Protocol - Questionnaire on Eating and Weight Patterns - Child

QUESTIONNAIRE ON EATING AND WEIGHT PATTERNS-5

Child/Adolescent

(QEWP-C-5)

1. During the past three months, did you ever eat what most people, like your friends, would think was a REALLY BIG amount of food?

1[ ]YES

2[ ]NO (IF NO, SKIP TO QUESTION 18)

2. When you ate a REALLY BIG amount of food, was it ever within a short time (2 hours or less)?

1[ ]YES

2[ ]NO (IF NO, SKIP TO QUESTION 18)

3. When you ate a REALLY BIG amount of food, did you ever feel you could not stop eating or control what or how much you were eating?

1[ ]YES

2[ ]NO (IF NO, SKIP TO QUESTION 18)

4. During the past three months, how often did you eat like this—ate a REALLY BIG amount of food along with the feeling that your eating was out of control? There may have been some weeks where this did not happen—just give your best guess.

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 7 times a week

5[ ]8 to 13 times a week

6[ ]14 or more times a week

5. When you ate a REALLY BIG amount of food and felt like you could not control your eating, did you usually:

a. Eat very fast?

1[ ]YES

2[ ]NO

b. Eat until your stomach hurt or you felt sick to your stomach?

1[ ]YES

2[ ]NO

c. Eat REALLY BIG amounts of food even when you were not hungry?

1[ ]YES

2[ ]NO

d. Eat by yourself because you did not want anyone to see how much you ate?

1[ ]YES

2[ ]NO

e. Feel REALLY BAD about yourself because of what or how much you were eating?

1[ ]YES

2[ ]NO

6. Think about a usual time when you ate a REALLY BIG amount of food and felt you could not control your eating:

a. During that time, when did you start eating?

1[ ](8 AM to 12 Noon)

2[ ](12 Noon to 4 PM)

3[ ](4 PM to 8 PM)

4[ ](8 PM to 12 Midnight)

5[ ](12 Midnight to 8 AM)

b. For how long did you eat during this time?

____ hours

____ minutes

c. As best as you can remember, please list everything you ate or drank during this time. Be specific - include brand names where possible, and amounts as best you can guess.

d. At the time you started eating, how long had it been since you had last eaten a meal or snack?

____ hours

____ minutes

7. During the past three months, how bad did you feel when you ate a REALLY BIG amount of food and felt your eating was out of control?

1[ ]Not bad at all

2[ ]Just a little bad

3[ ]Pretty bad

4[ ]Very bad

5[ ]Very, very bad

8. During the past three months, did you ever make yourself vomit, throw up, or get sick in order to keep from gaining weight after eating like you described (when you ate a REALLY BIG amount of food and felt your eating was out of control)?

1[ ]YES

2[ ]NO

IF YES: How often, in general, did you do that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 7 times a week

5[ ]8 to 13 times a week

6[ ]14 or more times a week

9. During the past three months, did you ever take medicine to make you poop or have a bowel movement (laxatives) in order to keep from gaining weight after eating like you described (when you ate a REALLY BIG amount of food and felt your eating was out of control)?

1[ ]YES

2[ ]NO (IF NO, SKIP TO QUESTION 11)

10. Did you take more medicine than the directions on the box or bottle say to take?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 5 times a week

5[ ]6 to 7 times a week

6[ ]8 or more times a week

11. During the past three months, have you ever taken medicine to make you pee or urinate (diuretics or water pills) in order to keep from gaining weight after eating like you described (when you ate a REALLY BIG amount of food and felt your eating was out of control)?

1[ ]YES

2[ ]NO

12. Did you take more medicine than the directions on the box or bottle say to take?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 5 times a week

5[ ]6 to 7 times a week

6[ ]8 or more times a week

13. During the past three months, did you ever eat nothing at all for at least 24 hours (a full day) in order to keep from gaining weight after eating like you described (when you ate a REALLY BIG amount of food and felt your eating was out of control)?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 day a week

2[ ]1 day a week

3[ ]2 days a week

4[ ]3 days a week

5[ ]4 to 5 days a week

6[ ]More than 5 days a week

14. During the past three months, did you ever exercise too much (for example, even though you were hurt or sick or it kept you from doing important things) MAINLY in order to keep from gaining weight after eating like you described (when you ate a REALLY BIG amount of food and felt your eating was out of control)?

1[ ]YES

2[ ]NO

IF YES: How often in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 7 times a week

5[ ]8 to 13 times a week

6[ ]14 or more times a week

15. During the past three months, did you ever take diet pills in order to keep from gaining weight after eating like you described (when you ate a REALLY BIG amount of food and felt your eating was out of control)?

1[ ]YES

2[ ]NO

16. Did you take more medicine than the directions on the box or bottle say to take?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 5 times a week

5[ ]6 to 7 times a week

6[ ]8 or more times a week

17. During the past three months, how important has your weight or shape been in how you feel about yourself as a person-as compared to other things in your life, such as your schoolwork, friends, sports, or getting along with your family?

1[ ]Weight and shape were not very important

2[ ]Weight and shape were played a part in how you felt about yourself

3[ ]Weight and shape were among the main things that affected how you felt about yourself

4[ ]Weight and shape were the most important things that affected how you felt about yourself

Continue here after completing question 17 OR if you skipped to question 18 from Question 1, 2, or 3

18. During the past three months, did you ever have times when you felt that you could not stop eating or control what or how much you were eating, but when you did not eat a REALLY BIG amount of food?

1[ ]YES

2[ ]NO

19. During the past three months, how often did you eat like this-felt that your eating was out of control, but you did not eat a REALLY BIG amount of food. There may have been some weeks where this did not happen-just give your best guess.

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 7 times a week

5[ ]8 to 13 times a week

6[ ]14 or more times a week

20. When you felt your eating was out of control but you did not eat a REALLY BIG amount of food, did you usually:

a. Eat very fast?

1[ ]YES

2[ ]NO

b. Eat until your stomach hurt or you felt sick to your stomach?

1[ ]YES

2[ ]NO

c. Eat REALLY BIG amounts of food even when you were not hungry?

1[ ]YES

2[ ]NO

d. Eat by yourself because you did not want anyone to see how much you ate?

1[ ]YES

2[ ]NO

e. Feel REALLY BAD about yourself because of what or how much you were eating?

1[ ]YES

2[ ]NO

21. Think about a usual time when you felt you could not stop eating or control what or how much you were eating, but you did not eat a REALLY BIG amount of food:

a. What time of day did you start eating?

1[ ](8 AM to 12 Noon)

2[ ](12 Noon to 4 PM)

3[ ](4 PM to 8 PM)

4[ ](8 PM to 12 Midnight)

5[ ](12 Midnight to 8 AM)

b. For how long did you eat during this time?

____ hours

____ minutes

c. As best as you can remember, please list everything you ate or drank during this time. Be specific-include brand names where possible, and amounts as best you can estimate.

d. At the time you started eating, how long had it been since you had last eaten a meal or snack?

____ hours

____ minutes

22. During the past three months, how bad did you feel that you could not stop eating or control what or how much you were eating even when you did not eat a REALLY BIG amount of food?

1[ ]Not bad at all

2[ ]Just a little bad

3[ ]Pretty bad

4[ ]Very bad

5[ ]Very, very bad

23. During the past three months, did you ever make yourself vomit, throw up, or get sick in order to keep from gaining weight after eating like you described (when you felt your eating was out of control but you did not eat a REALLY BIG amount of food)?

1[ ]YES

2[ ]NO

IF YES: How often, in general, did you do that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 to 3 times a week

4[ ]4 to 7 times a week

5[ ]8 to 13 times a week

6[ ]14 or more times a week

24. During the past three months, did you ever take medicine to make you poop or have a bowel movement (laxatives) in order to keep from gaining weight after eating like you described (when you felt your eating was out of control, but you did not eat a REALLY BIG amount of food)?

1[ ]YES

2[ ]NO IF NO, SKIP TO QUESTION 26

25. Did you take more medicine than the directions on the box or bottle say to take?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 5 times a week

5[ ]6 to 7 times a week

6[ ]8 or more times a week

26. During the past three months, have you ever taken medicine to make you pee or urinate (diuretics or water pills) in order to keep from gaining weight after eating like you described (when you felt your eating was out of control, but you did not eat a REALLY BIG amount of food)?

1[ ]YES

2[ ]NO IF NO, SKIP TO QUESTION 28

27. Did you take more medicine than the directions on the box or bottle say to take?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 5 times a week

5[ ]6 to 7 times a week

6[ ]8 or more times a week

28. During the past three months, did you ever eat nothing at all for at least 24 hours (a full day) in order to keep from gaining weight after eating like you described (when you felt your eating was out of control, but you did not eat a REALLY BIG amount of food)?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 day a week

2[ ]1 day a week

3[ ]2 days a week

4[ ]3 days a week

5[ ]4 to 5 days a week

6[ ]More than 5 days a week

29. During the past three months, did you ever exercise too much (for example, even though you were hurt or sick or it kept you from doing important things) MAINLY in order to keep from gaining weight after eating like you described (when you felt your eating was out of control, but you did not eat a REALLY BIG amount of food)?

1[ ]YES

2[ ]NO

IF YES: How often in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 to 3 times a week

4[ ]4 to 7 times a week

5[ ]8 to 13 times a week

6[ ]14 or more times a week

30. During the past 3 months, did you ever take diet pills in order to keep from gaining weight after eating like you described (when you felt your eating was out of control, but you did not eat a REALLY BIG amount of food)?

1[ ]YES

2[ ]NO IF NO, SKIP TO QUESTION 32

31. Did you take more medicine than the directions on the box or bottle say to take?

1[ ]YES

2[ ]NO

IF YES: How often, in general, was that?

1[ ]Less than 1 time a week

2[ ]1 time a week

3[ ]2 or 3 times a week

4[ ]4 to 5 times a week

5[ ]6 to 7 times a week

6[ ]8 or more times a week

Continue here after completing question 31 OR if you skipped to question 32 from Question 18

32. Please look at these drawings of people. Pick the person that matches your biological (birth) father’s and mother’s sizes. If you don’t know your biological (birth) father or mother, don’t pick anything for that parent.

Decision Rules for Screening for Possible Diagnosis of Binge Eating Disorder (BED) Using the Questionnaire on Eating and Weight Patterns-5 for Children

Possible Diagnosis of BED

1) Response of 1 on Question 1

2) Response of 1 on Question 2

3) Response of 1 on Question 3 (binge eating)

4) Response of 2, 3, 4, 5, OR 6 on Question 4 (at least 1 binge episode per week for 3 months)

5) 3 OR MORE ITEMS MARKED "YES" (i.e. 1) on Questions 5a-e (at least associated symptoms during binge eating episodes)

6) Response of 4 or 5 on Question 7 (marked distress regarding binge eating)

POSSIBLE DIAGNOSIS OF BED REQUIRES ALL OF THE ABOVE SIX (6) ITEMS, ALONG WITH THE ABSENCE OF INAPPROPRIATE COMPENSATORY BEHAVIORS AS SEEN IN BULIMIA NERVOSA, AS DEFINED FURTHER BELOW.

POSSIBLE DIAGNOSIS OF BULIMIA NERVOSA REQUIRES ALL OF THE BELOW FOUR (4) ITEMS

1) Response of 1 on Question 1

2) Response of 1 on Question 2

3) Response of 1 on Question 3 (binge eating)

4) Response of 2, 3, 4, 5, OR 6 on Question 4 (at least binge 1 episode per week for 3 months)

5) ANY Response of 2, 3, 4, 5 OR 6 on Questions 8, 10, 12, 13, 14, or 16 (inappropriate compensatory behavior at least 1 time per week for 3 months)

6) Response of 3 or 4 on Question 17 (overvaluation of weight/shape).