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Received 06/01/11 Revised 09/30/11 Accepted 10/08/11

Assessment and Diagnosis of Eating Disorders: A Guide for Professional Counselors

Kelly C. Berg, Carol B. Peterson, and Patricia Frazier
Despite the prevalence of and risk associated with disordered eating, there are few guidelines for counselors on how to conduct an eating disorder assessment. Given the importance of the clinical interview, the purpose of this article is to provide recommendations for the assessment and diagnosis of eating disorders that (a) specifically focus on assessment in the context of a clinical interview and (b) can be used by counselors whether or not they specialize in eating disorder treatment. Keywords: assessment, clinical interview, eating disorders, anorexia nervosa, bulimia nervosa

Eating disorders are serious mental illnesses that are associated with a broad range of medical and psychiatric problems, including increased risk of mortality (Crow, 2005; Crow et al., 2009). Although the prevalence of eating disorders is less than 5% of the general population (Hoek & van Hoeken, 2003; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011), some studies have found much higher rates of subthreshold eating disorder symptoms in adolescent and young adult females (e.g., weekly binge eating or weekly self-induced vomiting; Berg, Frazier, & Sherr, 2009). Historically, eating disorders were thought to be problems limited to Caucasian females from privileged backgrounds. However, more recent epidemiological research has demonstrated that eating disorders are increasingly common in broader age ranges, both genders, and diverse ethnic groups (Swanson, Crow, et al., 2011). Additionally, although weight status or changes in weight status can be indicative of an eating disorder, individuals presenting at normal weight or without significant weight changes may suffer from eating disorders as well. Thus, because there are significant medical and psychiatric risks associated with eating disorders and disordered eating, because eating disorders are not restricted to any specific subgroup of clients, and because eating disorders may not be visually apparent, we recommend that the assessment of eating disorders should be considered an essential element of an intake assessment in all counseling settings and with all clients. Although assessing eating disorders may seem like a daunting prospect to some, it can have enormous benefits for both therapy outcome and the therapeutic relationship (Peterson, 2005). First, assessment is the foundation of ongoing treatment because it informs diagnosis, guides treatment planning, and can be used to measure progress and outcome. Careful assessment can also be used to detect potentially serious medical and psychiatric complications and, in some cases,

determine treatment priorities. Finally, assessment has been found to produce improvement in eating disorder symptoms and, when conducted well, it can facilitate trust and reduce the likelihood of attrition (Peterson, 2005). The book Assessment of Eating Disorders (Mitchell & Peterson, 2005) represents the most comprehensive resource for clinicians and researchers interested in eating disorder assessment; however, this resource may be most applicable to counselors who regularly treat eating disorder clients and may be too specialized for many professional counselors. Recommendations for eating disorder assessment are also provided in a recently published article (Anderson, Lundgren, Shapiro, & Paulosky, 2004); however, these recommendations are largely constrained to the use of structured assessment tools such as semistructured interviews and self-report questionnaires. Although there are advantages to using structured assessments, the clinical interview remains the most common assessment modality in professional counseling (Jones, 2010). Because there are no published guidelines for professional counselors on incorporating eating disorder assessment into a clinical interview, we outline recommendations for the assessment and diagnosis of eating disorders that (a) specifically focus on assessment in the context of a clinical interview and (b) can be used by counselors whether or not they specialize in eating disorder treatment. As such, this article will cover the following: (a) the diagnostic criteria for eating disorders, (b) how to integrate assessment of eating disorders into an unstructured clinical interview, and (c) special considerations during an eating disorder assessment.

Diagnostic Criteria for Eating Disorders

The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Asso-

Kelly C. Berg and Carol B. Peterson, Department of Psychiatry, and Patricia Frazier, Department of Psychology, University of Minnesota, Minneapolis. This work was supported, in part, by grants from the National Institute of Mental Health (T32 MH08276101) and the National Institute of Diabetes and Digestive and Kidney Diseases (P30DK 50456). Correspondence concerning this article should be addressed to Kelly C. Berg, Department of Psychiatry, University of Minnesota, 606 24th Avenue South, Suite 602, Minneapolis, MN 55454 (e-mail: bergx143@umn.edu). 2012 by the American Counseling Association. All rights reserved.

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Assessment and Diagnosis of Eating Disorders ciation [APA], 2000) recognizes two formal eating disorders: anorexia nervosa and bulimia nervosa. Criteria for anorexia include minimal body weight for age, gender, and height; fear of weight gain; at least one cognitive symptom (i.e., overevaluation of shape and weight, body image disturbance, or a denial of the seriousness of being at a low body weight); and amenorrhea (i.e., missing three consecutive menstrual cycles). The DSM-IV-TR also specifies two subtypes of anorexia: restricting (i.e., no regular binge eating or purging) and binge-eating/purging (i.e., regular binge eating, regular purging, or both). For bulimia, the DSM-IV-TR criteria include binge eating, defined as the consumption of an unusually large amount of food coupled with a subjective sense of a loss of control, and compensatory behaviors (i.e., self-induced vomiting, abuse of laxatives or diuretics, excessive exercise, or fasting) occurring at least twice per week for the previous 3 months and overevaluation of shape and weight. Two subtypes of bulimia are specified in the DSM-IV-TR: purging subtype (i.e., regular use of self-induced vomiting and/ or abuse of laxatives or diuretics) and nonpurging subtype (i.e., use of excessive exercise or fasting, but no regular use of purging behaviors). The criteria also specify that a diagnosis of anorexia trumps a diagnosis of bulimia, meaning that an underweight individual with bulimic symptoms would be diagnosed with anorexia, binge-eating/purging subtype, rather than bulimia. The DSM-IV-TR includes a third category titled eating disorder not otherwise specified (EDNOS), which is to be assigned to individuals with clinically significant eating disorder symptoms who do not meet criteria for either anorexia or bulimia (APA, 2000). Examples of EDNOS include purging without binge eating, binge eating without the use of compensatory behaviors (i.e., binge eating disorder), and meeting all criteria for anorexia, except amenorrhea. Epidemiological studies and clinical data suggest that rates of EDNOS are significantly higher than those of anorexia and bulimia (e.g., Fairburn et al., 2007; Hoek, 2006) and that the associated psychopathology, psychosocial impairment, treatment response, and medical/suicide risk of EDNOS are comparable with those of anorexia and bulimia (e.g., Crow et al., 2009; Fairburn et al., 2007). The proposed criteria for the DSM-5 (APA, 2011) have attempted to reduce the prevalence of EDNOS by instituting the following changes: (a) eliminating the amenorrhea requirement for anorexia, (b) including behavioral indices of fear of weight gain for anorexia (e.g., dietary restriction, use of compensatory behaviors), (c) reducing the required frequency of binge eating and compensatory behaviors for bulimia to once per week, (d) including binge eating disorder (BED) as a formal eating disorder diagnosis, and (e) reducing the required frequency of binge eating for BED to once per week for 3 months. Pilot testing has demonstrated that these changes result in a substantial decrease in EDNOS (e.g., Berg, Stiles-Shields, et al., 2011; Keel, Brown, Holm-Denoma, & Bodell, 2011). The proposed changes to the DSM will be finalized in 2012 and published in 2013 (APA, 2011). In summary, assessment of the following variables is essential for diagnosing eating disorders: (a) weight status (as determined by height, weight, age, and gender), (b) fear of weight gain, (c) overevaluation of shape and weight, (d) body image disturbance, (e) presence and frequency of binge eating, (f) presence and frequency of compensatory behaviors, and (g) menstrual status. If the client is underweight, it may also be necessary to determine whether the client is aware of the potential consequences associated with low weight. In addition, behaviors such as dietary restriction (e.g., skipping meals, avoidance of specific foods or food groups, overall caloric restriction) will be necessary for the diagnosis of DSM-5 eating disorders.

Integrating Eating Disorders Assessment Into a Clinical Interview

In any clinical interview, it is important to balance the dual goals of obtaining a comprehensive assessment with developing and maintaining rapport with the client (Peterson, 2005). Given that not all clients present with eating disorders or disordered eating, a comprehensive assessment of all eating disorder symptoms may not be necessary or feasible. Therefore, we recommend that counselors conduct a screen for eating disorder symptoms and follow up with a more comprehensive assessment if necessary. How to Screen for Eating Disorders Screening questions for eating disorders can be easily integrated into an unstructured clinical interview. Sleep and eating patterns are typically assessed at intake, and these questions can provide a good segue into an eating disorders screen. We recommend starting with general questions (e.g., What is your general eating pattern?, Do you ever skip meals?, Have you ever been on a diet?) that can serve as an effective strategy for introducing the topic of eating disorders without causing initial discomfort. These general questions can then lead into more specific questions regarding binge eating and compensatory behaviors (e.g., Have you ever felt a sense of loss of control over your eating?, Have you ever done anything to compensate for food youve consumed such as self-induced vomiting or laxative use?). Clinical interviews also typically include questions about exercise in the context of evaluating general self-care, and these questions can also provide information about eating disorders risk. When assessing activity level, we recommend assessing type, duration, and intensity of exercise. However, it is important to remember that the quantity of exercise is not always indicative of an eating disorder. For example, individuals participating on sports teams or training for athletic events such as marathons do not necessarily suffer from eating disorders despite substantial commitments to fitness 263

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Berg, Peterson, & Frazier routines. Thus, it is also important to gently probe about the motivation for exercise, whether the individual feels driven or compelled to do it, whether the client exercises when ill or injured, and whether he or she exercises at the expense of other activities (e.g., work, school, family, or social commitments). Last, general questions about self-esteem (e.g., How do you feel about yourself as a person?) can also be used as an introduction to asking more specific questions about body image (e.g., How do you feel about your weight and shape?). For additional examples of screening questions we recommend, see Table 1. When to Follow Up With Additional Questions A counselors observation of certain physical characteristics or a clients endorsement of certain behavioral or cognitive symptoms may require further evaluation. For example, additional probing is indicated in the following circumstances: (a) low body weight (in children and adolescents, this may present as failure to meet height and weight expectations or delays/interruptions to pubertal development), (b) significant weight changes, (c) recurrent binge eating, (d) purging behaviors, (e) regular fasting or extreme restriction, or (f) exercise that interferes with psychosocial functioning or that occurs in the context of illness or injury. In some cases, cognitive symptoms (e.g., presence of body image disturbance, overevaluation of shape or weight, intense fear of weight gain, or extreme distress about appearance) unaccompanied by eating or weight problems can warrant further evaluation. What Questions to Ask to Make Differential Diagnoses If an eating disorder is suspected, the first diagnostic priority is establishing that the problematic behavior, weight, or cognitions reflect an eating disorder and are not an indication of another medical or psychiatric condition. For example, weight change can be a symptom of an underlying medical (e.g., hyperthyroidism, cancer, or gastrointestinal problems) or psychiatric (e.g., depression or substance dependence) problem. Questions about

Table 1 Examples of Questions That Can Be Used to Assess Eating Disorder Symptoms
Type Screening Eating behaviors Sample Questions What is your general eating pattern? Do you ever skip meals? Have you ever been on a diet? What about following rules about what, when, or how much you can eat? Have you ever felt like your eating is out of control? Do you exercise? If so, what kind of exercise do you do? How often? Have you ever done anything to compensate for what you have eaten, such as self-induced vomiting or taking laxatives? What about fasting for 24 hours or longer? How do you feel about your shape and weight? Have you ever felt dissatisfied with your shape or weight? Have you ever been afraid of gaining weight? How would you feel if your weight changed? Does your shape/weight influence how you feel about yourself? If you imagine the things that influence how you feel about yourself, such as your performance at work/school or your relationships, and put the settings in order of importance to your self-evaluation, where does shape/weight fit in? Do you (or at your lowest weight, did you) still feel that your body or part of your body was too large? Has anyone told you (or when you were at your lowest weight, did anyone tell you) that it could be dangerous to be as thin as you are? If so, what do you think? If not, what would you think if someone told you that? Have you ever had a binge eating episode? For example, eating an unusually large amount of food and feeling like your eating was out of control? Have there been any times when youve eaten an amount of food other people might consider unusually large? Have you ever felt like your eating was out of control? For example, like you couldnt stop or resist eating? Or like you felt driven or compelled to eat? Can you think of a specific time when thats happened and describe what you had to eat and how much? How often have episodes like that happened? Have you ever self-induced vomiting to control your shape or weight? How often? Have you ever taken laxatives or diuretics to control your shape or weight? How often? Have you ever exercised to control your shape or weight? What kind of exercise do you do? How often? Do you ever feel driven or compelled to exercise? Do you ever exercise when youre sick/injured or instead of spending time with family or friends? Have you ever fasted for 24 hours or more to control your shape or weight? How often? Have you ever tried to follow any dietary rules such as rules about how much you can eat, what types of foods you can eat, or when you can eat?

Compensatory behaviors

Body esteem Diagnostic Fear of weight gain Overevaluation of shape/weight

Body image disturbance Seriousness of low body weight

Binge eating

Compensatory behaviors

Dietary restriction

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Assessment and Diagnosis of Eating Disorders the onset and nature of symptoms and referral to a medical specialist can clarify whether the weight change is due to an eating disorder or other condition. Other conditions that can resemble eating disorders include anxiety disorders and body dysmorphic disorder. Determining the focus of anxiety (e.g., Is the individuals anxiety in social situations reflective of a fear of saying something humiliating or a fear of judgment about body shape?), avoidance (e.g., not eating for fear of vomiting versus not eating in an attempt to lose weight), or body checking (e.g., scrutinizing for signs of skin imperfections vs. scrutinizing for signs of weight gain) can reveal the extent to which an eating disorder is present. Once other medical and psychiatric conditions have been ruled out, additional probing can be used to specify the eating disorder diagnosis (see Table 1 for examples of specific questions we recommend). Of primary importance to differential diagnosis is weight status, particularly the extent to which the individual is underweight. Although the DSM-IV-TR recommends that underweight be defined as less than 85% of expected weight, upcoming revisions (DSM-5) allow counselors to use more clinical judgment in determining weight status (examples can be found at www.dsm5.org). With regard to a diagnosis of bulimia, the hallmark symptoms are binge eating and the use of compensatory behaviors. However, as stated earlier, if these behaviors occur in the context of an individual being underweight, a diagnosis of anorexia (not bulimia) would be given. In contrast to bulimia, individuals with BED engage in binge eating without purging or other compensatory behaviors. Thus, the presence of binge eating accompanied by regular fasting or excessive exercise indicates a diagnosis of full or subthreshold bulimia rather than BED. Cognitive symptoms are also important to the diagnoses of anorexia, bulimia, and BED. For a diagnosis of anorexia, fear of weight gain and denial of the seriousness of low body weight, body image distortion, or overevaluation of shape and weight are required. Similarly, overevaluation of shape and weight and distress regarding binge eating are required for diagnoses of bulimia and BED, respectively. How to Assess Psychiatric Risk The rates of co-occurring psychiatric symptoms and syndromes are high among individuals with all eating disorder diagnoses. Suicide and self-injury pose the primary psychiatric risks for clients with eating disorders. Thus, detailed questions about suicidal ideation, plan, means, and intent are critically important to the assessment process. Self-injury without suicidal intent also occurs in individuals with eating disorders and should be evaluated in the assessment process. Assessment of nonsuicidal self-injury should include an evaluation of location of self-harm (e.g., arms, legs, stomach), type of self-harm (e.g., cutting, scratching, burning), and severity (e.g., Did the client draw blood? Was medical attention required?). Because clients with eating disorders may self-injure body parts that they believe are particularly problematic (e.g., stomach, thighs), it is important to assess self-injurious behavior even if such behavior is not visibly apparent. Even if suicidality or nonsuicidal self-injury are not present, co-occurring psychiatric disorders can complicate treatment. Rates of co-occurring mood disturbances are particularly high in clients with eating disorders (e.g., Wonderlich & Mitchell, 1997); however, the direct causal relationship between these disorders is unclear. For example, mood disorders may exacerbate eating disorder symptoms or vice versa. Additionally, the diagnosis of depression is complicated by the presence of semistarvation, which can mimic many of the symptoms of depression (e.g., low mood, inertia, poor concentration; Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950). In such cases, restoration of weight may alleviate depressive symptoms. Studies of comorbidity suggest that major depression is the most common mood disorder in individuals with eating disorders; however, bipolar disorder is also observed in a minority of clients (e.g., Wonderlich & Mitchell, 1997). Although binge eating can reflect impulsivity associated with mania, binge eating should not be counted as a symptom of mania if it is better explained by an eating disorder. In summary, assessment of eating disorders should always be accompanied by a careful screening of mood disorder symptoms. In addition to mood disorders, anxiety disorders such as phobias, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder are common in persons with eating disorders (e.g., Wonderlich & Mitchell, 1997). Notably, anxiety symptoms that are better explained by an eating disorder (e.g., fear of weight gain, rituals related to eating, weighing, or exercise) should not be considered evidence of a co-occurring anxiety disorder. Rather, if an eating disorder is present, the content of a co-occurring anxiety disorder should be unrelated to eating, shape, weight, exercise, and so on. Additionally, there is evidence that semistarvation can lead to anxiety symptoms, including obsessive thinking and hoarding (Keys et al., 1950). Substance abuse and dependence are observed in a significant minority of eating disorder clients (estimates ranging from 0% to 55%), particularly those with anorexia, binge eating/purging type, and bulimia (e.g., Holderness, Brooks-Gunn, & Warren, 1994; Wonderlich & Mitchell, 1997). Symptoms of Axis II personality disorders are also common in individuals with eating disorders. Borderline personality disorder symptoms, including impulsivity, intense anger, idealization/devaluation, fear of abandonment, feelings of emptiness, and self-injurious behavior are especially common in those with eating disorders (e.g., Wonderlich & Mitchell, 1997). Other common Axis II personality disorders among those with eating disorders include avoidant, obsessive-compulsive, narcissistic, and dependent personality disorders (e.g., Wonderlich & Mitchell, 1997). How to Assess Medical Risk Medical risk is significant in all eating disorder diagnoses, including EDNOS; thus, an important part of eating disorder 265

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Berg, Peterson, & Frazier assessments is a concurrent medical examination conducted by a physician or other medical provider. In general, any individual with eating disorder symptoms should be referred for medical screening, regardless of symptom severity. Certain conditions do require more immediate medical attention, including the following: (a) low body mass index (BMI), (b) recent and significant changes in weight status, (c) purging (which can result in electrolyte disturbance), and (d) conditions that indicate cardiac abnormalities (e.g., fainting, dizziness). Medical examinations should include an assessment of height and weight, vital signs (e.g., pulse, orthostatic hypertension blood pressure, electrocardiogram), electrolytes (e.g., potassium, sodium, glucose, calcium, phosphorous), bone density (e.g., dual-energy X-ray absorptiometry, or DEXA), and menstrual status (Crow & Swigart, 2005). Ideally, weight should be obtained with the client wearing a gown to improve the accuracy of measurement (Peterson, 2005). For example, the weight of a clients clothes can make it difficult to establish weight status at baseline and/or track weight changes over time. Additionally, clients may put heavy objects such as coins in their pockets to increase their observed weight. Given that a physician or other medical personnel is best qualified to assess medical risk and that medical risk should be evaluated on an ongoing basis, some clients may need to undergo weekly physical examinations. To ensure clear, ongoing communication across treatment providers, counselors who treat clients with eating disorders may find it useful to develop working relationships with medical providers to whom they can refer clients in need of medical monitoring. Regardless of whether clients with eating disorders are being monitored by a physician or medical personnel, height and weight should also be assessed regularly in the context of therapy to monitor weight status (particularly among clients who are underweight), which requires counselors to maintain calibrated scales in their offices or clinics or to collaborate with medical staff or dietitians who can obtain regular measurements. Menstrual status should also be assessed regularly in therapy, and although it is an inconsistent indicator of disease status, resumption of menses can be a useful indicator of recovery (e.g., Attia & Roberto, 2009). Additional resources and detailed recommendations can be found at http://www.aedweb.org/AM/Template. cfm?Section=Resources_for_Professionals&Template=/CM/ ContentDisplay.cfm&ContentID=2593. Determining Level of Care After the counselor has established the diagnostic status of the client, it is important to determine the level of care at which the client should be treated. Eating disorders are treated at all levels of care, including outpatient, intensive outpatient or partial day treatment, inpatient, and residential. Initial and ongoing assessment of eating disorder severity, co-occurring psychiatric symptoms, medical risk, and acute risk of selfinjury/suicide can be used to determine the appropriate level 266 of care and referral, if necessary. For example, clients with more severe symptoms (e.g., low BMI, suicide risk), medical instability, or symptoms that are unresponsive to outpatient counseling may require hospitalization, intensive outpatient treatment, or residential care. Fluctuations in level of care are not uncommon in those with eating disorders, and counselors often find it helpful to maintain relationships with other clinics and providers to ensure continuity of care. In summary, the rates of co-occurring psychiatric symptoms and syndromes are high among individuals with all eating disorder diagnoses, and some psychiatric problems (e.g., substance dependence, mania) may necessitate treatment prior to treatment of the eating disorder. Although psychological counseling has demonstrated efficacy equal to or surpassing that of psychotropic medication for eating disorders (e.g., Shapiro et al., 2007), referral to a psychiatrist for an evaluation and/or ongoing medication management can be useful, particularly if the client presents with multiple psychiatric problems or is not helped by psychological interventions.

Special Considerations During an Eating Disorder Assessment

As in all psychological assessments, evaluation of clients with eating disorder symptoms can be compromised by various biases (e.g., denial, minimization, confusion regarding terminology, recall biases). However, assessment of eating disorders is especially challenging for several reasons, including cognitive disturbances caused by semistarvation, the egosyntonic nature of eating disorder symptoms, fear of forced treatment, and limitations in insight. Denial/Minimization Clients with eating disorders may minimize or deny symptoms for a number of reasons. Some clients, especially children and adolescents, may have limited capacity for self-awareness. Others may deliberately withhold information about symptom severity because of feelings of shame, fear of hospitalization or treatment, or an attachment to their eating disorder symptoms (e.g., Vitousek, Watson, & Wilson, 1998). Additionally, some of the symptoms associated with eating disorders are abstract concepts that are complex to define and describe (e.g., binge eating, overevaluation of shape and weight) and can lead to confusion and inadvertent minimization. To enhance accurate self-disclosure, counselors may find it helpful to use the following techniques: (a) Maintain a collaborative and empathic stance; (b) avoid criticism and confrontation; (c) pose questions or statements in an open-ended format (e.g., Tell me more about your decision to become a vegetarian); (d) provide detailed and concrete information about the questions being asked (e.g., By binge eating, I mean eating an amount of food that other people may consider unusually large and feeling as though youre unable to control what or how much youre eating); (e) obtain concrete information

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Assessment and Diagnosis of Eating Disorders whenever possible (e.g., specific examples of quantity and type of food consumed during a binge, measured rather than self-reported height and weight); and (f) do not make assumptions (e.g., clients may be restricting for health reasons rather than shape- or weight-related reasons). Additionally, counselors can reassure clients of their expertise by conveying a matter-of-fact and accepting attitude about topics that may be a source of shame or embarrassment (e.g., frequency and/ or method of purging, quantity or type of food consumed during a binge). Lengthy silences, hesitation, and unsupportive nonverbal signals can imply judgment, lack of expertise, or fear and should also be avoided (Miller & Rollnick, 2002; Vitousek et al., 1998). Recall Biases Information provided retrospectively by clients with eating disorders may be influenced by a number of biases that are related to psychological and biological factors. Semistarvation can result in cognitive impairment, including concentration and memory problems, and indecisiveness (Keys et al., 1950), all of which can compromise the accuracy of information provided during an eating disorder assessment. In addition, retrospective recall bias, in which clients current mood and behavior influences their recollection of past events, is common and can limit the accuracy of how well clients can remember symptoms (Schacter, 1999). Because certain symptoms (e.g., binge eating, purging, exercise) are thought to function as strategies to avoid negative affect (Heatherton & Baumeister, 1991), these symptoms may be particularly difficult for clients to recall accurately. To enhance or maximize accurate recall, the timeline follow-back procedure (TLFB) can be used (e.g., Fairburn & Cooper, 1993; Sobell, Sobell, Klajner, Pavan, & Basian, 1986). The TLFB procedure is a structured interview that orients participants to the past 12 weeks and then asks participants to recall the frequency of behaviors during that period. This procedure can be helpful in enhancing memory accuracy when assessing behavior, cognitions, and emotion. In addition, the use of detailed questions and examples can reduce potential overgeneralization (e.g., What about during last months vacation?, Can you give me a specific example?). Assessment of Eating Disorders in Children and Adolescents There is considerable overlap between the symptom presentations of youth and adults with eating disorders; however, there are several issues that are unique to the assessment of eating disorders in children and adults. First, the criteria for both anorexia and bulimia require cognitive skills such as abstract reasoning and metacognition (e.g., overevaluation of shape and weight, loss of control over eating), which may not be fully developed in younger clients (Bravender et al., 2011). To enhance comprehension, age-appropriate metaphors (e.g., describing loss of control as a car rolling down a hill with no brakes) and concrete examples (e.g., Weight is what you see when you look at a scale and shape is what you see when you look in the mirror.) are useful techniques. Consideration may also be given to parental reports and behavioral indicators (e.g., changes in dietary patterns, food preferences, or exercise) when assessing potential eating disorder symptoms in children and adolescents. A second potential problem is that weight status is difficult to calculate in children and adolescents because they may not have reached their adult height and because growth rates vary by gender, age, and pubertal stage (Bravender et al., 2011). BMI percentiles, which can be calculated online (http://apps. nccd.cdc.gov/dnpabmi/) and take into account age, gender, and height, may be used to determine weight status in children and adolescents. However, BMI percentiles do not account for developmental status, which may vary between same-aged individuals; thus, it has been recommended that the DSM-5 criteria allow counselors to use clinical judgment (e.g., physical evidence of malnutrition) to determine weight status. Third, retrospective recall of type and quantity of food consumed during binges may be particularly difficult for children and adolescents. Relatedly, determining whether an amount of food is unusually large can be problematic because the nutritional requirements for children and adolescents vary by age, gender, height, and developmental status (Tanofsky-Kraff, Yanovski, & Yanovski, 2011). As with adults, using the TLFB procedure and obtaining concrete examples can enhance retrospective recall. Additionally, counselors may find it useful to use pictures of food or play food to help younger clients arrive at more accurate estimates of the quantity of food consumed. Finally, some counselors may consider concepts such as self-induced vomiting and laxative or diuretic abuse to be inappropriate topics for younger clients. In such cases, phrasing questions more generally (e.g., Do you remember the last time you threw up? When was that? Do you know why you threw up?, and Some types of medicines make you go to the bathroom; have you ever taken any of those kinds of medicines?) may provide sufficient information to determine whether the symptom is present. Assessment of Eating Disorders With Diverse Client Groups Recent epidemiological research in the United States demonstrated that although anorexia tended to be more common in non-Hispanic White Americans, bulimia was significantly more common in Hispanic participants, and BED may be more common in ethnic minorities than in non-Hispanic White Americans (Swanson, Crow et al., 2011). Additionally, ethnic minorities born and raised in the United States may be at even higher risk for eating disorders (Swanson, Saito, & Breslau, 2011) compared with ethnic minorities living outside the United States or first-generation immigrants to the United States. Given the high prevalence of eating disorders in ethnic minorities, it is recommended that 267

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Berg, Peterson, & Frazier counselors assess eating disorders in diverse client groups. However, assessing eating disorders in diverse client groups can also pose unique challenges because eating disorders consist of both cognitive and behavioral symptoms that can only be clinically significant relative to culturally normative experiences. For example, behaviors such as overeating and fasting may be culturally normative and, as such, would not be indicative of an eating disorder (Becker, 2011). Additionally, eating disorders may manifest differently across cultures. For example, fat phobia and/or drive for thinness may not be endorsed by Asian women with eating disorders (Lee, Ho, & Hsu, 1993). Other variations have also been noted, including the use of alternative compensatory behaviors such as herbal purgatives (Thomas, Crosby, Wonderlich, Striegel-Moore, & Becker, 2011) and variability in the extent to which shape and weight influence self-evaluation (Lynch, Crosby, Wonderlich, & Striegel-Moore, 2011). Additional problems for counselors to consider are that culturally diverse clients may misunderstand counselors questions if the question includes concepts that do not exist in the clients culture (Becker, 2011). Relatedly, counselors may misunderstand clients responses. For example, one study demonstrated that respondents endorsed preoccupation with food because of their experience with poverty and food insecurity (Le Grange, Louw, Breen, & Katzman, 2004). Thus, it is important to take a flexible, curious approach, ask open-ended questions, provide concrete examples, and ask for clarification to ensure accurate assessment.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2011). DSM-5 development. Retrieved from http://www.dsm5.org Anderson, D. A., Lundgren, J. D., Shapiro, J. R., & Paulosky, C. A. (2004). Assessment of eating disorders: Review and recommendations for clinical use. Behavior Modification, 28, 763782. doi:10.1177/0145445503259851 Attia, E., & Roberto, C. A. (2009). Should amenorrhea be a diagnostic criterion for anorexia nervosa? International Journal of Eating Disorders, 42, 581589. doi:10.1002/eat.20720 Becker, A. E. (2011). Culture and eating disorders classification. In R. H. Striegel-Moore, S. A. Wonderlich, B. T. Walsh, & J. E. Mitchell (Eds.), Developing an evidence-based classification of eating disorders: Scientific findings for DSM-5 (pp. 257266). Arlington, VA: American Psychiatric Association. Berg, K. C., Frazier, P., & Sherr, L. (2009). Change in eating disorder attitudes and behavior in college women: Prevalence and predictors. Eating Behaviors, 10, 137142. doi:10.1016/j. eatbeh.2009.03.003 Berg, K. C., Stiles-Shields, E. C., Swanson, S. A., Peterson, C. B., Lebow, J., & Le Grange, D. (2011, August 8). Diagnostic concordance of the interview and questionnaire versions of the eating disorder examination. International Journal of Eating Disorders. Advance online publication. doi:10.1002/eat20948 Bravender, T. D., Bryant-Waugh, R., Herzog, D. B., Katzman, D., Kreipe, R. E., Lask, B., . . . , Zucker, N. (2011). Classification of eating disturbance in children and adolescents. In R. H. StriegelMoore, S. A. Wonderlich, B. T. Walsh, & J. E. Mitchell (Eds.), Developing an evidence-based classification of eating disorders: Scientific findings for DSM-5 (pp. 167184). Arlington, VA: American Psychiatric Association. Crow, S. (2005). Medical complications of eating disorders. In S. Wonderlich, J. Mitchell, M. de Zwaan, & H. Steiger (Eds.), Eating disorders review: Part 1 (pp. 127136). Oxford, England: Radcliffe. Crow, S., & Swigart, S. (2005). Medical assessment. In J. E. Mitchell & C. B. Peterson (Eds), Assessment of eating disorders (pp. 120128). New York, NY: Guilford Press. Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 13421346. doi:10.1176/appi. ajp.2009.09020247 Fairburn, C. G., & Cooper, Z. (1993). The Eating Disorder Examination. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 317360). New York, NY: Guilford Press. Fairburn, C. G., Cooper, Z., Bohn, K., OConnor, M. E., Doll, H. A., & Palmer, R. L. (2007). The severity and status of eating disorder NOS: Implications for DSM-V . Behavior Research and Therapy, 45, 17051715. doi:10.1016/j.brat.2007.01.010

Conclusion
In summary, given the serious medical and psychiatric consequences associated with eating disorders, careful assessment of eating disorder symptoms should be conducted with all clients regardless of gender, age, weight status, race/ethnicity, or socioeconomic status. Additionally, when conducted effectively, an eating disorder assessment can potentially inform treatment planning and enhance therapeutic rapport. All eating disorder assessments should include an evaluation of both the cognitive and behavioral symptoms of eating disorders, which can be incorporated into general screening questions regarding self-care and self-esteem. If an eating disorder is suspected, further evaluation of potential medical and psychiatric risk is necessary regardless of symptom severity. Although problems such as denial, minimization, and recall biases may be particularly pronounced with eating disorders, counselors may be able to enhance accuracy by assuming an empathic, nonjudgmental stance, using the TLFB procedure, providing clear definitions of concepts, and obtaining concrete examples. Assessing eating disorders in children, adolescents, and clients from diverse backgrounds can be particularly difficult; however, the use of open-ended questions, metaphors, clarification, and a flexible approach can enhance comprehension and accuracy.

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