Sarah Forsberg

Can Adaptive Treatment Improve Outcomes in Family-Based Therapy for Adolescents with Anorexia Nervosa? Feasibility and Treatment Effects of a Multi-Site Treatment Study

OBJECTIVE Adolescents with Anorexia Nervosa (AN), treated with family-based treatment (FBT) who fail to gain 2.3 kg by the fourth week of treatment have a 40-50% lower chance of recovery than those who do. Because of the high risk of developing enduring AN, improving outcomes in this group of poor responders is essential. This study examines the feasibility and effects of a novel adaptive treatment (i.e., Intensive Parental Coaching-IPC) aimed at enhancing parental self-efficacy related to re-feeding skills in poor early responders to FBT. METHOD 45 adolescents (12-18 years of age) meeting DSM TR IV criteria for AN were randomized in an unbalanced design (10 to standard FBT; 35 to the adaptive arm). Attrition, suitability, expectancy rates, weight change, and psychopathology were compared between groups. OUTCOMES There were no differences in rates of attrition, suitability, expectancy ratings, or most clinical outcomes between randomized groups. However, the group of poor early responders that received IPC achieved full weight restoration (>95% of expected mean BMI) by EOT at similar rates as those who had responded early. CONCLUSIONS The results of this study suggest that it is feasible to use an adaptive design to study the treatment effect of IPC for those who do not gain adequate weight by session 4 of FBT. The results also suggest that using IPC for poor early responders significantly improves weight recovery rates to levels comparable to those who respond early. A sufficiently powered study is needed to confirm these promising findings.

Therapeutic alliance in two treatments for adolescent anorexia nervosa.

OBJECTIVE The aim of this study was to examine the relationship between therapeutic alliance and treatment outcome (remission status) in family-based treatment (FBT) and adolescent-focused therapy (AFT) for adolescents with anorexia nervosa (AN). METHOD Independent observers rated audiotapes of early therapy sessions using the Working Alliance Inventory-Observer Version (WAI-o). Outcome was defined using established cut-points for full and partial remission. To control for effects of early symptom improvement, changes in weight- and eating-related psychopathology prior to the alliance session were calculated and entered as a covariate in each analysis. RESULTS Participants in AFT had significantly higher alliance scores; however, overall scores were high in both therapies. The alliance was not a predictor of full remission for either treatment, though it was a non-specific predictor for partial remission. DISCUSSION Therapeutic alliance is achievable in adolescents with AN in both AFT and FBT, but demonstrated no relationship to full remission of the disorder.

Is There a Relationship Between Parental Self-Reported Psychopathology and Symptom Severity in Adolescents with Anorexia Nervosa?

The current study aimed to screen for indications of psychopathology displayed by the parents of adolescents diagnosed with Anorexia Nervosa (AN), and examine the relationship between severity of adolescent eating disorder symptoms and parental psychopathology. Sixty female adolescents diagnosed with DSM-IV-TR AN (restricting-type and binge-purge-type) were administered the Eating Disorder Examination (EDE) and parents completed the Symptom Checklist 90-Revised (SCL-90-R). As compared to established non-patient norms, both fathers and mothers of adolescents with AN reported greater levels of obsessive compulsive behaviors, hostility, depression, and anxiety as measured by the SCL-90-R. In addition, duration of AN was positively associated with hostility scores in fathers, and global EDE scores were associated with hostility in mothers. While parental scores on the SCL-90 were elevated as compared to community samples, results of this study do not support a direct influence of parental psychopathology on symptom severity of adolescent AN. Increasing rates of hostility scores in parents with increased duration of AN may represent either a response to the presence of the disorder or be a maintaining factor for AN.

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.

Family-based Treatment of Child and Adolescent Eating Disorders

Best-practice guidelines for the treatment of child and adolescent eating disorders recommend the inclusion of parents. Family-based treatment (FBT) posits that families are not only important in supporting their children but are critical change agents in the recovery process. As originally developed for anorexia nervosa, parents take a central role in managing and disrupting eating disorder symptoms. The most evidence-based treatment model for adolescent anorexia nervosa, FBT has also recently been found to be useful in the treatment of adolescent bulimia nervosa. This article provides a summary of the theoretic model, evidence base, and application of FBT.

Psychological symptoms among parents of adolescents with anorexia nervosa: a descriptive examination of their presence and role in treatment outcome

Parent psychological symptoms were examined in a randomized controlled trial comparing family-based treatment (FBT) and adolescent-focused therapy (AFT) for anorexia nervosa, and were explored across treatments and in relation to treatment outcomes. Moderator and mediator analyses were completed with parent symptoms as predictors and weight remission and recovery status as outcome variables. Few parents had clinically significant symptoms at presentation. At the end of treatment (EOT), parents had decreased psychological symptoms in both treatment arms. Higher baseline levels of overall maternal symptomology and improvement in maternal symptomology were non-specific predictors of adolescent weight outcome at EOT and 12-month follow up. Mothers with few to no depressive symptoms had children with the greatest improvement in weight at EOT when assigned to family treatment. In sum, parent symptoms did not appear to negatively impact on the treatment outcome among adolescents with anorexia nervosa. Practitioner points Parent involvement is considered best practice in the treatment of adolescent anorexia nervosa (AN). There are limited data on psychological symptoms among parents of individuals with AN, and their impact on treatment outcome. Among a sample of adolescents with AN, parent psychological symptoms improved across individual and family treatment. Future studies may wish to explore the impact of maternal depression on refeeding efforts in family-based treatment.

Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa

OBJECTIVE This study provides data on the psychometric properties of a newly developed measure of treatment fidelity in Family-Based Treatment (FBT) for adolescent anorexia nervosa (AN). The Family Therapy Fidelity and Adherence Check (FBT-FACT) was created to evaluate therapist adherence and competency on the core interventions in FBT. METHOD Participants were 45 adolescents and their families sampled from three randomized clinical trials evaluating treatment for AN. Trained fidelity raters evaluated 19 therapists across 90 early session recordings using the FBT-FACT. They also rated an additional 15 session 1 recordings of an alternate form of family therapy-Systemic Family Therapy for the purpose of evaluating discriminant validity of the FBT-FACT. The process of development and the psychometric properties of the FBT-FACT are presented. RESULTS Overall fidelity ratings for each session demonstrated moderate to strong inter-rater agreement. Internal consistency of the measure was strong for sessions 1 and 2 and poor for session 3. Principal components analysis suggests sessions 1 and 2 are distinct interventions. DISCUSSION The FBT-FACT demonstrates good reliability and validity as a measure of treatment fidelity in the early phase of FBT.

Adolescent Anorexia: Guiding Principles and Skills for the Dietetic Support of Family-Based Treatment

MS, RDN, a clinical dietitian II, Stanford University, Stanford, CA; Sarah E. Forsberg, PsyD, a clinical psychologist, University of California, San Francisco; and Kathleen Kara Fitzpatrick, PhD, a clinical assistant professor of psychiatry and behavioral sciences and child development, Department of Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford Hospital/Stanford Children’s Hospital, Stanford, CA.