Early intervention for caregivers of youth with restrictive eating disorders (CARE Skills Group): feasibility, outcomes and opportunities for spread and scale

Eating disorders are serious psychiatric conditions predominantly affecting children, adolescents, and young adults. While family-based treatment (FBT) is the gold standard outpatient treatment approach for adolescents with restrictive eating disorders, there is not a universally recognized best practice within higher levels of care. There is a particular dearth of literature detailing recommended psychological and behavioral interventions in the inpatient medical setting. The present article provides an account of how FBT principles have been incorporated in Children's Hospital of Orange County at Mission's inpatient medical stabilization program for children and adolescents with restrictive eating disorders. Practical examples illustrate how key FBT tenets are successfully translated into the inpatient multidisciplinary setting. The use of FBT can encourage a unified approach among medical and psychosocial providers and serves to destigmatize patients with eating disorders and associated behaviors. The successes and challenges of FBT implementation are discussed. Though anecdotal evidence and preliminary findings support positive outcomes from the implementation of FBT within a pediatric medical stabilization program for patients, families, and staff, research is needed to understand best practices within higher levels of care. Additional research efforts will also help elucidate whether adapted FBT can become a standard of care for patients with restrictive eating disorders in inpatient settings. This article describes how a children's hospital has adopted family-based treatment (FBT) for youth who are hospitalized due to an eating disorder. FBT is the most efficacious treatment for youth with eating disorders. This article describes specific examples of how FBT can be implemented within a medical setting. This article will support a greater understanding of FBT principles and guide providers to translate FBT into higher level of care settings.

Males With Restrictive Eating Disorders: Barriers to Their Care

ABSTRACTDialectical behavior therapy (DBT) is commonly used in the treatment of eating disorders (ED), yet few studies have examined the utility of DBT skills groups as an adjunct to evidence-based therapy for ED. Thus, we sought to examine the preliminary efficacy of a DBT skills group as an adjunct to Family-Based Treatment (FBT) for adolescent restrictive ED. Our preliminary pilot study included 18 adolescent girls ages 13–18 (M= 15.3, SD = 1.64) with restrictive ED, including Anorexia Nervosa (AN; N = 10), Atypical Anorexia Nervosa (AAN, N = 5), and Other Specific Feeding or Eating Disorder (OSFED; N = 3). All participants were enrolled in a 6-month, weekly DBT skills group and were concurrently receiving family-based treatment (FBT). Participants who completed the intervention experienced large effect sizes for increases in adaptive skills (Cohen’s d = .71) and decreases in general dysfunctional coping strategies (Cohen’s d = .85); and small to medium effect sizes for decreases in binge eating (Cohen’s d = .40) and increases in percent expected body weight (% EBW; Cohen’s d = .32). Finally, small effect sizes were evidenced in decreases in Global EDE-Q scores (Cohen’s d = .26), EDE-Q restraint (Cohen’s d = .29) and CDI scores (Cohen’s d = .28). Our study presents promising preliminary data suggesting that adolescents with restrictive EDs receiving FBT could benefit from an adjunctive DBT skills group. Feasibility of and considerations for tailoring a DBT skills group to an outpatient ED treatment program are discussed.

BackgroundOn the population level, the association of age and other sociodemographic factors with eating disorders (ED) is unclear.MethodsWe used cross-sectional data from the French general population-based NutriNet-Santé e-cohort (n=49 603...

Schleider et al. (2023, International Journal of Eating Disorders, current issue) propose multiple applications of single-session intervention (SSI) models to the eating disorders (EDs) intervention spectrum. In this commentary, we propose extending the potential of SSIs to target parents as agents of change for youth with restrictive EDs, particularly anorexia nervosa (AN). Directing SSIs to parents of children with AN can circumvent psychological barriers to care while capitalizing on the unique level of motivation in a parent to protect a child and advance their capacity to thrive. Key design components of effective SSIs map well onto the core principles of family-based treatment (FBT), which can be distilled to inform the development of SSIs for parents of youth at risk or exhibiting emerging or diagnostic AN. The participatory action research framework highlighted by Schleider et al. (2023) speaks to the importance of developing SSIs using co-design methodologies with parents. Doing so reflects the FBT principle of parent empowerment, acknowledges the research on parental self-efficacy as a mediator of FBT, and recognizes parents as both key stakeholders in the prevention and treatment of child and adolescent EDs, and as the intended recipients of the SSIs created for this population. PUBLIC SIGNIFICANCE: Schleider et al. (2023, International Journal of Eating Disorders, current issue) propose multiple applications of single-session intervention (SSI) models to eating disorders (EDs). In this commentary, we extend the potential of SSIs to target parents as agents of change for youth with restrictive EDs. Parent-focused SSIs can circumvent psychological barriers to care while capitalizing on the unique level of motivation in a parent to advance their child's capacity to thrive.

In order to identify factors that may impede youth access to evidence-based treatment, the current study examined child and adolescent mental health therapists’ use of Family-Based Treatment (FBT) and other psychotherapeutic approaches to treat adolescents with restrictive eating disorders. A sample of 91 therapists from a variety of backgrounds (e.g. social workers, doctoral-level psychologists, masters-level counselors, marriage and family therapists) completed a 74-item survey regarding their attitudes and beliefs about adolescent eating disorders and its treatment, as well as their use of FBT and other psychotherapeutic approaches. Only 5% of therapists indicated that they treat restrictive eating disorders and, of those who do provide care, few endorsed using FBT strategies. The majority of therapists reported using other psychotherapeutic approaches that may dilute the effect of FBT principles or may prove ineffective. Having more formal training in eating disorders was associated with FBT-consistent beliefs and the use of FBT strategies. Findings have implications for dissemination efforts that target common beliefs that can undermine the care of adolescent eating disorders. Finally, the field must consider disseminating treatments to general therapists in ways that are more accessible, such as a focus on basic over specialized competencies, and consider innovative approaches to engage other professionals in supporting families caring for young people with restrictive eating disorders.

ABSTRACTObjectiveTelehealth services have become part of many eating disorder (ED) treatment settings; yet, few studies have examined the effectiveness of family‐based treatment (FBT) delivered via telehealth. This study compared in‐person and telehealth FBT in rates of weight restoration, treatment completion, and metrics of treatment progress, and explored potential moderators of these outcomes.MethodRetrospective chart review identified 169 adolescents (10–18 years) with restrictive EDs who received FBT in person before the COVID‐19 pandemic (n = 92) or via telehealth during the pandemic (n = 77). Regression models examined the effect of FBT format, controlling for baseline percent of expected body weight (%EBW). Zip code‐based geospatial analyses compared the distance each format reached.ResultsTreatment format (in‐person versus telehealth) did not predict whether patients were weight restored to ≥ 95% of EBW at the end of treatment (OR = 0.74) or completed treatment (ORs = 0.53–1.74). Older age predicted lower odds of treatment completion among in‐person but not telehealth patients; there was no moderating effect of age on weight restoration or of baseline %EBW on either outcome. Patients who received FBT via telehealth were less likely to be early responders (i.e., gained 2.3 kg by session four; OR = 0.33). FBT format did not predict the number of sessions to 95% EBW (f2 = 0.01), hospitalization frequency, or distance reached (d = 0.27).DiscussionResults suggest no significant differences between telehealth and in‐person FBT in restoring weight or preventing hospitalization for adolescents with restrictive EDs, and support continued use of telehealth FBT to improve treatment accessibility and scalability. Additional research using a randomized design and ED psychopathology measures is needed.

The aim of this paper was to identify the characteristics of broader categories of eating disorders (ED) and help- and care-seeking among college students. An online cross-sectional study was conducted among students of the University of Rouen-Normandy, France. The Expali-validated algorithmic tool, combining SCOFF test (Sick, Control, One stone, Fat, Food) and body mass index, was used to screen eating disorders into three diagnostic categories: restrictive eating disorders, bulimic eating disorders, and hyperphagic eating disorders. A total of 1493 college students were included; mean age was 20.1 years (SD = 1.9). The prevalence of likely cases of eating disorder was 24.8% (95% CI, 22.6–27.0). Percentage distributions of bulimic eating disorders, hyperphagic eating disorders, and restrictive eating disorders were 13.3%, 8.6%, and 2.9%, respectively. The two main resources for help-seeking in emotional stress situations were friends and family, whatever the ED. Students with eating disorders consulted their general practitioner more often for stress or anxiety than students without eating disorders: hyperphagic eating disorders (44.9%), restrictive eating disorders (35.1%), bulimic eating disorders (30.2%), and no eating disorder (20.4%) (p < 0.0001). The prevalence of healthcare renunciation was 21.9%, with a higher risk among students with bulimic eating disorders (AOR CI 95% 1.91 (1.34–2.72). The findings show one quarter of students screened positive for an eating disorder. Stress management was not necessarily different between students with eating disorders and students without eating disorders, but the former had a greater risk of renouncing treatment, especially related to a fear of seeing a general practitioner.

To systematically review the literature reporting outcomes of augmentative family-based treatment (FBT) interventions for adolescents with restrictive eating disorders (EDs). Articles were identified through a systematic search of five electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Cochrane Database). Thirty articles were included, reporting on FBT augmentations featuring adjunctive treatment components, modified treatment structure and/or content with adherence to FBT principles, and adaptations allowing FBT delivery in different settings. All reported significant improvements in weight and/or ED symptoms at end-of-treatment, although few compared augmentative and standard FBT interventions and good quality follow-up data was generally lacking. There is early evidence for the effectiveness of augmentative FBT-based approaches in facilitating weight and/or ED symptom improvements for adolescents with restrictive EDs. There remains a lack of robust evidence demonstrating superior effects of such approaches over standard FBT, and further controlled studies are required to expand on the current evidence. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

BackgroundOutpatient family-based treatment (FBT) is effective in treating restrictive eating disorders among adolescents. However, little is known about whether FBT reduces higher level of care (HLOC) utilization or if utilization of HLOC is associated with patient characteristics. This study examined associations between utilization of eating disorder related care (HLOC and outpatient treatment) and reported adherence to FBT and patient characteristics in a large integrated health system.MethodsThis retrospective cohort study examined 4101 adolescents who received care for restrictive eating disorders at Kaiser Permanente Northern California. A survey was sent to each medical center to identify treatment teams as high FBT adherence (hFBT) and low FBT adherence (lFBT). Outpatient medical and psychiatry encounters and HLOC, including medical hospitalizations and higher-level psychiatric care as well as patient characteristics were extracted from the EHR and examined over 12 months post-index.Results2111 and 1990 adolescents were treated in the hFBT and lFBT, respectively. After adjusting for age, sex, race/ethnicity, initial percent median BMI, and comorbid mental health diagnoses, there were no differences in HLOC or outpatient utilization between hFBT and lFBT. Females had higher odds of any utilization compared with males. Compared to White adolescents, Latinos/Hispanics had lower odds of HLOC utilization. Asian, Black, and Latino/Hispanic adolescents had lower odds of psychiatric outpatient care than Whites.ConclusionsReported FBT adherence was not associated with HLOC utilization in this sample. However, significant disparities across patient characteristics were found in the utilization of psychiatric care for eating disorders. More efforts are needed to understand treatment pathways that are accessible and effective for all populations with eating disorders.

The aim of this review is to heighten awareness of the association between chronic functional abdominal pain (CFAP) and restrictive eating disorders (ED) in adolescents. We describe current diagnostic practices and propose future research efforts to improve the assessment and treatment of comorbid CFAP and restrictive EDs. A narrative review of the literature on CFAP and EDs was performed using PubMed, JSTOR, ScienceDirect, and PsycINFO and the following search terms: 'restrictive eating disorders', 'chronic functional abdominal pain', 'chronic pain' 'treatment' 'diagnosis' and 'adolescents'. Published studies on restrictive EDs and CFAP from May 2008 to March 2023 were included. Ascribable to the overlap in etiology and symptom presentation, adolescents with chronic pain are significantly less likely to have their ED pathology promptly identified by providers compared to adolescents without comorbid chronic pain. This highlights the importance of the time sensitive and accurate identification of EDs in adolescents with CFAP. Overall, assessment methods are limited and EDs take longer to be identified in adolescents with comorbid CFAP. Future efforts should address diagnostic practices in pediatric settings and improve the communication among medical and mental health providers in order to promote the rapid and effective diagnosis and treatment of comorbid CFAP and EDs.

This study aims to describe the spectrum of children with restrictive early onset eating disorders (EOEDs), defined as below 13 years of age, presenting to a tertiary institution in Asia and comparing them with older adolescents with eating disorders. This is a retrospective case review of Asian children who were treated in an eating disorder center. Baseline characteristics and inpatient management at first presentation of children younger than 13 years of age (EOED) were compared to those in older adolescents. A total of 288 patients with restrictive eating disorders were analyzed with 53 (18%) patients having onset younger than age 13 at initial presentation. There were no significant differences in percentage weight loss and hospitalization rates between the two age groups. Patients with EOED presented with significantly shorter duration of symptoms, and lower rates of secondary amenorrhea. More patients with EOED required phosphate supplementation compared to those in older age group. Despite having a shorter duration of illness, Asian children with EOED had similar percentage weight loss and rates of admission due to malnutrition as those in older Asian adolescent patients. This study underlined the severity of EOEDs and the need for early recognition and medical assessment.

Eating disorders (ED) are serious psychiatric illnesses with one of the highest mortality rate of any psychiatric disorder. The health sequelae of eating disorders are one of the most common causes of medical hospitalizations at freestanding pediatric hospitals in the United States. The economic impact of EDs on health systems and families is substantial. The Society for Adolescent Medicine (SAHM) recommends family-based treatment (FBT) as the first-line approach for adolescents with restrictive eating disorders due to a large body of evidence demonstrating the treatment’s efficacy and cost effectiveness. Although FBT was originally developed as an outpatient treatment, the tenets and principles of the treatment have also been used in higher levels of care. This brief report discusses how components of FBT were adapted for a medical inpatient unit at a pediatric hospital in order to integrate empirically based treatment.

Eating disorders (EDs) are a group of serious, potentially life-threatening illnesses that typically have their onset during adolescence and can be associated with severe medical and psychosocial complications. The impact of EDs on caregivers and other family members can also be significant. Health care providers (HCPs) play an important role in the screening and management of adolescents and young adults with EDs. This position statement assists community-based HCPs with recognizing, diagnosing, and treating EDs in the paediatric population. Screening modalities, indications for hospitalization, medical complications, and monitoring of young people with EDs are summarized. Current evidence supports the use of family-based treatment (FBT) as the first-line psychological therapeutic modality for adolescents with restrictive EDs. While the provision of FBT may be beyond the scope of practice for some community physicians, this statement reviews its core tenets. When an ED is diagnosed, early application of these principles in the community setting by HCPs may slow disease progression and provide guidance to families.

BackgroundOur study aims to explore and describe themes arising in sessions of clinical consultation with therapists implementing Family-Based Treatment (FBT) for adolescents with Anorexia Nervosa (AN). There is currently no literature describing the content of clinical consultation for FBT. Thus, this knowledge will add to the evidence-base on what therapists need from consultants in ongoing clinical consultation.MethodsEight therapists at four sites participated in this study, which spanned a two-year period. Following a two-day training workshop, each therapist treated at least one adolescent patient presenting with a restrictive eating disorder with FBT, focusing on adherence to the treatment manual. Clinical consultation sessions occurred monthly and were led by an external FBT expert. Thirty-five (average per site = 9) audio recorded group clinical consultation sessions were transcribed verbatim and coded for themes. Twenty percent of the transcripts were double-coded to ensure consistency. Fundamental qualitative description guided the sampling and data collection.ResultsThematic content analysis revealed ten common themes relating to the provision of clinical consultation to therapists implementing FBT in clinical practice: encouraging parental meal time supervision,discussing the role of mothers, how to align parents, ensuring parental buy-in, when to transition to Phase 2, weighing the patient and the patients’ knowledge of their weight, the role of siblings in FBT sessions, how best to manage patient co-morbidities, the role of the father in FBT and how best to manage the family meal.ConclusionsIn conclusion, clinical consultation themes aligned with many of the central tenets of FBT, including how to help parents align their supportive approach during the refeeding process, and how to help parents assume control of eating disordered behaviours. This knowledge helps to guide consultants to anticipate common issues brought forward by therapists attempting to implement FBT.