Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa.

OBJECTIVE: This study provides data on the psychometric properties of a newly developed measure of treatment fidelity in Family-Based Treatment (FBT) for adolescent anorexia nervosa (AN). The Family Therapy Fidelity and Adherence Check (FBT-FACT) was created to evaluate therapist adherence and competency on the core interventions in FBT. METHOD: Participants were 45 adolescents and their families sampled from three randomized clinical trials evaluating treatment for AN. Trained fidelity raters evaluated 19 therapists across 90 early session recordings using the FBT-FACT. They also rated an additional 15 session 1 recordings of an alternate form of family therapy-Systemic Family Therapy for the purpose of evaluating discriminant validity of the FBT-FACT. The process of development and the psychometric properties of the FBT-FACT are presented. RESULTS: Overall fidelity ratings for each session demonstrated moderate to strong inter-rater agreement. Internal consistency of the measure was strong for sessions 1 and 2 and poor for session 3. Principal components analysis suggests sessions 1 and 2 are distinct interventions. DISCUSSION: The FBT-FACT demonstrates good reliability and validity as a measure of treatment fidelity in the early phase of FBT.

Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa.

OBJECTIVE: Determine whether early weight gain predicts full remission at end-of-treatment (EOT) and follow-up in two different treatments for adolescent anorexia nervosa (AN), and to track the rate of weight gain throughout treatment and follow-up. METHOD: Participants were 121 adolescents with AN (mean age = 14.4 years, SD = 1.6), from a two-site (Chicago and Stanford) randomized controlled trial. Adolescents were randomly assigned to family-based treatment (FBT) (n = 61) or individual adolescent focused therapy (AFT) (n = 60). Treatment response was assessed using percent of expected body weight (EBW) and the global score on the Eating Disorder Examination (EDE). Full remission was defined as having achieved ≥95% EBW and within one standard deviation of the community norms of the EDE. Full remission was assessed at EOT as well as 12-month follow-up. RESULTS: Receiver operating characteristic analyses showed that the earliest predictor of remission at EOT was a gain of 5.8 pounds (2.65 kg) by session 3 in FBT (area under the curve (AUC) = 0.670; p = .043), and a gain of 7.1 pounds (3.20 kg) by session 4 in AFT (AUC = 0.754, p = .014). Early weight gain did not predict remission at follow-up for either treatment. A survival analysis showed that weight was marginally superior in FBT as opposed to AFT (Wald chi-square = 3.692, df = 1, p = .055). DISCUSSION: Adolescents with AN who receive either FBT or AFT, and show early weight gain, are likely to remit at EOT. However, FBT is superior to AFT in terms of weight gain throughout treatment and follow-up.

Challenges in conducting a multi-site randomized clinical trial comparing treatments for adolescent anorexia nervosa.

OBJECTIVE: To describe obstacles in the implementation of a controlled treatment trial of adolescent anorexia nervosa (AN). METHOD: The original aim was to enter 240 participants with AN to one of four cells: Behavioral family therapy (BFT) plus fluoxetine; BFT plus placebo; systems family therapy (SFT) plus fluoxetine; SFT plus placebo. RESULTS: Recruitment was delayed pending a satisfactory resolution concerning participant safety. After 6 months of recruitment it became clear that the medication was associated with poor recruitment leading to a study redesign resulting in a comparison of two types of family therapy with a projected sample size of 160. One site was unable to recruit and was replaced. DISCUSSION: Problems with the delineation of safety procedures, recruitment, re-design of the study, and replacement of a site, were the main elements resulting in a 1-year delay. Suggestions are made for overcoming such problems in future AN trials.

Stepped care and cognitive-behavioural therapy for bulimia nervosa: randomised trial.

BACKGROUND: This study compared the best available treatment for bulimia nervosa, cognitive-behavioural therapy (CBT) augmented by fluoxetine if indicated, with a stepped-care treatment approach in order to enhance treatment effectiveness. AIMS: To establish the relative effectiveness of these two approaches. METHOD: This was a randomised trial conducted at four clinical centres (Clinicaltrials.gov registration number: NCT00733525). A total of 293 participants with bulimia nervosa were randomised to one of two treatment conditions: manual-based CBT delivered in an individual therapy format involving 20 sessions over 18 weeks and participants who were predicted to be non-responders after 6 sessions of CBT had fluoxetine added to treatment; or a stepped-care approach that began with supervised self-help, with the addition of fluoxetine in participants who were predicted to be non-responders after six sessions, followed by CBT for those who failed to achieve abstinence with self-help and medication management. RESULTS: Both in the intent-to-treat and completer samples, there were no differences between the two treatment conditions in inducing recovery (no binge eating or purging behaviours for 28 days) or remission (no longer meeting DSM-IV criteria). At the end of 1-year follow-up, the stepped-care condition was significantly superior to CBT. CONCLUSIONS: Therapist-assisted self-help was an effective first-level treatment in the stepped-care sequence, and the full sequence was more effective than CBT suggesting that treatment is enhanced with a more individualised approach.

Treatment of bulimia nervosa: where are we and where are we going?

OBJECTIVE: The purpose of this article is to review the extant treatment literature on bulimia nervosa and to offer suggestions for future research directions. METHOD: The available treatment studies regarding both pharmacotherapy and psychotherapy are reviewed. RESULTS: Both pharmacotherapy and psychotherapy appear to play a role in the treatment of bulimia nervosa; however, available data suggest that cognitive behavioral therapy remains the treatment of choice. CONCLUSION: Additional work is clearly indicated regarding assisted and unassisted self-help. An enhanced form of CBT and the integrative cognitive-affective therapy both deserve further study. New approaches need to be piloted. More research is needed on treatment modeling.

Puberty and gender interact to predict social anxiety symptoms in early adolescence.

This study examines direct and interactive effects of puberty and gender on social anxiety symptoms in early adolescence. One hundred-six participants were assessed at ages 9.5 and 11 years. Results suggest that gender and puberty interact to predict social anxiety symptoms. Advanced puberty was associated with increased symptoms for girls only.

Predictors of dropout and remission in family therapy for adolescent anorexia nervosa in a randomized clinical trial.

OBJECTIVE: The purpose of this study is to explore the predictors of dropout and remission in the treatment of adolescent anorexia nervosa (AN) using family therapy. METHOD: Data derived from a randomized clinical trial comparing short and long term family therapy for adolescents with AN were used. A rotated component analysis was employed to reduce the number of variables and to address problems of collinearity and multiple testing. Dropout was defined as participating in less than 80% of the assigned therapy. Participants were classified as remitted if they obtained an ideal body weight greater than 95% and a global eating disorder Examination score within two standard deviations of community norms at the end of 12 months. RESULTS: Co-morbid psychiatric disorder and being randomized to longer treatment predicted greater dropout. The presence of co-morbid psychiatric disorder, being older, and problematic family behaviors led to lower rates of remission. A reduction of child behavioral symptoms, a decline in problematic family behaviors, and early weight gain were all within treatment changes that increased the chance of remission. CONCLUSION: Co-morbid psychiatric disorder, family behaviors, and early response to treatment are important factors when predicting dropout and remission in family therapy for adolescent AN.