In this In Conversation podcast, we are joined by Dr. Andrea Goldschmidt, from the University of Pittsburgh. Dr. Goldschmidt is a licensed clinical psychologist whose research focuses on eating behaviors that are associated with poor weight-related outcomes.
The focus of this podcast will be on her recent JCPP paper ‘Executive functioning and treatment outcome among adolescents undergoing cognitive-behavioral therapy for binge-eating disorder’ (https://doi.org/10.1111/jcpp.14031).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- An introduction to Binge Eating Disorders and why this area of eating disorders is often overlooked.
- The effects of executive functioning on Cognitive Behavioural Therapy (CBT) outcomes in adolescents and the impact of executive functioning on treatment engagement.
- More impulsive decision-making being both associated with more frequent LOC eating following treatment but also with a greater number of sessions attended.
- Apps that teach self-guided CBT and insight into an upcoming trial focusing on this type of intervention.
- Advice for people who think that they, or somebody they know, may have a Binge Eating Disorder.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Dr. Goldschmidt is a licensed clinical psychologist and Associate Professor of Psychiatry at the University of Pittsburgh School of Medicine. For the past 20 years, she has been studying eating behaviors that are associated with adverse health outcomes across the lifespan, particularly during the transition from childhood to adolescence. Her primary line of research is aimed at understanding onset and maintenance mechanisms that drive binge and loss of control eating (both characterized by feeling unable to control what or how much one is eating) in youth, with a particular focus on neurocognitive and self-regulation mechanisms. She also maintains a secondary research line focused on optimizing the quality of care for eating disorders in children and adolescents across community health settings using implementation science. Her overall scientific missions is to reduce suffering associated with eating- and weight-related problems in youth via development of neurobiologically-informed early intervention programs.
Transcript
[00:00:09.975] Clara Faria: Hello, welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Clara Faria. I’m ACAMH Young Person Ambassador, and in today’s episode, I have the pleasure to talk to Dr. Andrea Goldschmidt from the University of Pittsburgh.
Dr. Goldschmidt is a licensed Clinical Psychologist whose research focuses on eating behaviours that are associated with poor weight-related outcomes. Today, we will be discussing her recently published paper in JCPP, “Executive Functioning and Treatment Outcome Among Adolescents Undergoing Cognitive-Behavioral Therapy for Binge-Eating Disorder.” If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and share with friends and colleagues.
Welcome, Dr. Goldschmidt. Thank you so much for being here today. Can you start with an introduction, giving a short overview of what you do, to our audience, please?
[00:01:08.616] Dr. Andrea Goldschmidt: Sure, and thank you so much for having me. I’m excited to be here and to talk about this research. You already mentioned I’m a Clinical Psychologist. I’ve been interested in binge eating since I started my career as a grad student many, many years ago. And my current research focuses on trying to understand mechanisms that drive binge eating behaviours, both over longer periods of time, particularly the transition from childhood to adolescence, but also in real-time. So, what drives an individual to seek out large amounts of food and feel out of control of their eating, in the moment, in whatever environment they may be in?
And the idea is that if we can identify the mechanisms that contribute to onset and maintenance of these problems, that we can develop better intervention strategies early on in life to prevent negative health outcomes unfolding over the course of a lifespan. And I have a secondary line of research that focuses more on dissemination implementation, particularly with respect to evidence-based treatments for adolescents with restrictive type eating disorders. And so, this article actually, sort of, represents a confluence of my interests in both developmental mechanisms and intervention strategies.
And I’ve been at the University of Pittsburgh, I’m in the Department of Psychiatry here, I’ve been here for about three years, and I run the BITE Lab, which stands for Behavioral Investigations of Children’s and Teens’ Eating. So, if people are interested, they’re welcome to follow us on Twitter. Our handle is @BITELab_Pitt, with two ts. And that’s spelt B-I-T-E-L-a-b-underscore-P-i-t-t, and we’re conducting lots of interesting research here and hope to continue this line of research all the way up until retirement.
[00:03:01.507] Clara Faria: That’s brilliant, and I’m really looking forward to our conversation today, especially because we have a really nice opportunity to do a little bit of a deep dive into binge-eating disorders. And when thinking about eating disorders research, binge eating can be often overlooked. So, could you give us a brief introduction to this topic and why were you drawn to study adolescents with binge-eating disorder in the first place?
[00:03:26.016] Dr. Andrea Goldschmidt: Binge-eating disorder is often overlooked. Many people that I talked to, clinically, in the past and just lay public people, don’t really even consider that binge-eating disorder might be an actual eating disorder diagnosis. Oftentimes, when we hear about eating disorders in the popular media, the focus is really on anorexia nervosa and bulimia nervosa, which are both very serious and impairing disorders, but are much lower in prevalence than binge-eating disorder.
So, binge-eating disorder is defined primarily by two features. One is the presence of recurrent binge eating episodes. So, that is eating a large amount of food, significantly more than what most people would consider a large amount of food, given the context, accompanied by a feeling of loss of control while eating. So, feeling unable to control what or how much one is eating. And importantly, those binge-eating episodes are not associated with the regular use of compensatory behaviours designed to offset energy intake or prevent excess weight gain or reduce weight, like you would see in bulimia nervosa.
There are several other features associated with binge-eating disorder, including things like eating much more rapidly than normal during binge-eating episodes or feeling guilty or distressed after binge-eating episodes. My research has focused mainly on that loss of control construct. That’s really what drove me to become interested in eating disorders research in the first place and actually, is very strongly tied into the topic of the article that we’re discussing today because it reflects a, sort of, lack of self-regulation in the moment. So, an inability to regulate one’s impulses in pursuit of longer term goals. And that can be anything from people wanting to control their weight or shape, for whatever reasons, appearance reasons or health reasons, and any other type of long-term goal. So, they’re binge eating with that feeling that they just can’t stop themselves in the moment.
And I became interested in understanding what is going on in people’s brains when they’re feeling this lack of control over eating, and we know that this loss of control is very likely present in the moment when people are experiencing other types of dysregulated behaviours, like substance use, compulsive gambling, things like that. So, I was really interested in trying to understand that key feature of binge-eating episodes, particularly because we know that when you get to the younger side of the age spectrum, you know, children and adolescents don’t always have access to large amounts of food, but they often report feeling out of control while they’re eating, even if they’re eating a smaller amount of food.
So, that’s one of the reasons that I study that construct in kids, but I would say that the main reason I became interested in studying children and adolescents is because I noticed early on in my career, particularly clinically, talking to adults with binge-eating disorder. I trained in a lab that focused a lot on paediatrics, but also had a focus on development and testing of interventions for adults with binge-eating disorder. And talking to a lot of these adults, it became clear that many of them had been struggling with their binge eating for decades. So, sort of, looping back to what we talked about earlier, these were people that didn’t know that they had an eating disorder. They just thought, you know, “I have a weight problem, I sometimes feel out of control with my eating, but that’s because I lack willpower.” And it never occurred to them, or they were never able to access treatment earlier in their life, when it could’ve had the potential to, sort of, prevent a lot of the negative health consequences that people experience over many, many years and decades of engaging in binge-eating episodes.
So, I really wanted to get to the root of problem. I think prevention or early intervention is super important, again, because it’s just devastating to hear an adult in middle age, for the first time, seeking treatment for a problem that they’ve had since they were a child. And so, really, the main focus of my work is trying to prevent those adverse health outcomes that can persist over a life course.
[00:07:31.107] Clara Faria: That’s super interesting. Thank you, and moving to your paper, well, in your paper, you looked specifically at the effects of executive functioning on CBT outcomes in adolescence. Your initial hypothesis was that adolescents with poor functioning at pre-treatment would show more modest improvements when compared to those with better executive functioning and emotional regulation at baseline. And can you tell us a bit more about the rationale behind this hypothesis, since you were so interested in mechanisms?
[00:07:59.440] Dr. Andrea Goldschmidt: I actually was working on this paper at the same time I was working on a grant that is designed to study how to improve self-regulation in children with binge eating problems. And I think we’re going to talk about that later, so hopefully, everyone will stay tuned. But the idea behind this was I’ve always been interested in how neurocognitive functioning might be an onset and maintenance mechanism in relation to binge eating in kids. Particularly because we know that people who have binge eating problems tend to have more difficulties with self-regulation and, on top of that, that self-regulation is, sort of, naturally influxed during the transition from childhood to adolescence. So, that’s because children’s brains are still growing, their self-regulation is improving, but really isn’t at its peak until they’re later in young adulthood.
And so, we knew from the literature that cognitive behavioural therapy, which is a very structured evidence-based treatment focused on addressing maladaptive cognitions that might drive binge eating behaviours, as well as really normalising eating behaviours, is a very efficacious intervention for adults with binge eating. And in this study, it was adapted for a younger age range, so that kids could access and implement the intervention more readily. So, one of the caveats that I see about using an evidence-based intervention that was developed for adults and adapting it for children is that it might not consider all the factors that might make it hard for adolescents to implement the intervention in their real lives.
So, for example, CBT asks people to do things like self-monitor or engage in strategies like stimulus control, where they’re making their environment structured in a way that makes it harder for them to engage in a maladaptive behaviour. But when thinking about kids, if a child is having difficulties with their self-regulation, they may not really have the capability to remember the intervention that they were taught in a Therapist’s office and then apply it in their real world at a time when they might need it.
So, I was really interested in understanding how these baseline self-regulation factors might impact how kids would do in CBT, with the idea that kids that really struggle with self-regulation, executive functioning being one facet of self-regulation, might have a more difficult time adhering to the CBT skills that they learned in treatment and applying them in their regular lives.
So, that was, sort of, the impetus for this study and as I mentioned, I’m doing work now on trying to incorporate self-regulation, skill building and practice into a CBT-based intervention for teens. With the idea that if we can help them develop their self-regulation skills at the same time that they’re learning CBT, that they might have an easier time remembering to implement the CBT strategies in their real worlds and thus, benefit more from CBT than kids who were not addressing those strategies.
[00:11:07.107] Clara Faria: And in your analysis, one thing I thought really interesting is that besides analysing the impact of executive function pre-treatment on the CBT outcome, as we’ve just discussed, you also analyse the impact of executive function on treatment engagement. And I was just curious, what was the initial hypothesis behind this analysis? Did you also expect to find that young people with poor executive functioning at baseline would have poorer treatment engagement?
[00:11:34.896] Dr. Andrea Goldschmidt: Yes, that is exactly what I thought and one of the surprising findings was that the youth with higher impulsivity actually, were more engaged in treatment, according to one metric, which was session attendance. So, the idea here was that, you know, we thought that children that struggled with self-regulation more might find CBT more challenging and be more likely to be drop out or attend fewer sessions. That they might get frustrated with the intervention or, sort of, decide on the spot, “This treatment isn’t working.” You know, if you’re impulsive, you would tend to behave rashly in the moment and so, if the treatment isn’t working right away, you might assume it’s not going to work, I might as well stop and quit while I’m ahead.
But what we found was actually, that impulsivity was associated with better attendance, which, sort of, perplexed me at the time. But the way that we made sense of those findings is that perhaps as these kids are ageing into young adulthood, they’re recognising that “I really do have difficulties with regulating my behaviours and I think maybe treatment could benefit me even more because of that.” So, we need to do more around exploring this finding and in particular, I’d really like to see how children with different levels of self-regulation adhere to different components of the intervention. Like, we were hoping to be able to look at homework assignment completion and implementation of CBT skills in their real lives, and unfortunately, we didn’t have access to that data in this study, but that’s definitely an area of future research that we’re hoping to explore.
[00:13:06.267] Clara Faria: And continuing the conversation on the results. Regarding the predictors of CBT outcomes, what did your model show?
[00:13:14.056] Dr. Andrea Goldschmidt: Yeah, so we found that there were several facets of executive functioning that were associated with poor outcome. We were conceptualising outcome as being eating behaviours at post-treatment and follow-up, as well as weight outcomes. And the reason for that is because binge eating is associated, often, with excess weight gain, overdevelopment, both in children and adults. And so, weight is often a secondary outcome in intervention studies for binge-eating disorder.
So, we wanted to look at both of those constructs as indicators of treatment outcome and we found that impulsivity was associated with worse binge eating outcomes. That kids that had higher impulsivity at baseline showed smaller improvements in binge eating after treatment. Cognitive flexibility was associated with weight outcomes. So, children that struggled more with being flexible in their approach to their environment or flexible in terms of their behaviours, had attenuated weight outcomes at – after treatment, as well.
[00:14:19.827] Clara Faria: And did any result regarding the predictors of CBT outcomes particularly surprise you? ‘Cause I can make sense of the impulsivity, the predictor about the – yeah, the weight outcomes, I, yeah, I was really curious about.
[00:14:34.056] Dr. Andrea Goldschmidt: That was another finding that I, kind of, had to scratch my head, ‘cause I was predicting that, you know, of all the executive functioning constructs – and this is just, like, a great dataset to work in, because the Study Investigators – I joined up with the team in Germany that had done this study, to do a secondary data analysis, which ended up in this paper. But they were really thoughtful in adding some of these measures at baseline, and these are not typically included in measures of treatment outcome for any eating disorders. So, I was expecting some facets of executive functioning, like inhibition, ability to, like, stop oneself from engaging in a behaviour that is not associated with a positive health outcome, or one of their goals, that things like that would be more associated with eating and weight outcomes.
But the cognitive flexibility piece, I think, makes absolute sense ‘cause these are kids that might struggle to, kind of, change their response to a changing environment. So, maybe as an example, a kid has the intention of, “I’m going to go to the party,” you know, “that my friend’s hosting at their house. I’m really just going to focus on talking to my friends and stay completely away from the food table because I already ate before the party.” And then, lo and behold, they get to the party and their absolute favourite foods are on the buffet table. Those are kids that might have a hard time, kind of, changing their behaviour and sticking with their plan because the environment is different than what they expected. So, it makes sense that those are kids that might have more difficulties adaptively responding to their environment to support weight maintenance or weight loss, if that’s one of their goals.
[00:16:13.747] Clara Faria: Yeah, that totally makes sense, and coming back to the predictors of CBT engagement, I found it so intriguing, as you said before, that more impulsive decision-making was both associated with more frequent loss of control eating following treatment, but also, it was associated with a greater number of sessions attended. And you’ve explained a little bit about how you made sense of that finding, but I was wondering, do you think that this particular finding could have any clinical implications?
[00:16:43.136] Dr. Andrea Goldschmidt: I actually do, and one thing we haven’t really talked very much about was the role of parents in their adolescent’s eating and treatment attendance. So, these youth were at an age where parent involvement is still super important, and I think that we can’t really understate the role that parents might’ve had in engaging their kids in treatment. So, if you are seeing that your kid is really struggling with the behaviour, you might be more motivated to drive them to treatment or to enrol them in a treatment programme, even if your child is saying, like, “Nah, I’m not really sure I want to do this.” But what we’re seeing is that if those kids – kids that were able to stick to it, it seemed to have a benefit in terms of their eating behaviours.
So, I would say clinically, if you have families coming in with teenagers that are struggling with eating, and you’re offering them treatment and they’re, sort of, ambivalent about treatment, trying to use whatever clinical skills you might have to really encourage them to see all the possible pros and cons of sticking with treatment a little longer. As a Therapist, I can often tell when families are, sort of, on the verge of, like, “I don’t know if this is working. We’re thinking about dropping out,” or “It’s just too hard. We have other kids at home. We have other priorities, and I can’t force my 15-year-old to do anything anymore.” So, those conversations start happening.
A family dropping out of treatment usually doesn’t just happen completely out of nowhere. So, as a Clinician, I’d be thinking about, you know, pointing to the literature for a family and saying, “We know that, you know, kids that have struggles with their eating and maybe have more difficulties regulating their impulses, might be more tempted to drop out of treatment early. But we also know that if they stay in treatment, that it has a good chance of benefitting them. So, I’d encourage you to give it a little bit longer and we can work more closely on your particular treatment goals,” but, kind of, using the literature as this – as a prop to encourage families to stay in treatment. But I do think we really need to do a little bit of a deeper dive into understanding why these kids tended to stay in treatment longer, or at least attended more sessions.
[00:18:58.720] Clara Faria: And still on the CBT topic, well, we know that the study we’re talking about, as you said, was done in partnership with this German group and they did face-to-face CBT. And we know that sometimes face-to-face CBT is not a feasible option for everyone. In some countries it can be hard to access, due to a long waiting list, for instance. Could you talk a little bit more about apps that teach self-guided CBT? And as you have spotted in the beginning, I know you have an upcoming trial focusing on teaching those CBT-based techniques on this type of intervention and it would also be amazing to know more about it, if you can share with us.
[00:19:36.896] Dr. Andrea Goldschmidt: So, I mean, this is part of the reason why I became involved in implementation work, as well, is because we know that once a treatment has been shown to have efficacy, it takes a really long time to get it out to the public. And then, once it’s available, and I’m using air quotes when I think of the word ‘available’, many, many families cannot access it, for a variety of reasons. You named ‘wait lists’ as one of them. There aren’t tonnes and tonnes of practitioners in the community practising evidence-based treatments, especially for eating disorders.
Oftentimes, Therapists do not accept a range of insurances. So, particularly families that may be lower income might have a really hard time finding Therapists that both practise evidence-based treatment and accept the insurance, like Medicaid. At least that’s the case in the US.
And on top of that, treatment centres are often really located around densely populated urban areas of the country and so, families that live in more rural regions or don’t have reliable transportation, would physically have a hard time getting to treatment. And in my other line of research, we’re studying how to bring treatments into the home, so studying home-based treatments and how to adapt evidence-based treatments to be delivered in the home as one way to increase access.
But another really viable way is through digital interventions and CBT has been adapted to a digital format for many psychiatric disorders. Many years ago, I worked on a trial, before smartphones were really a thing, we adapted CBT to be delivered via the internet. But it involved, you know, sitting at a computer and having to do the intervention seated at your kitchen table or your desk while a computer was open in front of you.
And so, the trial that we’re working on now is really aiming to scale CBT to a wider audience by reformatting it for a digital intervention that can be used on any smartphone or mobile device. And the idea, kind of, ties back to what we talked about much earlier, which is, you know, if kids are struggling with remembering the skills that they learned in a Therapist’s office and figuring out how to implement them in their real lives in different contexts, what better way to help them than to have them carry the intervention with them? So, if they’re out in their natural environment and experiencing, you know, some sort of binge trigger, being able to access the treatment tools on their phones would potentially make it much easier for them to implement the skill when they need it.
And so, we are just starting a feasibility trial to look at the acceptability of a digital CBT-based intervention for teens with binge eating. Right now, we are in the first phase, which involves co-designing the intervention with the intended users. So, we’re bringing teens in to talk to us about what they would need in a digital CBT-based intervention, what type of graphics they would like, what types of tools they would use. What types of things would help them engage more with the intervention? We are adding self-regulation, skill building and practice, again with the idea that if we can help children build the areas of their brain that might be making it harder for them to adhere to CBT principles, that their adherence might be better and thereby, you know, they might show greater improvements in their binge eating and weight-related outcomes.
And so, once we are finished up designing the intervention, which we’re hopeful will be this upcoming fall, we’ll be testing it in an open trial of about 50 teens throughout the US and we are hoping to show that, you know, kids find this intervention engaging, that they find it acceptable. They’re actually clicking on the links that we’re giving them and reading the information that we’re giving them and implementing the intervention in their real lives. And then, the next step would be to do a randomised controlled trial and perhaps thinking about ways that we could personalise the intervention to kids that struggle in certain areas of executive functioning more than others.
[00:23:58.107] Clara Faria: That’s super interesting and so much needed research, and I’m looking forward to reading the papers that will come out of this phase I feasibility trial. To wrap up, I wanted to ask you, do you have any advice for people who think that they, or somebody they know, may have a binge-eating disorder? Do you know any particularly good online sources of support?
[00:24:21.616] Dr. Andrea Goldschmidt: As we talked about earlier, you know, I think the more typical presentation is for people to seek out treatment for binge-eating disorder only after many, many years of struggling. So, I would say if you or someone you know might be struggling with binge eating, that talking to a trusted healthcare provider sooner rather than later is really the best chance of, you know, preventing this cascading effect of negative health outcomes over the lifespan.
I also just think, as a Psychologist, like, why should people suffer unnecessarily? I think that we really need to do a better job at getting the word out around binge-eating disorder. That it is a real thing, it’s very common and I think sometimes, people feel, actually, a lot of relief at being given a diagnosis. That this is something that feels so shameful to people and they often have the perception that “I’m the only one that does this. This behaviour means I have no willpower or I’m a lazy person.” And I think understanding that so many people suffer from the same behaviours, that there’s actually a name for it and we have treatments for it, can come as a huge relief to people. And the thing that I would most commonly hear when treating adults is middle age, was, “I just wish that somebody had recognised this sooner.”
I do think it’s important to talk sensitively about this topic because many people do feel so much shame around their binge eating behaviours. These are behaviours that are often done in secret. Oftentimes, parents don’t know that their kid might be struggling with binge eating, but sometimes there are signs. You know, if they’re finding food wrappers in the child’s room or noticing large amounts of food missing without being able to account for it. Really important for parents to talk about this behaviour with their kids in a way that doesn’t shame them further. So, sticking to the facts and trying to understand empathically, you know, “What is going on with your eating? I want to help you.” As opposed to, “Why are you doing this? You need to get control of yourself,” or talking about it in a really blaming way.
And then, I would say the first step for families is to talk to a trusted healthcare provider. There are resources in the community. Again, like, some of them can be harder to access than others and oftentimes, what I hear is that families might need to go through a couple of Therapists before they find one that specialises in eating behaviours and eating disorders. But it’s definitely worth sticking with it and trying to get to a good course of treatment, because there are treatments that work pretty well for this disorder. And, you know, thinking about saving someone decades of suffering from a – something that they didn’t even know there was a treatment for can be lifechanging.
[00:27:09.067] Clara Faria: Well, thank you so much, Dr Goldschmidt, for sharing your research with us. Your enthusiasm for the field is clear and it’s just so important that we have people that are enthusiastic and empathetic doing research on eating disorders. Thank you so much for your time today.
[00:27:25.256] Dr. Andrea Goldschmidt: Thank you for having me.
[00:27:26.547] Clara Faria: You’re welcome, and for more details on Dr. Goldschmidt’s work, please visit her group website. Her group is called Behavioral Investigations of Children’s and Teens’ Eating, or BITE, and we – there will be a link for it in the podcast page. Also check out our Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and do keep an eye out for other podcasts in the In Conversation series. Don’t forget to follow us on your preferred social media or streaming platform, and let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues. Thank you so much for listening to us.
