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Using a new form of family-based therapy for a young age group.
Transition age youth (TAY), are teens and young adults from 16 to 25 years of age who, while seeking independence, still live with their family and/or receive substantial emotional and financial support, particularly when being treated for an eating disorder like AN. This is particularly true during treatment for AN. To better address this group’s needs and to improve treatment outcomes, Dr. Gina Dimitropoulos and colleagues conducted a multi-center study open trial of family-based treatment for TAY (J Canad Acad Child Adolesc Psychiatry. 2018; 27:50).
The traditional form of family-based therapy (FBT) for AN is delivered in three phases. The first enhances parental self-efficiency over AN, and parents are urged to assume chief responsibility for helping their child restore their weight by closely monitoring and preparing all meals. In the next two phases, the parents hand control back to the adolescent, and the entire family then discusses developmental issues as treatment ends. Some have questioned the appropriateness of using the current form of FBT for older adolescents and young adults who may be experiencing a number of transitions.
In a pilot open study, Dr. Dimitropoulos and fellow researchers made several changes to this traditional approach to better fit FBT to TAY adolescents and young adults. First, they recruited 26 participants between the ages of 16 and 22 years (mean age: 18.15 years) who were being treated for AN. The primary goal of their study was to assess the possibility and acceptance of a manualized model of FBT adapted for TAY in pediatric and adult specialized eating disorder programs. The authors’ second goal was to evaluate the clinical outcome (eating behaviors) and secondary outcome (weight restoration) of these patients. In the FBT-TAY approach, young adults with AN had the option to choose which family members to include in treatment. Next, a therapeutic stance was taken with the young adult. In the third phase, increased attention was placed upon developmental issues, and individual sessions were incorporated. Thus, the emphasis was on the individual patient, with secondary inclusion of family members. The major change that crossed all phases was integrating individual time with the young patient. The treatment program included 25 sessions, scheduled once weekly at first and then, when feasible, sessions were scheduled twice a month for the last two phases of treatment. Family was defined as a parent, sibling, extended family member, partner, friend or “supportive other.”
The majority of the 25 women and 1 male in the study lived with their families and most were single; two reported being in committed relationships. The mean duration of illness was 2.29 years. All chose to have their family members participate, and only 3 also asked that a friend or partner be included.
Three phases
In phase 1, which lasted for approximately 10 sessions, the patient and family members were urged to work together against the eating disorder, with the study therapist acting as a consultant. The patient had a say in how treatment was delivered by helping define the support needed from family members during meals. In the second phase (sessions 11 and on), control over meals was returned to the patient, and an emphasis was placed on preparing to eat meals in various situations, as well as in-home meal preparation. During phase 3, which usually involved the last 4 sessions, the patient attended 2 to 3 individual sessions to develop a plan to maintain recovery and also to talk about transition challenges, such as returning to school or a job or living with a partner or friend. The patient then shared this plan with family members during one to two final sessions. Some of the most common topics were warning signs of relapse, planning to transition into adult life and achieving long-term life goals.
The participants were assessed with the Eating Disorder Examination Questionnaire (EDE-Q) at baseline, at the end of treatment, and 3 months later. The researchers also evaluated weight restoration, defined as median body mass index (MBMI); for teens this was defined as the 50th percentile for age and gender; in adults the MBMI plateus as it approached 22 kg/m2 in young women aged 20. Height and weight were measured at baseline and because the median age was 18.5 years, past the linear growth spurt for most girls and boys, and height was not expected to change significantly during the study period, height was not reassessed at the end of the sessions.
How effective was the new approach?
According to the authors, FBT-TAY was found to be feasible for specialized pediatric and adult programs. One participant dropped out of therapy before the third phase began. All who completed treatment achieved weight restoration by the end of treatment; however, the authors reported a pattern of weight loss beginning at the 3-month follow-up.
It was interesting that more than 95% of participants chose to have their family of origin participate in their treatment, even though they had the option to invite nonfamily members to fill this role. The authors believe this is evidence that including parents in treatment for AN may be also be helpful for young adults, especially when they are still living at home. The high dropout rate raised questions about the unique challenges of working with TAY whose independence creates many opportunities for them to withdraw from family-based treatments.
Thirteen patients were lost to follow-up. In 5 cases, the patient and/or family initiated withdrawal from the study; 1 patient missed 3 consecutive sessions and thus was lost to follow-up. Fifteen of the 26 original participants were found to have comorbid conditions. Of the original 26 individuals in the study, 12 (46%) withdrew, 5 after 4 weeks of treatment.
Reasons for withdrawal included an overly long commute, acute suicidal ideation, need for inpatient treatment, and lack of financial means. Four families withdrew from the study due to high stress at seeing their family member’s distress while participating in the study. Global end-of treatment scores and scores at 3 month follow-up were significantly reduced from baselines scores. Of those who completed all sessions, 100% achieved weight restoration by the end of treatment. The authors acknowledged the high dropout rate but also had suggestions for improving this. First, the 3-month follow-up may have been too brief to adequately follow patients. Next, a random control study comparing CBT and FBT-TAY might reveal helpful information. Also, future adaptions in FBT-TAY could help address the ego-syntonic nature of AN and encourage parental empowerment to help young adults even if the support “does not seem developmentally appropriate,” write the authors.