Running head: FAMILY-BASED TREATMENT1

Family-Based Treatment for Full and Partial

Anorexia Nervosa in Adolescence
Melissa L. Lafferty
Wayne State University School of Social Work

FAMILY-BASED TREATMENT

Family-Based Treatment for Full and Partial

Anorexia Nervosa in Adolescence
Statement of the Problem
According to the National Library of Medicine (2013), anorexia nervosa is an eating
disorder that makes people lose more weight than is considered healthy for their age and height
(para. 1). Anorexia is the medical term for loss of appetite, and nervosa refers to a behavior that
affects a persons mind or body via the nervous system. Persons with anorexia nervosa often
have an intense fear of gaining weight, even when they are severely underweight, and they may
use drastic measures, such as starving themselves or over exercising, to lose weight. There are
many risk factors for anorexia nervosa, including having a negative self-image and an infatuation
with perfection. Due to malnutrition, individuals with anorexia nervosa may suffer serious
health complications, such as bone weakening, decrease in white blood cells, and dangerous
heart rhythms. According to Anorexia Nervosa and Other Related Eating Disorders (2011),
research suggests that about 1% of female adolescents have anorexia nervosa, and about 20% of
people who do not undergo treatment for their eating disorder die.
Anorexia nervosa is of particular interest to me because I used to suffer from it.
During my middle school and high school years, I was an overachiever who was preoccupied
with perfection and wanted to have the perfect, thin body. Now that I have overcome my
anorexia nervosa, I would like to help provide effective treatment to others who are suffering,
and therefore, I must know what evidence-based intervention effectively treats this disorder.
The Hough Center for Eating Disorders is a program run through
Beaumont Childrens Hospital in Royal Oak, Michigan that seeks to provide treatment for
middle school through high school-aged adolescents with eating disorders such as anorexia
nervosa. This practice setting emphasizes a team-centered approach to treatment that includes a

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number of adolescent health specialists, physicians, psychologists, social workers, and nurse
practitioners (Beaumont Childrens Hospital, 2013). So for effective treatment, what evidencebased intervention must social workers and other mental health professionals use to treat
anorexia nervosa in adolescents?
Research Design
The intervention study that I selected is called Open Trial of Family-Based Treatment
for Full and Partial Anorexia Nervosa in Adolescence: Evidence of Successful Dissemination,
and this study evaluated how well adolescents with anorexia nervosa (AN) or subthreshold AN
(SAN) responded to family-based treatment (FBT) in an outpatient setting. The study design
used in this experiment is the one-group pretest-posttest design, which is a type of
preexperimental design. This type of research design tends to have low internal validity.
In this experiment, testing and instrumentation changes were controlled. Testing
was consistent throughout the study, and the measures used before and after treatment remained
the same.

There were several potential threats to internal validity in this study, including

history, maturation or the passage of time, statistical regression, selection biases, and ambiguity
about the direction of causal influence. The participants in this study were treated as outpatients,
and factors in their lives may have changed their attitudes toward themselves and their treatment.
In addition, as this group of participants matured, they may have made progress with their eating
disorder on their own without intervention. Since there were several phases in the study, the
final number of participants could have had Eating Disorder Examination (EDE) subscales
scores and Childrens Depression Rating Scale-Revised (CDRS-R) scores that were artificially
high. Additionally, selection bias could have occurred in this study, as the participants who were
in this study were being compared to those whom refused to complete the requirements of the
study. In addition, there was ambiguity as to whether the FBT protocol helped the participants

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obtain good outcomes or the good outcomes obtained by the participants helped them be
successful in the treatment program.
There were also potential concerns about the external validity of this research, as the
study had strict criteria for who was selected to participate. The study did not include those with
AN who had bipolar disorder, psychotic disorder, substance dependence, mental retardation, who
were medically unstable, had unstable chronic medical conditions, or whose weight was below
75% of their ideal body weight (Loeb et al., 2007). Additionally, participants could not be in
another treatment program for AN, had to have at least one parent willing to participate in the
treatment, and had to have no history of physical or sexual abuse by the parent or guardian. This
study was also designed for outpatient treatment; therefore, it would not be generalized for
inpatient treatment of AN.
Since the researchers used a preexperimental design, the findings could be
impacted by the low internal validity of the study. For example, participants who had good
outcomes at the end of the study may have had good results because they had matured and
realized that they needed to take care of themselves. A causal inference was possible in this
study, as a one-group pre-test post-test design ensures that an assessment is completed prior to
the post-test measurement (Rubin & Babbie, 2013). Secondly, the two variables in this study the therapy itself and the patients outcomes - covary with each other, as there was an
improvement in the patients outcomes because of the therapy. Lastly, the final criteria required
to show a causal inference was demonstrated, as there was no third variable that was clearly
identifiable.
Sampling
The patients parents or guardians signed a records release form so that clinical data could

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be shared with the researchers. In addition, the researchers used interview data to collect the
samples for the study. The study included multiple therapy sessions (20-30) in which family
members as well as the patients were interviewed.
The twenty participants in this study were recruited or referred via newspaper
advertisements and mailings to local members of eating disorder professional organizations.
Fifteen patients (75%) were referred by pediatricians, psychiatrists, psychologists, or social
workers at other hospitals or eating disorders programs, and five (25%) were self-referred. The
average age of the patients was 14.85 years, the mean duration of illness was 13.8 months, and
95% were female, 75% were white, and 80% came from intact families. Additionally, 65% of
the participants had a full diagnosis of AN, 15% met criteria for AN binge-eating/purging
subtype, and 50% were in concurrent treatment for comorbid depressive or anxious symptoms
(Loeb et al., 2007).
In this study, the researchers used purposive sampling, a type of nonprobability sampling.
The researchers wanted to assess FBT on a specific group of patients with AN, so by using
purposive sampling, the researchers were able to select patients who met certain medical criteria.
Purposive sampling allows researchers to study a small subset of a population and is less costly
than probably sampling. Nonprobability sampling, however, has some disadvantages, including
biases in element selection by the researcher and an inability to calculate a sampling error (Rubin
& Babbie, 2013).
Although interviews are not always the most effective way to collect data, the researchers
in this study had at least 20 sessions with the participants and used reliable and valid therapeutic
tools to make assessments and draw conclusions. In addition, the researchers were provided with
additional medical information to help track the patients progress. Since the patients were seen

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over the course of about one year, the therapist working with the participants had the opportunity
to assess progress in a consistent and reliable way. All therapists followed scientific methods in
conducting the data for this study, and any patients that were unable to complete the study
successfully were not included in the analytical part of the study.
The results of the study would have been significantly different if data had been collected
in an alternative way. For example, if the patients had just completed a paper survey to let their
therapists know how they were doing, the treatment may not have been successful, as an
adolescent with an eating disorder could easily lie about his or her eating behavior and weight.
Ideally, the same criteria should be used before and after treatment to accurately measure the
patients progress. Researchers should always conduct sampling in the same way; otherwise,
they could not accurately compare the changes that the patients have made in their eating
behaviors, psychological state, or weight.
The researchers used known valid and reliable methods of collecting, measuring, and
analyzing the data, so the sampling was considered scientific. This study, however, only
contained 20 participants, so the small sample size could be viewed as inadequate. Further
studies with a larger number of participants could help validate the conclusions of this study.
There is a question asking how similar the sample for the study is to the one used in my agency
or volunteer setting. I cannot answer this question because I am not currently in an agency or
volunteer setting.
Measurement
The key independent variable in this study is the FBT that the participants received, and
the key dependent variable is the clinical outcome after treatment. The studys authors define
FBT as, An outpatient weight gain protocol that is designed to be conducted in about 20
sessions over the course of 1 year (Loeb et al., 2007, p. 793). The outcomes of the study were

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measured using the percentage of ideal body weight (IBW), changes in menstrual status, the
EDE subscales scores, and the CDRS-R scores. Other variables in this study included criteria of
whether the participant had AN or SAN, age, therapist training, parent cooperation, length of
treatment, height, weight, binge eating, purging, secondary amenorrhea, and sex. The
researchers included an indicator variable to test the intensity levels related to predicting end-oftreatment percentage of IBW. The percentage of IBW was a covariate and the interactions
between these two variables were tested and used in the study.
The percentage of IBW was defined by measuring height and weight on a physicians
balance scale (without shoes and in single-layer street clothes). The EDE assesses eating
behavior, inappropriate compensatory behaviors, and four additional dimensions of eating
disorder pathology. The CDRS-R is an assessment tool used by therapists to assess adolescent
depression, and both the EDE and CDRS-R have well-established reliability and validity (Loeb
et al., 2007).
There are multiple ways that findings could have been different if the variables were not
consistently defined. For example, if the physicians did not calculate IBW using the same scale
or weighed a patient in a different manner than outlined, then a patient who did not meet the
studys criteria could have been included in the study. Incorrectly measuring or accounting for
any of the variables in this study could have had negatively impacted the study or skewed the
results.
This study found its results valid based on criterion-related validity. In particular, the
researchers in this study used predictive validity, as they measured outcomes of participants and
a prediction of their future recovery. The researchers analyzed the data using a standard
statistical software package (SPSS), paired t tests (for normally distributed variables) or

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Wilcoxon signed-rank tests (for non-normally distributed variables), and McNemar's test. The
researchers performed Independent samples t tests (for normally distributed continuous
variables) and X2 analyses (for categorical variables) that revealed no significant differences
between the two groups or any of these variables. In addition, the researchers conducted
regression analyses to examine the relationship between treatment intensity and percentage of
IBW. In this study, a good outcome was defined as weight restoration (>85% IBW) plus
resumption or onset of menses, intermediate outcome was defined as weight restoration in the
absence of menses, and poor outcome was defined as neither weight restoration nor resumption
or onset of menses (Loeb et al., 2007).
Data Collection
The patients participated in pre and post study evaluations. The pre-test data included
percentage of IBW, menstrual status, a depression rating record (using CDRS-R), and EDE
assessment. Five clinicians with extensive experience in working with adolescents with eating
disorders and training in family-based treatment for AN conducted the therapy sessions. The
clinicians consisted of two psychologists and three psychiatrists and included consultation with
the authors of the FBT manual. The researchers collected post-data in the same manner that they
collected the pre-test data.
The researchers used reliable and valid methods for collecting the data in this study. In
order to participate in the study, all patients had to acquire clearance from their pediatricians as
well as meet certain physical and mental health criteria. In addition, all participants had to
receive FBT for at least 20 sessions and complete all three phases, and all of the therapists were
trained in FBT in the same manner. These are all strengths of this data collection method, as it
helped maintain the integrity of the variables in the study; however, this data collection method
also had weaknesses and disadvantages. For example, if a clinician collecting data was not

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appropriately trained in working with patients with eating disorders, he or she may not have
accurately collected the data, as a patient could lie about the last time she had a period or have
multiple layers of clothing on when being weighed. In addition, if different therapists performed
the pre and post assessments, there may have been some differences in the EDE and CDRS-R
scores.
The researchers in this study could have used computerized data collection from the
families of the patients as an alternative method for collecting data. Specific questions about
their childs behaviors, self-esteem and image, eating patterns, and overall health could have
been asked to both parents as well as siblings. The researchers could have used this method to
clarify the overall impact that FBT had on the patient based on his or her behaviors in a home
environment versus a clinical setting. Perhaps the families would answer the questions more
truthfully in their homes versus in an interview with a therapist, which would then impact the
studys findings.
Ethics and Cultural Considerations
The results of the study indicated that adolescents with AN can be helped by this
intervention. Patients gained a significant amount of weight without hospitalization, and the
majority of patients met the criteria for a good outcome by the end of treatment. The
intervention is sensitive to the unique characteristics of a person with AN, as it deals with the
disease in multiple phases and involves multiple family members in its approach. Families will
be able to maintain their own cultural traditions or beliefs as long as it does not conflict with the
treatment of the patient. In addition to family members, FBT also involves the adolescents
physician and therapist, who will follow professional codes of ethics and respect diversity.
Although this approach may be difficult in some families, it would likely still be effective, as the
therapist and other professionals can make adjustments when working with the individual and

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families and maintain cultural sensitivity and respect.

This study did reflect multiple ethical components, including a commitment to clients,
self-determination, informed consent, competence, and cultural competence and social diversity.
The study also specifically mentioned that written informed consent was obtained from parents
or legal guardians for their own participation and for permission for their child with AN/SAN
and any underage siblings to participate. Consent to participate was also obtained from adult
siblings, and written assent was obtained from all the minors in the study.
Overall, there did not appear to be any blatant deficiencies in the area of ethics or cultural
sensitivity; however, the authors of the study could have addressed more ethical concerns. The
fact that the study was done on adolescents and is a family-based approach does mean that some
privacy for the patient would be lost, as the family members would be opening and honestly
discussing many issues that centered around the patient with AN/SAN. Perhaps FBT itself could
be very difficult for some individuals with eating disorders, as some family dynamics or
underlying issues may have led to the development of the disorder itself. For example, a parent
who is very critical of his or her childs physical appearance or demands straight As may not
be helpful in the therapy session. The study did not discuss how these potential issues would be
discovered or dealt with in FBT.
Results and Implications
The intervention addressed many of the medical issues and long-term effects that occur
with AN, including weight stabilization, loss of menses, and abnormal eating patterns. Overall,
the results indicated that adolescents with AN can be helped by this intervention, as the majority
of patients met the criteria for a good outcome by the end of treatment. Specifically, the study
revealed that the percentage of IBW improved significantly during the course of treatment,
increasing from 82.30 at baseline to 93.61 at termination. Analyses also showed significant

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improvement over time in EDE Restraint subscale and EDE Eating Concern subscale. Two of
the three patients who were binge eating or purging at the start of treatment had stopped at
termination. Additionally, there was a significant increase in the percentage of female patients
menstruating by the end of treatment (11% vs. 67%). Thirteen (65%) of patients met revised
Morgan-Russell criteria for good outcome, three (15%) for intermediate outcome, and four
(20%) for poor outcome. Each of the seven participants with SAN met criteria for a good
outcome by the end of treatment.
I believe that FBT is an effective intervention for adolescents suffering from anorexia
nervosa. Although this treatment plan is not ideal (or generalizable) for all patients with AN or
eating disorders, the study revealed that it would be useful for many in outpatient treatment.
Thirteen of the fifteen who completed the program had a good prognosis for recovery, while the
other two had an intermediate prognosis for recovery. Overall, this research indicated that FBT
was very successful in treating AN and SAN and will help those suffering from AN recover.
In order to implement this intervention, a practitioner would need to be trained in
FBT. Once trained, practitioners should review techniques and receive feedback from others
who have been trained. Additionally, practitioners should maintain their education in order to
practice FBT.
The implementation of this type of intervention would be somewhat costly, as it
requires specialized training and education that would not be readily available. There are not
many practitioners who specialize in AN, and even fewer who would be trained in FBT. In
addition, this approach may not be appealing to many people who seek help for AN. Many
families may be unable or unwilling to commit to FBT, which is necessary for this treatment to
be effective. In addition, many of the adolescents may be very resistant to a family treatment

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plan, feeling too ashamed, embarrassed, or uncomfortable to complete the requirements of FBT.
The relatively small number of people who would actually use FBT makes this somewhat
inefficient and not cost effective for many agencies to implement.

References
Anorexia Nervosa and Other Related Eating Disorders. (2011). Statistics:
How many people
have eating disorders? Retrieved from
http://www.anred.com/stats.html

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Beaumont Childrens Hospital. (2013). Teen eating disorders. Beaumont

Heath System.
Retrieved from http://www.beaumontchildrenshospital.com/eatingdisorders
Loeb, K. L., Walsh, B. T., Lock, J., LeGrange, D., Jones, J., Marcus, S., Weaver,
J., & Dobrow I.
(2007, January 7). Open trial of family-based treatment for full and
partial anorexia
nervosa in adolescence: Evidence of successful dissemination. Journal
of the American
Academy of Child and Adolescent Psychiatry, 46(7). Retrieved from
http://eds.b.ebscohost.com.proxy.lib.wayne.edu/eds/detail?
sid=473c8cfe-ce2a-47e484b73c3a805539e9%40sessionmgr113&vid=1&hid=115&bdata=JnNp
dGU9ZWRzLWx
pdmUmc2NvcGU9c2l0ZQ%3d%3d#db=eric&AN=EJ944862
National Library of Medicine. (2013, February 26). Anorexia nervosa. A. D. A. M. Medical
Encyclopedia. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmedhealth/PMH0001401/
Rubin, A., & Babbie, E. (2013). Essential research methods for social work (3rd ed.). Belmont,
CA: Brooks/Cole, Cengage Learning.