Family therapy for 12- to 18-year-olds with anorexia nervosa, in which all household members participate and a meal is held in the clinician’s office, may be less effective than a streamlined model involving only the parents and without the meal.
In a study published online in the Journal of the American Academy of Child & Adolescent Psychiatry, 107 adolescents with anorexia nervosa were divided into two groups: those patients undergoing therapy with their family, which is the current standard of care, and those whose parents alone had the counseling while they received “supportive oversight” from a nurse.
“The goal of both treatment models was to try to assist the parents to support their child toward nutritional rehabilitation and weight restoration,” said lead author Daniel Le Grange, PhD, Benioff UCSF Professor in children’s health in the departments of psychiatry and pediatrics at UCSF Benioff Children’s Hospital San Francisco and member of the UCSF Weill Institute for Neurosciences.
Both treatments tested in the study entailed guiding the parents to take full control of food intake and transitioning that control back to their child as they developed healthier eating habits and gained weight, said Le Grange, who was working with colleagues at the University of Melbourne, Australia.
Family Meal Nixed In Parents Group
One significant difference in the two models was that in the parents group, known as parent-focused treatment or PFT, there was no meal in the clinician’s office, an intervention considered critical in the family model, known as family-based treatment or FBT. Instead the clinician focused almost exclusively on helping the parents manage the illness in the therapy sessions. “It would seem that the family meal, which used to be considered crucial for successful outcome, might not be quite as necessary,” said Le Grange.
Both treatment types comprised 18 outpatient sessions over six months at the Royal Children’s Hospital in Melbourne, Australia. Most patients were female (88 percent), the average age was 15 and everyone met the diagnostic criteria for anorexia nervosa.
When treatment ended, 43 percent of the adolescents whose parents had participated in counseling had reached remission, defined as attaining a normal or near-normal weight and having “healthy thinking about eating.” In contrast, 22 percent of the adolescents who had participated in the family model achieved remission.
Remission rates started to converge six months after treatment, dipping to 39 percent in the parents group and remaining at 22 percent in the family group. This trend continued at 12 months, at 37 percent and 29 percent respectively, suggesting that the differences in effectiveness between the two models might be less pronounced in the long term.
“What we have learned is that both models are equally effective in patients with a high degree of eating disorder-related obsessions and compulsions, such as rituals and other behaviors around calories and forbidden foods, and those whose psychopathology meant they judged themselves entirely by the number on the scale,” said Le Grange.
“But in patients with a relatively low level of obsessions and compulsions and psychopathology, patients did much better if therapy was limited to the parents,” he said.
“It could be that the parents-only model enables parents and the clinician to spend the full therapy session on developing strategies that help them support their child. In the family model, a tremendous amount of effort on the part of the patient is spent on derailing the discussion and a tremendous effort on the part of the clinician is spent keeping the discussion on track.”
‘High Expressed Emotions’ Not Conducive To Recovery
Of note, the researchers found that patients were more likely to achieve remission at 12 months after treatment if their fathers did not demonstrate “high expressed emotion,” such as over-involvement with the child, hostility and criticism – traits that have already been identified as deleterious in the treatment of eating disorders.
“The take-home message is that a parents-only model is as good if not better than the family model and it provides us with an intervention than might be easier to implement and disseminate. This may be an issue in clinicians without formal family therapy training, who are hesitant to work in a format that includes the patient, parents, other caregivers and siblings,” said Le Grange, who is also professor emeritus at the University of Chicago.
The study was supported by funding from the Baker Foundation (Australia).
Co-lead author was Susan Sawyer, FRACP, MD, from the University of Melbourne, Centre for Adolescent Health, Royal Children’s Hospital and Murdoch Children’s Research Institute in Australia. Co-authors were Elizabeth Hughes, PhD, from the University of Melbourne and Murdoch Children’s Research Institute, in Australia; Andrew Court, MBBS, FRANZP, and Michele Yeo, FRACP, PhD, both from the Centre for Adolescent Health, Royal Children’s Hospital in Australia; and Ross Crosby, PhD, from the Neuropsychiatric Research Institute and University of North Dakota School of Medicine and Health Sciences, both in Fargo.
UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.