Elizabeth R Woods | Harvard Medical School (original) (raw)

Papers by Elizabeth R Woods

Research paper thumbnail of Early intervention in low birth weight premature infants : Results at 18 years of age for the infant health and development program. Commentary

Pediatrics, 2006

OBJECTIVE. To assess whether improvements in cognitive and behavioral development seen in prescho... more OBJECTIVE. To assess whether improvements in cognitive and behavioral development seen in preschool educational programs persist, we compared those in a multisite randomized trial of such a program over the first 3 years of life (INT) to those with follow-up only (FUO) at 18 months of age.METHODS. This was a prospective follow-up of the Infant Health and Development Program at 8 sites heterogeneous for sociodemographic characteristics. Originally 985 children were randomized to the INT (n = 377) or FUO (n = 608) groups within 2 birth weight strata: heavier low birth weight (HLBW; 2001–2499 g) and lighter low birth weight (LLBW; ≤2000 g). Primary outcome measures were the Peabody Picture Vocabulary Test (PPVT-III), reading and mathematics subscales of the Woodcock-Johnson Tests of Achievement, youth self-report on the Total Behavior Problem Index, and high-risk behaviors on the Youth Risk Behavior Surveillance System (YRBSS). Secondary outcomes included Weschler full-scale IQ, caregiver report on the Total Behavior Problem Index, and caregiver and youth self-reported physical health using the Medical Outcome Study measure. Assessors were masked as to study status.RESULTS. We assessed 636 youths at 18 years (64.6% of the 985, 72% of whom had not died or refused at prior assessments). After adjusting for cohort attrition, differences favoring the INT group were seen on the Woodcock-Johnson Tests of Achievement in math (5.1 points), YRBSS (−0.7 points), and the PPVT-III (3.8 points) in the HLBW youth. In the LLBW youth, the Woodcock-Johnson Tests of Achievement in reading was higher in the FUO than INT group (4.2).CONCLUSIONS. The findings in the HLBW INT group provide support for preschool education to make long-term changes in a diverse group of children who are at developmental risk. The lack of observable benefit in the LLBW group raises questions about the biological and educational factors that foster or inhibit sustained effects of early educational intervention.

Research paper thumbnail of Tax Credits and Health Equity: An Observational Study of Tax Credits and Asthma Outcomes

Research Square (Research Square), Mar 13, 2023

Federal tax credits are an evidenced-based strategy to promote health equity. Our objectives were... more Federal tax credits are an evidenced-based strategy to promote health equity. Our objectives were to describe families' knowledge and use of tax credits, to analyze the association between receipt of tax credits and asthma health outcomes, and to offer referrals for free tax preparation to families. We hypothesized that tax credit receipt would be associated with improved asthma outcomes. We surveyed the parents of children aged 2-18 years old with high-risk asthma living in low-income neighborhoods about tax credits. We then conducted a retrospective observational study using a convenience sample of 102 parents of children enrolled in the Community Asthma Initiative from March 2017-January 2020. We analyzed the association of report of tax credits with reductions in ED visits, inpatient stays, PCP visits, steroid courses, missed school days, days of inactivity, and missed parental workdays using a paired ttest. We enrolled 102 parents in this study. Nearly one third of the parents (29%) did not report any tax credits. Housing costs (34%) and paying bills and debts (34%) were the most common use of tax credits. Among the 55 with 6-month follow-up information, signi cant reductions were seen in inpatient stays (0.46, p-value < 0.01), steroid courses (0.73, p-value < 0.01), missed school days (4.19, p-value < 0.01), and days of inactivity (2.81, p-value < 0.01) compared to no signi cant reductions among non-tax credit recipients. Expansion of tax credits may be an important way for pediatricians to promote health equity in asthma outcomes.

Research paper thumbnail of Screening for Anal Dysplasia in Adolescent and Young Adult Men Who Have Sex With Men Living With HIV, a Review of Current Recommendations

Frontiers in Pediatrics, Apr 6, 2022

Research paper thumbnail of Gastrointestinal Manifestations of Eating Disorders

Journal of Pediatric Gastroenterology & Nutrition, 2016

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present wi... more Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

Research paper thumbnail of Anal dysplasia in adolescent and young adult men who have sex with men: a single-center retrospective and descriptive study (2010–2020)

Frontiers in Pediatrics

ObjectiveThere are limited studies evaluating anal cytology results or the prevalence of anal hum... more ObjectiveThere are limited studies evaluating anal cytology results or the prevalence of anal human papiloma virus in adolescent and young adult (AYA) men who have sex with men (MSM). The purpose of this study was to review anal cytology screening results and determine whether abnormal findings resulted in completion of anoscopy in AYA MSM (13–26 years old).Patients and MethodsThis was a retrospective study evaluating 84 anal Papanicolaou screening results among 36 AYA MSM patients aged 13–26 years who had an anal Papanicolaou test completed at an outpatient Adolescent/Young Adult Medicine Practice at Boston Children's Hospital, an urban, nonprofit, academic, free-standing children's hospital, from January 1, 2010, to December 31, 2020.ResultsThe findings of anal Papanicolaou screening included atypical squamous cells of undetermined significance (ASCUS) (37%), negative for squamous intraepithelial lesion (31%), inability to read (21.3%), and low-grade squamous intraepitheli...

Research paper thumbnail of The Association of Malnutrition, Illness Duration, and Pre-morbid Weight Status with Anxiety and Depression Symptoms in Adolescents and Young Adults with Restrictive Eating Disorders: A Cross-Sectional Study

Research Square (Research Square), Jan 29, 2021

Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression, pla... more Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and premorbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs. Methods 145 participants with restrictive EDs (anorexia nervosa [AN], otherwise speci ed eating or feeding disorder [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants' pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. We used multiple linear regression to examine the association of malnutrition, ED duration, and pre-morbid weight status with symptoms of anxiety and depression. Results Mean(SD) age was 16.4(3.0) years; 87% were female; 89% white; 85% had AN, 6% OSFED, 10% ARFID. Of these, 2/3 had ED symptoms ≥1 year, 1/3 had previous higher level of ED care (HLOC), and half were taking psychiatric medications. Mean %eBMI was 90% (range 57-112%). Mean GAD-7 was 9.4(5.9) and CES-D was 24(13.8), indicating most participants had clinically signi cant anxiety and/or depression. Degree of malnutrition was not signi cantly associated with anxiety or depression adjusting for age, sex, sexual orientation, ED diagnosis, and use of psychiatric medication. Those with longer duration of ED symptoms had higher depression (p=0.038) scores after adjusting for malnutrition, HLOC, length of ED symptoms, and time in our care. Patients with pre-morbid BMIs ≥75 th percentile had lower depression scores than those with pre-morbid BMIs <75 th percentile (p=0.014). Conclusions We nd high degree of clinically relevant anxiety and depression in a population of AYAs with EDs. Our ndings suggest that factors beyond malnutrition play a role in the co-morbid mood and anxiety disorders in this population. Overall, rapid ED diagnosis and comprehensive treatment for patients with EDs across the weight spectrum-and especially those with psychiatric co-morbidities-will likely aid in recovery.

Research paper thumbnail of Access to Care and Worsening Eating Disorder Symptomatology during the COVID-19 Pandemic

Research Square (Research Square), Mar 16, 2021

Background Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 ... more Background Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors. Methods AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, completed a COVID-19speci c survey (n=89). We examined bivariate associations of four markers of care: access to and changes in care as well as perceived disruption to and quality of care. Using multiple logistic regression, we examined the associations of our pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n=16). Results In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing to see at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly one-third (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were signi cantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching signi cance (p=0.07). Conclusions Our ndings show the majority of AYA who had care prior to the pandemic are still receiving some element of their multidisciplinary ED treatment and perceive their care as high quality. Although none of the markers of care described were statistically associated with increased ED thoughts and behaviors, our results may indicate that continued access to care may be protective against increased ED behaviors and patients who perceive their quality of care as worse than usual might be more likely to have intrusive ED thoughts.

Research paper thumbnail of 84. COVID-19’s Impact on Patients With Eating Disorders: The Relationship Between Eating Disorder/Mental Health Symptoms and Eating Disorder Motivation to Recover

Journal of Adolescent Health, Feb 1, 2021

Research paper thumbnail of How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians

International Journal of Eating Disorders, May 26, 2020

Objective: Recovery from an eating disorder (ED) may be defined differently by different stakehol... more Objective: Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians. Method: We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/ restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston

Research paper thumbnail of 79. Impact of COVID-19 on Access to Eating Disorder Treatment

Journal of Adolescent Health, Feb 1, 2021

Research paper thumbnail of Access to care and worsening eating disorder symptomatology in youth during the COVID-19 pandemic

Journal of eating disorders, Jun 10, 2021

Background: Shelter-in-place orders and social distancing guidelines, in response to the COVID-19... more Background: Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors. Methods: AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, and completed a COVID-19specific survey (n = 89). We examined bivariate associations of four markers of care: i) access to care, ii) changes in care, iii) perceived disruption to care, and iv) quality of care. Using multiple logistic regression, we examined the associations of pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n = 16). Results: In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing care with at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly onethird (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were significantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching significance (p = 0.07). Conclusions: Our findings show the majority of AYA who had care prior to the pandemic continued receiving some element of their multidisciplinary ED treatment and perceived their care as high quality. None of the markers of care described were statistically associated with increased ED thoughts and behaviors.

Research paper thumbnail of 99. In Eating Disorder Recovery: The Relationship Between Malnutrition and Symptoms of Anxiety/Depression in Youth With Restrictive Eating Disorders

Journal of Adolescent Health, Feb 1, 2021

Research paper thumbnail of The Impact of the COVID-19 Pandemic on the Number of Adolescents/Young Adults Seeking Eating Disorder-Related Care

Journal of Adolescent Health, Oct 1, 2021

The COVID-19 pandemic has led to the development and worsening of eating disorder (ED) symptoms i... more The COVID-19 pandemic has led to the development and worsening of eating disorder (ED) symptoms in adolescents and young adults. In order to examine COVID-19-related trends in ED care-seeking at our institution. Methods: We used interrupted time series regression to examine pre-and postpandemic monthly summary data of the following: (1) ED-related inpatient admissions for medical stabilization; (2) ED-related hospital bed-days; (3) completed outpatient ED assessments; and (4) ED outpatient care-related inquiries at a children's hospital in Boston, MA. Results: Inpatient admissions, hospital bed-days, and outpatient care-related inquiries increased on average over time postpandemic compared to stable volume over time prepandemic (p < .01). Outpatient assessments decreased precipitously initially following COVID-19-related limitations, and rose quickly back to baseline. Conclusion: These results indicate increased need for ED-related care during the pandemic. Bolstering resources to meet the needs of these vulnerable patients is critical as the effects of the pandemic continue to be felt.

Research paper thumbnail of Youth, risks, and chronic illness

Current Opinion in Pediatrics, Aug 1, 2011

Research paper thumbnail of COVID-19 related familial economic disruptions and eating disorder patients’ mental health concerns and motivation to recover

Journal of eating disorders, Dec 20, 2022

Background: Family support has been shown to be important for adolescents and young adults (AYA) ... more Background: Family support has been shown to be important for adolescents and young adults (AYA) in eating disorder (ED) treatment. Many families were impacted by the pandemic, potentially altering their ability to support individuals in ED treatment. This study examined the association of COVID-19 related familial economic change with self-reported mental health (MH) and ED concerns in AYA seeking treatment for ED. Methods: AYA patients with EDs aged 10-27 years enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) completed an additional COVID-19-specific survey (n = 89) that assessed their perception of the effects of the pandemic on their lives and their ED. Participants self-reported on familial economic disruptions, measured through a composite score of four markers: (1) family member's work hours cut, (2) family member was required to stop working, (3) family member lost job permanently, and (4) family lost health insurance/ benefits. In bivariate analyses, we examined the association between self-reporting any familial economic disruption and self-reported changes in intrusive ED thoughts, feelings of anxiety, feelings of depression, feelings of isolation, and motivation to recover from their ED. Logistic regression models were used to examine the association between familial economic disruptions on self-reported changes in ED/MH affect and motivation to recover adjusting for age and ED diagnosis. Results: Forty-six percent of participants self-reported that the pandemic had resulted in at least one economic familial disruption. Of patients reporting any familial economic disruption, 29% reported decreased motivation for ED recovery, and over 75% reported worsening feelings of depression, anxiety, isolation, and/or intrusive eating disorder thoughts. Reporting any COVID-19 familial economic disruption was marginally associated with feelings of isolation (p = 0.05). Though the findings were only marginally significant, the odds of reporting worsening feelings of depression, anxiety, intrusive ED thoughts or motivation to recover were nearly twice in those who reported a COVID-19-related familial economic disruption compared to those who did not report such a disruption. Conclusions: Family-related economic disruptions are associated with ED/MH-related concerns and motivation to recover from an ED during the COVID-19 pandemic in AYA patients.

Research paper thumbnail of 12. The Impact of the COVID-19 Pandemic on Adolescent/Young Adult Eating Disorder Patient Visits: Data from the National Eating Disorder Quality Improvement Collaborative

Journal of Adolescent Health, Apr 1, 2022

Research paper thumbnail of COVID-19’s Impact on Eating Disorder and Mental Health Concerns in Patients with Eating Disorders

Research Square (Research Square), Mar 17, 2021

Background The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescent... more Background The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines the implications of the COVID-19 pandemic on ED and MH symptoms and motivation for ED recovery in adolescents/young adults. Methods Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess the impact of the COVID-19 pandemic. Participants reported concerns of their ED worsening due to living in a "triggering environment" due to the pandemic as well as COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with MH and ED symptoms. Results The majority of respondents reported concern for "triggering environment" (63%), as well as increased ED thoughts (74%) and feelings of anxiety (77%), depression (73%), and isolation (80%) in response to the COVID-19 pandemic. Nearly one-third reported decrease in motivation to recover (29%). After adjusting for age and ED diagnosis, participants who reported triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report a triggering environment. Conclusions Our ndings demonstrate the negative impact the COVID-19 pandemic has had on the self-reported MH and ED symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

Research paper thumbnail of Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume

JAMA Pediatrics, Dec 1, 2022

IMPORTANCE The COVID-19 pandemic has affected youth mental health. Increases in site-specific eat... more IMPORTANCE The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. OBJECTIVE To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre-and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. EXPOSURES Onset of the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES Monthly number of patients seeking inpatient/outpatient ED-related care.

Research paper thumbnail of COVID-19 and eating disorder and mental health concerns in patients with eating disorders

Journal of eating disorders, Jul 2, 2021

Background: The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescen... more Background: The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines how young people with EDs feel the COVID-19 pandemic has affected their living environments as well as their ED and MH symptoms and motivation for ED recovery. Methods: Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess their perceptions of the impact of the COVID-19 pandemic. Participants reported on concerns of their ED worsening due to increased time living in a "triggering environment" due to the pandemic as well as perceived COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with ED and MH symptoms. Results: The majority of respondents reported concern for worsening of their ED due to a "triggering environment" (63%). Most reported an increase in ED thoughts (74%), feelings of anxiety (77%), depression (73%), and isolation (80%) they perceived to be related to the pandemic. Nearly one-third reported decrease in motivation to recover (29%) they perceived to be related to the pandemic. After adjusting for age and ED diagnosis, participants who reported concern for worsening of their ED due to a triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report concern for worsening of their ED due to a triggering environment. Conclusions: Our findings demonstrate the perceived negative impact the COVID-19 pandemic has had on the self-reported ED and MH symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

Research paper thumbnail of The Association of Malnutrition, illness duration, and pre-morbid weight status with anxiety and depression symptoms in adolescents and young adults with restrictive eating disorders: a cross-sectional study

Journal of Eating Disorders

Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symp... more Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symptoms, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and pre-morbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs. Methods 145 participants with restrictive EDs (anorexia nervosa [AN], other specified feeding and eating disorders [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants’ pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. ...

Research paper thumbnail of Early intervention in low birth weight premature infants : Results at 18 years of age for the infant health and development program. Commentary

Pediatrics, 2006

OBJECTIVE. To assess whether improvements in cognitive and behavioral development seen in prescho... more OBJECTIVE. To assess whether improvements in cognitive and behavioral development seen in preschool educational programs persist, we compared those in a multisite randomized trial of such a program over the first 3 years of life (INT) to those with follow-up only (FUO) at 18 months of age.METHODS. This was a prospective follow-up of the Infant Health and Development Program at 8 sites heterogeneous for sociodemographic characteristics. Originally 985 children were randomized to the INT (n = 377) or FUO (n = 608) groups within 2 birth weight strata: heavier low birth weight (HLBW; 2001–2499 g) and lighter low birth weight (LLBW; ≤2000 g). Primary outcome measures were the Peabody Picture Vocabulary Test (PPVT-III), reading and mathematics subscales of the Woodcock-Johnson Tests of Achievement, youth self-report on the Total Behavior Problem Index, and high-risk behaviors on the Youth Risk Behavior Surveillance System (YRBSS). Secondary outcomes included Weschler full-scale IQ, caregiver report on the Total Behavior Problem Index, and caregiver and youth self-reported physical health using the Medical Outcome Study measure. Assessors were masked as to study status.RESULTS. We assessed 636 youths at 18 years (64.6% of the 985, 72% of whom had not died or refused at prior assessments). After adjusting for cohort attrition, differences favoring the INT group were seen on the Woodcock-Johnson Tests of Achievement in math (5.1 points), YRBSS (−0.7 points), and the PPVT-III (3.8 points) in the HLBW youth. In the LLBW youth, the Woodcock-Johnson Tests of Achievement in reading was higher in the FUO than INT group (4.2).CONCLUSIONS. The findings in the HLBW INT group provide support for preschool education to make long-term changes in a diverse group of children who are at developmental risk. The lack of observable benefit in the LLBW group raises questions about the biological and educational factors that foster or inhibit sustained effects of early educational intervention.

Research paper thumbnail of Tax Credits and Health Equity: An Observational Study of Tax Credits and Asthma Outcomes

Research Square (Research Square), Mar 13, 2023

Federal tax credits are an evidenced-based strategy to promote health equity. Our objectives were... more Federal tax credits are an evidenced-based strategy to promote health equity. Our objectives were to describe families' knowledge and use of tax credits, to analyze the association between receipt of tax credits and asthma health outcomes, and to offer referrals for free tax preparation to families. We hypothesized that tax credit receipt would be associated with improved asthma outcomes. We surveyed the parents of children aged 2-18 years old with high-risk asthma living in low-income neighborhoods about tax credits. We then conducted a retrospective observational study using a convenience sample of 102 parents of children enrolled in the Community Asthma Initiative from March 2017-January 2020. We analyzed the association of report of tax credits with reductions in ED visits, inpatient stays, PCP visits, steroid courses, missed school days, days of inactivity, and missed parental workdays using a paired ttest. We enrolled 102 parents in this study. Nearly one third of the parents (29%) did not report any tax credits. Housing costs (34%) and paying bills and debts (34%) were the most common use of tax credits. Among the 55 with 6-month follow-up information, signi cant reductions were seen in inpatient stays (0.46, p-value < 0.01), steroid courses (0.73, p-value < 0.01), missed school days (4.19, p-value < 0.01), and days of inactivity (2.81, p-value < 0.01) compared to no signi cant reductions among non-tax credit recipients. Expansion of tax credits may be an important way for pediatricians to promote health equity in asthma outcomes.

Research paper thumbnail of Screening for Anal Dysplasia in Adolescent and Young Adult Men Who Have Sex With Men Living With HIV, a Review of Current Recommendations

Frontiers in Pediatrics, Apr 6, 2022

Research paper thumbnail of Gastrointestinal Manifestations of Eating Disorders

Journal of Pediatric Gastroenterology & Nutrition, 2016

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present wi... more Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

Research paper thumbnail of Anal dysplasia in adolescent and young adult men who have sex with men: a single-center retrospective and descriptive study (2010–2020)

Frontiers in Pediatrics

ObjectiveThere are limited studies evaluating anal cytology results or the prevalence of anal hum... more ObjectiveThere are limited studies evaluating anal cytology results or the prevalence of anal human papiloma virus in adolescent and young adult (AYA) men who have sex with men (MSM). The purpose of this study was to review anal cytology screening results and determine whether abnormal findings resulted in completion of anoscopy in AYA MSM (13–26 years old).Patients and MethodsThis was a retrospective study evaluating 84 anal Papanicolaou screening results among 36 AYA MSM patients aged 13–26 years who had an anal Papanicolaou test completed at an outpatient Adolescent/Young Adult Medicine Practice at Boston Children's Hospital, an urban, nonprofit, academic, free-standing children's hospital, from January 1, 2010, to December 31, 2020.ResultsThe findings of anal Papanicolaou screening included atypical squamous cells of undetermined significance (ASCUS) (37%), negative for squamous intraepithelial lesion (31%), inability to read (21.3%), and low-grade squamous intraepitheli...

Research paper thumbnail of The Association of Malnutrition, Illness Duration, and Pre-morbid Weight Status with Anxiety and Depression Symptoms in Adolescents and Young Adults with Restrictive Eating Disorders: A Cross-Sectional Study

Research Square (Research Square), Jan 29, 2021

Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression, pla... more Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and premorbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs. Methods 145 participants with restrictive EDs (anorexia nervosa [AN], otherwise speci ed eating or feeding disorder [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants' pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. We used multiple linear regression to examine the association of malnutrition, ED duration, and pre-morbid weight status with symptoms of anxiety and depression. Results Mean(SD) age was 16.4(3.0) years; 87% were female; 89% white; 85% had AN, 6% OSFED, 10% ARFID. Of these, 2/3 had ED symptoms ≥1 year, 1/3 had previous higher level of ED care (HLOC), and half were taking psychiatric medications. Mean %eBMI was 90% (range 57-112%). Mean GAD-7 was 9.4(5.9) and CES-D was 24(13.8), indicating most participants had clinically signi cant anxiety and/or depression. Degree of malnutrition was not signi cantly associated with anxiety or depression adjusting for age, sex, sexual orientation, ED diagnosis, and use of psychiatric medication. Those with longer duration of ED symptoms had higher depression (p=0.038) scores after adjusting for malnutrition, HLOC, length of ED symptoms, and time in our care. Patients with pre-morbid BMIs ≥75 th percentile had lower depression scores than those with pre-morbid BMIs <75 th percentile (p=0.014). Conclusions We nd high degree of clinically relevant anxiety and depression in a population of AYAs with EDs. Our ndings suggest that factors beyond malnutrition play a role in the co-morbid mood and anxiety disorders in this population. Overall, rapid ED diagnosis and comprehensive treatment for patients with EDs across the weight spectrum-and especially those with psychiatric co-morbidities-will likely aid in recovery.

Research paper thumbnail of Access to Care and Worsening Eating Disorder Symptomatology during the COVID-19 Pandemic

Research Square (Research Square), Mar 16, 2021

Background Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 ... more Background Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors. Methods AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, completed a COVID-19speci c survey (n=89). We examined bivariate associations of four markers of care: access to and changes in care as well as perceived disruption to and quality of care. Using multiple logistic regression, we examined the associations of our pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n=16). Results In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing to see at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly one-third (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were signi cantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching signi cance (p=0.07). Conclusions Our ndings show the majority of AYA who had care prior to the pandemic are still receiving some element of their multidisciplinary ED treatment and perceive their care as high quality. Although none of the markers of care described were statistically associated with increased ED thoughts and behaviors, our results may indicate that continued access to care may be protective against increased ED behaviors and patients who perceive their quality of care as worse than usual might be more likely to have intrusive ED thoughts.

Research paper thumbnail of 84. COVID-19’s Impact on Patients With Eating Disorders: The Relationship Between Eating Disorder/Mental Health Symptoms and Eating Disorder Motivation to Recover

Journal of Adolescent Health, Feb 1, 2021

Research paper thumbnail of How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians

International Journal of Eating Disorders, May 26, 2020

Objective: Recovery from an eating disorder (ED) may be defined differently by different stakehol... more Objective: Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians. Method: We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/ restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston

Research paper thumbnail of 79. Impact of COVID-19 on Access to Eating Disorder Treatment

Journal of Adolescent Health, Feb 1, 2021

Research paper thumbnail of Access to care and worsening eating disorder symptomatology in youth during the COVID-19 pandemic

Journal of eating disorders, Jun 10, 2021

Background: Shelter-in-place orders and social distancing guidelines, in response to the COVID-19... more Background: Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors. Methods: AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, and completed a COVID-19specific survey (n = 89). We examined bivariate associations of four markers of care: i) access to care, ii) changes in care, iii) perceived disruption to care, and iv) quality of care. Using multiple logistic regression, we examined the associations of pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n = 16). Results: In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing care with at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly onethird (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were significantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching significance (p = 0.07). Conclusions: Our findings show the majority of AYA who had care prior to the pandemic continued receiving some element of their multidisciplinary ED treatment and perceived their care as high quality. None of the markers of care described were statistically associated with increased ED thoughts and behaviors.

Research paper thumbnail of 99. In Eating Disorder Recovery: The Relationship Between Malnutrition and Symptoms of Anxiety/Depression in Youth With Restrictive Eating Disorders

Journal of Adolescent Health, Feb 1, 2021

Research paper thumbnail of The Impact of the COVID-19 Pandemic on the Number of Adolescents/Young Adults Seeking Eating Disorder-Related Care

Journal of Adolescent Health, Oct 1, 2021

The COVID-19 pandemic has led to the development and worsening of eating disorder (ED) symptoms i... more The COVID-19 pandemic has led to the development and worsening of eating disorder (ED) symptoms in adolescents and young adults. In order to examine COVID-19-related trends in ED care-seeking at our institution. Methods: We used interrupted time series regression to examine pre-and postpandemic monthly summary data of the following: (1) ED-related inpatient admissions for medical stabilization; (2) ED-related hospital bed-days; (3) completed outpatient ED assessments; and (4) ED outpatient care-related inquiries at a children's hospital in Boston, MA. Results: Inpatient admissions, hospital bed-days, and outpatient care-related inquiries increased on average over time postpandemic compared to stable volume over time prepandemic (p < .01). Outpatient assessments decreased precipitously initially following COVID-19-related limitations, and rose quickly back to baseline. Conclusion: These results indicate increased need for ED-related care during the pandemic. Bolstering resources to meet the needs of these vulnerable patients is critical as the effects of the pandemic continue to be felt.

Research paper thumbnail of Youth, risks, and chronic illness

Current Opinion in Pediatrics, Aug 1, 2011

Research paper thumbnail of COVID-19 related familial economic disruptions and eating disorder patients’ mental health concerns and motivation to recover

Journal of eating disorders, Dec 20, 2022

Background: Family support has been shown to be important for adolescents and young adults (AYA) ... more Background: Family support has been shown to be important for adolescents and young adults (AYA) in eating disorder (ED) treatment. Many families were impacted by the pandemic, potentially altering their ability to support individuals in ED treatment. This study examined the association of COVID-19 related familial economic change with self-reported mental health (MH) and ED concerns in AYA seeking treatment for ED. Methods: AYA patients with EDs aged 10-27 years enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) completed an additional COVID-19-specific survey (n = 89) that assessed their perception of the effects of the pandemic on their lives and their ED. Participants self-reported on familial economic disruptions, measured through a composite score of four markers: (1) family member's work hours cut, (2) family member was required to stop working, (3) family member lost job permanently, and (4) family lost health insurance/ benefits. In bivariate analyses, we examined the association between self-reporting any familial economic disruption and self-reported changes in intrusive ED thoughts, feelings of anxiety, feelings of depression, feelings of isolation, and motivation to recover from their ED. Logistic regression models were used to examine the association between familial economic disruptions on self-reported changes in ED/MH affect and motivation to recover adjusting for age and ED diagnosis. Results: Forty-six percent of participants self-reported that the pandemic had resulted in at least one economic familial disruption. Of patients reporting any familial economic disruption, 29% reported decreased motivation for ED recovery, and over 75% reported worsening feelings of depression, anxiety, isolation, and/or intrusive eating disorder thoughts. Reporting any COVID-19 familial economic disruption was marginally associated with feelings of isolation (p = 0.05). Though the findings were only marginally significant, the odds of reporting worsening feelings of depression, anxiety, intrusive ED thoughts or motivation to recover were nearly twice in those who reported a COVID-19-related familial economic disruption compared to those who did not report such a disruption. Conclusions: Family-related economic disruptions are associated with ED/MH-related concerns and motivation to recover from an ED during the COVID-19 pandemic in AYA patients.

Research paper thumbnail of 12. The Impact of the COVID-19 Pandemic on Adolescent/Young Adult Eating Disorder Patient Visits: Data from the National Eating Disorder Quality Improvement Collaborative

Journal of Adolescent Health, Apr 1, 2022

Research paper thumbnail of COVID-19’s Impact on Eating Disorder and Mental Health Concerns in Patients with Eating Disorders

Research Square (Research Square), Mar 17, 2021

Background The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescent... more Background The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines the implications of the COVID-19 pandemic on ED and MH symptoms and motivation for ED recovery in adolescents/young adults. Methods Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess the impact of the COVID-19 pandemic. Participants reported concerns of their ED worsening due to living in a "triggering environment" due to the pandemic as well as COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with MH and ED symptoms. Results The majority of respondents reported concern for "triggering environment" (63%), as well as increased ED thoughts (74%) and feelings of anxiety (77%), depression (73%), and isolation (80%) in response to the COVID-19 pandemic. Nearly one-third reported decrease in motivation to recover (29%). After adjusting for age and ED diagnosis, participants who reported triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report a triggering environment. Conclusions Our ndings demonstrate the negative impact the COVID-19 pandemic has had on the self-reported MH and ED symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

Research paper thumbnail of Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume

JAMA Pediatrics, Dec 1, 2022

IMPORTANCE The COVID-19 pandemic has affected youth mental health. Increases in site-specific eat... more IMPORTANCE The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. OBJECTIVE To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre-and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. EXPOSURES Onset of the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES Monthly number of patients seeking inpatient/outpatient ED-related care.

Research paper thumbnail of COVID-19 and eating disorder and mental health concerns in patients with eating disorders

Journal of eating disorders, Jul 2, 2021

Background: The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescen... more Background: The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines how young people with EDs feel the COVID-19 pandemic has affected their living environments as well as their ED and MH symptoms and motivation for ED recovery. Methods: Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess their perceptions of the impact of the COVID-19 pandemic. Participants reported on concerns of their ED worsening due to increased time living in a "triggering environment" due to the pandemic as well as perceived COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with ED and MH symptoms. Results: The majority of respondents reported concern for worsening of their ED due to a "triggering environment" (63%). Most reported an increase in ED thoughts (74%), feelings of anxiety (77%), depression (73%), and isolation (80%) they perceived to be related to the pandemic. Nearly one-third reported decrease in motivation to recover (29%) they perceived to be related to the pandemic. After adjusting for age and ED diagnosis, participants who reported concern for worsening of their ED due to a triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report concern for worsening of their ED due to a triggering environment. Conclusions: Our findings demonstrate the perceived negative impact the COVID-19 pandemic has had on the self-reported ED and MH symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

Research paper thumbnail of The Association of Malnutrition, illness duration, and pre-morbid weight status with anxiety and depression symptoms in adolescents and young adults with restrictive eating disorders: a cross-sectional study

Journal of Eating Disorders

Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symp... more Background Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symptoms, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and pre-morbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs. Methods 145 participants with restrictive EDs (anorexia nervosa [AN], other specified feeding and eating disorders [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants’ pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. ...