An anorexia nervosa treatment strategy that promotes parental involvement in restoring an adolescent to healthy weight and eating habits is more effective than traditional individual-based anorexia nervosa therapy, according to new research.
The study, published online October 4 in Archives of General Psychiatry, is the first randomized clinical trial to definitively demonstrate that family based treatment, also known as the Maudsley Approach, is the treatment of choice for this patient population.
More than 50 percent of patients receiving family based treatment (FBT) were in full remission after a year-long treatment period, compared to 23 percent of those receiving adolescent-focused individual therapy (AFT). After a year of follow-up, only 10 percent of patients who achieved remission during family based treatment relapsed, compared to 40 percent of AFT subjects.
"What this study unequivocally demonstrates is if you have an adolescent with anorexia nervosa who is medically stable, family based treatment should be the first line of treatment," said Daniel Le Grange, PhD, Professor of Psychiatry and Behavioral Neuroscience and Director of the Eating Disorders Clinic at the University of Chicago Medical Center. Le Grange and James Lock MD, PhD, Professor of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine, are co-senior authors of the study.
In the study, 120 anorexia nervosa patients were recruited at the University of Chicago and Stanford University and assigned randomly to the two treatments. Patients were enrolled in either FBT or AFT in regular sessions for one year.
Family based treatment is an intensive outpatient program where families are encouraged to play an active role in restoring their anorexic child to healthy weight. Developed at the Maudsley Hospital in London, the treatment seeks to avoid hospitalization of the child with anorexia and instead helps the parents encourage healthy eating habits at home.
"It's an approach where parents are utilized as the agents of change in treatment in trying to prevent unnecessary hospitalizations by really reinforcing the resources that most parents have for taking care of their children," Le Grange said. "At its very core, you're trying to mobilize the parents to take effective charge of combating the eating disorder."
During the year-long treatment phase of the trial, significantly fewer adolescents enrolled in FBT (15 percent) were hospitalized for medical stabilization compared to the subjects enrolled in AFT (37 percent).
In the second phase of FBT, parents transfer control of their son or daughter's behavior back to the adolescent. Finally, once the patient has reached 95 percent of his or her ideal body weight, the final phase of the approach focuses on establishing a healthy adolescent identity, with appropriate parental boundaries.
"We weren't the problem. We're part of the solution."
Rina Ranalli's 12-year-old daughter was diagnosed with anorexia by her pediatrician in February 2008, after several weeks of rapid weight loss at a time when the active seventh grader should have been gaining weight.
The girl (whose identity is anonymous at her family's request) was diagnosed by her pediatrician. Ranalli then arranged for her daughter to see a pediatric dietician and a psychologist for cognitive-behavioral therapy.
Realizing quickly that her daughter was not making enough progress, Ranalli desperately sought help from anywhere she could get it. After reading that Le Grange leads the eating disorders program at University of Chicago Medical Center, the couple immediately put their daughter on the program's wait list.
As the family waited for an opening, Ranalli and her husband adapted a home version of the Maudsley approach, with little initial success. The girl would bargain with her parents and the dietician, gaining just enough weight that she could continue or resume activities. "This negotiating went on for months. She'd gain a little weight then lose it right back," Ranalli said.
After their daughter officially started treatment in September 2008, Ranalli and her husband noticed immediate improvement. The parents, along with a University of Chicago Medical Center pediatrician and Le Grange, worked as a team on goals for weight restoration and developing healthy eating habits.
The high caloric intake to gain the necessary weight (about twice what a healthy person consumes) and around-the-clock supervision were tough on everyone. A parent had to be present at each meal and snack time throughout the day, no matter how long it took to coax the girl to eat. There were periods of refusal to eat and outright defiance.
Over approximately 20 sessions, all of which included both parents and their daughter, Ranalli came to understand the disease. "We weren't the problem. We're part of the solution. Anorexia is a disease of the mind and the body," Ranalli said. "You have to treat both."
The girl's acceptable weight was restored in January 2009 and in the following months freedoms were also restored. Now 15 years old, Ranalli's daughter has returned to full health and "actually enjoys eating," said Ranalli.
Ranalli is "amazed" that the Maudsley Method remains controversial. "Look, if your child has cancer, you do whatever it takes to try to get them better. This is no different and it works."
The First Gold Standard for Anorexia Nervosa
Despite the improved outcomes with family based treatment, the trial also confirmed the lower effectiveness of individual therapy. About one quarter of subjects receiving AFT showed full remission at the end of the treatment phase, and 60 percent of those patients had avoided relapsing to their eating disorder 1 year after treatment. But the new data suggests that eating disorder clinics should consider making the family based treatment the primary approach with anorexic patients, the authors said.
"I would like clinicians to see that parents can be helpful," Lock said. "The model of putting kids in the hospital, which excludes parents, or of professionals expecting young adolescents to manage their own eating without their parents' help when they're immersed in anorexic thinking, really should be reconsidered."
Ongoing trials are comparing the effectiveness of FBT and AFT in adolescents with bulimia nervosa, and research continues on ways to tailor FBT for patients that fail to respond to the standard treatment plan. But the current study should have a major impact on a field where randomized clinical trials have previously been scarce.
"This is only the sixth randomized controlled study for adolescents with anorexia nervosa in the over 130 years since this illness was first described," Le Grange said. "For the first time, we can confidently present parents with a treatment we consider the gold standard for this patient population."
The study, "Randomized clinical trial comparing family based treatment to adolescent focused individual therapy for adolescents with anorexia nervosa," appears in the October 4 issue of Archives of General Psychiatry. In addition to Lock and Le Grange, the authors include W. Stewart Agras, Susan W. Bryson, and Booil Jo of Stanford University School of Medicine, and private practitioner Ann Moye. Funding was provided by the National Institutes of Health.
Information about the Eating Disorders Program at The University of Chicago is available at http://eatingdisorders.uchicago.edu.
Archives of General Psychiatry