User satisfaction with family-based inpatient treatment for adolescent anorexia nervosa: retrospective views of patients and parents

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

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

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

PURPOSE

Anorexia nervosa (AN) is a mental disorder for which hospitalization is frequently needed in case of severe medical and psychiatric consequences. We aim to describe the state-of-the-art inpatient treatment of AN in real-world reports.

METHODS

A systematic review of the literature on the major medical databases, spanning from January 2011 to October 2023, was performed, using the keywords: "inpatient", "hospitalization" and "anorexia nervosa". Studies on pediatric populations and inpatients in residential facilities were excluded.

RESULTS

Twenty-seven studies (3501 subjects) were included, and nine themes related to the primary challenges faced in hospitalization settings were selected. About 81.48% of the studies detailed the clinical team, 51.85% cited the use of a psychotherapeutic model, 25.93% addressed motivation, 100% specified the treatment setting, 66.67% detailed nutrition and refeeding, 22.22% cited pharmacological therapy, 40.74% described admission or discharge criteria and 14.81% follow-up, and 51.85% used tests for assessment of the AN or psychopathology. Despite the factors defined by international guidelines, the data were not homogeneous and not adequately defined on admission/discharge criteria, pharmacological therapy, and motivation, while more comprehensive details were available for treatment settings, refeeding protocols, and psychometric assessments.

CONCLUSION

Though the heterogeneity among the included studies was considered, the existence of sparse criteria, objectives, and treatment modalities emerged, outlining a sometimes ambiguous report of hospitalization practices. Future studies must aim for a more comprehensive description of treatment approaches. This will enable uniform depictions of inpatient treatment, facilitating comparisons across different studies and establishing guidelines more grounded in scientific evidence.

LEVEL OF EVIDENCE

Level I, systematic review.

Fathers in the spotlight: parental burden and the effectiveness of a parental skills training for anorexia nervosa in mother-father dyads

PURPOSE

Research on the engagement of fathers in the treatment of childhood psychiatric disorders is scarce. This study aims to investigate differences between mothers and fathers of adolescents with anorexia nervosa regarding parental burden and effectiveness of a parental skills training.

METHODS

Ninety-one mother-father dyads caring for a child with anorexia nervosa participated in an 8-week parental skills training and completed a set of questionnaires assessing parental psychopathology, eating disorder related burden, caregiver skills and expressed emotion at baseline and post-intervention.

RESULTS

Fathers showed lower levels of general psychological distress, depression, anxiety and eating disorder related burden as well as lower emotional overinvolvement compared to mothers. The skills training was effective in reducing parental psychopathology, eating disorder-related burden and emotional overinvolvement as well as in increasing caregiver skills with no differences between mothers and fathers. However, session adherence and the willingness to practice skills between the sessions were slightly lower in fathers.

CONCLUSIONS

These findings show that fathers are a great resource for the child's eating disorder treatment as they may counterbalance maternal emotional overinvolvement and over-protection. Furthermore, this is the first study demonstrating that fathers can profit from a parental skills training for anorexia nervosa in a similar way as mothers.

LEVEL III

Evidence obtained from well-designed cohort or case-control analytic studies.

Design and testing of a health economic Markov model for treatment of anorexia nervosa

OBJECTIVES

Anorexia Nervosa (AN) is a severe psychiatric disorder and knowledge about the cost-effectiveness of potential interventions is limited. The aim of this paper is to introduce the Trimbos Institute health economic cost-effectiveness model for Anorexia Nervosa (AnoMod-TI), a flexible modelling tool for assessing the long-term cost-effectiveness of interventions for AN in late adolescent and adult patients, which could support clinical decision making.

METHODS

AnoMod-TI is a state-transition cohort simulation (Markov) model developed from a Dutch societal perspective, which consists of four health states - namely full remission (FR), partial remission (PR), AN and death. Results are expressed as total healthcare costs, QALYs and incremental cost-effectiveness ratio.

RESULTS

For the purpose of demonstrating AnoMod-TI and how it could be used to estimate cost-effectiveness over a 20-year time horizon, it was applied to a hypothetical treatment scenario. Results illustrate how a relatively costly intervention with only modest effects can still be cost-effective in the long term.

CONCLUSIONS

AnoMod -TI can be used to examine long-term cost-effectiveness of various interventions aimed at either treating AN or preventing relapse from a state of partial or full remission. AnoMod-TI is freely available upon request to the authors.

Satisfaction with in-patient child and adolescent psychiatric treatment: development and psychometric properties of the BEST questionnaires for adolescents and for parents

BACKGROUND

Interest in the assessment of patient satisfaction with in-patient psychiatric treatment has steadily increased and several measurement tools are available for the quantification of patients' experience. However, they are often uni-dimensional or focus mainly on therapeutic relationship and environment, and neglect other important issues such as information about treatment and participation. The BEST questionnaires were developed as comprehensive instruments that include items on all of the mentioned topics. The present study evaluates the psychometric properties of the BEST in a version for adolescents and for parents. Furthermore, the dimensionality of the satisfaction ratings is analyzed.

METHOD

Descriptive statistics were applied to data of 1582 adolescents (mean age = 15.0 years, SD = 1.65; 62.4% female) and 1998 parents/guardians assessed in seven in-patient units across Germany. The factorial structure of the BEST questionnaires was determined by exploratory and confirmatory factor analyses, including a bifactor model.

RESULTS

The psychometric quality of the scales was strong. Correlations with another assessment instrument of patient satisfaction were good to high, indicating good convergent validity. Exploratory factor analyses revealed three factors in adolescents that were labelled as: Therapeutic relationship, environment, and general satisfaction and treatment success. For parents, the same three factors could be distinguished. Confirmatory bifactor models suggested that the vast majority of variance was accounted for by the general factor; the three specific factors provided some additional information. Agreement between the subscales of adolescents and their parents was only moderate. Parents were usually more satisfied.

CONCLUSIONS

The BEST questionnaires can be considered as reliable and valid instruments to not only assess the "classical" aspects of patient satisfaction, but to also assess newer fundamental topics such as children's rights and treatment participation. For scientific usage, the total score seems superior because of the high explained variance by the general factor, but the subscale scores provide further information. The use of single items seems advantageous for quality management purposes.

Feasibility and acceptability of home treatment as an add-on to family based therapy for adolescents with anorexia nervosa. A case series

OBJECTIVE

This study examines the feasibility, acceptability, and preliminary effect sizes on outcome measures of home treatment (HT) as an add-on to family-based therapy (FBT) in adolescents with anorexia nervosa (AN). The HT intervention is delivered by specialized nurses and aims at supporting patients and parents to re-establish family meals in the home environment.

METHOD

Forty-five (43 female, 2 male) adolescents meeting ICD 10 criteria for anorexia nervosa or atypical anorexia nervosa received FBT augmented with HT over 12 weeks. Eating disorder (ED) diagnosis, psychopathology and severity of clinical symptoms were assessed using the Eating Disorder Examination (EDE) interview, the Eating Disorders Inventory (EDI-2) at baseline (BL) and after 3-months RESULTS: All participants and parents were retained and found HT acceptable. At the end of Treatment (EOT) participants showed a significant early weight gain, a reduction in the AN psychopathology assessed with the EDE interview and a reduction in EDI-2 total scores. None of the patients had to be admitted to hospital. Treatment satisfaction was high in both patients and parents.

DISCUSSION

Findings provide preliminary evidence that HT is feasible, acceptable and produces clinically significant improvements in targeted outcome.

Parental experiences with their child's eating disorder treatment journey

BACKGROUND

Parents are integral in the treatment of pediatric eating disorders. The current study was conducted to further understand the barriers and facilitators that parents experience in accessing specialized, tertiary level eating disorder treatment for children and adolescents. The goals of the study were to understand the processes leading to diagnosis and treatment, perceived barriers and facilitators to accessing care, and parents' experiences over the course of their child's eating disorder treatment.

METHODS

Ten parents whose children were admitted to a Canadian tertiary level specialized pediatric eating disorders program took part in an exit interview upon their child's completion of treatment in the program. In-depth semi-structured interviews were combined with a visual timeline. Interpretive induction was performed to generate high-level concepts that emerged from the interviews.

RESULTS

Five high-level concepts were identified: (1) delays in identifying eating disorder symptoms, (2) challenges in accessing eating disorder services, (3) the right treatment at the right time, (4) emotional impact on parents, and (5) parental expertise and involvement.

CONCLUSIONS

Several barriers were identified by parents that interfered with treatment, including system-related challenges when accessing specialized eating disorder treatment, concerns about a lack of appropriate mental health support for their child, and difficulties with transitioning between community and tertiary level care. Negative emotions, including guilt and self-blame, were common early in the treatment journey. Themes of parental involvement throughout treatment, and parents taking charge of their child's recovery, emerged across interviews. The results of this study suggest the importance of early identification of eating disorder symptoms, facilitating smoother transitions between levels of care (e.g., community services and hospital-based eating disorder care), and improving clinical decision-making to ensure children and adolescents with eating disorders receive the most appropriate treatment based on their clinical presentation.

Exploring alternatives for adolescent anorexia nervosa: adolescent and parent treatment (APT) as a novel intervention prospect

Recovery and remission rates of adolescent anorexia nervosa (AN) following Family Based Treatment (FBT) have seen a relative decline over recent years. While reasonably successful in achieving physical recovery (i.e. weight restoration), both empirical and anecdotal accounts highlight a lack of attention to the psychological recovery of the adolescent within manualised FBT. As such, there is a need for innovation to explore treatment variations and alternatives for the proportion of adolescents with AN who do not respond favourably to this first-line treatment. This paper introduces a new treatment framework to the field for clinical consideration and empirical assessment. Adolescent and Parent Treatment (APT) for adolescent AN draws from both family-based and individual treatment models, applying a developmental lens. APT attends to physical and psychological recovery simultaneously and from the start of treatment, with capacity to tailor individual psychological modules to the adolescent formulation. While clearly in its infancy, APT provides an exciting new avenue for exploration within the field, as we seek new avenues to support young people and their families to effectively combat this deadly illness.

Family members' reflections upon a family-based inpatient treatment program for adolescent anorexia nervosa: a thematic analysis

BACKGROUND

Family-based outpatient treatment is usually recommended as the treatment of choice when a child develops anorexia nervosa. However, some young persons will inevitably require higher levels of care. Qualitative research on family perspectives may help inform strategies to adapt family-based practices into intensified treatment settings. Our overarching aim was to investigate family members' perspectives following a family-based inpatient treatment program for adolescent anorexia nervosa and to discuss clinical implications for treatment providers.

METHODS

A subsample of eight families taking part in a naturalistic outcome study at a specialized eating disorder unit participated in the study (8 patients, 14 parents, and 10 siblings). The thematic analyses were inductive, predominantly descriptive, and guided by a multi-perspective framework.

RESULTS

Five main themes were identified: 1: Expectations and evaluation of needs. Entering treatment from different vantage points, 2: Interactions with peers during the admission as highly beneficial or problematic, 3: Perspectives on staff expertise and the eating disorder unit's structure, 4: Influencing within family relationships in different ways, and 5: Being admitted is at best only half the job: reflections on leaving the eating disorder unit.

CONCLUSIONS

Our study offers insight into how former inpatients and their family members experienced an inpatient treatment program designed to align treatment with the central elements of an outpatient family-based treatment approach for adolescent anorexia nervosa. Overall, the findings support emerging research underlining the necessity of strengthening the family-based treatment approach within intensified treatment settings. Moreover, the results emphasized the need for more knowledge on how to optimize inpatient treatment as well as the importance of providing smooth transitions between care settings.

Current Therapeutic Approaches to Anorexia Nervosa: State of the Art

Anorexia nervosa (AN) is a devastating psychiatric disorder characterized by extreme restriction of food intake and low body weight, both associated with significant medical and psychological morbidity. The clinical severity of AN has prompted the consideration and study of behavioral and pharmacological treatments in efforts to establish empirically based methods to reduce the burden of the disorder. Among adolescents, family-based treatment is considered a first-line behavioral treatment. Research continues to explore the efficacy of family-based treatment and predictors of treatment response to further improve outcomes. Several behavioral treatments for adults also exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain. Despite this, no one treatment is considered superior, and all existing behavioral approaches leave a proportion of adults symptomatic or at a high risk of relapse. As such, among adults, there is continued need for development of novel, mechanism-based approaches to better target the core symptoms of AN. Although antidepressants impart little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with AN. Most recently, the field's evolving conceptualization of AN as a biologically based disorder coupled with technological advancements has led to consideration of varying neuromodulation strategies as a potential therapeutic approach that remains under investigation.

Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa

OBJECTIVE

Safe, tolerable, effective approaches to weight restoration are needed for adults with anorexia nervosa (AN). We examined weight outcomes and patient satisfaction with an integrated, inpatient-partial hospitalization, meal-based behavioral program that rapidly weight restores a majority of patients.

METHOD

Consecutively discharged inpatients (N = 149) treated on weight gain protocol completed an anonymous questionnaire assessing treatment satisfaction at inpatient discharge. Responders (107/149) rated their satisfaction with program components, feeling included in treatment, and likelihood of returning, or recommending the program to others. Clinical and demographic data were abstracted by chart review on all cases.

RESULTS

Over 70% of adult patients met BMI≥19 kg/m² by program discharge. Mean inpatient rate of gain was 1.85 kg/week (SD = 0.89). A majority (83.2%) would recommend the program to others and 71.4% endorsed a willingness to return if needed. The behavioral treatment focus was rated highly by 82.9% of respondents and was the strongest predictor of likelihood of referring others.

DISCUSSION

Results indicate a behaviorally focused, integrated, meal-based specialty program for eating disorders that includes rapid weight gain is acceptable to most participants. Data have implications for quality care, outcome reporting, and cost-effectiveness of inpatient behavioral weight restoration programs for individuals with AN.

Adolescent and Parent Experience of Care at a Family-Based Treatment Service for Eating Disorders

OBJECTIVE

Incorporating consumer perspectives is an important but often overlooked opportunity to optimize treatment engagement and outcomes for adolescents with eating disorders. This study explored the experience of care of adolescents and their parents at a multidisciplinary specialist eating disorders service providing family-based treatment (FBT) as first-line treatment.

METHOD

Eighty-five adolescents and 145 parents who completed FBT at the service between 2013 and 2015 were surveyed in 2017 about their experience of care. A study-designed survey asked respondents to rate on Likert scales their experience of service access, intake assessment, education, support, interactions with the treatment team, recovery, and the discharge process. Open-ended comments on helpful and unhelpful aspects of the service provided further context on the ratings.

RESULTS

Overall families were very positive about their experience, particularly in regard to assessment, education, interactions with the team, and achieving physical health. Although parents tended to be more satisfied, adolescents also held the service in high regard. Some areas were identified that could be improved, including treatment delays, carer support, therapeutic alliance, and preparation for discharge.

CONCLUSIONS

Surveying families about their experience of care provides an important opportunity to identify service strengths as well as services gaps. The results indicated several areas that specialist eating disorder services could focus on to ensure that the services provided, including FBT, fully meet the needs of families and optimize adolescents' treatment experiences.

Physical restraint during inpatient treatment of adolescent anorexia nervosa: frequency, clinical correlates, and associations with outcome at five-year follow-up

BACKGROUND

Studies of the use and effects of physical restraint in anorexia nervosa (AN) treatment are lacking. The purpose of this study was to describe the frequency of physical restraint in a specialized program for adolescents with AN, and to examine if meal-related physical restraint (forced nasogastric tube-feeding) was related to 5-year outcome.

METHOD

Thirty-eight (66% of 58) patients with AN (mean age 15.9, SD = 1.9) admitted to a regional, specialized adolescent eating disorders (ED) inpatient unit. Patient data, including restraint episodes, were obtained from hospital records, and outcome was assessed at a 5-year follow-up.

RESULTS

A total of 201 restraint episodes occurred over 5513 days of inpatient treatment, including 109 meal-related episodes and 56 episodes to avoid self-harm. Twelve (32%) patients experienced at least one restraint episode during the admission, of which eight (21%) experienced meal-related restraint. Four patients represented 91% of all restraint episodes, experiencing 10 or more episodes during admission. Meal-related restraint was significantly associated with a higher rate of persisting ED diagnosis, but not with weight gain during admission, EDE-Q global score or BMI at follow-up.

CONCLUSIONS

Restraint episodes occurred rather infrequently. A small number of patients (n = 4) accounted for a high proportion of episodes (91%). More knowledge is important to reduce the need for restraint in treatment for AN.

External support and personal agency - young persons' reports on recovery after family-based inpatient treatment for anorexia nervosa: a qualitative descriptive study

BACKGROUND

Recommended treatment for adolescent anorexia nervosa (AN) is usually family-based and an overarching treatment aim is to empower the parents to manage the difficult meals and aid their child toward recovery. While family-based treatment prioritize collaborating with the parents, understanding the young persons' views on recovery is also important. Understanding the young person's views and ideas is relevant as this may facilitate the therapeutic alliance and thus aid the therapeutic process. The purpose of the present study was to investigate the reflections of young persons with a lived experience of anorexia nervosa, and what factors they consider important for the recovery process. All participants had been provided with a family-based inpatient treatment program, a program inspired by the core features of outpatient family-based treatment.

METHODS

Participants (n = 37) presented with an extensive treatment history, including outpatient and inpatient treatment for AN. Interview transcripts were analyzed by applying a predominantly inductive thematic approach to generate themes across participants.

RESULTS

The qualitative analysis generated a thematic structure entailing three levels. The superordinate theme, "Recovery is a long and winding journey: recognizing the need for support and highlighting the need for action", captured three main themes, "Realizing you have a problem", "Being involved in important relationships", and "Giving treatment a real chance".

CONCLUSIONS

Our results demonstrated that although young persons with a lived experience of anorexia nervosa recognized the importance of support from others, they placed a distinctive emphasis on self-responsibility and determination. We recommend clinicians working within the recommended family-based treatment frameworks be curious about young patient's subjective perspectives of the recovery process, as connecting with their views can potentially strengthen therapeutic relationships and facilitate change.

PLAIN ENGLISH SUMMARY

Recommended treatment for adolescent anorexia nervosa is usually family-based. These recommendations are supported by decades of research. In family-based treatment the overarching aim is to empower the young person's parents to manage and take charge of the difficult situation caused by the eating disorder. As recommended family-based treatments usually prioritize collaborating with the parents, it is important to be curious on the adolescents own views of what is regarded as important for the recovery process. The present study offers insights into factors considered important to the recovery process by young persons with lived experience of AN. Although voicing the importance of enlisting support from families, friends, and loved ones, the young participants distinctly emphasized their own responsibility, motivation and self-determination as critical factors for recovery. Inspired by our findings, we recommend that clinicians address the young patient's own preferred ideas for recovery during treatment.