Testing associations between assessments of cognitive flexibility and eating disorder symptoms in adolescent bulimia nervosa.

OBJECTIVE: Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents. METHODS: Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT). RESULTS: Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT. DISCUSSION: The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes. PUBLIC SIGNIFICANCE: Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

Family-based treatment (FBT) for loss of control (LOC) eating in youth: Current knowledge and future directions.

Loss of control (LOC) eating in youth is a common disordered eating behavior and associated with negative health and psychological sequalae. Family-based treatment (FBT) is an efficacious treatment for adolescent anorexia nervosa and bulimia nervosa (BN) but has not been formally evaluated for adolescents with LOC eating. This study is a secondary data analysis from a randomized controlled clinical trial (NCT00879151) testing FBT for 12-18-year-olds with BN. Data were reanalyzed to examine outcomes for LOC eating episodes, regardless of episode size. Abstinence rates, defined as zero LOC eating episodes (objective or subjective binge episodes) in the previous month, were calculated at the end-of-treatment (EOT), 6-month, and 12-month follow-up time points. Among 51 adolescent participants (M + SD: 15.94 + 1.53 y; 92% female; 23.5% Hispanic; 76.5% Caucasian), FBT significantly reduced LOC eating episodes, with 49% achieving LOC eating abstinence at EOT. At 6-month follow-up, 41% achieved LOC eating abstinence. Of those providing 12-month follow-up data, 73% achieved abstinence. This preliminary exploration suggests that FBT may be effective for youth with LOC eating, regardless of episode size. Additional research is needed to replicate these findings and extend treatments with developmental adaptations for younger children with LOC eating.

Who Responds to an Adaptive Intervention for Adolescents With Anorexia Nervosa Being Treated With Family-Based Treatment? Outcomes From a Randomized Clinical Trial.

OBJECTIVE: Anorexia nervosa (AN) is a serious psychiatric disorder with high morbidity and mortality. The current evidence supports the use of family-based treatment (FBT), but recovery rates are only about 40%. Improving treatment outcomes among adolescents with AN will save lives, improve health, and prevent chronicity. This study examined the relative efficacy of adding intensive parental coaching (IPC) to standard FBT for patients who do not respond by weight gain of 2.4 kg by session 4, a clinical predictor of outcome at the end of treatment, to improve remission rates (>94% of expected mean body mass index). METHOD: The study recruited 107 participants and their families from across the United States; 69 participants failed to respond early and were randomly assigned to continue with standard FBT or to receive 3 sessions of IPC. Participants were adolescents (ages 12-18) meeting DSM-5 criteria for AN; 6.5% were male, and 11% were Hispanic. RESULTS: Main outcomes were mean body mass index >94% expected for age, height, and sex. Secondary outcomes included change in eating-related cognitions. Adding IPC to early nonresponders did not improve outcomes except for participants whose parents demonstrated low parental self-efficacy at baseline (moderator). Early weight gain of 2.4 kg by session 4 was replicated as a predictor of end of treatment remission. CONCLUSION: Parental self-efficacy moderates IPC as an adaptive treatment for adolescents with AN. Baseline parental self-efficacy assessment can be used to identify families most likely to benefit from adding IPC to FBT. Future studies should consider earlier interventions to improve early response rates. PLAIN LANGUAGE SUMMARY: Anorexia nervosa is a serious psychiatric disorder. While family-based treatment (FBT) has the largest evidence base for adolescents with anorexia, recovery rates are only about 40%. This study investigated the addition of 3 sessions of intensive parental coaching intervention (IPC) to FBT among youth with anorexia who did not gain adequate weight early in treatment, a predictor of recovery by the end of treatment. Youth with inadequate weight gain were randomized to either receive FBT with IPC or FBT as usual. Overall, adding IPC did not improve outcomes among youth with anorexia. However among those whose parents demonstrated low parental self-efficacy at baseline, youth who received FBT with IPC had higher remission rates than youth who received FBT alone. CLINICAL GUIDANCE: Intensive parental coaching shows promise for improving outcomes among youth with anorexia whose parents report low parental self-efficacy. CLINICAL TRIAL REGISTRATION INFORMATION: Adaptive Treatment for Adolescent Anorexia Nervosa; https://clinicaltrials.gov/; NCT03097874.