Do in-vivo behaviors predict early response in family-based treatment for anorexia nervosa?

Families tackling adolescent anorexia nervosa: family wellbeing in family-based treatment or other interventions. A scoping review

PURPOSE

Family-based treatment (FBT) has contributed significantly to the treatment of anorexia nervosa (AN) in young people (YP). However, parents are concerned that FBT and the active role of parents in the task of refeeding may have a negative impact on family relations. The aim of the review is to assess whether families engaged in FBT for AN are more or less impacted in their family wellbeing and caregiver burden, compared to families with a YP diagnosed with AN, who are not undergoing treatment with FBT.

METHOD

Computerized searches across six databases complemented by a manual search resulted in 30 papers being included in the scoping review.

RESULTS

The review identified 19 longitudinal studies on change in family wellbeing in families in FBT-like treatments, and 11 longitudinal studies on change in family wellbeing in treatment where parents are not in charge of refeeding. Only three randomized controlled studies directly compare FBT to treatment without parent-led refeeding.

CONCLUSION

The available research suggests no difference between intervention types regarding impact on family wellbeing. Approximately half of the studies find improvements in family wellbeing in both treatment with and without parent-led refeeding, while the same proportion find neither improvement nor deterioration. As parents play a pivotal role in FBT, there is a need for good quality studies to elucidate the impact of FBT on family wellbeing. Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

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.

Caregiver and adolescent intuitive eating behavior: associations with weight change during family-based treatment for anorexia nervosa

PURPOSE

Intuitive eating (IE) is an adaptive eating construct for which little research exists in eating disorder (ED) samples. IE is negatively correlated with disordered eating behaviors in healthy adolescents and adults, and similar associations have been found in adults with EDs. This study aims to examine IE in a treatment seeking sample of adolescents and their caregivers to understand the role of IE in weight gain during FBT.

METHODS

Descriptive statistics and bivariate correlations were calculated in a sample of 47 pairs of adolescent patients and their caregivers who initiated outpatient FBT at a large academic medical center. Analyses examined associations between caregiver and adolescent IE on the Intuitive Eating Scale (IES), change in percent expected body weight (%EBW) by session 4 and end of treatment (EOT), clinical impairment, and ED pathology.

RESULTS

Significant correlations were found between aspects of adolescent IE, ED symptoms, and clinical impairment. Caregiver IES scores (Reliance on Hunger and Satiety Cues, Body-Food Choice Congruence, IES Total) were negatively related to adolescent ED symptoms (EDE-Q Weight Concerns, EDE-Q Shape Concerns, EDE-Q Global) at baseline. Caregiver IE (Eating for Physical Rather than Emotional Reasons) was positively associated with adolescent weight gain at FBT session 4 and EOT, even when statistically adjusting for gender and initial level of care.

CONCLUSION

Study results were consistent with past research indicating adolescent IE is negatively associated with ED behaviors, cognitions, and impairment. This study is the first to provide evidence that caregiver IE is positively associated with adolescent weight gain in FBT and is the first to provide evidence that caregiver IE is negatively related to adolescent ED symptoms. Future research should examine adolescent and caregiver IE throughout FBT to understand the role of IE in treatment response.

LEVEL OF EVIDENCE

Level III: Evidence obtained from cohort or case-control analytic studies.

Understanding outcomes in family-based treatment for adolescent anorexia nervosa: a network approach

BACKGROUND

Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa (AN). Yet, remission is not achieved for about half of adolescents with AN receiving FBT. Understanding patient- and parent-level factors that predict FBT response may inform treatment development and improve outcomes.

METHODS

Network analysis was used to identify the most central symptoms of AN in adolescents who completed the Eating Disorder Examination (EDE) prior to FBT (N = 409). Bridge pathways between adolescent AN and parental self-efficacy in facilitating their child's recovery from AN were identified in a subset of participants (n = 184). Central and bridge symptoms were tested as predictors of early response (⩾2.4 kg weight gain by the fourth session of FBT) and end-of-treatment weight restoration [⩾95% expected body weight (EBW)] and full remission (⩾95% EBW and EDE score within 1 standard deviation of norms).

RESULTS

The most central symptoms of adolescent AN included desiring weight loss, dietary restraint, and feeling fat. These symptoms predicted early response, but not end-of-treatment outcomes. Bridge symptoms were parental beliefs about their responsibility to renourish their child, adolescent discomfort eating in front of others, and adolescent dietary restraint. Bridge symptoms predicted end-of-treatment weight restoration, but not early response nor full remission.

CONCLUSIONS

Findings highlight the prognostic utility of core symptoms of adolescent AN. Parent beliefs about their responsibility to renourish their child may maintain associations between parental self-efficacy and AN psychopathology. These findings could inform strategies to adapt FBT and improve outcomes.

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

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

A scoping review of non-specific predictors, moderators, and mediators of family-based treatment for adolescent anorexia and bulimia nervosa: a summary of the current research findings

PURPOSE

This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa.

METHODS

We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research.

RESULTS

Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes.

CONCLUSION

In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.

Rescripting-A grounded theory study of the contribution that fathers make to Family-Based Treatment when a young person has anorexia nervosa

AIM

To present a grounded theory of the contribution that fathers make to family-based treatment when a young person has anorexia nervosa.

BACKGROUND

Research indicates a potential to improve outcomes by involving both parents in the treatment of anorexia nervosa. However, fathers are underrepresented both within treatment and research. Family-based treatment requiring the involvement of both parents presents an opportunity to better understand the role of the father in treatment.

DESIGN

Classic grounded theory.

METHODS

Individual interviews conducted with fifteen fathers involved in family-based treatment. The COREQ checklist was followed.

RESULTS

Fathers valued being involved in family-based treatment and felt they had an important contribution to make. The analysis captures the overall contribution that fathers make and the impact of their involvement. Four categories; Being on the Outside, Finding a Way In, Finding a Way to Be and Finding a Way to Let Go and one core category Repositioning were generated from the data. A substantive theory of Rescripting, generated from categories and the core category, describes the way that participating in family-based treatment changes fathers and their role.

CONCLUSIONS

Fathers make an important and significant contribution to family-based treatment when a young person has anorexia nervosa. The findings inform clinicians about the importance of including fathers in the treatment of young people with anorexia nervosa. They highlight the importance of incorporating support mechanisms into family-based treatment to harness and maximise the paternal contribution.

RELEVANCE TO CLINICAL PRACTICE

Paternal contribution to family-based treatment can be maximised to improve outcomes for young people with anorexia nervosa.

Early intervention in child and adolescent eating disorders: The role of a parenting group

OBJECTIVE

Parental involvement is emphasised in treatment guidelines for Eating Disorders (ED). The primary aim of this phase II study was to estimate the impact of a parent group intervention delivered immediately post-diagnosis on weight gain and ED psychopathology in a cohort of young people referred to a community ED service. A secondary aim was to identify predictor variables for early treatment response in children whose parents attended the programme.

METHOD

Parents of 64 new cases of Anorexia Nervosa (AN; n = 50) and Atypical Anorexia (AAN, n = 14) attended a 6 week parent group intervention in addition to treatment as usual in which patients were weighed and reviewed, but had no other contemporaneous psychological intervention. Age and gender adjusted BMI (%median [m] BMI) and ED psychopathology at baseline, 6-week and 6-month follow-up were analysed to assess weight gain and identify predictors of outcome.

RESULTS

The intervention was associated with weight gain and improved ED psychopathology by the end of the programme; these gains were sustained at 6 months %mBMI at 6 weeks was the only predictor of outcome (%mBMI) at 6 months.

CONCLUSIONS

This preliminary work highlights the positive benefit of an ED focused parent group early intervention that could be further evaluated.

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

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

CLINICAL TRIAL REGISTRATION

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Heterogeneous weight restoration trajectories during partial hospitalization treatment for anorexia nervosa

Early response to treatment has been shown to predict good outcome in family-based treatment, but little is known about who responds quickly.

OBJECTIVE

The purpose of the current study was to examine the short-term weight gain trajectories among youth receiving partial hospitalization program services for anorexia nervosa (AN), and to identify predictors of these trajectories.

METHOD

Adolescent and young adults (n = 102) with AN or subthreshold AN completed semi-structured interviews and self-report measures on admission to a family-based partial hospitalization program. Patients participated in programming 5 days a week.

RESULTS

Three weight gain trajectories were found to indicate slow, moderate, and rapid weight gain trajectories. All rapid responders gained at least four lbs. in the first 4 weeks of treatment, compared to 86.1% of moderate responders and 51.2% of slow responders. Patients were less likely to have a moderate or rapid response trajectory if they had a mood disorder diagnosis and higher parental expressed emotion. Additionally, the presence of compensatory behavior increased the likelihood of having a rapid response.

DISCUSSION

Despite the sometimes chronic nature of AN, most patients fell into one of the two favorable response trajectories. The identification of these trajectories underscores the importance of considering the core disordered eating behaviors (i.e., restricting, binge eating, and purging), comorbid psychopathology, and parental expressed emotion.

Open Trial of Family-Based Treatment of Anorexia Nervosa for Transition Age Youth

OBJECTIVE

This pilot study conducted an open trial of a manualized adaptation to Family-Based Treatment for Transition Age Youth (FBT-TAY) for Anorexia Nervosa (AN). The aims were: (1) determine the acceptability of FBT for TAY; and, (2) establish preliminary effect sizes for the impact of FBT-TAY on eating disorder behaviour and weight restoration.

METHOD

Twenty-six participants across two paediatric and one adult hospital site were recruited to participate. Participants completed the Eating Disorder Examination Questionnaire (EDE-Q) at the start of treatment, the end-of-treatment, and three-month follow-up.

RESULTS

FBT-TAY is an acceptable and feasible treatment to all study therapists as evidenced by their fidelity to the model. FBT-TAY is a feasible and acceptable intervention to transition age youth, given only 27.27% chose treatment as usual over FBT-TAY. Participants presented significant improvement at end-of-treatment and three-months post-treatment (p < .001; ES = 0.34) from baseline on the EDE-Q Global Score. Participants also achieved and maintained weight restoration at the end-of-treatment and three-months post-treatment when compared to baseline (p < .0001, ES = 0.54).

CONCLUSIONS

FBT-TAY, the first manualized AN treatment for TAY, demonstrated feasibility and acceptability with therapists and participants as well as improvement for participants in EDE-Q global score and weight. Given the current dearth of effective treatments for TAY with AN, FBT-TAY is a promising adaptation of FBT. A larger clinical trial with a 12-month follow-up is recommended.

Low weight gain at the start of a family-based intervention for adolescent girls with restrictive eating disorders predicted emergency hospital admission

AIM

This study examined predictors of emergency hospitalisation of adolescent girls with restrictive eating disorders and weight loss treated by a family-based intervention programme.

METHODS

We studied 339 girls aged 10-17 years treated in a specialist unit at Uppsala University Children's Hospital, Sweden, from August 2010 to December 2015. Historical weight data were obtained from school health services, and other weight data were determined at presentation. Weight controlling behaviour was recorded, and patients were evaluated using the Eating Disorder Examination Questionnaire. A family-based intervention started after assessment and the early weight gain after one week, one month and three months was assessed.

RESULTS

There were 17 emergency admissions of 15 patients for refusing food, progressive weight loss and medical instability. Logistic regression analysis showed that emergency admissions were predicted by a low body mass index standard deviation score at presentation (odds ratio 2.57), a high rate of weight loss before presentation (odds ratio 4.38) and a low rate of weight gain at the start of treatment (odds ratio 4.59).

CONCLUSION

Poor weight gain at the start of a family-based intervention for adolescent girls with restrictive eating disorders predicted emergency hospital admission.

Parental strategies used in the family meal session of family-based treatment for adolescent anorexia nervosa: Links with treatment outcomes

OBJECTIVE

Examine relationships between parental mealtime strategies used in the family meal session of family-based treatment (FBT) and adolescent outcomes at EOT (session 20).

METHOD

Eighteen families with an adolescent receiving FBT-AN participated. Parental strategies during videoed family meals were assessed using a family mealtime coding system. Change scores were calculated for both adolescent %EBW and EDE scores.

RESULTS

Increased use of parental direct and non-direct eating prompts during the family meal was associated with greater adolescent weight gain at EOT. Use of parental mealtime strategies was not associated with any significant change in adolescent eating psychopathology at EOT.

DISCUSSION

Parental verbal eating prompts during the family meal may be effective in promoting short-term weight gain. During the family meal session, parents should be encouraged to maintain a direct focus on their adolescent child's eating behaviour which may assist their child with food consumption and potential weight gain. Further research examining food-based interactions among parents and their adolescent child with AN is needed. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:433-436).

Rapid response to eating disorder treatment: A systematic review and meta-analysis

OBJECTIVE

This review aimed to (a) examine the effects of rapid response on behavioral, cognitive, and weight-gain outcomes across the eating disorders, (b) determine whether diagnosis, treatment modality, the type of rapid response (changes in disordered eating cognitions or behaviors), or the type of behavioral outcome moderated this effect, and (c) identify factors that predict a rapid response.

METHOD

Thirty-four articles met inclusion criteria from six databases. End of treatment and follow-up outcomes were divided into three categories: Behavioral (binge eating/purging), cognitive (EDE global scores), and weight gain. Average weighted effect sizes(r) were calculated.

RESULTS

Rapid response strongly predicted better end of treatment and follow-up cognitive and behavioral outcomes. Moderator analyses showed that the effect size for rapid response on behavioral outcomes was larger when studies included both binge eating and purging (as opposed to just binge eating) as a behavioral outcome. Diagnosis, treatment modality, and the type of rapid response experienced did not moderate the relationship between early response and outcome. The evidence for weight gain was mixed. None of the baseline variables analyzed (eating disorder psychopathology, demographics, BMI, and depression scores) predicted a rapid response.

DISCUSSION

As there is a solid evidence base supporting the prognostic importance of rapid response, the focus should shift toward identifying the within-treatment mechanisms that predict a rapid response so that the effectiveness of eating disorder treatment can be improved. There is a need for future research to use theories of eating disorders as a guide to assess within-treatment predictors of rapid response. © 2016 Wiley Periodicals, Inc. Int J Eat Disord 2016; 49:905-919.

Interventions for the Carers of Patients With Eating Disorders

The aim of this study is to evaluate the recent literature on carers/parenting interventions for people with eating disorders. Interesting and important new findings are highlighted as well as the implications that this may have for treatment. We have reviewed and critically analysed the recent literature. Close others often play an important role in recognising the early signs of eating disorders and accessing and implementing treatment. Their role in helping with recovery is to give support and hold a united front themselves and with the professional team to avoid those common interpersonal reactions that adversely impact on outcome such as accommodating to the illness and reacting with high expressed emotion (overprotection and hostility). Managing this role is difficult, and coping resources are often strained. Carers ask for and are now getting expert training in skills to manage this role. There is an overlap between carer/parenting interventions and family therapies. The interface with close others is critical both for early recognition and access and implementation of treatment. Interventions which equip families and close others with the skills to manage eating disorder behaviours are showing potential at improving outcomes.

Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder

Trauma-focused cognitive behaviour therapy is effective in treating posttraumatic stress disorder but non-response rates range between 25% and 50%. Results of previous research on patient characteristics predicting outcome are inconsistent and mainly focused on demographic and diagnostic variables. This study examined whether behavioural predictors of poor treatment response can be observed in early sessions. It was predicted that greater patient perseveration, lower expression of thoughts and feelings and weaker therapeutic alliance would be associated with poorer outcomes. We also explored the relationships of patient behaviours with therapeutic alliance and the efficiency and competence of treatment delivery. Audio or video recordings of the initial treatment sessions of 58 patients who had shown either good (n = 34) or poor response (n = 24) to cognitive therapy for PTSD (CT-PTSD, Ehlers & Clark, 2000) were blindly coded for patient perseveration, expression of thoughts and feelings, therapeutic alliance, efficiency and competency of treatment delivery and therapist competence. Poor responders showed more perseveration and less expression of thoughts and feelings in the initial session. Patient perseveration and low expression of thoughts and feelings were associated with poorer therapeutic alliance and compromised treatment delivery. Patients with these behavioural characteristics may benefit from additional treatment strategies. Limitations of the study and implications for clinical practice are discussed.

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The study examined whether patient behaviour in initial treatment sessions predicts outcome.

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Poor treatment responders showed more perseveration and lower expression of thoughts and feelings than good responders.

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These patient characteristics were associated with poorer therapeutic alliance.

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These characteristics were also associated with lower ratings of the efficacy and competency of treatment delivery.

Can adaptive treatment improve outcomes in family-based therapy for adolescents with anorexia nervosa? Feasibility and treatment effects of a multi-site treatment study

OBJECTIVE

Adolescents with Anorexia Nervosa (AN), treated with family-based treatment (FBT) who fail to gain 2.3 kg by the fourth week of treatment have a 40-50% lower chance of recovery than those who do. Because of the high risk of developing enduring AN, improving outcomes in this group of poor responders is essential. This study examines the feasibility and effects of a novel adaptive treatment (i.e., Intensive Parental Coaching-IPC) aimed at enhancing parental self-efficacy related to re-feeding skills in poor early responders to FBT.

METHOD

45 adolescents (12-18 years of age) meeting DSM TR IV criteria for AN were randomized in an unbalanced design (10 to standard FBT; 35 to the adaptive arm). Attrition, suitability, expectancy rates, weight change, and psychopathology were compared between groups.

OUTCOMES

There were no differences in rates of attrition, suitability, expectancy ratings, or most clinical outcomes between randomized groups. However, the group of poor early responders that received IPC achieved full weight restoration (>95% of expected mean BMI) by EOT at similar rates as those who had responded early.

CONCLUSIONS

The results of this study suggest that it is feasible to use an adaptive design to study the treatment effect of IPC for those who do not gain adequate weight by session 4 of FBT. The results also suggest that using IPC for poor early responders significantly improves weight recovery rates to levels comparable to those who respond early. A sufficiently powered study is needed to confirm these promising findings.

Family-based Treatment of Child and Adolescent Eating Disorders

Best-practice guidelines for the treatment of child and adolescent eating disorders recommend the inclusion of parents. Family-based treatment (FBT) posits that families are not only important in supporting their children but are critical change agents in the recovery process. As originally developed for anorexia nervosa, parents take a central role in managing and disrupting eating disorder symptoms. The most evidence-based treatment model for adolescent anorexia nervosa, FBT has also recently been found to be useful in the treatment of adolescent bulimia nervosa. This article provides a summary of the theoretic model, evidence base, and application of FBT.

How do parents of adolescent patients with anorexia nervosa interact with their child at mealtimes? A study of parental strategies used in the family meal session of family-based treatment

OBJECTIVE

To examine the range and frequency of parental mealtime strategies used during the family meal session of Family-Based Treatment (FBT) for adolescent anorexia nervosa, and to explore the relationships between parental mealtime strategies, mealtime emotional tone and parental 'success' at encouraging adolescent food consumption.

METHOD

Participants were 21 families with a child aged between 12 and 18 years receiving FBT for adolescent anorexia nervosa. Video recordings of the family meal session (FBT session two) were coded using the Family Mealtime Coding System adapted in this study for use with adolescents (FMCS-A) to identify frequency of parental strategies, emotional tone of the meal (measured by adolescent positive and negative vocalisations) and frequency of prompted mouthfuls consumed by the adolescent (measured by the number of mouthfuls consumed by the adolescent immediately following parental interactions).

RESULTS

A range of parental mealtime strategies were in use. Those used repeatedly included direct eating prompts, non-direct eating prompts, physical prompts, and providing information or food-related choices. Several parental mealtime strategies (direct and non-direct eating prompts) were found to be consistently associated with the tone of adolescents' vocalisations and the number of mouthfuls consumed in response to a parental prompt.

DISCUSSION

Despite associations with negativity from the adolescent, the use of food-related prompts (both verbal and physical) seems to be associated with increased eating. This indicates the potentially important role of parental control of eating. Following replication, these findings might provide a focus for therapists when supporting and coaching parents during the family meal session.

Just one more bite: a qualitative analysis of the family meal in family-based treatment for anorexia nervosa

OBJECTIVE

The family meal is an integral component of Maudsley family-based treatment for anorexia nervosa. The aim of this study was to determine whether there are different types of family meal, as suggested in the treatment manual, and whether within session processes differ according to meal type.

METHOD

Thirty video-recorded family meal sessions from a randomised controlled trial were transcribed and analysed using thematic analysis.

RESULTS

Analyses revealed two types of family meal. In the first, the patient ate one mouthful more than they were willing to eat. This meal type was characterised by processes that were consistent with the Maudsley model. In the second, the patient ate what was asked of them with little to no difficulty. Therapist and family avoidance differentiated this meal type from the first.

DISCUSSION

The current findings, along with the existing theory, suggest that avoidance may have reduced the therapeutic impact of the meal for many families. Strategies to challenge therapist and family avoidance are suggested. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa

OBJECTIVE

Determine whether early weight gain predicts full remission at end-of-treatment (EOT) and follow-up in two different treatments for adolescent anorexia nervosa (AN), and to track the rate of weight gain throughout treatment and follow-up.

METHOD

Participants were 121 adolescents with AN (mean age = 14.4 years, SD = 1.6), from a two-site (Chicago and Stanford) randomized controlled trial. Adolescents were randomly assigned to family-based treatment (FBT) (n = 61) or individual adolescent focused therapy (AFT) (n = 60). Treatment response was assessed using percent of expected body weight (EBW) and the global score on the Eating Disorder Examination (EDE). Full remission was defined as having achieved ≥95% EBW and within one standard deviation of the community norms of the EDE. Full remission was assessed at EOT as well as 12-month follow-up.

RESULTS

Receiver operating characteristic analyses showed that the earliest predictor of remission at EOT was a gain of 5.8 pounds (2.65 kg) by session 3 in FBT (area under the curve (AUC) = 0.670; p = .043), and a gain of 7.1 pounds (3.20 kg) by session 4 in AFT (AUC = 0.754, p = .014). Early weight gain did not predict remission at follow-up for either treatment. A survival analysis showed that weight was marginally superior in FBT as opposed to AFT (Wald chi-square = 3.692, df = 1, p = .055).

DISCUSSION

Adolescents with AN who receive either FBT or AFT, and show early weight gain, are likely to remit at EOT. However, FBT is superior to AFT in terms of weight gain throughout treatment and follow-up.