Patterns of expressed emotion in adolescent eating disorders

Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes

Background: This systematic review investigated the impact of familial factors on individuals aged 10-17 who have clinical signs or symptoms of eating disorders. Simultaneously, it scrutinized the involvement of the family in therapy, as well as other forms of intervention. Methods: The PsycINFO, PubMed, and Scopus databases were used to search for research material comprehensively. After applying specific criteria, 46 articles were deemed suitable and included in the systematic review. The study comprised a cohort of 4794 adolescents who received a diagnosis of either Anorexia Nervosa (AN), Bulimia Nervosa (BN), or Binge-Eating Disorder (BED). In addition, controls were utilized for 1187 adolescents, 1563 parents, 1809 siblings, and 11 other relatives. Results: The connection between family factors and eating disorders is primarily determined by the families' level of functioning, satisfaction with the family dynamic, parents' attitudes toward their children, and the role of food within the family system. Family Therapy was the most used psychotherapeutic approach in the treatment of AN. The incidence of reports in BN closely paralleled that of Cognitive-Behavioral Therapy (CBT) models. Articles about (Enhanced) CBT were exclusively associated with BED. Conclusions: Family-based approaches are crucial in comprehending, preventing, and addressing eating disorders in adolescents. Incorporating the study of family dynamics and actively engaging families in the treatment process can significantly enhance recovery rates and decrease the occurrence of relapses.

Expressed emotion and treatment outcome in higher levels of care for eating disorders

OBJECTIVE

Expressed emotion (EE) among caregivers toward the affected offspring is a negative prognostic indicator for adolescent patients with eating disorders (EDs) in outpatient treatment. Less research has examined its impact on adolescents in higher levels of care (HLOC). The current study examined differences in caregiver EE according to the subtype of anorexia nervosa (AN) (restricting [AN-R] versus binge/purge [AN-BP]), and level of care (LOC). We also examined the main effects of baseline caregiver EE (emotional overinvolvement [EOI] or criticism), AN subtype, and their interaction on eating pathology and depression at discharge.

METHOD

Adolescent patients (N = 203) receiving treatment at HLOCs completed measures of ED pathology (Eating Disorder Examination-Questionnaire) and depression (Patient Health Questionnaire-9) at baseline and discharge, and one caregiver of each patient completed a measure of EE (Family Questionnaire) at baseline.

RESULTS

No differences in caregiver EE were found between patients with AN-R versus AN-BP, or relative to LOC. Caregiver EE did not predict outcome for ED symptoms or depression at discharge.

DISCUSSION

The impact of high caregiver EE may be less substantial at HLOCs than outpatient care given that caregivers are less involved in treatment at HLOCs. Future research is needed to determine if high caregiver EOI leads to poor treatment outcome for adolescents as it does for adults, or whether it is an appropriate expression of care for patients who are ill enough to require HLOC treatment.

PUBLIC SIGNIFICANCE STATEMENT

High caregiver EE was not found to predict treatment outcome for adolescents with eating disorders in higher levels of care (HLOCs), possibly due to the limited involvement of caregivers in HLOCs. However, patients step down to outpatient treatment, where high caregiver EE can have a significant negative impact on outcome. HLOCs should incorporate efforts to reduce high caregiver EE in anticipation of step-down to outpatient treatment.

Treatment-engagement fears in family-oriented interventions: validation of the caregiver traps scale for eating disorders

As more caregivers of children (of any age) struggling with an eating disorder are recruited as partners in care, it is important to identify potential barriers to such involvement. The Caregiver Traps Scale for Eating Disorders (CTS-ED) was developed as a measure of caregiver fears with respect to treatment-engagement. The purpose of this study was to evaluate its psychometric properties. One hundred and twenty four parents of children with ED participated in the validation of this instrument. Data were analyzed through exploratory factor analysis. The exploratory factor analysis revealed one factor, accounting for 39% of the variance, with a mean of 3.99 (scale from 1 to 7), indicating that caregivers endorsed clinically significant fears relating to their involvement in their child's treatment. The scale yielded high internal consistency (α = .89). As expected, the CTS-ED was significantly positively correlated with a measure of accommodating and enabling of ED symptoms, and negatively correlated with a measure of parental self-efficacy. This scale shows promise as a measure for clinicians and researchers to identify parental fears that could potentially fuel accommodating, enabling or treatment-interfering behaviors. Suggestions for its utility as a clinical and supervision tool are also provided.Clinical SignificanceDevelopment of an assessment tool to identify caregiver fears with respect to therapy engagement in the context of family-oriented interventions for eating disordersTool has the potential to increase the positive involvement of caregivers to support their child (of any age) with an eating disorderTool can be used clinically and to support self-reflective practices to improve compassionate clinician engagement of caregivers struggling to support their child.

Maintaining Factors of Anorexia Nervosa Addressed from a Psychotherapeutic Group for Parents: Supplementary Report of a Patient's Therapeutic Success

(1) Background: Anorexia nervosa is an eating disorder (ED) where up to 30% of individuals remain unresponsive to treatments, whether they partially respond, or do respond and later relapse. It has been broadly reported how presenting maladaptive family functioning and communication style contributes to treatment drop-out, poor treatment compliance, and poor long-term outcomes. We studied the mother and father of a patient with AN, binge-purge subtype (according to DSM-IV TR) who achieved remission after her parents but not her attended an intervention through a psychotherapy group for parents (PGP). (2) Methods: We previously reported this patient's case report, and now, through an Interpretative Phenomenological Analysis (IPA) approach, we aimed to explore the understanding and meanings ascribed by the mother and father to their experience at the PGP and to their daughter's clinical and functional improvement. (3) Results: We identified two main stages along the process: one related to the presence of maintaining factors of their daughter's disorder, and the other related to the emergence of a reflective function and to the implementation of behavioral, emotional and cognitive changes. (4) Conclusions: The interview revealed both parents' experience at the PGP promoted a change process, where they were able to modify their previous style of communication and functioning, and to identify them as a contributors to maintain their daughter's disorder. Reflective function (RF) emerged in the mother and father throughout the psychotherapeutic process. Both parents also revealed some elements that were intergenerationally transmitted, that affected three generations and contributed to maintaining the ED. We observed the multilevel open-group structure of the PGP, enhancing the mother's and father's change process.

Multi-family therapy for bulimia nervosa: a qualitative pilot study of adolescent and family members' experiences

BACKGROUND

Multi-family therapy (MFT-BN) is a new treatment for adolescent bulimia nervosa with emerging empirical support. It extends the bulimia nervosa focussed family therapy model, by offering treatment in a group setting. Up to nine families work together with a team of clinicians over the course of 20 weeks. No qualitative study to date has investigated the experience of MFT-BN. This study aimed to explore this from the adolescent and parent/caregiver perspective.

METHODS

Participants from two consecutive MFT-BN groups facilitated at the Maudsley Hospital in London, UK, were invited to participate in either a focus group or individual qualitative interview about the experience of MFT-BN. Of the 19 eligible participants (from 9 families), 15 (8 parents, 1 older sibling, 6 adolescents) consented and participated. Audio-recordings of interviews and focus groups were transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

Three main themes were identified; (1) seeing and being seen, (2) holistic shift, (3) the unspoken. Participants reported overall shifts in cognitions, emotions, behaviours, and relationships both individually and within the family as a result of attending MFT-BN. Meeting other families with similar struggles and sharing experiences, skills and learning helped reduce isolation and promote change. There was also a sense from participants that some things did not, or could not, be spoken about in the group context and that more direct and challenging conversations might have been helpful at times.

DISCUSSION

The current study identifies some of the perceived benefits and challenges of MFT-BN. The three themes demonstrate the holistic nature of change that can occur across the treatment, as well as the power and limits of the group therapy setting and process. Further research is needed to explore the experience of MFT-BN and its outcomes across a more diverse range of participants and treatment settings.

Family accommodation in eating disorders: a preliminary examination of correlates with familial burden and cognitive-behavioral treatment outcome

Previous research suggests caregivers of individuals with eating disorders (EDs) may attempt to reduce family strain by engaging in accommodation and enabling behaviors to avoid conflict or alleviate stress of the affected individual. Moreover, families often reorganize life around the ED, reinforcing ED behaviors and exacerbating family dysfunction and caregiver distress. However, limited research has examined how accommodation relates to caregivers' distress, family functioning, and treatment outcomes. The current study provides an initial evaluation of these associations among treatment-seeking individuals with EDs and their family members. Forty family members of individuals receiving cognitive behavioral therapy for EDs in a residential treatment setting completed the Accommodation and Enabling Scale for Eating Disorders (AESED) and measures of anxiety (Patient-Reported Outcomes Measurement Information System anxiety scale) and family functioning (Family Assessment Device; FAD) at the time of their family member's treatment admission. Eighteen patients completed the Eating Disorder Examination-Questionnaire (EDE-Q) at admission and discharge. AESED scores were positively associated with family member anxiety, FAD roles, FAD behavioral control, and higher patient EDE-Q global scores at discharge. Findings provide preliminary evidence that greater family accommodation not only relates to poorer family functioning, but uniquely relates to worse ED treatment outcome.

Examining the Role of Expressed Emotion in the Intergenerational Transmission of Mental Health Problems

Introduction: The aim of this study was to test a model of the intergenerational transmission of mental health problems (indicated by depression, anxiety, and loneliness) in which expressed emotion (indicated by criticism and emotional involvement) was specified as a mediator of mental health problems over multiple family generations.

Method: The sample consisted of three generations of grandmothers, mothers, and daughters (N = 242 family triads), wherein participants completed online surveys in which they self-reported on their own mental health problems and perceptions of their mothers’ expressed emotion.

Results: Results revealed only modest evidence of direct effects for the intergenerational transmission of mental health problems. However, there were a number of significant indirect effects, with all of these effects occurring through the criticism component of expressed emotion.

Discussion: This research identified expressed emotion as both a risk factor for offspring's mental health problems as well as a behavior typical of parents with mental health problems. Specifically, the results revealed that mental health problems are intergenerationally transmitted via critical parent-child interactions.

Predictive factors for outcome in adolescents with anorexia nervosa: To what extent does parental Expressed Emotion play a role?

In studies on family therapy in Anorexia Nervosa, family relationships, as assessed by Expressed Emotion, have been associated with outcome. Our aim was to explore the contribution of Expressed Emotion as a predictor of 18-month outcome, above and beyond the usual predictive factors. Sixty adolescent girls suffering from Anorexia Nervosa and their parents were assessed at baseline and 18 months later. Levels of Expressed Emotion were evaluated in both parents with the Five-Minute Speech Sample. After controlling for treatment group and initial clinical status, high maternal Emotional Over-Involvement at baseline was significantly associated with better clinical state. More precisely, high maternal Emotional Over-Involvement was associated with higher nutritional status, lower eating disorder severity and fewer re-hospitalizations 18 months later. No associations were found with paternal levels of Expressed Emotion. Therefore, our study confirmed the importance of taking into account both maternal and paternal Expressed Emotion. Our results also underlined that high maternal Emotional Over-Involvement plays a positive role in the outcome of Anorexia Nervosa and needs to be explored further.

An Adjunctive Multi-family Group Intervention with or without Patient Participation during an Inpatient Treatment for Adolescents with an Eating Disorder: A Pilot Study

This study reports on a pilot study of a family group intervention with or without patient participation adjunctive to a specialized inpatient treatment for eating disorders (EDs). Participants were 112 female adolescent ED inpatients and one or both of their parents. The parents were invited to participate in an adjunctive multi-family group with patient (MFT) or in a similar multi-parent group without patient participation (MPT). Questionnaires assessing ED symptoms, family functioning and caregiving experiences were administered before and after intervention. Post-intervention results obtained from both patient and parent(s) indicated that improvement in ED symptoms and parental burden occurred after both types of interventions. Family functioning improved differently according to the informant: fathers reported an improvement of general family functioning, patients reported an improvement of problem solving and mothers reported a decrease in problem solving across both formats. This study emphasized the importance of including a multi-informant approach in family interventions. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Family-based treatment of eating disorders in adolescents: current insights

Eating disorders are serious illnesses associated with significant morbidity and mortality. Family-based treatment (FBT) has emerged as an effective intervention for adolescents with anorexia nervosa, and preliminary evidence suggests that it may be efficacious in the treatment of adolescents with bulimia nervosa. Multifamily therapy for anorexia nervosa provides a more intensive experience for families needing additional support. This review outlines the three phases of treatment, key tenets of family-based treatment, and empirical support for FBT. In addition, FBT in higher levels of care is described, as well as challenges in the implementation of FBT and recent adaptations to FBT, including offering additional support to eating-disorder caregivers. Future research is needed to identify families for whom FBT does not work, determine adaptations to FBT that may increase its efficacy, develop ways to improve treatment adherence among clinicians, and find ways to support caregivers better during treatment.