July/August 2017 Issue

Family-Based Treatment of Adolescents With Eating Disorders
By Jennifer Rollin, MSW, LCSW-C
Social Work Today
Vol. 17 No. 4 P. 20

FBT is considered a first-line treatment that some say can avoid a hospitalization and avert a progressive and chronic illness.

It was once believed that adolescents developed anorexia due to highly critical or dysfunctional family environments. However, we now know that eating disorders are caused by a combination of genetic, environmental, psychological, and temperamental factors. Parents are not to blame when their children develop eating disorders and can be incredible sources of support in their children's healing journeys.

A groundbreaking and evidence-based treatment approach, the Maudsley method, also known as family-based treatment (FBT), uses family members as critical allies when treating adolescents with anorexia. Incorporating the warning signs and symptoms of anorexia, as well as the application of this evidence-based treatment, FBT can provide quality care to adolescent clients and help them on their path to recovery from anorexia nervosa.

Background of Anorexia Nervosa
The term "anorexia nervosa" was coined in 1873 by William Gull, MD, a London physician. Although there were early documented cases of the illness, anorexia did not garner widespread public attention until the death of Karen Carpenter in 1983. Carpenter, a world-renowned singer, died at the age of 32 from anorexia; her death brought eating disorders into the media spotlight.

Warning Signs of Anorexia
The following are some warnings signs that experts agree may indicate that your client is currently experiencing, or at risk of struggling with, anorexia nervosa.

Changes in weight and increased fixation on weight and body size. If adolescent clients suddenly begin to lose weight and demonstrate an increased fixation on weight and body size, this could be one indication that they may be struggling with anorexia.

In fact, one of the DSM-5 criteria for anorexia is "(e)ither an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low in weight)." For instance, you might notice that a client is suddenly weighing themselves obsessively, as well as talking about their weight or their fear of weight gain. Clients might also present with a distorted view of their bodies and a belief that their sense of self-esteem is based on the way that their body looks.

There is a common myth that all individuals with anorexia will outwardly appear emaciated. While this may be true in some cases, it's important to note that someone does not need to look emaciated to be struggling with anorexia. For instance, if an individual in a larger body develops all the symptoms of anorexia, they might still be in a weight range that is considered "normal" or "overweight" per body mass index (BMI) charts. Another example could be an individual that may be early into the development of the illness.

DSM-5 specifies that one of the symptoms of anorexia is "(p)ersistent restriction of energy intake leading to significantly low body weight (relative to minimally expected for age, sex, developmental trajectory, and physical health)." Thus, DSM-5 does suggest the idea that "significantly low body weight" needs to be considered within a variety of contexts.

Ultimately, when exploring whether a client meets the criteria for anorexia, it's critical to ensure that as a clinician you are neither exhibiting weight bias nor diminishing the severity of someone's illness based on them not meeting the "underweight" criteria relative to BMI.

Many individuals with anorexia are not properly diagnosed and treated because of their weight. When clients (of any size) share that they feel they might be struggling with an eating disorder, clinicians must take their concerns seriously.

Changes in eating habits and food behaviors. Another warning sign that clients could be struggling with anorexia is if they begin to exhibit changes in their eating habits: skipping meals, restricting whole categories of foods (e.g., becoming a vegetarian, cutting out carbohydrates), and/or appearing preoccupied with calories or fat grams.

One warning sign could be an interest in low-fat foods. "Clean eating: It gets missed because initially parents (or clinicians) may be impressed with the young person's interest in healthy eating, until the diet becomes deadly, and the weight loss is alarming," says Barbara Reese, LCSW, CEDS, BC-DMT, owner and director of the Women's Therapy Service of Montclair, NJ, who has more than 25 years of experience working with eating disorders and body image problems as a psychotherapist and dance/movement therapist.

Adolescents who are struggling with anorexia may begin to exhibit uncharacteristic food behaviors, such as food rituals (e.g., cutting their food into tiny pieces, eating foods in a specific order, eating the same foods, or constantly measuring foods), hoarding food, cooking meals for others that they will not eat themselves, hoarding or collecting recipes, spending lots of time reading food blogs, or looking at pictures of food on social media.

Other red flags could be if an adolescent is using an excessive amount of condiments (e.g., mustard, ketchup, or spices), putting together strange combinations of food, and/or consuming a lot of diet soda or coffee in an effort to feel full.

Isolating themselves from people or becoming less interested in things they previously enjoyed. Another indicator that a teen might be struggling with anorexia is if they become socially withdrawn and start to isolate themselves. It is a warning sign that there may be a deeper problem if your client no longer desires to socialize and instead is consumed with researching recipes, going to the gym, and/or talking about food, calories, or dieting.

Additionally, your client might start to make excuses to avoid events or social situations involving food, as this can be highly anxiety provoking to an individual with anorexia.

When people are struggling with an eating disorder, often the eating disorder becomes their primary relationship and begins to take the place of the real relationships in their life. Often people struggling with anorexia find that their world becomes very small and that they are consumed with thoughts of food and weight.

Displaying common physical symptoms of anorexia. The following are some physical symptoms that could indicate that a client is struggling with anorexia: dizziness or fainting, intolerance of cold, constipation, loss of menstruation, loss of hunger/fullness cues, hair falling out, low blood pressure, irregular heart rhythms, insomnia, or soft-downy hair covering body.

It's important to note that not all individuals who are struggling with anorexia will experience these physical symptoms. Additionally, it is crucial to refer the client to their primary care physician (or the emergency department in extreme cases) if they are experiencing any of these physical symptoms.

Reese reports that children and young teens can fall off their growth chart for weight and height in fewer than 12 months of symptoms. Weight restoration can help resume height on a normal path. Without proper weight restoration, height can be stunted.

The Maudsley Method
The Maudsley method or FBT was developed by Christopher Dare, MD, and colleagues at Maudsley Hospital in London, England. Research demonstrates the effectiveness of this method in the treatment of adolescents with anorexia; it also indicates that FBT is most effective with younger clients who have had a shorter duration of the illness.

Phases of FBT
In the past, families have been unfairly blamed for their children developing anorexia. Dated theories that anorexia is caused by a controlling mother have contributed to the perpetuation of this myth. However, it's important to share with families that they are not to blame for their children's development of an eating disorder. Additionally, they can be crucial allies and sources of support for their children's recovery. The Maudsley method empowers families and utilizes them as central components of the treatment process.

"The parents are an integral part of this treatment. They have to feel supported. They have to feel empowered. They have to understand what's going on," Reese says. "In FBT, the parents and even siblings participate in the family-based sessions every week. It is a whole family model."

James Lock, MD, PhD, a professor of psychiatry and behavioral sciences at Stanford University, and Daniel Le Grange, PhD, a psychologist and joint director of the eating disorders program at University of California San Francisco Benioff Children's Hospital, took on the challenge of manualizing The Maudsley Approach in the United States. The approach consists of three distinct treatment phases and typically occurs within 12 to 20 treatment sessions over a one-year period.

Phase One: Weight Restoration
In the first phase, the focus is on helping the parents to refeed their child to help the child restore weight. The therapist will make every effort to help support the parents as they help their child in this effort.

"Stage one is the stage that can typically take the longest. The second session the parents are asked to bring in a picnic meal, and the therapist joins this meal with the family," Reese says.

"In this session, I coach them to have their child take 'one more bite.' If the parents bring in 'diet-y' food, we can assess that they are not aware how much food or calories is needed to feed their starving child. At the 'picnic' we can assess the parents' judgment in what they are feeding their child, how they are speaking to the child, and how they get them to eat one more bite.

"Food is medicine, so you are really healing the brain first with the weight restoration," Reese says.

Phase Two: Transitioning Control of Eating Back to the Adolescent
In this phase, parents begin to gradually transition control of eating back to the adolescent. For instance, they might allow the child to make his or her own snack at first under parental supervision.

"The criteria for beginning Phase Two are: 1) the client is nearly weight restored (the Lock and LeGrange manual specifies 87% of ideal body weight), 2) meals are going smoothly, and 3) parents are empowered to step back if need be. This final criterion is especially important; the reason for this is that the transition to Phase Two is rarely smooth," says Lauren Muhlheim, PsyD, FAED, CEDS, of Eating Disorder Therapy LA in Los Angeles.

Phase Three: Establishing Healthy Adolescent Identity
The third phase typically occurs when adolescents are able to maintain their weight above 95% of their ideal body weight on their own and are no longer in a period of semistarvation.

Essentially, the focus is on helping the adolescent to establish a healthy sense of identity. Themes might include personal autonomy as well as creating appropriate boundaries with parents.

"As a therapist, one of my goals for this phase is to explore normal adolescent development, which for every family is going to be a little bit different," says Kristen Anderson, MA, LCSW, cofounder of the Chicago Center for Evidence Based Treatment. The idea is to make sure that the adolescent is guided back to their developmental trajectory, because we know that anorexia can sometimes pull kids out from social activities or peer groups. So whether that's getting them back involved in sports or the play, we would start looking into that. I also will go over relapse prevention with them."

Benefits of Using FBT
When asked about the benefits of using FBT, clinicians agree that there are myriad benefits. "In FBT, parents are really replacing an entire inpatient team," Reese says. "It is their love and determination that are the greatest healing agents. When it's successful, it keeps the child out of a hospital. If the early intervention is successful, it can actually help a child to avoid a hospitalization. Eating disorders are competitive illnesses; there are pros and cons about going to a hospital. Most of the cases that I see are children who have struggled with anorexia for about six months."

Reese continues: "FBT is now considered the first line of treatment. As an early intervention method, the effects of FBT can be significant. One can not only can avoid a hospitalization; a successful trial of FBT can avert a progressive and chronic illness."

Anderson agrees. "One of the really wonderful benefits of using FBT is that it really uses the family as a resource for their adolescent who is struggling with an eating disorder. It really flips for many of the families the feelings of blame or guilt to feelings of empowerment and having a plan of what to do to support their kid. When you have an adolescent with an illness that typically causes a lot of ambivalence—which is not about who the kid is, but really about the nature of the illness—I think that often parents and family members feel very powerless in terms of what they can do to help their kids, so starting them out with this treatment offers them a lot of clarity and support."

According to Muhlheim, the benefits of this approach include the following:
• It's cost-effective as compared with residential treatment.
• It can lead to faster and more stable recovery as compared with other treatments.
• It focuses on addressing the dangerous symptom of starvation first.
• It often brings families closer together as they unite to fighting the common enemy of the eating disorder.
• It allows for the fact that teens with anorexia nervosa often don't believe they are ill and so do not want to get well.

"FBT offers an alternative by which the parents help their teens achieve recovery even when they are not willing," Muhlheim says.

The Bottom Line
Eating disorders are life-threatening and complex illnesses. Thus, if you do not specialize in treating eating disorders, it is crucial to refer out to someone who does. Additionally, when treating eating disorders, it's important to include a multidisciplinary team, which often consists of a doctor, psychiatrist, therapist, and dietitian.

Through FBT, families are empowered to serve as critical allies in their child's recovery from anorexia nervosa. With access to evidence-based treatment and support, adolescents with anorexia can recover and lead more rewarding and productive lives.

— Jennifer Rollin, MSW, LCSW-C, is an eating disorder therapist in private practice in Rockville, MD, specializing in helping teens and adults with eating disorders, including anorexia, bulimia, and binge eating disorder, as well as body image issues.