Examining clinicians' perceptions and experiences working with diverse families in family-based treatment: Common adaptations and considerations for treatment engagement

OBJECTIVE

Family-Based Treatment (FBT) is the leading manualized treatment for adolescent eating disorders; however, there is limited research on the adaptation of FBT for diverse families (i.e., families belonging to identity groups subject to systemic barriers and prejudices). The purpose of this qualitative study was to address: (1) adaptations made to the FBT model (if any) by clinicians working with diverse youth and families; (2) the barriers/facilitators of maintaining adherence (fidelity) to the model for these families; and, (3) the barriers/facilitators to access and engagement in FBT for diverse families.

METHOD

Forty-one FBT clinicians were recruited globally using purposive and snowball sampling, and listservs from eating disorder networks. Clinicians participated in individual interviews or focus groups, discussing their experiences delivering and adapting FBT for diverse families. Qualitative data was transcribed verbatim and analyzed using directed content analysis.

RESULTS

Some participants reported making adaptations to every phase of the FBT model, while others did not, when working with diverse families. In Phase 1, participants cited adapting the family meal, length/number of sessions provided, and addressed systemic barriers. In Phase 2, participants adapted the length of the phase and rate/level of independence given back to the adolescent. In Phase 3, participants increased or decreased the number of sessions, or eliminated this phase to address barriers to engagement in FBT.

DISCUSSION

This is the first study to qualitatively examine clinicians' experiences of implementing FBT with diverse families. Results may inform future FBT planning, clinician training, clinical decision-making tools, and opportunities for modifications to the foundational model.

PUBLIC SIGNIFICANCE

This qualitative study examined clinicians' perceptions and experiences implementing FBT with diverse families, specifically what adaptations (if any) were made to the foundational model, and the barriers and facilitators to adhering to and engaging in the model. Results show that some participants reported making adaptations to every phase of FBT, while others did not, with diverse families. Findings may inform future treatment planning, clinician training, clinical decision-making tools, and potential modifications to FBT.

Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: a non-randomized effectiveness trial

BACKGROUND

Family-based treatment (FBT) is an efficacious intervention for adolescents with an eating disorder. Evaluated to a lesser degree among adolescents, enhanced cognitive-behavior therapy (CBT-E) has shown promising results. This study compared the relative effectiveness of FBT and CBT-E, and as per manualized CBT-E, the sample was divided into a lower weight [<90% median body mass index (mBMI)], and higher weight cohort (⩾90%mBMI).

METHOD

Participants (N = 97) aged 12-18 years, with a DSM-5 eating disorder diagnosis (largely restrictive, excluding Avoidant Restrictive Food Intake Disorder), and their parents, chose between FBT and CBT-E. Assessments were administered at baseline, end-of-treatment (EOT), and follow-up (6 and 12 months). Treatment comprised of 20 sessions over 6 months, except for the lower weight cohort where CBT-E comprised 40 sessions over 9-12 months. Primary outcomes were slope of weight gain and change in Eating Disorder Examination (EDE) Global Score at EOT.

RESULTS

Slope of weight gain at EOT was significantly higher for FBT than for CBT-E (lower weight, est. = 0.597, s.e. = 0.096, p < 0.001; higher weight, est. = 0.495, s.e. = 0.83, p < 0.001), but not at follow-up. There were no differences in the EDE Global Score or most secondary outcome measures at any time-point. Several baseline variables emerged as potential treatment effect moderators at EOT. Choosing between FBT and CBT-E resulted in older and less well participants opting for CBT-E.

CONCLUSIONS

Results underscore the efficiency of FBT to facilitate weight gain among underweight adolescents. FBT and CBT-E achieved similar outcomes in other domains assessed, making CBT-E a viable treatment for adolescents with an eating disorder.

CLINICAL TRIAL REGISTRATION INFORMATION

Treatment Outcome in Eating Disorders; https://clinicaltrials.gov/; NCT03599921.

Attributes of children and adolescents with avoidant/restrictive food intake disorder

BACKGROUND

Avoidant/Restrictive Food Intake Disorder (ARFID) is a comparatively new DSM-5 diagnosis. In an effort to better understand this heterogeneous patient group, this study aimed to describe the physical and psychological attributes of children and adolescents with ARFID, and to compare them to patients with full-threshold or atypical anorexia nervosa (AN).

METHODS

Children and adolescents aged 7-to-19 years (N = 193) were examined upon presenting at a pediatric eating disorder center between July 2015 and December 2017. Data included diagnosis assessed via the semi-structured Eating Disorder Examination interview along with measures of anthropometrics, depression, anxiety, self-esteem, perfectionism and clinical impairment.

RESULTS

Compared to AN and atypical AN (n = 87), patients with ARFID (n = 106) were significantly younger (12.4 vs. 15.1 years, p < .0001), male (41% vs. 15%, p < .0002), and were more likely to be diagnosed with at least one co-morbid DSM-5 diagnosis (75% vs. 61%, p = .04). Patients with ARFID were less likely to be bradycardic (4.7% vs. 24.1%, p < .0001), amenorrheic (11.1 and 34.7%, p = .001), admitted to the hospital (14.2% vs. 27.6%, p = .02), and have a diagnosis of depression (18.9% vs. 48.3%, p < .0001). Patients with ARFID were significantly less likely to experience acute weight loss vs. chronic weight loss as compared with those with AN or atypical AN (p = .0001). On self-report measures, patients with ARFID reported significantly fewer symptoms of depression, anxiety, perfectionism, clinical impairment, concerns about weight and shape, and higher self-esteem than patients with AN or atypical AN (all ps < .0001). No differences were observed by race, anxiety disorder, orthostatic instability, suicidal ideation, and history of eating disorder treatment.

CONCLUSIONS

Study results highlight the clinical significance of ARFID as a distinct DSM-5 diagnosis and the physical and psychological differences between ARFID and AN/atypical AN. The novel finding that ARFID patients are more likely than those diagnosed with AN to experience chronic, rather than acute, weight loss suggests important related treatment considerations.

Youth with Avoidant/Restrictive Food Intake Disorder: Examining Differences by Age, Weight Status, and Symptom Duration

The primary purpose of this study was to examine differences among youth with avoidant/restrictive food intake disorder (ARFID) by age, weight status, and symptom duration. A secondary goal was to report the frequencies of ARFID using DSM-5 clinical presentations (i.e., fear of aversive consequences, lack of interest in food, sensory sensitivities). Participants (N = 102), ages 8-18 years, were recruited through an eating disorder service within a pediatric hospital. They were evaluated using semi-structured interviews and questionnaires. Patients were assigned to groups according to age, weight status, and symptom duration. Frequencies of clinical presentations, including combinations of DSM-5 categories, were also examined. Our findings suggest that adolescents presented with higher rates of Depression (p = 0.04). Youth with chronic ARFID symptoms presented with significantly lower weight (p = 0.03), and those with acute symptoms rated significantly higher suicidal ideation and/or self- harm (p = 0.02). Half of patients met criteria for more than one ARFID symptom presentation. This study provides preliminary evidence that youth with ARFID differ in clinical presentation depending on age, weight status, and symptom duration, and highlights safety concerns for those with acute symptoms of ARFID. High rates of overlapping symptom presentations might suggest a dimensional approach in the conceptualization of ARFID.

Maternal and adolescent report of mothers' weight-related concerns and behaviors: longitudinal associations with adolescent body dissatisfaction and weight control practices

OBJECTIVE

This population-based study examined mothers' weight-related concerns and behaviors (weight status, weight dissatisfaction, dieting, and encouraging child to diet) at baseline, as assessed by both mothers and adolescents, and associations with adolescents' body dissatisfaction and weight control practices 5 years later.

METHODS

Adolescents and their mothers (n = 443 pairs) were surveyed in 1998-1999; adolescents were resurveyed in 2003-2004.

RESULTS

Baseline maternal report of higher levels of her weight-related concerns/behaviors was associated with greater body dissatisfaction in girls 5 years later, controlling for adolescent weight status and other covariates. Baseline maternal report of weight-related concerns/behaviors was also associated with greater prevalence of trying to lose weight in both boys and girls 5 years later. Baseline adolescent report of higher maternal weight-related concerns/behaviors was associated with a higher prevalence of trying to lose weight 5 years later in girls.

CONCLUSIONS

These findings highlight the importance of mothers' weight-related concerns and behaviors for adolescents' weight-related outcomes.

Body dissatisfaction and body comparison with media images in males and females

This study examined the role of media body comparison as a mediator of the relationships between psychological factors and sociocultural pressures to be thin and body dissatisfaction in both females and males. Participants were 1,386 females (mean age = 19.37 years) and 1,130 males (mean age = 19.46) from diverse backgrounds who completed a self-report questionnaire. Path analysis was used to test a cross-sectional model in which media body comparison mediated the impact of self-esteem, depressive mood, parent dieting environment, friend dieting, TV exposure, magazine message exposure, weight teasing and body mass index (BMI) on body dissatisfaction. In females, media body comparison partially or fully mediated relationships between self-esteem, depressive mood, friend dieting, magazine message exposure and BMI, and body dissatisfaction. In males, media body comparison was not a significant predictor of body dissatisfaction. This research particularly highlights the need to further examine processes that are involved in the development of body dissatisfaction in males.

Relationships between maternal and adolescent weight-related behaviors and concerns: the role of perception

OBJECTIVE

The purpose of this study was to explore the relationship between maternal and adolescent weight-related behaviors and concerns in a population-based sample.

METHODS

Participants were 810 adolescents (n=429 girls and n=381 boys) and their mothers/guardians. Adolescents were part of the Project EAT (Eating Among Teens) study, which was a comprehensive study of eating patterns and weight concerns among adolescents in Minnesota. Outcome variables included child's body dissatisfaction, weight concerns, dieting, and use of healthy and unhealthy weight control behaviors.

RESULTS

Adolescents reported lower rates of maternal dieting than mothers. Maternal self-report of dieting was not significantly associated with children's weight-related concerns. Children's perceptions of their mothers' behaviors were significantly related to their level of weight concerns and use of weight control behaviors.

CONCLUSION

Adolescents' perceptions of maternal behavior affect their weight-related concerns and behaviors. This suggests that mothers who choose to diet should model healthy choices in the areas of nutrition and physical activity.

The impact of appearance-related teasing by family members

PURPOSE

This study evaluated the prevalence and effects of teasing by family members on body dissatisfaction, eating disturbance, and psychological functioning.

METHODS

Self-report data were collected from 372 middle school girls who were part of a larger study in a Tampa Bay, Florida area middle school (mean age: 12.6 years; 85% Caucasian).

RESULTS

Twenty-three percent of participants reported appearance-related teasing by a parent, and 12% were teased by a parent about being heavy. Nineteen percent of the girls reported appearance-related teasing by fathers, 13% reported appearance-related teasing by mothers, and 29% reported appearance-related teasing by siblings. After controlling for body mass index (BMI) and maternal teasing, paternal teasing was a significant predictor of body dissatisfaction, comparison, thin-ideal internalization, restriction, bulimic behaviors, self-esteem, and depression. After controlling for BMI and paternal teasing, maternal teasing was a significant predictor of depression. After controlling for BMI and maternal teasing, paternal teasing significantly increased the odds of having a sibling who teases. Girls who reported being teased by at least one sibling demonstrated significantly higher levels of body dissatisfaction, comparison, thin-ideal internalization, restriction, bulimic behaviors, depression, and significantly lower levels of self-esteem than those girls who reported they were not teased by their siblings. Frequency of teasing was associated with higher levels of negative outcomes.

CONCLUSIONS

This study has implications for treatment and prevention of eating disorders. The results suggest that health care providers should assess appearance-related teasing in their patients' lives to identify girls who may be at risk for body image and eating disturbance and poor psychological functioning.

An evaluation of the Tripartite Influence Model of body dissatisfaction and eating disturbance with adolescent girls

The Tripartite Influence Model of body image and eating disturbance proposes that three formative influences (peer, parents, and media) affect body image and eating problems through two mediational mechanisms: internalization of the thin-ideal and appearance comparison processes. The current study evaluated this model in a sample of 325 sixth through eighth grade girls. Simple path analyses indicated that internalization and comparison fully mediated the relationship between parental influence and body dissatisfaction and partially mediated the relationship between peer influence and body dissatisfaction. Additionally, internalization and comparison partially mediated the relationship between media influence and body dissatisfaction. Six a priori SEM models based on the full Tripartite Influence Model were also evaluated. A resulting model was found to be an adequate fit to the data, supporting the viability of the Tripartite Model as a useful framework for understanding processes that may predispose young women to develop body image disturbances and eating dysfunction.

The Sociocultural Internalization of Appearance Questionnaire - Adolescents (SIAQ-A): psychometric analysis and normative data for three countries

A brief measure of internalization of societal norms regarding appearance was developed and validated on six early adolescent female samples (mean ages 11.7-13.3) from three countries (US, Australia, India; total n = 2210). Internal consistency levels were uniformly high in all samples, ranging from 0.83 to 0.92. Convergent validity estimates were high in all samples. Level of internalization was significantly positively correlated with levels of body dissatisfaction and restriction for all samples. Internalization was also significantly positively correlated with bulimic behaviors and negatively correlated with levels of self-esteem for the four samples that included these variables. The findings indicate that the Sociocultural Internalization of Appearance Questionnaire - Adolescents (SIAQ-A) may be used to further explore a media influence cross-culturally, allowing for the investigation of the role of internalization as a potential risk factor for body image problems and eating disturbances in different contexts.