An Update on Evidence-Based Psychosocial Treatments for Eating Disorders in Children and Adolescents

Improving capacity and flow in a children and young people's Community Eating Disorder Service (CEDS): how a quality improvement initiative led to a reduction in waiting times in the service

Eating disorders are serious mental health conditions associated with significant morbidity and mortality. High levels of demand on services have led to increases in wait times to access support. Early intervention of eating disorders is critical to prevent entrenchment of illness and improve prognosis, with long wait times associated with higher rates of relapse.The East London Community Eating Disorder Service has seen an increase in wait time for routine referral from the 2-week local target to 17 weeks. Additionally, there have been long wait times to access treatment, including therapy and psychiatry support.A quality improvement (QI) framework was used in June 2022 to tackle the issues with capacity and flow with an aim to reduce wait times for routine referral from 17 weeks to 2 weeks in 12 months.A QI project team was formed which sought to understand the demands and capacity of the system using process mapping.From this, the team created a driver diagram and used Plan, Do, Study, Act cycles to test change iteratively. Measurements and data were displayed on control and run charts to help learn from the change ideas tested.Improvements were made and sustained, including reduction of routine referral wait time from 17 weeks to 2 weeks in 12 months. Additionally, internal wait lists reduced from 73 patients on the psychiatry list to 0 in 3 months and from 50 families waiting for therapy to 0 in 7 months.A number of inactive cases reduced from 65 to 0 during testing, thus contributing to improved flow through the service. A striking £130 233.21 annual savings in agency staff expenditure was achieved by January 2023.This has enabled a positive culture shift in the service.

Intervention research in anorexia nervosa - a plea for single case experimental designs

Anorexia nervosa (AN) is a severe eating disorder and among the mental disorders with the highest mortality rate. To date, not much is known about its development and maintenance, and treatment outcomes are improvable. At the same time, research on psychological interventions for AN is a complicated endeavor, often characterized by small sample sizes and methodological heterogeneity, which impedes the comparison and evaluation of treatment outcomes. In this paper, several population-related, therapist-related and methodological challenges that may be encountered during research on psychological interventions for AN are discussed. The use of single case experimental designs (SCEDs), which could account for several of these challenges, is suggested as a complementary approach to current methods of assessing treatment efficacy. The use of SCEDs could be beneficial to the field, by contributing to the knowledge about AN and to the development and evaluation of better treatments, which are sorely needed.

Brief Cognitive Analytic Therapy (CAT)-Informed Reformulation for Young People With Eating Disorders: A Case Series

BACKGROUND

Onset of Eating Disorder (ED) peaks in young people, and interpersonal factors can influence development and maintenance. With increased referrals to ED services, accessible, brief interventions may support early intervention and improve outcomes. Cognitive Analytic Therapy (CAT) is a transdiagnostic relational approach, which can offer benefit for a range of presenting difficulties. This study aimed to assess the feasibility and acceptability of a brief, CAT-informed reformulation for young people with ED.

DESIGN

A case series design recruited eight young people who met inclusion and exclusion criteria to participate in the five-session reformulation intervention.

METHOD

Recruitment took place from NHS ED services. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. Psychological distress, ED severity, personal recovery and motivation to change were assessed at baseline, post-intervention and follow-up. Participants also completed sessional measures of psychological distress and alliance.

RESULTS

Eight eligible participants aged 15-24 years (M = 20.25, SD = 3.58) consented to take part and received the intervention. All participants attended all intervention sessions and completed all assessments. Participants reported positive experiences of the intervention. There was an associated reduction across clinical outcomes, including psychological distress and ED severity.

CONCLUSIONS

This case series showed promising results on the feasibility and acceptability of a brief CAT-informed reformulation for young people with ED. However, the study had a small sample size and no comparator control group. Larger scale exploration of a brief CAT-informed reformulation for EDs among young people is warranted.

CLINICAL TRIAL REGISTRATION

The study was preregistered with clinicaltrials.gov (NCT05746364).

Family therapy and cognitive behavior therapy for eating disorders in children and adolescents in routine clinical care: a systematic review and meta-analysis

Family therapy for eating disorders (ED) is well-established and represents the treatment choice for ED in children and adolescents according to guidelines, with cognitive behavior therapy (CBT) as a second line treatment. There is limited knowledge about how these treatments work in routine clinical care. The goal of the present meta-analysis is to investigate the effectiveness of family therapy and CBT for various EDs in children and adolescents when carried out in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were searched for articles published until December 2023. The outcome of family therapy and CBT, methodological quality, risk of bias, and moderators of treatment outcome were examined and benchmarked by meta-analytically comparing with ED efficacy studies. Forty-four effectiveness studies comprising 3251 family therapy or CBT patients were included. Large to very large within-group effect sizes (ES) were found for ED-psychopathology (0.80) and weight measures for AN (1.64) at post treatment. The attrition rate was 15%. Risk of bias was considerable. Moderate to large ES were found for family therapy and CBT, respectively. The benchmarking analysis showed that effectiveness studies had comparable ESs to efficacy studies (0.80 and 0.84 for the ED-psychopathology at post treatment). The findings support family therapy and CBT for ED in children and adolescents as effective treatments when delivered in routine clinical care, with effects comparable with those found in efficacy studies. The evidence needs to be interpreted with caution because of the risk of bias in a high proportion of studies.PROSPERO [CRD42023441794].

Level of family involvement as a predictor of outcome in eating disorder patients with and without provisional PTSD during residential treatment

OBJECTIVE

Family involvement (FI) in the treatment of eating disorders (EDs) is critical for children/adolescents, yet its role during residential treatment (RT) in adults is uncharted. PTSD may play a role in influencing FI but is also unexplored.

METHOD

We examined the role of FI in 2786 ED patients (89% F) admitted to RT with and without provisional PTSD. At discharge, staff rated the degree of FI as follows: 1) Not at all; 2) Slightly/somewhat; 3) Very much/extremely. Changes in ED, depression, anxiety, PTSD, and quality of life measures from admission to discharge were examined via multivariate analyses of covariance using degree of FI as an independent variable and age, gender, admission BMI, age of ED onset, and baseline symptom levels as covariates.

RESULTS

Patients with the highest FI were the youngest, had the lowest BMIs and the oldest ages of ED onset. Rates of provisional PTSD were greatest in individuals with no FI and least in those with the highest FI. Those with no FI did significantly worse on all measures than those with higher levels of FI.

CONCLUSION

FI is an important component in ED treatment of adults in RT and is especially needed in patients with PTSD.

SEED-AN and a non-specialised, severe mental illness (SMI) community treatment model: perspectives of professionals and patients of a QoL-focussed treatment

BACKGROUND

Improving care for SEED-AN patients is urgently needed. Current specialist eating disorder (SEDU) programs have minimal impact, resulting in poor quality of life. Flexible assertive community treatment (FACT) focuses on improving the quality of life of people with severe mental illness.

AIM

This study systematically examined professionals' and patients' experiences with existing care for SEED AN in two settings in two health districts in the Netherlands. Specifically, the specialised Eating Disorder Unit and FACT.

METHODS

A qualitative approach was used: Twelve professionals participated in focus groups, and four professionals and six patients were interviewed individually. Reflective thematic analysis was used to analyse the data.

RESULTS

Four themes were constructed: "We feel ignorant in the treatment of SEED-AN patients"; "There is a disability to act"; "We are more than executive practitioners alone"; and "The professionals at FACT have given me back my confidence in treatment". The findings reflect how support for SEED-AN patients is provided by both FACT and SEDU professionals and how SEED-AN patients experience the FACT approach.

DISCUSSION

A resource group model promotes collaboration among professionals, patients and the patient's support system. The model is expected to increase knowledge about SEED-AN among stakeholders who support the quality of life of SEED-AN patients.

Anorexia nervosa-specific home treatment in children and adolescents and their families (the HoT study): a study protocol of a randomized, controlled, multicenter, open-label, parallel group superiority trial

BACKGROUND

New treatment approaches are urgently needed to improve the prognosis of children and adolescents with anorexia nervosa (AN). Recently, the feasibility of multidisciplinary home treatment that strongly involves the patients' parents/caregivers has been investigated. However, no RCT has yet been performed to test the efficacy and safety of this approach compared to standard treatment approaches, such as inpatient treatment.

METHODS

In this multicenter randomized-controlled trial, home treatment for children and adolescents with AN aged 12 to 18 years is established at 5 major treatment centers for AN in Germany. Approximately 240 patients who are admitted to the hospital for AN will be included in the trial. After a short inpatient somatic stabilization phase (5-8 weeks), patients are randomized to receive either treatment as usual (TAU), in the form of continued inpatient or day patient treatment, or the newly developed home treatment (HoT) (n = 82/arm, n = 164 in total). There are three assessments throughout treatment (admission, randomization, and discharge), as well as follow-up assessments at 9 and 12 months after admission. The BMI at 12 months after admission (primary outcome) is compared between groups (adjusted for premorbid BMI and admission BMI); secondary outcomes include eating disorder and general psychopathology, the number and duration of psychiatric rehospitalizations, quality of life, motivation for treatment and treatment satisfaction. Other secondary outcomes include the primary caregivers' burden and skills in handling the child's illness and direct treatment costs. Statistical analysis will be based on intention-to-treat principles, using mixed models for repeated measures. (Serious) adverse events are assessed throughout treatment. In addition, the feasibility and implementation of HoT as well as the satisfaction and workload of the members of the multidisciplinary treatment teams in both arms will be assessed.

DISCUSSION

In the case of a positive evaluation, HoT can be considered an effective treatment method to replace or complete established treatment methods, such as IP, for treating AN in children and adolescents. The home treatment setting might shorten inpatient stays in this patient group, increase treatment satisfaction, and help to reduce the risk of rehospitalization, which is associated with a better outcome in this vulnerable patient group.

TRIAL REGISTRATION

The trial was registered with the German Clinical Trial Register (DRKS) under the ID DRKS00025925 on November 26, 2021 (prospectively registered): https://drks.de/search/de/trial/DRKS00025925 .

Assessing Psychological Remission in Adolescent Anorexia Nervosa: A Comparison of Patient and Parent Report

OBJECTIVE

The definition and assessment of remission in anorexia nervosa (AN) needs greater consensus. Particularly in adolescents, the use of patient-reported composite indices (such as the Eating Disorder Examination [EDE] Global Score) as the sole measure of psychological remission has the potential to obscure patients' true clinical status, given developmental factors and the propensity towards symptom minimization in AN.

METHOD

End of treatment (EOT) data from a randomized controlled trial comparing two formats of manualized family-based treatment for adolescents with AN (N = 106) were analyzed. Participants completed the EDE, and their parents completed a parent-as-informant version of the EDE (Parent Eating Disorder Examination; PEDE). Rates of remission were compared across indices (i.e., EDE Global Score vs. diagnostic item analysis) and informant (i.e., adolescent vs. parent), both independently and in combination with the achievement of a percent median body mass index (% mBMI) greater than or equal to 95%.

RESULTS

For both adolescent and parent reports, there were higher rates of remission when defined by Global Score than when defined by EDE or PEDE diagnostic items. There were no significant differences in remission rates based on informant.

DISCUSSION

In the assessment of remission in AN, the EDE Global Score may not detect some adolescents who continue to exhibit clinically significant psychological symptoms. This study supports a detailed, multidimensional approach to assessing remission in adolescent AN to optimize sensitivity to patients' diagnostic profile. Future research should explore whether parent-child concordance on measures of ED psychopathology varies over the course of treatment.

Effective Treatment Approaches for Eating Disorders in Children and Adolescents: A Review Article

Eating disorders are serious psychiatric illnesses marked by disordered behaviors toward food and eating due to dissatisfactory body shape and weight, which impact the physical and psychological growth of children and adolescents. This review aims to recognize the effectiveness of psychotherapy and pharmacotherapy in treating eating disorders. The most common type of eating disorder is anorexia nervosa characterized by severe restriction of energy intake and an intense fear of gaining weight. Bulimia nervosa is characterized by episodes of binging and purging followed by compensatory behaviors. Binge eating disorder is characterized by binging without compensatory behaviors. Avoidant-restrictive food intake disorder is characterized by a lack of interest in eating unrelated to weight and shape concerns. Depending on the severity of the condition, patients could be treated as an inpatient, partial hospitalization, or outpatient treatment using different psychotherapies, including family-based therapy, psychodynamic individual treatment, cognitive behavioral therapy, adolescent-focused therapy, interpersonal psychotherapy or pharmacotherapy, or a combination of both. Studies in children and adolescents show that family-based therapy is considered the first-line treatment for anorexia nervosa, and the second evidence-based approach is adolescent-focused therapy. As for bulimia nervosa, both family-based treatment and cognitive behavioral therapy are almost equally effective. In binge eating disorder, cognitive behavioral therapy and interpersonal psychotherapy are the most beneficial psychotherapies. For avoidant-restrictive food intake disorder, psychotherapy or hospitalization could be considered. Concerning pharmacotherapy, none of the medications have been approved by the US Food and Drug Administration for children and adolescents.

Severe Sinus Bradycardia in Anorexia Nervosa: A Case Report and Focused Review of Cardiovascular Complications

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by restricted energy intake, intense fear of weight gain, and body image disturbances. It predominantly affects adolescent females, with rising prevalence, especially during the COVID-19 pandemic. AN leads to multiple medical complications, including cardiovascular issues such as bradycardia, which may result from malnutrition, electrolyte disturbances, and myocardial atrophy. We report a case of a 19-year-old female patient with a three-month history of weight loss, resulting in a weight of 38 kg and a body mass index of 14 kg/m², indicative of severe malnutrition. She presented with a fluctuating appetite, fatigue, muscle pain, mood changes, and sleep disturbances. Clinical evaluation revealed severe sinus bradycardia (30-40 bpm) and a small heart volume, with reduced stroke volume (<45 mL/beat) and cardiac output (<3.5 L/min). Electrolyte analysis showed mildly reduced magnesium, and inflammatory markers showcasing mild elevation of erythrocyte sedimentation rate. Additional psychiatric findings, including obsessive weight monitoring and self-induced vomiting, led to a diagnosis of AN. This report underscores the importance of recognizing bradycardia as a significant cardiovascular manifestation of AN. Early psychiatric intervention and multidisciplinary management are crucial to address malnutrition, electrolyte imbalances, and cardiac dysfunction to prevent further complications and improve patient outcomes.

Distinct functional connectivity phenotypes in preadolescent children with binge eating disorder by BMI status

OBJECTIVE

The neurobiological mechanisms underpinning binge eating disorder (BED) in children remain largely unclear, as the alterations that have been identified to date may be attributable to BED, obesity, or compound effects. This study aimed to delineate functional connectivity (FC) patterns in inhibitory control and reward networks in preadolescent children with and without BED from the Adolescent Brain Cognitive Development (ABCD) Study according to BMI.

METHODS

Resting-state FC was examined in the inhibitory control network by using seeds in the dorsolateral prefrontal cortex, the anterior cingulate cortex, and the posterior cingulate cortex, whereas the reward network included seeds in the orbitofrontal cortex, nucleus accumbens, and amygdala. Seed-to-voxel analyses characterized FC differences between preadolescent children with BED with a high BMI and those with BED with a low BMI.

RESULTS

We identified that BED was characterized by reduced connectivity between the reward network and regions in the default mode network, irrespective of weight status. Participants with BED also presented with hypoconnectivity in fronto-amygdalar circuits, which has been consistently associated with impaired emotion regulation capacity.

CONCLUSIONS

Our findings support that FC alterations between the reward network and the default mode network may be specifically impacted by the presence of BED as opposed to weight status.

Trauma-Focused Cognitive-Behavioral Therapy for Adolescents Bullied Because of Weight: A Feasibility Study

OBJECTIVE

The objective of this study was to test the feasibility and acceptability of a treatment for weight bullying.

METHOD

Participants who had experienced weight-related bullying and were currently experiencing traumatic stress were recruited and enrolled in a feasibility trial of trauma-focused cognitive behavioral therapy combined with cognitive-behavioral therapy for eating disorders (TF-CBT-WB). Thirty adolescents (aged 11-17) were determined eligible and 28 began treatment (12 weeks).

RESULTS

This study demonstrated the treatment feasibility and acceptability of TF-CBT-WB for adolescents with traumatic stress following weight-bullying experiences. Overall retention and treatment satisfaction were good. Within-subjects improvements were observed for intrusion symptoms of traumatic stress, global eating-disorder severity, overvaluation of weight/shape, dissatisfaction with weight/shape, dietary restraint, and depression. Clinically-meaningful improvements were attained for several patient outcomes. Clinically-meaningful decreases in functional impairment were attained by more than half of the participants.

CONCLUSIONS

Overall, this clinical trial testing TF-CBT-WB for adolescents experiencing traumatic stress following weight-bulling experiences demonstrated therapy feasibility, acceptability, and initial evidence that clinically-meaningful improvements in patient outcomes were feasible. However, some patient outcomes thought to be more central to how the youth viewed the world failed to show improvements, suggesting that additional content related to these constructs might yield greater benefit.

TRIAL REGISTRATION

This pilot study was registered on clinicaltrials.gov: NCT04587752, Cognitive-Behavioral Therapy for Weight-related Bullying.

Parent version of the Eating Disorder Examination: Reliability and validity in a treatment-seeking sample

BACKGROUND

Assessment of eating disorders (ED) in youth relies heavily on self-report, yet persistent lack of recognition of the presence and/or seriousness of symptoms can be intrinsic to ED. This study examines the psychometric properties of a semi-structured interview, the parent version of the Eating Disorder Examination (PEDE), developed to systematically assess caregiver report of symptoms.

METHODS

A multi-site, clinical sample of youth (N = 522; age range: 12 to 18 years) seeking treatment for anorexia nervosa (AN) and subsyndromal AN were assessed using the Eating Disorder Examination (EDE) for youth and the PEDE for collateral caregiver report.

RESULTS

Internal consistencies of the four PEDE subscales were on par with established ranges for the EDE. Significant medium-sized correlations and poor to moderate levels of agreement were found between the corresponding subscales on each measure. For the PEDE, confirmatory factor analysis of the EDE four-factor model provided a poor fit; an exploratory factor analysis indicated that a 3-factor model better fits the PEDE.

CONCLUSIONS

Findings suggest that the PEDE has psychometric properties on par with the original EDE. The addition of the caregiver perspective may provide incremental information that can aid in the assessment of AN in youth. Future research is warranted to establish psychometric properties of the PEDE in broader transdiagnostic ED samples.

Yoga as an adjunct treatment for eating disorders: a qualitative enquiry of client perspectives

BACKGROUND

This qualitative enquiry explores the experiences and perspectives of individuals with an eating disorder (ED) regarding their perceptions of yoga as an adjunct intervention to psychotherapy. It also explores the feasibility, acceptability, and safety of yoga from their perspectives.

METHODS

This study used a practice-based evidence framework and employed semi-structured interviews with 16 females with an ED. Participants were asked about their perspectives on the use of yoga as an adjunct intervention in ED recovery, perceived risks and what factors supported or hindered engagement. Thematic template analysis was used.

RESULTS

Three topic areas were elaborated. The first included participants' perceptions of how yoga enhanced their ED recovery. The second included how and when participants came to find yoga in their ED recovery. The final topic explored factors that supported participants with ED to engage in yoga. These resulted in the development of guiding principles to consider when designing a yoga intervention for EDs.

CONCLUSIONS

This study adds further to the emerging evidence that yoga can bring complementary benefits to ED recovery and provides a biopsychosocial-spiritual framework for understanding these. Findings provide an understanding of how yoga programs can be adapted to improve safety and engagement for people with an ED. Yoga programs for people with EDs should be co-designed to ensure that the physical, social, and cultural environment is accessible and acceptable.

Development and usability testing of an online platform for provider training and implementation of cognitive-behavioral therapy guided self-help for eating disorders

Background

Most individuals with eating disorders (EDs) do not receive treatment, and those who do receive care typically do not receive evidence-based treatment, partly due to lack of accessible provider training. This study developed a novel "all-in-one" online platform for disseminating training for mental health providers in cognitive-behavioral therapy guided self-help (CBTgsh) for EDs and supporting its implementation. The aim of the study was to obtain usability data from the online platform prior to evaluating its effects on provider training outcomes and patient ED symptom outcomes in an open pilot trial.

Methods

Nine mental health provider participants (n = 4 in Cycle 1; n = 5 in Cycle 2) and 9 patient participants (n = 4 in Cycle 1; n = 5 in Cycle 2) were enrolled over two cycles of usability testing. In Cycle 1, we recruited providers and patients separately to complete brief platform testing sessions. In Cycle 2, we recruited provider-patient dyads; providers completed training using the platform and subsequently delivered CBTgsh to a patient for three weeks. Usability was assessed using the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and semi-structured interviews.

Results

Interview feedback converged on two themes for providers (applicability of program for real-world use, platform structure and function) and two themes for patients (barriers and facilitators to engagement, perceived treatment effects). SUS and USE scores were in the "average" to "good" ranges across cycles.

Conclusions

Findings from this study demonstrate preliminary feasibility and acceptability of the online platform. Data collected in this study will inform further refinements to the online platform. The platform's effects on provider training outcomes and patient ED symptom outcomes will be evaluated in an open pilot trial. Given the wide treatment gap for EDs and barriers to dissemination and implementation of evidence-based treatments, the online platform represents a scalable solution that could improve access to evidence-based care for EDs.

Remote family education and support program for parents of patients with adolescent and early adulthood eating disorders based on interpersonal psychotherapy: study protocol for a pilot randomized controlled trial

BACKGROUND

In cases of adolescent and early adulthood eating disorders, despite the importance of the patients' relationship with their parents, conflict and confusion frequently occur among them. Interpersonal psychotherapy (IPT) is a present-focused psychotherapy that emphasizes the interpersonal context of symptoms. We developed a remote family education and support program exclusively for parents of patients with eating disorders, based on the principle of IPT. The use of IPT is expected to reduce conflicts in the patient-parent relationship. Consequently, parents will be better able to listen to patients, and patients will be better able to express their thoughts and desires. In this study, we describe the protocol for a randomized controlled trial designed to examine the effectiveness of this program in promoting effective communication in their home based on active listening skills of parents of patients with adolescent and early adulthood eating disorders.

METHODS

Participants will be parents of patients aged 12-29 years with adolescent and early adulthood eating disorders. Individually randomized, parallel-group trial design will be employed. Seventy participants will be allocated to one of two treatment conditions: (1) remote family education and support program (four, 150 min weekly group sessions) for parents plus treatment-as-usual for patients (consultation by physicians or no treatment), or (2) waiting for the control condition (parents will wait to start the program for 8 weeks) plus treatment-as-usual for patients. The primary outcome measure will be parents' active listening ability as measured by the Active Listening Attitude Scale at 8 weeks after randomization. Additionally, perception of social support (Social Provision Scale-10 item), loneliness (UCLA Loneliness Scale), mental health status (K6), family function (Family Assessment Device), and parent-evaluated eating disorder symptoms (Anorectic Behavior Observation Scale) will be assessed. Data from the intention-to-treat sample will be analyzed 8 weeks after randomization.

DISCUSSION

This is the first study to evaluate the effectiveness of a family education and support program for parents of patients with adolescent and early adulthood eating disorders based on IPT. If this type of intervention is effective, although indirect, it could be a new support method for this patient population.

TRIAL REGISTRATION

Clinical Trials. gov ID NCT05840614.

Feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program for adolescents with anorexia nervosa and atypical anorexia nervosa at six- and twelve-month follow-up

This study examined the feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program (PHP) for adolescents with anorexia nervosa (AN) and atypical AN (AAN), and described the outpatient services received following discharge. Participants (N = 31) completed anthropometric and self-report assessments at admission, discharge, and six and twelve months after discharge from the PHP. Descriptive statistics explored markers of feasibility. Paired samples t-tests evaluated changes in weight and eating disorder (ED) symptomatology from admission to discharge, admission to six-month follow-up, and admission to twelve-month follow-up. Descriptive statistics and effect sizes compared symptoms at each timepoint between participants with AN and AAN. Results indicated that we were successful at recruiting greater than 50% of adolescents approached for this study. We collected follow-up data from more than 70% of participants at discharge, but did not meet this retention benchmark at six-month and twelve-month follow-ups. The entire sample demonstrated significant improvements in weight and ED symptomatology from admission to discharge, and generally maintained these improvements at six- and twelve-month follow-up. While descriptive statistics suggested that participants with AN and AAN received similar outpatient services following discharge from the PHP, those with AN experienced greater improvement in self-reported ED symptomatology than those with AAN at six- and twelve-month follow-up. These findings provide preliminary support for the efficacy of PHPs in treating adolescents with AN and AAN. Further research with larger sample sizes should investigate whether adolescents with AAN experience poorer outcomes than those with AN following discharge from a PHP.

What is day hospital treatment for anorexia nervosa really like? A reflexive thematic analysis of feedback from young people

BACKGROUND

A significant proportion of young people do not respond to the NICE recommended treatment for anorexia nervosa: Family Therapy. Whilst historically these young people would be admitted to inpatient services, which are associated with greater treatment cost, greater risk of relapse, and worse outcome, more recently evidence is building for the effectiveness of day programmes. One day programme that has been found to be effective is the Intensive Treatment Programme (ITP) of the Maudsley Centre for Child & Adolescent Eating Disorders in London, UK. However, to-date no studies have investigated how young people experience such a day programme.

METHOD

Anonymous feedback was completed via online survey by 51 young people over a 5-year period (2018-2023) on discharge from ITP.

RESULTS

Four main themes were identified: (1) Support-young people expressed the importance of boundaries but also of feeling validated, and encouraged; (2) Uniqueness: an experience like no other-ITP was described as different to any other treatment received before (both outpatient and inpatient); (3) Relationships - young people valued connecting with others in a similar situation and reflected that relationships at home changed throughout treatment; (4) Self-development - learning skills, developing independence, and exploring an identity outside of the eating disorder was valued.

CONCLUSIONS

It is hoped that the reflections from these young people can help to inform clinicians working in DPs and those hoping to set up novel DPs about key aspects of treatment.

Pilot Trial of Online Measurement Training and Feedback in Family Therapy for Adolescent Behavior Problems

OBJECTIVE

Pragmatic procedures for sustaining high-fidelity delivery of evidence-based interventions are needed to support implementation in usual care. This study tested an online therapist training system, featuring observational coder training and self-report fidelity feedback, to promote self-report acumen and routine use of family therapy (FT) techniques for adolescent behavior problems.

METHOD

Therapists (N = 84) from nine substance use and mental health treatment sites reported on 185 adolescent clients. Therapists submitted baseline data on FT technique use with clients, completed a workshop introducing the 32-week training system, and were randomly assigned by site to Core Training versus Core Training + Consultation. Core Training included a therapist coder training course (didactic instruction and mock session coding exercises in 13 FT techniques) and fidelity feedback procedures depicting therapist-report data on FT use. Consultation convened therapists and supervisors for one-hour monthly sessions with an external FT expert. During the 32 weeks of training, therapists submitted self-report data on FT use along with companion session audiotapes subsequently coded by observational raters.

RESULTS

Therapist self-report reliability and accuracy both increased substantially during training. Observers reported no increase over time in FT use; therapists self-reported a decrease in FT use, likely an artifact of their improved self-report accuracy. Consultation did not enhance therapist self-report acumen or increase FT use.

CONCLUSIONS

Online training methods that improve therapist-report reliability and accuracy for FT use may confer important advantages for treatment planning and fidelity monitoring. More intensive and/or different training interventions appear needed to increase routine FT delivery.

Effects of family-based treatment on adolescent outpatients treated for anorexia nervosa in the Eating Disorder Unit of Helsinki University Hospital

BACKGROUND

Family therapy for adolescent anorexia nervosa (AN) has stronger evidence of efficacy in comparison with individual therapy, and family-based treatment (FBT) is the most evaluated in numerous randomized clinical trials. However, few studies have focused on how FBT performs outside of research settings. The current study is the first to assess clinical outcomes of FBT for adolescent AN in Finland, in a specialized outpatient clinic.

AIM

The naturalistic outcome of outpatient FBT for adolescent AN was investigated.

METHODS

Fifty-two female patients and their families who received FBT at a tertiary eating disorders unit participated in the study. Data on their pre-treatment parameters, treatment details, and condition at the end of treatment (EOT) was collected from their medical records.

RESULTS

At EOT, a majority (61.5%) had achieved a full weight restoration [percentage of expected body weight (%EBW) ≥ 95%]. Participants with an %EBW ≥ 95 at EOT had a significantly higher pre-treatment %EBW than those with an EBW < 95% at EOT. Participants with an EBW ≥ 95% at EOT showed significantly higher total weight gain during the treatment period, a higher rate of regular menstrual periods at EOT, significantly lower rates of dietary restrictions, and less cognitive or behavioral symptoms of the eating disorder overall, compared to participants who did not achieve a normal body weight. In 22 cases (42.3%), there was no need for further treatment at the end of FBT. Participants who needed further treatment after FBT, compared to those who did not, showed significantly higher rates of psychiatric comorbidity, history of mental health treatment, and need for psychopharmacological treatment.

CONCLUSIONS

In this naturalistic study, and in line with previous studies, FBT for AN appeared to be an effective and sometimes sufficient intervention, especially for patients with milder weight deficit and less severe psychiatric comorbidities. The results show that FBT can be successfully implemented in Finland and suggest that training more ED clinicians in FBT would be beneficial.

TRIAL REGISTRATION

The study was retrospectively registered on February 8th, 2023, in ClinicalTrials.gov Protocol Registration and Results System, identifier: NCT05734573.

Development of a transdiagnostic digital interactive application for eating disorders: psychometric properties, satisfaction, and perceptions on implementation in clinical practice

BACKGROUND

Given limited availability of informed treatments for people affected by eating disorders (EDs), there has been increasing interest in developing self-administered, technology-based ED interventions. However, many available interventions are limited to a specific ED diagnosis or assume that participants are ready to change. We developed a digital self-help application (called ASTrA) that was explicitly designed to be transdiagnostic and to help increase motivation for change. The aim of the present study was to describe the development and examine the psychometric properties, user satisfaction and rated potentials for practical use of our application.

METHODS

The content of our application was based on concepts derived from self-determination theory, the transtheoretical model of change, and cognitive theory. The application was developed by a multidisciplinary team of clinicians, researchers, staff members and individuals with lived ED experience, each being involved in all steps of the application's development. We tested validity, reliability, satisfaction and perceived feasibility for clinical implementation in an independent sample of 15 patients with an ED and 13 clinicians specialized in ED treatment. Psychometric properties were evaluated using descriptive statistics, correlations, content validity indices and intraclass coefficients. Differences in satisfaction ratings and perceived potential for clinical implementation of the application between clinicians and patients were examined using Mann-Whitney U tests.

RESULTS

The digital application showed excellent validity (mean i-CVI: .93, range: .86-.96) and internal reliability (all Cronbach alpha's > .88). Patients and clinicians both considered the application acceptable, appropriate, and feasible for use in clinical practice.

CONCLUSIONS

Findings suggest that our transdiagnostic interactive application has excellent psychometric properties. Furthermore, patients and clinicians alike were positive about the possible use of the application in clinical practice. The next step will be to investigate the application's effectiveness as an intervention to promote autonomous motivation and to facilitate remission in people on the waitlist for specialized ED treatment.

Core Elements of Family Therapy for Adolescent Behavioral Health Problems: Validity Generalization in Community Settings

OBJECTIVE

The core elements of family therapy for adolescent mental health and substance use problems, originally distilled from high-fidelity sessions conducted by expert clinicians, were tested for validity generalization when delivered by community therapists in routine settings.

METHOD

The study sampled recorded sessions from 161 cases participating in one of three treatment pools: implementation trial of Functional Family Therapy (98 sessions/50 cases/22 therapists), adaptation trial of Multisystemic Therapy (115 sessions/59 cases/2 therapists), and naturalistic trial of non-manualized family therapy in usual care (107 sessions/52 cases/21 therapists). Adolescents were identified as 60% male and 40% female with an average age of 15.4 years; 49% were Latinx, 27% White Non-Latinx, 15% African American, 3% another race/ethnicity, 6% race/ethnicity unknown. Session recordings (n = 320) were randomly selected for each case and coded for 21 discrete family therapy techniques. Archived data of one-year clinical outcomes were gathered.

RESULTS

Confirmatory factor analyses replicated the factor structure from the original distillation study, retaining all four clinically coherent treatment modules comprised of all 21 techniques: Interactional Change (ICC = .77, Cronbach's α = .81); Relational Reframe (ICC = .75, α = .81); Adolescent Engagement (ICC = .72, α = .78); Relational Emphasis (ICC = .76, α = .80). Exploratory analyses found that greater use of core techniques predicted symptom improvements in one treatment pool.

CONCLUSIONS

Core techniques of family therapy distilled from manualized treatments for adolescent behavioral health problems showed strong evidence of validity generalization, and initial evidence of links to client outcomes, in community settings.

Evidence Based Update on Psychosocial Treatments for Eating Disorders in Children and Adolescents

Eating disorders (EDs) are life-threatening psychiatric illnesses that occur in adolescents. Unfortunately, limited randomized controlled trials exist to address EDs in this vulnerable population. The current review updates a prior Journal of Clinical Child and Adolescent Psychology review from 2015. The recommendations in this review build upon those that were previously published. This update was completed through a systematic search of three major scientific databases (PsychInfo, Pubmed, and Cochrane) from 2015 to 2022 (inclusively) from three databases, employing relevant medial subject headings. Additionally, expert colleagues were asked for additional literature to include. Thirty-one new studies were added to this review. Psychosocial treatments included family therapies, individual therapy, cognitive-behavioral therapy, interpersonal psychotherapy, cognitive training, dialectical behavioral therapy, and more recently, virtual or telehealth-based practices and guided self-help modalities for carers of youth with EDs. Using the Journal of Clinical Child and Adolescent Psychology's methodological review criteria, this update found behavioral family-based treatment modalities (FBT) for both adolescent anorexia nervosa and bulimia nervosa met well-established treatment criteria. To date, there were no well-established treatments found for child and adolescent avoidant-restrictive food intake disorder, or binge eating disorder. Internet facilitated cognitive-behavioral therapy and family-based therapy were found to be possibly efficacious for binge eating disorder. Family-based treatment was found to be possibly efficacious for avoidant restrictive food intake disorder, with other clinical trials for cognitive treatment modalities under way. Ongoing research examining treatments for eating disorders in children and adolescents broadly is needed.

Disparities in access to eating disorders treatment for publicly-insured youth and youth of color: a retrospective cohort study

BACKGROUND

Eating disorders are associated with substantial morbidity and mortality that can be minimized by timely access to evidence-based treatment. However, disparate access to eating disorders treatment may contribute to significant health disparities amongst marginalized groups. This study examined the association between insurance type (public vs. private) and receipt of recommended mental health treatment in a sample of racially/ethnically diverse youth who presented to an adolescent medicine clinic with malnutrition secondary to disordered eating.

METHODS

A retrospective chart review was conducted for youth ages 11-25 years (N = 1060) who presented to an urban adolescent medicine specialty program between June 1, 2012 and December 31, 2019 for malnutrition secondary to disordered eating. Bivariate and logistic regression analyses examined the association between insurance type (public vs. private) and other demographic/clinical factors on receipt of recommended treatment within six months of the initial evaluation.

RESULTS

Patients with public insurance were one third as likely to receive recommended treatment as patients with private insurance (AOR = 3.23; 95% CI = 1.99, 4.52), after adjusting for demographic and clinical factors. Latinx (AOR = 0.49; 95% CI = 0.31, 0.77) and Asian (AOR = 0.55; 95% CI = 0.32, 0.94) patients were half as likely to receive recommended treatment as White patients.

CONCLUSIONS

Access to evidence-based mental health treatment is a necessary first step towards health equity for individuals with eating disorders. Additional work is needed to dismantle systemic inequities that contribute to disparities in care for youth of color and those with public insurance.

Paediatric eating disorders: Exploring virtual family therapy during a global pandemic

AIM

Explore treatment response and effectiveness of virtual treatment for a paediatric eating disorder sample.

METHODS

Twenty patients and their families who received either virtual or in-person family therapy were included in the study. Family therapy was informed by family-based treatment (FBT) principles. Patients' weight restoration at 1, 3, and 6 months after starting treatment was examined. Independent sample t tests assessed group differences and a Fisher exact test was used to evaluate the association between treatment group and weight restoration.

RESULTS

Weight restoration did not significantly differ between treatment groups (virtual vs. in-person) at any time point and there was no association between group and remission weight at 6 months.

CONCLUSIONS

Study results are considered exploratory. Future research addressing study limitations is needed. Results suggest that paediatric eating disorder patients may benefit from family therapy delivered via a virtual platform.

Promising effect of multi-family therapy on BMI, eating disorders and perceived family functioning in adolescent anorexia nervosa: an uncontrolled longitudinal study

This contribution reports on the results of an uncontrolled longitudinal study investigating the effects of a Multi-Family Therapy (MFT) as treatment for adolescent Anorexia Nervosa (AN) and the role played by perceived family functioning in these effects. 150 patients (144 females) and their families took part in an MFT and were assessed at the beginning, middle, end of the therapy, as well as 6 and 12 months after the end of therapy. BMI, eating disorders symptomatology (EDI-II) and perceived family functioning (FAD) all improved over the time of MFT, and these benefits remained at both times of follow-up. Ultimately, we found that the improvement of some dimensions of family functioning (i.e., roles, communication, and general family functioning) mediated the improvement of several dimensions of symptomatology (i.e., ineffectiveness, impulsivity, social insecurity, interpersonal distrust). These observations provide further support for MFT as useful for improving mental health, weight restoration, and perceived family functioning of adolescents with AN.

Chuna manual therapy for the treatment of anorexia in children: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Anorexia in children can cause malnutrition, low immunity, growth retardation, and various secondary infections, resulting in a huge burden on society. In East Asia, Chuna manual therapy has been widely used for the treatment of childhood anorexia. We aimed to comprehensively evaluate the effects of Chuna manual therapy for treating childhood anorexia.

METHODS

Twelve databases were comprehensively searched from their inception to September 13, 2022. Only randomized controlled trials assessing Chuna manual therapy for the treatment of childhood anorexia were included. The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool. The quality of evidence for each main outcome was evaluated using the grading of recommendations assessment, development, and evaluation approach. A meta-analysis was performed, and the pooled data were presented as risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes.

RESULTS

Twenty-five RCTs involving 2230 participants were included. The meta-analysis showed that Chuna manual therapy had a higher total effective rate (TER) based on anorexia symptoms than that of lysine inositol and vitamin B12 (RR: 1.53, 95% CI: 1.28-1.84), multi-enzyme and multi-vitamin (RR: 1.21, 95% CI: 1.11-1.33), and zinc calcium gluconate (RR: 1.22, 95% CI: 1.06-1.39). There was no significant difference in total effective rate between Chuna manual therapy and zinc gluconate plus lysine. No adverse events associated with Chuna manual therapy were reported. Overall, the included studies had an unclear risk of bias, and the quality of evidence was generally moderate to low.

CONCLUSION

Current evidence showed that Chuna manual therapy may be effective and safe for improving anorexia symptoms, especially compared with lysine inositol and vitamin B12, multi-enzyme plus multi-vitamin, and zinc calcium gluconate. However, owing to the low methodological quality of the included studies, more rigorous, high-quality RCTs are required on this topic.

Research in eating disorders: the misunderstanding of supposing serious mental illnesses as a niche specialty

PURPOSE

Eating disorders (EDs) are mental illnesses with severe consequences and high mortality rates. Notwithstanding, EDs are considered a niche specialty making it often difficult for researchers to publish in high-impact journals. Subsequently, research on EDs receives less funding than other fields of psychiatry potentially slowing treatment progress. This study aimed to compare research vitality between EDs and schizophrenia focusing on: number and type of publications; top-cited articles; geographical distribution of top-ten publishing countries; journal distribution of scientific production as measured by bibliometric analysis; funded research and collaborations.

METHODS

We used the Scopus database, then we adopted the Bibliometrix R-package software with the web interface app Biblioshiny. We included in the analyses 1,916 papers on EDs and 6491 on schizophrenia.

RESULTS

The ED field published three times less than schizophrenia in top-ranking journals - with letters and notes particularly lacking-notwithstanding a comparable number of papers published per author. Only 50% of top-cited articles focused on EDs and a smaller pool of journals available for ED research (i.e., Zones 1 and 2 according to Bradford's law) emerged; journals publishing on EDs showed an overall lower rank compared to the schizophrenia field. Schizophrenia research was more geographically distributed and more funded; in contrast, a comparable collaboration index was found between the fields.

CONCLUSION

These data show that research on EDs is currently marginalized and top-rank journals are seldom achievable by researchers in EDs. Such difficulties in research dissemination entail potentially serious repercussions on clinical advancements.

LEVEL OF EVIDENCE

Level V: opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Long-term follow-up of a randomized controlled trial comparing systemic family therapy (FT-S) added to treatment as usual (TAU) with TAU alone in adolescents with anorexia nervosa

BACKGROUND

Randomized controlled trials showed the efficacy of family therapy for anorexia nervosa during adolescence, but studies examining its long-term beneficial effect are still needed. This article presents the results of a 54-month post-randomization follow-up of a previously reported randomized controlled trial that compared two post-hospitalization outpatient treatment programs: Treatment As Usual alone versus Systemic Family Therapy added to Treatment As Usual.

METHODS

A consecutive series of 60 female adolescents with anorexia nervosa (DSM-IV) were randomized (30 per group). During the first 18 months, in the Treatment As Usual group, subjects received a multidisciplinary treatment. In the other group, Systemic Family Therapy sessions targeting intra-familial dynamics were added to Treatment As Usual. At 54 months, the primary outcome was defined using the Morgan and Russell global Outcome Categories (Good or Intermediate versus Poor). Secondary outcomes were the Global Outcome Assessment Schedule score, body mass index, amenorrhea, number of hospitalizations, eating disorder symptoms, psychopathological features, and family functioning. Analyses were carried out using an Intention-To-Treat with the Last Observation Carried Forward procedure. Data of 59/60 subjects were available.

RESULTS

At 54 months, significant effects in favor of adding Systemic Family Therapy to Treatment As Usual were shown for the Global Outcome Categories (60% of Good/Intermediate versus 31% in the control group, p = .026), mean body mass index (p = .048), resumption of menses (70.0% vs. 40% p = .020), and mental state score (p = .010). Family cohesion scores were lower in the Systemic Family Therapy group (p = .040).

CONCLUSIONS

Adding Systemic Family Therapy focusing on intra-familial dynamics to a multidimensional outpatient treatment program appeared to lead to a better long-term outcome in young women who suffered from severe anorexia nervosa during adolescence.

Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

BACKGROUND

Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

OVERVIEW OF PAPER

This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

Effects of the COVID-19 Restrictions on Eating Behaviour and Eating Disorder Symptomology in Female Adolescents

Confinement due to the COVID-19 pandemic imposes a burden on adolescents worldwide and may seriously impact patients with an eating disorder (ED). The current FRanconian Anorexia Nervosa during COVID-19 (FRANCO) study explored (1) perceived change of depressive and ED symptomology during lockdown, (2) the role of social media, and (3) coping strategies of anorexia nervosa (AN) patients and clinical as well as healthy comparison groups. From June 2021 to September 2021, 222 female adolescents (19 with AN, 20 with depression, 45 with a self-reported psychiatric disorder (SRPD), and 138 controls) aged 11.2 to 18.9 years completed a one-time anonymous survey retrospectively reporting back on ED and depressive symptomology before and during the pandemic, the impact of social media, and coping strategies. A reduced quality of life (QoL) due to confinement was observed in almost half of female adolescents. All groups reported a significant perceived increase of disordered eating, overeating, anxiety, and depressive symptoms and emotion-regulation problems. In AN patients, significantly higher percentual deterioration of disordered eating and anxiety and depressive symptoms was found. For controls, a younger age and higher susceptibility of the sociocultural body image significantly correlated with increased disordered eating. Large-scale media literacy interventions are recommended.

Working with families of adults affected by eating disorders: uptake, key themes, and participant experiences of family involvement in outpatient treatment-as-usual

BACKGROUND

Eating disorders are associated with significant personal and family costs. Clinical guidelines recommend family members be involved and supported during care, but little has been reported regarding the preferences of adults around carer involvement in treatment. The necessary intensity of family work with adults is also unknown. A trial of a standardised brief family involvement method was conducted in an adult eating disorder service offering treatment-as-usual. Uptake and feasibility of implementing the approach as part of standard outpatient care and the preliminary impact on issues identified by adult patients and carers were evaluated.

METHODS

Eligible referrals at an adult eating disorders outpatient clinic were offered as needed family consultation to address presenting interpersonal problems identified by patients and their family members, and outcomes were evaluated 4 weeks later. Pre and post intervention surveys identified participant self-reported change in (i) problem frequency, (ii) distress and disruption caused, and (iii) confidence regarding presenting problems. Open text responses provided an overview of patient and carer goals for family involvement and revealed how the novel method impacted these areas as well as overall experience of, and feedback regarding, the brief family intervention.

RESULTS

Twenty-four female participants aged 18-53, and 22 carers participated in 31 consultations. Common concerns raised were eating disorder related interpersonal and communication issues. The focused sessions, offered on a one-at-a-time basis, showed preliminary effectiveness for reducing both patients and carer concerns. For example, adult patients reported that life interference from interpersonal problems was lower and confidence to deal with them was higher following family consultation. Carers also reported that frequency, level of worry, and life interference around presenting problems were lower after the structured family intervention.

CONCLUSIONS

Brief family consultation, with a single focus on issues identified by family members and adult patients, was a safe and feasible procedure with adults affected by eating disorders. Effective at meeting the needs of participants, the framework investigated in the current study may also be a useful direction for adult services to consider when looking to support families and meet recommendations for their routine involvement in the outpatient care.

TRIAL REGISTRATION

Australian Clinical Trials Register number: ACTRN12621000047897 (www.anzctr.org.au).

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Associations between psychosis symptoms and eating disorders among a national sample of U.S. college students

This study aimed to determine the associations between psychosis symptoms and eating disorders among a national sample of college and university students ages 18 to 26 years. Data from the 2020-2021 Healthy Minds Study (United States) were analyzed (N = 96,791). Multiple modified Poisson regression analyses were conducted to estimate the association between four self-reported lifetime psychosis symptoms and a positive eating disorder screen (measured using the SCOFF) and any self-reported lifetime eating disorder diagnosis, while adjusting for demographic and confounding variables. Participants who reported all four lifetime psychosis symptoms were more likely to screen positive for an eating disorder, while participants who reported three lifetime psychosis symptoms were more likely to report any lifetime eating disorder diagnosis. Those who reported a higher cumulative number of lifetime psychosis symptoms and reported any psychosis symptoms in the past 12 months were more likely to screen positive for an eating disorder and report any lifetime eating disorder diagnosis. Psychosis symptoms were associated with eating disorders among a national sample of college students. Health care professionals should be aware of the relationship between psychosis symptoms and eating disorders to ensure effective screening and early-intervention.

Therapist Self-Report of Fidelity to Core Elements of Family Therapy for Adolescent Behavior Problems: Psychometrics of a Pragmatic Quality Indicator Tool

Therapist-report measures of evidence-based interventions have enormous potential utility as quality indicators in routine care; yet, few such tools have shown strong psychometric properties. This study describes reliability and validity characteristics of a therapist-report measure of family therapy techniques for treating adolescent conduct and substance use problems: Inventory of Therapy Techniques for Core Elements of Family Therapy (ITT-CEFT). Study participants included 31 staff therapists treating 68 adolescent clients in eight community-based mental health and substance use clinics. Therapists submitted ITT-CEFT checklists and companion audio recordings for 189 sessions. The ITT-CEFT contains 13 techniques identified as core elements of three manualized family therapy models that are empirically supported for the target group. Therapists also reported on their use of three motivational interventions, and independent observers coded the submitted recordings. ITT-CEFT factor validity was shown via confirmatory factor analyses of the tool's theoretical structure. Derived modules were: Family Engagement (four items; Cronbach's α = .72); Relational Orientation (five items; α = .74); and Interactional Change (four items; α = .66). Concurrent validity analyses showed fair-to-excellent therapist reliability compared to observer ratings (ICCs range .64-.75); they showed moderate therapist accuracy compared to observer mean scores, reflecting a tendency to overestimate delivery of the techniques. Discriminant validity analyses showed tool differentiation from motivational interventions. Results offer provisional evidence for the feasibility of using the therapist-report ITT-CEFT to anchor quality procedures for family therapy interventions in real-world settings.Trial Registration: The parent clinical trial is registered at www.ClinicalTrials.gov , ID: NCT03342872 (registration date: 11.10.17).

Home treatment as an add-on to family-based treatment in adolescents with anorexia nervosa: A pilot study

Objective

This pilot study examines the feasibility and the effectiveness of add‐on home treatment (HT) to family‐based treatment (FBT) in adolescents with anorexia nervosa (AN). The HT intervention is delivered by specialised nurses and aims at supporting patients and parents to re‐establish family meals in the home environment.

Method

We performed a 3‐month study in AN patients with a waiting‐list control design comparing 45 (43 females, 2 males) adolescents receiving FBT augmented with HT compared to 22 (21 females, 1 male) participants receiving FBT alone on the waiting list for additional HT. Eating disorder diagnosis, psychopathology and severity of clinical symptoms were assessed using the Eating Disorder Examination (EDE) interview, the Eating Disorders Inventory (EDI‐2) and clinical parameters (BMI, menstrual status, level of over‐exercising) at baseline and after 3 months.

Results

After 3 months of treatment, both treatment groups showed a significant early weight gain, a reduction in the rate of AN diagnoses assessed with the EDE interview and a reduction in EDI‐2 total scores. The combined HT/FBT group showed a significantly greater increase in BMI than the FBT‐only group. In the combined HT/FBT group, none of the patients had to be admitted to hospital, while three (13.6%) of the FBT‐only group had to be referred to inpatient treatment.

Discussion

Our results suggest that HT augmented FBT might be useful compared to FBT alone in terms of early weight gain and might reduce the risk of hospital admission in adolescent AN.

Home treatment as an add‐on to family‐based treatment seems to be a well‐accepted and very effective method for the treatment of eating disorders in adolescence.

Combining family‐based treatment with home treatment thus seems to even enhance the therapy effectiveness of FBT in terms of initial weight gain as well as psychopathology

Adolescents With Eating Disorders in Pediatric Practice - The European Academy of Paediatrics Recommendations

In the face of the growing number of adolescents suffering from eating disorders (EDs) and access to psychiatric care limited by the epidemiological and demographic situation, the primary care pediatrician's role in diagnosing and treating EDs is growing. The European Academy of Paediatrics (EAP) decided to summarize knowledge about EDs and formulate recommendations to support European pediatricians and improve care for adolescents with EDs.

Double trouble? Associations of parental substance use and eating behaviors with pediatric disordered eating

OBJECTIVE

Comorbidity between substance use disorders and eating disorders is common and related to severity of psychopathology. Parents' eating disorder or substance use disorder have been examined independently and appear to be related to psychopathology in their children. However, no prior work has examined whether co-occurring substance use and eating disorder behaviors in parents relate to eating-disorder psychopathology and weight in their children.

METHOD

Participants (N = 435) were parents who completed an online cross-sectional survey. Parents reported their personal substance use and eating-disorder behaviors. Relationships between parental substance use (SUD), parental binge eating (ED), and co-occurring parental substance use and binge eating (SUDxED) with child eating-disorder psychopathology and weight were examined using linear regression. Parent age and sex, child age and sex, parent impulsivity and parent depression scores were included as covariates in analyses.

RESULTS

Greater severity of co-occurring parental SUDxED behavior was associated with greater child eating-related psychopathology, including child binge eating and child purging. Additionally, greater parental binge eating (ED) alone was associated with greater child binge eating and overeating. Parental SUD and/or ED behavior were not related to child weight. Child age did not moderate relationships between parent SUDxED behaviors and child binge eating or overeating.

DISCUSSION

Overall, parents with greater co-occurring substance use and eating disorder behaviors had children with more severe eating-disorder psychopathology. Clinicians working with families, and those seeking to prevent pediatric eating-related problems, should consider assessing and addressing parents' psychopathology to improve prevention and treatment efforts.

Risk factors for binge eating severity among adolescent girls and boys. A structural equation modeling approach

OBJECTIVE

Parental bonding, low self-esteem, emotion dysregulation, and eating style are correlated with each other and are associated with binge eating among adolescents. However, no studies have yet examined all these variables simultaneously. In the current study, the independent and combined influences of such constructs on binge eating were tested with structural equation modeling.

METHOD

A sample of 973 students aged between 12 and 16 (M = 14.17, SD = 1.25) years was screened by means of self-report measures assessing parental bonding, self-esteem, emotion dysregulation, eating styles and binge eating severity.

RESULTS

Self-esteem (β = -0.205) and eating styles (emotional β = 0.313, external β = 0.133, and restrained β = 0.178) had a direct effect on binge eating severity. The model (χ²₍₂₂₎ = 57.679; RMSEA = 0.041; CFI = 0.987; TLI = 0.949; SRMR = 0.024) revealed that the paths from both maternal and paternal care and maternal overprotection to binge eating were mediated through low self-esteem, emotion dysregulation and each eating style, explaining 35% of the variance.

DISCUSSION

Findings provide support for a comprehensive theoretical-based model of risk factors for binge eating and suggest the possible mechanisms through which the quality of early parental relationships contribute to developing dysfunctional eating patterns. Treatment and prevention efforts should improve self-esteem and emphasize emotion regulation capabilities.

An evaluation of family-based treatment for restrictive-type eating disorders, delivered as standard care in a public mental health service

BACKGROUND

Family-based treatment (FBT) has demonstrated efficacy for anorexia nervosa (AN) in youth in randomized, controlled trials. It is important to assess if it shows a similar effectiveness when implemented in standard care.

AIM

To evaluate outcomes of FBT for restrictive-type eating disorders, delivered as standard care in a public mental health service. Outcomes are remission, frequency of hospital admissions and day-patient treatment, and frequency of other adaptations within 12 months from commencement of treatment. Second, to compare the collaborative clinical decisions of successful treatment in standard care made by family therapist at the end of treatment, with more objective definitions of recovery.

METHODS

The design is a prospective, uncontrolled study of a consecutive series of patients with restrictive-type eating disorders, treated with FBT in a specialty unit at the Child and Adolescent Mental Health Centre in the Capital Region of Denmark.

RESULTS

FBT was successfully completed within 12 months by 57% of participants, and 47% completed with 20 sessions or fewer. Weight restoration was achieved by 75% within 12 months, and 46% achieved both normalisation of body weight and behavioural symptoms of AN within 12 months. A total of 20% needed intensified treatment. All aspects of remission were often not present simultaneously, and the collaborative clinical decisions of successful treatment only partly aligned with other parameters of remission.

CONCLUSION

FBT showed good results when implemented as standard care, and it can be adapted to the specifics of local service organisation without compromising effectiveness.

Family-based treatment for pediatric eating disorders: Evidence and guidance for delivering integrated interdisciplinary care

Eating disorders (EDs) are complex psychiatric diagnoses requiring specialized care. Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa and is also efficacious for other EDs. This study describes practice changes due to the implementation of an integrated interdisciplinary FBT-aligned treatment program for EDs at a large tertiary care hospital in the United States. We examined the feasibility and acceptability of implementation, barriers to implementation, and impact on providers' roles over a one-year period. Practice changes came with shifts in roles, and were largely experienced as acceptable with good suitability. Barriers identified may inform future interdisciplinary implementation efforts.

A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders

BACKGROUND

Eating disorders have serious psychological and physical consequences. Current evidence-based treatments for adolescents with eating disorders have modest effects, underscoring the need to improve current treatment approaches. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) have been proposed as alternative treatment options, with burgeoning research in this area. This review aims to summarize and critically analyze the current literature on the feasibility, acceptability, effectiveness, and efficacy of CBT and DBT for adolescent eating disorders, and then proposes areas of future research.

METHODS

PsycINFO and PubMed were searched using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify studies examining the feasibility, acceptability, effectiveness and/or efficacy of CBT or DBT for adolescent eating disorders.

RESULTS

Eligible studies (N = 50; CBT: n = 40, DBT: n = 10) indicated that both treatments are reasonably feasible, acceptable, and possibly effective for adolescent eating disorders across diagnoses and levels of care, though efficacy trials are lacking.

CONCLUSIONS

CBT and DBT demonstrate promise as alternatives to family-based approaches for adolescent eating disorders. Adequately powered trials to establish the effectiveness and efficacy of CBT and DBT are needed, particularly ones that compare these treatments against other leading approaches. Despite high rates of relapse and likelihood for severe and enduring illness, there is a dearth of evidence-based treatment options for adolescents with eating disorders. Potentially viable but less well-studied treatments for adolescents with eating disorders include cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). This systematic review of CBT and DBT for adolescent eating disorders focuses on feasibility (i.e., how easy it was to implement the treatment), acceptability (i.e., how well the intervention was received by patients and therapists), effectiveness (i.e., how well the intervention performed under routine, real-world circumstances), and efficacy (i.e., how well the intervention performed in highly-controlled research settings). This review concludes that research supports the feasibility and acceptability of these approaches, as well as preliminary evidence of their effectiveness. However, the field is lacking studies that systematically compare CBT and DBT to other evidence-based approaches. Recommendations to advance research on CBT and DBT for adolescent eating disorders are provided, including a call for efficacy studies that clarify their performance compared to other leading approaches.

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

OBJECTIVE

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

METHOD

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

DISCUSSION

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

Characterization Study of Patients Presenting to an Acute Care Pediatric Hospital Identified With Avoidant/Restrictive Food Intake Disorder

OBJECTIVES

Nearly one-quarter of individuals diagnosed with avoidant/restrictive food intake disorder (ARFID) require medical admission. There have been efforts to characterize ARFID in outpatient and intensive day treatment settings; however, authors of few studies have examined this presentation in the inpatient pediatric hospital setting. In this study, we aim to further characterize patients presenting to the hospital with concerns for ARFID.

METHODS

This study involved a retrospective chart review of medically admitted patients with ARFID seen by the psychiatry consultation service at a tertiary care New England pediatric hospital from 2015 to 2016.

RESULTS

The typical hospitalized patient with ARFID was a 12.9-year-old, white girl with previous history of outpatient mental health treatment, anxiety disorder, and gastrointestinal-related diagnoses admitted to adolescent medicine or pediatric hospitalist services with >1 year of feeding difficulties often triggered by a precipitating event. Despite >80% of subjects receiving evaluations as outpatients for feeding-related concerns, including 60.5% seeing their primary care provider, <20% were diagnosed with ARFID before hospitalization. The average length of admission was 8 days. All imaging, scopes, and swallow studies conducted during the admission were nonrevealing. Almost half of patients required enteral tube feeds, and 63.2% required psychiatric medications during the admission. Only 31.6% of patients had the ARFID diagnosis documented in their discharge notes.

CONCLUSIONS

Consistent identification of ARFID remains variable, underrecognized by community providers, and underdocumented by hospital providers. Accurate recognition of ARFID and additional study into contributory factors and treatment approaches may help improve effective health care use and treatment outcomes.

Adaptation to family-based treatment for Medicaid-insured youth with anorexia nervosa in publicly-funded settings: Protocol for a mixed methods implementation scale-out pilot study

BACKGROUND

Family-based treatment (FBT) for anorexia nervosa is an evidence-based treatment, but its effectiveness is untested among socioeconomically disadvantaged and racially diverse youth. Adapting FBT may facilitate "scale-out" for Medicaid-insured youth served in publicly-funded settings and potentially improve outcomes for more diverse populations.

METHODS

This mixed methods effectiveness-implementation Hybrid Type 3 pilot study protocol included a planning period in collaboration with the San Francisco Department of Public Health, culminating in a two-day in-person FBT training for 25 therapists in the county, followed by the opportunity to engage in one year of weekly supervision. The training incorporated FBT adaptations intended to improve fit for low-income families within community-based settings. Treatment appropriateness and acceptability will be measured immediately post-training. Following the training, cases referred for FBT will only be assigned to the trained clinicians who voluntarily opted into long-term group supervision. Clinicians treating at least one FBT case during the supervision period will report on implementation, adaptations, and patient weight gain. Finally, semi-structured interviews with clinician participants will be conducted, focused on implementation challenges and facilitators, local treatment adaptations, and overall satisfaction with FBT.

DISCUSSION

Learning about clinician adaptations will advance knowledge about treatment of eating disorders in publicly-funded community clinics, which serve a racially/ethnically and socioeconomically diverse group of youth. This project is designed to accelerate FBT implementation in publicly-funded mental health systems, and inform service improvements for underserved youth with eating disorders.

Feeding and eating problems in children and adolescents with autism: A scoping review

LAY ABSTRACT

Feeding problems, such as picky eating and food avoidance, are common in youth with autism. Other, broader difficulties with feeding and eating (eating disorder symptoms such as restricting food intake or preoccupation with body shape or weight and insistence on specific food presentation) are also common in autistic individuals. Here, we describe the nature and extent of feeding and eating problems in youth with autism. We found no common characteristics (such as severity of autism symptoms) that best describe autistic youth who experience problems with feeding or eating. Almost all studies we reviewed focused on problems with feeding (selective or picky eating), and only a few studies focused on eating disorder symptoms (concern with weight, shape, and/or body image). However, some researchers reported that eating disorder symptoms may occur more often in autistic individuals compared to their peers without autism. Many studies used the terms "feeding" and "eating" problems interchangeably, but understanding the difference between these problems is important for researchers to be consistent, as well as for proper identification and treatment. We suggest future researchers use "eating problems" when behaviors involve preoccupation with food, eating, or body image, and "feeding problems" when this preoccupation is absent. We highlight the importance of understanding whether feeding or eating problems are separate from autism traits, and the role of caregivers and other adults in the child's treatment. Considerations for health-care providers to assist with diagnosis and treatment are also provided.

Coping With Adolescents Affected by Anorexia Nervosa: The Role of Parental Personality Traits

Introduction

Anorexia nervosa (AN) promotes psychological distress in caregivers who adopt different coping strategies. Dysfunctional caregiving styles exacerbate further distress in the patient promoting the maintenance of the illness. We aimed to assess the possible contribution of personality traits of caregivers to the adoption of different coping strategies to deal with the affected relative.

Methods

About 87 adolescents with AN were recruited. Their parents completed the Family Coping Questionnaire for Eating Disorders (FCQ-EDs) and the Temperament and Character Inventory-Revised (TCI-R). Differences between mothers and fathers were assessed through the independent sample t-test. Multivariate regression analyses were run to assess if personality traits, the occurrence of psychiatry conditions in the parents, the marital status, and the duration of the illness predicted parental coping strategies.

Results

The group of mothers showed higher levels of avoidance and seeking for information coping strategies than the sample of fathers. Lower illness duration predicted higher collusion with the illness in both parents. Harm avoidance, cooperativeness, and self-directedness positively predicted parental coercion, collusion, and seeking for information strategies with some differences between mothers and fathers.

Discussion

Illness duration and personality traits of parents affect the type of parental coping strategies developed to face AN in adolescents. These variables should be considered in the assessment of families of adolescents with AN and may be addressed to promote more fine-tuned clinical interventions for caregivers.