Family-based therapy for eating disorders

The incidence and prevalence of eating disorders (EDs) among children and adolescents necessitates that pediatricians be able to identify and treat these increasingly common conditions.¹ Many general pediatricians are uncomfortable treating anything beyond mild cases of ED, however, and prefer to refer for specialty care.²

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Traditional treatment focuses on inpatient hospitalization for weight and symptom stabilization followed by individual outpatient psychotherapy and nutritional counseling. Outpatient treatment is individually based therapy between a patient and a therapist, with parents often playing a secondary role. In fact, some traditional treatments assume that the family is part of the etiology of an ED. In this model, parents are not helpful in changing behaviors. Rather, the psychiatric issues of the parents are one of the causes of the ED and, thus, they are not able to help their children recover. In traditional treatment, there is an emphasis on inpatient treatment to achieve renourishment, which is followed by intensive monitoring of weight and physical condition, individual counseling, and nutritional counseling. This approach, however, has not demonstrated significant benefit when compared with outpatient treatment.³

Family-based therapy (FBT) presents a number of opportunities for a pediatrician in the treatment of ED. After making a diagnosis and ensuring that outpatient treatment is safe for the child or adolescent, the pediatrician primarily plays a supportive role and will not direct care unless there is a safety issue. In this manner, the pediatrician can address the medical issues with which they are more likely to be comfortable and support the patient and family through the difficult task of addressing disordered eating. This deference to other members of the treatment team, however, is fundamentally different from how pediatricians normally provide care and can make some pediatricians uncomfortable.^1,3

NEXT: What is family-based therapy for eating disorders? 

What is FBT for ED?

Family-based therapy, sometimes referred to as the Maudsley approach, is an intensive outpatient treatment plan that typically progresses in 3 phases. In the first phase, parents take responsibility, with the assistance of a therapist, for ensuring weight gain and limiting counterproductive weight control behaviors. In the second phase, the child or adolescent is helped to take back control and responsibility for their eating and weight. The final phase focuses on maintenance of weight and addresses healthy adolescent development.¹

Family-based therapy acknowledges a child or adolescent as part of the family. It assumes parents (or caregivers) are a key resource and part of the therapeutic plan, and that parental strengths can be mobilized for behavioral change in ED, utilizing parents as a treatment. It is essentially an intensive outpatient program in which the family is primarily responsible for renourishment of the child or adolescent. An FBT therapist does not direct care by providing meal plans or directed behavioral management recommendations. Rather, the FBT therapist promotes communication and problem-solving skills based on concepts and approaches from family systems therapy and family therapy intervention techniques.³

 Role of the pediatrician in FBT

The pediatrician participates in making a diagnosis of an ED and investigating any alternative diagnoses. The pediatrician will perform a comprehensive assessment and examination to identify any acute or chronic complications associated with disordered eating. Additionally, the pediatrician should screen for anxiety, depression, or other psychiatric comorbidities and make appropriate referrals if not able to adequately assess and treat.³

At diagnosis, the pediatrician needs to determine if outpatient treatment is appropriate from both a physical and an emotional aspect. If not, the pediatrician should admit the patient for medical stabilization and FBT can continue on an outpatient basis after stabilization. The pediatrician often will be the one to discuss the diagnosis with the patient and family, state the medical seriousness of the ED, and recommend FBT as a treatment approach.³

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The pediatrician’s role in FBT is often different compared with treating other illnesses. In FBT, the pediatrician is a consultant to the FBT therapist and parents, and often will defer to the therapist. The pediatrician is supportive and does not direct care unless there is a physical or an emotional concern for the child’s safety. Many pediatricians and parents are uncomfortable with this approach because both parties are familiar with a traditional medical model in which the pediatrician directs care. Rather than direct care, pediatricians should find themselves reflecting treatment-related questions back to the parents: “You know your child best. What do you think they need?” Such reflection will help parent and child develop their own treatment solutions for ED. Any treatment recommendations that are given directly, such as weight goals, should be given to both the parent and child so as to not undermine FBT.³

NEXT: What's the Maudsley approach

The Maudsley approach

Family-based therapy consists of the 3 distinct phases previously mentioned, and treatment is conducted over a year through approximately 20 sessions. Parents are essential to the treatment, playing an involved and optimistic role in return of weight to age/height normals (phase 1); allowing the child or adolescent to take back control of their eating (phase 2); and helping their child maintain weight on their own and develop a healthy identity (phase 3).^1,3

This work was originally undertaken at the Maudsley Hospital in London and has gained attention because it is evidence based and has demonstrated both short- and long-term positive outcomes.¹

Phase 1

Referred to as the weight restoration phase, the FBT therapist focuses on the dangers of malnutrition such as hormone abnormalities, cardiac dysfunction, emotional problems, and cognitive problems. A key part of the interactions are the therapist’s observations of the family’s interactions related to eating and assisting parents in developing strategies for treating their child. The therapist may attend a family meal to directly observe the dynamic around eating and assist parents in coaching their child about eating more than they are prepared to do.³

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A key strategy for the parents and therapist is to not criticize the child and externalize the ED. The child is not blamed or responsible for the ED. Rather, these are medical symptoms outside the child’s control and the goal is to learn strategies to address these debilitating symptoms. In pediatric terms, physiologic and psychologic development are significantly delayed as a result of the ED. Children with an ED make poor choices. Parents need to help their child get back on track as they would for other problems their child may encounter.^1,3

Parents are essentially playing the same role as the inpatient nurse during a residential inpatient treatment. Parents are taught to demonstrate empathy and understanding around the emotional predicament their child is facing related to eating while instructing them that starvation is also not an option. The primary goal in phase 1 is to provide coaching skills to parents that lead to weight restoration and expression of empathy, support, and understanding to the child. Realignment with siblings and peers through appropriate relationships is the final goal of therapy in phase 1.³

In phase 1, the pediatrician will collaborate with other members of the treatment team to determine a weight goal. Because weight and growth are moving targets in children and adolescents, the pediatrician will often need to adjust goals during treatment and communicate this to the parent, patient, and the rest of the treatment team.³

In FBT, the pediatrician will not prescribe a specified meal plan. Rather parents set and design meals trying to reintroduce foods that were eaten before onset of the ED. Although challenging, the pediatrician needs to reinforce to both parent and child that although eating more is good, the needed outcome is healthy weight gain. Ultimately, the goal is the number of calories per day needed to gain weight.³

If FBT progresses without complication, the pediatrician will primarily monitor and communicate with patient, family, and FBT therapist. The pediatrician should reinforce the value of the FBT treatment process. If there are problems with weight gain or a relapse of symptoms or significant disordered eating behaviors, the pediatrician needs to assess the safety of the child, determine if hospitalization is needed, and again reinforce the value of FBT for their ED.³

The pediatrician can provide support to parents who may begin to question FBT, because a child with an ED can display many worrisome behaviors in early treatment. Parents may feel that their child is actually worse in the early part of treatment. The FBT therapist, parent, and pediatrician will likely be unpopular with the patient in early treatment. The child often feels his or her concerns are not being heard and may act out in any number of ways that are alarming for parents. Although both the parent and pediatrician need to assess and take such behaviors seriously, these usually involve the child attempting to stop the refeeding efforts of the parents. Finally, parents also may need support and reassurance in the early phase of FBT as they begin to question its efficacy and wonder if an inpatient treatment program might be better.³

NEXT: Phase 2 and 3 of the Maudsley approach

Phase 2

Phase 2 begins when the child accepts parental demands for increased intake and weight gain, and parents begin the process of helping their child begin to take more control over their eating and activities. Parental control of disordered eating symptoms remains until the child is able to demonstrate weight gain independently. Therapy sessions examine relationships between the child’s issues and development of the ED. The sessions also may begin to focus on other day-to-day issues as these might impact the ED. An example would be negotiations related to the child’s activities and how these might impact treatment progression.

The pediatrician needs to monitor parents in this stage as well. Phase 1 can be physically and emotionally exhausting for parents, resulting in stress, burnout, and social isolation. This can lead to the parents not completing treatment. The pediatrician needs to remind parents that it is important for their child’s health to achieve goal weights. Further, parents may need to hear from the pediatrician that emotional and physical symptoms are normal when going through such an experience and do not mean that treatment is not working.³

Phase 3

In phase 3, the pediatrician primarily monitors for continued treatment compliance, relapse, and possible complications. As the ED treatment progresses, the pediatrician will participate in plans for relapse prevention and, finally, resumption of normal age-appropriate monitoring of behavioral and developmental issues.³

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Supporting FBT

There are a number of different things the pediatrician can do to support a child’s treatment with FBT.³ These include:

•  Performing a comprehensive medical assessment once an ED is diagnosed.

•  Involving parents at each visit and providing prompt communication with other members of the treatment team about what occurred and any change in plan from medical or monitoring perspectives.

•  Set age-appropriate weight and growth goals.

•  Remind patient and parents these goals will be adjusted over time.

•  Perform a medical assessment at each visit that includes weight, height, vital signs, and focused exam including screening of mental health.

•  Determining if outpatient treatment is still appropriate and safe. Medical visits can decrease in frequency once treatment shows results and the pediatrician believes it is safe to do so.

•  Participate in decisions with parents and members of the treatment team related to nutrition and activity.

• Create a backup plan for food refusal if it occurs.

It is important to note that parents will follow a learning curve in FBT, and there will be stumbles along the way. The pediatrician needs to realize this, allow for it, and resist being directive to the parents or the child. Additionally, the pediatrician can advocate for FBT, which is not available in all communities.

NEXT: A look at the evidence

Evidence

A number of different studies, both open and randomized, have demonstrated the efficacy of FBT in the treatment of ED.^4-6 Family-based therapy improves outcomes related to relapse compared with individual therapy.⁷ It does not work for all patients, however. Although 50% to 60% of patients are fully recovered after 1 year of treatment, 15% to 20% demonstrate no improvement at all.³ Importantly, FBT is not suitable for all patients. The presence of parental psychopathology or parental demonstration of hostility toward their child are situations in which the approach may not be appropriate.¹

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Conclusion

Unfortunately, there is a paucity of evidence to guide the pediatrician toward the most effective treatment of EDs. Nevertheless, some evidence exists to support FBT in certain populations. If there are appropriate resources in your community, this may be an effective mode of treatment, especially if the pediatrician is uncomfortable beyond the medical problems associated with ED.

REFERENCES

1. Rosen DS. American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126(6):1240-1253.

2. American Academy of Pediatrics. Committee on Adolescence. Identifying and treating eating disorders. Pediatrics. 2003;111(1):204-211.

3. Katzman DK, Peebles R, Sawyer SM, Locke J, Le Grange D. The role of the pediatrician in family-based treatment for adolescent eating disorders: opportunities and challenges. J Adolesc Health. 2013;53(4):433-440.

4. Eisler I, Simic M, Russell GF, Dare C. A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. J Child Psychol Psychiatry. 2007;48(6):552-560.

5. Lock J, Couturier J, Agras WS. Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. J Am Acad Child Adolesc Psychiatry. 2006;45(6):666-672.

6. Le Grange D, Eisler I. Family interventions in adolescent anorexia nervosa. Child Adolesc Psychiatr Clin N Am. 2009;18(1):159-173.

7. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010;67(10):1025-1032.

Dr Bass is chief medical information officer, Departments of Medicine and Pediatrics, Louisiana State University Health Sciences Center, Shreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.