A conceptual model of psychosomatic illness in children. Family organization and family therapy

Parent-adolescent communication quality does not moderate the association of emotional burden and somatic complaints in adolescents: a cross-sectional structural equation model

An explanation for somatic complaints in adolescence assumes that they have the function to express emotional burden if the communication of feelings in important relationships does not work sufficiently. Therefore, it can be hypothesized that in adolescents, lower quality of emotional communication with a parent goes along with a higher impact of emotional burden on somatic complaints. The aim of this study was to examine whether emotional communication quality between adolescents and parents moderates the association of emotional burden and somatic complaints. Based on data from a cross-sectional population sample (N = 1061), structural equation modeling (SEM) was used to test the hypothesis. In addition to the general model, models for boys and girls were compared. Emotional communication quality does not moderate the association of emotional burden and somatic complaints in the general model or in the gender-based models. However, communication quality is a significant predictor of somatic complaints for boys. Limitations are the cross-sectional nature of the data, the possible sampling bias due to the use of an online access panel, and the inclusion of one parent per adolescent. This study highlights that emotional communication quality is a predictor for somatic complaints in adolescent boys and should be addressed in therapy.Trial registration ClinicalTrials.gov: NCT05332236.

Affective and Behavioral Responses to Time-Out in Preschool Children With Conduct Problems and Varying Levels of Callous-Unemotional Traits

Punishment insensitivity characterizes individuals with callous-unemotional (CU) traits. This has been put forward as an explanation for their persistent conduct problems despite intervention. The purpose of the current study was to compare the emotional and behavioral responses to parent-implemented time-out within a behavioral parent training intervention between children with conduct problems who are high versus low on CU traits. Children (N = 87; M age = 4.88 years, SD = 1.32; 78% male) referred to a specialty clinic for the treatment of conduct problems were observed and coded during time-out, and their parents rated their conduct problem severity and CU traits using psychometrically robust measures. Children with conduct problems and high CU traits showed significantly more calm/neutral emotion and less negative emotion upon initial placement in time-out by parents, but did not engage in more negative behaviors or spend longer in time-out relative to children with conduct problems alone. After a minimum of 3 weeks of exposure to this form of parental discipline, most children complied with effective parental commands in that they did not require time-out for noncompliance during the fourth discipline-focused treatment session. Findings have implications for understanding why children with CU traits continue showing high levels of conduct problems post behavioral interventions, and they lend further support for the need to personalize treatment to their distinct needs.

[Parental Distress of Patients Who Refuse to Eat: Toward a Deeper Understanding and Greater Support for Parents of Children Suffering from an Eating Disorder]

Parental Distress of Patients Who Refuse to Eat: Toward a Deeper Understanding and Greater Support for Parents of Children Suffering from an Eating Disorder Abstract: Many parents experience their role as parents of a daughter/son with anorexia nervosa as very troublesome and demanding. In several departments of child and adolescen psychiatry in Germany, the contact between parents and adolescent patients with anorexia nervosa is still restricted because parents are often judged responsible for the eating disorder of their child - or at least seen as troublemakers during their child's inpatient treatment. Parents blame themselves for the development of anorexia nervosa, and in comparison to other mental disorders of adolescence, they experience even more guilt and shame. Many of them suffer from psychiatric disorders themselves (not a few from eating disorders), which reinforce feelings of helplessness and shame. Several parents have partnership problems and must take off work to support their child, which often leads to financial losses for the whole family. They complain that they have insufficient support and feel misunderstood by health professionals whom they wish to have a profound knowledge of the disorder and who would trust and understand the carers. This article provides several recommendations to improve the relationship between parents and therapists: termination of contact restrictions, detailed information for the parents about possible biological and psychological causes of eating disorders, including psychoeducational groups and involvement in treatment, not only through therapeutic conversations but also through practical exercises such as meal support. An innovative approach is home treatment, which offers the chance to integrate parents into treatment and thus improve their skills in handling their daughter´s/son´s illness. We should be aware that parents are the most important resource to help young patients with debilitating eating disorders.

The role of perceived parental overprotection in women's restrained eating behavior: A moderated mediation model of alexithymia, perfectionism, and asceticism

Restrained eating behavior (REB) refers to the tendency to rigidly restrict one's eating behavior in everyday life to influence body shape or weight. Parental overprotection, alexithymia, perfectionism, and asceticism are associated with REB among women. However, no studies have examined these variables simultaneously, integrating them into a theoretical model. In the current study, the combined influences of these variables on women's REB were tested. A total of 412 women (Mage = 23.53 ± 4.24; range = 16-54) completed well-known self-report measures: Parental Bonding Instrument, Toronto Alexithymia Scale, Multidimensional Perfectionism Scale, Protestant Work Ethic Scale, and Eating Disorder Examination Questionnaire. Parallel mediation and moderated mediation hypotheses were tested using PROCESS Model 4 and PROCESS Model 15, respectively. The paths from both maternal and paternal overprotection to REB were mediated through alexithymia and socially prescribed perfectionism. There was a significant interaction effect of asceticism with socially prescribed perfectionism on REB in the model concerning paternal overprotection (b = 0.0185, SE = 0.0091, 95% CI = 0.0007-0.0363). Moreover, asceticism significantly moderated the effect of paternal overprotection on REB through socially prescribed perfectionism (b = 0.0032, SE = 0.0019, 95% CI = 0.0001-0.0076). For the model concerning maternal overprotection, the moderated mediation model was not supported. The findings support a theoretical model of risk factors for REB and highlight the possible mechanisms through which the quality of early parental relationships contributes to REB.

A systematic review of eating disorders and family functioning

The purpose of the current review was to address four questions: 1) Are there differences in family functioning or family environment among patients with different eating disorder (ED) diagnoses? 2) Are there differences in the perception of family functioning or family environment among different family members? 3) Is family functioning or family environment related to ED symptomatology? 4) Does family functioning or family environment change as a result of ED treatment? and 4a) If so, does this impact ED treatment outcome? Although most studies found no differences among ED diagnostic groups, those that did generally found worse family functioning among those with binge/purge symptoms than among those with the restricting subtype of anorexia nervosa. Differences in perceptions of family functioning among family members were found, with patients generally reporting worse functioning than their parents. Worse family functioning was generally found to be related to worse ED symptoms. The variety of treatment approaches and different assessments of outcome made it somewhat unclear whether family functioning consistently improves with ED treatment. More research is needed on family functioning and EDs, particularly in understudied groups such as males, and those with ED diagnoses other than anorexia nervosa or bulimia nervosa.

Should pediatric cardiologists refer all patients with unexplained chest pain to a psychiatrist?

OBJECTIVE

The present study aimed to investigate the relationship between unexplained chest pain in children with parents' mental problems, parental attitudes, family functionality, and the child's mental problems.

MATERIAL AND METHOD

A total of 433 children (between 11 and 18 years of age) applied to the Pediatric Cardiology Outpatient Clinic due to chest pain in the last year. A clinical interview was conducted by a child psychiatrist with 43 patients and 33 controls included in the study due to unexplained chest pain.

RESULTS

Family history of physical illness was significantly higher in the chest pain group. When evaluated in terms of psychosocial risk factors, life events causing difficulties, derangement in the family, loss of a close person, and exposure to violence were statistically significantly higher in the group with chest pain. Mental disorders were observed in 67.4% of the children in the chest pain group as a result of the clinical interview. The total score of the DSM-5 somatic symptoms scale, which evaluates other somatic complaints in the chest pain group, was also significantly higher. When the family functions of both groups were evaluated, communication, emotional response, behaviour control, and general functions sub-dimensions were statistically significantly higher in families in the chest pain group.

CONCLUSION

We recommend that psychiatric evaluation be included in diagnostic research to prevent unnecessary medical diagnostic procedures in children describing unexplained chest pain, as well as to prevent the potential for diagnosing mental disorders in both children and adults.

Editorial: From the Identified Patient to Precision Medicine

The article by Lock et al.1 in this month's issue of the Journal highlights 3 features that are of interest to child and adolescent psychiatrists. First, it provides further evidence for an effective therapy for an extremely debilitating condition, with additional means for improving prognosis. Second, it underscores how families can be helpful in supporting therapy for their children, thus avoiding unnecessary scapegoating of parents. Finally, it is a fine example of a clinical trial performed in accordance with all the principles of modern methodology.

[New aspects in etiology and treatment of adolescent anorexia nervosa-a postulated bio-psycho-social model and the impact of the COVID-19 pandemic]

Anorexia nervosa is one of the most frequent chronic disorders of adolescence associated with a high mortality. During the COVID-19-pandemic, the number of hospitalized children and adolescents with anorexia nervosa significantly increased. This article outlines new research findings to decode the etiology of this serious disorder, especially a genetic disposition and changes of metabolism. Against the background of increasing rates during the COVID-19 pandemic, the importance of the gene-environment interaction is discussed, and new treatment forms are described. Besides the development of new biological treatment strategies, there is also some important progress in psychotherapeutic interventions. Carers should always be integrated when treating children and adolescents with anorexia nervosa, which is especially emphasized in the new "home treatment" setting. The new concept of anorexia nervosa as a metabo-psychiatric disorder gives us hope for new research ideas and treatment strategies in this often-debilitating disorder of childhood and adolescence.

The impact of family alexithymia on the severity of restrictive eating disorders in adolescent patients

BACKGROUND

Alexithymia is the inability to identify and describe one's own emotions. Adolescents who suffer from Restrictive Eating Disorders (REDs) show a higher prevalence of alexithymia than the general population.

METHODS

The study explored the correlation between levels of alexithymia in mothers, fathers, and adolescents affected by REDs and patients' ability to recognize their emotions. The study also aimed to evaluate if patients' emotional distress can significantly impact the severity of their disorder and functioning measured by the Clinical Global Impression Scale - Severity (CGI-S) and the Children's Global Assessment Scale (CGAS). We enrolled 67 families of adolescents affected by REDs. Parents and patients' levels of alexithymia were assessed through the Toronto Alexithymia Scale (TAS-20). Spearman's correlation shows a statistically significant correlation between mothers and patients' levels of alexithymia.

RESULTS

Our findings also suggest that fathers and mothers' TAS scores correlate with each other. However, there is no statistically significant relationship between the influence of the TAS scores of fathers and sons/daughters.

CONCLUSIONS

In conclusion, mothers' level of alexithymia could influence both fathers and patients' difficulty in identifying and describing their own emotions. This relationship can be investigated further when considering externally oriented thinking. However, the severity of the disease and overall functioning do not appear to be affected by patients' levels of alexithymia.

How Perceptions of Parents' Parenting Behaviors Pave the Way to Somatic Symptoms: The Mediating Role of Emotion Regulation Among Adults

The purpose of this study was to investigate adult participants' reflections on their parents' parenting behaviors during childhood (parental overprotection and parental rejection), and their current emotion-regulation strategies and somatic symptoms. The study consisted of 627 participants and Somatization subscale of the Symptom Checklist-90-Revised, Difficulties in Emotion Regulation Scale and Short EMBU Children Form were given to the participants. Four different multiple mediation analyses were conducted to test mediator roles of emotion regulation difficulties between perceptions of the parenting behaviors (parental overprotection and rejection) and somatic symptoms among adults. Participants' lack of goals and lack of strategies while dealing with negative emotions mediated the relationship between mother/father rejection and somatic symptoms. However, only participants' lack of strategies while dealing with negative emotions mediated the relationship between mother/father overprotection and somatic symptoms. As a clinical implication, problem-focused coping strategies may assist adults with somatic symptoms. Also, mental health practitioners may focus on perceptions of overprotective and rejecting parental behaviors while formulizing somatic symptoms of the adult patients. Findings, strengths and limitations of this study were discussed in the light of the literature.

Family Functioning and Suicide Attempts in Mexican Adolescents

Suicide is considered a public health problem that affects families worldwide. Family functioning is the capability of the family system to fulfill needs during the stages of its development. In this study, we focused on evaluating family cohesion and adaptability in a group of adolescents who had attempted suicide and were hospitalized at a hospital for mental health disorders, compared to a control group. Methods: based on Olson's circumplex model, we used the FACES III scale to gain insights into the family functioning of both suicidal and control groups. Results: The case group presented lower scores in cohesion and adaptability compared to the control group, with moderate effect-size for cohesion (Cohen's d/r test = 1.217/0.52) and low effect-size for adaptability (Cohen's d/r test = 0.746/0.35) (p < 0.001 for both variables), and also presented predominantly disengaged families (72.5% in the case group vs. 27.5% in the control group) and structured families (45% in the case group vs. 23.8% in the control group). The type of family described by the adolescents with a history of suicide attempts may explain the presence of low self-esteem and little emotional support usually present in this type of patient.

Pediatric Functional Neurological Symptoms Disorder: Walking Ability and Perceived Exertion Post-Pediatric Rehabilitation

BACKGROUND

Adolescents with functional neurological symptoms disorder (FNSD) commonly present walking abnormalities. Walking is influenced by 'objective' (e.g., fitness) and 'subjective' (e.g., fear) components. Rate of perceived exertion (RPE) reflects the interaction between these two components. This study compared the walking ability and RPE before and after rehabilitation of adolescents with FNSD to adolescents with moderate-to-severe traumatic brain injury (TBI). Factors predicting walking and RPE were also examined.

METHODS

Adolescents with FNSD (n = 31) and adolescents with moderate-to-severe TBI (n = 28) aged 6 to 18 years participated in the study. Participants received a multidisciplinary rehabilitation program. Six-minute walk test (6MWT) and RPE were assessed before and after rehabilitation.

RESULTS

At pre-test, the TBI group presented lower RPE than the FNSD group (3.38 ± 2.49 and 6.25 ± 2.71, respectively). In the FNSD group, pre-test 6MWT was a significant predictor of post-test 6MWT (adjusted R2 = 0.17; p = 0.01). In the TBI group, post-test 6MWT was significantly predicted by both the pre-test 6MWT and age (adjusted R2 = 0.16; p = 0.04).

CONCLUSIONS

Prior to the intervention, adolescents with FNSD perceived walking as a more difficult activity than adolescents with TBI. Post-intervention, although the intervention was effective in terms of changes in 6MWT and RPE, the 'subjective' component still contributed to the elevated RPE of the FNSD group.

Effects of family functioning on eating pathology and psychosocial quality of life: The mediating role of self-esteem

OBJECTIVE

Family dysfunction and self-esteem play an important role in the development of eating disorders (EDs), but this role has not been sufficiently examined regarding eating pathology and psychosocial quality of life (QoL), which often remains unchanged even after ED symptoms reduce. The purpose of this study was to therefore assess the mediating role of self-esteem between family dysfunction and both eating pathology and psychosocial QoL in ED patients and controls.

METHOD

One hundred and fifty four female adult ED patients and 154 female healthy adult controls were recruited from Athens, Greece, and self-reported measures were used to assess family dysfunction, eating pathology, self-esteem, and psychosocial QoL. Structural equation modelling (SEM) was employed to test the mediation hypotheses.

RESULTS

For both the ED and control groups, family dysfunction levels did impact eating pathology, but only through self-esteem. Family dysfunction, self-esteem, and eating pathology had a direct effect on both groups' psychosocial QoL.

CONCLUSION

Self-esteem's important role in EDs was confirmed in both groups, along with its sensitivity to family dysfunction. We propose a parsimonious yet comprehensive theoretical model of the role of family dysfunction and self-esteem in EDs which future studies should further investigate longitudinally and in other population groups.

Comparing randomized controlled trials of outpatient family-based or inpatient multimodal treatment followed by outpatient care in youth with anorexia nervosa: Differences in populations, metrics, and outcomes

OBJECTIVE

Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT.

METHOD

Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT.

RESULTS

Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented.

DISCUSSION

An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

The biobehavioral family model with a seminarian population: A systems perspective of clinical care

Seminary students remain unstudied in the research literature despite their eminent role in caring for the wellbeing of congregants. This study aimed to conduct baseline analysis of their family of origin health, psychological health, and physiological heath by utilizing the Biobehavioral Family Model (BBFM) as a conceptual framework for understanding the associations between these constructs. Statistical analysis utilizing structural equation modeling provided support that the BBFM was a sound model for assessing the relationships between these constructs within a seminary sample. Additionally, seminarians were found to have higher rates of anxiety and depression when compared to the general population. Together, findings indicate that clinical care for seminarians may be best if implemented from a global systemic perspective.

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.

Putting parental overprotection into a family systems context: Relations of overprotective parenting with perceived coparenting and adolescent anxiety

Previous research offers evidence for how overprotective parenting is related to psychosocial maladjustment among adolescents, and documents the parent-related and child-related antecedents of overprotective parenting. Using a family systems perspective, the present study aimed at extending this knowledge by looking into contextual determinants of overprotective parenting. More specifically, the goal of this study was to examine associations between adolescents' perceptions of the coparental relationship (i.e., the way parental figures relate to each other in their role as parents) and overprotective parenting, which in turn was expected to relate to more adolescent anxiety symptoms. A sample of 174 Swiss adolescents (M_age  =16.99 years, 73% girls) completed questionnaires assessing their perceptions of the coparental relationship (in terms of cooperation, conflict, and triangulation), overprotective parenting, and symptoms of anxiety. Analyses indicated that triangulation, in particular, was uniquely related to higher levels of overprotective parenting, which in turn was associated with more anxiety symptoms among adolescents. These results provide evidence for the importance of considering the larger family systems context for understanding the dynamics involved in overprotective parenting. Theoretical and clinical implications of these findings are discussed.

The five tenets of family-based treatment for adolescent eating disorders

Family-based treatment (FBT) is the leading treatment for adolescent eating disorders and is based on five tenets, or fundamental assumptions: (1) the therapist holds an agnostic view of the cause of the illness; (2) the therapist takes a non-authoritarian stance in treatment; (3) parents are empowered to bring about the recovery of their child; (4) the eating disorder is separated from the patient and externalized; and (5) FBT utilizes a pragmatic approach to treatment. Learning these tenets is crucial to the correct practice and implementation of manualized FBT. The purpose of the current paper is to provide an in-depth overview of these five tenets and to illustrate how they are used in clinical practice. This overview will aid clinicians who are learning FBT.

Family Health Development: A Theoretical Framework

In recognition of the family as central to health, the concept of family, rather than individual, health has been an important area of research and, increasingly, clinical practice. There is a need to leverage existing theories of family health to align with our evolving understanding of Life Course Health Development, including the opportunities and constraints of the family context for promoting lifelong individual and population health. The purpose of this article is to propose an integrative model of family health development within a Life Course Health Development lens to facilitate conceptualization, research, and clinical practice. This model provides an organizing heuristic model for understanding the dynamic interactions between family structures, processes, cognitions, and behaviors across development. Potential applications of this model are discussed.

Couple and family interventions for high mortality health conditions: A strategic review (2010-2019)

The earliest publications in the field of marriage and family therapy introduced interventions conducted with families experiencing complex health conditions. This strategic review captures an evaluation of efficacy for 87 couple and family interventions published between 2010 and 2019 with a focus on the leading causes of mortality in the United States. These health conditions include chromosomal anomalies and accidents with infants aged 0-4 years; accidents and cancer among children aged 5-14; accidents among adolescents aged 15-24; and heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer's disease, diabetes, influenza/pneumonia, and nephritis/nephrosis among adults 25 and older. Results support the need for greater inclusion of couples and families in assessments and interventions. The greatest chasm in efficacy research was with minoritized couples and families. Implications include ways to initiate couple and family interventions in the context of health conditions with attention given to accessibility, recruitment, retention, and evaluation.

Relationship between psychosocial characteristics and asthma management self-efficacy of caregiver mothers: a pilot study of pediatric asthma management in Turkey

We analyzed the relationships between family functionality, caregiver burden, perceived social support, and asthma management self-efficacy of 300 Turkish mothers who provide care to pediatric asthma patients in this cross-sectional sampling study. The mean age of the caregiver mothers was 31.82 ± 5.08. Our study results showed that the participants had above moderate but insufficient perceived social support and asthma management self-efficacy and they were moderately satisfied with caregiver burden and family functioning. As mothers' perceived social support increased, their satisfaction with family functioning and asthma management self-efficacy also increased but their caregiver burden decreased. Additionally, the caregiver mothers had a sufficiently high level of self-confidence in caregiving to children with asthma, and the caregiver mothers who received training or more information about asthma believed that they were able to manage asthma to a great degree. The researchers conducted regression analysis and they found that biological and social factors and the degree of caregiving burden were significantly associated with asthma management self-efficacy levels. The multivariate biopsychosocial model accounted for 37.4% of the total variance in asthma management self-efficacy. Parent asthma management self-efficacy levels of the caregiver mothers are largely linked to their biological and psychosocial characteristics.

Psychological Bases of Symptom Reporting: Perceptual and Emotional Aspects of Chemical Sensitivity

The reporting of physical symptoms is influenced to a large degree by psychological processes. Individuals are more likely to notice subtle sensations in environments lacking in stimulation than those demanding external attention. The beliefs or schemas that people hold dictate where and how they attend to their bodies as well. These normal perceptual processes help explain why people are of ten poor at accurately detecting internal physiological activity. Several individual differences are also related to the symptom reporting process. Females are more likely to base their symptom reports on external situational cues than are males. In addition, individuals with chronic anxiety those high in Negative Affectivity (NA) report more symptoms than those low in NA. Finally, individuals who have had traumatic experiences, either in childhood or within 16 months prior to a major symptom reporting episode, tend to be high symptom reporters. Several recommendations are made to help researchers and clinicians distinguish between psychological or perceptual factors with presumed biological effects. One implication of this work is that MCS and allied syndromes should be viewed as both a mental and a physical health problem.

Father-daughter relationship dynamics & daughters' body image, eating patterns, and empowerment: An exploratory study

Research indicates the role of parents in women's body dissatisfaction and maladaptive eating patterns. Fathers, in particular, have unique roles in determining daughters' protection against these health risks. Additionally, self-esteem, feminist values, and psychological empowerment are linked with body dissatisfaction and maladaptive eating patterns among women. This study examined the contributions of these psychological factors, family relational factors, and the role of fathers in empowering their daughters. Seventy-seven young adult women from intact families were recruited from Amazon Mechanical Turk and a university campus and completed self-report surveys. Participants were between the ages of 18 and 38 and primarily White. Results indicate that women with higher self-esteem and psychological empowerment endorsed greater body satisfaction. Women with higher self-esteem and endorsement of feminist values also reported significantly fewer maladaptive eating patterns. Greater family conflict was related to more maladaptive eating patterns. Analyses indicated increased body dissatisfaction and increased eating disorder risk decreased the odds of women reporting agency and fatherly supportive resources in their father-daughter communication narratives. Narrative data analysis revealed that fathers play a crucial role in promoting daughter's empowerment, egalitarian gender-role socialization, and healthy psychological wellbeing. Implications for research and clinical community-based treatment and prevention strategies are discussed.

A Multi-Site Study of Traumatic Brain Injury in Mexico and Colombia: Longitudinal Mediational and Cross-Lagged Models of Family Dynamics, Coping, and Health-Related Quality of Life

Latin America has high rates of traumatic brain injury (TBI), yet reduced mental and physical health outcomes due to limited rehabilitation services. To understand the psychosocial adjustment process in TBI patients in Latin America, the incorporation of cultural values including family-based variables is imperative. The current study examined relations among healthy family dynamics, coping, and mental and physical health related quality of life (HRQL) among a sample of TBI patients across three sites and two countries over the first 4 months post-injury. A sample of 109 acute TBI patients from Mexico and Colombia were recruited, and a series of longitudinal mediation and cross-lag panel analyses were run. Mental and physical HRQL were positively associated with each other, as well as healthy family dynamics and coping. Coping partially mediated the effects of healthy family dynamics on both mental and physical HRQL. Family dynamics showed the strongest cross-lag relationships with coping going from 2 months to 4 months. Similarly, coping showed the strongest cross-lag relationships with both mental and physical HRQL going from baseline to 2 months. Results provide empirical support for the importance of a rehabilitation workforce that has been trained in and can effectively implement family-based interventions for individuals with TBI in Latin America.

Eating Disorders, Heredity and Environmental Activation: Getting Epigenetic Concepts into Practice

Epigenetic mechanisms are believed to link environmental exposures to alterations in gene expression, and in so doing, to provide a physical substrate for the activation of hereditary potentials by life experiences. In keeping with this idea, accumulating data suggest that epigenetic processes are implicated in eating-disorder (ED) etiology. This paper reviews literature on putative links between epigenetic factors and EDs, and examines ways in which epigenetic programming of gene expression could account for gene-environment interactions acting in the EDs. The paper also presents evidence suggesting that epigenetic processes link malnutrition and life stresses (gestational, perinatal, childhood, and adult) to risk of ED development. Drawing from empirical evidence and clinical experience, we propose that an epigenetically informed understanding of ED etiology can benefit patients, caregivers, and clinicians alike, in the sense that the perspective can reduce judgmental or blameful attitudes on the part of clinicians and caregivers, and increase self-acceptance and optimism about recovery on the part of those affected.

The Explanation of Eating Disorders: A Critical Analysis

Eating disorders (EDs) are one of the most severe and complex mental health problems facing researchers and clinicians today. The effective prevention and treatment of these conditions is therefore of paramount importance. However, at present our treatments fall short: generally demonstrating only poor to moderate efficacy, and often completely ineffective for severe or chronic cases. A possible reason for this is that the current theories underlying these treatments are flawed. In this paper, we review and evaluate several prominent theoretical explanations associated with current frontline and promising treatments for ED. In doing so, we identify fundamental problems within the construction of current ED explanations and their implications for treatment. In response to these findings, we propose several strategies for the construction of future ED explanations which we believe have the power to ameliorate these problems and potentially help to develop more efficacious treatment downstream.

On bells, saliva, and abdominal pain or discomfort: Early aversive visceral conditioning and vulnerability for anorexia nervosa

Gastrointestinal (GI) symptoms are common in anorexia nervosa (AN), can predate illness onset, complicate renourishment, and persist after recovery. We explore how, through processes of aversive visceral conditioning, early GI pain and discomfort may increase vulnerability to AN in some individuals. Processes include enhanced preoccupation with the gut resulting from aversive visceral memories and disruptions in the typical acquisition of self-attunement when children learn to map and interpret interoceptive sensations and develop adaptive actions. We question whether a fear of weight gain, in some cases, may be an epiphenomenon of the recapitulation of actual or perceived GI symptoms that is especially relevant during puberty, especially in girls. This conceptualization has immediate clinical implications and offers ideas for future research. We propose that GI discomfort associated with renourishment may reignite prior aversive visceral experiences. We encourage development of a formulation that organizes the individual's current experience of the body with respect to these prior aversive experiences. Our conceptualization underscores the importance of assessment of GI experiences in individuals with AN; the examination of dietary strategies that minimize GI symptoms and enhance renourishment efficacy; and strategies that attempt to alter this aversive visceral conditioning by mapping sensations to meanings and adaptive actions.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Internalizing and externalizing behaviors in chronically ill adolescents in the context of family system functioning

Background

Diagnosis of chronic illness, which constitutes a life-threatening situation such as in Marfan syndrome or dis-ease with periods of remission and severity such as in juvenile idiopathic arthritis (JIA), leads to problems with the functioning of the adolescent and the whole family system. Therefore the aim of the study was to determine the differences in severity of internalizing and externalizing problems and in the perception of the family sys-tem between adolescents with Marfan syndrome, with JIA, and without chronic disease, as well as to determine whether characteristics of the family system are associated with externalizing and internalizing behaviors in those groups.

Participants and procedure

The study involved three groups of adolescents: 1) with Marfan syndrome (n = 25), 2) with JIA (n = 29), and 3) without chronic illness (n = 20). We used the adolescent version of the Child Behavior Checklist (CBCL) Youth Self-Report (YSR) and the Family Assessment Scale.

Results

Our results indicated that adolescents with Marfan syndrome have similar scores compared to adolescents without illness on all subscales concerning both internalizing and externalizing behaviors, as well as the family system’s characteristics. Compared to adolescents with JIA, adolescents with Marfan syndrome had lower scores on externalization symptoms and Attention Problems and they also perceive their families as less bal-anced. Additionally, in the perception of adolescents with Marfan syndrome and with JIA the weaker the family bond, the stronger the intensity of externalizing behaviors.

Conclusions

Although in the light of our novel research, adolescents with Marfan syndrome do not present behavioral prob-lems different from healthy peers, it is worth continuing such research in order to verify the results. Adolescents with JIA present more externalizing behaviors than peers without chronic illness, which is consistent with some previous research. Research on families of an adolescent child with Marfan and JIA are quite novel and they should be continued.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or other psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Introduction: Novel perspectives on the psychology and psychotherapy of eating disorders

The aim of this introduction to this issue is to review and summarize significant new psychological perspectives and psychotherapeutic interventions in the treatment of eating disorder (EDs). In this issue, five novel therapeutic strategies for the treatment of EDs are presented. These include a combination of psychodynamic psychotherapy and neuropsychology, two recent modifications of cognitive behavioral therapy (the MANTRA, and the conceptualization of change in patients with ED in terms of sense of agency), a specific group movement therapy, and an innovative rehabilitation treatment. In addition, one article offers an historic review of the development of psychotherapy of EDs, and two articles highlight specific considerations related to the treatment of EDs: compulsory treatment, and culturally sensitive treatment.

Family-based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders

OBJECTIVE

Family therapy has long been advocated as an effective intervention for eating disorders. A specific form of family therapy, one that utilizes family resources, has proven especially effective for adolescents with anorexia or bulimia nervosa (AN and BN). First developed in London, a behaviorally focused adaptation, called family-based treatment (FBT), has been manualized and systematically studied in six randomized clinical trials for adolescent AN and two for adolescent BN.

METHOD

This Commentary focuses on manualized FBT; what we know, what we do not know (yet), and what we hope for.

RESULTS

We do know that efficacy data for FBT, especially adolescent AN, are quite robust, even though remission rates remain elusive for more than half of all cases. While preliminary, moderators of FBT for adolescent AN have been identified and could aid us in determining the most (or least) responsive patient groups. And weight gain (∼2.5kg) by week four has been confirmed as an early predictor of remission at end-of-treatment. What we do not know, yet, is whether specific adaptations to manualized FBT will confer improved remission rates.

DISCUSSION

Finally, and in terms of what is hoped for, we highlight the promise of improved access, dissemination, and implementation of FBT.

Treatment of children and adolescents with avoidant/restrictive food intake disorder: a case series examining the feasibility of family therapy and adjunctive treatments

BACKGROUND

To date, little research has examined the effectiveness of either modified Family-Based Therapy or psychopharmacological treatments for patients diagnosed with avoidant/restrictive food intake disorder (ARFID), and there is little evidence to guide clinicians treating children and adolescents with ARFID. This case series describes the clinical presentations, treatments and outcomes of six patient diagnosed with ARFID who were treated sequentially by a child psychiatrist and adolescent medicine physician in a hospital-based eating disorder program.

CASE PRESENTATIONS

Five out of six cases were female and median age of patients at assessment was 12.9 (SD = 1.13) years. On average, patients' percentage of treatment goal weight was 80.5% at initial assessment (SD = 8.56) and 81.9% (SD = 7.08) when family therapy began. Cases 1, 2 and 3 were admitted to a specialized inpatient unit at assessment due to medical instability (2) or failed outpatient treatment (1), and all six cases presented with severe co-morbid anxiety. All patients were treated using a combination of medical monitoring, family therapy, medication (including olanzapine, fluoxetine and in two cases cyproheptadine), and cognitive behavioural therapy. At treatment termination, all six patients had achieved their goal weight.

CONCLUSION

These cases illustrate the complex ways in which young patients with ARFID can present, the illness' effect on development and mental health, and the positive outcomes associated with weight gain and concurrent treatment for co-morbid anxiety disorders.

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.

Are family relations connected to the quality of the outcome in adolescent anorexia nervosa? An observational study with the Lausanne Trilogue Play

The study aims to explore the connection between the family interactive patterns, investigated with a standardized observational tool based on a recorded play session, the Lausanne Trilogue Play, and the outcome of adolescent patients with anorexia nervosa after a 6 months treatment, based on the Morgan-Russel Outcome Assessment Schedule. Seventy-two parents and adolescent daughters with anorexia nervosa, consecutively referred to an adolescent neuropsychiatric service, participated in the study and underwent an integrated model of treatment, based on constant neuropsychiatric and dietary monitoring, weekly individual psychotherapy for the daughter, and parental counselling and support. A better adolescents' functioning in family relationships, in particular in the triadic ones, at first assessment, was associated with a better outcome. Data on family interactions may help predict the most appropriate intervention for the patient and his family.

An exploratory study of challenges and successes in implementing adapted family-based treatment in a community setting

Although family-based treatment (FBT) is accepted as the first-line treatment for adolescent anorexia nervosa, studies show that it is infrequently used by clinicians in community settings. To elucidate some of the barriers to implementing this evidence-based treatment, mixed (quantitative and qualitative) methods were used in this exploratory study to examine therapist experiences with FBT. Twelve clinicians (N = 12) at a community treatment center retrospectively reported on their experiences with FBT training and supervision in FBT. A subset of clinicians (n = 7) additionally completed a structured interview about their experiences in using FBT. Results demonstrate that therapists endorsed certain common misconceptions about FBT prior to training, but that negative beliefs about FBT decreased after its implementation in their setting. These findings suggest that increased education about evidence-based treatments may diminish negative stereotypes about such treatments, which may ultimately increase their uptake in community settings. Sustainability of FBT is discussed in the context of how this community setting incorporated FBT principles into their ongoing clinical practice.

Parents' and Children's ADHD in a Family System

ADHD symptoms "run in families". However, relatively little is known about the ways in which parents' symptoms might additively and interactively work with the parenting environment, to influence (and be influenced by) the developmental trajectory of symptoms in children and adolescents. In this commentary on the special section addressing this gap in knowledge, emphasis is placed on the importance of replicating and extending family-wide studies of ADHD symptoms and etiology. The current papers exemplify the leading-edge of such efforts, demonstrating the feasibility and rigor with which studies are being conducted, utilizing longitudinal and experimental designs. Families and parenting environments operate as a system in which individuals influence each other's symptoms and functioning. In so doing, parents produce tremendous variability within (as well as between) each family in individuals' ADHD symptoms from childhood through adulthood, via gene-environment transactions that may even begin during prenatal development.

Eating behavior and psychological profile: associations between daughters with distinct eating disorders and their mothers

Background

Associations of eating behaviors and psychological profile between mothers and daughters with eating disorders exist, but it is important to dissect the influence of the mother in each specific disorder since all eating disorders must be seen or treated not as one entity. The aim of the present study was to evaluate the association of eating behavior and psychological profile between mothers and daughters with different eating disorders and a control group.

Methods

The study group included young girls with anorexia nervosa (AN, n = 30), bulimia nervosa (BN, n = 30), binge eating disorder (BED, n = 19), and a control group of women (Non-ED, n = 54) together with their mothers. BMI was calculated for dyads and Eating Disorder Inventory, Beck Depression Inventory, Beck Anxiety Inventory, Toronto Alexithymia Scale and Three-Factor Eating Questionnaire were applied. The differences between dyads were tested by Student’s t test and Pearson’s correlation was used to study the association between BMI, variables of eating behavior and psychological profile in each dyad.

Results

The study found significant inverse correlations between the AN dyad; some correlations between the BN dyad, and the highest positive correlations exist in BED dyad, especially in eating behavior. Finally, between the control dyads, low but significant correlations were found in the majority of cases.

Conclusions

The study concluded that the associations between mothers and daughters with distinct eating disorders varied depending on the specific diagnosis of the daughter, indicating it is necessary to analyze them individually, given that there may be different implications for treatment.

Parent-child interactions in children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the parenting factors that may underlie this relationship. The aim of the current study was to examine observed parenting behaviours - involvement and negativity - associated with asthma and anxiety in children using the tangram task and the Five Minute Speech Sample (FMSS). Eighty-nine parent-child dyads were included across four groups of children (8-13 years old): asthma and anxiety, anxiety only, asthma only and healthy controls. Overall, results from both tasks showed that parenting behaviours of children with and without asthma did not differ significantly. Results from a subcomponent of the FMSS indicated that parents of children with asthma were more overprotective, or self-sacrificing, or non-objective than parents of children without asthma, and this difference was greater in the non-anxious groups. The results suggest that some parenting strategies developed for parents of children with anxiety may be useful for parents of children with asthma and anxiety (e.g. strategies targeting involvement), however, others may not be necessary (e.g. those targeting negativity).

Examining Profiles of Family Functioning in Pediatric Asthma: Longitudinal Associations With Child Adjustment and Asthma Severity

Objective

Identify profiles of functioning in families of children with asthma and examine whether profile membership predicts subsequent child mental and physical well-being.

Methods

Primary caregivers and children ( N  = 1,030) from the Childhood Asthma Management Program completed questionnaires assessing family functioning and child adaptation at five time points. Asthma severity was also assessed via spirometry.

Results

Latent profile analyses identified a four-profile solution as best fitting the data: cohesive, permissive, controlling/disengaged, and controlling/enmeshed families. Distal outcome analyses using Bolck-Croon-Hagenaars techniques suggested that children from families that were more cohesive had fewer internalizing and externalizing symptoms. These associations remained stable across time. Family profiles did not differ with regards to child asthma severity.

Conclusion

Results highlight the importance of looking beyond the effects of distinct components of family functioning and instead using pattern-based approaches. Recommendations for incorporating screenings and services for families in pediatric care settings are provided.

Identifying Predictors Associated with the Severity of Eating Concerns in Females with Eating Disorders

Considering how to improve efficacy of therapeutic strategies, the overall objective of the present study was to investigate the extent of eating concerns and to identify predictors associated with the severity of disordered eating symptomatology among people with eating pathologies. We screened 80 female eating disordered patients, ranging from 13 to 40 years, by means of self-report measures of parental behavior as perceived by the offspring, self-esteem, perfectionism, body shame and eating disorder severity. Self-reported weight and height were obtained. The diagnosis of bulimia nervosa resulted to be associated with a greater severity of the eating symptomatology. Maladaptive perfectionism, body shame and self-esteem, significantly predicted the level of eating concerns. The recognition of potential maintaining factors may support the choice of particular therapeutic strategies to improve the treatment of eating pathologies and their outcomes.

Using Intervention Mapping to develop the Parents as Agents of Change (PAC©) intervention for managing pediatric obesity

Background

Pediatric obesity has become increasingly prevalent over recent decades. In view of the psychosocial and physical health risks, and the high likelihood that children with obesity will grow to become adults with obesity, there is a clear need to develop evidence-based interventions that can be delivered in the health care system to optimize the health and well-being of children with obesity and their families. The aim of this paper is to describe the development, implementation, and planned evaluation of a parent-based weight management intervention designed for parents of 8–12 year olds with obesity.

Methods/results

The principles of Intervention Mapping (IM) were used to develop an intervention called Parents as Agents of Change (PAC^©). From 2006 to 2009, an environmental scan plus qualitative (individual interviews with parents and children), quantitative (medical record reviews), and literature review data were collected to gain broad insight into family factors related to pediatric obesity and its management. Theoretical frameworks and empirical evidence guided curriculum development, which was founded primarily on the tenets of family systems theory and cognitive behavioral theory. PAC was developed as a manualized, 16-session, group-based, health care professional-led intervention for parents to address individual, family, and environmental factors related to the management of pediatric obesity. The intervention was refined based on feedback from local and international experts, and has been implemented successfully in a multi-disciplinary weight management centre in a children’s hospital.

Conclusion

IM provided a practical framework to guide the systematic development of a pediatric weight management intervention for parents of children with obesity. This logical, step-by-step process blends theory and practice and is broadly applicable in the context of obesity management intervention development and evaluation. Following intervention development, the PAC intervention was evaluated within a randomized clinical trial.

Trial registration NCT01267097; clinicaltrials.gov