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

Emotion coaching skills as an augmentation to family-based therapy for adolescents with anorexia nervosa: A pilot effectiveness study with families with high expressed emotion

OBJECTIVE

To examine the feasibility and acceptability of augmenting family-based treatment (FBT) for adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) with a parent emotion coaching intervention (EC) focused on reducing parent expressed emotion.

METHOD

In this pilot effectiveness trial, families of adolescents with AN/AAN exhibiting high expressed emotion received standard FBT with either (1) EC group or (2) support group (an attention control condition focused on psychoeducation).

RESULTS

Forty-one adolescents with AN or AAN were recruited (88% female, Mage  = 14.9 ± 1.6 years, 95% White: Non-Hispanic, 1% White: Hispanic, 1% Bi-racial: Asian). Most study adolescents were diagnosed with AN (59%) while 41% were diagnosed with AAN. Participating parents were predominantly mothers (95%). Recruitment and retention rates were moderately high (76% and 71%, respectively). High acceptability and feasibility ratings were obtained from parents and interventionists with 100% reporting the EC intervention was "beneficial"-"very beneficial." The FBT + EC group demonstrated higher parental warmth scores at post-treatment compared to the control group (standardized effect size difference, d = 1.58), which was maintained at 3-month follow-up. Finally, at post-treatment, the FBT + EC group demonstrated higher rates of full remission from AN/AAN (40%) compared to FBT + support (27%), and were nine times more likely to be weight restored by 3-month follow-up.

DISCUSSION

Augmenting FBT with emotion coaching for parents with high expressed emotion is acceptable, feasible, and demonstrates preliminary effectiveness.

PUBLIC SIGNIFICANCE

Family based treatment for AN/AAN is the recommended treatment for youth but families with high criticism/low warmth are less likely to respond to this treatment. Adding a parent emotion coaching group (EC) where parents learn to talk to their adolescents about tough emotions is feasible and well-liked by families.

Adapting Behavioral Treatments for Primary Care Using a Theory-Based Framework: The Case of Adolescent Eating Disorders

Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs.

Traditional versus virtual partial hospital programme for eating disorders: Feasibility and preliminary comparison of effects

OBJECTIVE

Minimal research has examined teletherapy for group or intensive eating disorder (ED) treatment, particularly partial hospital programme (PHP). This study compared treatment outcomes for individuals treated before and after a pandemic-driven implementation of virtual PHP.

METHOD

Patients received care at ED treatment centres using the Renfrew Unified Treatment for Eating Disorders and Comorbidity. Patients treated with virtual PHP were compared to patients treated with traditional PHP. Measures of ED symptomology and behaviours, depressive symptoms, anxiety severity, anxiety sensitivity, experiential avoidance, mindfulness, and body mass index (BMI; reported for anorexia nervosa [AN] patients only) were collected at intake and discharge. Multiple regression analyses were conducted to examine the effect of treatment group on outcomes, controlling for intake score, comorbidity, discharge status, AN diagnosis, and step-down status.

RESULTS

Differences in treatment type were only found for binge eating frequency, with those in virtual PHP reporting significantly lower binge eating episodes at discharge than those in traditional PHP. Body mass index showed significantly less improvement in virtual PHP than in traditional PHP.

CONCLUSIONS

Preliminary results suggest virtual PHP is feasible and effective, potentially increasing access to evidence-based, intensive ED treatment. However, additional research is needed to establish efficacious support for weight gain among individuals with AN in virtual programs.

A Randomized Clinical Trial of Technology-Enhanced Family-Focused Therapy for Youth in the Early Stages of Mood Disorders

Objective

Family-focused therapy (FFT) is associated with enhanced outcomes in youth with bipolar and depressive disorders, but has not been evaluated in conjunction with mobile health tools. In symptomatic adolescents whose parents had histories of mood disorders, we examined whether the effects of telehealth-based FFT were augmented by mobile health apps that emphasized mood tracking and family coping skills.

Method

Participants (aged 13-19 years) had active mood symptoms and a parent with major depressive or bipolar disorder. Participants received 12 sessions in 18 weeks of telehealth FFT, with random assignment to (1) a mobile app (MyCoachConnect, MCC) that enabled mood tracking, reviews of session content, and text reminders to practice mood management and family communication skills (FFT-MCC); or (2) a mobile app that enabled mood tracking only (FFT-Track). Independent evaluators assessed youth every 9 weeks over 6 months on depressive symptoms (primary outcome), anxiety, and psychosocial functioning.

Results

Participants (N = 65; mean age 15.8 ± 1.6 years) significantly improved in depressive symptoms over 6 months (F1,170 = 45.02, p < .0001; ή2 = 0.21, 95% CI = 0.11-0.31), but there were no effects of treatment condition or treatment by time interactions on depression scores. When secondary outcome measures were considered, the subgroup of youth with bipolar spectrum disorders showed greater improvements in anxiety and global functioning in FFT-MCC compared with FFT-Track.

Conclusion

Youth in the early stages of mood disorder may benefit from FFT enhanced by mobile health apps. Collaborations between researchers and information technologists on mobile app design and user experience may lead to increases in engagement among adolescents.

Clinical trial registration information

Technology Enhanced Family Treatment; https://clinicaltrials.gov/; NCT03913013.

Do People Want the 'New Normal'? A Mixed Method Investigation of Young Person, Parent, and Clinician Experience and Preferences for Eating Disorder Treatment Delivery in the Post-COVID-19 World

Eating disorder treatment was predominantly provided online during the COVID-19 pandemic, which has continued into the post-pandemic world. This mixed method study explored young person, parent/caregiver, and clinician experiences of child and adolescent eating disorder treatment. In total, 90 participants (25 young people, 49 parents/caregivers, and 16 clinicians) completed online surveys about the experience of online working. Data were compared to similar data collected by the same service earlier in the pandemic. The results show that preferences are largely unchanged since 2020; online treatment is considered helpful and acceptable by all groups. Nevertheless, face-to-face assessment sessions (young people: 52.2%; and parents/caregivers: 68.9%) and final sessions (young people: 82.6%; and parents/caregivers: 82.2%) were preferred compared to online. There was also a preference for early treatment sessions to either be always or mostly face-to-face (young people: 65.2%; and parents/caregivers: 73.3%). The middle and latter parts of treatment were a time when preferences shifted slightly to a more hybrid mode of delivery. Participants reported finding engagement with the therapist (young people: 70.6%; and parents/caregivers: 52.5%) easier during face-to-face treatment. Stepping away from the binary of online or face-to-face, the current data suggest that a hybrid and flexible model is a way forward with current findings providing insights into how to structure this.

Adapting family-based treatment for adolescent anorexia nervosa delivered in the home: A novel approach for improving access to care and generalizability of skill acquisition

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness associated with high rates of morbidity and mortality. Family-based treatment (FBT) is a well-established treatment for adolescent AN, yet it is underutilized in community settings and is unavailable to many families, particularly those from lower income and racial and ethnic minority backgrounds. Furthermore, some families do not respond optimally to FBT, possibly because of challenges translating skills acquired in office-based treatment settings to naturalistic settings. Home-based treatment could reduce barriers to access and enhance generalization of newly learned treatment skills. Home-based models demonstrate initial feasibility, acceptability, and efficacy for adolescent AN, however, FBT principles have yet to be applied as a stand-alone intervention in a home-based level of care. This paper describes the rationale for and process of adapting FBT principles/interventions to improve fit within a home-based model delivered in the context of community mental health, and discusses potential strengths and opportunities associated with this approach.

RESULTS

Adaptations were made through consultation with collaborating community agencies and were guided by the complex interventions framework. The primary modifications included: (1) altered dose; (2) multiple family meals; (3) additional support for meal preparation and supervision; (4) clinician attendance at medical appointments; (5) cultural adaptation; and (6) introduction of distress tolerance and emotion regulation skills.

CONCLUSIONS

Implementing FBT in the home may present one promising and novel approach to enhance engagement and treatment outcomes for adolescents with restrictive eating disorders, particularly those who are underserved, but evaluation of efficacy/effectiveness is needed.

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.

The Help-Seeking Experiences of Family and Friends Who Support Young People With Mental Health Issues: A Qualitative Study

Little has been documented of the journey that family and friends (F&F) undertake when supporting a young person aged 12-25 years struggling with mental illness. The experiences of family and friends were explored using an online qualitative survey (N = 58) and semi-structured interviews (n = 15). Recruitment was through a national youth mental health service Facebook page and website. An experiential thematic analysis was conducted focusing on participants' experiences and sense of their world.Strong feelings and challenging life circumstances made the context of help-seeking complicated. Despite following usual avenues for advice or support, F&F still came across professionals and a health/mental health system that compounded their distress. It was the simpler things that some professionals did that made their journey more bearable. Useful insights derived from the narratives allow service improvement recommendations such as reminding professionals of the multiplicity of stressors commonplace to families and the value of validation and acknowledgement.

Digitally Delivered Dietary Interventions for Patients with Eating Disorders Undergoing Family-Based Treatment: Protocol for a Randomized Feasibility Trial

BACKGROUND

Eating disorders (EDs) affect 9% of the United States population, and anorexia nervosa (AN), specifically, has the second highest mortality rate of all psychiatric disorders. Yet, only 20% are able to access treatment. Access to care issues include long waitlists, lack of trained specialists, financial, and geographic barriers, all of which highlight the need for effective telehealth interventions. Family-based therapy (FBT) is a first-line treatment for adolescents and young adults with EDs, and weight gain early in treatment is considered a primary predictor of success with FBT. However, nutrition requirements for patients with EDs are uniquely complex. A variety of dietary interventions for guiding the renourishment process are used in practice, but empirical data on the effectiveness and acceptability of the various interventions are sparse. The significance of nutritional restoration and issues with access to first-line treatments underscore the need for further research exploring virtually delivered dietary interventions.

OBJECTIVE

Our objective is to compare the effectiveness and acceptability of 2 digitally delivered dietary interventions frequently used in eating disorder treatment settings: (1) calorie-based meal plans and (2) the Plate-by-Plate approach. Specifically, we will explore any potential differences in weight restoration achieved over 8 weeks of treatment as a primary measure of effectiveness, as well as additional treatment outcomes (ED symptoms, anxiety, depression, caregiver burden, and perceived effectiveness and acceptability for both caregivers and clinicians).

METHODS

Patients (N=100) with either AN or avoidant restrictive food intake disorders (ARFID) aged 6-24 years seeking treatment at a nationwide virtual eating disorder treatment program, were enrolled between May and August 2022. Upon admission, patients were randomly assigned to receive either the calorie-based intervention or Plate-by-Plate approach from their registered dietitian, all of whom have received training as study interventionists. While we were primarily interested in responses during the first 8 weeks of treatment, patients will be followed for up to 12 months. Descriptive statistics were used to describe patient characteristics and demographics. Weight changes and other treatment outcomes between groups will be compared using generalized linear models. Semistructured caregiver and clinician interview transcripts will undergo qualitative analysis.

RESULTS

Enrollment ran from March to August 2022, and we anticipate completion of data collection by November 2022. Analyses will be completed in January 2023.

CONCLUSIONS

This study contributes to existing FBT literature by thoroughly exploring the acceptability of dietary interventions and their influence on weight restoration, an area in which research is sparse.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41837.

Paediatric eating disorders: Exploring virtual family therapy during a global pandemic

AIM

Explore treatment response and effectiveness of virtual treatment for a paediatric eating disorder sample.

METHODS

Twenty patients and their families who received either virtual or in-person family therapy were included in the study. Family therapy was informed by family-based treatment (FBT) principles. Patients' weight restoration at 1, 3, and 6 months after starting treatment was examined. Independent sample t tests assessed group differences and a Fisher exact test was used to evaluate the association between treatment group and weight restoration.

RESULTS

Weight restoration did not significantly differ between treatment groups (virtual vs. in-person) at any time point and there was no association between group and remission weight at 6 months.

CONCLUSIONS

Study results are considered exploratory. Future research addressing study limitations is needed. Results suggest that paediatric eating disorder patients may benefit from family therapy delivered via a virtual platform.

Adolescent eating disorder treatment outcomes of an in-person partial hospital program versus a virtual intensive outpatient program

OBJECTIVE

Though virtual outpatient psychotherapy for eating disorders is likely effective, less is known about virtual higher levels of care. The current study examined the clinical outcomes of a family-based virtual intensive outpatient program (vIOP) for youth with eating disorders which was developed in response to the COVID-19 pandemic, compared to the same institution's in-person partial hospital program (PHP).

METHODS

Treatment outcomes were assessed via chart review in 102 patients between the ages of 9-23 (M = 15.2, SD = 2.5) who were predominantly cisgender female (84.3%) and primarily diagnosed with anorexia nervosa (64.7%) or atypical anorexia (23.5%). Participants were either treated in the in-person PHP before the pandemic (n = 49) or the vIOP during the pandemic (n = 53). Percent expected body weight (%EBW) was examined at baseline, end of treatment, 3-months post-treatment, and 6-months post-treatment, as well as the frequency of medical, psychiatric, and residential admissions before, during, and after vIOP or PHP participation.

RESULTS

Linear mixed models demonstrated no effect of treatment modality (in-person versus virtual) on %EBW over time. The duration of the vIOP was, on average, 12 calendar days longer, though the amount billed for the vIOP was lower. Survival analyses and Cox regression models did not suggest differences in the frequency of hospital and residential treatment admissions during treatment (vIOP: 9.4%, PHP: 10.0%) or post-treatment (vIOP: 15.0%, PHP: 10.2%).

DISCUSSION

Findings support virtual family-based programs as suitable alternatives to in-person treatment and underscore the potential cost-effectiveness of a family-based IOP versus PHP.

PUBLIC SIGNIFICANCE

This study demonstrates that a virtual, family-based, intensive outpatient program for youth with eating disorders had similar treatment outcomes to an in-person partial hospitalization program. Specifically, the virtual and in-person programs had similar weight restoration outcomes and rates of medical, psychiatric, or residential treatment admissions during or after treatment initiation. Findings support the use of virtual treatment, even for youth requiring a high level of intervention.

Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth

Barriers limit access to eating disorder treatment. Evidence-based treatment delivered using telemedicine could expand access. This study determined the effectiveness of enhanced Family-Based Treatment (FBT+) delivered using telemedicine for children and adolescents with eating disorders. Participants had a confirmed eating disorder diagnosis, lived in states where treatment was available, and lived with a family member willing to participate. Virtual FBT+ was administered by a five-person team including a therapist, dietitian, medical provider, peer mentor, and family mentor for up to 12 months. Measures were recorded at baseline and varying frequencies throughout treatment. Weight was self-reported. Eating disorder symptoms were assessed with the Eating Disorder Examination-Questionnaire Short Form (EDE-QS) and depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Caregiver burden and self-efficacy were measured using the Burden Assessment Scale, and Parent Versus Eating Disorder scale. The majority of patients (N = 210; 6 to 24 years old [mean 16 · 1 years]) were cisgender female (83%) White, (71%), required weight restoration (78%), and had anorexia nervosa, restricting type (63%). After 16 weeks, patients on weight restoration gained on average 11 · 3 [9 · 86, 12 · 8] pounds and the average change in EDE-QS score was -6 · 31 [-8 · 67, -4 · 10] points. Similar reductions were seen for depression (-2 · 62 [-4 · 24, -1 · 04]), anxiety (-1 · 44 [-1 · 12, 0 · 78]), and caregiver burden (-4 · 41 [2 · 45, 6 · 31]). Caregiver self-efficacy increased by 4 · 56 [3 · 53, 5 · 61] points. Patients and caregivers reported satisfaction with treatment. Virtual FBT+ for eating disorders can transcend geographical and psychosocial treatment barriers, expanding access to evidence-based eating disorder treatment.

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.

The use of technology in the treatment of youth with eating disorders: A scoping review

BACKGROUND

Adolescence and young adulthood is a high-risk period for the development of eating disorders. In recent years, there has been an increase in use of technology-based interventions (TBIs) for the treatment of eating disorders. The objective of this study was to determine the types of technology used for eating disorder treatment in youth and their effectiveness.

METHODS

A scoping review was conducted according to PRISMA-ScR guidelines. Four databases were searched. Eligible articles included: (1) a TBI (2) participants with a mean age between 10- and 25-years and meeting DSM-IV or DSM-5 criteria for any eating disorder and (3) qualitative or quantitative designs. Quantitative and qualitative studies were assessed for quality.

RESULTS

The search identified 1621 articles. After screening of titles and abstracts, 130 articles were read in full and assessed for eligibility by two raters. Forty-nine (29 quantitative and 20 qualitative, observational, or mixed methods studies) met inclusion criteria. Quality ratings indicated that 78% of quantitative studies had a low risk of bias and 22% had a moderate risk. Technologies reviewed in our study included videoconference therapy, mobile applications, and online self-help. We considered interventions used both within sessions with clinicians as well as those used in between sessions by patients alone. Fifteen of 18 (83%) quantitative studies found that TBIs reduce eating disorder symptomatology, with nine of those reporting medium-to-large effect sizes. Qualitative data was of high quality and suggested that virtual interventions are acceptable in this population.

CONCLUSIONS

Although identified studies are of high quality, they are limited in number. More research is needed, particularly regarding videoconferencing and mobile applications. Nonetheless, TBIs show promise for the treatment of eating disorders in youth.

TRIAL REGISTRATION

Not applicable.

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.

Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

A qualitative evaluation of team and family perceptions of family-based treatment delivered by videoconferencing (FBT-V) for adolescent Anorexia Nervosa during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, outpatient eating disorder care, including Family-Based Treatment (FBT), rapidly transitioned from in-person to virtual delivery in many programs. This paper reports on the experiences of teams and families with FBT delivered by videoconferencing (FBT-V) who were part of a larger implementation study.

METHODS

Four pediatric eating disorder programs in Ontario, Canada, including their therapists (n = 8), medical practitioners (n = 4), administrators (n = 6), and families (n = 5), participated in our study. We provided FBT-V training and delivered clinical consultation. Therapists recorded and submitted their first four FBT-V sessions. Focus groups were conducted with teams and families at each site after the first four FBT-V sessions. Focus group transcripts were transcribed verbatim and key concepts were identified through line-by-line reading and categorizing of the text. All transcripts were double-coded. Focus group data were analyzed using directed and summative qualitative content analysis.

RESULTS

Analysis of focus group data from teams and families revealed four overarching categories-pros of FBT-V, cons of FBT-V, FBT-V process, and suggestions for enhancing and improving FBT-V. Pros included being able to treat more patients and developing a better understanding of family dynamics by being virtually invited into the family's home (identified by teams), as well as convenience and comfort (identified by families). Both teams and families recognized technical difficulties as a potential con of FBT-V, yet teams also commented on distractions in family homes as a con, while families expressed difficulties in developing therapeutic rapport. Regarding FBT-V process, teams and families discussed the importance and challenge of patient weighing at home. In terms of suggestions for improvement, teams proposed assessing a family's suitability or motivation for FBT-V to ensure it would be appropriate, while families strongly suggested implementing hybrid models of FBT in the future which would include some in-person and some virtual sessions.

CONCLUSION

Team and family perceptions of FBT-V were generally positive, indicating acceptability and feasibility of this treatment. Suggestions for improved FBT-V practices were made by both groups, and require future investigation, such as examining hybrid models of FBT that involve in-person and virtual elements. Trial registration ClinicalTrials.gov NCT04678843 .

Effects of the COVID-19 Restrictions on Eating Behaviour and Eating Disorder Symptomology in Female Adolescents

Confinement due to the COVID-19 pandemic imposes a burden on adolescents worldwide and may seriously impact patients with an eating disorder (ED). The current FRanconian Anorexia Nervosa during COVID-19 (FRANCO) study explored (1) perceived change of depressive and ED symptomology during lockdown, (2) the role of social media, and (3) coping strategies of anorexia nervosa (AN) patients and clinical as well as healthy comparison groups. From June 2021 to September 2021, 222 female adolescents (19 with AN, 20 with depression, 45 with a self-reported psychiatric disorder (SRPD), and 138 controls) aged 11.2 to 18.9 years completed a one-time anonymous survey retrospectively reporting back on ED and depressive symptomology before and during the pandemic, the impact of social media, and coping strategies. A reduced quality of life (QoL) due to confinement was observed in almost half of female adolescents. All groups reported a significant perceived increase of disordered eating, overeating, anxiety, and depressive symptoms and emotion-regulation problems. In AN patients, significantly higher percentual deterioration of disordered eating and anxiety and depressive symptoms was found. For controls, a younger age and higher susceptibility of the sociocultural body image significantly correlated with increased disordered eating. Large-scale media literacy interventions are recommended.

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.

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.

Higher admission and rapid readmission rates among medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa during COVID-19

The COVID-19 pandemic has had sweeping and deleterious effects on the well-being of individuals worldwide. Eating disorders (EDs) are no exception, with incidence and prevalence of EDs rising since COVID-19 onset. The current study examined inpatient census and readmission rates among youth (aged 8-18) hospitalized for medical complications of anorexia nervosa (AN) or atypical anorexia nervosa (AAN) throughout distinct periods of the COVID-19 pandemic, including pre-COVID-19 (n = 136), COVID-19 lockdown (n = 3), and post COVID-19 lockdown (n = 24). Data from the COVID-19 lockdown period was excluded from analyses due to low sample size. Youth hospitalized during post COVID-19 lockdown were over 8-times more likely to be readmitted within 30-days of discharge compared to patients hospitalized before the pandemic (p = .002). Further, the inpatient census of youth with AN/AAN was significantly higher during post COVID-19 lockdown compared to pre-COVID-19 (p = .04). One-third of patients hospitalized since the pandemic identified COVID-19 consequences as a primary correlate of their ED. Our findings, although not causal, suggest an association between COVID-19 and AN/AAN development and exacerbation in youth, thus prompting more medical admissions and rapid readmissions among this demographic. This study has important implications for understanding how AN/AAN onset and exacerbation in youth has been affected by the COVID-19 pandemic and can inform new efforts to support individuals navigating treatment during a global crisis.

Use of Telehealth Amid the COVID-19 Pandemic: Experiences of Mental Health Providers Serving Rural Youth and Elderly in Pennsylvania

Stay-at-home orders and public health safety concerns precipitated by the COVID-19 pandemic facilitated rapid changes in policy and reimbursement regulations and resulted in the sudden uptake of telehealth in mental health practices across the United States. This study explored how mental health service providers experienced the use of telehealth in serving their rural clients who are youth and older adults. A purposive sampling strategy was employed to identify and recruit mental health service providers and insurance agency representatives for this study. By means of online focus groups, this statewide study explored the experiences of 147 mental health and public insurance providers using telehealth to serve rural youth and elderly in Pennsylvania amid the pandemic in 2020. NVivo 12 qualitative analysis software was used in data analysis. The findings suggest that telehealth is perceived as both: silver linings during the pandemic (service continuation during the pandemic, improved parental involvement and responsiveness, easing the transportation challenges, and decrease in no-show rates) and some roadblocks to success (Not for every youth!, Technology challenges among the older adults, and “Dead zones” without internet and cellphone reception). Policy and practice recommendations are suggested including incentives for proactive telehealth uptake, telehealth parity laws and reimbursement policies, and incentivizing innovative use of technology for specific populations and therapeutic modalities. Continuous policy support and organizational efforts to provide customized telemental health are called for to remediate rural disparities in access to mental health services beyond the pandemic period.

Evaluation of the Effects of Telepsychotherapy in the Treatment and Prevention of Eating Disorders in Adolescents

According to the WHO definition, "telemedicine is the provision of health services, where distance is a critical factor, by all health professionals who use information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of diseases, research and evaluation, and for the continuous training of health professionals, all in the interest of advancing the health of individuals and their communities". The purpose of our review work is specifically to investigate the effects of telemedicine in the treatment and prevention of eating disorders in adolescents. From June 2021 to (September 2021) in the databases of the Web of Science, EMBASE, PsycINFO and CINHAL, using search terms such as telehealth, eating disorder, adolescents, Internet/online treatments CBT and FB-T, anorexia nervosa, bulimia nervosa and binge eating disorder. The articles resulting from the search phases in the databases listed above produced a total of 176 items. Once the procedures for selecting the works were completed, only four studies were included in the review. Modern e-health psychological approaches in the treatment of eating disorders provide potential bases of continuous assistance that are decidedly less burdensome in the costs of territorial services in the case that they are not identified as necessary.

Perspectives on Telemedicine from a National Study of Youth in the United States

Introduction: Telemedicine is increasingly popular with the recent surge in use due to the COVID-19 pandemic. Despite youth status as "tech natives," limited data are available on their perspectives on telemedicine. Our study seeks to understand youth telemedicine knowledge, prior experiences, preferences for use, and the impact of COVID-19 on these perspectives. Methods: Participants in MyVoice, a national text message cohort of U.S. youth age 14-24, were sent five open-ended questions in October 2019 and October 2020. A codebook was iteratively developed by using inductive analysis. Responses were independently coded by two investigators, with discrepancies resolved by discussion or a third investigator. Results: Sixty-five percent (836/1,283) and 77% (887/1,129) of participants responded to at least 1 question in 2019 and 2020, respectively. Most youth reported awareness of telemedicine and although many have not used it, COVID-19 has increased use. Further, many are willing to try telemedicine services. Most youth noted a preference for video rather than phone visits, but they believe both to be less effective than in person. Youth also reported varied preferences on services best suited for telemedicine, with COVID-19 positively impacting their views. Discussion: Youth are aware of and willing to use telemedicine services, with many reporting use during the COVID-19 pandemic. Youth are willing to accept a wide variety of telemedicine services, though they still desire in-person options. Health systems and clinics should offer a wide range of services via telemedicine to fit the varying needs of youth both during and after the COVID-19 pandemic.

Is this the 'new normal'? A mixed method investigation of young person, parent and clinician experience of online eating disorder treatment during the COVID-19 pandemic

INTRODUCTION

Prior to the COVID-19 pandemic, research in virtual care for young people with eating disorders was preliminary and implementation rare. This study explored the experience of young people, parents and clinicians when therapy was transitioned to virtual provision as a result of the UK lockdown in March 2020.

METHODS

A mixed-method approach was used in this study. Online questionnaires that included a mixture of rating (Likert scale) and free-text response questions were completed by 53 young people with any eating disorder, 75 parents and 23 clinicians. Questions focused on the experience of online treatment as well as the impact on engagement, perceived treatment efficacy and preferences around treatment mode in the future. Likert scale questions were analysed using a summary approach. Free-text responses were analysed qualitatively using reflexive thematic analysis.

RESULTS

Responses to rating scale questions indicate satisfaction with treatment, good engagement and ability to manage technology. Young people who had transitioned care, rather than started care virtually in lockdown, rated therapy as less effective. However, individual accounts of experience were more varied. Reflexive thematic analysis of free-text responses identified key themes of 1) Making it work, 2) Home as a therapeutic space, and 3) Disrupted connection and 4) Into the future.

CONCLUSIONS

These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and therapeutic engagement and depth and need for consideration of equal access to treatment in socially unequal societies.

Access to care and worsening eating disorder symptomatology in youth during the COVID-19 pandemic

BACKGROUND

Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors.

METHODS

AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, and completed a COVID-19-specific survey (n = 89). We examined bivariate associations of four markers of care: i) access to care, ii) changes in care, iii) perceived disruption to care, and iv) quality of care. Using multiple logistic regression, we examined the associations of pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n = 16).

RESULTS

In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing care with at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly one-third (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were significantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching significance (p = 0.07).

CONCLUSIONS

Our findings show the majority of AYA who had care prior to the pandemic continued receiving some element of their multi-disciplinary ED treatment and perceived their care as high quality. None of the markers of care described were statistically associated with increased ED thoughts and behaviors.

Virtually delivered family-based eating disorder treatment using an enhanced multidisciplinary care team: A case study

Both patients experienced meaningful clinical improvements with this virtual approach and the augmented treatment team in regards to weight gain, acceptability, and clinical assessment scores. These findings offer preliminary support for this model.

Anorexia nervosa: COVID-19 pandemic period (Review)

Anorexia nervosa is an eating disorder characterized by restrictive eating and an intense fear of gaining weight. It is a disease with an increasing incidence during the last few decades, and represents a complex psychiatric condition which includes secondary amenorrhea, nutritional and metabolic damage, and impaired endocrine panel up to bone loss as well as cardiac, gastrointestinal and hematological complications. This is a narrative review which includes an update on this eating disorder from the perspective of an endocrine panel of anomalies, especially of the skeleton, considering the pressure of the recent global COVID-19 pandemic changes. Practically affecting every organ, anorexia nervosa needs to be taken into consideration during the pandemic period because of the higher risk of relapse due to new living conditions, social distancing, self-isolation, changes in food access, more intense use of social media platforms, disruption of daily habits, and more difficult access to healthcare practitioners. The lack of physical activity in addition to vitamin D deficiency related to low sun exposure or to the use of facial masks may also be connected to further bone damage related to this disease.

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.

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.

"It's splendid once you grow into it:" Client experiences of relational teletherapy in the era of COVID-19

The novel Coronavirus pandemic (COVID-19) and subsequent social distancing practices have altered the way we move through the world and access physical and mental healthcare. While researchers and clinicians have begun to explore the impact of telehealth delivery on psychotherapy and treatment outcomes, the purpose of this study was to explore the lived experiences of individuals in teletherapy, specifically those engaging in teletherapy with a romantic partner or family member. Using a thematic analysis of open-ended online survey questions, we explored the experiences of 25 individuals who engaged in couple or family teletherapy after social distancing began. The resulting themes included "making do," safe therapeutic space, convenience, logistical challenges, and therapist accommodation. We discuss the clinical implications of these themes to support effective couple and family teletherapy and offer suggestions and considerations for remote clinical interventions and practices. [Correction added on 22 March 2021, after first online publication: The term '19' has been changed to '(COVID-19)' in the first line of the Abstract section, in this version.].

The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family based treatment for adolescents with anorexia nervosa

BACKGROUND

Adolescents with anorexia nervosa have set-shifting inefficiencies that can be exacerbated by starvation and that may interfere with outcomes of treatment interventions. Cognitive Remediation Therapy (CRT), an adjunctive treatment focused on improving set-shifting, can target inefficiencies and may augment treatment effectiveness. The best way to add CRT to the standard of care (Family Based Treatment, FBT) for adolescents with anorexia remains understudied.

METHODS/DESIGN

This is a randomized controlled trial designed to determine if CRT is effective in increasing flexibility in adolescents with anorexia and/or their parents. Participants are adolescents 12-18 years old with anorexia and their parents. 54 family groups will be randomized into one of three groups: FBT only, FBT plus Parent-focused CRT, or FBT plus Adolescent-focused CRT. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study.

DISCUSSION

This is the first study of its kind to apply CRT to parents. All forms of CRT in the context of anorexia have targeted the individual with anorexia's thinking style. We propose that it may be impactful to target the parent of the adolescent with anorexia as parents carry the burden of treatment and re-nourishment of their child during FBT and may have similar thinking styles.

CONCLUSION

This study takes an experimental therapeutics approach to further our understanding of the mechanisms of treatment for adolescents with anorexia. It focuses on increasing cognitive flexibility in patients or their parents and determining the appropriate dose of CRT needed to achieve positive change.

TRIAL REGISTRATION

ClinicalTrails.gov Identifier NCT03928028.

Systemic teletherapists' meaningful experiences during the first months of the coronavirus pandemic

Fifty-five clinicians who provided teletherapy to couples, partnerships, families, and kin networks during the first two months of the coronavirus pandemic responded to a survey about their most and least meaningful experiences. Reflexive thematic analysis indicated that the participants experienced adjustments to their schedule or routines, they used technology glitches to promote client growth, and they altered how they engaged clients. Participants noted shifts in their personal and relational dynamics. They reported feeling fatigued and resilient. Participants described their adaptability, gratitude, digital and relational connectivity, and an ability to reframe negative experiences into opportunities for growth.

Videoconferencing psychotherapy for couples and families: A systematic review

The delivery of videoconferencing psychotherapy (VCP) has been found to be an efficacious, acceptable and feasible treatment modality for individual therapy. However, less is known about the use of VCP for couple and family therapy (CFT). The focus of this systematic review was to examine the efficacy, feasibility and acceptability of using VCP as a treatment delivery modality for CFT. A systematic search was conducted, data relating to efficacy, feasibility and acceptability were extracted from included studies. The search returned 7,112 abstracts, with 37 papers (0.005%) included. The methods of the review were pre-registered (PROSPERO; CRD42018106137). VCP for CFT was demonstrated to be feasible and acceptable. A meta-analysis was not conducted; however, results from the included studies indicate that VCP is an efficacious delivery method for CFT. Recommendations for future research and implications regarding clinical practice are made, which may be of interest to practitioners given the COVID-19 pandemic.

Acceptability of Telehealth for Gender-Affirming Care in Transgender and Gender Diverse Youth and Their Caregivers

Gender-affirming care (GAC) is critical to the well-being of transgender and gender diverse youth and was limited by COVID-19 stay-at-home orders. Telehealth created opportunities for youth to continue receiving lifesaving care. We examined the attitudes of patients (n=21) and caregivers (n=38) receiving telehealth-delivered GAC (TGAC) from May to July 2020. Participants completed surveys after telehealth visits. Descriptive statistics compared telehealth with in-person visits across key domains. Overall, 86.5% of patients and 95.4% of caregivers were satisfied with medical TGAC and 94.3% and 93.3% were satisfied with behavioral health TGAC. Future research should determine the effectiveness of TGAC and identify areas for improvement.

Exploring the Efficacy of Telehealth for Family Therapy Through Systematic, Meta-analytic, and Qualitative Evidence

There is a current escalating need for telehealth (TH) options in family mental health services. In the absence of replicated evidence, TH guidelines from peak bodies are largely based on assumptions of the effectiveness of TH methods. New investments in TH would optimally be based in evidence of clinical efficacy. To this end, we conducted three studies in which we (1) systematically reviewed eight professional guidelines for TH family therapy, (2) examined replicated evidence for the efficacy of TH family therapy through systematic review of 20 studies and meta-analyses of 13 effects, and (3) synthesised clinical accommodations to TH methodology from a study of 12 experienced TH family therapists. The studies found (1) a predominant focus in existing TH guidelines on operational matters pertaining to TH and relative neglect of therapeutic process; (2) meta-analyses of efficacy for child behavioural problems (k = 8) and parental depression (k = 5) showed equivalent outcomes in TH and face-to-face therapy and enhanced outcomes in TH relative to treatment as usual, resource provision (i.e. written materials), or wait-list control. Narrative review of 20 studies for a range of relational and mental health outcomes aligned with these findings; and (3) therapists defined clear conditions for enhanced engagement and therapeutic process via TH and reflected on cautions and accommodations for purposes of rapport building and mitigating risk. Given moderate-strong evidence for the efficacy of TH methods of family therapy for a range of conditions, we offer recommendations for future implementation of TH for family therapy.

Pediatric behavioral telehealth in the age of COVID-19: Brief evidence review and practice considerations

Considerable efforts over the last decade have been placed on harnessing technology to improve access to behavioral health services. These efforts have exponentially risen since the outbreak of the Coronavirus disease 2019 (COVID-19), which has prompted a move to novel systems of care, largely based on telehealth delivery. This article aims to provide a broad review of evidence for telehealth assessment and treatment of externalizing disorders and internalizing disorders in children and discuss practice considerations and established guidelines for telehealth delivery. Existing literature supports the promise of behavioral health interventions including behavioral parent training and combination approaches for externalizing disorders as well as cognitive-behavioral based interventions for internalizing disorders. There is a scarcity of work on assessment via telehealth compared with the available treatment literature. While treatment may be most pressing given the COVID-19 circumstances to continue delivery of care, movement toward establishing evidence-based assessment via telehealth will be of increased importance. Lastly, practice guidelines have been set forth by national associations, professional societies, and supported by the development of national Telehealth Centers of Excellence. These guidelines and practice considerations are discussed within the context of COVID-19.

Telehealth transition in a comprehensive care unit for eating disorders: Challenges and long-term benefits

The 2019 novel coronavirus disease (COVID-19) pandemic has forced many eating disorder medical stabilization units to consider adjustments that uphold both the quality of care delivered to patients while also observing social distancing public health directives for patients and staff. To date, inpatient facilities for eating disorders (both medical stabilization units and higher level of care facilities) have not needed to consider how to translate services to electronic platforms, given that most of these programs have in-person staff. We outline our transition to telehealth broadly, emphasizing some unexpected benefits of using telehealth services that we plan on integrating into our work-flow post COVID-19. These may be useful for other higher level of care eating disorder programs, including medical stabilization units, residential, partial hospitalization, and intensive outpatient programs. We also highlight aspects of transition that have been more challenging for this particular patient population, warranting the need for in-person services.

Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine

BACKGROUND

Family-based treatment (FBT) is an efficacious outpatient intervention for young people diagnosed with Anorexia Nervosa (AN). To date, treatment to protocol has relied on standard face-to-face delivery. Face-to-face therapy is subject to geographic, temporal and human factors, rendering it particularly susceptible to inequities and disruption. This has resulted in poorer service provision for rural and regional families, and recently a significant challenge to providing face-to-face services during the COVID-19 global pandemic. The present study examines whether FBT for AN can be successfully translated to a digital delivery platform to address these access issues.

METHOD

Forty young people aged 12 to 18 years who meet DSM-5 diagnostic criteria for AN, and live in a rural or regional setting, will along with their family be recruited to the study. Trained therapists will provide 18 sessions of FBT over 9 months via telemedicine to the home of the young person and their family. The analysis will examine treatment effectiveness, feasibility, acceptability, and cost-effectiveness.

DISCUSSION

The study addresses the treatment needs of families not able to attend face-to-face clinical services for evidence-based treatment for eating disorders. This might be due to several barriers, including a lack of local services or long travel distances to services. There has been a recent and unprecedented demand for telemedicine to facilitate the continuity of care during COVID-19 despite geographical circumstances. If delivering treatment in this modality is clinically and economically effective and feasible, it will facilitate access to potentially lifesaving, evidence-based treatments for families formerly unable to access such care and provide evidence for the continuity of services when and where face-to-face treatment is not feasible.

Exploring the impact of the COVID-19 pandemic and UK lockdown on individuals with experience of eating disorders

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic may raise unique challenges for individuals with experience of eating disorders. Many factors have potential for detrimental impacts on psychological wellbeing and eating disorder recovery, including: Disruption to living situations, 'social distancing' restrictions, difficult access to healthcare, and societal changes to food behaviours and technology usage. To date, little is known on the impact of the pandemic on this population, particularly within the UK.

METHOD

A mixed-methods online survey was developed for the purpose of this study. Data was collected from 129 individuals currently experiencing, or in recovery from, an eating disorder during the early stages of the UK pandemic lockdown. Participants were aged between 16 and 65 years, with 121 participants identifying as female, 7 male and 1 participant preferring not to disclose their gender.

RESULTS

Findings suggest that the pandemic is having a profound, negative impact upon individuals with experience of eating disorders. Eight key themes were generated: Disruption to living situation, increased social isolation and reduced access to usual support networks, changes to physical activity rates, reduced access to healthcare services, disruption to routine and perceived control, changes to relationship with food, increased exposure to triggering messages, and positive outcomes. The results suggest detrimental impacts on psychological wellbeing including decreased feelings of control, increased feelings of social isolation, increased rumination about disordered eating, and low feelings of social support.

CONCLUSIONS

Individuals with eating disorders are at significant risk of negative impacts of the pandemic. There is a vital need for interventions to support this population. Inequalities in healthcare provision were identified, emphasising a need for a more cohesive approach to remote treatment across UK healthcare services. Positive aspects of technology use were identified but the results suggest a need to address and/or limit the potential for negative impacts of public messages around food and exercise behaviours, and to co-design technologies with end-users to facilitate effective treatment.

The COVID-19 Pandemic and Rapid Implementation of Adolescent and Young Adult Telemedicine: Challenges and Opportunities for Innovation

PURPOSE

This study describes the rapid implementation of telemedicine within an adolescent and young adult (AYA) medicine clinic in response to the Coronavirus Disease 2019 (COVID-19) pandemic. While there are no practice guidelines specific to AYA telemedicine, observations made during this implementation can highlight challenges encountered and suggest solutions to some of these challenges.

METHODS

Over the course of several weeks in March, 2020, the Adolescent and Young Adult Medicine Clinic at the University of California San Francisco rapidly replaced most in-person visits with telemedicine visits. This required logistical problem-solving, collaboration of all clinic staff members, and continuous reassessment of clinical practices. This article describes observations made during these processes.

RESULTS

Telemedicine visits increased from zero to 97% of patient encounters in one month. The number of visits per month was comparable with that one year prior. While there were limitations to the clinic's ability to carry out health supervision visits, many general health, mental health, reproductive health, eating disorders, and addiction treatment services were implemented via telemedicine. Providers identified creative solutions for challenges that arose to managing general confidentiality issues as well as specific challenges related to mental health, reproductive health, eating disorders, and addiction care. Opportunities to implement and expand high-quality AYA telemedicine were also identified.

CONCLUSIONS

The COVID-19 pandemic is leading to widespread telemedicine implementation. While telemedicine seems to be feasible and acceptable for our clinic patients, unanswered questions remain regarding confidentiality, quality of care, and health disparities. Clinical guidelines are also needed to guide best practices for telemedicine in this patient population.

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.

Cognitive-behavioral therapy in the time of coronavirus: Clinician tips for working with eating disorders via telehealth when face-to-face meetings are not possible

OBJECTIVE

The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence-based interventions. This article draws together clinician experiences of the issues that should be attended to, and how to address them within a telehealth framework.

METHOD

Seventy clinical colleagues of the authors were emailed and invited to share their concerns online about how to deliver cognitive-behavioral therapy for eating disorders (CBT-ED) via telehealth, and how to adapt clinical practice to deal with the problems that they and others had encountered. After 96 hr, all the suggestions that had been shared by 22 clinicians were collated to provide timely advice for other clinicians.

RESULTS

A range of themes emerged from the online discussion. A large proportion were general clinical and practical domains (patient and therapist concerns about telehealth; technical issues in implementing telehealth; changes in the environment), but there were also specific considerations and clinical recommendations about the delivery of CBT-ED methods.

DISCUSSION

Through interaction and sharing of ideas, clinicians across the world produced a substantial number of recommendations about how to use telehealth to work with people with eating disorders while remaining on track with evidence-based practice. These are shared to assist clinicians over the period of changed practice.

Caring for Children and Adolescents With Eating Disorders in the Current Coronavirus 19 Pandemic: A Singapore Perspective

Our public pediatric tertiary hospital in Singapore has been a part of a robust public health response to coronavirus 19 that has been calibrated in a timely manner to the evolving international situation. As of mid-March, Singapore remains in a containment mode with enhanced surveillance and limited community spread. Within this context, our service for pediatric eating disorder care has had to make significant adaptations to our models of service delivery as well as respond to the changing psychosocial needs of our patients. Given infection control requirements, we have instituted modular staffing for our inpatient and outpatient settings, necessitating task shifting and an increased use of technology for communication. Because of the reduced outpatient capacity and the need to minimize nonurgent trips to the hospital, we have implemented telemedicine and have leveraged on partnerships with school counselors and other community partners. "Coronaphobia" has influenced our patients' willingness to attend visits and worsened existing health anxiety for some. Responsiveness to families' and patients' health and financial concerns has been essential. As coronavirus 19 impacts more countries, our institution's experience can provide insight into challenges and possible adaptations to providing ongoing care for eating disorder patients in this environment.

Predictors of Adolescents' First Episode of Homelessness Following Substance Use Treatment

PURPOSE

A growing body of research has identified correlates (i.e., predictors) of youth homelessness. However, such risk and protective factors have not been identified for youth receiving substance use treatment. Using characteristics collected at treatment intake, the present study sought to identify predictors of youths' first episode of homelessness during the 12 months after substance use treatment entry.

METHODS

Data come from a longitudinal study of adolescents (n = 17,911; aged 12-17 years) receiving substance use treatment throughout the U.S. Participants completed surveys at intake and at 3, 6, and 12 months later. Logistic regression and Lasso machine learning regression were used to predict participants' first episode of homelessness in the 12 months after treatment intake.

RESULTS

After excluding adolescents reporting previous experiences of homelessness, 5.0% of adolescents reported their first episode of homelessness over the 12 months after treatment intake. The results from logistic and lasso models were generally consistent. Final models revealed that adolescents who were older, male, reported more victimization experiences, mental health problems, family problems, deviant peer relationships, and substance use problems (more treatment episodes and illicit drug dependence) were more likely to report experiencing homelessness. Hispanic/Latino adolescents were less likely to experience homelessness, compared with white adolescents.

CONCLUSIONS

The results point to the important risk and protective factors that can be assessed at treatment entry to identify adolescents at greater risk of experiencing their first episode of homelessness.

The Impact of the COVID-19 Pandemic on Pediatric Clinical Practice in Wenzhou, China: A Retrospective Study

Introduction: The COVID-19 pandemic has affected all aspects of life worldwide. The aim of the present study was to review and describe and acknowledge the impact of COVID-19 on the pediatric health care system at a pediatric tertiary hospital in Wenzhou. Methods: A retrospective study was conducted at Yuying Children's Hospital of Wenzhou Medical University, a public pediatric tertiary hospital in Southern Zhejiang Province that specializes in pediatrics. The data regarding the primary diagnosis of patients were extracted from the electronic medical records system of the hospital. Data for outpatients and inpatients treated at the pediatric department were analyzed in the time frame of 22 weeks since the beginning of the pandemic (from December 30, 2019 to June 2, 2020) and compared with data from the same period in 2019. Results: The total number of outpatient cases in the previous 22 weeks of the year declined from 560,620 in 2019 to 247,030 in 2020, and inpatient cases decreased from 14,177 to 7,555. This negative trend settled by week 6 and 7 and subsequently approached the 2019 numbers. The most noticeable decrease in the number of cases was observed in children of preschool age. Moreover, the number of weekly visits decreased at the beginning of the epidemic, reached the lowest value during the lockdown period, and recovered after the lockdown. Conclusion: Based on the results of this study, clinical practice in a pediatric department in Wenzhou was substantially affected by the epidemic and measures such as physical distancing and increased personal hygiene, particularly in preschool-age children. An understanding of the trends and impacts of the pandemic on pediatric patients and health systems will facilitate better preparation of pediatricians in the future.

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.