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Lebow J, Sim L, Redmond S, Billings M, Mattke A, Gewirtz O'Brien JR, Partain P, Narr C, Breland R, Soma D, Schmit T, Magill S, Leonard A, Crane S, Le Grange D, Loeb K, Clark M, Phelan S, Jacobson RM, Enders F, Lyster-Mensh LC, Leppin A. Adapting Behavioral Treatments for Primary Care Using a Theory-Based Framework: The Case of Adolescent Eating Disorders. Acad Pediatr 2024; 24:208-215. [PMID: 37567443 DOI: 10.1016/j.acap.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023]
Abstract
Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs.
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Affiliation(s)
- Jocelyn Lebow
- Department of Psychiatry and Psychology (J Lebow, L Sim, M Clark), Mayo Clinic School of Medicine, Rochester, Minn; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (J Lebow, RM Jacobson, F Enders), Rochester, Minn; Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn.
| | - Leslie Sim
- Department of Psychiatry and Psychology (J Lebow, L Sim, M Clark), Mayo Clinic School of Medicine, Rochester, Minn
| | - Sarah Redmond
- Department of Quantitative Health Sciences (S Redmond, S Phelan, RM Jacobson, F Enders), Mayo Clinic School of Medicine, Rochester, Minn
| | - Marcie Billings
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | - Angela Mattke
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | | | - Paige Partain
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | - Cassandra Narr
- Department of Undergraduate Nursing (C Narr), Winona State University, Winona, Minn
| | - Renee Breland
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | - David Soma
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | - Tammy Schmit
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | - Saraphia Magill
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | - Antoinette Leonard
- Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn
| | - Sarah Crane
- Department of Internal Medicine (S Crane), Mayo Clinic School of Medicine, Rochester, Minn
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences (D Le Grange), University of California, San Francisco; Department of Psychiatry and Behavioral Neuroscience (D Le Grange), The University of Chicago, Chicago, Ill
| | - Katharine Loeb
- Chicago Center for Evidence-Based Treatment (K Loeb), Chicago, Ill
| | - Matthew Clark
- Department of Psychiatry and Psychology (J Lebow, L Sim, M Clark), Mayo Clinic School of Medicine, Rochester, Minn
| | - Sean Phelan
- Department of Quantitative Health Sciences (S Redmond, S Phelan, RM Jacobson, F Enders), Mayo Clinic School of Medicine, Rochester, Minn
| | - Robert M Jacobson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (J Lebow, RM Jacobson, F Enders), Rochester, Minn; Department of Pediatric and Adolescent Medicine (J Lebow, M Billings, A Mattke, P Partain, R Breland, D Soma, T Schmit, S Magill, A Leonard, RM Jacobson), Mayo Clinic School of Medicine, Rochester, Minn; Department of Quantitative Health Sciences (S Redmond, S Phelan, RM Jacobson, F Enders), Mayo Clinic School of Medicine, Rochester, Minn
| | - Felicity Enders
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (J Lebow, RM Jacobson, F Enders), Rochester, Minn; Department of Quantitative Health Sciences (S Redmond, S Phelan, RM Jacobson, F Enders), Mayo Clinic School of Medicine, Rochester, Minn
| | | | - Aaron Leppin
- Department of Quantitative Health Sciences (S Redmond, S Phelan, RM Jacobson, F Enders), Mayo Clinic School of Medicine, Rochester, Minn
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Lebow J, Billings M, Mattke A, Partain P, Gewirtz O'Brien J, Narr C, Breland R, Jacobson RM, Loeb K, Sim L. Does embedding pediatric eating disorder treatment in primary care bridge the access gap? Eat Disord 2024:1-14. [PMID: 38206038 DOI: 10.1080/10640266.2023.2299592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Given the numerous barriers to accessing child and adolescent eating disorder treatment, there is a need for innovation in how this care is delivered. Primary care-based eating disorder treatment has established proof-of-concept, yet it is unclear whether this model can bridge the treatment-access gap. This retrospective chart review study compared demographic and illness characteristics of 106 adolescents (M age = 15.1 years) SD = 1.8 consecutively evaluated in a primary care-based eating disorder clinic with 103 adolescent patients (M age = 15.2 years) SD = 2.2 seen consecutively in a specialty eating disorder clinic at the same medical center. Relative to adolescents in specialty care, those in the primary care group presented at a significantly higher BMI percentile, had less weight suppression, a shorter illness duration, lower rates of amenorrhea and lower scores on the EDE-Q Dietary Restraint subscale. In addition, more patients in the primary care group identified as non-white and had government/public assistance insurance compared to those in the specialty group. The results suggest that, compared to traditional specialty care clinics, embedded eating disorder treatment in primary care may reach a more racially and socioeconomically diverse group of adolescents when they are earlier in the course of their illness. Future research determining the relative effectiveness of this model as compared to interventions delivered in specialty care is needed.
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Affiliation(s)
- Jocelyn Lebow
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Marcie Billings
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Angela Mattke
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Paige Partain
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | | | - Cassandra Narr
- Department of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Renee Breland
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
- Department of Quantitative Health Science Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Katharine Loeb
- Chicago Center for Evidence, Based Treatment, Chicago, IL, USA
| | - Leslie Sim
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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Lebow J, O'Brien JRG, Mattke A, Narr C, Geske J, Billings M, Clark MM, Jacobson RM, Phelan S, Le Grange D, Sim L. A primary care modification of family-based treatment for adolescent restrictive eating disorders. Eat Disord 2021; 29:376-389. [PMID: 31675286 DOI: 10.1080/10640266.2019.1656468] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although eating disorders pose a significant threat to the health and well-being of children and adolescents, due to a profound scarcity of specialty providers, only a small percentage of patients receives evidence-based treatment. To improve access to care for restrictive eating disorders, we developed a modified version of Family-Based Treatment to be delivered by primary care providers (PCPs) and conducted a pilot study to evaluate the feasibility and preliminary outcomes of this intervention. Fifteen adolescents (mean age = 15.5 years) with restrictive eating disorders and their caregiver(s) were enrolled in Family-Based Treatment for Primary Care (FBT-PC), delivered by three trained PCPs. Retention for the intervention was high (n = 13, 86.7%). Over the course of 3 months, participants attended an average of 9.2 (SD = 2.8) sessions and experienced a significant increase in BMI percentile from 39.1 to 54.8 (t (13) = -6.71, p < .001; d = .61). FBT-PC appears to be feasible for implementation in the primary care setting and has the potential to improve access to treatment and yield positive outcomes for young patients with restrictive eating disorders.
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Affiliation(s)
- Jocelyn Lebow
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, MN, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | | | - Angela Mattke
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Cassandra Narr
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Jennifer Geske
- Department of Health Science Research, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Marcie Billings
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA.,Department of Health Science Research, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Sean Phelan
- Department of Health Science Research, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Daniel Le Grange
- Department of Psychiatry, University of California, San Francisco, CA, USA.,Department of Psychiatry & Behavioral Neuroscience, The University of Chicago, Chicago, IL, USA (Emeritus)
| | - Leslie Sim
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, MN, USA
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Gewirtz O'Brien JR, Sim L, Narr C, Mattke A, Billings M, Jacobson RM, Lebow J. Addressing Disparities in Adolescent Eating Disorders: A Case Report of Family-Based Treatment in Primary Care. J Pediatr Health Care 2021; 35:320-326. [PMID: 33516619 DOI: 10.1016/j.pedhc.2020.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/23/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
Eating disorders typically have a protracted course, marked by significant morbidity. Male adolescents and adolescents of color are at risk of delayed care. Primary care providers are well-positioned to identify eating disorders early and initiate treatment. This case report describes an adaptation of Family-Based Treatment delivered by a primary care provider to an Asian-American male adolescent from an immigrant family with restrictive anorexia nervosa. The adolescent achieved full-weight restoration and remission of his anorexia through treatment in primary care. Embedding eating disorder treatment within primary care could improve detection, engagement, and retention in treatment among young people from diverse backgrounds.
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Lebow J, Mattke A, Narr C, Partain P, Breland R, Gewirtz O'Brien JR, Geske J, Billings M, Clark MM, Jacobson RM, Phelan S, Harbeck-Weber C, Le Grange D, Sim L. Can adolescents with eating disorders be treated in primary care? A retrospective clinical cohort study. J Eat Disord 2021; 9:55. [PMID: 33892810 PMCID: PMC8067301 DOI: 10.1186/s40337-021-00413-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Family-Based Treatment (FBT) is considered the first-line intervention for adolescent anorexia nervosa. However, access to this treatment is limited. Treatment programs for other pediatric mental health conditions have successfully overcome barriers to accessing evidence-based intervention by integrating mental health services into primary care. This study evaluated the proof-of-concept of a novel modification of FBT, Family-Based Treatment for Primary Care (FBT-PC) for adolescent restrictive eating disorders designed for delivery by primary care providers in their practices. METHODS This retrospective clinical cohort study evaluated 15 adolescents with restrictive eating disorders receiving FBT-PC and 15 adolescents receiving standard FBT. We examined improvement in BMI percentile, reduction in weight suppression, and clinical benchmarks of eating disorder recovery including weight restoration to > 95% of expected body weight (EBW) and resolution of DSM-5 criteria for eating disorders. RESULTS In both groups, effect sizes for increased BMI percentile exceeded Cohen's convention for a large effect (FBT-PC: d = .94; standard FBT: d = 1.15) as did effect sizes for reduction in weight suppression (FBT-PC: d = 1.83; standard FBT: d = 1.21). At the end of treatment, 80% of the FBT-PC cohort and 87% in the standard FBT group achieved > 95%EBW and 67% in the FBT-PC group and 60% in the standard FBT group no longer met DSM-5 criteria for an eating disorder. There were no cohort differences in the number of treatment drop-outs or referrals to a more intensive level of eating disorder treatment. CONCLUSIONS Findings suggest that primary care providers have potential to improve weight and clinical status in adolescents with restrictive eating disorders. Based on these results, more rigorous testing of the FBT-PC model is warranted.
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Affiliation(s)
- Jocelyn Lebow
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, 200 First Street SW, Rochester, MN, 55905, USA. .,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
| | - Angela Mattke
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Cassandra Narr
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Paige Partain
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Renee Breland
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | | | - Jennifer Geske
- Department of Health Science Research, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Marcie Billings
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert M Jacobson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.,Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA.,Department of Health Science Research, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Sean Phelan
- Department of Health Science Research, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Cynthia Harbeck-Weber
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | - Daniel Le Grange
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA.,Department of Psychiatry & Behavioral Neuroscience, The University of Chicago, Chicago, IL, USA
| | - Leslie Sim
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, 200 First Street SW, Rochester, MN, 55905, USA
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Gentile N, Kaufman TK, Maxson J, Klein DM, Merten S, Price M, Swenson L, Weaver AL, Brewer J, Rajjo T, Narr C, Ziebarth S, Lynch BA. The Effectiveness of a Family-Centered Childhood Obesity Intervention at the YMCA: A Pilot Study. ACTA ACUST UNITED AC 2018; 8. [PMID: 29732240 DOI: 10.4172/2161-0711.1000591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Objective Community-based, family-centered obesity prevention/treatment initiatives have been shown to be effective in reducing body mass index (BMI) and improving healthy habits in children if implemented with high intensity and sufficient duration. Let's Go! 5-2-1-0 Program (5-2-1-0) was incorporated into family-centered, monthly physical activity classes and cooking classes over six months delivered by Young Men's Christian Association (YMCA) staff. We hypothesized that implementation of this intervention would improve 5-2-1-0 knowledge attainment, increase healthy behavior (based on 5- 2-1-0 curriculum), and improve BMI and waist circumference measurements in children. Methods Children attending YMCA summer camps in Rochester, MN, during 2016 were recruited via study packets mailed to their families. Height, weight, and waist circumference measurements as well as the results of the Modified Healthy Habits Survey and the 5-2-1-0 Knowledge Acquisition Survey were recorded for each participating child at baseline and 6-month follow-up. The intervention group received monthly healthy habit reminder emails, and was invited to monthly evening cooking and physical activity classes for 7 sessions over a 6-month period. Results Fifteen families in the intervention group attended classes. Of those, 13 families regularly participated in (attended at least 5 out of 7) both the monthly physical activity and cooking classes. The children in the intervention group had a significant improvement in the number of Knowledge Acquisition Survey questions answered correctly (p<0.001), while there was no improvement in the control group. As compared to children in the control group, there was no significant change in BMI or waist circumference or healthy habits in the intervention group. Conclusion Our study findings indicate that our intervention resulted in improved knowledge about healthy habits, but did not significantly impact healthy habits or BMI. Potential reasons for this were the small sample size and the attenuated length and/or intensity of the intervention.
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Affiliation(s)
- N Gentile
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - T K Kaufman
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - J Maxson
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - D M Klein
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - S Merten
- Viterbo University, La Crosse, WI, USA
| | - M Price
- Viterbo University, La Crosse, WI, USA
| | - L Swenson
- Office of Patient Education, Mayo Clinic, Rochester, MN, USA
| | - A L Weaver
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - J Brewer
- Rochester Area Family YMCA, Rochester, MN, USA
| | - T Rajjo
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - C Narr
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - S Ziebarth
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - B A Lynch
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
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