The Implementation and Evaluation of the SCOFF (Sick, Control, One Stone, Fat, Food) Eating Disorder Screening Tool for Children and Adolescents
Ashley K. Read and Carmel A. McComiskey
Background: Eating disorders are life-threatening conditions that can present in children with a variety of signs and symptoms. The prevalence rates are as high as 6.1%, and mortality rates are higher than any other psychiatric illness. Prevalence of eating disorders is increasing in minorities, males, and children younger than 12 years of age; hospitalizations for eating disorders have increased by 119% in children younger than age 12 years. Research suggests that primary care providers lack the necessary knowledge and skill to assess patients for eating disorders and recommends the use of a screening tool to improve detection.
Local Problem: At a suburban pediatric primary care setting in Maryland, providers did not use a routine screening tool to identify eating disorders, relying instead on suspicious history and physical findings. Only three children were identified last year. Compared to national prevalence rates, there was concern that many had gone undetected. Although proactive in screening for lead, tuberculosis, HIV, and high cholesterol at well visits, it was believed that identification of eating disorders might improve if providers used a screening tool, preferably the SCOFF (Sick, Control, One Stone, Fat, Food) questionnaire.
Interventions: This quality improvement project focused on the use of the SCOFF questionnaire to increase identification of children with or at risk of an eating disorder to provide prompt referral and treatment. The sample consisted of pediatric patients aged 7 to 18 years scheduled for their annual visit. The intervention included staff and provider education about eating disorder prevalence rates, presenting signs and symptoms, effectiveness of a screening tool, primary care provider's role, and local referral options. Patients completed the questionnaire while waiting for their visit, and the provider viewed and scored the questionnaire prior to seeing the patient. Children who screened positive with a score of 2 or above were referred to a mental health specialist, nutritionist, and/or psychiatrist based on insurance coverage and provider discretion.
Results: The SCOFF screening lasted for eight weeks. Of 204 eligible patients, a total of 125 patients received a screening tool (61%). Seven patients screened positive, resulting in a 5.6% detection rate. Of these, one patient whose screen scored 4/5 points was referred to a mental health specialist, while the other patient whose screen scored 2/5 points was referred to a nutritionist. The remainder received diet counseling in the office.
Conclusion: Results of this quality improvement project indicated that the use of the SCOFF questionnaire detected children and adolescents at risk of developing an eating disorder. The number of patients scoring positive on the SCOFF questionnaire correlates with the national average of 6.1%. Providers also found the screening tool to be brief and practical in the primary care setting. Using the SCOFF questionnaire at all well visits for children aged 7 to 18 years can increase detection and allow earlier intervention to prevent the progression of an eating disorder.