Andrew Wallis

A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents

Background Anorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest that longer initial hospitalizations that normalize weight produce better outcomes and fewer admissions than shorter hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of hospitalization for weight restoration (WR) to medical stabilization (MS) in adolescent AN. Method We performed a randomized controlled trial (RCT) with 82 adolescents, aged 12–18 years, with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for gender, age and height, both followed by 20 sessions of out-patient, manualized family-based treatment (FBT). Results The primary outcome was the number of hospital days, following initial admission, at the 12-month follow-up. Secondary outcomes were the total number of hospital days used up to 12 months and full remission, defined as healthy weight (>95% EBW) and a global Eating Disorder Examination (EDE) score within 1 standard deviation (s.d.) of published means. There was no significant difference between groups in hospital days following initial admission. There were significantly more total hospital days used and post-protocol FBT sessions in the WR group. There were no moderators of primary outcome but participants with higher eating psychopathology and compulsive features reported better clinical outcomes in the MS group. Conclusions Outcomes are similar with hospitalizations for MS or WR when combined with FBT. Cost savings would result from combining shorter hospitalization with FBT.

Do the components of manualized family‐based treatment for anorexia nervosa predict weight gain?

OBJECTIVE Family-based treatment for anorexia nervosa (FBT) has demonstrated efficacy in the treatment of adolescents with anorexia nervosa (AN) in a number of randomized control trials (RCT). The aim of the current research was to determine whether adherence to the key components of the model as outlined in the treatment manual predict weight gain or dropout. METHOD The 59 participants were under 19 years and had AN for less than 3 years. Five core treatment objectives and working alliance were measured across 20 sessions of FBT. RESULTS The core objectives of parents taking control, being united, not criticizing the patient and externalizing the illness predicted greater weight gain. Sibling support did not predict weight gain. The relationship between therapeutic alliance and weight gain was positive for mothers but negative for fathers. Dropout was predicted by low control and poor maternal-therapeutic alliance. DISCUSSION The results of this study lend further support for the efficacy of the FBT, demonstrating that the principles guiding clinical practice are those which lead to weight gain. The finding that parental control is the central predictor of change can also support the development of augmentations to the model.

Five-years of family based treatment for anorexia nervosa: The Maudsley Model at the Children's Hospital at Westmead

The Eating Disorder Service at the Childrens Hospital at Westmead (CHW) in Sydney, provides comprehensive inpatient and outpatient treatment for children and adolescents with eating disorders. In 2003 the Maudsley Model of family based treatment for anorexia nervosa was introduced to support outpatient care. This has resulted in positive changes in the dynamics of the eating disorder team, a change in the philosophies that underpin the program and the experience of families that consult the service. There has also been a significant decrease in readmission rates. Our experience with the model has resulted in requests to provide training to other clinicians around Australia and a number of ongoing consultative relationships have followed. Implementation of the Maudsley model at CHW is described, followed by an overview of the theory and a summary of the key changes and challenges since moving in this new direction in 2003.

Early weight gain in family-based treatment predicts greater weight gain and remission at the end of treatment and remission at 12-month follow-up in adolescent anorexia nervosa.

OBJECTIVE To Identify whether early weight gain in family-based treatment (FBT) predicted greater weight and remission at end of FBT and 12-month follow-up. METHOD Eighty-two adolescents, with anorexia nervosa, participated in a randomized control trial comparing brief hospitalization for medical stabilization and hospitalization for weight restoration to 90% expected body weight (EBW) (1:1), followed by 20 sessions of FBT. Sixty-nine completed trial protocol. Receiver operating characteristic analyses were conducted investigating whether early weight-gain in FBT predicted outcomes at end of FBT and 12-month follow-up. Participants were analyzed according to their original randomization and as a combined set. Binary logistic regression was used to control for randomization arm effect in combined set analysis. RESULTS Weight gain greater than 1.8 kg at FBT Session 4 predicted greater %EBW (99.18 SD = 6.93 vs. 92.79 SD = 7.74, p < .05) and remission at end of FBT (46% vs. 11%, p < .05) and at 12-month follow-up (64% vs. 36%, p = .05). Binary logistic regression confirmed weight gain greater than 1.8 kg predicted remission (p < .05) while treatment arm randomization did not add significantly to the model. DISCUSSION Early weight gain has potential to distinguish likely responders in FBT from those who may need more intensive intervention to achieve remission offering the potential to improve outcomes.

Selective eating in a 9-year-old boy: family therapy as a first-line treatment

Whilst empirical studies continue to demonstrate the efficacy of family-based therapy in the treatment of adolescent anorexia nervosa, less comprehensive evidence exists in guiding the treatment of pre-adolescent eating disorders, which are typically characterised by a greater variety of symptom presentation. We present the case of a pre-adolescent male who met criteria for selective eating who was treated into full remission with eating-disorder-focused family therapy. This family-based intervention deviated significantly from recently manualised family-based therapy interventions, and we suggest continued exploration of family therapy techniques in the treatment of pre-adolescent eating disorders.

Just One More Bite: A Qualitative Analysis of the Family Meal in Family-based Treatment for Anorexia Nervosa

OBJECTIVE The family meal is an integral component of Maudsley family-based treatment for anorexia nervosa. The aim of this study was to determine whether there are different types of family meal, as suggested in the treatment manual, and whether within session processes differ according to meal type. METHOD Thirty video-recorded family meal sessions from a randomised controlled trial were transcribed and analysed using thematic analysis. RESULTS Analyses revealed two types of family meal. In the first, the patient ate one mouthful more than they were willing to eat. This meal type was characterised by processes that were consistent with the Maudsley model. In the second, the patient ate what was asked of them with little to no difficulty. Therapist and family avoidance differentiated this meal type from the first. DISCUSSION The current findings, along with the existing theory, suggest that avoidance may have reduced the therapeutic impact of the meal for many families. Strategies to challenge therapist and family avoidance are suggested. Copyright

The effectiveness of family-based treatment for full and partial adolescent anorexia nervosa in an independent private practice setting: Clinical outcomes.

OBJECTIVE Anorexia nervosa (AN) is a severe psychiatric illness with little evidence supporting treatment in adults. Among adolescents with AN, family-based treatment (FBT) is considered first-line outpatient approach, with a growing evidence base. However, research on FBT has stemmed from specialist services in research/public health settings. This study investigated the effectiveness of FBT in a case series of adolescent AN treated in a private practice setting. METHOD Thirty-four adolescents with full or partial AN, diagnosed according to DSM-IV criteria, participated, and were assessed at pretreatment and post-treatment. Assessments included change in % expected body weight, mood, and eating pathology. RESULTS Significant weight gain was observed from pretreatment to post-treatment. 45.9% of the sample demonstrated full weight restoration and a further 43.2% achieved partial weight-based remission. Missing data precluded an examination of change in mood and ED psychopathology. DISCUSSION Effective dissemination across different service types is important to the wider availability of evidence-based treatments. These weight restoration data lend preliminary support to the implementation of FBT in real world treatment settings.

Inside the family meal: a thematic analysis of session two in Maudsley family-based treatment for anorexia nervosa

Results Two types of family meal were identified. The first was characterised by processes that were consistent with the Maudsley model, and resulted in the patient eating one mouthful more than they were prepared to. The second was defined by processes that were mixed in terms of their consistency with the model, and resulted in the patient eating what was asked of them with little to no difficulty. Therapist and family avoidance differentiated the second meal type from the first. Discussion Avoidance seemed to diminish the therapeutic impact of the family meal for a significant number of families. Strategies to challenge avoidance during the session are suggested. This abstract was presented in the Peter Beumont Young Investigator award finalist stream of the 2014 ANZAED Conference.

Does continuing family-based treatment for adolescent anorexia nervosa improve outcomes in those not remitted after 20 sessions?

Objective: Our aim was to investigate the benefit of ongoing family-based treatment (FBT) sessions for adolescent anorexia nervosa if remission criteria were not met at session 20. Method: Participants were 69 medically unstable adolescents with Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) anorexia nervosa from a randomized controlled trial investigating length of hospital admission prior to outpatient FBT. Participants were divided post hoc into those meeting remission criteria at session 20 (n = 16), those that had not remitted but continued with FBT (n = 39) and those who ceased FBT undertaking alternative treatments (n = 14). Outcome was assessed as remission and hospital readmission days at 12 months after FBT session 20. Results: There were no differences between groups at baseline. There was a significant difference in the use of hospital admission days with those in the Alternate Treatment Group who did not continue with FBT using 71.93 days compared to those in Additional FBT Group with only 12.51 days (F(2, 66) = 13.239, p < .01). At 12 months after FBT session 20, the Additional FBT Group had a 28.2% increase in remission rate, significantly higher than those in the Alternate Treatment Group (χ2(2) = 17.68, p < .001). Discussion: Continuing FBT after session 20 if remission is not achieved can significantly reduce hospital readmission days and improve remission rates.

Multiple family therapy for anorexia nervosa at the Eating Disorder Service, the Children's Hospital at Westmead

The Eating Disorder Service at The Childrens Hospital at Westmead (CHW) is a tertiary service that offers a range of family focused treatment options for young people with an eating disorder. Multiple Family Therapy (MFT) is the newest treatment option provided by the service. MFT is now a key intervention offered by a number of services overseas, most notably at the Maudsley Hospital, London, where the model was developed. Despite its use for more than a decade overseas, we are the first service in Australia to systemically integrate MFT as an additional treatment option within the standard suite of interventions offered. MFT theoretically builds upon the core constructs of family based treatment for anorexia nervosa, whilst adding the unique experience of solidarity for young people and their families. The content of MFT is experiential, involving activities and specific debriefing techniques to help families develop ways to work together against anorexia, increase attunement to their childs needs and feel more agency around the process of recovery. The MFT program at CHW provides the opportunity for up to eight families to work together for a 4-day workshop. Follow-up care is provided by outpatient family therapy or integration into the Intensive Family and Adolescent Eating Disorders Day Program. MFT targets families not progressing in outpatient care or who present with some other complexity with the view that engagement in treatment may be enhanced through the group experience of MFT and the opportunity to receive treatment input from multiple sources. The presentation will describe MFT constructs, the programs implementation at CHW, show material from the therapeutic activities completed and present preliminary data and family experiences from the first five groups.