Family-based Treatment Research Articles

When parents and clinicians disagree: Consequences for high-risk youth receiving in-home family-based psychiatric treatment

Children, parents and clinicians often disagree about how children are doing at the outset of psychotherapy. Besides complicating the formal diagnostic process, such disagreements are conspicuous indicators of distance between individuals whose ability to form constructive working relationship is crucial to ensure good treatment outcomes. No studies to date have investigated the impact of parent-clinician disagreements on child outcomes in intensive in-home psychiatric treatment. The present study used multiple regression modeling to analyze data from 7845 high-risk adolescents participating in a manualized, 6-month family-based intervention (Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS). Parent-clinician disagreement on child functioning, but not symptom severity, predicted worse treatment outcomes for adolescents. Youth whose parents thought they were doing much worse than clinicians, had almost no effect of treatment at the group level whereas youth whose parents thought they were doing better than clinicians experienced clinically significant change on average. This finding lends empirical support to the notion that parent-clinician disagreements at the outset of youth psychotherapy may jeopardize not only diagnostic validity, but treatment outcomes for high-risk adolescents.

The introduction of treatment and the cultural adaptability of western psychotherapies for eating disorders in China

In the past 40 years, the prevalence of eating disorders (ED) in China has shown an increasing trend, leading to an urgent need to develop efficient treatment modes and methods. Since the beginning of the new century, the diagnosis, treatment, and research of ED in China have been under development. This article gives an introduction and commentary on the treatment modes, treatment methods and their applications in ED in China. There are two main treatment forms for ED until now, that is, inpatient treatment and outpatient treatment. Inpatient treatment is recommended as the first choice. Since 2008, clinical psychotherapies such as cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), and family-based treatment (FBT), which are effective for pathological symptoms of ED, have been introduced into China and developed clinically. Group CBT and group DBT for patients with ED and group FBT for caregivers might be the most efficient psychotherapy in China nowadays. A multi-family FBT support group could be developed as the basic treatment of ED patients. Although these new types of psychotherapy have observed effectiveness in clinical application, the Randomized Controlled Trials (RCT) are rare and need to be developed.

Implementation of family‐based treatment for Asian adolescents with anorexia nervosa: A consecutive cohort examination of outcomes

This study describes the implementation of family-based treatment (FBT) in an eating disorder program in Asia as well as clinical outcomes of Asian adolescents with anorexia nervosa (AN) treated with FBT. This retrospective consecutive cohort study of 147 Asian adolescents with AN was compared between those in FBT (n = 65) versus treatment as usual (TAU) (n = 82). Variables associated with weight restoration were analyzed between groups. Participants' mean age was 14.2 (SD = 1.5) years and 93% were female. Mean presenting %mBMI was 74.0 (SD = 7.8) and average illness duration was 7.7 (SD = 6.1) months. The two groups' baseline characteristics were not significantly different. Weight restoration rates in the FBT group were significantly higher than the TAU group at 6-, 12-, and 24-month time points. A linear mixed model showed the mean %mBMI was significantly higher at 0, 6, 12, and 24 months in the FBT group. The median time to weight restoration for patients on FBT was shorter (FBT: 7.0 months, TAU: 19.0 months; 95% CI [14.5, 23.5] χ2 = 15.84, p < .001). Within the FBT group, those that completed ≥9 FBT sessions had significantly higher rates of weight restoration at 12 months. Across all participants, those with a lower starting %mBMI were less likely to achieve weight restoration by 12 months. FBT can be effectively implemented in a multidisciplinary eating disorder program managing Asian adolescents with AN with improved rates of weight restoration. Further research is needed to understand the predictors and moderators of remission using FBT in Asian adolescents with AN.

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

Family-based treatment (FBT) is an efficacious intervention for adolescents with an eating disorder. Evaluated to a lesser degree among adolescents, enhanced cognitive-behavior therapy (CBT-E) has shown promising results. This study compared the relative effectiveness of FBT and CBT-E, and as per manualized CBT-E, the sample was divided into a lower weight [<90% median body mass index (mBMI)], and higher weight cohort (⩾90%mBMI). Participants (N = 97) aged 12-18 years, with a DSM-5 eating disorder diagnosis (largely restrictive, excluding Avoidant Restrictive Food Intake Disorder), and their parents, chose between FBT and CBT-E. Assessments were administered at baseline, end-of-treatment (EOT), and follow-up (6 and 12 months). Treatment comprised of 20 sessions over 6 months, except for the lower weight cohort where CBT-E comprised 40 sessions over 9-12 months. Primary outcomes were slope of weight gain and change in Eating Disorder Examination (EDE) Global Score at EOT. Slope of weight gain at EOT was significantly higher for FBT than for CBT-E (lower weight, est. = 0.597, s.e. = 0.096, p < 0.001; higher weight, est. = 0.495, s.e. = 0.83, p < 0.001), but not at follow-up. There were no differences in the EDE Global Score or most secondary outcome measures at any time-point. Several baseline variables emerged as potential treatment effect moderators at EOT. Choosing between FBT and CBT-E resulted in older and less well participants opting for CBT-E. Results underscore the efficiency of FBT to facilitate weight gain among underweight adolescents. FBT and CBT-E achieved similar outcomes in other domains assessed, making CBT-E a viable treatment for adolescents with an eating disorder. Treatment Outcome in Eating Disorders; https://clinicaltrials.gov/; NCT03599921.

Therapist Strategies for Managing Midtreatment Problems in Evidence-based Interventions in Community Settings.

The National Institute of Health has made it a priority to identify, develop, and refine strategies to disseminate and implement effective interventions (National Institute of Health, 2015). This study examined qualitative reports of the strategies therapists used to manage common implementation problems they encountered during midtreatment in Multisystemic Therapy® (MST) and Functional Family Therapy (FFT), two widely disseminated evidence- and family-based treatments for substance abusing and delinquent adolescents. Experienced therapists from dissemination sites across the U.S. described cases in which they encountered midtreatment problems they perceived as serious threats to treatment success. They indicated why each case terminated and rated the outcome of the case. Qualitative analyses examined 16 treatment failures and then 16 treatment successes to identify contextual obstacles that accompanied the problems therapists identified, along with strategies they reported using with families that ultimately succeeded or failed. Therapists reported that midtreatment problems were often embedded in additional related difficulties and that they employed multiple relationship techniques and process-focused strategies to try to resolve these problems. For the most part, therapists described obstacles and strategies for successful and unsuccessful families in similar ways. Patterns of themes and subthemes suggested, however, that therapists in successful cases may be more likely to report "on-script" strategies and therapists in unsuccessful cases may describe more "off-script" strategies as well as more generic relationship building and advice-giving strategies.

Exploring Differences in the Role of Hospitalization on Weight Gain Based on Treatment Type From Randomized Clinical Trials for Adolescent Anorexia Nervosa.

Background: This study explores the impact of weight gain during medical stabilization hospitalization on weight outcomes between three outpatient treatments for adolescent anorexia nervosa (AN): Adolescent Focused Therapy (AFT), Systemic Family Therapy (SyFT), and Family Based Treatment (FBT).Methods: A secondary analysis of weight gain data (N = 215) of adolescents (12–18 years) meeting DSM-IV criteria for AN (exclusive of amenorrhea criteria) who participated in two randomized clinical trials (RCTs) was conducted. Main outcomes examined were changes in weight restoration (≥95% expected body weight or EBW) and differences in weight change attributable to hospital weight gain.Results: Weight gain resulting from hospitalizations did not substantially change weight recovery rates. Hospital weight gain contributed most to overall treatment weight gain in AFT compared to FBT and SyFT.Conclusion: Brief medical stabilization weight gain does not contribute substantially to weight recovery in adolescents with AN who participated in RCTs.

Introduction of family-based treatment to Japan with adaptations to optimize the cultural acceptability and advance current traditional treatments of adolescent anorexia nervosa.

Given the lack of clear consensus on effective treatment models for adolescent anorexia nervosa in Japan, treatment programs offered to this population vary widely between treatment facilities with limited testing of outcomes. Importantly, families have traditionally been left out of the core treatment process, as they are commonly viewed as being powerless in renourishing their child. The purpose of this commentary was to report the authors' preliminary efforts to introduce and implement family-based treatment (FBT) in Japan so that, on par with international standards of practice, FBT may become the first-line treatment option for Japanese families. This commentary will describe the systemic and cultural barriers which posed as challenges in introducing FBT to Japan in its manualized standard format and how these were addressed by introducing FBT during the patient's hospital admission and by assigning the father with a role which resembles the traditional gender role within the Japanese family culture. Authors have thus far observed that these adaptations led to increased accessibility of FBT and improved outcomes such as reduced number of hospitalizations and shorter time taken to reach 85-90% EBW. Further considerations for the broad dissemination and implementation of FBT in Japan are also presented.

Parental Contributors to the Prevalence and Long-term Health Risks of Family Weight Teasing in Adolescence

PurposeWeight teasing from family members is common during adolescence. However, little is known about parental factors that increase adolescents' risk for family weight teasing and its adverse health sequelae. Using multi-informant data from adolescents, mothers and fathers, the current longitudinal study examined how parental concerns about their child's weight and their own weight contribute to family weight teasing in adolescence and its long-term health consequences. MethodsData were collected in the population-based Project EAT 2010–2018 (Eating and Activity over Time) study, following a longitudinal cohort of young people (N = 2,793). Parental weight concerns for their adolescent and themselves were reported by mothers (N = 2,298) and fathers (N = 1,409) at baseline and examined as a predictor of family weight teasing in adolescence as well as a moderator of family weight teasing effects on health eight years later. ResultsMothers' and fathers' concerns about their child's weight, as well as mothers' dieting frequency, increased the likelihood of adolescents experiencing family weight teasing. Longitudinal analyses revealed that adolescents teased about their weight by family had higher levels of stress (β = .21, 95% confidence interval [CI] = .09–.33) and substance use (β = .16, 95% CI = .04–.28), and lower self-esteem (β = −.16, 95% CI = −.28 to −.05) in young adulthood. ConclusionsFindings highlight parent weight concern, particularly concern for their child's weight, as a risk factor for family weight teasing. These findings underscore the importance of encouraging parental attention to health, rather than weight, in family-based treatment and public health initiatives.

I'm Not Being Critical, You're Just Too Sensitive: Pediatric Bipolar Disorder and Families.

The present study examines the relationship between Perceived Criticism (PC) and Sensitivity to Criticism (SC) in youth with Bipolar Spectrum Disorder (BPSD), their symptomatic experiences, and family functioning. We hypothesized that findings for youth would be consistent with findings for adults indicating that PC and SC would be associated with a worse clinical presentation, and that associations between family criticism and sensitivity and youth symptoms would be stronger for youth with BPSD than with other clinical diagnoses. We examined 828 youths ages 4-18 years (M=10.9, SD=3.4) and their caregivers from diverse ethnic and socioeconomic backgrounds using the Longitudinal Expert evaluation of All Data (LEAD) diagnoses (Spitzer, 1983), the parent-reported General Behavior Inventory (Youngstrom et al., 2001), The Perceived Criticism Scale (Hooley & Teasdale, 1989), and the Family Assessment Device (Epstein et al., 1983). We found significant positive association between parent reports of youth criticalness and more severe manic and depression symptoms, greater mood lability, higher suicidality, and worse overall functioning. Youth with BPSD were significantly more critical and had higher SC than youth without BPSD. Interactions between BPSD and family criticalness and sensitivity were found in their links with youth symptoms. Negative associations between criticism and sensitivity and youth global family functioning were significant only for youth with BPSD. The positive association between criticism and youth mood lability was significant only for youth with BPSD. Our findings suggest that family factors and interactional patterns impact and are influenced by functioning in youth with BPSD and that family-based treatments should be considered routinely with these youth.

The Effectiveness of Family-Based Treatment on Attitude towards Substance Use in Female Students with Substance Use Disorder

The Effectiveness of Family-Based Treatment on Attitude towards Substance Use in Female Students with Substance Use Disorder

Randomized Controlled Trial of an Integrated Family-Based Treatment for Adolescents Presenting to Community Mental Health Centers.

Most adolescents presenting to community mental health centers have one or more comorbidities (internalizing, externalizing, and substance use problems). We evaluated an integrated family-based outpatient treatment for adolescents (OPT-A) that can be delivered in a community mental health center by a single therapist. A sample of 134 youth/families were randomized to receive OPT-A or usual services, delivered at the same public sector mental health center. Repeated, multi-informant assessments occurred through 18-months post-baseline. At baseline, the sample displayed low internalizing symptoms, moderate substance use, and high externalizing problems. Compared to usual services, OPT-A had effects on abstinence rates, retention, motivation, parent involvement, and satisfaction, but not on internalizing or externalizing problems. While OPT-A achieved some key improvements for youth who present to community mental health centers, and families were satisfied with treatment, continued work is necessary to examine treatments for comorbidity while balancing treatment feasibility and complex strategies to boost treatment effectiveness.

Family Dynamics and Pediatric Weight Management: Putting the Family into Family-Based Treatment.

The treatment of pediatric obesity entails working with entire families. However, aside from parenting and family health behaviors, family dynamics and relationships are not often incorporated in clinical treatment of obesity. Evidence across several studies suggest a relationship between family dynamics and child weight, with impaired family dynamics associated with higher weight status in children. Evidence is mixed if child age and family function are associated. Unfortunately, there is little evidence that addressing family dynamics (i.e., relationships and overall family system) will improve weight in children with obesity. Notably, few studies target family dynamics specifically. There are several validated measures of family dynamics available for researchers to explore the family system as it relates to child health and behaviors. A deeper understanding of family dynamics and relationships may provide new avenues to address issues of weight in children; accounting for the family, and their underlying functioning, may benefit the clinician and child engaged in weight management.

Perfectionism, anorexia nervosa, and family treatment: How perfectionism changes throughout treatment and predicts outcomes.

This study uses data from a multisite randomized clinical trial to study the role of perfectionism in family-based treatment (FBT) for adolescent anorexia nervosa (AN). The main aim is to examine the role of baseline perfectionism in treatment response. Adolescents (N = 158; ages 12-18; 89.2% female) and their families were randomized to receive either FBT or systemic family treatment for AN. Eating disorder (ED) pathology, obsessive-compulsive symptoms, and perfectionism were assessed at baseline, end of treatment, and 6- and 12-month follow-up. Linear regression analyses were used to test whether perfectionism and obsessive-compulsive symptoms at baseline predict ED pathology at all timepoints. An independent samples t test was used to test whether there was a significant difference in the change in perfectionism in either treatment group. Baseline maladaptive perfectionism significantly predicted ED pathology but not ideal body weight at all timepoints. The model that included obsessive-compulsive symptoms also predicted ED pathology at all timepoints except 12-month follow-up. Perfectionism scores did not change during treatment regardless of treatment type. Baseline perfectionism predicted treatment response in this study. Interventions might target perfectionism to improve treatment response in AN.

Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine

BackgroundFamily-based treatment (FBT) is an efficacious outpatient intervention for young people diagnosed with Anorexia Nervosa (AN). To date, treatment to protocol has relied on standard face-to-face delivery. Face-to-face therapy is subject to geographic, temporal and human factors, rendering it particularly susceptible to inequities and disruption. This has resulted in poorer service provision for rural and regional families, and recently a significant challenge to providing face-to-face services during the COVID-19 global pandemic. The present study examines whether FBT for AN can be successfully translated to a digital delivery platform to address these access issues.MethodForty young people aged 12 to 18 years who meet DSM-5 diagnostic criteria for AN, and live in a rural or regional setting, will along with their family be recruited to the study. Trained therapists will provide 18 sessions of FBT over 9 months via telemedicine to the home of the young person and their family. The analysis will examine treatment effectiveness, feasibility, acceptability, and cost-effectiveness.DiscussionThe study addresses the treatment needs of families not able to attend face-to-face clinical services for evidence-based treatment for eating disorders. This might be due to several barriers, including a lack of local services or long travel distances to services. There has been a recent and unprecedented demand for telemedicine to facilitate the continuity of care during COVID-19 despite geographical circumstances. If delivering treatment in this modality is clinically and economically effective and feasible, it will facilitate access to potentially lifesaving, evidence-based treatments for families formerly unable to access such care and provide evidence for the continuity of services when and where face-to-face treatment is not feasible.

Rationale and protocol for translating basic habituation research into family-based childhood obesity treatment: Families becoming healthy together study

This publication describes the rationale and protocol, including design, aims, intervention, and measures, of Families Becoming Healthy Together, a randomized clinical trial examining the effect of a limited RED (non-nutrient-dense, energy-dense) food variety prescription delivered within an 18-month family-based behavioral obesity treatment (FBT) on body mass index (BMI) and habituation rate to RED foods. One hundred fifty-six children (ages: 8–12 y; BMI: ≥ 85th percentile-for-age) and a caregiver (BMI: ≥ 25 kg/m2), both with overweight or obesity, will be randomized to one of two, interventions: FBT or FBT + Variety. All participants will receive 29 sessions of FBT and be prescribed the Traffic Light Diet (1000–1500 kcal/day, ≤ 2 RED food servings/day), and a physical activity goal (≥ 60 min/day [child] or 150 min/week [adult] of moderate-vigorous physical activity (MVPA)). FBT + Variety will also identify two RED foods, a dinner entrée and snack food, and develop meal plans that reduce variety of RED foods by regularly consuming these foods and limiting consumption of other RED foods. Measures of anthropometrics, dietary intake, habituation of salivary response to food cues, and physical activity will be assessed at 0, 6, 12, and 18-months. This study translates a line of basic behavioral research examining how dietary variety influences habituation into a dietary prescription that will be tested within an efficacy trial. It is hypothesized that a novel, limited dietary variety prescription within FBT should promote a faster food habituation rate, reducing energy intake and amplifying long-term weight loss in children.

General and Eating Disorder Psychopathology in Relation to Short- and Long-Term Weight Change in Treatment-Seeking Children: A Latent Profile Analysis.

Concurrent general psychopathology (GP) and eating disorder psychopathology (EDP) are commonly reported among youth with overweight/obesity and may impact weight change. We identified patterns of GP and EDP in children with overweight/obesity and examined the impact on weight change following family-based behavioral obesity treatment (FBT) and maintenance interventions. Children (N = 172) participated in 4 month FBT and subsequent 8 month weight maintenance interventions. GP and EDP were assessed prior to FBT (baseline). Child percentage overweight was assessed at baseline, post-FBT (4 months), and post-maintenance (12 months). Latent profile analysis identified patterns of baseline GP and EDP. Linear mixed-effects models examined if profiles predicted 4- and 12-month change in percentage overweight and if there were two-way and three-way interactions among these variables, adjusting for relevant covariates. Results indicated a three-profile structure: lower GP and EDP (LOWER); subclinically elevated GP and EDP without loss of control (LOC; HIGHER); and subclinically elevated GP and EDP with LOC (HIGHER + LOC). Across profiles, children on average achieved clinically meaningful weight loss (i.e., ≥9 unit change in percentage overweight) from baseline to 4 month FBT and sustained these improvements at 12 month maintenance. There was no evidence that latent profiles were related to percentage overweight change from baseline to FBT (p > .05) or baseline to maintenance (p > .05). There was no evidence for two-way or three-way interactions (p > .05). Concurrent GP and EDP do not portend differential short- or long-term weight change following FBT and maintenance. Future research is warranted on the durability of weight change among youth with GP and EDP. NCT00759746.

Developments in the psychological treatment of anorexia nervosa and their implications for daily practice.

Purpose of reviewOur aim is to give an overview of the recent literature on psychological treatment for young adults and adults with anorexia nervosa and to discuss the implications of the findings for clinical practice.Recent findingsThree systematic reviews and meta-analyses have recently been published on psychological treatments for anorexia nervosa. Treatment outcomes are still modest and mainly focus on weight outcome, although outcomes for eating disorder disease and quality of life have also been reported. Adhering to a treatment protocol might lead to faster and better results.SummaryFor children and adolescents with anorexia nervosa, the major guidelines recommend a family-based treatment. The treatments of choice for young adults and adults with anorexia nervosa are the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), Cognitive Behaviour Therapy-Enhanced (CBT-E) and Specialist Supportive Clinical Management (SSCM), but none of these treatments seem to be superior. In search of other ways to improve outcome, shared decision making may be a way to help patients become more involved in their treatment, enhance their motivation and consequently improve the outcome.

Examining the interdependence of parent-child dyads: Effects on weight loss and maintenance.

This study aimed to further elucidate correlated weight changes in parent-child dyads enrolled in family-based treatment (FBT) by modeling the interdependence of weight changes during treatment. Parent-child dyads (n = 172) with overweight/obesity (child mean zBMI = 2.16 ± 0.39; parent mean BMI = 37.9 ± 9.4 kg/m2 ) completed 4 months of FBT and were randomized to one of three 8-month maintenance interventions (Social Facilitation Maintenance [SFM]-high dose, SFM-low dose or control). Weight/height was measured at 0, 4 and 12 months. Structural equation models simultaneously estimated the effect that an individual had on their own (actor effect) and on one another's (partner effect) weight-status across time using the actor-partner interdependence model. Actor paths were significant over time for parent and child. Partner paths were significant for child zBMI predicting parent BMI at 4 and 12 months. Maintenance condition moderated actor/partner paths in the model. Child weight change may motivate parents to make environmental and behavioural changes that impact their own weight. ClinicalTrials.gov Identifier: NCT00759746.

Child neurobiology impacts success in family-based behavioral treatment for children with obesity.

Background and Objectives:Family-based behavioral treatment (FBT) is the recommended treatment for children with common obesity. However, there is a large variability in short- and long-term treatment response and mechanisms for unsuccessful treatment outcomes are not fully understood. In this study, we tested if brain response to visual food cues among children with obesity before treatment predicted weight or behavioral outcomes during a 6-mo. behavioral weight management program and/or long-term relative weight maintenance over a 1-year follow-up period.Subjects and Methods:Thirty-seven children with obesity (age 9–11y, 62% male) who entered active FBT (attended 2 or more sessions) and had outcome data. Brain activation was assessed at pre-treatment by functional magnetic resonance imaging across an a priori set of appetite-processing brain regions that included the ventral and dorsal striatum, medial orbitofrontal cortex, amygdala, substantia nigra/ventral tegmental area and insula in response to viewing food images before and after a standardized meal.Results:Children with more robust reductions in brain activation to high-calorie food cue images following a meal had greater declines in BMI z-score during FBT (r= 0.42; 95% CI: 0.09, 0.66; P=0.02) and greater improvements in Healthy Eating Index scores (r= −0.41; 95% CI: −0.67, −0.06; P=0.02). In whole-brain analyses, greater activation in the ventromedial prefrontal cortex, specifically by high-calorie food cues, was predictive of better treatment outcomes (whole-brain cluster corrected P=0.02). There were no significant predictors of relative weight maintenance and initial behavioral or hormonal measures did not predict FBT outcomes.Conclusions:Children’s brain responses to a meal prior to obesity treatment were related to treatment-based weight outcomes, suggesting that neurophysiologic factors and appetitive drive, more so than initial hormone status or behavioral characteristics, limit intervention success.

Recognizing and Responding to Child Maltreatment: Strategies to Apply When Delivering Family-Based Treatment for Eating Disorders

Child maltreatment encompasses a constellation of adverse parental behaviors that include physical, sexual, or emotional abuse, physical or emotional neglect, as well as exposure to violence between parents. A growing body of literature indicates that exposure to child maltreatment is a significant risk factor for the development and maintenance of eating disorders (EDs) and that practitioners experience challenges related to recognizing and responding to various forms of child maltreatment in their practice. Parent-child interactions signifying possible child maltreatment can be subtle; furthermore, the emotional and behavioral symptoms associated with an ED can overlap with those linked with child maltreatment, making it difficult for practitioners to distinguish whether children’s symptoms are attributable to underlying psychopathology versus exposure to child maltreatment. This challenge can be further complicated in the context of delivering family-based treatment (FBT); FBT reaffirms that there is no single cause of EDs and asserts the leadership role of parents in their child’s recovery process—both of which may lead practitioners to inadvertently miss indicators of child maltreatment. In this article, we provide an overview of the evidence linking child maltreatment to EDs among children and adolescents, as well as evidence-informed strategies for practitioners to safely recognize and respond to suspected child maltreatment when delivering FBT to children and adolescents in their practice.