Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa

Protocol for a randomized clinical trial to confirm the effectiveness of online guided self-help family-based treatment for adolescent anorexia nervosa

BACKGROUND

The leading evidence-based treatment for anorexia nervosa (AN) in adolescents is Family-based Treatment (FBT). However, due to the intensive training requirements and lack of practitioners, it is often difficult for families to access FBT. Thus, innovations that improve access to care are needed. A pilot randomized study of a guided self-help version of Family-based Treatment (GSH-FBT) that utilized approximately 1/4 the amount of therapist time compared to FBT found that the approach was acceptable and appeared to achieve similar outcomes. The study protocol detailed in this manuscript compares the efficiency (clinician time) of GSH-FBT to Family-based Treatment via Videoconferencing (FBT-V) in a fully powered study in achieving clinical outcomes through a multi-site randomized clinical trial across the US and Ontario, Canada.

METHODS

This study will randomize the families of adolescents ages 12-18 (n = 200) who meet DSM-5 criteria for AN to receive either GSH-FBT or FBT-V. Participants will be randomized to 15 sixty-minute sessions of FBT-V or to 10 twenty-minute sessions of online GSH-FBT. Major assessments will be conducted by a masked assessor at baseline, within treatment, at the end of treatment (EOT), and 6 and 12 months after the end of treatment (EOT). The primary outcomes of this study are changes to body weight and eating disorder cognitions relative to clinician time used (relative efficiency of treatment modality).

CONCLUSIONS

The findings of this study may help increase access to care by providing a time efficient, affordable, more scalable intervention for adolescent AN compared to standard FBT.

Development, Acceptability, and Usability of a Virtual Intervention for Vertebral Fractures

OBJECTIVE

This project aimed to develop a virtual intervention for vertebral fractures (VIVA) to implement the international recommendations for the nonpharmacological management of osteoporotic vertebral fractures and to test its acceptability and usability.

METHODS

VIVA was developed in accordance with integrated knowledge translation principles and was informed by the Behavioral Change Wheel, the Theoretical Domains Framework, and the affordability, practicability, effectiveness and cost-effectiveness, acceptability, side effects/safety, and equity (APEASE) criteria. The development of the prototype of VIVA involved 3 steps: understanding target behaviors, identifying intervention options, and identifying content and implementation options. The VIVA prototype was delivered to 9 participants to assess its acceptability and usability.

RESULTS

VIVA includes 7 1-on-1 virtual sessions delivered by a physical therapist over 5 weeks. Each session lasts 45 minutes and is divided in 3 parts: education, training, and behavioral support/goal setting. Four main themes emerged from the acceptability evaluation: perceived improvements in pain, increased self-confidence, satisfaction with 1-on-1 sessions and resources, and ease of use. All of the participants believed that VIVA was very useful and were very satisfied with the 1-on-1 sessions. Four participants found the information received very easy to practice, 4 found it easy to practice, and 1 found it somewhat difficult to practice. Five participants were satisfied with the supporting resources, and 4 were very satisfied. Potential for statistically significant improvements was observed in participants' ability to make concrete plans about when, how, where, and how often to exercise.

CONCLUSION

VIVA was acceptable and usable to the participants, who perceived improvements in pain and self-confidence.

IMPACT

The virtual implementation of the recommendations for the nonpharmacological management of vertebral fractures showed high acceptability and usability. Future trials will implement the recommendations on a larger scale to evaluate their effectiveness.

Development and initial pilot validation of a treatment fidelity instrument for family-based interoceptive exposure for adolescents with low-weight eating disorders

BACKGROUND

This pilot study outlines the development and psychometric evaluation of a therapist adherence coding measure for a novel treatment, Family-Based Treatment Interoceptive Exposure (FBT-IE).

METHODS

The IE Adherence Coding Framework (IE-ACF) was developed from the FBT-IE Manual using an iterative process. Items on the IE-ACF were coded by two independent coders as either present or absent with therapists considered adherent if both independent coders coded the item as "present." Videotaped sessions of FBT-IE of 30 adolescents with low-weight eating disorders (DSM-5 typical/atypical anorexia nervosa) and their families were coded. Participants received the FBT-IE intervention as part of a randomized controlled trial.

RESULTS

Seventy FBT-IE videos were coded. The IE-ACF identified a mean (SD) rating of 80% (±5%) therapist adherence to the protocol across the six-session treatment, with a per item adherence ranging from 36-100%. Two independent coders demonstrated moderate to almost perfect inter-rater reliability (κ range 0.78-0.96) across the sessions.

CONCLUSION

IE-ACF measured therapist adherence to our novel FBT-IE treatment for adolescents with low-weight eating disorders. Through this study, we demonstrated that 1) our therapists were adherent to the FBT-IE manual in the context of an ongoing clinical trial and 2) that independent coders reliably coded sessions using our novel IE-ACF.

Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial

Understanding what attributes or characteristics of those delivering interventions affect intervention fidelity and patient outcomes is important for contextualising intervention effectiveness. It may also inform implementation of interventions in future research and clinical practice. This study aimed to explore the relationships between attributes of Occupational Therapists (OTs), their faithful delivery of an early stroke specialist vocational rehabilitation intervention (ESSVR), and stroke survivor return-to-work (RTW) outcomes. Thirty-nine OTs were surveyed about their experience and knowledge of stroke and vocational rehabilitation and were trained to deliver ESSVR. ESSVR was delivered across 16 sites in England and Wales between February 2018 and November 2021. OTs received monthly mentoring to support ESSVR delivery. The amount of mentoring each OT received was recorded in OT mentoring records. Fidelity was assessed using an intervention component checklist completed using retrospective case review of one randomly selected participant per OT. Linear and logistic regression analyses explored relationships between OT attributes, fidelity, and stroke survivor RTW outcome. Fidelity scores ranged from 30.8 to 100% (Mean: 78.8%, SD: 19.2%). Only OT engagement in mentoring was significantly associated with fidelity (b = 0.29, 95% CI = 0.05-0.53, p < 0.05). Increased fidelity (OR = 1.06, 95% CI = 1.01-1.1, p = 0.01) and increasing years of stroke rehabilitation experience (OR = 1.17, 95% CI = 1.02-1.35) was significantly associated with positive stroke survivor RTW outcomes. Findings of this study suggest that mentoring OTs may increase fidelity of delivery of ESSVR, which may also be associated with positive stroke survivor return-to-work outcomes. The results also suggest that OTs with more experience of stroke rehabilitation may be able to support stroke survivors to RTW more effectively. Upskilling OTs to deliver complex interventions, such as ESSVR, in clinical trials may require mentoring support in addition to training to ensure fidelity.

Multidisciplinary implementation of family-based treatment delivered by videoconferencing (FBT-V) for adolescent anorexia nervosa during the COVID-19 pandemic

Family-Based Treatment (FBT)-the most widely supported treatment for pediatric eating disorders-transitioned to virtual delivery in many programs due to COVID-19. Using a blended implementation approach, we systematically examined therapist adherence to key components of FBT and fidelity to FBT by videoconferencing (FBT-V), preliminary patient outcomes, and team experiences with our FBT-V implementation approach as well as familial perceptions of FBT-V effectiveness. We examined our implementation approach across four pediatric eating disorder programs in Ontario, Canada, using mixed methods. Participants included therapists (n = 8), medical practitioners (n = 4), administrators (n = 6), and families (n = 5; 21 family members in total). We developed implementation teams at each site, provided FBT-V training, and offered clinical and implementation consultation. Therapists submitted video recordings of their first four FBT-V sessions for fidelity rating, and patient outcomes. Therapists self-reported readiness, attitudes, confidence, and adherence to FBT-V. Focus groups were conducted with each team and family after the first four sessions of FBT-V. Quantitative data were analyzed using repeated measures ANOVA. Qualitative data were analyzed using directed and summative content analysis. Therapists adhered to key FBT components and maintained FBT-V fidelity. Changes in therapists' readiness, attitudes, and confidence in FBT-V over time were not significant. All patients gained weight. Focus groups revealed implementation facilitators/barriers, positives/negatives surrounding FBT-V training and consultation, suggestions for improvement, and effectiveness attributed to FBT-V. Our implementation approach appeared to be feasible and acceptable. Future research with a larger sample is required, furthering our understanding of this approach and exploring how organizational factors influence treatment fidelity.

Development and refinement of the open dialog adherence protocol in complex mental health care

Introduction

Open dialog (OD) is a both a therapeutic practice and a service delivery model that offers an integrated response to mental health care through mobilizing resources within the service user's family and community networks through joint network meetings. Therapist adherence is a crucial to the effective delivery of interventions. A key way to measure this is through structured observation tools.

Aims

The aim of this research project is to develop and refine the Dialogic Practice Adherence Scale, for use in OD research trials in the United Kingdom.

Methods

This study was a mixed methods approach to the development of an OD practitioner adherence measure. Initial steps involved meetings and discussions with experts and a review of the literature. Content validation studies were completed using a modified Delphi technique. To assess reliability of the measure, OD network meetings were audio-recorded, and tapes were rated by two independent researchers. Inter-rater reliability and internal consistency were assessed through quantitative approaches assessing variance.

Results

Results provide a description of how the OD Adherence Manual was developed in collaboration. Validation surveys showed high levels on consensus among experts in the field on the key elements of OD network meetings. Inter-rater reliability for the total score was excellent and internal consistency analyses suggest the scale is highly reliable.

Discussion

The scale presented here is an initial attempt at rating practitioner adherence in OD network meetings. It provides encouraging evidence that this can be done with strong validity and reliability and can be completed by a range of raters with varying levels of clinical experience.

Protocol for a randomized clinical trial for Avoidant Restrictive Food Intake Disorder (ARFID) in low-weight youth

Background Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder recently added to the Diagnostic and Statistical Manual, 5th Edition (DSM-5) that involves nutritional, developmental, and/or psychosocial impairment, and often presents with a lack of interest in eating, sensory-related eating concerns, and/or fear of adverse consequences related to eating. There is limited evidence on treatments for ARFID, and in particular, treatments for children in the outpatient setting. Pilot data suggest that Family-Based Treatment (FBT) modified for ARFID is efficacious, and that improvements in parental self-efficacy may be the mechanism behind its success. This manuscript describes a study protocol seeking to confirm these preliminary findings through an adequately powered, randomized clinical trial (RCT). METHODS: This trial will randomize 100 children ages 6-12 years old who meet DSM-5 criteria for ARFID and their families to receive either 14 telehealth sessions of FBT-ARFID (n = 50) or a manualized Psychoeducational Motivation Therapy (PMT) treatment (n = 50), an individual therapy addressing the child's understanding of the problems ARFID is causing and promoting non-behavioral motivation and exploration of changing their eating patterns. Masked assessments will be conducted at baseline, one and two months within treatment, end-of-treatment, and six-month follow-up. Primary outcomes include change in body weight, parental self-efficacy, and parent feeding behaviors between baseline and end-of-treatment. CONCLUSIONS: The results of this RCT will advance our understanding of effective treatments for low-weight ARFID in youth.

Weight restoration in adolescent anorexia: parents' goal-directed processes

BACKGROUND

Parent-led weight restoration is a key intervention of family-based treatment, an empirically supported treatment for adolescent anorexia. Successful outcomes in family-based treatment depend almost entirely on parental action, yet current understandings of this intervention are primarily informed by professional theory and expert perspectives. Comparatively little is known about parents' goals and actions while implementing the treatment, despite goal-directed action being an explicit framework of family-based treatment. This study seeks to investigate parents' involvement in weight restoration from the perspective of the goal-directed actions they construct and engage in themselves and with others. This study focuses on the phenomenon of parent-led weight restoration as a project and addresses the following research question: "How do parents participate in the weight restoration of their adolescent as the adolescent recovers from anorexia nervosa?".

METHOD

This multicase study used the action project method and conceptual framework of contextual action theory to examine four cases of five parents engaged in actions to help their adolescent regain weight and recover from anorexia. Data were collected using multi-part interviews and analyzed according to the action project method and the multicase approach.

RESULTS

Parents' weight restoration projects were identified and grouped based on three common a themes. The primary theme, progressing toward health and well-being, was supported by three key processes: maintaining a holistic focus, trusting, and monitoring progress. Two secondary themes captured actions that were integral to the parents' projects, but with less prominence. Secondary themes were creating capacity, which was supported by three processes (managing emotions to maintain a helpful focus, personal work, and resourcing time and finances), and coordinating and negotiating partnerships. The socio-cultural valuing of the thin ideal emerged as a unique process salient in one case. This study presents a goal-directed and contextual perspective on how parents translated the principles of family-based treatment into their daily lives. It joins a small but growing body of work concerned with generating new understandings and frameworks for practitioners and researchers to enhance the effectiveness of family-based treatment in community settings.

Implementation and outcomes of home-based treatments for adolescents with anorexia nervosa: Study protocol for a pilot effectiveness-implementation trial

OBJECTIVE

Although family-based treatment (FBT) is considered a first-line treatment for adolescent anorexia nervosa (AN), it is underutilized in community settings and is unavailable to many families for a multitude of practical reasons (e.g., costs of treatment, transportation constraints). Adapting FBT interventions for delivery in home-based and community-based settings may reduce pragmatic barriers to treatment uptake and engagement.

METHODS

This pilot effectiveness-implementation trial will assess outcomes, implementation, and mechanisms of FBT adapted for the home setting (FBT-HB), delivered in the context of community-based behavioral health agencies. Adolescents with AN-spectrum disorders (n = 50) and their caregivers will be randomly assigned to either FBT-HB or home-based treatment as usual (TAU; integrated family therapy approach). Caregivers and adolescents will provide data on weight, eating, and putative treatment mechanisms, including caregiver self-efficacy and adolescent eating-related and weight-related distress. Implementation constructs of feasibility, acceptability, and appropriateness will be measured among providers and participating families.

HYPOTHESES

We expect that FBT-HB will be feasible, acceptable, and appropriate, and will outperform TAU in terms of improvements in adolescent weight and eating-related psychopathology. We further expect that caregiver self-efficacy and adolescent eating-related and weight-related distress, but not general distress, will show greater improvements in FBT-HB relative to TAU and will be associated with better adolescent weight and eating outcomes in FBT-HB.

POTENTIAL IMPLICATIONS

The proposed study has clear potential to advance scientific and clinical understanding of the real-world effectiveness of FBT for AN, including whether adapting it for the home setting improves its accessibility and effects on treatment outcome.

Study protocol for training providers in private practice in family-based treatment for adolescents with anorexia nervosa: A randomized controlled feasibility trial

BACKGROUND

Private practice clinicians make up approximately 50% of US mental health outpatient providers and treat a high number of eating disorder patients. While family-based treatment (FBT) is a first-line treatment for adolescent anorexia nervosa (AN), private practice clinicians experience difficulties receiving training in evidence-based treatments such as FBT. This report outlines the study protocol for a randomized control trial (RCT) training private practice clinicians in FBT for adolescent AN (NCT04428580).

METHODS

In this study, we intend to recruit 140 private practice mental health practitioners and randomize them to complete either a standard webinar-based online training or an enhanced online training that incorporates additional modules related to the putative mechanisms of treatment effect in FBT (i.e., use of externalization and agnosticism). Following the training, participants will begin expert case consultation for an adolescent with AN using FBT from their private practice.

CONCLUSION

Based on preliminary studies suggesting the importance of enhanced skills related to agnosticism and externalization, we hypothesize that feasibility data will support a larger randomized clinical trial (RCT) and that the enhanced training arm will significantly improve FBT knowledge and skills compared to the standard webinar training arm. We also expect that patient weight gain early in treatment will be associated with clinician fidelity to the inventions used in FBT regardless of training type.

Phase 2 of family-based treatment: an exploratory assessment of clinician practices

PURPOSE

In manualized family-based treatment (FBT) for eating disorders, phase 1 of the 3-phase treatment-during which parents are put in control of eating-related issues-is perhaps the most critical phase, and is comprehensively addressed in the manual. Phase 2, during which control over eating is gradually returned to the patient, is more variable and the manual dedicates less space to this phase. The purpose of the current exploratory study was to assess Phase 2 practices of clinicians providing FBT and to compare these practices to the guidance offered in the manual.

METHODS

In the current study, a survey assessing Phase 2 practices was sent to clinicians. Twenty-seven providers responded. Two providers reported that they did not provide FBT in an outpatient setting. One reported not currently providing outpatient FBT but had in the past. The remaining providers were currently providing FBT in an outpatient setting.

RESULTS

No items addressing the core interventions of Phase 2, including encouraging age-appropriate independent eating, were endorsed by 100% of respondents as being addressed 100% of the time in Phase 2.

CONCLUSION

Responses reflected some adherence to the manual, along with examples of therapist drift and incorporation of therapeutic interventions that are not described in the FBT manual. Adherence to manualized treatments may improve outcome for some patients, while allowing for flexibility to address clinical situations that are not addressed in the manual.

LEVEL OF EVIDENCE

V. Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

The five tenets of family-based treatment for adolescent eating disorders

Family-based treatment (FBT) is the leading treatment for adolescent eating disorders and is based on five tenets, or fundamental assumptions: (1) the therapist holds an agnostic view of the cause of the illness; (2) the therapist takes a non-authoritarian stance in treatment; (3) parents are empowered to bring about the recovery of their child; (4) the eating disorder is separated from the patient and externalized; and (5) FBT utilizes a pragmatic approach to treatment. Learning these tenets is crucial to the correct practice and implementation of manualized FBT. The purpose of the current paper is to provide an in-depth overview of these five tenets and to illustrate how they are used in clinical practice. This overview will aid clinicians who are learning FBT.

Treatment fidelity in eating disorders and psychological research: Current status and future directions

OBJECTIVE

The evaluation and use of treatment fidelity procedures are rare in the development and implementation of psychological interventions. This article aims to review the construct of treatment fidelity, highlight limitations to currently available measures, and introduce a conceptual framework for studying and adapting fidelity measures in clinical research and practice using eating disorders as an example.

METHOD

As treatment fidelity assesses whether an intervention was delivered as intended, we operationalized this construct as: (a) treatment adherence, (b) therapist competence, and (c) treatment differentiation.

RESULTS

There is a significant gap in the literature assessing and documenting treatment fidelity. Available studies indicate that existing adherence measures can be time consuming, costly, and are not widely used in the field. Furthermore, therapist competence is a complex and context-dependent construct that is challenging to measure. Finally, treatment differentiation is often inferred by ensuring adherence.

DISCUSSION

The development of simplified formal tests of treatment fidelity would help draw conclusions about treatment efficacy and improve the dissemination and implementation of interventions to promote optimal clinical outcomes.

Family-based treatment for children and adolescents with eating disorders: a mixed-methods evaluation of a blended evidence-based implementation approach

In this study, we evaluated a blended implementation approach with teams learning to provide family-based treatment (FBT) to adolescents with eating disorders. Four sites participated in a sequential mixed method pre-post study to evaluate the implementation of FBT in their clinical settings. The implementation approach included: (a) preparatory site visits; (b) the establishment of implementation teams; (c) a training workshop; (d) monthly clinical consultation; (e) monthly implementation consultation; and (f) fidelity assessment. Quantitative measures examining attitudes toward evidence-based practice, organizational learning environment and organizational readiness for change, as well as, individual readiness for change were delivered pre- and postimplementation. Correlational analyses were used to examine associations between baseline variables and therapist fidelity to FBT. Fundamental qualitative description guided the sampling and data collection for the qualitative interviews performed at the conclusion of the study. Seventeen individuals participated in this study (nine therapists, four medical practitioners, and four administrators). The predetermined threshold of implementation success of 80% fidelity in every FBT session was achieved by only one therapist. However, mean fidelity scores were similar to those reported in other studies. Participant attitudes, readiness, and self-efficacy were not associated with fidelity and did not change significantly from pre- to postimplementation. In qualitative interviews, all participants reported that the implementation intervention was helpful in adopting FBT. Our blended implementation approach was well received by participants. A larger trial is needed to determine which implementation factors predict FBT fidelity and impact patient outcomes.

Adapting and adopting highly specialized pediatric eating disorder treatment to virtual care: a protocol for an implementation study in the COVID-19 context

BACKGROUND

The COVID-19 pandemic has negatively impacted individuals with eating disorders; resulting in increased symptoms, as well as feelings of isolation and anxiety. To conform with social distancing requirements, outpatient eating disorder treatment in Canada is being delivered virtually, but a lack of direction surrounding this change creates challenges for practitioners, patients, and families. As a result, there is an urgent need to not only adapt evidence-based care, including family-based treatment (FBT), to virtual formats, but to study its implementation in eating disorder programs. We propose to study the initial adaptation and adoption of virtual family-based treatment (vFBT) with the ultimate goal of improving access to services for youth with eating disorders.

METHODS

We will use a multi-site case study with a mixed method pre/post design to examine the impact of our implementation approach across four pediatric eating disorder programs. We will develop implementation teams at each site (consisting of therapists, medical practitioners, and program administrators), provide a remote training workshop on vFBT, and offer ongoing consultation during the initial implementation phase. Therapists will submit videorecordings of their first four vFBT sessions. We propose to study our implementation approach by examining (1) whether the key components of standard FBT are maintained in virtual delivery measured by therapist self-report, (2) fidelity to our vFBT model measured by expert fidelity rating of submitted videorecordings of the first four sessions of vFBT, (3) team and patient/family experiences with vFBT assessed with qualitative interviews, and (4) patient outcomes measured by weight and binge/purge frequency reported by therapists.

DISCUSSION

To our knowledge, this is the first study to evaluate an implementation strategy for virtually delivered FBT for eating disorders. Challenges to date include confirming site participation and obtaining ethics approval at all locations. This research is imperative to inform the delivery of vFBT in the COVID-19 context. It also has implications for delivery in a post-pandemic era where virtual services may be preferable to patients and families living in remote locations, where access to specialized services is extremely limited.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04678843 , registered on December 21, 2020.

The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial

A common metric for determining implementation success is the measurement of clinician adherence to, and competence in, delivering a psychotherapy. The present study examined clinician and organizational factors as predictors of early adherence and competence among 78 clinicians delivering cognitive processing therapy (CPT), an evidence-based psychotherapy (EBP) for posttraumatic stress disorder, in a randomized controlled implementation trial. Results indicated that clinicians' willingness to adopt an EBP if required to do so was significantly associated with early adherence and competence in CPT delivery. Level of clinician education was significantly associated with early competence in delivering CPT. Organizational factors did not predict early adherence or competence. Implications of the findings are discussed.

Assessing fidelity to family-based treatment: an exploratory examination of expert, therapist, parent, and peer ratings

INTRODUCTION

Fidelity is an essential component for evaluating the clinical and implementation outcomes related to delivery of evidence-based practices (EBPs). Effective measurement of fidelity requires clinical buy-in, and as such, requires a process that is not burdensome for clinicians and managers. As part of a larger implementation study, we examined fidelity to Family-Based Treatment (FBT) measured by several different raters including an expert, a peer, therapists themselves, and parents, with a goal of determining a pragmatic, reliable and efficient method to capture treatment fidelity to FBT.

METHODS

Each therapist audio-recorded at least one FBT case and submitted recordings from session 1, 2, and 3 from phase 1, plus one additional session from phase 1, two sessions from phase 2, and one session from phase 3. These submitted files were rated by an expert and a peer rater using a validated FBT fidelity measure. As well, therapists and parents rated fidelity immediately following each session and submitted ratings to the research team. Inter-observer reliability was calculated for each item using the intraclass correlation coefficient (ICC), comparing the expert ratings to ratings from each of the other raters (parents, therapists, and peer). Mean scale scores were compared using repeated measures ANOVA.

RESULTS

Intraclass correlation coefficients revealed that agreement was the best between expert and peer, with excellent, good, or fair agreement in 7 of 13 items from session 1, 2 and 3. There were only four such values when comparing expert to parent agreement, and two such values comparing expert to therapist ratings. The rest of the ICC values indicated poor agreement. Scale level analysis indicated that expert fidelity ratings for phase 1 treatment sessions scores were significantly higher than the peer ratings and, that parent fidelity ratings tended to be significantly higher than the other raters across all three treatment phases. There were no significant differences between expert and therapist mean scores.

CONCLUSIONS

There may be challenges inherent in parents rating fidelity accurately. Peer rating or therapist self-rating may be considered pragmatic, efficient, and reliable approaches to fidelity assessment for real-world clinical settings.

Family-based treatment via videoconference: Clinical recommendations for treatment providers during COVID-19 and beyond

The necessity to employ distance-based methods to deliver on-going eating disorder care due to the novel coronavirus (COVID-19) pandemic represents a dramatic and urgent shift in treatment delivery. Yet, TeleHealth treatments for eating disorders in youth have not been adequately researched or rigorously tested. Based on clinical experience within our clinic and research programs, we aim to highlight the common challenges clinicians may encounter in providing family-based treatment (FBT) via TeleHealth for children and adolescents with anorexia nervosa and bulimia nervosa. We also discuss possible solutions and offer practical considerations for providers delivering FBT in this format. Additional research in TeleHealth treatment for eating disorders in youth may lead to improved access, efficiency, and effectiveness of FBT delivered via videoconferencing.

Confirming the Efficacy of an Adaptive Component to Family-Based Treatment for Adolescent Anorexia Nervosa: Study Protocol for a Randomized Controlled Trial

Family-based treatment (FBT) has the largest evidence base for treating adolescents with anorexia nervosa (AN); 35-50% of cases remit at the end-of-treatment and remain remitted 3-4 years after treatment. Studies of FBT demonstrate that weight restoration by session 4 (of 2.4 kgs) predicts remission at end of treatment in 85-90% of cases. One way to improve outcomes is to tailor treatments to patients depending on successful weight restoration at session 4. Pilot data found that by adding three sessions of Intensive Parental Coaching (IPC) after session 4 improved outcomes in early non-responders. Further, data suggest that the mechanism underlying FBT is early improvements in parental self-efficacy related to re-feeding their child. This manuscript describes a study protocol to examine whether adding IPC to FBT improves outcomes in early non-responders and confirm whether change in parental self-efficacy is the mechanism by which FBT works. This two-site randomized controlled trial (RCT) will randomize 60 adolescents with a DSM-5 diagnosis of AN (30 per site) who are between the ages of 12-18 years old and do not gain 2.4 kgs by session 4 of FBT. Randomized participants will either continue standard FBT or receive the three sessions of IPC and then continue FBT as usual. Both arms include up to 18 sessions over the course of 9 months. Blinded assessments will be conducted at baseline, 3-month within-treatment, end of treatment, and at 6 and 12-month follow-up. Parental-self efficacy will be assessed using the Parent versus Anorexia Scale at all major assessment time points and at each of the first eight sessions of treatment. The primary outcome is achievement of weight remission (> 94% expected mean percent body mass index (BMI) adjusted for age, height, and gender).

CLINICAL TRIAL REGISTRATION

http://www.ClinicalTrials.gov, identifier NCT03097874.

Therapist adherence to family-based treatment for adolescents with anorexia nervosa: A multi-site exploratory study

OBJECTIVE

This exploratory study is the first to examine family-based treatment (FBT) adherence and association to treatment outcome in the context of a large-scale, multi-centre study for the treatment of adolescents with anorexia nervosa.

METHOD

One hundred and ninety recorded FBT sessions from 68 adolescents with anorexia nervosa and their families were recruited across multiple sites (N = 6). Each site provided 1-4 tapes per family over four treatment time points, and each was independently rated for therapist adherence.

RESULTS

There were differences in adherence scores within and between sites. ANOVA produced a main effect for site, F(5, 46) = 8.6, p < .001, and phase, F(3, 42) = 12.7, p < .001, with adherence decreasing in later phases. Adherence was not associated to end of treatment percent ideal body weight after controlling for baseline percent ideal body weight (r = .088, p = .48).

CONCLUSIONS

Results suggest that FBT can be delivered with adherence in phase one of treatment. Adherence was not associated with treatment outcome as determined using percent ideal body weight.

A systematic review of the quality of randomized controlled trials of psychological treatments for emotional distress in breast cancer

OBJECTIVE

Meta-analyses of trials of psychological treatments for emotional distress in breast cancer (BCa) conclude that efficacious treatments exist. Subsequently, their implementation in routine care is widely promoted by health policy. However, the methodological quality of these trials has not been systematically evaluated. The present review investigates this issue.

METHOD

A systematic search identified randomized controlled trials of psychological treatments for emotional distress in BCa. The Psychotherapy Outcome Study Methodology Rating Form was used to assess the quality of trials. Generic design elements, including representativeness of sample, control of concomitant treatments, reporting clinical significance outcomes, and design elements specific to psychotherapy trials, including manualisation, therapist training, and therapist adherence and competence were evaluated.

RESULTS

91 trials were eligible. Overall, methodological quality was low. Generic design elements were limited in most trials: 15% specified as an inclusion criterion that participants were distressed; 10% controlled for concomitant treatments; and 11% reported the clinical significance of findings. Design elements specific to psychotherapy trials were also implemented poorly: 51% used treatment manuals; 8% used certified trained therapists; and monitoring of adherence and competence occurred in 15% and 4%, respectively.

CONCLUSION

The methodological quality of psychological treatment trials for emotional distress in BCa is improving. However, if relevant health policies are to be adequately empirically informed, trials of greater methodological rigour are essential. Trials should include participants with clinical levels of distress, control for concomitant treatments and report the clinical significance of findings. Trialists must also consider the specific requirements of psychotherapy trials.

Using Technology to Improve Treatment Outcomes for Children and Adolescents with Eating Disorders

Dissemination and implementation of evidence-based treatments are among the biggest challenges facing clinical psychiatry. Developing scalable evidence-based treatments is a major priority and fraught with challenges. This article describes the development of 3 technology-based innovations. It discusses the use of massive open online courses (MOOCs) and mobile applications. Three projects are presented: (1) the modification of a MOOC methodology for psychotherapy training clinicians in manualized family-based therapy (FBT) for adolescents with anorexia nervosa; (2) a modified MOOC platform for the delivery of FBT; and (3) the development of mobile applications for treatment augmentation and delivery.

Implementing highly specialized and evidence-based pediatric eating disorder treatment: protocol for a mixed methods evaluation

Background

Eating disorders, which include anorexia nervosa and bulimia nervosa, are common in adolescent females and can have serious emotional and physical consequences, including death. Despite our knowledge about the severity of these illnesses, previous research indicates that adolescent patients are not receiving the best available treatment with fidelity. The main goal of this project is to reduce the knowledge gap between what research indicates is the best known treatment and what is actually delivered in clinical practice. Informed by the National Implementation Research Network model and the Consolidated Framework for Implementation Research meta-theory, our primary study aim is to increase the capacity of Ontario-based therapists to provide family-based treatment, by providing training and ongoing supervision.

Methods/design

We will use a multi-site case study with a mixed method pre/post design to examine several implementation outcomes across four eating disorder treatment programs. We will provide a training workshop on family-based treatment as well as ongoing monthly supervision. In addition, we will assemble implementation teams at each site and coach them by phone on a monthly basis regarding any process issues. Our main outcomes include fidelity to the treatment model using quantitative evaluation of audio-recorded therapy sessions, as well as qualitative analysis of the perceptions of the implementation process using audio-recorded focus groups with all clinicians and administrators involved in the study.

Discussion

To our knowledge, this is the first study to evaluate an implementation strategy for an evidence-based treatment for eating disorders. Challenges to date include obtaining ethics approval at all sites, and recruitment. This research will help to inform future studies on how to best implement evidence-based treatments in this field.