Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation

Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation Background: Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment. Methods: The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN. The secondary aim was to determine if changes in parental self-efficacy and caregiver accommodation contributed to improvements in eating disorder behaviour and weight restoration in the transition age youth with AN. Twenty-six participants (ages 16–22) and 39 caregivers were recruited. Caregivers completed the Parents versus Anorexia Scale and Accommodation and Enabling Scale for Eating Disorders at baseline, end-of-treatment (EOT), and 3 months follow-up. Results: Unbalanced repeated measures designs for parental self-efficacy and caregiver accommodation towards illness behaviours were conducted using generalized estimation equations. Parental self-efficacy increased from baseline to EOT, although not significantly (p= .398). Parental self-efficacy significantly increased from baseline to 3 months post-treatment (p = .002). Caregiver accommodation towards the illness significantly decreased from baseline to EOT (p = 0.0001), but not from baseline to 3 months post-treatment (p = 1.000). Stepwise ordinary least squares regression estimates of eating disorder behaviour and weight restoration did not show that changes in parental-self efficacy and caregiver accommodation predict eating disorder behaviour or weight restoration at EOT or 3 months post-treatment. Conclusions: Our findings demonstrate, albeit preliminary at this stage, that FBT-TAY promotes positive increases in parental self-efficacy and assists caregivers in decreasing their accommodation to illness behaviours for transition age youth with AN. However, changes in the parental factors did not influence changes in eating and weight in the transition age youth. Keywords: Family-based treatment, Family therapy, Anorexia nervosa, Eating disorders, Transition age youth, Caregivers * Correspondence: gdimit@ucalgary.ca Faculty of Social Work, Matheson Centre for Mental Health Research, University of Calgary, 4212-2800 University Way N.W., Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, 4212-2800 University Way N.W., Calgary, Alberta, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 2 of 11 Plain English summary eating disorder symptomatology at end of treatment Family-Based Treatment for Transition Age Youth were when compared to individual treatment and full remis- delivered to 26 participants with Anorexia Nervosa (ages sion at 6- and 12-month follow-up [17]. 16–22) and their families. This study evaluated how fam- ily members responded to eating disorder (ED) behav- Family-based treatments for transition age youth with iours throughout the course of this treatment. This anorexia nervosa study also evaluated how confident family members felt Althought studies of FBT indicate that it is an effect- about their ability to help their loved one with ED be- ive treatment [18] and that for participants ages 9 to haviours throughout the course of treatment. The im- 19 years, there are not significant differences in treat- pact of changes in parental responses and confidence in ment outcomes based on age [19], FBT is not com- helping with eating disorder symptoms and weight gain monly used in specialized adult eating disorder was examined. Throughout the course of treatment programs (EDPs). This is possibly becausefamilies are caregiver accommodation to eating disorder behaviour not intrinsically present in adult ED treatment, decreased and feelings of parental self-efficacy increased. whereas families often accompany youth to assess- However, changes in parental self-efficacy and accom- ments and treatment in the pediatric system. How- modation did not predict changes in eating disorder be- ever, there may be special considerations for haviour and weight restoration in transition age youth transition age youth (ages 16 to approximately 25) with AN. that may necessitate unique family involvement, vital to the treatment of their illness in both pediatric and Background adult care. Anorexia Nervosa (AN) is a life threatening mental Transition age youth experience many transitions health condition [1] with severe consequences such as that define their developmental stage, such as cardiac failure, osteoporosis [2], increased risk for sui- post-secondary education, increased fiscal responsibil- cide [3, 4] and significant comorbidities such as anxiety, ity, changing geographic location, and increased per- depression and substance use disorders [5]. To prevent sonal responsibility and autonomy [20]. For transition severe and enduring presentations of AN it is important age youth with AN, these markers of young adult- that effective early interventions be provided to promote hood are present despite the limitations of their ill- the best outcomes [6]. There is evidence for the use of ness. Dimitropoulos et al., [21] found that eating disorder family therapies (FT) with adolescents with AN [7], in- clinicians identified that many transition age youth ex- cluding Family-Based Treatment (FBT). However, there press a desire for age appropriate support from their care- is limited evidence-based practice models for transition givers, including negotiating levels of involvement and age youth between the ages of 18 to 24 [8–10]. support for their growing independence and confidence to Researching effective treatments for this age group is a overcome their ED. Due to a better understanding of these necessary next step in the treatment of AN. concerns for young adult development, experts in the field have begun exploring how to adapt FBT for transition age Family-based treatment for adolescent anorexia nervosa youth [8, 9]. There are a variety of family therapy approaches devel- An open trial of FBT for transition age youth oped for the treatment of AN such as Family Therapies (FBT-TAY) that encouraged negotiation between sup- for AN (FT-AN) and Multi-Family Therapy for AN portive caregivers and the independence of the youth (MFT-AN) [11]. The current study has focused on treat- has recently shown promising outcomes for individ- ment using manualized FBT. At this time, FTs for AN uals with AN [9]. FBT-TAY was designed for those are the most efficacious treatment for medically stable between the ages of 16 to 25 and is an adaptation of adolescents with AN [12, 13], and FT-AN is considered FBT, which emphasises a collaboration between the an appropriate treatment for this population [14]. The transition age youth and his/her family, while main- current study focuses on a manualized form of FT-AN: taining their age-appropriate autonomy. Another Family-Based Treatment (FBT). This treatment is guided pilot study of FBT for Young Adults (FBT-Y), where by five fundamental principles: an agnostic view of the a similar collaborative approach to treatment was illness, externalization of the illness as something separ- used, also showed promise with 59% of participants ate from the adolescent, emphasis on increasing parental who completed treatment retaining weight restor- empowerment, a focus on restoring healthy eating, and ation at 12 months post-treatment [8]. These adapta- the therapist as a consultant to the family [15]. When tions of FBT are important for those ages 16 to 25 compared to other treatments for AN, FBT has been who are going through major life transitions [22], as found to reduce the need for hospital admissions during well as moving from the pediatric to adult health treatment [16], and has superior treatment outcomes on care system [23]. Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 3 of 11 Caregivers’ impact on family-based treatment The second aim of the study was to determine if changes Parental self-efficacy has been identified as a potential in parental self-efficacy and caregiver accommodation mechanism of change that promotes positive treatment influenced changes in eating disorder behaviour and outcome in FBT [24, 25]. Parental self-efficacy, as mea- weight restoration at EOT and 3 months post-treatment sured by the Parents versus Anorexia scale (PvA), is the in transition age youth with AN. ability for caregivers to be empowered in terms of sup- porting weight gain in their child [26]. Behavioural sup- Method port around weight gain is required as in FBT parents Data collection are responsible for the re-nourishment of their child An open trial of FBT-TAY was conducted across one through consistent meal support as well as halting ED adult and two pediatric hospital sites in Ontario, Canada behaviours such as purging or excessive exercise. When between August 2014 and September 2016. The accept- parents achieve confidence in the re-nourishment ability, feasibility, and impact of FBT-TAY on eating dis- process during the first four sessions of FBT, the adoles- order behaviors and weight restoration is described by cent is more likely to be weight restored at the end of Dimitropoulos et al. [9]. Three hospital sites were se- treatment, as well as greater reductions in symptoms of lected to ensure a diverse sample of adolescents and depression and anxiety [26, 27]. Further, Robinson et al. young adults from pediatric and adult speciality ED [26] found that parents undergoing FBT with their ado- clinics was obtained. Each hospital contained a special- lescent had significant increases in parental self-efficacy ized EDP and participants were recruited at the point of throughout treatment which was predictive of reduc- assessment for admittance into the EDP, as well as tions in ED psychopathology as well. Taken together, through community advertising. During initial assess- parental self-efficacy seems an important factor for posi- ment or a the time of self-referral from the community, tive treatment outcomes for adolescents in FBT. How- confirmation of diagnosis was made by a psychologist or ever, there were no studies that directly assessed psychiatrist and if a potential participant was still inter- caregiver self-efficacy in FBT for transition age youth ested in the study, they then met with the study coordin- with AN. ator and participated in informed consent. For an in Caregivers may also engage in behaviours that inad- depth description of the treatment please see Dimitro- vertently exacerbate ED symptoms [27, 28]. Eating disor- poulos et al., 2017 [9]. ders often lead families to ‘re-organize’ such that All potential participants were offered treatment as monitoring and managing symptoms become the pri- usual (TAU) or FBT-TAY. FBT was the TAU in both mary concern. When this occurs, family functioning can pediatric hospital sites (ages 12–18). In the pediatric decline and caregivers can feel helpless [28]. When care- hospitals, potential participants were offered either trad- givers inadvertantly accommodate the illness, they are itional FBT or FBT-TAY. At the adult hospital site, TAU engaging in maladaptive behaviours such as avoiding so- was an intensive cognitive behavioral therapy (CBT) cial situations, allowing meal restrictions, or enabling based group program within an inpatient (average stay their loved one to continue a strenuous exercise regimen of 5 months) or day hospital (average stay of 5 weeks) [29]. In a recent study by Stillar et al. [30], caregivers setting. In the adult hospital, family therapy was an op- that experienced more fear and self-blame were also tional component of treatment. At the point of assess- more likely to allow recovery-interfering behaviours in ment, if a potential participant met eligibility criteria their loved one. It is important to note that the longer a (described below) for the FBT-TAY open trial, they were loved one has had an ED, the more accommodating referred to the study coordinator. Potential participants caregivers become to the illness’ symptoms as measured were asked to identify at least one caregiver to partici- by the Accommodation and Enabling Scale of Eating pate in treatment. To support the autonomy of the tran- Disorders (AESED) [29]. It is clear that accommodation sition age youth, caregiver selection was entirely left to and enabling behaviors seen in caregivers can negatively their discretion and was defined broadly to include par- influence parental self-efficacy and thus negatively im- ents, guardians, siblings, partners, extended family and/ pact treatment outcomes. To date, there are no studies or friends. All caregivers and participants with an eating directly assessing caregiver accommodation and enabling disorder gave informed consent and were then assigned behaviours in FBT for transition age youth with AN. to a FBT-TAY study therapist. Further details about the methodology and participants are described by Dimitro- Aims polous et al. [9]. The primary aim of the study was to determine if paren- tal self-efficacy and caregiver accommodation changed Family-based treatment for transition age youth in a course of FBT-TAY from baseline to the FBT-TAY includes 25 sessions over the course of three end-of-treatment (EOT), and 3 months post-treatment. phases [31]. These phases and their goals are briefly Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 4 of 11 outlined in Fig. 1. Caregivers were integrally involved in Participant and caregiver characteristics each phase in the treatment. During phase one, the ther- A total of 26 young people participated in this study (M apist worked collaboratively with the transition age = 18.15 years, SD = 2.11). The majority of participants youth to identify ways that their caregivers could specif- were female (96.2%), Caucasian (61.5%), single (88.5%), ically support them with meal support and symptom living with family or relatives (92.3%), unemployed management. Explicitly, the caregivers were asked to (53.9%), and had completed some high school education support the transition age youth during mealtimes and (46.2%). A total of 39 caregivers (23 mothers, 16 fathers) monitor symptoms. The transition age youths were (M = 50.59 years old, SD = 6.80) were included in the asked to be responsible for communicating to their fam- analysis. Two parents did not complete the question- ilies what type of support they required to assist with re- naires required for inclusion in the analysis. The major- covery from the eating disorder. In this way, the transition ity of caregivers were Caucasian (66.7%), married/ age youth had input in how their treatment was delivered. partnered (79.5%), employed full-time (74.4%), and had In phase two of treatment, the entire family was encour- an undergraduate university degree or higher (61.5%). aged to allow the transition age youth more independent See Table 1 for information regarding caregiver eating in a variety of normal situations (e.g., on a univer- demographics. sity campus, at work, with friends). Finally, in phase three, the transition age youth was asked to develop a plan for maintained recovery and shared this plan with their care- Measures givers. The caregivers were tasked with being the first To assess the impacts of FBT-TAY on caregiver accom- point of contact should a struggle with the eating disorder modation to the illness, parental self-efficacy, participant behaviours re-emerge. eating disorder behaviour, and weight restoration, analyses Fig. 1 Summary of Family-Based Treatment for Transition Age Youth Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 5 of 11 Table 1 Caregiver Characteristics (n = 39) to age and sex [34]. For each participant aged 20.1–22, the weight restoration goal was a BMI of 20.0. At base- n Percent or Mean SD line, each participant’s height and weight was measured Age 50.59 6.80 by the intake nurse. Subsequently, each participant’s Gender weight was measured at the end of treatment and was Female 23 58.97 self-reported for the EDE-Q three-month follow-up Male 16 41.03 questionnaire. The BMI achieved by each participant Race aged 16–20 was divided by the median BMI for their age Caucasian 26 66.67 and sex to calculate weight restoration at baseline, end of treatment, and 3 months post-treatment. The BMI Non-Caucasian 13 33.33 achieved by each participant aged 20.1–22 was divided Marital Status by 20.0 to calculate weight restoration at each timepoint. Single 8 20.51 Partnered/Married 31 79.49 Caregiver instruments Living Situation Parental self-efficacy With family, relatives, friends or partner 36 92.31 The Parents versus Anorexia (PvA) scale was developed to assess parental self-efficacy in the role of Alone 3 7.69 re-nourishing a child back to health [35]. This instru- Education ment has seven items rated on a five-point Likert Scale High school diploma 3 7.69 ranging from strongly disagree to strongly agree. Scores Undergraduate university degree 24 61.54 range from seven to 35. Higher scores indicate greater Some graduate education 1 2.56 self-efficacy [35]. Parental self-efficacy was measured at Graduate degree or higher 11 28.21 baseline, end of treatment, and at 3 months post-treatment for mothers and fathers. Employment Part-time 5 12.82 Caregiver accommodation Unemployed 2 5.13 The Accommodation and Enabling Scale for Eating Dis- Employed full-time 29 74.36 orders (AESED) is a 33-item self-report scale which is Homemaker 2 5.13 used to assess the degree to which caregivers accommo- Disabled 1 2.56 date and enable illness behaviours in their loved one [29]. Responses are measured on a five-point Likert Religion Scale ranging from zero (never) to four (every day). The Christian 21 53.85 total scores range from zero (0) to 132 with higher None 8 20.51 scores indicating greater enabling and tolerating of ED Jewish 6 15.38 behaviours. This scale is made up of five subscales which Hindi 3 7.69 have Cronbach’s alpha values between .77 and .90. For Muslim 1 2.56 the purpose of this study, we only used the total score of the AESED. Caregiver accommodation was measured at were performed across three timepoints: pre-treatment, baseline, end of treatment, and 3 months post-treatment post-treatment, and 3 months post-treatment. for mothers and fathers. Instruments administered to transition age youth Missing data Eating disorder behaviour Missing data was addressed using multiple imputation The Eating Disorder Examination Questionnaire [36] The process of multiple imputation involves mul- (EDE-Q) is a 33-item, self-report measure which com- tiple copies of a dataset being created and the missing prises four subscales (Restraint, Weight Concern, Shape values being replaced by imputed values. These imputed Concern and Eating Concern) [32]. Each subscale has values are “sampled from a predictive distribution based demonstrated excellent reliability and validity [33]. The on the observed data” [Pg. 2, 37]. This procedure takes EDE-Q global score is calculated by averaging all sub- into consideration the uncertainty associated with the scale scores. prediction of missing values by including appropriate variability within the multiply imputed values [37]. The Weight restoration data of every caregiver who provided data at baseline For each participant aged 16–20, the weight restoration was analyzed, regardless of their completion or with- goal was comprised their median BMI (kg/m ) according drawal. Multiple imputation is superior to other Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 6 of 11 approaches to address missing data, such as mean sub- order to standardize measurement. This process is im- stitution or listwise deletion [38]. perative when performing OLS regressions from multiply imputed data [39]. Data analyses Analyses were performed in IBM SPSS Statistics Version Results 24. The primary objective of this study was to investigate Changes in parental self-efficacy changes in parental self-efficacy and caregiver accommo- Table 2 presents the unbalanced repeated measures de- dation from baseline to end of treatment and from base- signs of parental self-efficacy by treatment time-point line to 3 months post-treatment. Due to the unbalanced showing a statistically significant time effect (χ = 11.95, and correlated nature of the data, unbalanced repeated p = .003). Pairwise comparisons revealed that the total measures designs for parental self-efficacy and caregiver mean score of parental self-efficacy did not significantly accommodation were conducted using generalized esti- increase from baseline (M = 18.91, SE = 0.62) to EOT mation equations (GEEs) to determine the time effect (M = 19.82, SE = 0.69; p = .398), but did increase signifi- while controlling for each participant. Separate analyses cantly increased from baseline (M = 18.91, SE = 0.62) to were undertaken for each of the predictors (the PvA 3 months post-treatment (M = 21.59, SE = 0.50; p = .002). total score and the AESED total score) due to concerns with multicollinearity. Bonferroni adjusted p values are Changes in caregiver accommodation reported for each GEE that was performed. Table 2 also presents the unbalanced repeated measures The second objective of this study was to investigate the designs of caregiver accommodation by treatment impact of parental self-efficacy and caregiver accommoda- time-point showing a statistically significant time effect tion to the illness on eating disorder behaviour and weight (χ = 37.45, p = .0001). Pairwise comparisons revealed restoration in the transition age youth with AN. Ordinary that the total mean score of caregiver accommodation Least Square (OLS) regression estimates of eating disorder significantly decreased from baseline (M = 46.31, SE = behaviour and weight restoration were conducted at end 3.62) to EOT (M = 37.75, SE = 3.13; p = 0.0001), but not of treatment and 3 months post-treatment. Separate re- from baseline (M = 46.31, SE = 3.62) to 3 months gression analyses were undertaken for each of the predic- post-treatment (M = 45.16, SE = 3.17; p = 1.000). tors (changes in PvA and changes in AESED) due to concerns with multicollinearity. First, we examined Effects of parental self-efficacy on eating disorder whether the changes in parental self-efficacy from baseline behaviour and weight restoration to end of treatment predicted eating disorder behaviour Table 3 presents the OLS regression estimates for the ef- and weight restoration at the end of treatment. Second, fects of changes in parental self-efficacy on participant eat- we examined whether the changes in parental self-efficacy ing disorder behaviour and weight restoration at EOT and from baseline to 3 months post-treatment predicted eating 3 months post-treatment. Changes in parental self-efficacy disorder behaviour and weight restoration at 3 months from baseline to EOT, or from baseline to 3 months post-treatment. Third, we examined whether changes in post-treatment did not significantly predict eating disorder caregiver accommodation from baseline to end of treat- behaviour or weight restoration in the transition age youth. ment predicted eating disorder behaviour and weight res- toration at end of treatment. Finally, we examined Effects of caregiver accommodation to the illness on the whether changes in caregiver accommodation from base- transition age youth participant eating disorder line to 3 months post-treatment predicted t eating dis- behaviour and weight restoration order behaviour and weight restoration at 3 months Table 4 presents the OLS regression estimates for the ef- post-treatment. Z-scores were created for each variable in fects of changes in caregiver accommodation on eating Table 2 Parental Self-Efficacy and Accommodation Baseline End of Treatment Three Month Follow-Up n Mean (SE) n Mean (SE) n Mean (SE) Parental Self-Efficacy PvA Total Score 39 18.91 (0.61) 39 19.82 (0.69) 39 21.59 (0.50) Significance .003 Caregiver Accommodation AESED Total Score 37 46.31 (3.62) 37 37.75 (3.13) 37 45.16 (3.17) Significance 0.0001 PvA Parents versus Anorexia scale, AESED Accommodation and Enabling Scale Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 7 of 11 Table 3 OLS Regressions for the Effects of Parental Self-Efficacy on Patient Eating Behaviours and Weight Restoration (n = 39) EDE Globa Score Weight Restoration BB Parental Self-Efficacy Change in PvA total score from time 1 to time 2 0.09 −0.33 Significance 0.591 0.223 Parental Self-Efficacy Change in PvA total score from time 1 to time 3 −0.09 0.01 Significance 0.735 0.985 PvA Parents versus Anorexia scale, EDE Global Eating Disorder Examination Global score disorder behaviour and weight restoration at EOT and 3 did not predict change in the transition age youth’seating months post-treatment. Changes in caregiver accommo- disorder symptoms or weight. dation from baseline to EOT, or at 3 months post-treatment, did not significantly predict eating dis- Change in parental self efficacy and Accomodation order behaviour. Behaviours Transition age youth are between pediatric and adult Discussion systems of care, which requires special treatment atten- The current study of FBT for transition age youth with tion to their unique developmental challenges. The ex- AN aimed to explore how parental self-efficacy and care- perience of both wanting the support of family and giver accommodation to the illness changed over the friends while also negotiating boundaries for increased course of treatment. We further sought to identify autonomy and independence can complicate how care- whether such changes in parental self-efficacy and care- givers and transition age youth work together to dimin- giver accommodation were predictive of changes in eating ish AN behaviours. Previous research on adolescent FBT disorder behaviour and weight in the transition age youth found decreased parental self-efficacy and fear was at EOT and/or three-months post-treatment. We found linked with higher accommodation to the illness [30]. that parental self-efficacy increased, but not significantly, When families participate in FBT, caregiver mood and from baseline to EOT. However, parental self-efficacy in- anxiety improve which correlates with increased creased significantly from baseline to 3 months self-efficacy [26]. post-treatment. The results further revealed that accom- It is important to note that the tool used to assess par- modation to the illness decreased significantly from base- ental self-efficacy, the PvA, was developed for and is pri- line to EOT, but not from baseline to 3 months marily used to assess empowerment in the context of post-treatment. Neither parental self-efficacy nor caregiver child and adolescent treatment of EDs using FT [35]. accommodation predicted change in ED symptoms and Items on the PvA scale include: “I feel equipped with the weight in the transition age youth at EOT or 3 months specific practical strategies for the task of bringing about post-treatment. Overall, this study demonstrated that the complete recovery of my child in the home setting”, caregivers became increasingly more confident in their “while parents are important, children with anorexia will ability to support their loved one with AN, and perceived never get better until they receive some sort of individ- themselves as engaging less with/or permitting fewer ED ual therapy themselves”, and “It is more my responsibil- symptoms throughout treatment. However, these changes ity than my child’s to bring him/her to a healthy weight” Table 4 OLS Regressions for the Effects of Parental Accommodation to Eating Disorders on Patient Eating Behaviours and Weight Restoration (n = 37) EDE Global Score Weight Restoration BB Accommodation Change in AESED total score from time 1 to time 2 0.03 −0.12 Significance 0.865 0.582 Accommodation Change in AESED total score from time 1 to time 3 0.05 0.19 Significance 0.873 0.579 AESED Accommodation and Enabling Scale for Eating Disorders, EDE Global Eating Disorder Examination Global score Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 8 of 11 [35]. These items indicate a scale used to understand situations while in phase 2, control of eating across parental empowerment in the context of child and ado- various situations was gradually shifted entirely back lescent EDs treated with FTs where parents are an inte- to the transition age youth. This was focused upon so gral part of the support young people need as they are that transition age youth could practice and gain con- working to make behavioural changes [12, 13]. The fidence eating and maintaining their recovery while items on the scale may not be applicable to transition also successfully engaging in the transitions inherent age youth or a FBT-TAY model given the treatment to emerging adulthood such as changes in school, goals: creating a collaborative approach between transi- work, finances and relationships [20, 22]. The use of tion age youth and their families, individual therapy with FBT TAY is different from FBT for adolescents as the transition age youth, and individual development of young adults were asked to grant permission to their recovery and maintenance plans in the final phase of parents to take control of the provision of food prep- treatment. aration, serving and support during meals. It was also Interestingly, despite the limitations of the scale and different from adult models of care where those over the collaborative focus of FBT for TAY, caregivers still the age 18 are viewed as the most primarily respon- experienced a significant increase in parental sible for their own recovery. self-efficacy from baseline to EOT. Working to empower The result of increased parental self-efficacy over the parents and reduce fear and self-blame is a focus of FBT course of FBT-TAY provides context for the caregiver’s and other family therapies for AN (ex: FT-AN) [40]. significant decrease in accommodation behaviours over Therefore, empowerment was prioritized in the develop- the course of treatment. Despite the unique features of ment of FBT-TAY despite the increased autonomy in the transition age youth, caregivers in our sample were com- transition age youth, which may explain the increased parable to other adolescent and adult caregiver samples sense of self-efficacy throughout treatment and at 3 in terms of baseline accommodation and enabling scores month follow-up. The majority of the transition age [41–44]. The behavioural focus on FBT for transition youth in the study sample were living at home (92.3%) age youth supports the identified caregivers, in every and were struggling with AN-R or AN-BP. Within the session, to collaborate with their transition age youth to FBTTAY model, parents were purposefully supported to support a reduction of eating disorder symptoms and fa- feel empowered in helping their young adult with eating cilitate weight gain. This treatment focus may explain and recovery. The young adult was purposefully sup- why caregivers experienced a significant decrease in ac- ported to develop acceptance of this parental support. commodation behaviours, however, the effects of this This was achieved by the therapist acting as consultant change were not maintained at 3 months to both the transition age youth and their caregivers. For post-treatment, indicating that this change may have example, therapists provided psychoeducation of the po- been treatment dependent. tential benefits of family involvement in meal support, particularly in the early phase of treatment; given the se- Change in caregivers associated with change in transition verity of complications that can develop when an indi- age youth ED outcomes vidual is suffering with an ED [1–5], transition age youth In the current study, neither parental self-efficacy nor may benefit from time limited support from their care- accommodation predicted change in eating disorder givers that would not typically be considered age symptoms. This differs from past literature in the treat- appropriate. ment of adolescent AN has found that parental The collaborative approach outlined above may be self-efficacy increases during treatment with FBT [45]. counter intuitive to families at this life stage where it In a study of 121 adolescents with AN, Byrne et al. is developmentally appropriate for young adults and (2015) found that families randomized to FBT had sig- parents to begin separating financially, geographically, nificantly greater increases in parental self-efficacy which and shifting their relationship from one of depend- was predictive of greater weight gain by EOT [24]. Most ence to interdependence [20, 22]. However, FBT-TAY recently, parental self-efficacy has been found to be a therapists collaborated with families to help them significant mediator for increased weight gain in the understand that short-term parental support may help adolescent by session 10 of FBT [46]. The transition age transition age youth eventually achieve independent, youth in the current sample differed from previously age-appropriate, levels of autonomy around food and studied adolescents, and there was no predictive effect eating. FBT-TAY progressively focused on the devel- of change in parental self efficacy for FBT-TAY. opment of healthy eating behaviours in a wide variety FBT-TAY differs from standard manualized FBT [15]. of settings such as at home, school and with persons It begins with a very close collaboration with the transi- outside the family. In phase 1 of treatment parents tion age youth and parents and then an important goal provided significant support for eating in a variety of of the therapy is to promote autonomous and Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 9 of 11 independent eating in the transition age youth as well as Strengths and limitations age appropriate life re-integration (e.g..: return to Col- FBT-TAY was manualized and all study therapists were lege/University, living independelty and/or with peers or provided initial training followed by weekly supervision partner, etc.). This heightened focus on the transition throughout the study. Even though the study used a age youth’s autonomy may account for why changes in novel model of treatment, it was developed using direct caregiver’s self efficacy was not predictive of ED out- feedback from clinicians focused on working with transi- comes for the transition age youth. In the treatment of tion age youth with AN [21]. Finally, the study sample pediatric AN with standard FBT, it has been found that and setting included both pediatric and adult programs while parental self-efficacy is a significant predictor of which increases the real-world applicability of study weight gain, adolescent’s own self-efficacy is not [24] findings to transition age youth accessing eating disorder which again reinforces that the age appropriate nature of treatment. The present study was not without limita- behavioural control by a caregiver may be different in tions. We recruited a diverse range of caregivers in adolescent vs transition age youth with AN. terms of age (range of 40–71 years), and gender (58.54% Therapies that swiftly target caregiver beliefs about mothers), however, most were Caucasian (65.98%), held their ability to support a loved one are very important in a college education or higher (90.25%), and were within facilitating their efforts to address disordered eating par- an hour’s drive from a major city centre, limiting the ticularly during meal times. A caregiver’s ability to cope generalizability of our findings. The study recruited a and provide support is impacted over time by feelings of modest number of individuals with AN and their care- fear and self-blame which erode a caregiver’s efficacy givers, and was only able to follow participants for 3 (e.g., accommodating to symptoms of restriction, pur- months post-treatment which is not sufficient to ascer- ging, or over-exercise) [27, 28, 42, 47, 48]. The erosion tain the long-term impacts of the FBT-TAY on of previously held caregiving skills can quickly spark a caregivers. cyclical relationship between those with AN and their caregivers that makes the illness harder to overcome and Conclusion increases the degree and duration of burden on care- The current study is the first to describe the impact of givers [49]. Caregivers often experience social isolation, FBT-TAY on caregivers of transition age youth with AN stigma, psychological distress [50, 51]. Acknowledging the unique needs of transition age youth who are between pediatric and adult systems of care is an important line of inquiry given the limited involve- Clinical implications and future directions ment of family members in treatment for older adoles- It is possible that FBT-TAY can be effective in halting or cents and young adults. The current study aimed to reversing caregiver disempowerment as well as decreas- identify if involving family in the treatment of transition ing accommodation behaviours in caregivers during the age youth using FBT-TAY would elicit benefits in the course of treatment. This is an important advancement caregivers. This study demonstrates that FBT-TAY has in terms of our knowledge of the role of caregivers in promise and may lead to changes in caregivers of transi- the treatment of EDs in transition age youth. Currently, tion age youth with AN presenting for treatment in both care for transition age youth receiving treatment in adult pediatric and adult programs. Future studies should assess systems do not routinely involve caregivers, but instead the impact of treatments on caregivers given the mental prioritize individual or group-based models. Therefore, health impacts (e.g. depression, anxiety, burden) of care- caregivers who are still intimately involved in the daily giving (e.g. meal support, attending appointments, moni- life of transition age youth are typically excluded from toring symptoms), and the positive treatment impacts for treatment of those over the age of 18. This is a problem- those with an ED (e.g. reduced hospital stays, decreased atic systemic issue that the current study proposes can ED psychopathology, and increased quality of life). be amended by introducing a developmentally appropri- Abbreviations ate model of treatment that recognizes the role that par- AESED: Accomodation and enabling scale for eating disorders; AN: Anorexia ents can play in supporting their adult child while also nervosa; AN-BP: Anorexia nervosa binge purge sub-type; AN-R: Anorexia empowering the individual with the illness. Programs nervosa restrictive sub-type; CBT: Cognitive behavioral therapy; EDPs: Eating disorder programs; EDs: Eating disorders; EOT: End of treatment; FBT: Family- should begin to identify the unique needs of transition based treatment; FBT-TAY: Family-based treatment for transition age youth; age youth and their caregivers to better serve this popu- FT: Family therapy; MFT: Multi-family therapy; PvA: Parents versus anorexia lation. Future research should establish the efficacy of scale; RCT: Randomized controlled trial; TAU: Treatment as usual; TAY: Transition age youth FBT-TAY via a randomized controlled trial. We also rec- ommend furture research evaluating FBT-TAY to other Acknowledgements family based treatment modalities like FT-AN or The study authors would like to thank all of the participating young adults MFT-AN [11]. and caregivers in this study, without whom the research would not have Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 10 of 11 been possible. We would also like to thank all participating hospital sites and 5. Vardar E, Erzengin M. The prevalence of eating disorders (EDs) and FBT-TAY clinicians who conducted therapy. comorbid psychiatric disorders in adolescents: a two-stage community- based study. Turkish J Psychiatry. 2011;22:205–12. 6. Treasure J, Russell G. The case for early intervention in anorexia nervosa: Funding theoretical exploration of maintaining factors. Br J Psychiatry. 2011;199:5–7. The current study was partically funded by the Ontario Mental Health 7. Fisher CA, Hetrick SE, Rushford N. Family therapy for anorexia nervosa. Foundation (OMHF). Cochrane Database Syst Rev. 2010;4:CD004780. 8. Chen EY, Weissman JA, Zeffiro TA, Yiu A, Eneva KT, Arlt JM, Swantek MJ. Availability of data and materials Family-based therapy for young adults with anorexia nervosa restores The data collected at each hospital site has been transferred to Toronto weight. Int J Eat Disord. 2016;49(7):701. General Hospital for maintenance and will be held in accordance with the 9. Dimitropoulos G, Landers A, Freeman VE, Novick J, Garber A, Le Grange D: Research Ethic Board’s standards of data management. Documents will be Open trial for family-based treatment of anorexia nervosa for tansition age kept for a period of 7 years post-study completion. youth. J Can Acad Child Adolesc Psychiatry in press. 10. Hay PJ, Claudino AM, Touyz S, Abd Elbaky G. Individual psychological Authors’ contributions therapy in the outpatient treatment of adults with anorexia nervosa. GD with collaboration from DLG developed and manualized the FBT-TAY Cochrane Database Syst Rev. 2015;7:CD003909. model. ME and CS maintained data sets at their respective hospital sites be- 11. Eisler I, Simic M, Hodsoll J, Asen E, Berelowitz M, Connan F, Ellis G, Hugo P, fore all data was transferred for analysis. VF and GD collected and maintained Schmidt U, Treasure J, Yi I. A pragmatic randomised multi-Centre trial of the full data set which was fully analyzed by AL and JN under the supervi- multifamily and single family therapy for adolescent anorexia nervosa. BMC sion of GD. GD, VF, AL, JN, OC, ME, CS and DLG were major contributors in psychiatry. 2016;16(1):422. writing the manuscript. All authors read and approved the final manuscript. 12. Jewell T, Blessitt E, Stewart C, Simic M, Eisler I. Family therapy for child and adolescent eating disorders: a critical review. Fam Process. 2016; Ethics approval and consent to participate 13. Watson HJ, Bulik CM. Update on the treatment of anorexia nervosa: This study achieved research ethics approval from all participating hospital review of clinical trials, practice guidelines and emerging interventions. sites. Psychol Med. 2012; 14. National Institute for Health and Care Excellence (UK). Eating Disorders: Consent for publication Regonigition and treatment. London. 2017. Retrieved at: https://www.nice. The current study has consent through the research ethics approval boards org.uk/guidance/ng69. of each hospital to publish. Study participants also consented to their data 15. Lock J, le Grange D. Family-based treatment of eating disorders. Int J being used for the development of manuscripts fro publication. Eat Disord. 2005; 16. Lock J, Agras WS, Bryson SW, Brandt H, Halmi KA, Kaye W, Wilfley D, Woodside B, Pajarito S, Jo B. Does family-based treatment reduce the need Competing interests for hospitalization in adolescent anorexia nervosa? 2016. 49(9): 891–894. Dr. Le Grange receives Royalties from Guilford Press and Routledge, and is 17. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized Co-Director of the Training Institute for Child and Adolescent Eating Disor- clinical trial comparing family-based treatment with adolescent-focused ders, LLC. All other study authors have no competing interests to declare. individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010.Oct 4;67(1):1025–32. 18. Couturier J, Kimber M, Szatmari P. Efficacy of family-based treatment for Publisher’sNote adolescents with eating disorders: a systematic review and meta-analysis. Springer Nature remains neutral with regard to jurisdictional claims in Int J Eat Disord. 2013; published maps and institutional affiliations. 19. Loeb KL, LeGrange D. Family-based treatment for adolescent eating Author details disorders: current status, new applications and future directions. Int J Child Faculty of Social Work, Matheson Centre for Mental Health Research, Adolesc health. 2009;2(2):243–54. University of Calgary, 4212-2800 University Way N.W., Calgary, Alberta, 20. 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Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation

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Psychology; Psychology, general; Health Promotion and Disease Prevention; Psychiatry; Clinical Psychology
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Abstract

Background: Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment. Methods: The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN. The secondary aim was to determine if changes in parental self-efficacy and caregiver accommodation contributed to improvements in eating disorder behaviour and weight restoration in the transition age youth with AN. Twenty-six participants (ages 16–22) and 39 caregivers were recruited. Caregivers completed the Parents versus Anorexia Scale and Accommodation and Enabling Scale for Eating Disorders at baseline, end-of-treatment (EOT), and 3 months follow-up. Results: Unbalanced repeated measures designs for parental self-efficacy and caregiver accommodation towards illness behaviours were conducted using generalized estimation equations. Parental self-efficacy increased from baseline to EOT, although not significantly (p= .398). Parental self-efficacy significantly increased from baseline to 3 months post-treatment (p = .002). Caregiver accommodation towards the illness significantly decreased from baseline to EOT (p = 0.0001), but not from baseline to 3 months post-treatment (p = 1.000). Stepwise ordinary least squares regression estimates of eating disorder behaviour and weight restoration did not show that changes in parental-self efficacy and caregiver accommodation predict eating disorder behaviour or weight restoration at EOT or 3 months post-treatment. Conclusions: Our findings demonstrate, albeit preliminary at this stage, that FBT-TAY promotes positive increases in parental self-efficacy and assists caregivers in decreasing their accommodation to illness behaviours for transition age youth with AN. However, changes in the parental factors did not influence changes in eating and weight in the transition age youth. Keywords: Family-based treatment, Family therapy, Anorexia nervosa, Eating disorders, Transition age youth, Caregivers * Correspondence: gdimit@ucalgary.ca Faculty of Social Work, Matheson Centre for Mental Health Research, University of Calgary, 4212-2800 University Way N.W., Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, 4212-2800 University Way N.W., Calgary, Alberta, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 2 of 11 Plain English summary eating disorder symptomatology at end of treatment Family-Based Treatment for Transition Age Youth were when compared to individual treatment and full remis- delivered to 26 participants with Anorexia Nervosa (ages sion at 6- and 12-month follow-up [17]. 16–22) and their families. This study evaluated how fam- ily members responded to eating disorder (ED) behav- Family-based treatments for transition age youth with iours throughout the course of this treatment. This anorexia nervosa study also evaluated how confident family members felt Althought studies of FBT indicate that it is an effect- about their ability to help their loved one with ED be- ive treatment [18] and that for participants ages 9 to haviours throughout the course of treatment. The im- 19 years, there are not significant differences in treat- pact of changes in parental responses and confidence in ment outcomes based on age [19], FBT is not com- helping with eating disorder symptoms and weight gain monly used in specialized adult eating disorder was examined. Throughout the course of treatment programs (EDPs). This is possibly becausefamilies are caregiver accommodation to eating disorder behaviour not intrinsically present in adult ED treatment, decreased and feelings of parental self-efficacy increased. whereas families often accompany youth to assess- However, changes in parental self-efficacy and accom- ments and treatment in the pediatric system. How- modation did not predict changes in eating disorder be- ever, there may be special considerations for haviour and weight restoration in transition age youth transition age youth (ages 16 to approximately 25) with AN. that may necessitate unique family involvement, vital to the treatment of their illness in both pediatric and Background adult care. Anorexia Nervosa (AN) is a life threatening mental Transition age youth experience many transitions health condition [1] with severe consequences such as that define their developmental stage, such as cardiac failure, osteoporosis [2], increased risk for sui- post-secondary education, increased fiscal responsibil- cide [3, 4] and significant comorbidities such as anxiety, ity, changing geographic location, and increased per- depression and substance use disorders [5]. To prevent sonal responsibility and autonomy [20]. For transition severe and enduring presentations of AN it is important age youth with AN, these markers of young adult- that effective early interventions be provided to promote hood are present despite the limitations of their ill- the best outcomes [6]. There is evidence for the use of ness. Dimitropoulos et al., [21] found that eating disorder family therapies (FT) with adolescents with AN [7], in- clinicians identified that many transition age youth ex- cluding Family-Based Treatment (FBT). However, there press a desire for age appropriate support from their care- is limited evidence-based practice models for transition givers, including negotiating levels of involvement and age youth between the ages of 18 to 24 [8–10]. support for their growing independence and confidence to Researching effective treatments for this age group is a overcome their ED. Due to a better understanding of these necessary next step in the treatment of AN. concerns for young adult development, experts in the field have begun exploring how to adapt FBT for transition age Family-based treatment for adolescent anorexia nervosa youth [8, 9]. There are a variety of family therapy approaches devel- An open trial of FBT for transition age youth oped for the treatment of AN such as Family Therapies (FBT-TAY) that encouraged negotiation between sup- for AN (FT-AN) and Multi-Family Therapy for AN portive caregivers and the independence of the youth (MFT-AN) [11]. The current study has focused on treat- has recently shown promising outcomes for individ- ment using manualized FBT. At this time, FTs for AN uals with AN [9]. FBT-TAY was designed for those are the most efficacious treatment for medically stable between the ages of 16 to 25 and is an adaptation of adolescents with AN [12, 13], and FT-AN is considered FBT, which emphasises a collaboration between the an appropriate treatment for this population [14]. The transition age youth and his/her family, while main- current study focuses on a manualized form of FT-AN: taining their age-appropriate autonomy. Another Family-Based Treatment (FBT). This treatment is guided pilot study of FBT for Young Adults (FBT-Y), where by five fundamental principles: an agnostic view of the a similar collaborative approach to treatment was illness, externalization of the illness as something separ- used, also showed promise with 59% of participants ate from the adolescent, emphasis on increasing parental who completed treatment retaining weight restor- empowerment, a focus on restoring healthy eating, and ation at 12 months post-treatment [8]. These adapta- the therapist as a consultant to the family [15]. When tions of FBT are important for those ages 16 to 25 compared to other treatments for AN, FBT has been who are going through major life transitions [22], as found to reduce the need for hospital admissions during well as moving from the pediatric to adult health treatment [16], and has superior treatment outcomes on care system [23]. Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 3 of 11 Caregivers’ impact on family-based treatment The second aim of the study was to determine if changes Parental self-efficacy has been identified as a potential in parental self-efficacy and caregiver accommodation mechanism of change that promotes positive treatment influenced changes in eating disorder behaviour and outcome in FBT [24, 25]. Parental self-efficacy, as mea- weight restoration at EOT and 3 months post-treatment sured by the Parents versus Anorexia scale (PvA), is the in transition age youth with AN. ability for caregivers to be empowered in terms of sup- porting weight gain in their child [26]. Behavioural sup- Method port around weight gain is required as in FBT parents Data collection are responsible for the re-nourishment of their child An open trial of FBT-TAY was conducted across one through consistent meal support as well as halting ED adult and two pediatric hospital sites in Ontario, Canada behaviours such as purging or excessive exercise. When between August 2014 and September 2016. The accept- parents achieve confidence in the re-nourishment ability, feasibility, and impact of FBT-TAY on eating dis- process during the first four sessions of FBT, the adoles- order behaviors and weight restoration is described by cent is more likely to be weight restored at the end of Dimitropoulos et al. [9]. Three hospital sites were se- treatment, as well as greater reductions in symptoms of lected to ensure a diverse sample of adolescents and depression and anxiety [26, 27]. Further, Robinson et al. young adults from pediatric and adult speciality ED [26] found that parents undergoing FBT with their ado- clinics was obtained. Each hospital contained a special- lescent had significant increases in parental self-efficacy ized EDP and participants were recruited at the point of throughout treatment which was predictive of reduc- assessment for admittance into the EDP, as well as tions in ED psychopathology as well. Taken together, through community advertising. During initial assess- parental self-efficacy seems an important factor for posi- ment or a the time of self-referral from the community, tive treatment outcomes for adolescents in FBT. How- confirmation of diagnosis was made by a psychologist or ever, there were no studies that directly assessed psychiatrist and if a potential participant was still inter- caregiver self-efficacy in FBT for transition age youth ested in the study, they then met with the study coordin- with AN. ator and participated in informed consent. For an in Caregivers may also engage in behaviours that inad- depth description of the treatment please see Dimitro- vertently exacerbate ED symptoms [27, 28]. Eating disor- poulos et al., 2017 [9]. ders often lead families to ‘re-organize’ such that All potential participants were offered treatment as monitoring and managing symptoms become the pri- usual (TAU) or FBT-TAY. FBT was the TAU in both mary concern. When this occurs, family functioning can pediatric hospital sites (ages 12–18). In the pediatric decline and caregivers can feel helpless [28]. When care- hospitals, potential participants were offered either trad- givers inadvertantly accommodate the illness, they are itional FBT or FBT-TAY. At the adult hospital site, TAU engaging in maladaptive behaviours such as avoiding so- was an intensive cognitive behavioral therapy (CBT) cial situations, allowing meal restrictions, or enabling based group program within an inpatient (average stay their loved one to continue a strenuous exercise regimen of 5 months) or day hospital (average stay of 5 weeks) [29]. In a recent study by Stillar et al. [30], caregivers setting. In the adult hospital, family therapy was an op- that experienced more fear and self-blame were also tional component of treatment. At the point of assess- more likely to allow recovery-interfering behaviours in ment, if a potential participant met eligibility criteria their loved one. It is important to note that the longer a (described below) for the FBT-TAY open trial, they were loved one has had an ED, the more accommodating referred to the study coordinator. Potential participants caregivers become to the illness’ symptoms as measured were asked to identify at least one caregiver to partici- by the Accommodation and Enabling Scale of Eating pate in treatment. To support the autonomy of the tran- Disorders (AESED) [29]. It is clear that accommodation sition age youth, caregiver selection was entirely left to and enabling behaviors seen in caregivers can negatively their discretion and was defined broadly to include par- influence parental self-efficacy and thus negatively im- ents, guardians, siblings, partners, extended family and/ pact treatment outcomes. To date, there are no studies or friends. All caregivers and participants with an eating directly assessing caregiver accommodation and enabling disorder gave informed consent and were then assigned behaviours in FBT for transition age youth with AN. to a FBT-TAY study therapist. Further details about the methodology and participants are described by Dimitro- Aims polous et al. [9]. The primary aim of the study was to determine if paren- tal self-efficacy and caregiver accommodation changed Family-based treatment for transition age youth in a course of FBT-TAY from baseline to the FBT-TAY includes 25 sessions over the course of three end-of-treatment (EOT), and 3 months post-treatment. phases [31]. These phases and their goals are briefly Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 4 of 11 outlined in Fig. 1. Caregivers were integrally involved in Participant and caregiver characteristics each phase in the treatment. During phase one, the ther- A total of 26 young people participated in this study (M apist worked collaboratively with the transition age = 18.15 years, SD = 2.11). The majority of participants youth to identify ways that their caregivers could specif- were female (96.2%), Caucasian (61.5%), single (88.5%), ically support them with meal support and symptom living with family or relatives (92.3%), unemployed management. Explicitly, the caregivers were asked to (53.9%), and had completed some high school education support the transition age youth during mealtimes and (46.2%). A total of 39 caregivers (23 mothers, 16 fathers) monitor symptoms. The transition age youths were (M = 50.59 years old, SD = 6.80) were included in the asked to be responsible for communicating to their fam- analysis. Two parents did not complete the question- ilies what type of support they required to assist with re- naires required for inclusion in the analysis. The major- covery from the eating disorder. In this way, the transition ity of caregivers were Caucasian (66.7%), married/ age youth had input in how their treatment was delivered. partnered (79.5%), employed full-time (74.4%), and had In phase two of treatment, the entire family was encour- an undergraduate university degree or higher (61.5%). aged to allow the transition age youth more independent See Table 1 for information regarding caregiver eating in a variety of normal situations (e.g., on a univer- demographics. sity campus, at work, with friends). Finally, in phase three, the transition age youth was asked to develop a plan for maintained recovery and shared this plan with their care- Measures givers. The caregivers were tasked with being the first To assess the impacts of FBT-TAY on caregiver accom- point of contact should a struggle with the eating disorder modation to the illness, parental self-efficacy, participant behaviours re-emerge. eating disorder behaviour, and weight restoration, analyses Fig. 1 Summary of Family-Based Treatment for Transition Age Youth Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 5 of 11 Table 1 Caregiver Characteristics (n = 39) to age and sex [34]. For each participant aged 20.1–22, the weight restoration goal was a BMI of 20.0. At base- n Percent or Mean SD line, each participant’s height and weight was measured Age 50.59 6.80 by the intake nurse. Subsequently, each participant’s Gender weight was measured at the end of treatment and was Female 23 58.97 self-reported for the EDE-Q three-month follow-up Male 16 41.03 questionnaire. The BMI achieved by each participant Race aged 16–20 was divided by the median BMI for their age Caucasian 26 66.67 and sex to calculate weight restoration at baseline, end of treatment, and 3 months post-treatment. The BMI Non-Caucasian 13 33.33 achieved by each participant aged 20.1–22 was divided Marital Status by 20.0 to calculate weight restoration at each timepoint. Single 8 20.51 Partnered/Married 31 79.49 Caregiver instruments Living Situation Parental self-efficacy With family, relatives, friends or partner 36 92.31 The Parents versus Anorexia (PvA) scale was developed to assess parental self-efficacy in the role of Alone 3 7.69 re-nourishing a child back to health [35]. This instru- Education ment has seven items rated on a five-point Likert Scale High school diploma 3 7.69 ranging from strongly disagree to strongly agree. Scores Undergraduate university degree 24 61.54 range from seven to 35. Higher scores indicate greater Some graduate education 1 2.56 self-efficacy [35]. Parental self-efficacy was measured at Graduate degree or higher 11 28.21 baseline, end of treatment, and at 3 months post-treatment for mothers and fathers. Employment Part-time 5 12.82 Caregiver accommodation Unemployed 2 5.13 The Accommodation and Enabling Scale for Eating Dis- Employed full-time 29 74.36 orders (AESED) is a 33-item self-report scale which is Homemaker 2 5.13 used to assess the degree to which caregivers accommo- Disabled 1 2.56 date and enable illness behaviours in their loved one [29]. Responses are measured on a five-point Likert Religion Scale ranging from zero (never) to four (every day). The Christian 21 53.85 total scores range from zero (0) to 132 with higher None 8 20.51 scores indicating greater enabling and tolerating of ED Jewish 6 15.38 behaviours. This scale is made up of five subscales which Hindi 3 7.69 have Cronbach’s alpha values between .77 and .90. For Muslim 1 2.56 the purpose of this study, we only used the total score of the AESED. Caregiver accommodation was measured at were performed across three timepoints: pre-treatment, baseline, end of treatment, and 3 months post-treatment post-treatment, and 3 months post-treatment. for mothers and fathers. Instruments administered to transition age youth Missing data Eating disorder behaviour Missing data was addressed using multiple imputation The Eating Disorder Examination Questionnaire [36] The process of multiple imputation involves mul- (EDE-Q) is a 33-item, self-report measure which com- tiple copies of a dataset being created and the missing prises four subscales (Restraint, Weight Concern, Shape values being replaced by imputed values. These imputed Concern and Eating Concern) [32]. Each subscale has values are “sampled from a predictive distribution based demonstrated excellent reliability and validity [33]. The on the observed data” [Pg. 2, 37]. This procedure takes EDE-Q global score is calculated by averaging all sub- into consideration the uncertainty associated with the scale scores. prediction of missing values by including appropriate variability within the multiply imputed values [37]. The Weight restoration data of every caregiver who provided data at baseline For each participant aged 16–20, the weight restoration was analyzed, regardless of their completion or with- goal was comprised their median BMI (kg/m ) according drawal. Multiple imputation is superior to other Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 6 of 11 approaches to address missing data, such as mean sub- order to standardize measurement. This process is im- stitution or listwise deletion [38]. perative when performing OLS regressions from multiply imputed data [39]. Data analyses Analyses were performed in IBM SPSS Statistics Version Results 24. The primary objective of this study was to investigate Changes in parental self-efficacy changes in parental self-efficacy and caregiver accommo- Table 2 presents the unbalanced repeated measures de- dation from baseline to end of treatment and from base- signs of parental self-efficacy by treatment time-point line to 3 months post-treatment. Due to the unbalanced showing a statistically significant time effect (χ = 11.95, and correlated nature of the data, unbalanced repeated p = .003). Pairwise comparisons revealed that the total measures designs for parental self-efficacy and caregiver mean score of parental self-efficacy did not significantly accommodation were conducted using generalized esti- increase from baseline (M = 18.91, SE = 0.62) to EOT mation equations (GEEs) to determine the time effect (M = 19.82, SE = 0.69; p = .398), but did increase signifi- while controlling for each participant. Separate analyses cantly increased from baseline (M = 18.91, SE = 0.62) to were undertaken for each of the predictors (the PvA 3 months post-treatment (M = 21.59, SE = 0.50; p = .002). total score and the AESED total score) due to concerns with multicollinearity. Bonferroni adjusted p values are Changes in caregiver accommodation reported for each GEE that was performed. Table 2 also presents the unbalanced repeated measures The second objective of this study was to investigate the designs of caregiver accommodation by treatment impact of parental self-efficacy and caregiver accommoda- time-point showing a statistically significant time effect tion to the illness on eating disorder behaviour and weight (χ = 37.45, p = .0001). Pairwise comparisons revealed restoration in the transition age youth with AN. Ordinary that the total mean score of caregiver accommodation Least Square (OLS) regression estimates of eating disorder significantly decreased from baseline (M = 46.31, SE = behaviour and weight restoration were conducted at end 3.62) to EOT (M = 37.75, SE = 3.13; p = 0.0001), but not of treatment and 3 months post-treatment. Separate re- from baseline (M = 46.31, SE = 3.62) to 3 months gression analyses were undertaken for each of the predic- post-treatment (M = 45.16, SE = 3.17; p = 1.000). tors (changes in PvA and changes in AESED) due to concerns with multicollinearity. First, we examined Effects of parental self-efficacy on eating disorder whether the changes in parental self-efficacy from baseline behaviour and weight restoration to end of treatment predicted eating disorder behaviour Table 3 presents the OLS regression estimates for the ef- and weight restoration at the end of treatment. Second, fects of changes in parental self-efficacy on participant eat- we examined whether the changes in parental self-efficacy ing disorder behaviour and weight restoration at EOT and from baseline to 3 months post-treatment predicted eating 3 months post-treatment. Changes in parental self-efficacy disorder behaviour and weight restoration at 3 months from baseline to EOT, or from baseline to 3 months post-treatment. Third, we examined whether changes in post-treatment did not significantly predict eating disorder caregiver accommodation from baseline to end of treat- behaviour or weight restoration in the transition age youth. ment predicted eating disorder behaviour and weight res- toration at end of treatment. Finally, we examined Effects of caregiver accommodation to the illness on the whether changes in caregiver accommodation from base- transition age youth participant eating disorder line to 3 months post-treatment predicted t eating dis- behaviour and weight restoration order behaviour and weight restoration at 3 months Table 4 presents the OLS regression estimates for the ef- post-treatment. Z-scores were created for each variable in fects of changes in caregiver accommodation on eating Table 2 Parental Self-Efficacy and Accommodation Baseline End of Treatment Three Month Follow-Up n Mean (SE) n Mean (SE) n Mean (SE) Parental Self-Efficacy PvA Total Score 39 18.91 (0.61) 39 19.82 (0.69) 39 21.59 (0.50) Significance .003 Caregiver Accommodation AESED Total Score 37 46.31 (3.62) 37 37.75 (3.13) 37 45.16 (3.17) Significance 0.0001 PvA Parents versus Anorexia scale, AESED Accommodation and Enabling Scale Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 7 of 11 Table 3 OLS Regressions for the Effects of Parental Self-Efficacy on Patient Eating Behaviours and Weight Restoration (n = 39) EDE Globa Score Weight Restoration BB Parental Self-Efficacy Change in PvA total score from time 1 to time 2 0.09 −0.33 Significance 0.591 0.223 Parental Self-Efficacy Change in PvA total score from time 1 to time 3 −0.09 0.01 Significance 0.735 0.985 PvA Parents versus Anorexia scale, EDE Global Eating Disorder Examination Global score disorder behaviour and weight restoration at EOT and 3 did not predict change in the transition age youth’seating months post-treatment. Changes in caregiver accommo- disorder symptoms or weight. dation from baseline to EOT, or at 3 months post-treatment, did not significantly predict eating dis- Change in parental self efficacy and Accomodation order behaviour. Behaviours Transition age youth are between pediatric and adult Discussion systems of care, which requires special treatment atten- The current study of FBT for transition age youth with tion to their unique developmental challenges. The ex- AN aimed to explore how parental self-efficacy and care- perience of both wanting the support of family and giver accommodation to the illness changed over the friends while also negotiating boundaries for increased course of treatment. We further sought to identify autonomy and independence can complicate how care- whether such changes in parental self-efficacy and care- givers and transition age youth work together to dimin- giver accommodation were predictive of changes in eating ish AN behaviours. Previous research on adolescent FBT disorder behaviour and weight in the transition age youth found decreased parental self-efficacy and fear was at EOT and/or three-months post-treatment. We found linked with higher accommodation to the illness [30]. that parental self-efficacy increased, but not significantly, When families participate in FBT, caregiver mood and from baseline to EOT. However, parental self-efficacy in- anxiety improve which correlates with increased creased significantly from baseline to 3 months self-efficacy [26]. post-treatment. The results further revealed that accom- It is important to note that the tool used to assess par- modation to the illness decreased significantly from base- ental self-efficacy, the PvA, was developed for and is pri- line to EOT, but not from baseline to 3 months marily used to assess empowerment in the context of post-treatment. Neither parental self-efficacy nor caregiver child and adolescent treatment of EDs using FT [35]. accommodation predicted change in ED symptoms and Items on the PvA scale include: “I feel equipped with the weight in the transition age youth at EOT or 3 months specific practical strategies for the task of bringing about post-treatment. Overall, this study demonstrated that the complete recovery of my child in the home setting”, caregivers became increasingly more confident in their “while parents are important, children with anorexia will ability to support their loved one with AN, and perceived never get better until they receive some sort of individ- themselves as engaging less with/or permitting fewer ED ual therapy themselves”, and “It is more my responsibil- symptoms throughout treatment. However, these changes ity than my child’s to bring him/her to a healthy weight” Table 4 OLS Regressions for the Effects of Parental Accommodation to Eating Disorders on Patient Eating Behaviours and Weight Restoration (n = 37) EDE Global Score Weight Restoration BB Accommodation Change in AESED total score from time 1 to time 2 0.03 −0.12 Significance 0.865 0.582 Accommodation Change in AESED total score from time 1 to time 3 0.05 0.19 Significance 0.873 0.579 AESED Accommodation and Enabling Scale for Eating Disorders, EDE Global Eating Disorder Examination Global score Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 8 of 11 [35]. These items indicate a scale used to understand situations while in phase 2, control of eating across parental empowerment in the context of child and ado- various situations was gradually shifted entirely back lescent EDs treated with FTs where parents are an inte- to the transition age youth. This was focused upon so gral part of the support young people need as they are that transition age youth could practice and gain con- working to make behavioural changes [12, 13]. The fidence eating and maintaining their recovery while items on the scale may not be applicable to transition also successfully engaging in the transitions inherent age youth or a FBT-TAY model given the treatment to emerging adulthood such as changes in school, goals: creating a collaborative approach between transi- work, finances and relationships [20, 22]. The use of tion age youth and their families, individual therapy with FBT TAY is different from FBT for adolescents as the transition age youth, and individual development of young adults were asked to grant permission to their recovery and maintenance plans in the final phase of parents to take control of the provision of food prep- treatment. aration, serving and support during meals. It was also Interestingly, despite the limitations of the scale and different from adult models of care where those over the collaborative focus of FBT for TAY, caregivers still the age 18 are viewed as the most primarily respon- experienced a significant increase in parental sible for their own recovery. self-efficacy from baseline to EOT. Working to empower The result of increased parental self-efficacy over the parents and reduce fear and self-blame is a focus of FBT course of FBT-TAY provides context for the caregiver’s and other family therapies for AN (ex: FT-AN) [40]. significant decrease in accommodation behaviours over Therefore, empowerment was prioritized in the develop- the course of treatment. Despite the unique features of ment of FBT-TAY despite the increased autonomy in the transition age youth, caregivers in our sample were com- transition age youth, which may explain the increased parable to other adolescent and adult caregiver samples sense of self-efficacy throughout treatment and at 3 in terms of baseline accommodation and enabling scores month follow-up. The majority of the transition age [41–44]. The behavioural focus on FBT for transition youth in the study sample were living at home (92.3%) age youth supports the identified caregivers, in every and were struggling with AN-R or AN-BP. Within the session, to collaborate with their transition age youth to FBTTAY model, parents were purposefully supported to support a reduction of eating disorder symptoms and fa- feel empowered in helping their young adult with eating cilitate weight gain. This treatment focus may explain and recovery. The young adult was purposefully sup- why caregivers experienced a significant decrease in ac- ported to develop acceptance of this parental support. commodation behaviours, however, the effects of this This was achieved by the therapist acting as consultant change were not maintained at 3 months to both the transition age youth and their caregivers. For post-treatment, indicating that this change may have example, therapists provided psychoeducation of the po- been treatment dependent. tential benefits of family involvement in meal support, particularly in the early phase of treatment; given the se- Change in caregivers associated with change in transition verity of complications that can develop when an indi- age youth ED outcomes vidual is suffering with an ED [1–5], transition age youth In the current study, neither parental self-efficacy nor may benefit from time limited support from their care- accommodation predicted change in eating disorder givers that would not typically be considered age symptoms. This differs from past literature in the treat- appropriate. ment of adolescent AN has found that parental The collaborative approach outlined above may be self-efficacy increases during treatment with FBT [45]. counter intuitive to families at this life stage where it In a study of 121 adolescents with AN, Byrne et al. is developmentally appropriate for young adults and (2015) found that families randomized to FBT had sig- parents to begin separating financially, geographically, nificantly greater increases in parental self-efficacy which and shifting their relationship from one of depend- was predictive of greater weight gain by EOT [24]. Most ence to interdependence [20, 22]. However, FBT-TAY recently, parental self-efficacy has been found to be a therapists collaborated with families to help them significant mediator for increased weight gain in the understand that short-term parental support may help adolescent by session 10 of FBT [46]. The transition age transition age youth eventually achieve independent, youth in the current sample differed from previously age-appropriate, levels of autonomy around food and studied adolescents, and there was no predictive effect eating. FBT-TAY progressively focused on the devel- of change in parental self efficacy for FBT-TAY. opment of healthy eating behaviours in a wide variety FBT-TAY differs from standard manualized FBT [15]. of settings such as at home, school and with persons It begins with a very close collaboration with the transi- outside the family. In phase 1 of treatment parents tion age youth and parents and then an important goal provided significant support for eating in a variety of of the therapy is to promote autonomous and Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 9 of 11 independent eating in the transition age youth as well as Strengths and limitations age appropriate life re-integration (e.g..: return to Col- FBT-TAY was manualized and all study therapists were lege/University, living independelty and/or with peers or provided initial training followed by weekly supervision partner, etc.). This heightened focus on the transition throughout the study. Even though the study used a age youth’s autonomy may account for why changes in novel model of treatment, it was developed using direct caregiver’s self efficacy was not predictive of ED out- feedback from clinicians focused on working with transi- comes for the transition age youth. In the treatment of tion age youth with AN [21]. Finally, the study sample pediatric AN with standard FBT, it has been found that and setting included both pediatric and adult programs while parental self-efficacy is a significant predictor of which increases the real-world applicability of study weight gain, adolescent’s own self-efficacy is not [24] findings to transition age youth accessing eating disorder which again reinforces that the age appropriate nature of treatment. The present study was not without limita- behavioural control by a caregiver may be different in tions. We recruited a diverse range of caregivers in adolescent vs transition age youth with AN. terms of age (range of 40–71 years), and gender (58.54% Therapies that swiftly target caregiver beliefs about mothers), however, most were Caucasian (65.98%), held their ability to support a loved one are very important in a college education or higher (90.25%), and were within facilitating their efforts to address disordered eating par- an hour’s drive from a major city centre, limiting the ticularly during meal times. A caregiver’s ability to cope generalizability of our findings. The study recruited a and provide support is impacted over time by feelings of modest number of individuals with AN and their care- fear and self-blame which erode a caregiver’s efficacy givers, and was only able to follow participants for 3 (e.g., accommodating to symptoms of restriction, pur- months post-treatment which is not sufficient to ascer- ging, or over-exercise) [27, 28, 42, 47, 48]. The erosion tain the long-term impacts of the FBT-TAY on of previously held caregiving skills can quickly spark a caregivers. cyclical relationship between those with AN and their caregivers that makes the illness harder to overcome and Conclusion increases the degree and duration of burden on care- The current study is the first to describe the impact of givers [49]. Caregivers often experience social isolation, FBT-TAY on caregivers of transition age youth with AN stigma, psychological distress [50, 51]. Acknowledging the unique needs of transition age youth who are between pediatric and adult systems of care is an important line of inquiry given the limited involve- Clinical implications and future directions ment of family members in treatment for older adoles- It is possible that FBT-TAY can be effective in halting or cents and young adults. The current study aimed to reversing caregiver disempowerment as well as decreas- identify if involving family in the treatment of transition ing accommodation behaviours in caregivers during the age youth using FBT-TAY would elicit benefits in the course of treatment. This is an important advancement caregivers. This study demonstrates that FBT-TAY has in terms of our knowledge of the role of caregivers in promise and may lead to changes in caregivers of transi- the treatment of EDs in transition age youth. Currently, tion age youth with AN presenting for treatment in both care for transition age youth receiving treatment in adult pediatric and adult programs. Future studies should assess systems do not routinely involve caregivers, but instead the impact of treatments on caregivers given the mental prioritize individual or group-based models. Therefore, health impacts (e.g. depression, anxiety, burden) of care- caregivers who are still intimately involved in the daily giving (e.g. meal support, attending appointments, moni- life of transition age youth are typically excluded from toring symptoms), and the positive treatment impacts for treatment of those over the age of 18. This is a problem- those with an ED (e.g. reduced hospital stays, decreased atic systemic issue that the current study proposes can ED psychopathology, and increased quality of life). be amended by introducing a developmentally appropri- Abbreviations ate model of treatment that recognizes the role that par- AESED: Accomodation and enabling scale for eating disorders; AN: Anorexia ents can play in supporting their adult child while also nervosa; AN-BP: Anorexia nervosa binge purge sub-type; AN-R: Anorexia empowering the individual with the illness. Programs nervosa restrictive sub-type; CBT: Cognitive behavioral therapy; EDPs: Eating disorder programs; EDs: Eating disorders; EOT: End of treatment; FBT: Family- should begin to identify the unique needs of transition based treatment; FBT-TAY: Family-based treatment for transition age youth; age youth and their caregivers to better serve this popu- FT: Family therapy; MFT: Multi-family therapy; PvA: Parents versus anorexia lation. Future research should establish the efficacy of scale; RCT: Randomized controlled trial; TAU: Treatment as usual; TAY: Transition age youth FBT-TAY via a randomized controlled trial. We also rec- ommend furture research evaluating FBT-TAY to other Acknowledgements family based treatment modalities like FT-AN or The study authors would like to thank all of the participating young adults MFT-AN [11]. and caregivers in this study, without whom the research would not have Dimitropoulos et al. Journal of Eating Disorders (2018) 6:13 Page 10 of 11 been possible. We would also like to thank all participating hospital sites and 5. Vardar E, Erzengin M. The prevalence of eating disorders (EDs) and FBT-TAY clinicians who conducted therapy. comorbid psychiatric disorders in adolescents: a two-stage community- based study. Turkish J Psychiatry. 2011;22:205–12. 6. Treasure J, Russell G. The case for early intervention in anorexia nervosa: Funding theoretical exploration of maintaining factors. Br J Psychiatry. 2011;199:5–7. The current study was partically funded by the Ontario Mental Health 7. Fisher CA, Hetrick SE, Rushford N. Family therapy for anorexia nervosa. Foundation (OMHF). Cochrane Database Syst Rev. 2010;4:CD004780. 8. Chen EY, Weissman JA, Zeffiro TA, Yiu A, Eneva KT, Arlt JM, Swantek MJ. Availability of data and materials Family-based therapy for young adults with anorexia nervosa restores The data collected at each hospital site has been transferred to Toronto weight. Int J Eat Disord. 2016;49(7):701. General Hospital for maintenance and will be held in accordance with the 9. Dimitropoulos G, Landers A, Freeman VE, Novick J, Garber A, Le Grange D: Research Ethic Board’s standards of data management. Documents will be Open trial for family-based treatment of anorexia nervosa for tansition age kept for a period of 7 years post-study completion. youth. J Can Acad Child Adolesc Psychiatry in press. 10. Hay PJ, Claudino AM, Touyz S, Abd Elbaky G. Individual psychological Authors’ contributions therapy in the outpatient treatment of adults with anorexia nervosa. GD with collaboration from DLG developed and manualized the FBT-TAY Cochrane Database Syst Rev. 2015;7:CD003909. model. ME and CS maintained data sets at their respective hospital sites be- 11. Eisler I, Simic M, Hodsoll J, Asen E, Berelowitz M, Connan F, Ellis G, Hugo P, fore all data was transferred for analysis. VF and GD collected and maintained Schmidt U, Treasure J, Yi I. A pragmatic randomised multi-Centre trial of the full data set which was fully analyzed by AL and JN under the supervi- multifamily and single family therapy for adolescent anorexia nervosa. BMC sion of GD. GD, VF, AL, JN, OC, ME, CS and DLG were major contributors in psychiatry. 2016;16(1):422. writing the manuscript. All authors read and approved the final manuscript. 12. Jewell T, Blessitt E, Stewart C, Simic M, Eisler I. Family therapy for child and adolescent eating disorders: a critical review. Fam Process. 2016; Ethics approval and consent to participate 13. Watson HJ, Bulik CM. Update on the treatment of anorexia nervosa: This study achieved research ethics approval from all participating hospital review of clinical trials, practice guidelines and emerging interventions. sites. Psychol Med. 2012; 14. National Institute for Health and Care Excellence (UK). Eating Disorders: Consent for publication Regonigition and treatment. London. 2017. Retrieved at: https://www.nice. The current study has consent through the research ethics approval boards org.uk/guidance/ng69. of each hospital to publish. Study participants also consented to their data 15. Lock J, le Grange D. Family-based treatment of eating disorders. Int J being used for the development of manuscripts fro publication. Eat Disord. 2005; 16. Lock J, Agras WS, Bryson SW, Brandt H, Halmi KA, Kaye W, Wilfley D, Woodside B, Pajarito S, Jo B. Does family-based treatment reduce the need Competing interests for hospitalization in adolescent anorexia nervosa? 2016. 49(9): 891–894. Dr. Le Grange receives Royalties from Guilford Press and Routledge, and is 17. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized Co-Director of the Training Institute for Child and Adolescent Eating Disor- clinical trial comparing family-based treatment with adolescent-focused ders, LLC. All other study authors have no competing interests to declare. individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010.Oct 4;67(1):1025–32. 18. Couturier J, Kimber M, Szatmari P. Efficacy of family-based treatment for Publisher’sNote adolescents with eating disorders: a systematic review and meta-analysis. Springer Nature remains neutral with regard to jurisdictional claims in Int J Eat Disord. 2013; published maps and institutional affiliations. 19. Loeb KL, LeGrange D. Family-based treatment for adolescent eating Author details disorders: current status, new applications and future directions. Int J Child Faculty of Social Work, Matheson Centre for Mental Health Research, Adolesc health. 2009;2(2):243–54. University of Calgary, 4212-2800 University Way N.W., Calgary, Alberta, 20. 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Journal

Journal of Eating DisordersSpringer Journals

Published: Jun 6, 2018

References

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