Predictors and moderators of outcome in family-based treatment for adolescent bulimia nervosa

Family-based treatment takes longer for adolescents with mental health comorbidities: findings from a community mental health service

Children and adolescents diagnosed with an eating disorder often meet the diagnosis of another mental health disorder. In addition to eating disorders, individuals with comorbid disorders have higher suicide rates and more severe and chronic eating disorder symptoms. The present research aimed to investigate the influence of comorbid conditions on the treatment outcomes of children and adolescents that attended a public community mental health service. It was hypothesised that the patients with comorbidities would have a more extended treatment duration, slower rates of weight restoration, more hospital admissions for medical compromise, and poorer functioning than those without comorbidities. Data from 78 past patients at the Eating Disorder Program in Queensland, Australia, were analysed. Patients with comorbidities demonstrated similar recovery rates to those without comorbidities. However, those with comorbid conditions had longer episodes of treatment. The study's results support using Family Based Treatment for patients with and without comorbidities. The implications of the findings for public mental health services and directions for future research are discussed.

Predictors of Treatment Outcome in Eating Disorders: A Roadmap to Inform Future Research Efforts

PURPOSE OF REVIEW

With the current review, we provide a brief summary of recent literature that tests clinically observable characteristics at baseline that may impact treatment response, across eating disorder diagnoses. We then provide a critical discussion regarding how researchers may shift their approach to this research to improve treatment implications and generalizability of these findings.

RECENT FINDINGS

Recent work has broadly replicated prior findings suggesting a negative impact of lower weight status, poor emotion regulation, and early-life trauma on eating disorder treatment outcomes. Findings are more mixed for the relative contributions of illness duration, psychiatric comorbidity, and baseline symptom severity. Recent studies have begun to explore more specific domains of previously tested predictors (e.g., specific comorbidities) as well as previously neglected identity-related and systemic factors. However, recent research continues to use similar sampling techniques and approaches to analysis used in prior work. We propose that resolving remaining questions and illuminating predictors of treatment outcome in eating disorders requires a new approach to research sampling and study design. Suggested changes that can be applied within a traditional clinical trial framework may yield new insights with relevance across transdiagnostic eating disorder presentations.

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.

An evaluation of family-based treatment for restrictive-type eating disorders, delivered as standard care in a public mental health service

BACKGROUND

Family-based treatment (FBT) has demonstrated efficacy for anorexia nervosa (AN) in youth in randomized, controlled trials. It is important to assess if it shows a similar effectiveness when implemented in standard care.

AIM

To evaluate outcomes of FBT for restrictive-type eating disorders, delivered as standard care in a public mental health service. Outcomes are remission, frequency of hospital admissions and day-patient treatment, and frequency of other adaptations within 12 months from commencement of treatment. Second, to compare the collaborative clinical decisions of successful treatment in standard care made by family therapist at the end of treatment, with more objective definitions of recovery.

METHODS

The design is a prospective, uncontrolled study of a consecutive series of patients with restrictive-type eating disorders, treated with FBT in a specialty unit at the Child and Adolescent Mental Health Centre in the Capital Region of Denmark.

RESULTS

FBT was successfully completed within 12 months by 57% of participants, and 47% completed with 20 sessions or fewer. Weight restoration was achieved by 75% within 12 months, and 46% achieved both normalisation of body weight and behavioural symptoms of AN within 12 months. A total of 20% needed intensified treatment. All aspects of remission were often not present simultaneously, and the collaborative clinical decisions of successful treatment only partly aligned with other parameters of remission.

CONCLUSION

FBT showed good results when implemented as standard care, and it can be adapted to the specifics of local service organisation without compromising effectiveness.

Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials

OBJECTIVE

To critically appraise papers reporting on moderators and mediators of recommended psychological treatments for anorexia nervosa (AN) and bulimia nervosa (BN) in adolescents.

METHOD

A systematic search of databases was conducted including PsycINFO, Embase, MEDLINE, AMED, CINAHL, and the Cochrane Library. Studies were included where a randomized controlled trial (RCT) compared therapies for AN or BN and reported on moderators or mediators of treatment effect. Twenty-one eligible papers were included, all based on data from eight RCTs.

RESULTS

Family therapies were dominant in the literature. Individual or separated treatment appeared superior for families with more difficult relationships, whereas conjoint family treatment appeared to be superior where good family relationships were reported. Where there was greater eating disorder psychopathology in AN, including eating disorder-related obsessions and compulsions, the response was better to a family approach than to individual therapies. There was some evidence that a family treatment was superior for those engaging in purging behaviors in BN. Measures of family relationships, parental self-efficacy, and early change emerged as possible mediators; however, the quality of evidence was mixed and the findings, in some cases, arguably circular. Moderator and mediator analyses were underpowered in all studies, with multiple, and post-hoc, analyses being run, and a broad range of outcome measures used.

DISCUSSION

This review recommends that emerging findings are explored further in adequately powered trials of the different recommended therapies, with a move toward focusing on effect sizes. A consensus on acceptable definitions of outcome, including remission and recovery, would benefit future research.

Update on Treatments for Adolescent Bulimia Nervosa

There are few systematic studies of treatment of bulimia nervosa (BN) in adolescents. Although family-based treatment has demonstrated preliminary evidence to support involvement of caregivers in treatment, there is significant opportunity for improvement in mitigating binge-eating and purging symptoms among adolescents afflicted with BN. When caregivers are unable to participate in treatment, there is evidence that BN-specific cognitive behavioral therapy approaches are helpful for some adolescents. Further research is needed to determine for whom, and under what conditions certain types of family involvement might be most effective in adolescent treatment of BN.

Predictors of Weight Restoration in a Day-Treatment Program that Supports Family-Based Treatment for Adolescents with Anorexia Nervosa

Family-Based Treatment (FBT) is considered a first-line treatment for adolescents with eating disorders. The traditional outpatient model of FBT may not, however, be appropriate for adolescents requiring more intensive treatment due to severe medical complications or insufficient progress in traditional outpatient FBT. In response, efforts have been made to incorporate FBT into higher levels of care, such as day-treatment programs (DTPs), for families who need additional support. Little is known about the factors that predict weight restoration for DTPs intended to support FBT. The current study examined the ability of specific adolescent and caregiver variables to predict weight restoration at discharge for adolescents with anorexia nervosa (AN) enrolled in a skills-based DTP that supports FBT. Participants were 87 adolescents diagnosed with AN and their caregivers (N = 74). Body Mass Index (BMI) at baseline, percentage of Expected Body Weight (%EBW) gain within the first 4 weeks, and caregiver empowerment level at baseline were found to significantly predict weight restoration. Higher BMI at baseline and higher %EBW gained in the first 4 weeks of treatment were predictive of weight restoration, whereas lower caregiver empowerment at baseline was predictive of weight restoration. Additionally, the rate of weight gain is reported for this DTP grounded in FBT philosophy.

Desired weight and treatment outcome among adolescents in a novel family-based partial hospitalization program

The purpose of the current study was to investigate desired weight percentage and weight difference percentage and their association with treatment outcome in a novel family-based partial hospitalization program. Twenty-six adolescents with anorexia nervosa or subthreshold anorexia nervosa between the ages of 12 and 19 completed the Eating Disorder Examination (EDE) at intake and upon completion from a partial hospitalization program in which parents played a large role in the recovery process, consistent with family-based treatment principles. Lower desired weight percentage at baseline was associated with higher scores on the restraint subscale of the EDE at end of treatment. Higher weight difference percentage (greater desire to lose weight) at baseline was associated with higher scores on all EDE subscales and global score at end of treatment. Neither desired weight percentage nor weight difference percentage at baseline were associated with treatment dropout or percent expected body weight at end of treatment. In a family-based program, participants' desired weight may be related to eating disorder thoughts (for example, shape or weight concerns) but not to behavioral outcomes such as weight gain or treatment dropout, which may be more directly under the influence of the parents.

Comorbid depressive symptoms and self-esteem improve after either cognitive-behavioural therapy or family-based treatment for adolescent bulimia nervosa

This study examined the effect of family-based treatment for bulimia nervosa (FBT-BN) and cognitive behavioral therapy for adolescents (CBT-A) on depressive symptoms and self-esteem in adolescents with BN. Data were collected from 110 adolescents, ages 12-18, who met Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, text revision criteria for BN or partial BN. Participants were randomly assigned to FBT-BN or CBT-A and completed measures of depressive symptoms and self-esteem before and after treatment and at 6- and 12-month follow-up assessments. Depressive symptoms and self-esteem significantly improved in both treatments, and neither treatment appeared superior on these clinical outcomes. Parents often worry whether FBT-BN addresses comorbid depressive symptoms and low self-esteem. Our findings address this concern, as they demonstrate that FBT-BN does not differ from CBT-A in improving depressive symptoms and self-esteem, and both treatments result in symptom improvement. These findings can help clinicians guide families to choose a treatment that addresses BN and depressive symptoms and low self-esteem.

Predictors of long-term recovery in anorexia nervosa and bulimia nervosa: Data from a 22-year longitudinal study

OBJECTIVE

The objective of this study was to investigate predictors of long-term recovery from eating disorders 22 years after entry into a longitudinal study.

METHOD

One hundred and seventy-six of the 228 surviving participants (77.2%) were re-interviewed 20-25 years after study entry using the Longitudinal Interval Follow-up Evaluation to assess ED recovery. The sample consisted of 100 women diagnosed with anorexia nervosa (AN) and 76 with bulimia nervosa (BN) at study entry.

RESULTS

A comorbid diagnosis of major depression at the start of the study strongly predicted having a diagnosis of AN-Restricting type at the 22-year assessment. A higher body mass index (BMI) at study intake decreased the odds of being diagnosed with AN-Binge Purge type, relative to being recovered, 22 years later. The only predictor that increased the likelihood of having a diagnosis of BN at the 22-year assessment was the length of time during the study when the diagnostic criteria for BN were met.

CONCLUSIONS

Together, these results indicate that the presence and persistence of binge eating and purging behaviors were poor prognostic indicators and that comorbidity with depression is particularly pernicious in AN. Treatment providers might pay particular attention to these issues in an effort to positively influence recovery over the long-term.

Multidimensional Predictors of Treatment Outcome in Usual Care for Adolescent Conduct Problems and Substance Use

This study investigated baseline client characteristics that predicted long-term treatment outcomes among adolescents referred from school and community sources and enrolled in usual care for conduct and substance use problems. Predictor effects for multiple demographic (age, sex, race/ethnicity), clinical (baseline symptom severity, comorbidity, family discord), and developmental psychopathology (behavioral dysregulation, depression, peer delinquency) characteristics were examined. Participants were 205 adolescents (52 % male; mean age 15.7 years) from diverse backgrounds (59 % Hispanic American, 21 % African American, 15 % multiracial, 6 % other) residing in a large inner-city area. As expected, characteristics from all three predictor categories were related to various aspects of change in externalizing problems, delinquent acts, and substance use at one-year follow-up. The strongest predictive effect was found for baseline symptom severity: Youth with greater severity showed greater clinical gains. Higher levels of co-occurring developmental psychopathology characteristics likewise predicted better outcomes. Exploratory analyses showed that change over time in developmental psychopathology characteristics (peer delinquency, depression) was related to change in delinquent acts and substance use. Implications for serving multiproblem adolescents and tailoring treatment plans in routine care are discussed.

Family Therapy for Child and Adolescent Eating Disorders: A Critical Review

Eating disorder-focused family therapy has emerged as the strongest evidence-based treatment for adolescent anorexia nervosa, supported by evidence from nine RCTs, and there is increasing evidence of its efficacy in treating adolescent bulimia nervosa (three RCTs). There is also emerging evidence for the efficacy of multifamily therapy formats of this treatment, with a recent RCT demonstrating the benefits of this approach in the treatment of adolescent anorexia nervosa. In this article, we critically review the evidence for eating disorder-focused family therapy through the lens of a moderate common factors paradigm. From this perspective, this treatment is likely to be effective as it provides a supportive and nonblaming context that: one, creates a safe, predictable environment that helps to contain anxiety generated by the eating disorder; two, promotes specific change early on in treatment in eating disorder-related behaviors; and three, provides a vehicle for the mobilization of common factors such as hope and expectancy reinforced by the eating disorder expertise of the multidisciplinary team. In order to improve outcomes for young people, there is a need to develop an improved understanding of the moderators and mediators involved in this treatment approach. Such an understanding could lead to the refining of the therapy, and inform adaptations for those families who do not currently benefit from treatment.

Predictors and moderators of response to enhanced cognitive behaviour therapy and interpersonal psychotherapy for the treatment of eating disorders

Consistent predictors, and more especially moderators, of response to psychological treatments for eating disorders have not been identified. The present exploratory study examined predictors and moderators of outcome in adult patients who took part in a randomised clinical trial comparing two leading treatments for these disorders, enhanced cognitive behavioural therapy (CBT-E) and interpersonal psychotherapy (IPT). Four potentially important findings emerged. Firstly, patients with a longer duration of disorder were less likely to benefit from either treatment. Second, across the two treatments the presence, at baseline, of higher levels of over-evaluation of the importance of shape predicted a less good treatment outcome. Third DSM-IV diagnosis did not predict treatment outcome. Fourth, with the exception of patients with baseline low self-esteem who achieved a better outcome with CBT-E, it was generally not possible to identify a subgroup of patients who would differentially benefit from one or other treatment.

The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives

BACKGROUND

Evidence-based practice in eating disorders incorporates three essential components: research evidence, clinical expertise, and patient values, preferences, and characteristics. Conceptualized as a 'three-legged stool' by Sackett et al. in 1996 (BMJ), all of these components of evidence-based practice are considered essential for providing optimal care in the treatment of eating disorders. However, the extent to which these individual aspects of evidence-based practice are valued among clinicians and researchers is variable, with each of these stool 'legs' being neglected at times. As a result, empirical support and patient preferences for treatment are not consistently considered in the selection and implementation of eating disorder treatment. In addition, clinicians may not have access to training to provide treatments supported by research and preferred by patients. Despite these challenges, integrating these three components of evidence-based practice is critical for the effective treatment of eating disorders.

DISCUSSION

Current research supports the use of several types of psychotherapies, including cognitive-behavioral, interpersonal, and family-based therapies, as well as certain types of medications for the treatment of eating disorders. However, limitations in current research, including sample heterogeneity, inconsistent efficacy, a paucity of data, the need for tailored approaches, and the use of staging models highlight the need for clinical expertise. Although preliminary data also support the importance of patient preferences, values, and perspectives for optimizing treatment, enhancing treatment outcome, and minimizing attrition among patients with eating disorders, the extent to which patient preference is consistently predictive of outcome is less clear and requires further investigation. All three components of evidence-based practice are integral for the optimal treatment of eating disorders. Integrating clinical expertise and patient perspective may also facilitate the dissemination of empirically-supported and emerging treatments as well as prevention programs. Further research is imperative to identify ways in which this three-legged approach to eating disorder treatment could be most effectively implemented.

Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis

OBJECTIVE

Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out.

METHOD

A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor.

RESULTS

The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type.

DISCUSSION

To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types.

A pilot study of maudsley family therapy with group dialectical behavior therapy skills training in an intensive outpatient program for adolescent eating disorders

OBJECTIVE

The goal of this study was to provide pilot clinical data on the effectiveness of an intensive outpatient treatment model for adolescent eating disorders that combines Maudsley-based family therapy and group dialectical behavior therapy skills training.

METHOD

Measures of physical and psychological status were gathered upon admission, discharge, and at 3 follow-up intervals.

RESULTS

Adolescents who completed the program gained a significant amount of weight and experienced a significant decrease in eating disorder psychopathology. At the 1-year follow-up, 64% of adolescents were weight restored and menstruating normally. Measures of eating disorder psychopathology continued to improve up to a year after treatment.

CONCLUSIONS

This pilot, multimodal program warrants further investigation and may be an effective intermediate level of care treatment option for adolescent eating disorders.

Predictors and moderators of psychological changes during the treatment of adolescent bulimia nervosa

This study examined predictors of psychological change among 80 adolescents with bulimia nervosa (BN) participating in a randomized-controlled trial comparing family-based treatment (FBT) to supportive psychotherapy (SPT). Psychological outcomes (cognitive eating disorder pathology, depression, and self-esteem) were explored at baseline, post-treatment, and 6-month follow-up. Multi-level growth models examined predictors of rate of change in psychological outcomes and moderators of treatment effects. All psychological outcomes improved through 6-month follow-up (moderate to large effect sizes) across both treatments. Overall, few significant predictors were identified. Older adolescents had faster change in self-esteem relative to younger adolescents (p = 0.03). Adolescents taking psychotropic medication at baseline had faster change in eating concerns relative to adolescents not taking medication (p = 0.02). Age (p = 0.02) and baseline purging severity (p = 0.03) moderated the relationship between treatment condition and change in eating concerns, where younger adolescents and individuals with high baseline purging had greater change when treated with FBT relative to SPT. Age and purging did not significantly moderate change in other psychological outcomes. Bulimic symptom improvement did not predict change in psychological symptoms. Generally, FBT and SPT were equally efficacious with respect to psychological improvement, although FBT may be more efficacious in younger adolescents and those with more frequent purging.

An Update on Evidence-Based Psychosocial Treatments for Eating Disorders in Children and Adolescents

Eating disorders are relatively common and serious disorders in adolescents. However, there are few controlled psychosocial intervention studies with this younger population. This review updates a previous Journal of Clinical Child and Adolescent Psychology review published in 2008. The recommendations in this review were developed after searching the literature including PubMed/Medline and employing the relevant medical subject headings. In addition, the bibliographies of book chapters and treatment guideline articles were reviewed; last, colleagues were asked for suggested additional source materials. Psychosocial treatments examined include family therapy, individual therapy, cognitive behavioral therapy, interpersonal psychotherapy, cognitive training, and dialectical behavior therapy. Using the most recent Journal of Clinical Child and Adolescent Psychology methodological review criteria, family treatment-behavior (FT-B) is the only well-established treatment for adolescents with anorexia nervosa. Family treatment-systemic and insight oriented individual psychotherapy are probably efficacious treatments for adolescents with anorexia nervosa. There are no well-established treatments for adolescents with bulimia nervosa, binge eating disorder, or avoidant restrictive food intake disorder. Possibly efficacious psychosocial treatments for adolescent bulimia nervosa include FT-B and supportive individual therapy. Internet-delivered cognitive behavioral therapy is a possibly efficacious treatment for binge eating disorder. Experimental treatments for adolescent eating disorders include enhanced cognitive behavioral therapy, dialectical behavioral therapy, cognitive training, and interpersonal psychotherapy. FT-B is the only well-established treatment for adolescent eating disorders. Additional research examining treatment for eating disorders in youth is warranted.

Moderators and Predictors of Response to Eating Disorder Risk Factor Reduction Programs in Collegiate Female Athletes

OBJECTIVE

The primary aim of this paper was to investigate moderators and predictors of response to two programs designed to reduce eating disorder risk factors in collegiate female athletes. This study served as an ancillary study to a parent trial that investigated the feasibility of an athlete modified cognitive dissonance-based program (AM-DBP) and an athlete modified healthy weight intervention program (AM-HWI).

DESIGN

157 female collegiate athletes were randomized to either the AM-DBP or the AM-HWI program. Participants completed surveys at baseline, post-intervention, 6 weeks, and 1 year.

METHODS

After classifying sports as either lean or non-lean, we investigated if sport type acted as a moderator of program response to AM-DBP and AM-HWI using ANOVAs. Next, we examined whether baseline thin-ideal internalization, weight concern, shape concern, bulimic pathology, dietary restraint, and negative affect acted as predictors of changes in bulimic pathology using linear regression models.

RESULTS

Athletes in non-lean sports who received AM-DBP showed more improvement in negative affect versus non-lean sport athletes in AM-HWI. Higher baseline scores of bulimic pathology predicted greater response in bulimic pathology to both programs at 6-weeks. In contrast, athletes with higher dietary restraint and negative affect baseline scores showed decreased response to both interventions at 6-weeks. Finally, athletes with higher baseline shape concern showed a decreased response to the AM-HWI intervention at the post intervention time point.

CONCLUSION

Results from the present study indicate that lean/non-lean sport may not play a strong role in determining response to efficacious programs. Further, factors such as pre-existing bulimic pathology, dietary restraint, negative affect, and shape concern may affect general response to intervention versus specific responses to specific interventions.

Normative data for female adolescents with eating disorders on the Children's Depression Inventory

OBJECTIVE

Given the importance of assessing depressive symptoms and suicidal ideation in adolescents with eating disorders (EDs), the aim was to provide normative data on the Children's Depression Inventory (CDI) for female adolescents presenting for treatment of an ED.

METHOD

The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N = 1000), a prospective, ongoing registry study comprising consecutive pediatric tertiary ED referrals. Females (N = 256; 12-17 years) with DSM-5 EDs completed the CDI at intake.

RESULTS

Results on the CDI revealed a pattern of increasing depressive scores with age and higher scores among patients with anorexic spectrum disorders. The prevalence of suicidal ideation was high and had the same pattern as CDI scores. The mean score on the CDI in the sample was higher than community samples and clinical samples of adolescents with post-traumatic stress disorder, obsessive compulsive disorder, and other clinical disorders.

DISCUSSION

Females adolescents with EDs are at high-risk of depression and suicidal ideation. These data provide information about variation in CDI scores to guide clinicians in interpretation of scores.

Two pathways toward impulsive action: an integrative risk model for bulimic behavior in youth

BACKGROUND

This study provides an integrative review of existing risk factors and models for bulimia nervosa (BN) in young girls. We offer a new model for BN that describes two pathways of risk that may lead to the initial impulsive act of binge eating and purging in children and adolescents.

SCOPE

We conducted a selective literature review, focusing on existing and new risk processes for BN in this select population.

FINDINGS

We identify two ways in which girls increase their risk to begin engaging in the impulsive behavior of binge eating and purging. The first is state-based: the experience of negative mood, in girls attempting to restrain eating, leads to the depletion of self-control and thus increased risk for loss of control eating. The second is personality-based: elevations on the trait of negative urgency, or the tendency to act rashly when distressed, increase risk, particularly in conjunction with high-risk psychosocial learning. We then briefly discuss how these behaviors are reinforced, putting girls at further risk for developing BN.

CONCLUSIONS

We highlight several areas in which further inquiry is necessary, and we discuss the clinical implications of the new risk model we described.

Observed connection and individuation: relation to symptoms in families of adolescents with bulimia nervosa

OBJECTIVE

To examine the relation between observed familial connection and individuation and adolescent bulimia nervosa (BN) symptoms.

METHOD

As part of a treatment study for adolescent BN, adolescents (n = 54) and their parents participated in a videotaped semi-structured interview. Participants were rated on observed connection and individuation from these interviews using the Scale of Intergenerational Relationship Quality and two measures of connection.

RESULTS

There was a significant negative relation between individuation from parents and adolescent BN symptoms. Connection both to and from mothers and adolescents was negatively associated with BN symptoms. Increased eating concern was significantly associated with a greater likelihood of expressing a desire for more connection with the family.

DISCUSSION

Investigating and understanding family factors present at the time of adolescent BN may assist in providing treatment specific to the needs of the family to best aid the adolescent's recovery process.

Adolescent bulimia nervosa

Onset of bulimia nervosa (BN) typically occurs in adolescence and is frequently accompanied by medical and psychiatric sequelae that may have detrimental effects on adolescent development. Potentially serious medical consequences and high comorbid rates of mood disorders and suicidality underscore the need for early recognition and effective treatments. Research among adolescents with BN has lagged behind that of adults, although evidence is accumulating to support the efficacy of family-based interventions and cognitive behavioral treatments that are adapted for use with adolescent populations. The aim of the current article is to provide an overview of recent research on epidemiology, risk factors, diagnostic issues, and treatment interventions focusing on adolescent BN, and to highlight areas for future research.

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Intervention research in couple and family therapy: a methodological and substantive review and an introduction to the special issue

This article serves as an introduction to this third version of research reviews of couple and family therapy (CFT) that have appeared in this journal beginning in 1995. It also presents a methodological and substantive overview of research in couple and family therapy from about 2001/2002 to 2010/2011 (the period covered in this issue), while also making connections with previous research. The article introduces quantitative research reviews of family-based intervention research that appear in this issue on 10 substantive areas including conduct disorder/delinquency, drug abuse, childhood and adolescent disorders (not including the aforementioned), family psycho-education for major mental illness, alcoholism, couple distress, relationship education, affective disorders, interpersonal violence, and chronic illness. The paper also introduces the first qualitative research paper in this series, as well as a paper that highlights current methodologies in meta-analysis. The first part of this article rates the 10 content areas on 12 dimensions of methodological strength for quantitative research and makes generalizations about the state of quantitative methodology in CFT. The latter part of the papers summarizes and makes comments on the substantive findings in the 12 papers in this issue, as well as on the field as a whole.

Family-based interventions for child and adolescent disorders

Emotional and behavioral symptoms and disorders are prevalent in children and adolescents. There has been a burgeoning literature supporting evidence-based treatments for these disorders. Increasingly, family-based interventions have been gaining prominence and demonstrating effectiveness for myriad childhood and adolescent disorders. This article presents the current evidence in support of family-based interventions for mood, anxiety, attention-deficit hyperactivity, disruptive behavior, pervasive developmental particularly autism spectrum, and eating disorders. This review details recent data from randomized controlled trials (RCTs) and promising interventions not yet examined using a randomized controlled methodology. It highlights the evidence base supporting various specific family-based interventions, some of which are disorder dependent. A practitioner perspective is then offered with regard to recommendations for future practice and training. The article closes with a summary and directions for future research.

Moderators and mediators of remission in family-based treatment and adolescent focused therapy for anorexia nervosa

Few of the limited randomized controlled trails (RCTs) for adolescent anorexia nervosa (AN) have explored the effects of moderators and mediators on outcome. This study aimed to identify treatment moderators and mediators of remission at end of treatment (EOT) and 6- and 12-month follow-up (FU) for adolescents with AN (N = 121) who participated in a multi-center RCT of family-based treatment (FBT) and individual adolescent focused therapy (AFT). Mixed effects modeling were utilized and included all available outcome data at all time points. Remission was defined as ≥ 95% IBW plus within 1 SD of the Eating Disorder Examination (EDE) norms. Eating related obsessionality (Yale-Brown-Cornell Eating Disorder Total Scale) and eating disorder specific psychopathology (EDE-Global) emerged as moderators at EOT. Subjects with higher baseline scores on these measures benefited more from FBT than AFT. AN type emerged as a moderator at FU with binge-eating/purging type responding less well than restricting type. No mediators of treatment outcome were identified. Prior hospitalization, older age and duration of illness were identified as non-specific predictors of outcome. Taken together, these results indicate that patients with more severe eating related psychopathology have better outcomes in a behaviorally targeted family treatment (FBT) than an individually focused approach (AFT).

Naturalistic study of course, effectiveness, and predictors of outcome among female adolescents in residential treatment for eating disorders

Few empirical data address naturalistic outcomes of residential eating disorder (ED) treatment. Study aims were to evaluate course, effectiveness, and predictors of outcome in a residential treatment program. We evaluated 80 consecutively admitted female adolescents with the SCID-IV. Primary outcomes were treatment completion, subsequent readmission, clinical global impressions, and changes in body weight. Mean length of stay was 51 days, and 80% of patients were discharged according to treatment plans. Mean expected body weight (EBW) for AN patients increased from 80% to 91%. Patients reported significant improvements in ED symptoms, depression, and quality of life. Low admission %EBW and previous psychiatric hospitalizations were associated with premature termination. Overall, findings support that residential treatment is largely acceptable to patients, and that residential care may provide an opportunity for substantive therapeutic gains.

Are single-parent families different from two-parent families in the treatment of adolescent bulimia nervosa using family-based treatment?

OBJECTIVE

To examine whether family-based treatment (FBT) for adolescent bulimia nervosa (BN), which emphasizes family involvement in helping to reduce binge eating and purging behaviors, is differentially efficacious in single-parent families versus two-parent families.

METHOD

Forty-one adolescents (97.6% female; 16.0 +/- 1.7 years old) with either BN (n = 18) or subthreshold BN (n = 23) were randomized to FBT as part of a larger randomized controlled trial studying treatments for adolescent BN.

RESULTS

Two-parent (n = 27; 65.9%) and single-parent (n = 14; 34.2%) families were compared on demographic variables, presence of comorbid psychiatric illnesses, and symptoms of BN at baseline, post, and 6-month follow-up. ANOVA and chi-square analyses revealed no statistically significant differences between two-parent and single-parent families on any variables with the exception of ethnicity, for which a greater proportion of Caucasians and Hispanic families had two- parent families compared with African-American families (chi(2) = 8.68, p = .01).

DISCUSSION

These findings suggest that FBT may be an appropriate and efficacious treatment for single-parent families as well as two-parent families, despite the reliance on parental intervention to reduce bulimic symptoms and normalize eating patterns.

Early response to treatment in adolescent bulimia nervosa

OBJECTIVE

The purpose of this study was to determine if early response predicted remission at the end of a controlled trial.

METHOD

Eighty adolescents with bulimia nervosa participated in an RCT comparing family-based treatment and individual supportive psychotherapy. Response to treatment was assessed via self-report of bingeing and purging. Remission was defined as abstinence from bingeing and purging for the last 28 days and measured by investigator-based interview, that is, the Eating Disorder Examination.

RESULTS

Receiver-operating characteristic analyses showed that, regardless of treatment, symptom reduction at session six predicted remission at posttreatment (AUC = 0.814 (p < .001)) and 6-month follow-up (AUC = 0.811 (p < .001)).

CONCLUSION

Results suggest that adolescents with BN who do not show early reductions in bulimic symptoms are unlikely to remit at posttreatment or follow-up.