Guided self-help treatment for children and young people with threshold and subthreshold eating disorders: A pilot study protocol.

BACKGROUND: Prompt access to evidence-based treatment for children and young people with eating disorders is important for outcomes, yet the gap in service provision remains pervasive. Record levels of young people are waiting for eating disorder treatment and access to care is limited. Guided self-help interventions that are brief and require minimal clinician support have the potential to meet the unprecedented demand for treatment quickly and effectively. OBJECTIVE: To examine the feasibility, acceptability and proof of concept of a novel, CBT guided self-help intervention for children and young people with threshold and subthreshold eating disorders. METHODS: A single-arm, proof-of-concept pilot study of the CBT guided self-help intervention will be conducted. Children and young people (aged 11-19) with threshold and subthreshold eating disorders will receive a self-help intervention covering the core components of CBT, supported by 8 weekly guidance sessions delivered remotely. Clinical outcomes (eating-related psychopathology and associated impairment, changes in weight, depression, anxiety, and behavioural difficulties) will be assessed at baseline and post-intervention (12 weeks). Feasibility and acceptability of the intervention will be measured using various outcomes, including adherence to, and engagement with the intervention, rates of recruitment and retention, measure completion and treatment satisfaction. Qualitative data will also be collected for future intervention refinement. DISCUSSION: If the intervention is shown to produce clinical benefits in this pilot study, a fully powered randomised pilot study will be warranted with the ultimate goal of increasing access to psychological treatment for children and young people threshold and subthreshold eating disorders. ADMINISTRATIVE INFORMATION: This study protocol (S1 File) adheres to the guidelines outlined in the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist for trial protocols [1, 2] which can be found in S1 Checklist. The numbers in parentheses in this protocol correspond to the item numbers in the SPIRIT checklist. The order of items has been modified to group similar items.

The Role of the Dietitian within Family Therapy for Anorexia Nervosa (FT-AN): A Reflexive Thematic Analysis of Child and Adolescent Eating Disorder Clinician Perspectives.

BACKGROUND: Despite dietitians being important members of the multidisciplinary team delivering family therapy for anorexia nervosa (FT-AN), their specific responsibilities and roles are unclear and their involvement in the treatment can be a contentious issue. METHODOLOGY: Clinicians (n = 20) experienced in the delivery of FT-AN who were working at a specialist child and adolescent eating disorder service responded to an online survey about their experience of including a dietitian in FT-AN and how they understand the role. Both categorical and open-ended questions were used. Reflexive thematic analysis was used to analyse the qualitative free-text responses of clinician perspectives on the role of the dietitian in FT-AN. RESULTS: All clinicians agreed that dietetics had a role within FT-AN and most frequently sought dietetic involvement in the early phases of FT-AN. Reflexive thematic analysis of responses identified three main themes. These were (1) collaboration is key, (2) confidence as a core consideration and (3) case-by-case approach. These themes evidenced the role of the dietitian within FT-AN and highlighted both the benefits and concerns of this involvement. CONCLUSIONS: This study demonstrated that dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counselling should be offered in joint sessions with the therapist rather than separately. The findings of the study were limited by the small sample size of participants recruited from a single centre and heterogeneity in the professional background of respondents. Although the integration of dietetics within the multidisciplinary team and the ability of dietitians to individualise patient care can enhance FT-AN treatment, potential benefits and disbenefits should be considered for each case.

Introducing a Smart Toy in Eating Disorder Treatment: A Pilot Study.

Individuals with eating disorders (EDs) often encounter challenges related to body image, emotional, and sensory difficulties during nutritional rehabilitation. To address these challenges, a novel technology-enabled smart toy, Purrble, designed for immediate assistance in emotion regulation, is being explored. A mixed-method approach involving workshops, diaries, and focus groups was employed to examine the feasibility of Purrble as a therapeutic tool and its impact on participants' daily routines, sensory experiences, and emotional states. The study results demonstrate the engagement and acceptability of this device. Qualitative analysis revealed that participants independently used and integrated Purrble into their emotional and sensory regulation practices. These pilot results support the potential for a shift in the delivery of adjunct therapeutic tools through technology, particularly for ED patients with complex presentations. Future research is necessary to further explore the psychological benefits of this intervention.

How young people perceive change to occur in family therapy for anorexia nervosa: a qualitative study.

BACKGROUND: Family therapy for anorexia nervosa (FT-AN) is the first line recommended treatment for child and adolescent anorexia nervosa. Despite evidence of its efficacy, little is understood about the treatment mechanisms. This study aimed to understand how young people who have received FT-AN perceive change to occur across treatment. METHOD: Fifteen adolescents (age 12-18 years) completed individual semi-structured interviews online. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS: Four inter-connected themes describing the process of change during treatment were generated; (1) relationships as the vehicle for change, (2) an awakening, (3) through, not around - no way out, (4) the life beyond. CONCLUSIONS: Current data match relatively closely with theoretical models of FT-AN and emphasise the importance of building trust with all family members, including the young person. Additionally, supporting the family to create a trusting context in which there is a sense that the only way out of the illness is by going through it (rather than avoiding it) is critical. Empirical investigation of each of the described mechanisms is needed.

Family therapy for anorexia nervosa (FT-AN) is the first line recommended treatment for child and adolescent anorexia nervosa. While outcomes are generally good, little is understood about how the treatment works. This study aimed to understand how young people who have received FT-AN perceive change to occur across treatment. Fifteen adolescents (age 12­18 years) completed individual interviews online. All interviews followed a similar structure, with recordings transcribed word-for-word and analysed using a methodology called reflexive thematic analysis. Four inter-connected themes were generated from the interviews; (1) relationships as the vehicle for change, (2) an awakening, (3) through, not around ­ no way out, (4) the life beyond. These themes match relatively closely with descriptions of FT-AN theory and emphasise the importance of building trust with all family members in treatment, including the young person. Additionally, supporting the family to create a trusting context in which there is a sense that the only way out of the illness is by going through it (rather than avoiding it). More data are needed to test these ideas empirically and with other populations.

What is day hospital treatment for anorexia nervosa really like? A reflexive thematic analysis of feedback from young people.

BACKGROUND: A significant proportion of young people do not respond to the NICE recommended treatment for anorexia nervosa: Family Therapy. Whilst historically these young people would be admitted to inpatient services, which are associated with greater treatment cost, greater risk of relapse, and worse outcome, more recently evidence is building for the effectiveness of day programmes. One day programme that has been found to be effective is the Intensive Treatment Programme (ITP) of the Maudsley Centre for Child & Adolescent Eating Disorders in London, UK. However, to-date no studies have investigated how young people experience such a day programme. METHOD: Anonymous feedback was completed via online survey by 51 young people over a 5-year period (2018-2023) on discharge from ITP. RESULTS: Four main themes were identified: (1) Support-young people expressed the importance of boundaries but also of feeling validated, and encouraged; (2) Uniqueness: an experience like no other-ITP was described as different to any other treatment received before (both outpatient and inpatient); (3) Relationships - young people valued connecting with others in a similar situation and reflected that relationships at home changed throughout treatment; (4) Self-development - learning skills, developing independence, and exploring an identity outside of the eating disorder was valued. CONCLUSIONS: It is hoped that the reflections from these young people can help to inform clinicians working in DPs and those hoping to set up novel DPs about key aspects of treatment.

This study examined the experiences of young people who attended an intensive treatment day programme (ITP) over a five-year period. 51 young people completed online questionnaires up to one-month after being discharged from the programme between 2018 and 2023. All young people were between the ages of 11­18 and had a diagnosis of anorexia nervosa. The authors explored all free text responses from the young people (for example: what were the most important parts of ITP) and found four common themes. These were: (1) Support ­ feeling validated, encouraged, and finding boundaries helpful, (2) Uniqueness: an experience like no other ­ treatment was different to any received before, (3) Relationships ­ connecting with others in a similar situation and relationships at home changing, (4) Self-development ­ learning skills, finding their identity, and developing independence. It is hoped that the reflections from these young people can help to inform clinicians working in DPs and those hoping to set up novel DPs about key aspects of treatment.

Moderators of treatment effect in a randomised controlled trial of single- and multi-family therapy for anorexia nervosa in adolescents and emerging adults.

INTRODUCTION: Multi-family therapy for anorexia nervosa (MFT-AN) is a novel, group-based intervention that intensifies single-family therapy for anorexia nervosa (FT-AN), with the aim of improving outcomes. The current study explored treatment moderators in a randomised controlled trial (N = 167) of FT-AN and MFT-AN for young people (adolescents/emerging adults aged 13-20 years) with anorexia nervosa. METHODS: Data were analysed using multiple linear regression. Six hypothesised baseline participant and parent factors were tested as possible moderators of treatment effect on end-of-treatment and follow-up percentage of median Body Mass Index (%mBMI); age, eating disorder symptom severity, perceived family conflict (young person and parent ratings) and parent-rated experiences of caregiving (positive and negative). RESULTS: Greater parent-rated positive caregiving experiences moderated treatment outcomes at follow-up (ß = -0.47, 95%CI: -0.91, -0.03, p = 0.04), but not end-of-treatment. Participants who had fewer parent-rated positive caregiving experiences at baseline had higher weight at follow-up if they had MFT-AN compared to FT-AN. No other hypothesised baseline factors moderated treatment outcome (p's > 0.05). DISCUSSION: The current study suggests MFT-AN may be indicated for families who present with fewer positive caregiving experiences to treatment. The MFT-AN group context may help to promote mentalisation and hope for these families, which may be harder to achieve in single-family treatment. Future research is needed to empirically evaluate how and why MFT-AN supports this group more. TRIAL REGISTRATION: ISRCTN registry: ISRCTN11275465, registered 29 January 2007.

Do People Want the 'New Normal'? A Mixed Method Investigation of Young Person, Parent, and Clinician Experience and Preferences for Eating Disorder Treatment Delivery in the Post-COVID-19 World.

Eating disorder treatment was predominantly provided online during the COVID-19 pandemic, which has continued into the post-pandemic world. This mixed method study explored young person, parent/caregiver, and clinician experiences of child and adolescent eating disorder treatment. In total, 90 participants (25 young people, 49 parents/caregivers, and 16 clinicians) completed online surveys about the experience of online working. Data were compared to similar data collected by the same service earlier in the pandemic. The results show that preferences are largely unchanged since 2020; online treatment is considered helpful and acceptable by all groups. Nevertheless, face-to-face assessment sessions (young people: 52.2%; and parents/caregivers: 68.9%) and final sessions (young people: 82.6%; and parents/caregivers: 82.2%) were preferred compared to online. There was also a preference for early treatment sessions to either be always or mostly face-to-face (young people: 65.2%; and parents/caregivers: 73.3%). The middle and latter parts of treatment were a time when preferences shifted slightly to a more hybrid mode of delivery. Participants reported finding engagement with the therapist (young people: 70.6%; and parents/caregivers: 52.5%) easier during face-to-face treatment. Stepping away from the binary of online or face-to-face, the current data suggest that a hybrid and flexible model is a way forward with current findings providing insights into how to structure this.

Change processes during intensive day programme treatment for adolescent anorexia nervosa: a dyadic interview analysis of adolescent and parent views.

Background: Day programmes for adolescent anorexia nervosa (AN) can function as an alternative to inpatient admissions and/or an increase in outpatient treatment intensity. Processes of change during treatment for AN are currently poorly understood. This study aimed to explore how adolescents with AN and their parents understood the helpful and unhelpful factors and processes that impacted them during day programme treatment. Method: A critical realist paradigm was used to qualitatively explore the views of 16 participants. Participants were recruited from the Intensive Treatment Programme (ITP) at the Maudsley Center for Child and Adolescent Eating Disorders (MCCAED) at the end of treatment. Dyadic Interview Analysis (DIA) was used to compare and contrast the narratives of the seven adolescent-parent pairs after two inductive reflexive thematic analyses were conducted for the group of eight adolescents and the group of eight parents separately. Results: Eight subthemes across three themes were identified: 1) "Like me she didn't feel so alone anymore"-families connect with staff, peers, and each other; 2) "You have to eat because ITP say so"-the programme provides families with containment through its structure and authority; and 3) "I found that I was using the skills I learnt there like in multiple aspects of my life, not just around food"-families take in new ideas and generalize these into their lives. These interconnected themes generated hope and change. However, helpful elements individually could be unhelpful if one or more of the other factors were missing. For example, staff firmness, which participants often found helpful (theme two), could be experienced as harshness when adolescents did not feel related to as individuals (theme one). Conclusion: The findings can be conceptualized within recent descriptions regarding the therapeutic change, including epistemic trust and mentalization. Treatment characteristics, such as intensity and containment, as well as illness-specific factors and processes, such as control and collaboration, the role of peer support, and the potential for family members to experience the impact of the adolescent's AN and treatment non-response as traumatic, are equally important to consider.

Perceived change mechanisms in multi-family therapy for anorexia nervosa: A qualitative follow-up study of adolescent and parent experiences.

OBJECTIVE: Multi-family therapy (MFT-AN) is a promising group-based treatment for adolescent anorexia nervosa. This study aimed to explore how young people and parents perceived change to occur during MFT treatment. METHODS: Young people (10-18 years) diagnosed with anorexia nervosa or atypical anorexia nervosa and their parents who completed MFT-AN alongside family therapy for anorexia nervosa within the preceding 2 years were eligible for this study. Semi-structured qualitative interviews were conducted. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS: Twenty-three participants (8 young people, 10 mothers and 5 fathers) completed interviews. Five main themes were identified; (1) Powerful connection, (2) Intensity, (3) New learning and perspective shifts, (4) Comparisons, and (5) Discharge is not recovery. There was a strong sense that being with others in a similar position in an intense environment were key factors in promoting change. Comparisons were inevitable and could promote insight and foster motivation, but could also be unhelpful at times. Participants spoke about how recovery continues beyond service use and requires ongoing attention and support. CONCLUSIONS: Through the mechanisms of connection, intensity, new learning and comparisons change is perceived to occur in MFT-AN. Some of these are considered unique to this treatment format.

Processes of change in a randomized clinical trial of radically open dialectical behavior therapy (RO DBT) for adults with treatment-refractory depression.

OBJECTIVE: Radically open dialectical behavior therapy (RO DBT) is an empirically supported psychotherapy for treatment-refractory depression (TRD) that targets psychological inflexibility and interpersonal functioning within the context of maladaptive overcontrol. However, it is unknown whether change in these mechanistic processes is associated with decreased symptoms. This study tested whether change in psychological inflexibility and interpersonal functioning is associated with change in depressive symptoms in RO DBT. METHOD: Adults with TRD from The Refractory Depression: Mechanisms and Efficacy of RO DBT (RefraMED) randomized controlled trial of RO DBT, n = 250; M (SD) age = 47.2 (11.5); 65% female; 90% White, were assigned to RO DBT or treatment as usual. Psychological inflexibility and interpersonal functioning were assessed at baseline, 3 (midtreatment), 7 (posttreatment), 12, and 18 months. Mediation analyses and latent growth curve modeling (LGCM) assessed whether change in psychological inflexibility and interpersonal functioning was associated with change in depressive symptoms. RESULTS: The effect of RO DBT in decreasing depressive symptoms was mediated by changes in psychological inflexibility and interpersonal functioning at 3 (95% CI [-2.35, -0.15]; [-1.29, -0.04], respectively), 7 (95% CI [-2.80, -0.41]; [-3.39, -0.02]), and only psychological inflexibility at 18 (95% CI [-3.22, -0.62]) months. LGCM indicated only in RO DBT was a decrease in psychological inflexibility through 18 months associated with a decrease in depressive symptoms (B = 0.13, p < .001). CONCLUSIONS: This supports RO DBT theory about targeting processes related to maladaptive overcontrol. Interpersonal functioning, and in particular, psychological flexibility, may be mechanisms that decrease depressive symptoms in RO DBT for TRD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Silent witnesses: the experience of having a sibling with anorexia nervosa.

BACKGROUND: This study explored the experience of having a sibling with anorexia nervosa and the sibling perspectives on service provision. METHOD: Four focus groups were conducted with 14 siblings (8 female, 6 male, age 11-19 years) of adolescents with anorexia nervosa or related restrictive eating disorders. Group discussions were transcribed and analysed using thematic analysis. RESULTS: Four themes and eight sub-themes were generated. These illustrated siblings feel greatly affected by the way the family needs to change to support someone with anorexia nervosa. Feelings of ambivalence and acceptance were also evident. They described silencing their own emotions and needs so as not to trouble others, and distancing themselves from their families in order to cope. Some female (but no male) siblings identified an impact on their own perceptions of eating and body image. Siblings generally felt that services had not attended to their needs, and that they had not been appropriately included in treatment. CONCLUSIONS: Data from this study suggest the sibling experience needs to be more carefully considered and included in treatment. This may include a more explicit invitation to sessions and a more active discussion about their own needs and useful involvement in treatment sessions. Findings point to ways siblings may be better supported, such as peer support groups.

This study investigated the experience of having a sibling with anorexia nervosa, and the sibling perspectives on the treatment they get. Four focus groups were held with siblings (11­19 year-olds) of adolescents with anorexia nervosa. Group discussions were written down word-for-word and analysed using thematic analysis. Four themes and eight sub-themes were identified. These illustrated siblings feel very affected by the way the family needs to change to support someone with anorexia nervosa. Feelings of ambivalence and acceptance were also evident. Siblings said they silenced their own emotions and needs so as not to trouble others, and distanced themselves from their families in order to cope. Siblings generally felt that services had not attended to their needs, and that they had not been appropriately included in treatment. Findings from this study point to ways siblings may be better supported, such as peer support groups.

Adolescent experience of radically open dialectical behaviour therapy: a qualitative study.

BACKGROUND: Radically Open Dialectical Behaviour Therapy (RO DBT) is a novel transdiagnostic treatment that targets 'maladaptive overcontrol'; a transdiagnostic cluster of traits associated with excessive emotional and behavioural inhibitory control. Outcomes are promising for adults with a range of psychiatric disorders. No study to date has explored the adolescent experience of RO DBT. METHODS: Of the 25 eligible adolescents who received RO DBT between March 2015 and April 2017, 15 (14-17 years) consented and completed a semi-structured interview about their experience of treatment within 1 month of discharge. Interviews were recorded and then transcribed manually. Free text responses were analysed using reflexive thematic analysis. RESULTS: The majority (n = 13) had a primary diagnosis of anorexia nervosa, although comorbidity was the norm, with 80.0% having two or more predicted comorbid psychiatric diagnoses. All had received some prior psychological treatment. Four themes were identified from analysis of transcripts: 1) Broadening Horizons, 2) Building Connections, 3) Flexibility, 4) Information Overload. Generally, RO DBT was perceived as helpful in both content and process. The focus on social and broader well-being, rather than specific mental health symptoms, was considered beneficial by many. Adolescents appreciated the group-based format of skills classes and reported benefiting from learning and practicing skills each week. The fourth theme, Information Overload, highlighted that for some, the amount of content felt overwhelming and that it was hard to remember and digest all the information, suggesting that adaptations, or simplifications, may be required to ensure accessibility for adolescents. CONCLUSIONS: RO DBT is perceived as a relevant and beneficial new treatment for adolescents with maladaptive overcontrol. The broad treatment focus is perceived as unique and of particular benefit. It is reported to help with general and social functioning and foster cognitive and behavioural flexibility. Nevertheless, the amount and complexity of material was felt to be very large by some and may suggest the need for modified adolescent-specific materials.

Multi-family therapy for bulimia nervosa: a qualitative pilot study of adolescent and family members' experiences.

BACKGROUND: Multi-family therapy (MFT-BN) is a new treatment for adolescent bulimia nervosa with emerging empirical support. It extends the bulimia nervosa focussed family therapy model, by offering treatment in a group setting. Up to nine families work together with a team of clinicians over the course of 20 weeks. No qualitative study to date has investigated the experience of MFT-BN. This study aimed to explore this from the adolescent and parent/caregiver perspective. METHODS: Participants from two consecutive MFT-BN groups facilitated at the Maudsley Hospital in London, UK, were invited to participate in either a focus group or individual qualitative interview about the experience of MFT-BN. Of the 19 eligible participants (from 9 families), 15 (8 parents, 1 older sibling, 6 adolescents) consented and participated. Audio-recordings of interviews and focus groups were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS: Three main themes were identified; (1) seeing and being seen, (2) holistic shift, (3) the unspoken. Participants reported overall shifts in cognitions, emotions, behaviours, and relationships both individually and within the family as a result of attending MFT-BN. Meeting other families with similar struggles and sharing experiences, skills and learning helped reduce isolation and promote change. There was also a sense from participants that some things did not, or could not, be spoken about in the group context and that more direct and challenging conversations might have been helpful at times. DISCUSSION: The current study identifies some of the perceived benefits and challenges of MFT-BN. The three themes demonstrate the holistic nature of change that can occur across the treatment, as well as the power and limits of the group therapy setting and process. Further research is needed to explore the experience of MFT-BN and its outcomes across a more diverse range of participants and treatment settings.

Multi-family therapy (MFT-BN) is a new treatment for adolescent bulimia nervosa. It involves a group of families (maximum nine) working together with a team of therapists over the course of 20 weeks. This study aimed to explore the experience of MFT-BN from the adolescents and parent/caregiver perspective, as this has not been explored before. Participants from two consecutive MFT-BN groups were invited to participate in either a focus group or individual interview. 8 parents, 1 older sibling, and 6 adolescents participated. Three themes were identified from what they said. Participants described overall shifts in their thoughts, emotions, behaviours, and relationships both individually and within their families, as a result of attending MFT-BN. Meeting other families with similar struggles and sharing experiences, skills and learning helped reduce isolation and promote change. There was also a sense from participants that some things did not, or could not, be spoken about in the group context and that more direct and challenging conversations might have been helpful at times. More research is needed to explore the experience of MFT-BN and its outcomes across a more diverse range of participants and treatment settings.

From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (Part 2): 7-year follow-up.

BACKGROUND: Eating disorders are often characterised as disabling, chronic or relapsing conditions with high mortality rates. This study reports follow-up outcomes for patients seen at the Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED), whose end of treatment outcomes are reported in a separate paper. METHODS: Three-hundred-and-fifty-seven former patients, who received evidence-based treatment for an eating disorder as a child or adolescent in MCCAED between 2009 and 2014 were eligible to participate. Current contact information was available for 290, of whom 149 (51.4%) consented to follow-up. Participants were sent links to online questionnaires, with additional demographic information extracted from medical records. Descriptive analyses of key socioeconomic and health outcomes were performed on data collected. RESULTS: Mean length of follow-up was 6 years 11 months. Ten (6.7%) participants reported a current diagnosis of an eating disorder at follow-up. The great majority reported no (63.8%) or minimal (26.8%) interference from eating disorder difficulties. More than half (53.6%) reported other mental health diagnoses with most reporting no (33.8%) or minimal (50.7%) interference from those difficulties. One third (33.3%) had sought help for an eating disorder and around 20% received prolonged/intensive treatment during the follow-up period. Approximately 70% had sought treatment for other mental health difficulties (mostly anxiety or depression) and 35.4% had substantial treatment. At follow-up more than half (55.5%) reported doing generally well, and around two-thirds reported general satisfaction with their social well-being (65%). The majority (62.7%) had a good outcome on the Morgan Russell criteria, which was consistent with low self-reported ratings on EDE-Q, and low impact of eating disorder or mental health symptoms on work and social engagement. Most of the former patients who had day and/or inpatient treatment as a part of their comprehensive integrated care at MCCAED did well at follow-up. CONCLUSIONS: Young people seen in specialist eating disorder services do relatively well after discharge at longer-term follow-up especially regarding eating disorders but less favourably regarding other mental health difficulties. Few reported a diagnosable eating disorder, and the great majority went on to perform similarly to their peers in educational and vocational achievements.

The aim of this study was to evaluate the long term outcome of children and adolescents who had received evidence-based treatments for an eating disorder in a specialist eating disorders service. The study was designed in collaboration with former service users, to ensure that measures of recovery were relevant to people with lived experience. One-hundred-and-forty-nine former patients consented to participate and completed online questionnaires. Very few (6.7%) reported having an eating disorder at follow-up, however, more than half (53.6%) reported other mental health difficulties during the follow up period. One third sought help for an eating disorder and around 20% had prolonged and intensive eating disorder treatment. Approximately 70% sought help for other mental health difficulties and nearly a third had substantial treatment for these during the follow-up period. Regarding education and work, most participants were functioning equivalently to their peers. More than half (55.5%) reported doing generally well with respect to overall well-being, and around two-thirds reported general satisfaction with their social well-being and quality of life. The follow-up study suggests that most young people treated in specialist eating disorder services do relatively well at long-term follow-up, but many continue to need help with other mental health problems.

From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (part 1)-treatment course and outcomes.

BACKGROUND: Findings from randomised control trials inform the development of evidence-based eating disorder (ED) practice guidelines internationally. Only recently are data beginning to emerge regarding how these treatments perform outside of research settings. This study aimed to evaluate treatment pathways and outcomes for a specialist child and adolescent ED service across a five-year period. METHODS: All consecutive referrals between August 2009 and January 2014 seen at the Maudsley Centre for Child and Adolescent Eating Disorders in London were included. Data are reported on for all young people who were offered treatment (N = 357). RESULTS: Most young people referred to the service were diagnosed with anorexia nervosa (AN)/Atypical AN (81%). Treatment for AN/Atypical AN (median 11 months) was predominantly ED focused family therapy (99%). Treatment for bulimia nervosa (BN)/Atypical BN (median seven months) was most commonly a combination of cognitive behavioural therapy and ED focused family therapy (87%). At discharge, 77% of the AN/Atypical AN group had a good or intermediate outcome and 59% of the BN/Atypical BN group reported no or fewer than weekly bulimic episodes. 27% of the AN/Atypical AN group had enhanced treatment with either day- and/or inpatient admissions (AIM group). The %mBMI at 3 months of treatment was strongest predictor of the need for treatment enhancement and more modestly EDE-Q and age at assessment. The AIM group at assessment had significantly lower weight, and higher ED and comorbid symptomatology and went on to have significantly longer treatment (16 vs. 10 months). At discharge, this group had significantly fewer good and more poor outcomes on the Morgan Russell criteria, but similar outcomes regarding ED and comorbid symptoms and quality of life. When analysis was adjusted for %mBMI at assessment, 1 and 3 months of treatment, differences in Morgan Russell outcomes and %mBMI were small and compatible with no difference in outcome by treatment group. CONCLUSIONS: This study shows that outcomes in routine clinical practice in a specialist community-based service compare well to those reported in research trials. The finding from research trials that early weight gain is associated with improved outcomes was also replicated in this study. Enhancing outpatient treatment with day treatment and/or inpatient care is associated with favourable outcome for most of the young people, although a longer duration of treatment is required.

Most research reports on outcomes for clinical trials. This study aimed to evaluate outcomes in a 'real world' setting of a specialist child and adolescent eating disorder service (ED) in the UK. Case notes of 357 young people seen for treatment between August 2009 and January 2014 were reviewed. Demographic and treatment characteristics, physical health, ED symptoms, other psychological symptoms and quality of life data are reported. Most young people referred had anorexia nervosa or related difficulties and most received ED focused family therapy. At the end of treatment, the majority had a good or intermediate outcome, regardless of ED diagnosis. In a quarter of the young people, their treatment was enhanced with day or inpatient admissions. This group had more severe difficulties at assessment and had longer treatment but had similar outcomes at the end of treatment.

Multi-family therapy for eating disorders: A systematic scoping review of the quantitative and qualitative findings.

OBJECTIVE: This study reviewed the quantitative and qualitative evidence-base for multi-family therapy (MFT) for eating disorders regarding change in physical and psychological symptoms, broader individual and family factors, and the experience of treatment. METHOD: A systematic scoping review was conducted. Four databases (PsycInfo, Medline, Embase, CENTRAL) and five grey literature databases were searched on 24th June 2021 for relevant peer-reviewed journal articles, book chapters, and dissertations. No beginning time-point was specified. Only papers that presented quantitative or qualitative data were included. No restrictions on age or diagnosis were imposed. Studies were first mapped by study design, participant age, and treatment setting, then narratively synthesized. RESULTS: Outcomes for 714 people who received MFT across 27 studies (one mixed-method, 17 quantitative and nine qualitative) were synthesized. MFT is associated with improvements in eating disorder symptomatology and weight gain for those who are underweight. It is also associated with improvements in other individual and family factors including comorbidities, self-esteem, quality of life, and some aspects of the experience of caregiving, although these findings are more mixed. MFT is generally experienced as both helpful and challenging due to the content addressed and intensive group process. DISCUSSION: MFT is associated with significant improvements in eating disorder symptoms across the lifespan and improvement in broader individual and family factors. The evidence base is small and studies are generally underpowered. Larger, higher-quality studies are needed, as is research investigating the unique contribution of MFT on outcomes, given it is typically an adjunctive treatment.

OBJETIVO: Este estudio revisó la evidencia cuantitativa y cualitativa para la terapia multifamiliar (MFT, por sus siglas en inglés) para los trastornos de la conducta alimentaria con respecto al cambio en los síntomas físicos y psicológicos, los factores individuales y familiares más extensos, y la experiencia del tratamiento. MÉTODO: Se realizó una revisión sistemática del alcance. Se realizaron búsquedas en cuatro bases de datos (PsycInfo, Medline, Embase, CENTRAL) y en cinco bases de datos de literatura gris el 24.06.2021 para obtener artículos relevantes de revistas revisadas por pares, capítulos de libros y disertaciones. No se especificó ningún punto de tiempo inicial. Sólo se incluyeron los artículos que presentaban datos cuantitativos o cualitativos. No se impusieron restricciones de edad o diagnóstico. Los estudios se mapearon primero por el diseño del estudio, la edad de los participantes y el entorno de tratamiento, y luego se sintetizaron narrativamente. RESULTADOS: Se sintetizaron los resultados de 714 pacientes que recibieron MFT en 27 estudios (un método mixto, 17 cuantitativos y nueve cualitativos). MFT se asocia con mejoras en la sintomatología del trastorno de la conducta alimentaria y el aumento de peso para aquellos que tienen bajo peso. También se asocia con mejoras en otros factores individuales y familiares, incluidas las comorbilidades, la autoestima, la calidad de vida y algunos aspectos de la experiencia del cuidador, aunque estos hallazgos son más mixtos. MFT generalmente se experimenta como útil y desafiante debido al contenido abordado y al proceso grupal intensivo. DISCUSIÓN: La MFT se asocia con mejoras significativas en los síntomas del trastorno de la conducta alimentaria a lo largo de la vida y una mejora en factores individuales y familiares más amplios. La base de evidencia es pequeña y los estudios generalmente tienen poco poder. Se necesitan estudios más grandes y de mayor calidad, al igual que la investigación que investiga la contribución única de la MFT en los resultados, dado que generalmente es un tratamiento complementario. PALABRAS CLAVE: terapia multifamiliar (MFT), terapia familiar de Maudsley, tratamiento basado en la familia (FBT), trastornos de la conducta alimentaria, anorexia nerviosa, bulimia nerviosa, niño, adolescente, adulto joven, adulto, cuidador.

Radically open dialectical behaviour therapy adapted for adolescents: a case series.

BACKGROUND: Overcontrol is a transdiagnostic cluster of traits associated with excessive psychological, behavioural and social inhibitory control. It is associated with psychiatric diagnoses of depression, restrictive eating disorders and/or obsessive-compulsive personality disorder. Radically Open Dialectical Behaviour Therapy is a transdiagnostic treatment for maladaptive overcontrol. This case series evaluates an adolescent adaption (RO-A) for a transdiagnostic group of adolescents identified as overcontrolled. METHODS: Twenty-eight adolescents were consecutively referred for RO-A from two different National and Specialist Child and Adolescent Mental Health Services between June 2017 and February 2020. Baseline self-report measures assessed overcontrol characteristics, relationship and attachment quality and mental health symptoms of depression and eating disorders, which were repeated at discharge. RESULTS: Adolescents in this case series reported high rates of depression (78.6%), self-harm (64.3%) and eating disorders (78.6%). Most (85.7%) had two or more mental health diagnoses and all had previous mental health treatments before starting RO-A. The mean number of RO-A sessions attended was 18 group-based skills classes and 21 individual sessions over a mean period of 34 weeks. Significant improvements with medium and large effect sizes were reported in cognitive flexibility (d = 1.63), risk aversion (d = 1.17), increased reward processing (d = .79) and reduced suppression of emotional expression (d = .72). Adolescents also reported feeling less socially withdrawn (d = .97), more connected to others (d = 1.03), as well as more confident (d = 1.10) and comfortable (d = .85) in attachment relationships. Symptoms of depression (d = .71), eating disorders (d = 1.06) and rates of self-harm (V = .39) also significantly improved. Exploratory correlation analyses suggest improvements in overcontrol are moderately to strongly correlated with improvements in symptoms of depression and eating disorders. CONCLUSIONS: This case series provides preliminary data that RO-A may be an effective new treatment for adolescents with overcontrol and moderate to severe mental health disorders like depression and eating disorders. RO-A led to improved management of overcontrol, improved relationship quality and reduced mental health symptoms. Further evaluation is indicated by this case series, particularly for underweight young people with eating disorders. More rigorous testing of the model is required as conclusions are only tentative due to the small sample size and methodological limitations.

Formulation in eating disorder focused family therapy: why, when and how?

In the broadest sense, formulation, or case conceptualisation, is the process of collaborative sense-making. It is something all clinicians are doing constantly, whether formally and consciously or not. Most clinicians are familiar with the general principals and need to formulate as it is a core part of clinical training across most disciplines. Treatment manuals often discuss formulation, but the practical steps involved and the process of developing, building upon and revising formulations are not always provided. In clinical practice, the active use and continued development of formulation during treatment is not always prioritised, especially beyond the initial assessment. This could be due to a number of reasons, such as a potential lack of clarity, understanding or confidence in the use of formulation across treatment, a lack of dedicated time and reflective space for formulation in the context of increasingly busy clinical settings, or a perception that it may be less necessary in the context of treatment approaches that are more structured and prescriptive. This article outlines the use of formulation in family therapy for child and adolescent eating disorders, provides guidance on how to actively include formulation more throughout treatment and discusses why this might be useful.

All clinicians, families and young people are constantly trying to make sense of the difficulties people present to treatment with and how it progresses once it has started. This process is called formulation and is occurring whether people are conscious of it or not. It is through the formulation process that a person's specific difficulties are understood, how treatment goals are established, and how treatments can be more effectively reviewed when there is a lack of progress. Despite these potential benefits, formulation is not always prioritised in day-to-day practice. This article outlines formulation practices in eating disorder focused family therapy. It then provides guidance on why, when and how formulation could be incorporated more consistently. Potential benefits and pitfalls are considered, as well as considerations of how to make sure the formulation is collaboratively developed with the families and team to avoid individual biases and assumptions.

Is this the 'new normal'? A mixed method investigation of young person, parent and clinician experience of online eating disorder treatment during the COVID-19 pandemic.

INTRODUCTION: Prior to the COVID-19 pandemic, research in virtual care for young people with eating disorders was preliminary and implementation rare. This study explored the experience of young people, parents and clinicians when therapy was transitioned to virtual provision as a result of the UK lockdown in March 2020. METHODS: A mixed-method approach was used in this study. Online questionnaires that included a mixture of rating (Likert scale) and free-text response questions were completed by 53 young people with any eating disorder, 75 parents and 23 clinicians. Questions focused on the experience of online treatment as well as the impact on engagement, perceived treatment efficacy and preferences around treatment mode in the future. Likert scale questions were analysed using a summary approach. Free-text responses were analysed qualitatively using reflexive thematic analysis. RESULTS: Responses to rating scale questions indicate satisfaction with treatment, good engagement and ability to manage technology. Young people who had transitioned care, rather than started care virtually in lockdown, rated therapy as less effective. However, individual accounts of experience were more varied. Reflexive thematic analysis of free-text responses identified key themes of 1) Making it work, 2) Home as a therapeutic space, and 3) Disrupted connection and 4) Into the future. CONCLUSIONS: These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and therapeutic engagement and depth and need for consideration of equal access to treatment in socially unequal societies.

Due to the COVID-19 pandemic specialist eating disorder treatment needed to quickly adapt to new technologies. All but urgent and crisis appointments needed to be delivered online. This study looked at what that was like for the young people, their parents and clinicians engaged in treatment in a large specialist eating disorder service in London, UK. Fifty-three young people with an eating disorder, 75 parents and 23 clinicians completed anonymous online surveys about their experience. Results showed that generally people were satisfied with treatment, the therapeutic relationship was maintained and most managed technological issues well. Four main themes were identified from responses to open ended free-text response questions. All three groups wrote about 1) making it work, 2) home as a therapeutic space, and 3) disrupted connection. The fourth theme, 4) into the future, came from parent and clinician responses only. These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and the potential impact on the therapeutic relationship. There is also a need to make sure there is equal access to treatment in socially unequal societies.

Brief early adolescent multi-family therapy (BEAM) trial for anorexia nervosa: a feasibility randomized controlled trial protocol.

INTRODUCTION: Multi-family therapy (MFT) is a recommended treatment for adolescent anorexia nervosa internationally. Despite recent significant advances in single-family therapy, the evidence base for MFT remains relatively small. Several individual and family factors have been associated with poorer outcomes in single-family therapy, many of which may be addressed or ameliorated by MFT if delivered early in treatment. This trial aims to determine the feasibility and acceptability of adding a five-day multi-family therapy group to the early stages of family therapy for anorexia nervosa. Secondary objectives are to explore effect size changes in key individual and family factors across treatment. METHODS: This feasibility trial will use a randomised controlled design. Sixty adolescents (age 10-17 inclusive) with anorexia nervosa or atypical anorexia nervosa and their parents will be recruited from a community-based specialist eating disorder service in London, UK. Participants will be randomly allocated to receive six months of eating disorder focussed family therapy with a five-day MFT group (experimental group) or without (control group). Block randomisation will be conducted by the King's Clinical Trials Unit and researchers will be blind to participants' intervention allocation. Feasibility, acceptability and secondary outcomes measures will be collected at baseline, post-MFT, end of treatment, six-month and 12-month follow-up. Feasibility and acceptability will be assessed according to trial sign-up rates, retention, measure completion rates and satisfaction. Secondary outcomes include physical health improvements, changes in psychiatric symptoms, emotion regulation and reflective function capacity, expressed emotion, parental difficulties and therapeutic alliance. Descriptive data and exploration analysis of trends and effect sizes will be reported upon at trial completion. DISCUSSION: The five-day MFT program developed for this study is novel, brief and more accessible than previous MFT models. The inclusion of a data collection point during treatment and follow-up will allow for an investigation of trends during and after treatment. This will allow exploration and comparison of future potential mediators and moderators of MFT and FT-AN outcomes and how these may differ between treatments. TRIAL REGISTRATION: ISRCTN registry; ISRCTN93437752 , on 27 January 2021.