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Abstract

Anorexia nervosa is a severe psychiatric disorder with high morbidity and mortality, particularly among adolescents. Family-based treatment (FBT) is the leading evidence-based intervention for adolescent anorexia nervosa, involving parents in renourishment and behavior interruption. Despite its effectiveness, challenges in distress tolerance and emotion regulation during high-stress situations, such as mealtimes, contribute to suboptimal treatment outcomes, with only 35% to 50% of adolescents achieving full recovery. Enhancing distress tolerance skills during FBT may improve treatment responses and recovery rates. The BALANCE mobile app was developed to address this need, offering real-time, dialectical behavior therapy (DBT)-based distress tolerance skills to support adolescents and families during mealtimes.Our aim was to explore the feasibility and acceptability of a mobile app designed to deliver distress tolerance skills to adolescents with and adolescents without anorexia nervosa. When fully programmed and optimized, we plan to use the mobile app to improve distress tolerance during mealtimes for adolescents with anorexia nervosa undergoing FBT.BALANCE was developed collaboratively with Stanford University's Center for Biodesign, leveraging the expertise of clinical psychologists and using biodesign student input and the Stanford Spezi ecosystem. The app underwent an iterative development process, with feedback from adolescent users. The initial feasibility and acceptability of the app were assessed through self-reported questionnaires and structured interviews with 24 adolescents aged 12 to 18 years, including 4 diagnosed with anorexia nervosa and 20 healthy controls. Adolescents with anorexia nervosa specifically used the app during mealtimes, and healthy controls used it as needed. Participants assessed the app's usability, perceived effectiveness, and its impact on their distress tolerance.The app demonstrated high usability and acceptability. Of 24 participants, 83% (n=20) reported enjoying the app, 88% (n=21) would recommend it to peers, and 100% (n=24) found it user-friendly. Adolescents with anorexia nervosa reported that BALANCE helped them manage stressful mealtimes more effectively, highlighting features such as guided meditation, breathing exercises, and gamification elements as particularly effective. Healthy controls provided additional feedback, confirming the app's broad appeal to the target audience and potential scalability. Preliminary findings suggest that BALANCE may enhance distress tolerance in adolescents with and adolescents without anorexia nervosa.BALANCE shows promise as an innovative mobile health intervention for enhancing distress tolerance in adolescents with anorexia nervosa. Its user-friendly design and tailored DBT-based skills make it a feasible tool for integration into FBT. Future research should explore its integration into clinical practice and its impact on treatment outcomes. As distress tolerance skills are relevant to a range of mental health conditions, future research may also expand BALANCE's application to broader adolescent populations.

View details for DOI 10.2196/70278

View details for PubMedID 40019817

Abstract

While Family-based treatment for anorexia nervosa (FBT-AN) is effective for weight restoration and improvement in eating-related cognitions, its effect on exercise attitudes and behaviors is little studied. Compulsive exercise is common in AN and often challenging to change.This secondary analysis examined changes in attitudes toward compulsive exercise (Compulsive Exercise Test-CET) and behaviors (Eating Disorder Examination-EDE) using data from a randomized clinical trial testing an adjunctive treatment for adolescents with AN who failed to gain 2.4 kg by Session 4-a predictor of poor outcome. The main hypothesis is that attitudes toward compulsive exercise and decreases in compulsive exercise behavior would improve over the course of treatment.Participants reported decreases in compulsive exercise attitudes by Session 4 and compulsive exercise episodes by end of treatment (EOT). There were no differences between early FBT responders (weight gain of 2.4 kg by session 4) and early non-responders.These results suggest that FBT facilitates adolescents with AN to change attitudes toward compulsive exercise early in treatment (by Session 4) as well as reduction in compulsive exercise behaviors by EOT. Future studies should assess whether changes in attitudes toward compulsive exercise early in treatment is a mechanism of FBT treatment effect.

View details for DOI 10.1002/eat.24334

View details for PubMedID 39579160

View details for DOI 10.1016/j.jaac.2024.07.465

View details for Web of Science ID 001330511901146

Abstract

Research on treatments for children with avoidant restrictive food intake disorder (ARFID) is needed. This pilot case series describes outcome data for 20 children ages 6-12 years old with a diagnosis of ARFID and who are low-weight.Participants were recruited nationwide as part of an ongoing randomized clinical trial. All participants in this study received a 14-session psychoeducational and motivational treatment (PMT) protocol. Parents completed measures of ARFID severity (the Pica, ARFID, Rumination Disorder Interview) and parental self-efficacy (Parents vs. ARFID scale). Height and weight were self-reported by parents and percent of estimated body weight (%EBW) was calculated. Assessments occurred at baseline, 1-month within treatment, 2-months within treatment, end-of-treatment (EOT), and 6-month follow-up.Twenty children (10.34 ± 1.76 years; 85% Non-Hispanic; 75% White; 70% female; 84.16 ± 4.66% EBW) with low-weight ARFID and their parents received PMT-ARFID with a clinician specializing in eating disorders. By EOT, PARDI severity scores decreased (large effect size) parental self-efficacy increased (medium effect size), but %EBW remained unchanged.Additional research evaluating PMT in adequately powered clinical trials for youth with ARFID is needed.

View details for DOI 10.1002/eat.24273

View details for PubMedID 39120094

Abstract

The leading evidence-based treatment for anorexia nervosa (AN) in adolescents is Family-based Treatment (FBT). However, due to the intensive training requirements and lack of practitioners, it is often difficult for families to access FBT. Thus, innovations that improve access to care are needed. A pilot randomized study of a guided self-help version of Family-based Treatment (GSH-FBT) that utilized approximately 1/4 the amount of therapist time compared to FBT found that the approach was acceptable and appeared to achieve similar outcomes. The study protocol detailed in this manuscript compares the efficiency (clinician time) of GSH-FBT to Family-based Treatment via Videoconferencing (FBT-V) in a fully powered study in achieving clinical outcomes through a multi-site randomized clinical trial across the US and Ontario, Canada.This study will randomize the families of adolescents ages 12-18 (n = 200) who meet DSM-5 criteria for AN to receive either GSH-FBT or FBT-V. Participants will be randomized to 15 sixty-minute sessions of FBT-V or to 10 twenty-minute sessions of online GSH-FBT. Major assessments will be conducted by a masked assessor at baseline, within treatment, at the end of treatment (EOT), and 6 and 12 months after the end of treatment (EOT). The primary outcomes of this study are changes to body weight and eating disorder cognitions relative to clinician time used (relative efficiency of treatment modality).The findings of this study may help increase access to care by providing a time efficient, affordable, more scalable intervention for adolescent AN compared to standard FBT.

View details for DOI 10.1016/j.cct.2024.107618

View details for PubMedID 38971303

View details for DOI 10.1176/appi.focus.20230033

View details for PubMedID 38988460

View details for PubMedCentralID PMC11231476

Abstract

Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents.Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT).Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT.The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes.Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

View details for DOI 10.1002/eat.24235

View details for PubMedID 38840408

Abstract

Family-based treatment (FBT) is an efficacious treatment for adolescent anorexia nervosa (AN). A parent-only guided self-help version of FBT (GSH-FBT) demonstrated preliminary efficacy in pilot investigations. To address challenges in access to care, we adapted GSH-FBT into a parent-only multi-family group format (MF-GSH-FBT) delivered via videoconferencing.This report details the feasibility and acceptability of a parent-only group-based multi-family GSH-FBT (MF-GSH-FBT) for adolescent AN delivered virtually. The MF-GSH-FBT intervention consisted of 12 weekly 60-min sessions facilitated by a clinician in addition to online FBT video content and recommended readings. Adolescents and parents completed assessments at baseline and post-treatment. Parents reported their child's weight each week.A total of 13 adolescents (15.57 + 1.63 years; 92% female; 23% Hispanic) with AN and their parents enrolled and initiated treatment. Four consecutive cohorts of groups of 3-4 families were completed from April 2022 to April 2023. Across cohorts, parents attended 85% of sessions. Most parents rated the treatment sessions as helpful (79%; agree/strongly agree) and felt supported by the other group members (84%). All parents (100%) reported MF-GSH-FBT helped their child, and most (90%) reported their child had improved by end-of-treatment. On average, adolescents gained 3.53 kg (SD: 3.76) from pre- to post-treatment, with percent estimated mean body weight increasing 5% on average. Parental self-efficacy also increased from baseline to end-of-treatment.MF-GSH-FBT for AN appears feasible and acceptable to parents participating in this pilot study. Challenges with recruitment and adolescent data collection remain questions for future investigation.This study describes initial pilot testing of a virtual guided self-help family-based treatment for adolescents with anorexia nervosa delivered in a multi-family group format. This treatment aims to enhance access to family-based treatment for anorexia nervosa whilst providing additional support to parents.

View details for DOI 10.1002/eat.24182

View details for PubMedID 38419434

Abstract

Loss of control (LOC) eating in youth is a common disordered eating behavior and associated with negative health and psychological sequalae. Family-based treatment (FBT) is an efficacious treatment for adolescent anorexia nervosa and bulimia nervosa (BN) but has not been formally evaluated for adolescents with LOC eating. This study is a secondary data analysis from a randomized controlled clinical trial (NCT00879151) testing FBT for 12-18-year-olds with BN. Data were reanalyzed to examine outcomes for LOC eating episodes, regardless of episode size. Abstinence rates, defined as zero LOC eating episodes (objective or subjective binge episodes) in the previous month, were calculated at the end-of-treatment (EOT), 6-month, and 12-month follow-up time points. Among 51 adolescent participants (M + SD: 15.94 + 1.53 y; 92% female; 23.5% Hispanic; 76.5% Caucasian), FBT significantly reduced LOC eating episodes, with 49% achieving LOC eating abstinence at EOT. At 6-month follow-up, 41% achieved LOC eating abstinence. Of those providing 12-month follow-up data, 73% achieved abstinence. This preliminary exploration suggests that FBT may be effective for youth with LOC eating, regardless of episode size. Additional research is needed to replicate these findings and extend treatments with developmental adaptations for younger children with LOC eating.

View details for DOI 10.1080/10640266.2023.2229091

View details for PubMedID 38149636

View details for PubMedCentralID PMC10753090

Abstract

Anorexia Nervosa (AN) is a serious psychiatric disorder with high morbidity and mortality. The current evidence supports the use of Family-Based Treatment (FBT), but recovery rates are about 40%. Improving treatment outcomes among adolescents will save lives, improve health, and prevent chronicity. This study examined the relative efficacy of adding Intensive Parental Coaching (IPC) to standard FBT for those who do not respond by weight gain of 2.4 kg by session 4, a clinical predictor of outcome at the end of treatment (EOT), to improve remission rates (>94% of expected mean body mass index (mBMI)).107 adolescents and their families were recruited, of whom 69 failed to respond early and were randomized to continue with standard FBT or to receive 3 sessions of IPC. Participants were adolescents with DSM-5 AN between the ages of 12-18 years recruited from across the US; 6.5% were male participants and 11% were Hispanic.Main outcomes were mBMI >94% expected for age, height, and sex. Secondary outcomes include change in eating-related cognitions. Adding IPC to early non-responders did not improve outcomes except for those whose parents demonstrated low parental self-efficacy at baseline (moderator). Early weight gain of 2.4kg by session 4 was replicated as a predictor of end of treatment remission.Parental self-efficacy (PSE) moderates IPC as an adaptive treatment for adolescent AN. Baseline PSE assessment can be used to identify those families most likely to benefit from adding IPC to FBT. Future studies should consider earlier interventions to improve early response rates.

View details for DOI 10.1016/j.jaac.2023.10.012

View details for PubMedID 38142046

Abstract

This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12-18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced.

View details for DOI 10.1080/10640266.2023.2277054

View details for PubMedID 37942724

Abstract

This proof-of-concept study explores the role of aberrant interoception as a possible mechanism underlying restrictive eating symptoms in avoidant/restrictive food intake disorder (ARFID) compared to anorexia nervosa (AN) and healthy comparisons (HC).We report preliminary normative adolescent interoceptive data in HCs (n = 100) compared to adolescents with ARFID (n = 30) and AN (N = 23). Adolescents (12-18) participated in a one-time virtual visit to assess heartrate guessing accuracy (interoceptive accuracy), correlation between confidence in heartrate guess and accuracy (interoceptive awareness), and self-reported interoception (interoceptive sensibility).HC adolescents had comparable interoceptive outcomes relative to published adult norms, consistent with existing literature. Data suggest that adolescents with ARFID have poor heartbeat guessing accuracy and experience challenges deciphering interoceptive signals, possibly contributing to symptoms. While adolescents with AN have greater heartbeat guessing accuracy, they cite difficulty trusting body cues, perhaps contributing to their lack of confidence in interoceptive cue detection.Preliminary results reflect differences in interoception between the three groups.

View details for DOI 10.1186/s40337-023-00914-9

View details for PubMedID 37872615

View details for PubMedCentralID 10108140

View details for DOI 10.1016/j.jaac.2023.09.050

View details for Web of Science ID 001098830400548

View details for DOI 10.1080/10640266.2023.2229091

View details for Web of Science ID 001013472100001

Abstract

OBJECTIVE: To examine the psychometric properties of the Parent Eating Disorder Examination Questionnaire (PEDE-Q), developed to improve eating disorder (ED) assessment among youth by including parents as informants.METHODS: A multi-site, transdiagnostic sample of 355 adolescents with EDs completed the Eating Disorder Examination Questionnaire (EDE-Q) and their parents completed the PEDE-Q.RESULTS: The internal consistencies of the PEDE-Q subscales were on par with established EDE-Q ranges (.73 to .90), both when examined using the original four-factor EDE-Q subscales and the seven-item, three-factor subscales of the brief EDE-Q. Statistically significant medium- to large-sized correlations and poor to moderate levels of agreement were found between the corresponding EDE-Q and PEDE-Q subscales. Receiver-operator characteristic (ROC) curves showed that the PEDE-Q had a statistically significant area under the curve (AUC) to maximize sensitivity and specificity in diagnosing full-syndrome AN, whereas the EDE-Q did not. Based on chi-square analyses, the PEDE-Q identified a statistically significantly greater number of AN cases than the EDE-Q. The EDE-Q yielded a BN diagnosis more frequently than the PEDE-Q, although this difference was not statistically significant.DISCUSSION: Results suggest that the PEDE-Q has good psychometric properties and provides incremental information that can aid in the assessment and diagnosis of adolescents with EDs, particularly those with AN.PUBLIC SIGNIFICANCE: There exist complex challenges to identifying clinically significant eating disorders among youth. The PEDE-Q is a questionnaire measure that improves eating disorder assessment among children and adolescents by asking parents to report on the symptoms and behaviors they have observed in their child and that youth may not fully disclose. The PEDE-Q can aid in the diagnosis of adolescents with eating disorders, particularly those with anorexia nervosa.

View details for DOI 10.1002/eat.23999

View details for PubMedID 37248808

Abstract

BACKGROUND: Individuals with Avoidant/Restrictive Food Intake Disorder (ARFID) experience restrictive or highly selective eating problems that interfere with growth and development. Despite the increasing number of referrals for ARFID, no evidence-based treatments exist. This compilation of case composites describes a novel manualized treatment, Psychoeducational and Motivational Treatment (PMT) for children with ARFID, focusing on exploring motivation to change eating behaviors. This approach is based on motivational non-directive psychotherapy models, psychoeducational interventions, and the usefulness of play to support psychotherapeutic learning in school-age children.CASE PRESENTATIONS: Three cases of children with ARFID treated using PMT are presented: a 7-year-old, a 10-year-old, and a 12-year-old. These cases illustrate how a clinician delivers PMT interventions in the context of developmental abilities and common comorbidities associated with ARFID.CONCLUSION: PMT is a promising therapy for ARFID in school-age children. Challenges and strategies are discussed, including ways to address obstacles such as young age, comorbidities, and use of the virtual environment.

View details for DOI 10.1177/13591045231169141

View details for PubMedID 37032311

Abstract

OBJECTIVE: Family-based treatment (FBT) is a well-established intervention for adolescent anorexia nervosa (AN). Although FBT is efficacious in promoting weight gain and improvements in psychological symptoms, for some adolescents, cognitive/attitudinal recovery lags behind weight gain. This study conducted an exploratory post hoc analysis of outcomes of adolescents who achieved weight gain by the end of FBT but continued to experience elevated psychological symptoms post-treatment.METHODS: Data were drawn from two randomised controlled trials (RCTs) testing two forms of FBT (conjoint/whole family and parent-focussed). Descriptive statistics and generalised estimating equations were used to examine differences in treatment outcomes between non-cognitive responders (NCRs) (those who regained weight but continued to experience psychological symptoms) and full responders (FRs) (those who achieved both weight and cognitive restoration by the end of treatment) (n=80; 83.7% female, Agemean [SD]=14.66 [1.73]).RESULTS: By 12months post-treatment, there were no differences in weight between NCRs and FRs. However, NCRs had a slower trajectory of weight gain than FRs and continued to have elevated levels of psychological symptoms throughout the follow-up period.CONCLUSIONS: A subset of adolescents appear to continue to experience clinically significant levels of eating pathology up to 12months after FBT even when weight restoration is achieved.

View details for DOI 10.1002/erv.2968

View details for PubMedID 36715459

View details for DOI 10.1186/s40337-022-00714-7

View details for PubMedID 36482292

Abstract

Misconceptions around which patients will and will not benefit from family-based treatment (FBT) for adolescent eating disorders (EDs) limit referrals and access to this treatment modality. The present study explored whether common demographic and clinical factors that may prevent referral to FBT predict treatment outcomes in adolescent anorexia nervosa (AN) and bulimia nervosa (BN).The following predictors of treatment outcomes were assessed: baseline family and diagnostic factors (socioeconomic status, comorbidity, illness duration, parent feelings of self-efficacy, family status, prior treatment, sex and prior hospitalizations) in a combined sample of adolescents receiving FBT compared to those randomized to other treatment conditions, across six clinical trials in the United States and Canada (total n = 724, ages 12-18, 90% female across both diagnoses). AN and BN samples were examined separately.Any prior ED treatment emerged as the only predictor of outcome in AN and BN, such that having no prior treatment predicted better outcomes in FBT for AN, and in both FBT and other treatment modalities for BN. No other sociodemographic or clinical variables predicted outcomes for AN or BN in FBT or in other evidence-based treatment modalities.The findings of this exploratory analysis suggest that commonly assumed factors do not predict outcome in FBT. Specifically socioeconomic and demographic factors or clinical variability in families seeking treatment do not predict treatment outcomes in FBT, or other evidence-based treatment modalities, with the exception of prior treatment. Providers should consider referring to FBT even when these factors are present.This manuscript reports that commonly assumed family, sociodemographic and diagnostic factors do not predict outcome in FBT or other evidence-based treatment modalities, with the exception of prior treatment. This data may be helpful for providers when considering referrals to FBT in the context of variability in these variables.

View details for DOI 10.1002/eat.23867

View details for PubMedID 36454189

Abstract

Background Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder recently added to the Diagnostic and Statistical Manual, 5th Edition (DSM-5) that involves nutritional, developmental, and/or psychosocial impairment, and often presents with a lack of interest in eating, sensory-related eating concerns, and/or fear of adverse consequences related to eating. There is limited evidence on treatments for ARFID, and in particular, treatments for children in the outpatient setting. Pilot data suggest that Family-Based Treatment (FBT) modified for ARFID is efficacious, and that improvements in parental self-efficacy may be the mechanism behind its success. This manuscript describes a study protocol seeking to confirm these preliminary findings through an adequately powered, randomized clinical trial (RCT). METHODS: This trial will randomize 100 children ages 6-12 years old who meet DSM-5 criteria for ARFID and their families to receive either 14 telehealth sessions of FBT-ARFID (n = 50) or a manualized Psychoeducational Motivation Therapy (PMT) treatment (n = 50), an individual therapy addressing the child's understanding of the problems ARFID is causing and promoting non-behavioral motivation and exploration of changing their eating patterns. Masked assessments will be conducted at baseline, one and two months within treatment, end-of-treatment, and six-month follow-up. Primary outcomes include change in body weight, parental self-efficacy, and parent feeding behaviors between baseline and end-of-treatment. CONCLUSIONS: The results of this RCT will advance our understanding of effective treatments for low-weight ARFID in youth.

View details for DOI 10.1016/j.cct.2022.107036

View details for PubMedID 36460266