Jennifer Couturier

Family-Based Treatment for Adolescents With Anorexia Nervosa: A Dissemination Study

This open trial of Family-Based Treatment for Anorexia Nervosa was completed in order to assess the dissemination of this treatment, including effectiveness, fidelity, and acceptability. Fourteen adolescents with Anorexia Nervosa were recruited with mean age 14.0+1.5 years (range 12–17 years). Therapists were trained using a workshop, manual and weekly supervision. Sessions were videotaped and rated for treatment fidelity. Pre- and post- treatment assessments were compared. Weight was significantly increased by an average of 7.8 kg. Dietary restraint showed significant improvement, as did interoceptive deficits and maturity fears. Of the 9 participants who had secondary amenorrhea at baseline, 8 had regained menstrual function. Treatment fidelity was rated as at least considerable 72% of the time in phase I of the treatment. Adolescents and parents found the treatment to be acceptable. This preliminary investigation of the dissemination of Family-Based Treatment for adolescents with Anorexia Nervosa indicates that this treatment is effective not only for weight restoration, but also in improving some psychological symptoms including dietary restraint, interoceptive deficits, and maturity fears. In addition, this treatment was adopted with considerable fidelity and was acceptable to adolescents and parents.

Therapeutic alliance and family-based treatment for adolescents with anorexia nervosa.

This pilot study examines the role of therapeutic alliance in relation to weight gain and change in psychological measures during family-based treatment for adolescent anorexia nervosa (AN). Our sample consisted of 14 adolescents with AN and their families. Therapeutic alliance was measured using the System for Observing Family Therapy Alliances Scale. Those adolescents who attained at least 85% of their ideal body weight at the end of treatment had parents who showed a stronger therapeutic alliance with the therapist during the second session of treatment, while adolescents who were remitted on psychological measures showed a higher therapeutic alliance between themselves and the therapist early in treatment. It appears that therapeutic alliance plays an important role in outcome in family-based treatment for AN. Further study is needed in this area to explore the role of the therapist in creating and maintaining a strong therapeutic alliance.

Costs of remission and recovery using family therapy for adolescent anorexia nervosa: a descriptive report.

This paper reports on the costs of overall treatment for a cohort of adolescent patients with AN treated with a similar regimen consisting of inpatient medical stabilization, outpatient family therapy, and psychiatric medications for co-morbid psychiatric conditions. Most of the costs associated with outcome were secondary to medical hospitalization. However, the overall costs per remission varied widely depending on the threshold used. However, compared to costs described for adults with AN, adolescent treatment costs appear to be lower when families are used effectively to aid in treatment.

Do end of treatment assessments predict outcome at follow-up in eating disorders?

OBJECTIVE To examine the predictive value of end of treatment (EOT) outcomes for longer term recovery status. METHOD We used signal detection analysis to identify the best predictors of recovery based on outcome at EOT using five different eating disorder samples from randomized clinical treatment trials. We utilized a transdiagnostic definition of recovery that included normalization of weight and eating related psychopathology. RESULTS Achieving a body weight of 95.2% of expected body weight by EOT is the best predictor of recovery for adolescents with anorexia nervosa (AN). For adults with AN, the most efficient predictor of weight recovery (BMI > 19) was weight gain to greater than 85.8% of ideal body weight. In addition, for adults with AN, the most efficient predictor of psychological recovery was achievement of an eating disorder examination (EDE) weight concerns score below 1.8. The best predictor of recovery for adults with Bulimia Nervosa (BN) was a frequency of compensatory behaviors less than two times a month. For adolescents with BN, abstinence from purging and reduction in the EDE restraint score of more than 3.4 from baseline to EOT were good predictors of recovery. For adults with binge eating disorder, reduction of the Global EDE score to within the normal range (<1.58) was the best predictor of recovery. DISCUSSION The relationship between EOT response and recovery remains understudied. Utilizing a transdiagnostic definition of recovery, no uniform predictors were identified across all eating disorder diagnostic groups.

Anorexia nervosa and gender dysphoria in two adolescents.

Little has been published about the co-occurrence of gender dysphoria (GD) and eating disorders (ED) in adults, with no cases described in the adolescent population. The emphasis on body shape in both conditions suggests that there may be some overlap in symptomatology. We report two adolescent cases initially diagnosed with anorexia nervosa who later met criteria for GD. The drive for thinness for the 16-year-old male was associated with a wish to achieve a feminine physique whereas there was an emphasis for stunted breast growth and a desire for muscularity in the 13-year-old female. Complexities in presentation, evolution of symptoms over time, and the treatment of the two cases are discussed. Clinicians should inquire about sexual issues in the presentation of ED and should monitor for symptoms of GD, not only at initial presentation, but throughout treatment, especially as weight gain progresses.

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

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

Bone mineral density in adolescents with eating disorders exposed to selective serotonin reuptake inhibitors.

Retrospective chart review was used to collect data from adolescents seen in a specialized eating disorder program over an 11-year period in order to investigate any association between exposure to selective serotonin reuptake inhibitors (SSRIs) and bone mineral density (BMD). SSRI users were matched with controls based on age (within 1.5 years), gender, eating disorder diagnosis, and percent ideal body weight (within 5%), resulting in a sample of 31 pairs. SSRI users had significantly lower BMD z-scores, compared to controls (–1.094 vs. –0.516, p < .035), suggesting that exposure to SSRIs may be a risk factor for lowered BMD.

Meal Support Therapy Reduces the Use of Nasogastric Feeding for Adolescents Hospitalized With Anorexia Nervosa

The objective of this study was to assess the impact of meal support therapy on the use of nasogastric feeding for adolescent patients hospitalized with Anorexia Nervosa. Charts of 21 adolescents (mean age 15.1 ± 1.9 years) were reviewed. The incidence of nasogastric feeding was substantially reduced after the implementation of meal support therapy (67% versus 11% [p < .02]). No differences in length of stay, change in weight, or readmission rates were observed. Meal support therapy significantly reduces the use of nasogastric feeding on inpatient units treating children and adolescents with Anorexia Nervosa.

Using a knowledge transfer framework to identify factors facilitating implementation of family‐based treatment

OBJECTIVE To conduct a qualitative study to identify factors that would facilitate the transfer of the research evidence on Family-Based Treatment (FBT) into clinical practice. METHOD Fundamental qualitative description guided sampling, data collection, and analytic decisions for this study. Forty therapists who treat children and adolescents under the age of 18 with Anorexia Nervosa (AN) and belong to Ontarios provincial network of specialized eating disorder services completed an in-depth interview focusing on elements proposed by the Lavis knowledge transfer framework. An experienced coder conducted content analysis, with 20% of the interviews double-coded for reliability purposes. RESULTS Participants requested training in the FBT model, including the provision of research evidence (i.e., journal articles), as well as the specific tenets of the model according to the FBT manual. The suggested audience for implementation included not only therapists themselves, but administrators, physicians, and community members. The development of best practice guidelines was also supported. Local FBT experts were suggested as credible messengers. Infrastructure relating to financial support and time away from clinical duties were reported to be essential for training. Ongoing supervision and mentorship were reported to be important elements of implementation and evaluation processes. DISCUSSION Suggestions for moving FBT into practice were consistent with previous research, however, the importance of obtaining the evidence in the form of primary research articles and obtaining team buy-in were remarkable. Developing context-specific training programs and administrative processes for the implementation of FBT are warranted.

Severe avoidant/restrictive food intake disorder and coexisting stimulant treated attention deficit hyperactivity disorder

There is a growing body of literature describing the development, clinical course, and treatment of avoidant/restrictive food intake disorder (ARFID), a diagnostic category introduced in the DSM-5. However, information surrounding complex cases of ARFID involving coexisting medical and/or psychiatric disorders remains scarce. Here we report on two cases of young patients diagnosed concurrently with ARFID and attention deficit hyperactivity disorder (ADHD) who both experienced significant growth restriction following initiation of stimulant medication. The appetite suppressant effect of stimulants exacerbated longstanding avoidant and restrictive eating behaviors resulting in growth restriction and admission to an inpatient eating disorders unit. The implications of ARFID exacerbated by stimulant-treated ADHD are explored, as well as the treatment delivered. These cases suggest that further research is needed to explore management options to counteract the appetite suppression effects of stimulants, while simultaneously addressing attention deficit symptoms and oppositional behavior.