Delivery of Family-Based Treatment for Adolescent Anorexia Nervosa in a Public Health Care Setting: Research Versus Non-Research Specialty Care.

Comparing evidence-based psychotherapy (EBP) to usual care typically demonstrates the superiority of EBPs, although this has not been studied for eating disorders EBPs such as family-based treatment (FBT). The current study set out to examine weight outcomes for adolescents with anorexia nervosa who received FBT through a randomized clinical research trial (RCT, n = 54) or non-research specialty care (n = 56) at the same specialist pediatric eating disorder service. Weight was recorded throughout outpatient treatment (up to 18 sessions over 6 months), as well as at 6- and 12-month follow-up. Survival curves were used to examine time to weight restoration [greater than 95% median body mass index (mBMI)] as predicted by type of care (RCT vs. non-research specialty care), baseline clinical and demographic characteristics, and their potential interaction. Results did not indicate a significant main effect for type of care, but there was a significant effect for baseline weight (p = .03), such that weight restoration was achieved faster across both treatment types for those with a higher initial %mBMI. These data suggest that weight restoration achieved in non-research specialty care FBT was largely similar to that achieved in a controlled research trial. Clinical Trial Registration:http://www.anzctr.org.au/, identifier ACTRN12610000216011

Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa.

BACKGROUND:Lower weight has historically been equated with more severe illness in anorexia nervosa (AN). Reliance on admission weight to guide clinical concern is challenged by the rise in patients with atypical anorexia nervosa (AAN) requiring hospitalization at normal weight. METHODS:We examined weight history and illness severity in 12- to 24-year-olds with AN (n = 66) and AAN (n = 50) in a randomized clinical trial, the Study of Refeeding to Optimize Inpatient Gains (www.clinicaltrials.gov; NCT02488109). Amount of weight loss was the difference between the highest historical percentage median BMI and admission; rate was the amount divided by duration (months). Unpaired t tests compared AAN and AN; multiple variable regressions examined associations between weight history variables and markers of illness severity at admission. Stepwise regression examined the explanatory value of weight and menstrual history on selected markers. RESULTS:Participants were 16.5 ± 2.6 years old, and 91% were of female sex. Groups did not differ by weight history or admission heart rate (HR). Eating Disorder Examination Questionnaire global scores were higher in AAN (mean 3.80 [SD 1.66] vs mean 3.00 [SD 1.66]; P = .02). Independent of admission weight, lower HR (β = -0.492 [confidence interval (CI) -0.883 to -0.100]; P = .01) was associated with faster loss; lower serum phosphorus was associated with a greater amount (β = -0.005 [CI -0.010 to 0.000]; P = .04) and longer duration (β = -0.011 [CI -0.017 to 0.005]; P = .001). Weight and menstrual history explained 28% of the variance in HR and 36% of the variance in serum phosphorus. CONCLUSIONS:Weight history was independently associated with markers of malnutrition in inpatients with restrictive eating disorders across a range of body weights and should be considered when assessing illness severity on hospital admission

Subjective and Objective Binge Eating in Relation to Eating Disorder Symptomatology, Depressive Symptoms, and Self-Esteem among Treatment-Seeking Adolescents with Bulimia Nervosa: Subjective and Objective Binge Eating

This study investigated the importance of the distinction between objective (OBE) and subjective binge eating (SBE) among 80 treatment-seeking adolescents with bulimia nervosa (BN). We explored relationships among OBEs, SBEs, eating disorder (ED) symptomatology, depression, and self-esteem using two approaches. Group comparisons showed that OBE and SBE groups did not differ on ED symptoms or self-esteem; however, the SBE group had significantly greater depression. Examining continuous variables, OBEs (not SBEs) accounted for significant unique variance in global ED pathology, vomiting, and self-esteem. SBEs (not OBEs) accounted for significant unique variance in restraint and depression. Both OBEs and SBEs accounted for significant unique variance in eating concern; neither accounted for unique variance in weight/shape concern, laxative use, diuretic use, or driven exercise. Loss of control, rather than amount of food, may be most important in defining binge eating. Additionally, OBEs may indicate broader ED pathology while SBEs may indicate restrictive/depressive symptomatology

Therapeutic alliance in a randomized clinical trial for bulimia nervosa.

This study examined the temporal relation between therapeutic alliance and outcome in two treatments for bulimia nervosa (BN)

Therapeutic alliance and outcomes in usual care child psychotherapy

Therapeutic alliance may be an important predictor of mental health outcomes for children and their families, but the research literature in this area is limited. This study examined the extent to which child and caregiver alliance are associated with therapeutic outcomes in a sample of 209 children (ages 4-13) with disruptive behavior problems and their caregivers who received usual care services in community mental health clinics. Children, therapists, and observers rated child-therapist alliance, while caregivers, therapists, and observers rated caregiver-therapist alliance at four, eight, and twelve months, provided the family was active in treatment within the given time point. All families were active in treatment at four months, but only 67% (n=141) were in treatment within eight months and 48% (n=100) within twelve months due to naturalistic attrition. Autoregressive cross-lagged models were used to examine alliance-outcome associations within and across time points with child symptom severity, positive parenting practices, and family functioning (positive versus negative family interactions) as outcomes. Results indicated that child self-report of alliance and therapist -reported child alliance were simultaneously associated with less severe child symptomatology (at least one time point), but neither predicted decreased symptomatology with cross-lagged associations. No associations were found between child symptoms and caregiver alliance across reporters. For family functioning, observer-coded child alliance and caregiver self-reported alliance were simultaneously associated with family functioning at each time point, but only caregiver ratings of their alliance with the therapist were predictive of improved family functioning at eight months. No other reports of child- therapist or caregiver-therapist alliance were associated with improved family functioning. Similarly, observer- reported child alliance and caregiver self-reported alliance were simultaneously associated with positive parenting practices, but only caregiver-reported alliance was predictive of later improvements in these practices at twelve months. Again, no other reports of child or caregiver alliance were associated with positive parenting practices. This study helps to disentangle the differential impact of child-therapist and caregiver- therapist alliance, from multiple perspectives, on therapeutic outcomes in child psychotherapy. Given the predictive validity of the caregiver alliance for improved family functioning and parenting practices, future research might examine psychotherapy processes that impact this therapeutic allianc