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Abstract

Online training programs offer accessible, cost-effective solutions to disseminate evidence-based interventions. Yet, online training is typically insufficient without additional clinical case consultation (CCC). This is particularly salient in adolescent eating disorders treatment, where clinical demand far outstrips capacities of providers trained in evidence-based treatment approaches. This study seeks to better understand attitudes and barriers to receiving CCC among private practice clinicians treating adolescent eating disorders.Licensed private practice clinicians (n = 47; 100% female, average age 36 y old; 75% master's degree; average of 4y experience) across the United States enrolled in a randomized trial offering online training (webinar or e-learning) in family-based treatment (FBT) for anorexia nervosa. Post online training, participants were asked before and after 12 sessions of expert CCC to self-report attitudes and barriers to obtaining CCC.Prior to CCC, participants rated expert CCC in learning FBT as important/very important (100%). The majority participated in CCC since licensure (82%) and in the last year (68%), rating it valuable or very valuable (77%). Participants predicted that CCC would be valuable (96%) and an important motivation in completing the training study (96%). After CCC, participants viewed CCC as important/very important in learning FBT (94%). Common obstacles included finding a study-eligible patient (44%), scheduling constraints (19%), lost wages (16%), mismatch with consultant (3%), and hesitation to discuss cases (3%).Clinicians reported favorable perspectives on CCC in complimenting learning FBT via online training. Future studies are needed to determine methods to deliver, assess, and scale CCC to enhance treatment fidelity.

View details for DOI 10.1186/s40337-025-01511-8

View details for PubMedID 41476312

Abstract

Describe the feasibility, acceptability and preliminary efficacy of family-based treatment for adolescents with avoidant/restrictive food intake disorders (FBT-ARFID) in a real-world clinical cohort. Explore differences between adolescents and younger children with ARFID using FBT-ARFID.A retrospective chart review from 2017 to 2023 identified 39 children (< age 13) and 40 adolescents (age 13-18) who were assessed and then treated with FBT-ARFID in an outpatient clinic at a large academic medical hospital. We pulled data from patient charts on demographics and clinical characteristics and completed chart reviews for clinical outcome data (acceptability, feasibility, hospitalization rates, concurrent treatments, and parental learning). We used independent sample t tests and χ2 testing, and reported effect size differences on comparisons.A total of 46/55 (84%) children began FBT-ARFID after an initial evaluation (feasibility), and of those, 39 (85%) received more than four sessions (acceptability). A total of 42/66 (64%) adolescents started FBT-ARFID; of those, 40 (95%) received more than four sessions of FBT-ARFID. Children and adolescents presented similarly prior to treatment and achieved comparable practical clinical outcomes when treated with FBT-ARFID. There were more neurodivergent adolescents receiving FBT-ARFID than children, defined as diagnoses of comorbid ASD, ADHD, or both (37% vs. 15%). Adolescents used a greater number of sessions (M = 21, SD = 11.9) compared to children receiving FBT-ARFID (M = 15.2, SD = 7.4).Findings from this retrospective outpatient clinic chart review indicate that FBT-ARFID is feasible for treating, retaining, and obtaining clinical outcomes in adolescents.

View details for DOI 10.1002/eat.24597

View details for PubMedID 41220388

Abstract

Guided self-help family-based treatment (GSH-FBT) is emerging as a promising, more efficient alternative to traditional family-based treatment (FBT). The present study is designed to examine the real-world implementation of GSH-FBT at pediatric treatment sites across nine provinces in Canada.Implementation teams at each site consisting of a GSH-FBT coach, a medical provider, and a program administrator will be formed. Clinician coaches will be trained in this new modality and supported with weekly GSH-FBT consultation. Each site will recruit ten families with an adolescent with anorexia nervosa and the parents will undergo ten virtual GSH-FBT sessions. The implementation approach will be evaluated using qualitative and quantitative methods. Outcomes of interest include (1) treatment fidelity, (2) treatment wait times, (3) change in adolescent symptoms and parent/caregiver self-efficacy, (4) change in provider readiness, attitudes, and confidence towards the intervention, and (5) the overall experience of the implementation of the intervention from the perspective of the provider teams, and participant families.The findings of this study will help to identify factors important to the acceptability and implementation of GSH-FBT in real-world clinical settings.This study was first registered with clinicaltrials.gov (registration # NCT06851273) on February 12, 2025 (url: https://clinicaltrials.gov/study/NCT06851273?id=NCT06851273&rank=1 ).

View details for DOI 10.1186/s12888-025-07545-1

View details for PubMedID 41199206

View details for PubMedCentralID PMC12593892

Abstract

This acceptability and feasibility study utilized a mixed methods approach to examine patient and clinician perspectives on telehealth across multiple eating disorder presentations and evidence-based treatment modalities. Youth ages 6-19 received psychotherapy for eating disorders in an outpatient specialty clinic. The Telehealth Expectations Questionnaire (TEQ) assessed baseline expectations of telehealth. Satisfaction with telehealth was assessed monthly through the Telehealth Satisfaction Questionnaire (TSQ). Experiences with telehealth were measured at end of treatment through the Telehealth Usability Questionnaire (TUQ) and Implementation of Telehealth Treatment Questionnaire. The Eating Disorder Examination Questionnaire (EDE-Q) measured clinical improvement. Use of telehealth services was associated with clinically significant reductions in eating disorder symptoms. Qualitatively, patients and families reported advantages of telehealth, specifically saving time and ease of use, and identified disadvantages, including technological difficulties and feeling disconnected from therapists. Clinicians reported benefits of telehealth, such as insight into the home environment, and challenges, such as managing distractions and reading body language. Clinicians identified specific adaptations for telehealth when conducting one-on-one time with patients and taking weights. The perspectives of youth, families, and clinicians highlight important clinical considerations in the utilization of telehealth to promote accessible and effective care for eating disorders.

View details for DOI 10.1080/10640266.2025.2580717

View details for PubMedID 41182076

View details for DOI 10.1016/j.jaac.2025.07.586

View details for Web of Science ID 001603117800185

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