Caring for an adolescent with anorexia nervosa: parent's views and experiences

A systematic review of eating disorders and family functioning

The purpose of the current review was to address four questions: 1) Are there differences in family functioning or family environment among patients with different eating disorder (ED) diagnoses? 2) Are there differences in the perception of family functioning or family environment among different family members? 3) Is family functioning or family environment related to ED symptomatology? 4) Does family functioning or family environment change as a result of ED treatment? and 4a) If so, does this impact ED treatment outcome? Although most studies found no differences among ED diagnostic groups, those that did generally found worse family functioning among those with binge/purge symptoms than among those with the restricting subtype of anorexia nervosa. Differences in perceptions of family functioning among family members were found, with patients generally reporting worse functioning than their parents. Worse family functioning was generally found to be related to worse ED symptoms. The variety of treatment approaches and different assessments of outcome made it somewhat unclear whether family functioning consistently improves with ED treatment. More research is needed on family functioning and EDs, particularly in understudied groups such as males, and those with ED diagnoses other than anorexia nervosa or bulimia nervosa.

"The third wing of the plane": Fathers' perceptions of their role in the treatment process for daughters with eating disorders

Eating disorders are complex mental health conditions exacerbated by high mortality rates. International and national guidelines recommend family involvement in the treatment process, recognising the family as an important source of support to young people. Research suggests fathers engage less in the process compared to mothers. In studies exploring parental perspectives, most samples consisted of mothers, with fathers minimally represented. Few studies explore family involvement from the perspective of fathers. This study aimed to explore the experiences of fathers regarding their involvement in the treatment process. Qualitative descriptive methods were used, involving focus group interviews of seven fathers. Interviews were assisted by a semi-structured interview guide. A qualitative content analysis approach was used to analyse the data regarding paternal experiences of engagement in the treatment process. Fathers understood the importance of the whole family working together but viewed mothers as taking a more central role in the treatment process, with fathers more at the periphery. Gender emerged as an influencing factor in paternal involvement, with mothers primarily taking on responsibility for the child with the eating disorder and fathers providing secondary support. Healthcare providers need to be aware of the contribution of gendered roles within the family system and consider this when working with families within the treatment process. Consequently, mental health nurses have an important role in encouraging fathers to become actively involved in the treatment process.

Parents' perspectives of anorexia nervosa treatment in adolescents: a systematic review and metasynthesis of qualitative data

BACKGROUND

Studies have established the central role of the family in the recognition, treatment, and recovery of anorexia nervosa. The objective of this study was to review, synthesize, and critically appraise the literature on parents' views on the treatment and recovery process of anorexia nervosa in their adolescent child.

METHOD

A systematic search of Medline, PsychINFO, CINHAL, EMBASE, Cochrane library, and SSCI was conducted for qualitative studies published regarding parents' views about the treatment of anorexia nervosa. The quality of articles was assessed using the critical appraisal skills program (CASP) and findings were analysed using thematic synthesis.

RESULTS

A total of 25 studies from nine countries reporting the views of 357 parents met the inclusion criteria. Four major themes were developed from the analysis: understanding the child and the disease, experience of services and treatment modalities, the role of professionals, and the experience of recovery.

CONCLUSION

Parents report struggles with delays in finding help, judgmental attitudes of professionals, and uncertainty about the future. Recognition of the challenges faced by parents and families empowers clinicians to build stronger therapeutic relationships essential for long-term recovery from anorexia nervosa.

Die Selbstwirksamkeitserwartung von Jugendlichen mit Anorexia nervosa im poststationären Setting

Zusammenfassung. Hintergrund: Die in diese Studie involvierte Population betrifft Personen mit Anorexia nervosa (AN). AN ist eine Erkrankung mit teilweise lebensbedrohlichem Untergewicht. Selbstwertproblematik, Ängste und soziale Probleme begleiten Betroffene. AN verläuft oft chronisch. Hospitalisiert nehmen die Betroffenen an Gewicht zu, oft persistiert die zugrundeliegende Essproblematik, was zur Rehospitalisation führt. Untersuchungen zur Selbstwirksamkeitserwartung (SWE) Betroffener fehlen weitgehend. Ziel: Das Ziel dieser Arbeit ist die Untersuchung der SWE bei Betroffenen im poststationären Setting mit Bezug zum Alter, der Anzahl Hospitalisationen und des Krankheitsverlaufs. Methode: Im Rahmen dieser Querschnittstudie wurden Betroffene im poststationären, psychosomatischen Setting anhand eines standardisierten Fragebogens „Allgemeine SWE“ befragt. Die Daten wurden deskriptiv und mittels Inferenzstatistik ausgewertet. Ergebnis: Befragt wurden 85 Jugendliche. Bei der Stichprobe lag der SWE-Score bei durchschnittlich = 28.53 bis und mit drei und bei = 24.68 ab vier Hospitalisationen. Lag der stationäre Aufenthalt erst kürzlich zurück, wies der SWE-Score einen tieferen Wert auf (= 26.08) als bei jenen mit länger zurückliegendem Aufenthalt (= 29.00). Schlussfolgerung: Die Resultate weisen darauf hin, dass die SWE den Krankheitsverlauf von Betroffenen beeinflussen können. Personen mit höheren SWE-Werten zeigen einen günstigeren Krankheitsverlauf mit weniger Rehospitalisationen. Die Stärkung der SWE ist deshalb im stationären und ambulanten Setting durch gezielte Interventionen seitens Fachpersonen von großer Bedeutung.

"Balancing within a closed family system": a grounded theory study of how family life is affected by having a family member with an eating disorder

BACKGROUND

This qualitative study explores how having an adult daughter or sister with anorexia nervosa or bulimia nervosa affects the family's daily life. Previous research has focused on the family's role in the development of an eating disorder, while more recently the focus has been on the illness's impact on the family. Caring for an individual with an eating disorder can involve distress, guilt, extra burdens, and unmet needs. By interviewing the family members of adults with eating disorders this study aims to gain insights into how the family members experience the impact of the eating disorder over time.

METHODS

A constructivist grounded theory approach was comprised to gather and analyse data to develop a theory on how families experience life with an adult daughter or sister with an eating disorder. Semi-structured individual interviews were conducted with 21 parents and siblings from across Norway.

RESULTS

The participants reported a lack of professional help and the families had to handle the challenges related to the illness themselves, hence being left to themselves as a family was identified as the participants' main concern. To manage this concern the families had to balance a pattern of care within the closed family system, and this comprises the core category of the study. Families balanced a pattern of care by shifting roles, adapting meal routines, and maintaining openness within the family.

CONCLUSIONS

The findings implicate that families need clarification of roles and responsibilities in relation to the health services in caring for the individual with an eating disorder. More research on taking a family perspective concerning adults with eating disorders is needed.

Parental-Bonding and Alexithymia in Adolescents with Anorexia Nervosa, Their Parents, and Siblings

Anorexia nervosa (AN) patients and their family-members share alexithymia, anxiety, depression, and other psychological symptoms, in the context of altered attachment. These domains have been individually studied in the context of eating disorders; few attempts have been made to study their interaction, especially including family members. In this study, alexithymia, parental-bonding, and psychopathology were assessed in 32 Italian families consisting of an adolescent AN patient, a sibling, and their parents. We aimed to (a) describe a sample of Italian families with a child affected by AN, notably including siblings; (b) investigate interactions between assessed constructs in patients and their siblings; and (c) investigate possible intergenerational effects. Results showed high alexithymia and psychopathological symptoms in patients but not in siblings, although the latter reported high obsession-compulsion and paranoid ideation scores. Patients' and siblings' alexithymia correlated with psychopathology. Parents reported generally low alexithymia. Perceived parental bonding was found to be suboptimal in most participants, yet no clear relationship was found between specific parenting styles and other measured traits, nor did we find any other relevant intergenerational effect. Anorexia nervosa implies psychological difficulties for all family members. Siblings' psychopathological traits are especially concerning and currently understudied. Implications for future research and clinical interventions are discussed.

Holistic nursing care for people diagnosed with an eating disorder: A qualitative study based on patients and nursing professionals' experience

PURPOSE

To analyze eating disorder patients and nursing professionals' views and experience of the relationship-based care established.

DESIGN AND METHODS

A qualitative study that employs an interpretative phenomenological analysis. Nineteen patients and 19 nurses participated in the research through interviews and narrations.

FINDINGS

Nurses' help is both unexpected and relevant during the patients' recovery process. They provide care not focusing just on nutritional aspects, other factors such as mutual help, the psychological, emotional, social, and personal aspects are highlighted.

PRACTICE IMPLICATIONS

This study provides a deep understanding of the relationship-based care established that makes it possible to expand knowledge and to individualize the care provided.

Modifiable factors associated with mental health symptoms in siblings of adolescents with anorexia nervosa

PURPOSE

Research demonstrates that anorexia nervosa (AN) takes a significant toll on affected families, yet the well-being of siblings has been largely overlooked. This study examines mental health symptoms in siblings of adolescents with AN and seeks to identify modifiable factors associated with well-being.

METHOD

Participants included 34 siblings (aged 11-19) of adolescents with AN and 47 age and sex matched controls. Participants and their caregivers completed assessments of anxiety, depression, internalizing and externalizing problems, and parentification. Siblings of adolescents with AN also completed the Sibling Perception Questionnaire, an assessment of perceptions and attitudes about AN.

RESULTS

Analyses indicated that siblings of adolescents with AN reported greater anxiety and parentification than controls. On caregiver reports of participants' internalizing and externalizing symptoms, no significant differences were found across groups. In siblings of adolescents with AN, females were more vulnerable to anxiety, depression, and negative attitudes and perceptions about AN than males. Perceived negative interpersonal interactions, specific to having a brother or sister with AN, were associated with greater anxiety and depression among AN siblings.

CONCLUSION

Findings from this pilot study suggest that siblings of adolescents with AN are vulnerable to anxiety and parentification behaviors. Negative interpersonal interactions specific to having a brother or sister with AN may perpetuate risk for poorer well-being. Caregivers may not be attuned to these struggles, highlighting the importance of provider and family education about sibling vulnerabilities. Therapeutic interventions that target siblings of adolescents with AN are also indicated.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

"Putting your own oxygen mask on first": a qualitative study of siblings of adults with anorexia or bulimia

BACKGROUND

In families where one of the siblings has an eating disorder (ED), research indicates that the siblings without eating disorders (EDs) experience insufficient care and negative changes in family life. The illness then takes up a great deal of space within the family. Support from the siblings without EDs is considered to be important for the recovery of the sibling with ED. A key issue is how to involve siblings without EDs in treatment and establish what kind of support they themselves need. A majority of the research on EDs and family has focused on children and adolescents with EDs. The aim of this study is to expand knowledge about the experiences and coping strategies of sisters and brothers of adult women with anorexia nervosa or bulimia nervosa.

METHODS

This qualitative study used a constructivist grounded theory approach. Individual semi-structured interviews were conducted with 10 sisters and brothers (aged 20-31 years). They were recruited from eating disorders and general psychiatrics units and from user organisations for patients with eating disorders within Norway. An iterative process of data collection, coding and analysis was employed in order to generate a theory about these participants' experiences and strategies.

RESULTS

The core category is "put your own oxygen mask on first". It indicates that the siblings realize that they need to take care of themselves first, in order to be able to stay involved with their sister with the ED. The three subcategories; "taking a new role", "distancing" and "adapted care" describe how the siblings handle their situation as the relatives of adult sisters with an ED. The siblings without ED became more responsible and independent and assumed a caregiving role. They downplayed their own needs to reduce their parents' burden. This new role became difficult to fulfil and the siblings experienced that over time they needed more distance. Eventually, they developed a more manageable way of caring for their sister.

CONCLUSIONS

The findings suggest that the ED challenged the boundaries within the family. The siblings without ED assumed a caregiver role, gradually leading to exhaustion and the need to distance from the sister with the ED, to take care of themselves.

The experiences and strategies of parents' of adults with anorexia nervosa or bulimia nervosa: a qualitative study

BACKGROUND

Caring for an individual with an eating disorder involves guilt, distress and many extra burdens and unmet needs. This qualitative study explored the experiences of parents with adult daughters suffering from anorexia nervosa or bulimia nervosa and the strategies they adopted. A subsidiary aim of the study was to explore the relationship between the caregivers' perceived need for professional support and the support they reported receiving in practice from the health services.

METHODS

Semi-structured interviews were conducted with 11 mothers and fathers from across Norway. Data collection, coding and analysis was conducted using the principles of constructivist grounded theory in an iterative process. The main concern shared by participants was identified by this process and their "solution" to the main concern then formed the content of the core category.

RESULTS

″Wearing all the hats″ emerged as the core category, indicating that the parents have to fulfil several roles to compensate the lack of help from health services. The three subcategories: "adapting to the illness", "struggling for understanding and help" and "continuing to stay strong" described how the participants handled their situation as parents of adult daughters with eating disorders.

CONCLUSIONS

In daily life, the parents of adults with eating disorders have to attend to a wide range of caregiver tasks to help their ill daughters. This study suggests that the health services that treat adults with eating disorders should be coordinated, with a professional carer in charge. The parents need easy access to information about the illness and its treatment. They also need professional support for themselves in a demanding situation.

"If she had broken her leg she would not have waited in agony for 9 months": Caregiver's experiences of eating disorder treatment

This study aims to explore caregivers' experiences of eating disorder services and subsequent impacts on the caregiving burden and patient outcomes. Thematic analysis was employed to investigate qualitative data from a caregiver-targeted online survey run by BEAT, the UK's largest eating disorder charity. Six hundred and 16 caregivers completed the survey. Participants' experiences of eating disorder treatment were predominantly negative, characterised by three main themes: (a) Barriers to care: enduring obstacles caregivers face in accessing support for their loved ones, (b) Experiences of services: high levels of unmet needs for caregivers and patients alike, (c) Affected domains: the pervasive impact of caregiving, influenced by experiences of services. This study is the largest of its kind to explore caregivers' experiences of eating disorder treatment services and aims to give voice to this overlooked group within research. Notably, little has been done to address broader systemic challenges faced by caregivers in accessing support for loved ones. Results indicate these challenges may play a substantial role in shaping the caregiving burden, carer coping styles, and subsequent patient outcomes. Findings denote wider systemic issues and a lack of specificities of information and practical skills that could help prevent caregivers from experiencing the caregiving burden and subsequent consequences on eating disorder patient outcomes.

Eating disorders "mental health literacy": a scoping review

Background: While it is apparent that much has been learned about "mental health literacy" (MHL) relating to certain mental health problems, such as depression, in recent years, what has been learned about MHL relating to eating disorders (ED-MHL) is unclear.Aims: A scoping review was conducted to inform the current state of knowledge in this field.Methods: A systematic search of relevant literature published between 1997 and 2017 was followed by a narrative synthesis of the findings.Results: The number of eligible studies increased from 32 in 1997-2001 to 98 in 2012-2017 (total = 264). Most studies originated from North America or Europe, recruited individuals with EDs receiving treatment or college students and included both female and male or only female participants. The majority of studies examined MHL relating to anorexia nervosa or bulimia nervosa and examined attitudes which facilitate recognition and appropriate help-seeking and knowledge and beliefs about professional help available.Conclusion: Interest in ED-MHL is increasing and there is now a considerable body of research addressing some aspects of ED-MHL in a range of study populations. Notable gaps in the literature exist, including a paucity of information about ED-MHL relating to EDs other than anorexia nervosa and bulimia nervosa, ED behaviour in males and the use of self-help interventions. We hope the findings will provide an incentive to further research in these and other aspects of ED-MHL.

Current eating disorder healthcare services - the perspectives and experiences of individuals with eating disorders, their families and health professionals: systematic review and thematic synthesis

BACKGROUND

Eating disorders have the highest mortality rate of mental disorders and a high incidence of morbidity, but if diagnosed and treated promptly individuals can benefit from full recovery. However, there are numerous problems at the healthcare interface (i.e. primary and secondary care) for eating disorders. It is important to examine these to facilitate appropriate, seamless treatment and improve access to specialist care.

AIMS

To examine the current literature on the experiences and perspectives of those across healthcare interfaces for eating disorders, to include individuals with eating disorders, people close to or caring for those with eating disorders such as family and friends, and health professionals.

METHOD

To identify relevant papers, a systematic search of electronic databases was conducted. Other methods, including hand-searching, scanning reference lists and internet resources were also used. Papers that met inclusion criteria were analysed using a systematic methodology and synthesised using an interpretative thematic approach.

RESULTS

Sixty-three papers met the inclusion criteria. The methodological quality was relatively good. The included papers were of both qualitative (n = 44) and quantitative studies (n = 24) and were from ten different countries. By synthesising the literature of these papers, three dominant themes were identified, with additional subthemes. These included: 'the help-seeking process at primary care'; 'expectations of care and appropriate referrals' and 'opposition and collaboration in the treatment of and recovery from eating disorders'.

CONCLUSIONS

This review identifies both facilitators and barriers in eating disorder healthcare, from the perspectives of those experiencing the interface first hand. The review provides recommendations for future research and practice.

DECLARATION OF INTEREST

None.

Parenting skills after participation in skills-based training inspired by the New Maudsley Method: a qualitative study in an outpatient eating disorder setting

BACKGROUND

Eating disorders affect the whole family and it is recommended that parents play an important role in their adolescents' recovery. Being a parent to an adolescent with an eating disorder is often linked to feelings of guilt and hopelessness and at the same time parents often feel left alone with unmet needs when it comes to handling symptoms in family life. Little is known about parents' perspectives to skills-based training in adolescent eating disorder treatment. This knowledge is urgently required, since previous research has focused mainly on adult patients showing positive effects of skills-based training as a promising adjunct in eating disorder treatment.

OBJECTIVE

To examine parents' perception of their new skills after having participated in skills-based training inspired by the New Maudsley Method.

METHODOLOGY

A qualitative study using deductive dominant content analysis.

METHODS

In total, 21 parents participated in focus groups.

FINDINGS

Three categories were identified (i) Standing outside oneself and realise that one has become entangled in the illness, (ii) Understanding the daughter's inner life with the illness offers new opportunities in the relationship, (iii) Courage to find new ways of parenting. The parents experienced themselves more calm and confident in their ability to recognise and confront the eating disorder symptoms. They expressed increased communication skills, which improved their relationship with their child and gave access to her inner life.

CONCLUSION

Skills-based training serves as an important intervention and it may improve parental skills, reduce high expressed emotions and reduce anxiety, guilt and stress. Skills-based training may contribute to reinforcing parents to regain parenting authority and enable parents and adolescents to 'be on the same side' in the beating the eating disorder.

Metasynthesis of the Views about Treatment of Anorexia Nervosa in Adolescents: Perspectives of Adolescents, Parents, and Professionals

BACKGROUND

Anorexia nervosa in adolescents can be a difficult-to-treat disease. Because qualitative research is a well-established method for deepening our understanding of subjective experiences, such as eating disorders and their treatment, we sought to perform a systematic review of qualitative studies to synthesize the views of adolescents with this disease, their parents, and their healthcare providers about its treatment.

METHODS

We performed a thematic synthesis to develop the central themes that summarize all of the topics raised in the articles included in our review. The quality of the articles was assessed by the Critical Appraisal Skills Program.

RESULTS

We included 32 articles from seven different countries. Two central themes were inductively developed from the analysis: (1) the treatment targets (i.e., symptoms and patients in context), and (2) a therapeutic tool-a relationship, specifically the core concept of the therapeutic relationship.

CONCLUSION

Our results underline the difficulty in establishing a therapeutic alliance, the barriers to it, especially the risk that professionals, adolescents, and parents will not converse about treatment; although such a dialogue appears to be an essential component in the construction of a therapeutic alliance.

The lived experience of anorexia nervosa in adolescence, comparison of the points of view of adolescents, parents, and professionals: A metasynthesis

BACKGROUND

Anorexia nervosa in adolescence has been increasingly documented in numerous quantitative and qualitative studies. Qualitative research, which focuses on subjective experience, is a well-established method to deepen our understanding and provide new insights about specific diseases.

OBJECTIVE

We conducted a metasynthesis of qualitative studies to explore how anorexia nervosa is experienced by adolescents, their families, and the health professionals who provide care for them and to compare their perspectives.

REVIEW METHODS

Five databases (Medline, PsycINFO, CINHAL, EMBASE, SSCI; 1990-2015) were systematically searched for qualitative studies reporting participants' views about anorexia nervosa. Article quality was assessed with the Critical Appraisal Skills Program (CASP). We used thematic synthesis to examine and summarize the topics found in the articles selected and develop their central themes.

RESULTS

We included 30 articles from seven different countries. Two domains of experience were inductively developed from the analysis: (1) constructs and beliefs about etiological theories of anorexia nervosa, and (2) the experience of the disease from the points of view of adolescents, parents, and healthcare providers.

CONCLUSIONS

We found important disparities between the three stakeholders. The adolescents underlined the psychological and emotional aspects of their experience, while the visible state of these patients' bodies impeded the work of the professionals. These difficulties shed new light on the stakes of treatment of anorexia nervosa in adolescence, which must integrate both its psychological and physical components.