Parental guided self-help family based treatment for adolescents with anorexia nervosa: A feasibility study

Guided Self-Help Treatment for Children and Young People With Eating Disorders: A Proof-Of-Concept Pilot Study

OBJECTIVE

To conduct a proof-of-concept pilot study of a CBT guided self-help intervention for children and young people with eating disorders.

METHOD

Children and young people were recruited from two outpatient eating disorder services in England. They received a CBT guided self-help intervention consisting of eight modules and weekly support sessions. Clinical outcomes (eating disorder psychopathology and associated impairment, changes in %median BMI, depression, anxiety, and behavioural difficulties) were assessed at baseline and post-intervention (12 weeks). Qualitative data were collected for future intervention refinement.

RESULTS

Six female adolescents (aged 13-17) received the CBT guided self-help intervention. All participants completed a minimum of six modules and six support sessions. Quantitative and qualitative feedback suggested that the intervention was acceptable. From baseline to post-intervention, there was a reduction in eating disorder psychopathology and impairment, along with an increase in %median BMI. Outcomes for depression, anxiety and behavioural difficulties were mixed.

CONCLUSIONS

The CBT guided self-help intervention was feasibly implemented, acceptable to participants, and showed potential to produce clinical benefits. While promising, these findings are preliminary and derived from a small, non-randomised sample of White female adolescents. More rigorous evaluation with a randomised design and a larger, representative sample is warranted.

"The only way that they can access help quickly": a qualitative exploration of key stakeholders' perspectives on guided self-help interventions for children and young people with eating disorders

BACKGROUND

There is a significant unmet treatment need for children and young people (CYP) with eating disorders. Guided self-help interventions have the potential to expand access to evidence-based treatments. Guided self-help is a type of low intensity psychological intervention where individuals engage with a workbook or online programme, with the support of a health professional. Its primary aim is to equip patients and/or their caregivers with self-management skills. However, little is currently known about the acceptability and suitability of guided self-help interventions for CYP with eating disorders. This study aimed to explore the perspectives of three key stakeholder groups - CYP with lived experience of eating disorders, parents/carers, and healthcare professionals - on guided self-help for this population.

METHODS

Qualitative focus groups and semi-structured interviews were conducted with 11 CYP (aged 13-19 years) with lived experience of eating disorders, 12 parents/carers, and 10 healthcare professionals. The study comprised a total of seven focus groups (including 2 with CYP, 3 with parent/carers, and 2 with healthcare professionals), as well as four semi-structured interviews (including 3 with CYP and 1 with a parent/carer). Discussion topics included past experiences of using/delivering guided self-help, the suitability of guided self-help for CYP with eating disorders, and preferences towards the content, structure and modes of guided self-help. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes were generated across all three stakeholder groups. Theme one, Bridging the gap, highlighted the role of guided self-help in increasing access to psychological support for CYP with eating disorders. Theme two, Timing matters, considered the suitability of guided self-help for CYP with eating disorders at different stages of illness and the care pathway. Theme three, One size does not fit all, emphasised the heterogeneity of eating disorders and the need for a personalised and flexible approach in guided self-help.

CONCLUSIONS

Findings from this study lay a foundation for the future design and delivery of guided self-help interventions for CYP with eating disorders. Future work must consider these findings in the context of best available research evidence to optimise the potential utility of guided self-help for this population.

Experts' views on the implementation of digital interventions for eating disorders: a Delphi study

BACKGROUND

Eating disorders (EDs) constitute a considerable burden for individuals and society, but adequate and timely professional treatment is rare. Evidence-based Digital Mental Health Interventions (DMHIs) have the potential both to reduce this treatment gap and to increase treatment effectiveness. However, their integration into routine care is lacking. Understanding practitioners' attitudes towards DMHIs for EDs is crucial for their effective use.

AIMS

To investigate the consensus among German ED treatment experts on the relevance of different influencing factors for DMHI use in EDs.

METHODS

This Delphi study consisted of two rounds and was conducted online with an initial sample of N = 24 ED experts (Mage=41.96, SDage=9.92, n = 22 female). Prior to the Delphi rounds, semi-structured qualitative telephone interviews were performed to explore participants' attitudes, experiences, and expectations towards DMHIs. In order to construct the Delphi survey, content analysis was applied to a subset of ten interviews. A total of 63 influencing factors were identified and grouped into three main categories: contextual conditions, design, and content of DMHIs. In both Delphi rounds, the interview participants were subsequently invited to rate each of the factors with regard to their importance on 10-point scales. Group percentages and individual ratings of the first round (n = 23) were presented in the second round (n = 21). Consensus was calculated for each item (defined as IQR ≤ 2).

RESULTS

Importance ratings were high across items (M = 7.88, SD = 2.07, Mdn = 8). In the first round, 48% of the items reached consensus, with its most important (Mdn = 10) factors referring to data security, evidence base, technical requirements, usability, and specific DMHI content (psychoeducation, crisis intervention). In the second Delphi round, a consensus was reached on 73% of the items. No consensus was reached on 17 items.

CONCLUSIONS

The findings on practitioners' attitudes and priorities have relevant implications for subsequent DMHI development, dissemination, and implementation strategies, indicating that the highest-rated factors should be highlighted in the process.

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.

Feasibility and acceptability of a pilot studying investigating multi-family parent-only guided self-help family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Family-based treatment (FBT) is an efficacious treatment for adolescent anorexia nervosa (AN). A parent-only guided self-help version of FBT (GSH-FBT) demonstrated preliminary efficacy in pilot investigations. To address challenges in access to care, we adapted GSH-FBT into a parent-only multi-family group format (MF-GSH-FBT) delivered via videoconferencing.

METHOD

This report details the feasibility and acceptability of a parent-only group-based multi-family GSH-FBT (MF-GSH-FBT) for adolescent AN delivered virtually. The MF-GSH-FBT intervention consisted of 12 weekly 60-min sessions facilitated by a clinician in addition to online FBT video content and recommended readings. Adolescents and parents completed assessments at baseline and post-treatment. Parents reported their child's weight each week.

RESULTS

A total of 13 adolescents (15.57 + 1.63 years; 92% female; 23% Hispanic) with AN and their parents enrolled and initiated treatment. Four consecutive cohorts of groups of 3-4 families were completed from April 2022 to April 2023. Across cohorts, parents attended 85% of sessions. Most parents rated the treatment sessions as helpful (79%; agree/strongly agree) and felt supported by the other group members (84%). All parents (100%) reported MF-GSH-FBT helped their child, and most (90%) reported their child had improved by end-of-treatment. On average, adolescents gained 3.53 kg (SD: 3.76) from pre- to post-treatment, with percent estimated mean body weight increasing 5% on average. Parental self-efficacy also increased from baseline to end-of-treatment.

DISCUSSION

MF-GSH-FBT for AN appears feasible and acceptable to parents participating in this pilot study. Challenges with recruitment and adolescent data collection remain questions for future investigation.

PUBLIC SIGNIFICANCE

This study describes initial pilot testing of a virtual guided self-help family-based treatment for adolescents with anorexia nervosa delivered in a multi-family group format. This treatment aims to enhance access to family-based treatment for anorexia nervosa whilst providing additional support to parents.

A Narrative Review of Early Intervention for Eating Disorders: Barriers and Facilitators

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence and emerging adulthood. Early intervention is important for improved outcomes for young people with EDs, yet help-seeking is low and individuals often have a significantly protracted start to treatment, suggesting that early intervention is not well established in the ED field. Previous reviews on facilitators and barriers to early intervention for EDs largely cover perceived barriers related to patient variables and perspectives, whereas clinician-, service-, and healthcare system-related facilitators and barriers are less frequently reviewed. The aim of this review is to synthesize the literature on barriers to and facilitators of early intervention for EDs, regarding patient-, clinician-, service-, and healthcare system-related factors. A narrative review was conducted by searching for relevant peer-reviewed, English-language articles published up until July 2023 on PubMed and PsychINFO. The search was conducted in two steps. First, key search terms were used to identify existing reviews and meta-analyses on facilitators and barriers to early intervention for EDs. Then, additional search terms were added to search for primary and secondary research on patient/family, clinician, service, and healthcare system-related barriers and facilitators. The identified literature shows that, after overcoming intrinsic, motivational barriers (such as self-stigma, denial, and ambivalence), help-seeking individuals may be met with long service waiting lists and limited treatment options. Despite these barriers, there is ongoing research into early intervention in practice, which aims to reach underserved populations and facilitate early intervention despite high service demands and shortages of trained healthcare professionals. Funding for ED research and services has historically been low, and there is also a research-practice gap. This highlights the need for increased consideration of, and funding for early intervention for EDs, to remove barriers as well as facilitate discussions around how to make early intervention programs scalable and sustainable.

Low intensity psychological interventions for the treatment of feeding and eating disorders: a systematic review and meta-analysis

BACKGROUND

Feeding and eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Low intensity psychological interventions have the potential to increase such access.

METHODS

A systematic review and meta-analysis were conducted on the use of low intensity psychological interventions for the treatment of feeding and eating disorders. Studies comparing low intensity psychological interventions against high intensity therapies and non-eating disorder specific psychological interventions were included, as well as those with waiting list control arms. There were three primary outcomes: eating disorder psychopathology, diagnostic and statistical manual of mental disorders (DSM) severity specifier-related outcomes and rates of remission/recovery.

RESULTS

Thirty-three studies met the inclusion criteria, comprising 3665 participants, and 30 studies were included in the meta-analysis. Compared to high intensity therapies, low intensity psychological interventions were equivalent on reducing eating disorder psychopathology (g = - 0.13), more effective at improving DSM severity specifier-related outcomes (g = - 0.15), but less likely to achieve remission/recovery (risk ratio (RR) = 0.70). Low intensity psychological interventions were superior to non-eating disorder specific psychological interventions and waiting list controls across all three primary outcomes.

CONCLUSION

Overall, findings suggest that low intensity psychological interventions can successfully treat eating disorder symptoms. Few potential moderators had a statistically significant effect on outcome. The number of studies for many comparisons was low and the methodological quality of the studies was poor, therefore results should be interpreted with caution. More research is needed to establish the effectiveness of low intensity psychological interventions for children and young people, as well as for individuals with anorexia nervosa, avoidant/restrictive food intake disorder, pica and rumination disorder.

Examining the feasibility of a parental self-help intervention for families awaiting pediatric eating disorder services

OBJECTIVE

Waitlists for eating disorder (ED) services grew immensely during the COVID-19 pandemic. To address this, we studied the feasibility of a novel parental self-help waitlist intervention.

METHOD

Parents of a child/adolescent (7-17 years) awaiting pediatric ED services were provided with our intervention, adapted from the family-based treatment model, and consisting of videos and reading material with no therapist involvement. Parent-reported child/adolescent weight was collected weekly 6 weeks pre-intervention, 2 weeks during the intervention, and 6-week post-intervention. Recruitment and retention rates were calculated. Regression-based interrupted time series analyses were completed to measure changes in the rate of weight gain.

RESULTS

Ninety-seven parents were approached, and 30 agreed to participate (31% recruitment rate). All but one completed end-of-study measures (97% retention rate). The average rate of weight gain was 0.24 lbs/week pre-intervention, which increased significantly to 0.78 lbs/week post-intervention (p < .034).

DISCUSSION

Our findings provide preliminary evidence that this intervention is feasible. Future research is needed to confirm the efficacy of this intervention on a larger scale.

PUBLIC SIGNIFICANCE

The COVID-19 pandemic has resulted in several challenges in providing care for children and adolescents with eating disorders, including long waiting lists and delays in treatment. This study suggests that providing parents on a waitlist with educational videos and reading material is acceptable to parents, and may even help in improving the child's symptoms of an eating disorder.

"I'm not alone": a qualitative report of experiences among parents of children with eating disorders attending virtual parent-led peer support groups

BACKGROUND

The treatment for children with eating disorders (EDs) requires extensive involvement of parents. The parents of children with EDs have voiced a need for greater support, including connecting with other parents with lived experience of caring for a child with an ED. We aimed to qualitatively explore parental experiences of these groups, including their benefits and areas for improvement.

METHODS

This study examined the delivery of four virtual parent-led peer support groups in Ontario, Canada for parents of children with EDs with approximately 10 parent participants per group and two parent facilitators leading each group. Parents (n = 44) were asked to attend 12 bi-weekly support group sessions over 6 months, and then complete an individual end-of-study qualitative interview. Interview data were analyzed using content analysis, following the qualitative description design.

RESULTS

Thirty-six parents completed the end-of-study qualitative interview. Participants shared their experiences and impressions related to the group's structure and content. Notable helpful aspects of the group included being able to receive support from those with similar experiences, access to education and resources about EDs, and being able to support others. Suggestions for improvements were made, which included organizing groups according to the child's ED diagnosis or duration of illness.

CONCLUSION

The findings indicate that this intervention is acceptable to parents and is perceived as helpful. Future research is needed to strengthen this support group model and to study its effects for parents in different settings and for parents of children with various EDs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04686864.

Parent and clinician perspectives on virtual guided self-help family-based treatment (GSH-FBT) for adolescents with anorexia nervosa

PURPOSE

Guided self-help (GSH) treatments have the capacity to expand access to care, decrease costs, and increase dissemination compared to traditional therapist-directed treatment approaches. However, little is known about parent and clinician perspectives about the acceptability of GSH for adolescents with eating disorders.

METHODS

This study utilized a mixed methods approach to obtain qualitative and quantitative data regarding clinician and participants' experiences with GSH. Parent participants were enrolled in a randomized trial comparing GSH family-based treatment (GSH-FBT) to family-based treatment delivered via videoconferencing (FBT-V) for adolescents (12-18 years old) with a DSM-5 diagnosis of anorexia nervosa (AN). Parent participants provided qualitative feedback using the Helping Alliances Questionnaire about their experience of treatment. Clinician participants were six master's or PhD-level therapists. These clinicians were trained in and provided both treatments (GSH-FBT and FBT-V). They provided responses to questionnaires and participated in a 1-h focus group about their experience as treatment providers.

RESULTS

Regardless of treatment condition, parents listed more improvement than worsening of symptoms in their child with AN. Clinicians reported lower scores on competency and comfort metrics with GSH-FBT compared to FBT-V. Qualitatively, clinicians reported both advantages and disadvantages of delivering GSH-FBT.

CONCLUSION

Further studies are needed to better understand how GSH interventions can be disseminated to patients and families, particularly those with limited access to specialized eating disorder treatment centers. Level of evidence Level I, data collected as part of a randomized controlled trial.

A systematic review of the impact of carer interventions on outcomes for patients with eating disorders

PURPOSE

Eating disorder (ED) prevalence and illness severity is rapidly increasing. The complicated interplay of factors contributing to the maintenance of EDs, including family/carer influences, highlights the importance of carer interventions within ED treatment. Carer interventions demonstrate positive outcomes for carers themselves, though are also hypothesised to benefit the patient indirectly. A systematic review was conducted to greater understand the impact of carer interventions on ED patient outcomes.

METHODS

Eight databases, including CINAHL, MEDLINE and PsychINFO, were systematically searched. Intervention studies for parent(s)/carer(s) of a patient with an ED were included, provided they reported outcomes for the patient. No publication date restrictions were set. Included studies were quality appraised.

RESULTS

Twenty-eight studies met inclusion for the review; all of which varied in intervention type, duration, content and setting. Patient diagnosis and treatment setting were mixed across studies, though the majority focused on Anorexia Nervosa within outpatient settings. Intervention content broadly included consideration of relationship issues and interactional patterns, psychoeducation, skill development, behavioural management, and peer support. Therapeutic models utilised were diverse, including but not limited to: family, interpersonal, cognitive, and psychodynamic approaches.

CONCLUSION

Several carer interventions showed positive outcomes for patients with EDs, with small group treatment formats being commonly used and proving effective through intervention content alongside a peer support element. Separate family therapy was suggested to be of equal efficacy, if not better, than family therapy alongside the patient. Recommendations for clinical practice and future research are considered.

LEVEL OF EVIDENCE: 1

Systematic review, evidence mostly obtained from randomised controlled trials.

Applying online parental guided self-help family-based treatment for adolescent anorexia nervosa: A comparison to family-based treatment delivered by videoconferencing

Guided self-help has become an important treatment option in the field of eating disorders as access to in person evidence-based treatments is limited. Given the scant amount of literature published on guided self-help for the treatment of eating disorders in the child and adolescent population, our aim was to describe online GSH-FBT sessions in detail as conducted as part of a larger feasibility study, examining quotations from therapists that illustrate the GSH-FBT stance and also describing how online GSH-FBT differs from FBT delivered by videoconferencing within a descriptive case report.

Is guided self-help family-based treatment for parents of adolescents with anorexia nervosa on treatment waitlists feasible? A pilot trial

OBJECTIVE

The aim of the study was to assess the feasibility (recruitment and retention) of an online 12-session guided self-help family-based treatment (GSH-FBT) for families on the waitlist for face-to-face FBT utilizing trainee psychologists to assist carers of children with anorexia nervosa (AN) or atypical AN.

METHOD

The primary outcomes were feasibility of GSH-FBT for families on the waitlist and secondary exploratory outcomes examined improvement of child and parental function.

RESULTS

Of 187 eligible families on the waitlist, 24 (13%) expressed interest in the study; 16 (67%) of these families completed baseline, 13 (54%) completed GSH-FBT over a 6-month recruitment period. Children (mean age = 13.92, SD = .86; mean body mass index [BMI] centile = 29.47, SD = 24.80) had an average weight gain of 6 kg (BMI centile effect size = 2.61, 95% CI: 1.77-3.44) and a decrease in eating disorder behaviors (effect size = 1.11, 95% CI: .27-1.95). Improvements also occurred for general mood and behaviors in the child, and the impact of eating disorder symptoms on their functioning. Parents reported improvements in knowledge, skills, and confidence in managing AN.

DISCUSSION

Use of this low-cost intervention while families are on the waitlist for FBT is engaging and useful but strategies to improve initial recruitment are needed.

PUBLIC SIGNIFICANCE STATEMENT

Although most eligible families did not enroll in an online 12-session guided self-help family-based treatment for families on the waitlist for face-to-face FBT for anorexia nervosa, families who participated found it engaging. The children experienced improvements in BMI centile, eating and behavior. Parents reported increased confidence, knowledge, and skills. We need to examine how families can be encouraged to participate on online training when on waitlists for treatment.

Eating disorder severity and psychological morbidity in adolescents with anorexia nervosa or atypical anorexia nervosa and premorbid overweight/obesity

PURPOSE

A significant proportion of adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) experience premorbid overweight/obesity, yet distinct characteristics among this subset of patients remain unclear. This study examined eating disorder (ED) symptom severity, psychological morbidity, and weight stigma in patients with premorbid overweight/obesity as compared to patients with premorbid normal weights.

METHODS

Participants included adolescents with AN or AAN (aged 12-18) who received multidisciplinary treatment at a pediatric medical center in the United States. ED symptoms, anxiety, and depression were compared among patients with premorbid overweight/obesity (n = 43) and premorbid normal weights (n = 63). Associations between weight stigma, ED severity, and psychological morbidity were also examined.

RESULTS

Patients with premorbid overweight/obesity reported greater ED severity (p = 0.04), anxiety (p < 0.003), depression (p = 0.02), and a higher frequency of weight-based teasing by peers (p = 0.003) and parent weight talk about their own weights (p < 0.001). Weight-based teasing was positively associated with ED symptoms, anxiety, and depression for all patients, regardless of premorbid weight status.

CONCLUSIONS

Adolescents with AN or AAN and a history of overweight/obesity may present with greater ED symptom severity and psychological morbidity than patients with normal weight histories. Distinct prevention and treatment interventions for adolescents with AN or AAN and premorbid overweight/obesity may be warranted.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Eating disorders during the COVID-19 pandemic and quarantine: an overview of risks and recommendations for treatment and early intervention

Individuals with eating disorders (EDs) are at significant risk for increases in symptomatology and diminished treatment access during the COVID-19 pandemic. Environmental precautions to limit coronavirus spread have affected food availability and access to healthy coping mechanisms, and have contributed to weight-stigmatizing social media messages that may be uniquely harmful to those experiencing EDs. Additionally, changes in socialization and routine, stress, and experiences of trauma that are being experienced globally may be particularly deleterious to ED risk and recovery. This paper presents a brief review of the pertinent literature related to the risk of EDs in the context of COVID-19 and offers suggestions for modifying intervention efforts to accommodate the unique challenges individuals with EDs and providers may be experiencing in light of the ongoing public health crisis.

Feasibility of conducting a randomized controlled trial comparing family-based treatment via videoconferencing and online guided self-help family-based treatment for adolescent anorexia nervosa

OBJECTIVE

This report describes the feasibility, acceptability, and outcomes from a pilot randomized clinical trial (RCT) comparing an online guided self-help program version of family-based treatment (GSH-FBT) for parents with a child with DSM-5 anorexia nervosa (AN) to FBT delivered via videoconferencing (FBT-V).

METHOD

Between August 2019 and October 2020, 40 adolescents ages 12-18 years with DSM-5 AN and their families were recruited at two sites and randomized to either twelve 20-min guided sessions of GSH-FBT for parents or fifteen 60-min sessions of FBT-V for the entire family. Recruitment, retention, and acceptability of treatment were the primary outcomes. Secondary outcomes were changes in weight, eating disorder examination (EDE), parental self-efficacy, weight remission, full remission, and outcome efficiency (therapist time needed to achieve treatment outcomes).

RESULTS

Descriptive data are reported. Recruitment and retention rates are similar to RCTs using in-person treatments. Both treatments received similar acceptability rates. Medium and large effect sizes (ES) related to improvements in weight, EDE, parental self-efficacy, and remission were achieved in both treatments and were maintained at a 3-month follow-up. Clinical outcomes between groups were associated with a small ES. Differences in efficiency (outcome/therapist time) were associated with a large ES difference favoring GSH-FBT.

DISCUSSION

These data support the feasibility of conducting an adequately powered RCT comparing online GSH-FBT to FBT-V to determine which approach is more efficient in achieving improvements in clinical outcomes in adolescents with AN.

The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond

OBJECTIVE

The COVID-19 pandemic has had detrimental effects on mental health. Literature on the impact on individuals with eating disorders is slowly emerging. While outpatient eating disorder services in Canada have attempted to transition to virtual care, guidelines related to optimal virtual care in this field are lacking. As such, the objective of our Canadian Consensus Panel was to develop clinical practice guidelines related to the provision of virtual care for children, adolescents, and emerging adults living with an eating disorder, as well as their caregivers, during the COVID-19 pandemic and beyond.

METHODS

Using scoping review methodology (with literature in databases from 2000 to 2020 and grey literature from 2010 to 2020), the Grading of Recommendations, Assessment, Development, and Evaluation system, the Appraisal of Guidelines, Research and Evaluation tool, and a panel of diverse stakeholders from across Canada, we developed high quality treatment guidelines that are focused on virtual interventions for children, adolescents, and emerging adults with eating disorders, and their caregivers.

RESULTS

Strong recommendations were supported specifically in favour of in-person medical evaluation when necessary for children, adolescents, and emerging adults, and that equity-seeking groups and marginalized youth should be provided equal access to treatment. For children and adolescents, weak recommendations were supported for telehealth family-based treatment (FBT) and online guided parental self-help FBT. For emerging adults, internet cognitive-behavioural therapy (CBT)-based guided self-help was strongly recommended. Weak recommendations for emerging adults included CBT-based group internet interventions as treatment adjuncts, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps as treatment adjuncts. For caregivers of children and adolescents, weak recommendations were supported for virtual parent meal support training, and moderated online caregiver forums and support groups. For caregivers of emerging adults, guided parental self-help CBT was strongly recommended, and unguided caregiver psychoeducation self-help was weakly recommended.

CONCLUSIONS

Several gaps for future work were identified including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents, and emerging adults with eating disorders, as well as research on more intensive services, such as virtual day hospitals.

Longer-term follow-up of college students screening positive for anorexia nervosa: psychopathology, help seeking, and barriers to treatment

The purpose of this study was to conduct a longer-term (i.e., 9-month) follow-up of students identified with possible anorexia nervosa (AN) as part of the Healthy Body Image Program, an online platform for screening and delivering tailored feedback and interventions, offered at 36 US universities. Participants were 61 individuals who screened positive for AN and who completed the follow-up. Regarding results, some indices of ED pathology and psychiatric comorbidity decreased over time, while others did not. Participants most commonly endorsed feeling ashamed, nervous, validated, and sad in response to receiving the referral. One-third (33%) reported already being in treatment at the time they received the referral, 26% initiated treatment since that time, and 41% did not initiate treatment. The most common reasons for seeking treatment were emotional distress, concern with eating, and health concerns. The strongest treatment barriers were believing one should be able to help themselves, believing the problem was not serious enough to warrant treatment, and not having time. Findings highlight the high level of pathology in students identified with possible AN, even nine months after they were first identified and provided resources, and the relatively low rates of treatment utilization given the seriousness of these illnesses.

Effectiveness and influencing factors of online education for caregivers of patients with eating disorders during COVID-19 pandemic in China

Objective

The goals were twofold: To estimate the depression and anxiety levels among caregivers of patients with eating disorders (ED) in China during the COVID‐19 pandemic when compared with a control group, and to assess whether an online education program was effective in decreasing the anxiety and depression of the caregivers of patients with ED, and associated factors.

Method

Caregivers of patients with ED (n = 254) and a comparison group of non‐ED caregivers (N = 254) were recruited at baseline. Additionally, caregivers of patients with ED were invited into a free 4‐week online education program, with an additional online group as support. Depression and anxiety levels were assessed at baseline and after the intervention.

Results

Caregivers of patients with ED showed significantly higher levels of depression and anxiety than the comparison group of non‐ED caregivers. The online education program showed no significant effect on decreasing depression and anxiety levels of caregivers of patients with ED overall. Caregivers who had older loved ones and not living with them were more likely to decrease their depression levels. Caregivers of patients with longer illness duration were less likely to decrease their anxiety levels.

Discussion

These results showed that caregivers of ED patients suffered more serious psychological distress during the pandemic. A more structured and intensive online intervention with a limited number of participants might be required to address caregivers' distress in post‐COVID‐19 China.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Use of Technology in the Assessment and Treatment of Eating Disorders in Youth

For countless young people, technology plays an essential role in their lives. However, its many advantages have not yet been widely applied to the treatment of youth with eating disorders. This article looks at how smartphone applications, Web conferencing, and other developments could widen the range of care available in a field where suitable support can be hard to find. Various barriers to treatment exist, such as cost, access, and the stigma attached to eating disorders, but existing and new technologies could overcome those obstacles, if clinicians are willing and able to meet the requirements associated with digitally enhanced treatment.

Task-sharing interventions for patients with anorexia nervosa or their carers: a systematic evaluation of the literature and meta-analysis of outcomes

The eating disorder clinical and scientific community advocates for the use of a shared approach to healthcare that actively involves patients and carers. A systematic review of the literature on guided self-help or self-help in anorexia nervosa (targeting either the individual affected by the illness or their carers) and meta-analyses of studies using randomised controlled designs for the evaluation of the outcomes: (1) drop-out from end-of-treatment assessment, (2) body mass index (BMI), (3) anxiety, (4) depression and (5) quality of life, were undertaken. Guided self-help was directed to patients in 15 studies and to carers in seven studies. The interventions were based on a variety of theoretical models, used different formats (books and digital materials), and were delivered by individuals with a range of experiences and expertise (e.g. individuals with lived experience of the illness, graduate students, or clinically trained professionals). Guided self-help was associated with significantly lower drop-out from the completion of end-of-treatment assessments compared to a control condition. There was an improvement in carers' wellbeing from skill-sharing interventions. Guided self-help may facilitate patients' treatment engagement and also improve carers' wellbeing.

Family-based Treatment of Eating Disorders: A Narrative Review

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood, indicating that individuals with EDs may benefit from early intervention. Family-based treatment is the leading treatment of youth with anorexia nervosa, with increasing evidence of its efficacy for youth with bulimia nervosa. This review describes the role of family engagement within family-based treatment of EDs, followed by a summary of current empirically supported, family-based ED interventions. It concludes with discussion of the ways in which family interventions are expanding and adapting to improve the breadth and scope of ED treatment in adolescence and young adulthood.

Family-based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders

OBJECTIVE

Family therapy has long been advocated as an effective intervention for eating disorders. A specific form of family therapy, one that utilizes family resources, has proven especially effective for adolescents with anorexia or bulimia nervosa (AN and BN). First developed in London, a behaviorally focused adaptation, called family-based treatment (FBT), has been manualized and systematically studied in six randomized clinical trials for adolescent AN and two for adolescent BN.

METHOD

This Commentary focuses on manualized FBT; what we know, what we do not know (yet), and what we hope for.

RESULTS

We do know that efficacy data for FBT, especially adolescent AN, are quite robust, even though remission rates remain elusive for more than half of all cases. While preliminary, moderators of FBT for adolescent AN have been identified and could aid us in determining the most (or least) responsive patient groups. And weight gain (∼2.5kg) by week four has been confirmed as an early predictor of remission at end-of-treatment. What we do not know, yet, is whether specific adaptations to manualized FBT will confer improved remission rates.

DISCUSSION

Finally, and in terms of what is hoped for, we highlight the promise of improved access, dissemination, and implementation of FBT.

Family therapy for eating disorders in youth: current confusions, advances, and new directions

PURPOSE OF REVIEW

Family interventions for eating disorders are often recommended for the treatment of children and adolescents. Treatment studies and a range of treatment guidelines now recommend family-based treatment (FBT) for adolescents with anorexia nervosa (AN) and bulimia nervosa. The current report focused on studies that have been conducted over the past 2 years, most of them aimed at augmenting or improving outcomes using a range of new family approaches or adding other forms of therapy to standard FBT.

RECENT FINDINGS

There is increasing confusion of what type of family therapy is supported by the evidence, including FBT, FT-AN, MFT-AN, and parent-focused therapy. Seventy-five percentages of the adolescents with anorexia nervosa studies in randomized clinical trials used manualized FBT. None of the other family therapy approaches have more than 16% of the total adolescents with anorexia nervosa studied. Thus, FBT is the only form of family therapy with a substantive evidence base. Augmentation by varying the format of family therapy may be clinically useful, but differences in outcome from standard FBT are minor.

SUMMARY

The evidence base supporting the use of family therapy for adolescent anorexia nervosa is for manualized FBT. Augmentations of FBT using different formats (e.g., parents only, family groups, addition of individual therapy) have not demonstrated substantially improved outcomes over standard FBT for anorexia nervosa.

Fiction-reading for good or ill: eating disorders, interpretation and the case for creative bibliotherapy research

Compared with self-help bibliotherapy, little is known about the efficacy of creative bibliotherapy or the mechanisms of its possible efficacy for eating disorders or any other mental health condition. It is clear, however, that fiction is widely used informally as a therapeutic or antitherapeutic tool and that it has considerable potential in both directions, with a possibly significant distinction between the effects of reading fiction about eating disorders (which may-contrary to theoretical predictions-be broadly negative in effect) or one's preferred genre of other fiction (which may be broadly positive). Research on creative bibliotherapy, especially systematic experimental research, is lacking and requires a medical humanities approach, drawing on knowledge and methods from psychology and cognitive literary studies as well as clinical disciplines to expand our understanding of how the dynamic processes of interpretation mediate between textual structures and characteristics of mental health and illness.

Utilizing Telehealth to deliver family-based treatment for adolescent anorexia nervosa

OBJECTIVE

The purpose of this study was to test the feasibility and preliminary effect size on the main outcome measure (weight gain) of family-based treatment (FBT) for adolescents with anorexia nervosa (AN) and their families delivered via a Telehealth platform (i.e., an HIPAA compliant videoconferencing format).

METHOD

Ten adolescents, mean age of 16.08 years (SD = 1.99), meeting DSM-5 criteria for AN or atypical AN, were enrolled in the study and offered FBT via a Telehealth platform. Feasibility and acceptability were evaluated by rates of recruitment and retention. Treatment outcome was determined utilizing percent median body mass index (%mBMI), the eating disorder examination (EDE), and measures for depression and self-esteem.

RESULTS

Recruitment target was achieved within allotted time, and all participants were retained for the course of treatment. Percent mBMI improved significantly from baseline to the end-of-treatment (p = .013) and from baseline to the 6-month follow-up (p = .032). Similar results were achieved for the EDE Global Score (p = .002 and .001, respectively).

DISCUSSION

These findings provide preliminary evidence that it is feasible to deliver FBT via Telehealth and that satisfactory clinical outcomes are achievable.