How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment?

Feasibility and acceptability of a pilot studying investigating multi-family parent-only guided self-help family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Family-based treatment (FBT) is an efficacious treatment for adolescent anorexia nervosa (AN). A parent-only guided self-help version of FBT (GSH-FBT) demonstrated preliminary efficacy in pilot investigations. To address challenges in access to care, we adapted GSH-FBT into a parent-only multi-family group format (MF-GSH-FBT) delivered via videoconferencing.

METHOD

This report details the feasibility and acceptability of a parent-only group-based multi-family GSH-FBT (MF-GSH-FBT) for adolescent AN delivered virtually. The MF-GSH-FBT intervention consisted of 12 weekly 60-min sessions facilitated by a clinician in addition to online FBT video content and recommended readings. Adolescents and parents completed assessments at baseline and post-treatment. Parents reported their child's weight each week.

RESULTS

A total of 13 adolescents (15.57 + 1.63 years; 92% female; 23% Hispanic) with AN and their parents enrolled and initiated treatment. Four consecutive cohorts of groups of 3-4 families were completed from April 2022 to April 2023. Across cohorts, parents attended 85% of sessions. Most parents rated the treatment sessions as helpful (79%; agree/strongly agree) and felt supported by the other group members (84%). All parents (100%) reported MF-GSH-FBT helped their child, and most (90%) reported their child had improved by end-of-treatment. On average, adolescents gained 3.53 kg (SD: 3.76) from pre- to post-treatment, with percent estimated mean body weight increasing 5% on average. Parental self-efficacy also increased from baseline to end-of-treatment.

DISCUSSION

MF-GSH-FBT for AN appears feasible and acceptable to parents participating in this pilot study. Challenges with recruitment and adolescent data collection remain questions for future investigation.

PUBLIC SIGNIFICANCE

This study describes initial pilot testing of a virtual guided self-help family-based treatment for adolescents with anorexia nervosa delivered in a multi-family group format. This treatment aims to enhance access to family-based treatment for anorexia nervosa whilst providing additional support to parents.

Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

PURPOSE

Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables.

METHODS

A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included.

RESULTS

The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome.

CONCLUSION

The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended.

LEVEL OF EVIDENCE

Level I, systematic review.

Family-based treatment via videoconference: Clinical recommendations for treatment providers during COVID-19 and beyond

The necessity to employ distance-based methods to deliver on-going eating disorder care due to the novel coronavirus (COVID-19) pandemic represents a dramatic and urgent shift in treatment delivery. Yet, TeleHealth treatments for eating disorders in youth have not been adequately researched or rigorously tested. Based on clinical experience within our clinic and research programs, we aim to highlight the common challenges clinicians may encounter in providing family-based treatment (FBT) via TeleHealth for children and adolescents with anorexia nervosa and bulimia nervosa. We also discuss possible solutions and offer practical considerations for providers delivering FBT in this format. Additional research in TeleHealth treatment for eating disorders in youth may lead to improved access, efficiency, and effectiveness of FBT delivered via videoconferencing.

Predictors of early response in conjoint and separated models of family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Early response, as indicated by early weight gain, in family-based treatment (FBT) for adolescent anorexia nervosa (AN) predicts remission at end of treatment. However, little is known about what factors contribute to early response. Further, no previous studies have examined early response to separated forms of FBT.

METHOD

Data from a randomised clinical trial of conjoint FBT and separated FBT (parent-focused treatment, PFT) were analysed to examine the timing and amount of early weight gain that predicted remission and identify factors associated with early response.

RESULTS

Weight gain of at least 2.80 kg in FBT (N = 55) and 2.28 kg in PFT (N = 51), by Session 5, were the best predictors of remission at end of treatment. Early response in FBT was predicted by greater paternal therapeutic alliance and lower paternal criticism. Early response in PFT was predicted by less severe eating-disorder symptoms and negative affect at baseline, lower maternal criticism, and greater adolescent therapeutic alliance.

CONCLUSIONS

The results confirm that early weight gain is an important prognostic indicator in both conjoint FBT and PFT and suggest that addressing negative emotion, parental criticism, and therapeutic alliance early in treatment could improve remission rates.

Therapist adherence and therapeutic alliance in individual cognitive-behavioural therapy for adolescent binge-eating disorder

To evaluate psychological treatments for adolescent binge-eating disorder (BED), reliable information on therapeutic process factors is needed. This study examines therapist adherence and therapeutic alliance and their associations in cognitive-behavioural therapy (CBT) for adolescents with BED. In a randomised-controlled efficacy trial, adherence and alliance were objectively determined based on 247 audio-taped CBT sessions from a sample of N = 64 adolescents with BED. Variability of adherence and alliance, explained by treatment module, patient, and therapist were examined using multilevel modeling. Although adherence and alliance were excellent and unaffected by treatment module and therapist, there was significant between-patient variability for both concepts. Adherence was negatively associated with patient's treatment expectation. Alliance was negatively associated with the number of loss of control eating episodes and positively associated with adherence. Excellent adherence supported the internal validity of CBT for adolescent BED. Associations between process factors and patient characteristics demand adequate supervision in CBT.

The association between program credibility, expectancy, and acceptability with baseline pathology and outcome for a body acceptance prevention program

OBJECTIVE

The current study sought to investigate whether credibility, expectancy, and acceptability of the Body Project is impacted by level of disordered eating pathology and whether perceived credibility, expectancy, and acceptability impacts treatment outcomes.

METHODS

The sample included 170 undergraduate women from a large public university. Participants completed self-report questionnaires on perceived credibility, expectancy, treatment acceptability, and disordered eating measures. A random subset of 51 participants provided 3-month follow-up measurements.

RESULTS

Analyses revealed that post-prevention credibility, expectancy, and treatment acceptability scores were negatively associated with baseline thin-ideal internalization, baseline weight, and shape concerns, and positively associated with baseline body satisfaction and the baseline restraint subscale of the EDEQ. Perceived credibility, expectancy, and treatment acceptability were not associated with session attendance or 3-month follow-up disordered eating scores.

DISCUSSION

The Body Project is effective at reducing disordered eating regardless of whether participants liked the program or not.

Alliance and Treatment Outcome in Family-Involved Treatment for Youth Problems: A Three-Level Meta-analysis

Alliance has been shown to predict treatment outcome in family-involved treatment for youth problems in several studies. However, meta-analytic research on alliance in family-involved treatment is scarce, and to date, no meta-analytic study on the alliance-outcome association in this field has paid attention to moderating variables. We included 28 studies reporting on the alliance-outcome association in 21 independent study samples of families receiving family-involved treatment for youth problems (N = 2126 families, M age youth ranging from 10.6 to 16.1). We performed three multilevel meta-analyses of the associations between three types of alliance processes and treatment outcome, and of several moderator variables. The quality of the alliance was significantly associated with treatment outcome (r = .183, p < .001). Correlations were significantly stronger when alliance scores of different measurement moments were averaged or added, when families were help-seeking rather than receiving mandated care and when studies included younger children. The correlation between alliance improvement and treatment outcome just failed to reached significance (r = .281, p = .067), and no significant correlation was found between split alliances and treatment outcome (r = .106, p = .343). However, the number of included studies reporting on alliance change scores or split alliances was small. Our findings demonstrate that alliance plays a small but significant role in the effectiveness of family-involved treatment. Future research should focus on investigating the more complex systemic aspects of alliance to gain fuller understanding of the dynamic role of alliance in working with families.

Practitioner Review: Therapist variability, patient-reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment - a systematic review and meta-analysis

BACKGROUND

Previous meta-analyses have only found small correlations (r = .10 to r = .19) between therapeutic alliance and clinical outcomes in samples of adolescents receiving psychological therapy. Although study-level variables have been found to moderate this, little is known about the impact of therapist variability. The present meta-analysis aimed to address this gap by using patient-therapist ratio as a moderator variable.

METHODS

Contrary to previous reviews of adolescent alliance, individual effect sizes were extracted using a preregistered conceptual hierarchy. Controlling for treatment-level confounds, a random effects meta-analysis assessed the moderating effect of patient-therapist ratio on the alliance-outcome relationship in predefined single-predictor and multipredictor meta-regressions.

RESULTS

The alliance-outcome relationship was found to be larger than previously thought (k = 28, N = 2,911, r = .29, 95% Confidence Interval 0.21, 0.37; p < .0001, I²  = 80%). When study samples exceeding the adolescent 12-19 age range were removed, the correlation rose (k = 15, N = 1,797, r = .34, 95% Confidence Interval 0.23, 0.45; p < .0001, I²  = 83%). In contrast to research with adults, patient-therapist ratio did not moderate this relationship in either single-predictor (p = .26) or multi-predictor (p = .22) models.

CONCLUSIONS

The alliance-outcome relationship for adolescents was larger than previously thought, and comparable to estimates in adult samples. The failure of patient-therapist ratio to moderate its strength, however, challenges the hypothesis that variability in therapist characteristics is an important determinant of the alliance-outcome effect in this age group.

A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, βs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.

Randomized Clinical Trial of Parent-Focused Treatment and Family-Based Treatment for Adolescent Anorexia Nervosa

OBJECTIVE

There have been few randomized clinical trials (RCTs) for adolescents with anorexia nervosa (AN). Most of these posit that involving all family members in treatment supports favorable outcomes. However, at least 2 RCTs suggest that separate parent and adolescent sessions may be just as effective as conjoint treatment. This study compared the relative efficacy of family-based treatment (FBT) and parent-focused treatment (PFT). In PFT, the therapist meets with the parents only, while a nurse monitors the patient.

METHOD

Participants (N = 107) aged 12 to 18 years and meeting DSM 4(th)Edition criteria for AN or partial AN were randomized to either FBT or PFT. Participants were assessed at baseline, end of treatment (EOT), and at 6 and 12 months posttreatment. Treatments comprised 18 outpatient sessions over 6 months. The primary outcome was remission, defined as ≥95% of median body mass index and Eating Disorder Examination Global Score within 1 SD of community norms.

RESULTS

Remission was higher in PFT than in FBT at EOT (43% versus 22%; p = .016, odds ratio [OR] = 3.03, 95% CI = 1.23-7.46), but did not differ statistically at 6-month (PFT 39% versus FBT 22%; p = .053, OR = 2.48, CI = 0.989-6.22), or 12-month (PFT 37% versus FBT 29%; p = .444, OR = 1.39, 95% CI = 0.60-3.21) follow-up. Several treatment effect moderators of primary outcome were identified.

CONCLUSION

At EOT, PFT was more efficacious than FBT in bringing about remission in adolescents with AN. However, differences in remission rates between PFT and FBT at follow-up were not statistically significant.

CLINICAL TRIAL REGISTRATION INFORMATION

A Randomised Controlled Trial of Two Forms of Family-Based Treatment and the Effect on Percent Ideal Body Weight and Eating Disorders Symptoms in Adolescent Anorexia Nervosa; http://www.anzctr.org.au/; ACTRN12610000216011.

A qualitative analysis of aspects of treatment that adolescents with anorexia identify as helpful

This study aimed to identify aspects of treatment that adolescents with anorexia nervosa (AN) believe are helpful or unhelpful. Adolescent females receiving treatment for AN or subthreshold AN (n=21) were prompted during semi-structured interviews to generate responses to open-ended questions on what they felt would be most helpful or unhelpful in treating adolescents with eating disorders. Eight codes were developed and the two most frequently endorsed categories were (1) Alliance, where the therapist demonstrates clinical expertise and also expresses interest in the patient (n=21, 100.0%), and (2) Client Involvement in treatment (n=16, 76.2%). These top two categories were shared by participants with AN versus subthreshold AN and participants with high versus low readiness to change their dietary restriction behaviours. Development of the coding scheme and sample participant responses will be discussed. The integration of identified factors into empirically supported treatments for adolescent AN, such as Family-based Treatment, will be considered. This study provides initial information regarding aspects of treatment that adolescents identify as most helpful or unhelpful in their treatment.

Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa

BACKGROUND

Therapeutic alliance (TA) has been found to be a significant predictor of outcome for patients with severe and enduring anorexia nervosa (SE-AN), accounting for more variance than treatment type. To better understand how to promote TA for this population, the aim of the current study was to investigate predictors of TA in adults with SE-AN.

METHODS

Participants were 63 adult females with SE-AN presenting to an outpatient, multi-site randomized controlled trial conducted at two clinical sites. Participants' perception of the quality of their therapeutic relationship, demographic information, and eating disorder symptomatology were assessed via interview and questionnaire measures.

RESULTS

Baseline ratings of how successful participants believed treatment would be for them was the only variable to significantly predict early (p = .01), mid (p = .009), and late treatment alliance (p = .03). No other variables investigated predicted the quality of patient rated TA at any point in treatment (ps > .57).

CONCLUSIONS

Results suggest instilling hope in treatment outcome may enhance TA, and in turn, outcomes for patients with SE-AN in outpatient therapy.

Eating disorders treatment patterns by age

This longitudinal, retrospective study examines patterns in eating disorder outpatient mental health treatment by age. Participants (n = 5,445) included patients treated for an eating disorder, with claims for treatment from Cigna, a leading health care insurance provider in the United States. Treatments for individuals 55 and older were less expensive and shorter than for any other age group. Treatments for individuals 44-55 were less expensive than for 15-24. Individual therapy is the most common treatment modality, but younger individuals are likely to receive family therapy. Younger individuals have lower dropout and higher return to care rates.

The role of the therapeutic alliance in eating disorder treatment outcomes: a systematic review

The therapeutic alliance has proven to be an important construct in psychotherapy outcomes research for numerous psychiatric disorders. Given that dropout rates from treatment are especially high for individuals with eating disorders, it is critical to clarify the role that the therapeutic alliance plays in predicting treatment outcomes for this specific population. MEDLINE, CINAHL, and PsycINFO databases were systematically reviewed for studies that formally measured the therapeutic alliance construct and at least one other treatment variable in the context of eating disorder treatment. We identified 19 studies that indicate the therapeutic alliance may be an important factor in eating disorder treatment, yet reflect on the paucity of research on this topic in the context of treatment outcomes for both adult and adolescent populations. Current trends and limitations in the literature are highlighted to guide future research and ultimately improve clinical outcomes for patients with eating disorders.

The therapeutic process in psychological treatments for eating disorders: a systematic review

OBJECTIVE

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled.

METHOD

Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified.

RESULTS

Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated.

DISCUSSION

As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

Family therapy for adolescent eating disorders: an update

Family therapy has featured in the treatment of adolescent eating disorders for over 40 years, and the evolution of family therapy approaches, through a variety of theoretical lenses, has been significant. For instance, the recent dissemination of family-based treatment has resulted in a growing number of controlled empirical trials which continue to inform and augment treatment outcomes. In addition, a burgeoning number of alternate approaches to family therapy for eating disorders leave clinicians with more clinical considerations in practicing family therapy for eating disorders. In this paper, we aim to review the recent developments in family therapy for adolescent eating disorders, underscoring the impact on clinical practice and the likely implications for future research.

Parent-focused treatment for adolescent anorexia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Family-based treatment is an efficacious outpatient intervention for medically stable adolescents with anorexia nervosa. Previous research suggests family-based treatment may be more effective for some families when parents and adolescents attend separate therapy sessions compared to conjoint sessions. Our service developed a novel separated model of family-based treatment, parent-focused treatment, and is undertaking a randomised controlled trial to compare parent-focused treatment to conjoint family-based treatment.

METHODS/DESIGN

This randomised controlled trial will recruit 100 adolescents aged 12-18 years with DSM-IV anorexia nervosa or eating disorder not otherwise specified (anorexia nervosa type). The trial commenced in 2010 and is expected to be completed in 2015. Participants are recruited from the Royal Children's Hospital Eating Disorders Program, Melbourne, Australia. Following a multidisciplinary intake assessment, eligible families who provide written informed consent are randomly allocated to either parent-focused treatment or conjoint family-based treatment. In parent-focused treatment, the adolescent sees a clinical nurse consultant and the parents see a trained mental health clinician. In conjoint family-based treatment, the whole family attends sessions with the mental health clinician. Both groups receive 18 treatment sessions over 6 months and regular medical monitoring by a paediatrician. The primary outcome is remission at end of treatment and 6 and 12 month follow up, with remission defined as being ≥ 95% expected body weight and having an eating disorder symptom score within one standard deviation of community norms. The secondary outcomes include partial remission and changes in eating pathology, depressive symptoms and self-esteem. Moderating and mediating factors will also be explored.

DISCUSSION

This will be first randomised controlled trial of a parent-focused model of family-based treatment of adolescent anorexia nervosa. If found to be efficacious, parent-focused treatment will offer an alternative approach for clinicians who treat adolescents with anorexia nervosa.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12610000216011.

Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa

OBJECTIVE

The aim of this study was to investigate the strength and role of therapeutic alliance in a trial comparing Cognitive Behavioral Therapy for anorexia nervosa (CBT-AN) and Specialist Supportive Clinical Management for the treatment of severe and enduring AN (SE-AN).

METHOD

Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized controlled trial conducted at two clinical sites. Participants completed measures assessing their perception of the quality of the therapeutic relationship, eating disorder (ED) symptomatology, and depressive symptomatology.

RESULTS

Beyond the effect of early treatment change and treatment assignment, early therapeutic alliance was a significant predictor of Restraint and Shape Concern at follow-up (ps < .02). Late therapeutic alliance was a significant predictor of weight change, depressive symptomatology, and ED symptomatology at end of treatment and follow-up (ps < .008), with the exception of Shape Concern at follow-up (p = .07).

DISCUSSION

The results suggest that therapeutic alliance can be effectively established in the treatment of SE-AN and may be relevant for treatment response, particularly in late treatment, on some aspects of ED and depressive symptomatology.

Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa

This study examined the relationship between therapeutic alliance and primary symptom change (weight gain) during CBT for anorexia nervosa. The aims were threefold: (1) to establish the strength of the therapeutic alliance across the treatment, (2) to determine whether early therapeutic alliance is associated with the completion of CBT for this client group, and (3) to determine the direction of the relationship between therapeutic alliance and weight gain. Adult outpatients (N=65) with a diagnosis of anorexia nervosa (or atypical anorexia nervosa) completed a measure of alliance at session six and at the end of treatment. Weight was recorded at the start of treatment, session six and at the end of treatment. The strength of the alliance was consistently high in the sample. However, early therapeutic alliance was not associated with either the likelihood of completing treatment or subsequent weight gain. In contrast, both early and later weight gain were associated with the strength of subsequent alliance. These findings indicate that it might be advisable to focus on techniques to drive weight gain rather than rely on the therapeutic alliance to bring about therapeutic change.

Therapeutic alliance in two treatments for adolescent anorexia nervosa

OBJECTIVE

The aim of this study was to examine the relationship between therapeutic alliance and treatment outcome (remission status) in family-based treatment (FBT) and adolescent-focused therapy (AFT) for adolescents with anorexia nervosa (AN).

METHOD

Independent observers rated audiotapes of early therapy sessions using the Working Alliance Inventory-Observer Version (WAI-o). Outcome was defined using established cut-points for full and partial remission. To control for effects of early symptom improvement, changes in weight- and eating-related psychopathology prior to the alliance session were calculated and entered as a covariate in each analysis.

RESULTS

Participants in AFT had significantly higher alliance scores; however, overall scores were high in both therapies. The alliance was not a predictor of full remission for either treatment, though it was a non-specific predictor for partial remission.

DISCUSSION

Therapeutic alliance is achievable in adolescents with AN in both AFT and FBT, but demonstrated no relationship to full remission of the disorder.

An examination of adults on antipsychotic medication at risk for metabolic syndrome: a comparison with obese and eating disorder populations

Little research has explored how eating disorders (ED) may be involved in the increased risk for metabolic syndrome in adults on antipsychotic medication. This pilot study compared participants on antipsychotic medication with obese and ED samples with respect to demographic and psychosocial factors. Participants (antipsychotic medication n = 12; obese n = 12; ED n = 12), were adults presenting to an outpatient psychiatry department (83.3% women; M age = 45.75 ± 11.5). Analysis of variance, analysis of covariance and chi-square tests were used to compare the samples. Participants on antipsychotic medications had a significantly lower mean body mass index than the obese (p < .001) and ED (p < .05) samples, as well as significantly lower Restraint Total scores (p < .05) and subjective binge episode frequency (p < .05) than the ED sample. The lack of significant differences that occurred between the antipsychotic medication sample and two eating disorder samples significantly different from one another indicates that this population may have unique symptomology and treatment needs.

Adolescent bulimia nervosa

Onset of bulimia nervosa (BN) typically occurs in adolescence and is frequently accompanied by medical and psychiatric sequelae that may have detrimental effects on adolescent development. Potentially serious medical consequences and high comorbid rates of mood disorders and suicidality underscore the need for early recognition and effective treatments. Research among adolescents with BN has lagged behind that of adults, although evidence is accumulating to support the efficacy of family-based interventions and cognitive behavioral treatments that are adapted for use with adolescent populations. The aim of the current article is to provide an overview of recent research on epidemiology, risk factors, diagnostic issues, and treatment interventions focusing on adolescent BN, and to highlight areas for future research.

The use of multiple methods of compensatory behaviors as an indicator of eating disorder severity in treatment-seeking youth

OBJECTIVE

This study investigated the use and frequency of multiple methods of compensatory behaviors and how they relate to eating-related and general psychopathology for youth with eating disorders (ED).

METHOD

Participants were 398 referrals to a pediatric ED treatment program (91.2% female; M age = 14.9 ± 2.2). ANOVA and chi-square tests compared participants reporting multiple methods of compensatory behaviors, single method of compensatory behaviors, and no compensatory behaviors on measures of ED and general psychopathology. Partial correlations examined associations between compensatory behavior, frequency and severity of ED and general psychopathology.

RESULTS

Participants reporting multiple methods of compensatory behaviors had significantly greater ED and general psychopathology than the other groups (ps < .001). Frequency of compensatory behaviors was associated with ED psychopathology (partial r = .14; p = .007) but not with general psychopathology.

DISCUSSION

Engaging in multiple methods of compensatory behaviors is related to greater ED and general psychopathology, whereas frequency is only related to greater ED symptom severity.

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Driven exercise among treatment-seeking youth with eating disorders

PURPOSE

This study evaluated the prevalence and clinical significance of driven exercise (DE) in treatment-seeking youth.

METHODS

Participants were 380 consecutive referrals to a pediatric eating disorder program (90.8% female; M age=14.9±2.2). Spearman's rho correlations examined the relation between DE frequency, and Beck Depression Inventory (BDI) and Eating Disorders Examination (EDE) Global Severity scores. ANOVA compared those reporting only DE, only vomiting, or both DE and vomiting on the aforementioned measures.

RESULTS

51.3% of participants (n=193) reported DE in the past 3 months, with an average of 21.8 (SD=32.6) episodes. Frequency of DE was related to EDE global severity score (Spearman's rho=.46; p<.001) and BDI Total Score (Spearman's rho=.33; p<.001). Participants reporting both vomiting and DE had the highest EDE global severity and BDI total scores.

CONCLUSIONS

DE is associated with greater eating disorder and depressive symptomatology, especially when paired with vomiting. The findings highlight the importance of assessing for DE in youth presenting for eating disorder treatment.

Psychotherapy approaches for adolescents with eating disorders

PURPOSE OF REVIEW

Adolescence is the most common period for the onset of eating disorders, and early intervention is critical. Primary care providers should feel equipped to discuss psychotherapy approaches for eating disorders with adolescents and their families and to provide appropriate referrals. The present review focuses on six prominent treatment modalities and the evidence supporting each approach.

RECENT FINDINGS

Although the majority of studies about psychotherapy approaches for eating disorders focus on adult women, there is a growing body of research on effective treatments for an adolescent population. Family-based treatment (the 'Maudsley method') and supportive psychotherapy appear to be promising approaches for anorexia in teens. Treatments for bulimia yield extremely high relapse rates, but cognitive-behavioral therapy and family-based treatment are favored modalities. Dialectical behavior therapy and interpersonal psychotherapy may also be applicable to adolescent bulimia and binge eating. Most psychotherapists draw upon a variety of these treatment approaches, depending upon the patient's unique presentation. Regardless of the modality used, some degree of family involvement is important in limiting dropout and improving outcomes.

SUMMARY

Adolescent health providers need to be aware of the psychotherapy approaches recommended for teens with eating disorders in order to effectively refer patients to and collaborate with mental health providers.