement in BMI-SDS. This
scale is able to assess the severity of childhood eating
disorder and identify therapeutic fragments that should
receive more support, which would lead to a better
prognosis for children with eating disorders.
Acknowledgements
We gratefully thank the participants in this study, and also thank Audrey
Holmes, MA, from Edanz Group (www.edanzediting.com/ac) for editing a
draft of this manuscript.
Authors’ contributions
SN, YF, and SU participated in the design of this study and SN compiled
the manuscript. All authors except TK and YY collected patient data. TK
conducted the statistical analyses. YY supervised the preparation of themanuscript. All authors read and approved the final manuscript.
Funding
This work was supported by grants from the Ministry of Education, Culture,
Sports, Science and Technology (#16 K01806) and the Ministry of Health,Labour and Welfare (#H28Sukoyaka-001, H29Sukoyaka-005 #29040501,
H30Sukoyaka-004), and the Japan Agency for Medical Research and Development (BIRTHDAY). The funding organizations had no role in the study design,collection, analysis or interpretation of the data, writing the manuscript, or
the decision to submit the paper for publication.
Availability of data and materials
The datasets of this study are available from the corresponding author on
reasonable request.
Ethics approval and consent to participate
The design of this study and procedures for obtaining informed consent
were approved by the Medical Ethics Committee of Kurume University
School of Medicine (#13211). All participants provided informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Pediatrics and Child Health, Kurume University School of
Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan. 2Psychosomatic
Medicine, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan.
3
Department of Pediatrics, Tachikawa Hospital, Tachikawa, Japan.
4
Department of Neuropsychiatry, Kurume University School of Medicine,
Kurume, Japan. 5Department of Pediatrics Hoshigaoka Maternity Hospital,
Nagoya, Japan. 6Department of Pediatrics, Okayama University Graduate
School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
7Child Development and Psychosomatic Medicine Center, Dokkyo Medical
University Saitama Medical Center, Saitama, Japan. 8Himeji City Center for the
Disabled, Himeji, Japan. 9Nagasaki Prefectural Center of Medicine andWelfare for Children, Nagasaki, Japan. 10Department of Pediatrics, Fukushima
Medical University School of Medicine, Fukushima, Japan. 11Department ofPediatrics, National Hospital Organization Mie National Hospital, Mie, Japan.
12Department of Pediatrics, School of Medicine, Sapporo Medical University,
Sapporo, Japan. 13Mental and Developmental Clinic for Children “ELM TREE”,
Sapporo, Japan. 14Psychiatry Department, Kobe City Nishi-Kobe Medical
Center, Kobe, Japan. 15Takamiya Medical Clinic, Akashi, Japan. 16Departmentof Pediatrics, Okayama University Hospital, Okayama, Japan. 17Biostatistics
Center, Kurume University, Kurume, Japan.

Nagamitsu et al. BioPsychoSocial Medicine(2019) 13:21

Received: 4 June 2019 Accepted: 30 August 2019

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