The Society for Clinical Child and Adolescent Psychology (SCCAP):
Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent
Mental Health Problems
With additional support from Florida International University and The Children’s Trust.
Keynote Evidence-Based Treatment for Adolescents with Anorexia and Bulimia
Daniel Le Grange, Ph.D. Director: Eating Disorders Clinic
Professor of Psychiatry and Behavioral Neuroscience The University of Chicago Medical Center
Outline of Presentation
① The role of the family in eating disorders
② Evidence-based treatment for AN
Implications of findings
③ Evidence-based treatment for BN
Implications of findings
④ Resources and current studies
The Role of the Family
Adolescent Anorexia Nervosa Le Grange et al., IJED, 2010
Part 1
“The patients should be
fed at regular intervals,
and surrounded by
persons who would
have moral control over
them; relatives and
friends being generally
the worst attendants.”
William Gull (1816-1890)
“None should be surprised to note that I always
consider the morbid state of the hysterical patient side
by side with the preoccupations of her relatives.”
Charles Lasegue (1816-1883)
“In view of the undoubted
psychological aspects (of the
disorder), it would be equally
regrettable to ignore or
misinterpret the patient’s
psychological surroundings.”
“It is necessary to
separate both children
and adults from their
father and mother,
whose influence, as
experience teaches, is
particularly pernicious”
Jean Martin Charcot
(1825-1893)
The 20th Century
First Half - Parentectomy*: “A slang term
meaning removal of a parent (or both
parents) from the child.” *MedicineNet.com
Second Half - Salvador
Minuchin, Child Psychiatrist
and parent of Structural
Family Therapy
The Maudsley Approach
There is little doubt that the
presence of an ED has a
major impact on family life.
With time, food, eating, and
their concomitant concerns
begin to saturate the family
fabric. Consequently, daily
family routines as well as
coping and problem solving
behaviors are all affected.
Ivan Eisler, Parent
of Family Therapy
for Adolescent AN
Evidence-Based Treatment
Adolescent Anorexia Nervosa
Part 2
First Uncontrolled Study:
Structural Family Therapy
Characteristics
53 patients
Ages 9-21 years
16 therapists
Problems
No outcome measures
No control group
First Maudsley RCT
(N=80)
Subgr. 1 + 5 Yr FU
60
70
80
90
100
110
Inpt Dis 1yr 3yr 5yr
%IB
W FT
IT
Russell, Szmukler, Dare, Eisler, Arch Gen Psych,
1987; Eisler, Dare, Russell, Szmukler, Le Grange,
Dodge, Arch Gen Psych, 1997.
60
70
80
90
100
Adm Dis 3mo 6mo 9mo 1 yr
%IB
W FT
IT
FBT n=10
Supportive therapy n=9
12 months Tx post hosp
5-year FU
Conclusions
Family therapy was found to be more
effective than individual therapy in patients
whose illness was not chronic and had begun
before the age of 19 years.
Much of the improvements found at 5-year
follow-up can be attributed to the natural
outcome of the illness. Nevertheless, it was
still possible to detect long-term benefits of
family therapy completed 5 years previously.
Second Maudsley
RCT (N=58)
70
80
90
100
Start Tx End Tx 2 Yr FU
%IB
W
Pilot n=18
Larger study n=40
Conjoint FT (CFT)
Separated FT (SFT)
4-Year FU
Le Grange, Eisler, Dare and Russell, IJED, 1992;
Squire-Dehouck, 1993; Eisler, Dare, Hodes, Russell,
Dodge & Le Grange, J Child Psychol, 2000.
Conclusions
On global measure of outcome, the two
forms of family therapy were associated with
equivalent end of treatment results.
For those patients with high levels of
maternal criticism toward the patient, SFT was
shown to be superior to the CFT.
Detroit RCT
(N=37)
BFST n=19
EOIT n=18
12-18 months of Tx
1 year follow-up
Robin, Siegel, Moye, Gilroy, Baker Dennis &
Sikand, JAACAP, 1999.
Conclusions
BFST and EOIT proved to be effective
treatments for adolescents with AN, but BFST
produced a faster return to health.
Stanford Dosage
Study (N=86)
0
1
2
3
4
5
6
7
8
0 6 12
Kg
's
Long-term
Short-term
Lock, Agras, Bryson & Kraemer, JAACAP, 2005;
Lock, Couturier, Agras & Bryson, JAACAP, 2006.
Long-term FBT
Short-term FBT
12mo vs 6mo Tx
48mo FU
BMI Over Time
10
12
14
16
18
20
22
0 6 12 18 24 30 36 42 48
Months
BM
I short
long
Conclusions
A short course of family therapy is as
effective as a longer course.
These good outcomes were maintained at
4-year follow-up.
Liverpool RCT
(N=167)
CAHMS n=55
Specialized Outpt n=55
Inpt treatment n=57
One and two year FU
Gowers, Clark, Roberts, Griffiths, Edwards,
Bryan, Smethurst, Byford & Barrett, Br J Psych,
2007.
One Yr FU
0
25
50
75
100
Good Interm Poor
CAHMS
SOP
INPT
Two Yr FU
0
25
50
75
100
Good Interm Poor
CAHMS
SOP
INPT
Conclusions
First-line in-patient psychiatric treatment
does not provide advantages over out-patient
management.
Out-patient treatment failures do very poorly
on transfer to in-patient facilities.
Summary of these five studies
5 RCTs comparing psychosocial treatments
for adolescents with AN
4 of these involve family therapy (FBT or
BFST)
3 of these involve individual therapy
(supportive, adolescent focused therapy, CBT)
Evidence supports effectiveness of FBT, but
comparative efficacy data is limited
Family-Based Treatment vs
Adolescent Focused Therapy for
adolescent anorexia nervosa
A multisite comparison
Lock, Le Grange, Agras, Moye, Bryson & Jo, Arch Gen Psych, 2010
Rationale
The predominant models for treating
adolescent AN are:
Family-Based Treatment (FBT) is a therapy
aimed at symptom management by parents
early in treatment
Adolescent Focused Therapy (AFT) is a
therapy aimed at promoting self-efficacy,
self-esteem, and self-management of
eating problems by the adolescents
Chicago
(Le Grange)
Stanford
(Lock)
Assessors &
Therapists
Assessors &
Therapists
DCC
(Agras)
Study Design
Study Design
FBT > AFT in promoting full + partial remission; Meds will moderate outcome
Randomized 121 med stable adolescent AN (excl amenorrhea) to FBT or AFT; 2 mo on stable meds dose still meeting entry criteria
12 mo (24 contact hrs) of tx (24-1 hr sessions in FBT & 32-45 min sessions in AFT including collaterals with parents alone)
Independent assessments of weight + EDE at BL, EOT, 6 and 12 month follow-up
Primary Outcome
Full remission, i.e., 95% IBW for height and age according to CDC norms + EDE within 1SD of community norms
Approximates weight needed for return to full physical health in young adolescents and addresses growth, bone health, and hormonal function
EDE threshold is in the normal range for community sample and addresses minimization common in adolescent AN
Remitted at 3 months
*Fisher’s Exact
p=.021
Observed Partial and Full
Remission by Treatment
Time until %IBW > 95%
Relapse: Post-Treatment to
12-Month Follow-Up
*Fisher’s Exact
p=.021 Relapse at 12mo FU
Summary Findings
FBT is superior to AFT in promoting full
remission at follow-up
FBT is superior to AFT in promoting partial
remission at EOT, but diminishes over time
More participants treated with FBT reached
weight restoration by 3 months than in AFT
Maintenance of remission in FBT is superior
to AFT
FBT in Clinical Practice
Adolescent Anorexia Nervosa
Chicago Case Series (N=45)
*
*t(44)-8.153, p<.001 Le Grange, Binford & Loeb, JAACAP, 2005.
Columbia Open Trial (N=20)
Tx Response
75% completed full
course of treatment
67% menstruating by
end of treatment
%IBW changed from
81.9 to 94.1 (p=.000)
Sign changes in EDE
Res, EC, binge/purge,
and BDI
Loeb, Walsh, Lock, Le Grange, Jones,
Marcus, Weaver & Dobrow, JAACAP, 2007.
Weight gain >1.36 kgs at week 4 correctly
characterized:
Receiver Operating
Characteristic Analysis (N=65)
79% of responders [AUC = .814 (p<.001)]
71% of non-responders [AUC = .811 (p<.001)]
Doyle, Le Grange, Celio-Doyle, Loeb & Crosby, IJED, 2009.
Summary Findings
Preliminary support for the feasibility of an
outpatient approach with active parental
involvement in the treatment of C&A AN.
FBT can be successfully disseminated,
replicating high retention rates and significant
improvement in the psychopathology of
adolescent AN seen at the original sites.
Adolescents with AN, receiving FBT, who
show early weight gain are likely to remit at
end of treatment.
Implications for AN
FBT should be the first line intervention for
adolescents with AN who are medically fit
for outpatient treatment
Most patients respond favorably after
relatively few treatment sessions if illness
is recognized early on
AFT could be a credible alternative for
some patients
Evidence-Based Treatment
Adolescent Bulimia Nervosa
Part 3
40
Chicago RCT
FBT-BN vs SPT
N=80 adolescent BN
FBT-BN n = 41
SPT n = 39
6 months of therapy
6 month follow-up
Le Grange, Crosby, Rathuaz & Leventhal,
Arch Gen Psych, 2007.
Remission
0
10
20
30
40
50
60
70
80
90
100
Baseline Post-treatment 6 mo. Follow-up
Percen
t
FBT-BN
SPT
p = .049
p = .050
Partial Remission
0
10
20
30
40
50
60
70
80
90
100
Baseline Post-treatment 6 mo. Follow-up
Percen
t
FBT-BN
SPT
p = .055
p = .377
Conclusions
Family-based treatment showed a clinical
and statistical advantage over SPT at post-
treatment and at 6-month follow-up.
Reduction in core bulimic symptoms was
also more immediate for patients receiving
FBT vs SPT.
Maudsley RCT
FBT vs CBT-GSC
N = 85 adolescent BN
Family Therapy n = 41
CBT-GSC n = 44
6 months of therapy
6 month follow-up
Schmidt, Lee, Beecham, et al., Am J Psych,
2007.
Conclusions
Compared with family therapy, CBT guided
self-care has the slight advantage of offering a
more rapid reduction of bingeing, lower cost,
and greater acceptability for adolescents with
bulimia or eating disorder not otherwise
specified.
Summary Findings
Significantly greater early reductions in
symptomatic behavior for patients in FBT-BN
than in SPT
Significantly more patients in FBT-BN than in
SPT remitted at EOT and FU
No differences between FBT-BN and CBT-
GSC, although CBT more cost effective
40% remitted at EOT is still just a “foot in the
door”
Implications for BN
FBT and CBT for adolescents with BN are promising
Further work is required
Type of family involvement
CBT with parental support for adolescent BN
Role of medication
Resources and Current Studies
Adolescent Anorexia and Bulimia
Nervosa
Part 4
Resources
Family-Based Treatment can be successfully
disseminated
- Clinician Manual for AN (Lock & Le Grange, 2012)
- Clinician Manual for BN (Le Grange & Lock, 2007)
- Parent Handbook (Lock & Le Grange, 2007)
- Parent Case Book (Alexander & Le Grange, 2009)
- Clinician Handbook (Le Grange & Lock, 2011)
Clinician Manuals available for CBT-BN, AFT-
AN and SPT (AN & BN)
Current Studies for AN & BN
Several studies are currently underway
FBT-AN vs Inpatient Tx (Westmead Hospital)
FBT-AN vs FT (Six sites in US and Canada)
FBT-PO vs NEC (Chicago & Mt Sinai, NY)
FBT-AN vs PFT (Chicago & Melbourne)
FBT-SAN vs SPT (Mt Sinai, NY)
FBT-AN vs MFGT (Maudsley Hospital)
FBT for Young Adults with AN (Chicago)
CBT-A vs FBT-BN (Chicago & Stanford)
Adaptive FBT (Chicago & Stanford)
For more information, please go to the main website and browse for workshops
on this topic or check out our additional resources.
Additional Resources
Online resources: 1. SCCAP: Society of Clinical Child & Adolescent Psychology: https://clinicalchildpsychology.org
Books: 1. Le Grange, D., & Lock, J. (Eds.) (2011). Children and Adolescents with Eating Disorders: Handbook of Assessment and Treatment. New York: Guilford Press. 2. Robin, A.L., & Le Grange, D. Treating adolescents with anorexia nervosa using behavioral family systems therapy. In J.R. Weisz and A.E. Kazdin (Eds.), Evidence-based Psychotherapies for Children and Adolescents (2nd Edition), (pp. 345-358). New York: Guilford Press, 2010.
Peer-reviewed Journal Articles: 1. Eisler, I., Dare, C., Hodes, M., Russell, G.F.M., Dodge, E., & Le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41, 727-736. 2. Gowers, S., Clark, A., Roberts, C., Griffiths, A., Edwards, V., et al. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents. Randomised controlled trial. British Journal of Psychiatry, 91, 427-435 3.Grange, D., & Schmidt, U. (2005). The treatment of adolescents with bulimia nervosa. Journal of Mental Health, 14, 587-597. 4.Loeb, K.L., Walsh, B.T., Lock, J., Le Grange, D., Jones, J., Marcus, S., Weaver, J., Dobrow, I. (2007). Open Trial of Family-Based Treatment for Adolescent Anorexia Nervosa: Evidence of Successful Dissemination. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 792-800. 5. Lock, J., Couturier, J., & Agras, W.S. (2006). Comparison of long term outcomes in adolescents with anorexia nervosa treated with family therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 666-672. 6. Lock, J., Le Grange, D., Agras, S., Bryson, S., & Booil, J. (2011). Randomized clinical trial comparing family-based treatment to adolescent focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67, 1025-1032. 7. Schmidt, U., Lee, S., Beecham, J., Perkins, S., Treasure, J., et al. (2007). A randomized controlled trial of family therapy and cognitive behavior therapy guided self-care for adolescents with bulimia nervosa and related disorders. American Journal of Psychiatry, 164, 591-598.
Full Reference List Keynote: Evidence-Based Treatment for Adolescent Eating Disorders Books: Alexander, J., & Le Grange, D. (2009). My kid is back. Family intervention for anorexia nervosa.
Melbourne: University of Melbourne Press. Dare, C., & Eisler, I. (1997). Family therapy for anorexia nervosa. In D.M. Garner & P.E. Garfinkel (Eds.)
Handbook of treatment for eating disorders (pp.307-324). New York: The Guilford Press. Le Grange, D., & Lock, J. (2007). Treating bulimia in adolescents: A family-based approach. New York:
Guilford Press. Le Grange, D., & Lock, J. (Eds.) (2011). Children and Adolescents with Eating Disorders: Handbook of
Assessment and Treatment. New York: Guilford Press. Lock, J., & Le Grange, D. (2005). Help your teenager beat an eating disorder. New York: Guilford Press. Lock, J., Le Grange, D., Agras, S., & Dare, C. (2001). Treatment manual for anorexia nervosa: A family-
based approach. New York: Guilford Press. Robin, A.L., & Le Grange, D. Treating adolescents with anorexia nervosa using behavioral family systems
therapy. In J.R. Weisz and A.E. Kazdin (Eds.), Evidence-based Psychotherapies for Children and Adolescents (2nd Edition), (pp. 345-358). New York: Guilford Press, 2010.
Case Descriptions: Le Grange, D. Family therapy for adolescent anorexia nervosa (1999). Journal of Clinical Psychology, 5,
727-740. Le Grange, D. Family-based treatment for adolescent bulimia nervosa (2010). Australian and New
Zealand Journal of Family Therapy, 31, 165-175. Le Grange, D., Lock, J., & Dymek, M. (2003). Family-based therapy for adolescents with bulimia
nervosa. American Journal of Psychotherapy, 57, 2003, 237-251 Peer Reviewed Journal Articles: Dare, C., Eisler, I., Russell, G.F.M., & Szmukler, G.I. (1990). The clinical and theoretical impact of a
controlled trial of family therapy in anorexia nervosa. Journal of Marital and Family Therapy, 16, 39-57.
Eisler, I., Dare, C., Russell, G.F.M., Szmukler, G.I., Le Grange, D., & Dodge, E. (1997). Family and individual therapy in anorexia nervosa: a five-year follow-up. Archives of General Psychiatry, 54, 1025-1030.
Eisler, I., Dare, C., Hodes, M., Russell, G.F.M., Dodge, E., & Le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41, 727-736.
Gowers, S., Clark, A., Roberts, C., Griffiths, A., Edwards, V., et al. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents. Randomised controlled trial. British Journal of Psychiatry, 91, 427-435.
Le Grange, D., & Eisler, I. (2009). Family interventions in adolescent anorexia nervosa. Child and Adolescent Psychiatric Clinics of North America, 18, 159-173.
Le Grange, D., & Lock, J. (2005). The dearth of psychological treatment studies for anorexia nervosa. International Journal of Eating Disorders, 37, 79-91.
Le Grange, D., & Schmidt, U. (2005). The treatment of adolescents with bulimia nervosa. Journal of Mental Health, 14, 587-597.
Le Grange, D., Binford, R., & Loeb, K.L. (2005). Manualized family-based treatment for anorexia nervosa: A case series. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 41-46.
Full Reference List Le Grange, D., Crosby, R.D., Rathouz, P.J., & Leventhal, B.L. (2007). A randomized controlled comparison
of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry. 64, 1049-1056.
Le Grange, D., Eisler, I., Dare, C., & Russell, G.F.M. (1992). Evaluation of family treatments in anorexia nervosa: A pilot study. International Journal of Eating Disorders, 12, 347-358.
Le Grange, D., Lock, J., Loeb, K., & Nicholls, D (2010). An academy for eating disorders position paper. The role of the family in eating disorders. International Journal of Eating Disorders, 43, 1-5.
Le Grange, D., Loeb, K., Van Orman, S., & Jellar, C. (2004). Adolescent bulimia nervosa: A disorder in evolution? Archives of Pediatrics and Adolescent Medicine, 158, 478-482.
Loeb, K.L., Walsh, B.T., Lock, J., Le Grange, D., Jones, J., Marcus, S., Weaver, J., Dobrow, I. (2007). Open trial of family-based treatment for adolescent anorexia nervosa: Evidence of successful dissemination. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 792-800.
Lock, J., & Le Grange, D. (2001). Can family-based treatment of anorexia nervosa be manualized? The Journal of Psychotherapy Practice and Research, 10, 253-261.
Lock, J., Agras, S., Bryson, S., & Kraemer, H. (2005). A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 632-639.
Lock, J., Couturier, J., & Agras, W.S. (2006). Comparison of long term outcomes in adolescents with anorexia nervosa treated with family therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 666-672.
Lock, J., Le Grange, D., Agras, S., Bryson, S., & Booil, J. (2011). Randomized clinical trial comparing family-based treatment to adolescent focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67, 1025-1032.
Lock, J., Le Grange, D., Fordsburg, S., & Hewell, K. (2006). Is Family Therapy Effective for Children with Anorexia Nervosa? Journal of the American Academy of Child and Adolescent Psychiatry, 45, 1323-1238.
Robin, A.L., Siegel, P.T., Moye, A.W., Gilroy, M., Baker Dennis, A., & Sikand, A. (1999). A controlled comparison of family vs. individual therapy for adolescents with anorexia nervosa. Journal of the American Academy for Child and Adolescent Psychiatry, 38, 1482-1489.
Russell, G.F.M., Szmukler, G.I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44, 1047-1056.
Schmidt, U., Lee, S., Beecham, J., Perkins, S., Treasure, J., et al. (2007). A randomized controlled trial of family therapy and cognitive behavior therapy guided self-care for adolescents with bulimia nervosa and related disorders. American Journal of Psychiatry, 164, 591-598.
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