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A Randomised Controlled Treatment Trial of Two Forms of Family Therapy in Adolescent Anorexia Nervosa: A Five-Year Follow-Up

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Title: A Randomised Controlled Treatment Trial of Two Forms of Family Therapy in Adolescent Anorexia Nervosa: A Five-Year Follow-Up
Language: English
Authors: Eisler, Ivan, Simic, Mima, Russell, Gerald F. M.
Source: Journal of Child Psychology and Psychiatry. Jun 2007 48(6):552-560.
Availability: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp
Peer Reviewed: Y
Physical Description: PDF
Page Count: 9
Publication Date: 2007
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Intervention, Eating Disorders, Mothers, Parent Child Relationship, Questionnaires, Patients, Family Counseling, Therapy, Adolescents, Interviews, Symptoms (Individual Disorders), Outcomes of Treatment
DOI: 10.1111/j.1469-7610.2007.01726.x
ISSN: 0021-9630
Abstract: Background: There is growing evidence that family therapy is an effective treatment for adolescent anorexia nervosa. This study aimed to ascertain the long-term impact of two forms of outpatient family intervention previously evaluated in a randomised controlled trial (RCT). Method: A five-year follow-up was conducted on a cohort of 40 patients who had received either "conjoint family therapy" (CFT) or "separated family therapy" (SFT). All patients were traced and 38 agreed to be reassessed (29 interviewed in person, 3 completed telephone interviews, 6 completed questionnaires and/or agreed for parents/GP to be interviewed). Results: Overall there was little to distinguish the two treatments at 5 years, with more than 75% of subjects having no eating disorder symptoms. There were no deaths in the cohort and only 8% of those who had achieved a healthy weight by the end of treatment reported any kind of relapse. Three patients developed bulimic symptoms but only one to a degree warranting a diagnosis of bulimia nervosa. The one difference between the treatments was in patients from families with raised levels of maternal criticism. This group of patients had done less well at the end of treatment if they had been offered conjoint family meetings. At follow-up this difference was still evident, as shown in the relative lack of weight gain since the end of outpatient treatment. Conclusions: This study confirms the efficacy of family therapy for adolescent anorexia nervosa, showing that those who respond well to outpatient family intervention generally stay well. The study provides further support for avoiding the use of conjoint family meetings at least early on in treatment when raised levels of parental criticism are evident.
Abstractor: As Provided
Entry Date: 2008
Accession Number: EJ813260
Database: ERIC
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  Value: <anid>AN0025182222;jyy01jun.07;2024Jun04.07:36;v2.2.500</anid> <title id="AN0025182222-1">A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. </title> <p>Background:  There is growing evidence that family therapy is an effective treatment for adolescent anorexia nervosa. This study aimed to ascertain the long‐term impact of two forms of outpatient family intervention previously evaluated in a randomised controlled trial (RCT). Method:  A five‐year follow‐up was conducted on a cohort of 40 patients who had received either 'conjoint family therapy' (CFT) or 'separated family therapy' (SFT). All patients were traced and 38 agreed to be reassessed (29 interviewed in person, 3 completed telephone interviews, 6 completed questionnaires and/or agreed for parents/GP to be interviewed). Results:  Overall there was little to distinguish the two treatments at 5 years, with more than 75% of subjects having no eating disorder symptoms. There were no deaths in the cohort and only 8% of those who had achieved a healthy weight by the end of treatment reported any kind of relapse. Three patients developed bulimic symptoms but only one to a degree warranting a diagnosis of bulimia nervosa. The one difference between the treatments was in patients from families with raised levels of maternal criticism. This group of patients had done less well at the end of treatment if they had been offered conjoint family meetings. At follow‐up this difference was still evident, as shown in the relative lack of weight gain since the end of outpatient treatment. Conclusions:  This study confirms the efficacy of family therapy for adolescent anorexia nervosa, showing that those who respond well to outpatient family intervention generally stay well. The study provides further support for avoiding the use of conjoint family meetings at least early on in treatment when raised levels of parental criticism are evident.</p> <p>Keywords: anorexia nervosa; adolescence; Family therapy</p> <p></p> <ulist> <item> Abbreviations:</item> <p></p> <item> ABW average body weight</item> <p></p> <item> CFT conjoint family therapy</item> <p></p> <item> EE expressed emotion</item> <p></p> <item> SFT separated family therapy</item> </ulist> <p>Anorexia nervosa arises most commonly in adolescence, the highest at‐risk group being women between 15 and 22 years. The seriousness of the illness is shown, for instance, by [<reflink idref="bib30" id="ref1">30</reflink>] review of 119 studies covering 5,590 patients. The estimated mortality was high and among the surviving patients, less than one‐half had recovered, one‐third improved and 20% remained chronically ill. Co‐morbidity was also common at follow‐up. Follow‐up studies confined to adolescent patients are less bleak. Outcome in these studies is variable but the recovery rates reported at follow‐up are typically over 60% and sometimes higher ([<reflink idref="bib2" id="ref2">2</reflink>]; [<reflink idref="bib33" id="ref3">33</reflink>]; [<reflink idref="bib24" id="ref4">24</reflink>]; [<reflink idref="bib36" id="ref5">36</reflink>]). These findings carry an important caveat well illustrated by the findings of [<reflink idref="bib33" id="ref6">33</reflink>] showing that, although 87% adolescents suffering from anorexia nervosa were rated as having a good outcome after 12 years, the illness tended to be protracted, with the majority taking over 5 years to overcome the illness. Two studies have shown ([<reflink idref="bib28" id="ref7">28</reflink>]; [<reflink idref="bib7" id="ref8">7</reflink>]) that outcome was much better for patients who were never admitted to hospital.</p> <p>A number of follow‐up studies of adolescents with anorexia nervosa have shown positive responses to family therapy ([<reflink idref="bib20" id="ref9">20</reflink>]; [<reflink idref="bib19" id="ref10">19</reflink>]; [<reflink idref="bib9" id="ref11">9</reflink>]) and several small randomised controlled trials (RCTs) comparing either family therapy with individual therapy ([<reflink idref="bib27" id="ref12">27</reflink>], [<reflink idref="bib6" id="ref13">6</reflink>]; [<reflink idref="bib26" id="ref14">26</reflink>]) or different forms of family intervention ([<reflink idref="bib15" id="ref15">15</reflink>]; [<reflink idref="bib5" id="ref16">5</reflink>]; [<reflink idref="bib17" id="ref17">17</reflink>]) have provided further evidence for the value of family therapy in the treatment of adolescent anorexia nervosa (see [<reflink idref="bib4" id="ref18">4</reflink>] for a review).</p> <p>This paper presents a five‐year follow‐up of one of the above RCTs ([<reflink idref="bib5" id="ref19">5</reflink>]). We reported the end‐of‐treatment results of 40 adolescent patients with anorexia nervosa treated with 'conjoint family therapy' (CFT) or 'separated family therapy' (SFT). Both therapies were provided on an outpatient basis unless the patient's physical condition deteriorated to such an extent that inpatient treatment became unavoidable (necessary in 10% of the cases). Considerable improvement in nutritional and psychological state occurred across both treatment groups at 3 months, at 6 months and at the end of treatment at 12 months. On global measures of outcome, the two forms of therapy showed comparable end‐of‐treatment results. Two main findings differentiated the treatments. First, for patients from families with high levels of maternal expressed emotion (EE), SFT was shown to be superior to CFT. Second, on measures of individual psychological change (e.g., depression, self‐esteem, obsessionality and attitude to sexuality) there was significantly more improvement in those who received CFT.</p> <hd id="AN0025182222-2">Methodology</hd> <p>The original study compared two forms of family therapy by means of a randomised controlled trial: conjoint family therapy (CFT) in which the whole family was seen together for treatment, and separated family therapy (SFT) in which the adolescent was seen individually, the parents attending for separate sessions with the same therapist. The two treatments, their similarities and differences were described in our original paper ([<reflink idref="bib5" id="ref20">5</reflink>]). The distinctiveness of the therapies was ensured by regular supervision provided by different supervisors. The treatments were one year in duration and were conducted on an outpatient basis. The treatment allocation was stratified to control for levels of critical comments using the Expressed Emotion (EE) index ([<reflink idref="bib16" id="ref21">16</reflink>]) (using three or more critical comments made by either parent as the threshold) to take into account previous findings that levels of criticism predicted the outcome of treatment [<reflink idref="bib14" id="ref22">14</reflink>]).</p> <p>Independent research assessments were conducted by researchers who were not connected with the treatment team at intake, 3 months, 6 months, 12 months (end of treatment) and at 5 years after the end of treatment. The research assessments were carried out on all subjects regardless of whether they completed the planned 12‐month course of treatment. The design of the study and procedures for obtaining consent from participants was approved by the Institute of Psychiatry Research Ethics Committee.</p> <hd id="AN0025182222-3">Subjects</hd> <p>The patients were from a consecutive series of referrals of adolescents to the Eating Disorder Services of the Maudsley Hospital in London. Of 57 referrals, 14 did not reach diagnostic criteria for anorexia nervosa at assessment and a further three refused participation when asked to give informed consent to take part in the study. Forty patients entered into the study. Their average age was 15 years (x = 15.5; s.d. = 1.6) and they had been ill on average for approximately one year, although the duration of the illness varied considerably (x = 12.9 months; s.d. = 9.4; range 2–36 months). All but one were female. Most of them were severely underweight, with an average body weight of 74.3% (s.d. = 9.8) (weights and heights were converted to average body weights (ABW) using a weight for height calculator based on the (1990) Child Growth Foundation charts) and a mean BMI of 15.4 (s.d. = 2.0). Nearly two‐thirds had previous treatment for anorexia nervosa (17 inpatient, 7 outpatient). Twenty‐five per cent of the patients were inducing vomiting and/or bingeing (and in some cases also abusing laxatives) at least once a week. There were no statistically significant differences on any of the demographic variables between the two treatment groups.</p> <hd id="AN0025182222-4">Individual assessment measures</hd> <p>The patients completed a number of questionnaires assessing mood, self‐esteem and obsessional phenomena as well as two eating disorder inventories. However, as relatively few of the subjects completed these at follow‐up we do not report on these here. A semi‐structured interview was used ([<reflink idref="bib22" id="ref23">22</reflink>]; [<reflink idref="bib21" id="ref24">21</reflink>]) to obtain details of the history, clinical manifestations of the illness and the psychosocial functioning of the adolescent. The [<reflink idref="bib22" id="ref25">22</reflink>]) Scales (M‐R Scales) were used to obtain ratings on the adolescents' Nutritional Status, Menstrual Functioning, Mental State, Psycho‐Sexual Adjustment, and Socio Economic Status. The average of these five scales was used as an Average Outcome Score (rated 0–12, with 12 indicating normal functioning). Analogous ratings were also made to score for the presence of bingeing, vomiting and laxative abuse. At the end of treatment and at follow‐up, overall outcome was categorised using the classification devised by [<reflink idref="bib22" id="ref26">22</reflink>]: 1) A <emph>good outcome</emph> for patients whose weight is within 15% of ABW, in whom menstruation has returned and there is no evidence of bulimic pathology; 2) an <emph>intermediate outcome </emph>for patients who had reached a normal weight but without the return of menstruation or who report bulimic symptoms at a frequency of less than once per week; 3) a <emph>poor outcome </emph>for patients whose weight is below 85% ABW, or who are bingeing and/or vomiting once a week or more. We report weight and changes in weight as a percentage of ABW and as BMI (Body Mass Index = kg/m<sups>2</sups>).</p> <hd id="AN0025182222-5">Family measures</hd> <p>Families were interviewed using the Standardised Clinical Family Interview ([<reflink idref="bib11" id="ref27">11</reflink>]), which was used for rating of EE ([<reflink idref="bib16" id="ref28">16</reflink>]). The use of a family interview for the ratings of EE was validated in 17 families against the customary Camberwell Family Interview ([<reflink idref="bib10" id="ref29">10</reflink>]).</p> <hd id="AN0025182222-6">Statistical procedures</hd> <p>Continuous data were analysed using paired <emph>t</emph>‐tests, ANOVA and ANCOVA procedures, categorical data was assessed using the Fisher Exact test or McNemar test. The statistical program, from [<reflink idref="bib29" id="ref30">29</reflink>]), was STATISTICA 7 running on a PC. The results comparing the two therapies are reported on an intention to treat basis, that is, regardless of whether or not the patient continued for the whole course of treatment.</p> <hd id="AN0025182222-7">Results</hd> <p></p> <hd id="AN0025182222-8">Engagement in treatment and follow‐up</hd> <p>Of the 40 patients in the study, 36 either completed a full year of treatment (29 subjects) or at least continued for a significant period of time defined here as a minimum of 3 months (7 subjects). Only four subjects dropped out within the first 3 months of treatment. Dropout rate was the same in both treatments. The end‐of‐treatment follow‐up was completed for all patients insofar as the patients' symptomatic status was concerned, although a number of the patients did not return their questionnaires and similarly some families did not attend the follow‐up interview. The five‐year follow‐up post treatment was complete for 38 patients insofar as patients' symptomatology was concerned, although again a number of patients did not complete all the questionnaires (29 patients were interviewed in person, 3 completed telephone interviews, 2 completed questionnaires supplemented by interviews with parent or GP, 4 agreed for parents/GP to be interviewed but did not return questionnaire and 2 refused all follow‐up). Family interviews were not repeated at follow‐up. The mean length of time between the start of treatment and the follow‐up was 71.9 months (s.d. = 9.1), i.e., approximately five years after the end of the outpatient treatment.</p> <hd id="AN0025182222-9">Overall response to treatment</hd> <p>Table 1 shows the changes between end of treatment and follow‐up for the group of patients as a whole (initial assessments are also included for comparison). During the follow‐up period there was a statistically significant increase in average weight from 87% to just under 95% of expected weight (<emph>t</emph> = 2.7; <emph>p</emph> = .01) and a similar improvement in menstrual functioning (at the end of treatment 36.4% of patients were menstruating compared to 86.2% at follow‐up – McNemar <emph>χ</emph><sups>2</sups> = 9.6, <emph>p</emph> = .002). There were small increases on all the ratings on the other Morgan–Russell scales, although the relatively high scores at the end of treatment produced a ceiling effect and none of the increases were statistically significant (with a maximum score of 12, the range of average scores of 9–11 on the different scales indicates essentially normal functioning). The average Morgan–Russell score was significantly improved (<emph>t</emph> = 2.4; <emph>p</emph> < .02).</p> <p>1  Changes during treatment and follow‐up</p> <p> <ephtml> <table><thead valign="bottom"><tr><th>Variable</th><th>Pre‐treatment</th><th>End of treatment</th><th>Follow‐up</th><th><italic>t</italic></th><th><italic>p</italic></th></tr></thead><tbody valign="top"><tr><td>%ABW</td><td align="left">74.3 (9.8) (40)</td><td>87.0 (13.1) (40)</td><td>94.3 (11.2) (33)</td><td>2.7</td><td>.01</td></tr><tr><td>BMI</td><td align="left">15.4 (2.0) (40)</td><td>18.5 (2.7) (40)</td><td>19.8 (2.4) (33)</td><td>2.1</td><td>.04</td></tr><tr><td>MRA</td><td align="left"> 3.3 (1.8) (40)</td><td>8.7 (3.0) (37)</td><td>9.3 (3.2) (36)</td><td>.6</td><td>.55</td></tr><tr><td>MRB</td><td align="left"> 1.9 (3.0) (39)</td><td>4.5 (5.3) (33)</td><td>9.7 (4.3) (35)</td><td>4.0</td><td>.00</td></tr><tr><td>MRC</td><td align="left"> 7.1 (1.9) (40)</td><td>10.2 (2.6) (38)</td><td>10.9 (2.0) (34)</td><td>1.1</td><td>.28</td></tr><tr><td>MRD</td><td align="left"> 6.9 (3.7) (40)</td><td>7.7 (3.6) (36)</td><td>9.1 (3.1) (34)</td><td>1.6</td><td>.13</td></tr><tr><td>MRE</td><td align="left"> 8.0 (3.0) (40)</td><td>9.7 (3.6) (38)</td><td>10.4 (2.4) (34)</td><td>1.4</td><td>.18</td></tr><tr><td>MR_AVE</td><td align="left"> 5.5 (1.7) (40)</td><td>8.3 (2.3) (38)</td><td>9.8 (2.5) (36)</td><td>2.4</td><td>.02</td></tr></tbody></table> </ephtml> </p> <p>1 Values are given as Mean (SD) (<emph>n</emph>).</p> <p>2 ABW – average body weight (adjusted for age, sex & height according to [<reflink idref="bib3" id="ref31">3</reflink>] charts); MR – Morgan–Russell Scales; A – Nutrition; B – Menstruation; C – Mental state; D – Psychosexual, E – Social.</p> <p>Table 2 compares end‐of‐treatment and follow‐up results in terms of categorised outcome. There were clear improvements, with those rated as having a good outcome rising from under 40% to over 76% and similarly those with a poor outcome reducing from 34% to under 16%. Notably, only two patients had a poorer outcome at follow‐up than at the end of treatment. One of these had lost a significant amount of weight (to 75.6% of average) and the other had developed bulimic symptoms, bingeing and vomiting up to once a week. In general, bulimic symptoms were rare, with only two other patients reporting significant symptoms and only one bingeing and vomiting more than once a week.</p> <p>2  Global outcome at end of treatment and 5‐year follow‐up</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="center">5 yr follow‐up</th></tr><tr><th>End of treatment</th><th>Good</th><th>Intermediate</th><th>Poor</th><th>Totals</th></tr></thead><tbody valign="top"><tr><td>Good</td><td align="left">13</td><td align="left">1</td><td>1</td><td>15 (39.5%)</td></tr><tr><td>Intermediate</td><td align="left"> 8</td><td align="left">2</td><td>0</td><td>10 (26.3%)</td></tr><tr><td>Poor</td><td align="left"> 8</td><td align="left">0</td><td>5</td><td>13 (34.2%)</td></tr><tr><td>Total</td><td>29 (76.3%)</td><td align="left">3 (7.9%)</td><td /><td>6 (15.9%)</td></tr></tbody></table> </ephtml> </p> <p>3 Fisher test G + I vs. P <emph>p</emph> = .01.</p> <hd id="AN0025182222-10">Changes in core eating disorder symptoms and psychosocial functioning</hd> <p>The categorisation of outcome using the Morgan–Russell classification is limited to weight, menstrual functioning and the presence or absence of bulimic symptoms and it is therefore important to examine the extent to which this outcome reflects psychosocial functioning. Figure 1 shows the breakdown of the individual Morgan–Russell ratings by the good, intermediate and poor outcome groups, showing the relationship between improvement in core eating disorder symptoms and the normalisation of psychosocial functioning. All the scales have average scores between 9 and 12 for those in the good outcome group, with statistically significantly lower scores on most scales for the poor outcome and to a lesser extent for the intermediate outcome group.</p> <p>Graph: 1 Relationship between symptomatic outcome and psychosocial outcome at follow‐up. MR – Morgan–Russell Scale; A – Nutrition; B – Menstruation; C – Mental state; D – Psychosexual, E – Social significance tests (ANOVA) –***p < 0.001; **p < .01; *p < .05.</p> <hd id="AN0025182222-11">Predictors of outcome</hd> <p>Our end‐of‐treatment analysis ([<reflink idref="bib5" id="ref32">5</reflink>]) found that a number of factors predicted a poorer outcome. These included the amount and type of previous treatment, the duration of the illness, the degree of weight loss at the beginning of treatment, maternal criticism and a history of psychiatric disorder. At the time of the follow‐up only two of these pre‐treatment variables were still found to be associated with outcome. The first was a history of having inpatient treatment; of the 16 patients who had prior treatment in hospital, 5 had a poor outcome at follow‐up compared to only one of the 22 with no hospital treatment (Fisher exact probability test <emph>p</emph> =.04). The second predictor was having a critical mother. Patients whose mothers made three or more critical comments during the initial assessment family interview had poorer Average Outcome Morgan–Russell scores (x = 8.9, s.d. 3.0 for High EE vs. x = 10.6, s.d. = 1.5 for low EE; <emph>F</emph> = 4.6, <emph>p</emph> < .04). The obvious question arises whether these two factors might be correlated, but while the frequency of previous admissions was nearly twice as high in the high EE group the difference was not statistically significant (<emph>p</emph> = .07 Fisher test), suggesting that these factors may be operating independently of one another. An additional finding that makes interpretation of the relationship between these variables more difficult is that patients from high EE families were significantly lower in weight at the start of the study (x = 70.5%; s.d. 7.5 for High EE vs. x = 77.1%; s.d. 10.3 for Low EE; <emph>t</emph> = 2.18; <emph>p</emph> < .04). When weight is added as a covariate, the relationship between High EE and follow‐up outcome is no longer statistically significant. No association was found between end‐of‐treatment assessment of EE and outcome at follow‐up.</p> <hd id="AN0025182222-12">Comparison of outcome between the two treatments</hd> <p>Figure 2 shows the progress of the patients in the two treatment groups during treatment and follow‐up. A repeated measure analysis of variance (using end of treatment and follow‐up ABW; with baseline ABW and baseline EE as covariates) shows a main effect of time (<emph>F</emph> = 7.53; <emph>p</emph> = .01) but no interaction between treatment and time (<emph>F</emph> = .7; <emph>p</emph> = .41). Table 3 shows that the patients in the two treatments also had similar general outcome at follow‐up. Overall, 72.2% of patients in CFT group and 80% of patients in SFT had good outcome. Patients in the CFT group were somewhat lighter than those treated in SFT but the difference was below the level of statistical significance (CFT x = 91.0% ABW s.d. = 12.2; SFT x = 97.7% s.d. = 9.32; <emph>t</emph> = −1.76, <emph>p</emph> < .09). The only significant difference between the two groups was in the number of patients whose menstrual functioning had returned to normal: 19/20 in the SFT group but only 13/18 in the CFT group (Fisher exact probability <emph>p</emph> = .02). This difference, as will be described in the subsequent section, is almost entirely (4 out of 5) accounted for by patients in high EE families.</p> <p>Graph: 2 Average weight gain during treatment and follow‐up</p> <p>3  Comparison of outcome at follow‐up by treatment</p> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th>Good</th><th>Intermediate</th><th>Poor</th><th>Total</th></tr></thead><tbody valign="top"><tr><td>CFT</td><td>13 (72.2%)</td><td>1 (5.6%)</td><td>4 (22.2%)</td><td>18</td></tr><tr><td>SFT</td><td>16 (80%)</td><td>2 (10%)</td><td>2 (10%)</td><td>20</td></tr></tbody></table> </ephtml> </p> <hd id="AN0025182222-13">The effect of expressed emotion on outcome in the two treatment groups</hd> <p>Previous work has suggested that response to family therapy may be different in high and low EE families; in other words, that EE may act as a treatment moderator. A moderator analysis showed a statistically significant three‐way interaction between type of treatment, EE and time (<emph>F</emph> = 5.74; <emph>p</emph> < .03), indicating a need for a separate analysis of treatment outcome for patients from high and low EE families. A somewhat different picture emerges from the one described above in the continuation of weight gain in the two treatments. As is seen in Figure 3, those in the high EE group who were treated with SFT continued to gain weight post treatment, and at follow‐up reached an average weight of 99.9% (s.d. 10.8) compared to 85.8% (s.d. 11.9) in the CFT treated group (ANCOVA <emph>F</emph> = 5.6; <emph>p</emph> < .04 controlling for weight reached at the end of treatment). This difference in weight is reflected in the fact that 4 of the 7 patients had not yet resumed their menstrual function. In the low EE group the patients who were treated with CFT continued to gain weight post treatment, reaching a comparable weight at follow‐up (95%) to those treated with SFT (96.1%).</p> <p>Graph: 3 Weight progress during treatment and follow‐up in low and high maternal EE families</p> <hd id="AN0025182222-14">The need for additional outpatient or inpatient treatment</hd> <p>Although the treatment provided during the study was offered for one year, there were inevitably some patients who required additional treatment, returning either to the Maudsley Hospital or in some cases seeking treatment elsewhere. During the follow‐up interview patients and/or other informants were asked to provide details of any additional treatments. As these are retrospective accounts a degree of caution is needed in interpreting the data. Of the 31 patients for whom information was available, six reported having additional outpatient treatment, although not always for their eating problem (e.g., seeking help for depression or anxiety). Five further patients, however, required admission to hospital – in three cases having never achieved any significant weight gain during the outpatient treatment and in two cases relapsing following a brief period of normal weight. Four of those who had been admitted during the follow‐up period had had previous admissions either during the treatment received as part of the study and/or prior to enrolling in the study. No association was found between additional treatment and outcome at follow‐up. The number of those requiring additional treatment was evenly distributed between the two treatments but a significant association was found between maternal expressed emotion at initial assessment and the need for additional treatment (<emph>p</emph> < .03; Fisher test). The two patients who had relapsed and needed admission to hospital, having been rated as having a good outcome at the end of treatment, were both from high EE families.</p> <hd id="AN0025182222-15">Discussion</hd> <p>While there is considerable agreement about the value of family interventions in the treatment of adolescent anorexia nervosa ([<reflink idref="bib23" id="ref33">23</reflink>]), this consensus draws on relatively few studies. This current study adds to this evidence by providing longer‐term outcome data from one of the earlier RCTs, examining factors that are associated with outcome and comparing the contribution of the two treatments to eventual recovery. This is a relatively modest‐sized RCT and any conclusions drawn from the findings, therefore, have to be treated with a degree of caution, particularly when they concern putative interactions between several factors. The other reason for caution is that the treatments were not manualised as would be the case with most RCTs being conducted today. On the other hand, the fact that follow‐up data were obtained for all but 2 of the original cohort adds to the value of the study, extending our understanding of the impact of treatment on the course of anorexia nervosa.</p> <p>The most encouraging finding is the generally good outcome for the majority of the cohort at the 5‐year follow‐up, bearing in mind the degree of malnutrition before treatment. More than 75% of subjects had no eating disorder symptoms at follow‐up and there were no deaths in the cohort. If we assume that the two patients who did not participate in the follow‐up were continuing to progress poorly, 20% of the whole group had a poor outcome at the time of the follow‐up and 73% had a good outcome. This compares favourably with follow‐up studies of adolescents treated primarily as inpatients that have had a similar length follow‐up (4–6 years), which have reported a good outcome (using comparable criteria) in 43–58% of patients ([<reflink idref="bib31" id="ref34">31</reflink>]; [<reflink idref="bib37" id="ref35">37</reflink>]; [<reflink idref="bib12" id="ref36">12</reflink>]; [<reflink idref="bib25" id="ref37">25</reflink>]). Studies with longer follow‐up periods (8–15 years) generally provide a picture more similar to our study, with many reporting 65–85% cases with a good outcome ([<reflink idref="bib2" id="ref38">2</reflink>]; [<reflink idref="bib8" id="ref39">8</reflink>]; [<reflink idref="bib36" id="ref40">36</reflink>]; [<reflink idref="bib33" id="ref41">33</reflink>]; [<reflink idref="bib24" id="ref42">24</reflink>]), although several report only around 50% recovered even at this longer follow‐up ([<reflink idref="bib28" id="ref43">28</reflink>], [<reflink idref="bib38" id="ref44">38</reflink>]; [<reflink idref="bib34" id="ref45">34</reflink>]). The [<reflink idref="bib33" id="ref46">33</reflink>]) study, which has a follow‐up of 15 years, is particularly useful as it provides year‐by‐year recovery figures. At five years 55% of their sample had achieved a good outcome, rising to 70 and 75% in the two subsequent years, while the high rate of 87% good outcome was only reached after 12 years. In addition to the higher proportion of good outcome ratings in our follow‐up compared to other studies, the point needs to be emphasised that already at the end of treatment 40% of our patients were rated as having a good outcome.</p> <p>The findings of the current study are, however, quite consistent with the results of follow‐up studies of adolescents treated with family therapy and followed up for 5–6 years. [<reflink idref="bib19" id="ref47">19</reflink>] and [<reflink idref="bib9" id="ref48">9</reflink>] report a good outcome of 80% and 60% respectively, and similarly in our earlier RCT of family therapy and individual therapy following weight restoration in hospital ([<reflink idref="bib27" id="ref49">27</reflink>]; [<reflink idref="bib6" id="ref50">6</reflink>]), in the subgroup of adolescents with a history of illness of less than 3 years, those treated with family therapy had 90% good outcome compared to 36% of those treated individually. [<reflink idref="bib18" id="ref51">18</reflink>] have recently reported the results of a 4‐year follow‐up of an RCT of family therapy provided for either 6 or 12 months in which approximately 90% of patients would have met the Morgan–Russell criteria for good outcome.</p> <p>The other feature that seems to distinguish our follow‐up findings from other studies is the low rate of relapse once recovery has been achieved. A number of studies have reported very high rates of relapse following weight restoration in hospital, typically 25–30% following an initial admission, rising to as high as 60–75% following second and subsequent admissions ([<reflink idref="bib32" id="ref52">32</reflink>]; [<reflink idref="bib13" id="ref53">13</reflink>]). [<reflink idref="bib33" id="ref54">33</reflink>] follow‐up study, which has similarly high relapse rates following discharge from hospital, has, however, shown that once patients reach recovery outside of hospital, relapses are much less frequent, being less than 10% for those who reach partial recovery, while those who remitted completely had no further periods of illness. Our follow‐up study showed similar low rates of relapse (8% of those who had achieved a healthy weight by the end of treatment). A caveat needs to be made about the relapse data. As mentioned above, these figures are based on retrospective reports at the time of the follow‐up, unlike, e.g., [<reflink idref="bib33" id="ref55">33</reflink>] who assessed patients at least yearly during the entire follow‐up. Moreover, our data on relapse were only available for less than 80% of the patients and it is likely that the true relapse rates are somewhat higher.</p> <p>The third positive finding from our follow‐up is that only three patients developed bulimic symptoms and only one to a degree warranting a diagnosis of bulimia nervosa. This compares with around 30% who were reported to develop a binge‐eating pattern during the course of recovery in other studies ([<reflink idref="bib33" id="ref56">33</reflink>]; [<reflink idref="bib34" id="ref57">34</reflink>]).</p> <p>Only one pre‐treatment factor was clearly associated with outcome at follow‐up: a history of having been treated as an inpatient before entering the study. While this finding is consistent with other studies ([<reflink idref="bib7" id="ref58">7</reflink>]; [<reflink idref="bib28" id="ref59">28</reflink>]), one must not automatically conclude that this association is due to the negative effect of admitting an adolescent to hospital. Patients who have a history of being treated in hospital are likely to be more severely ill and/or have personal factors (poorer motivation, higher levels of co‐morbidity etc.) or family factors (such as high parental EE) that make it less likely that they will engage in effective outpatient treatment ([<reflink idref="bib35" id="ref60">35</reflink>]; [<reflink idref="bib1" id="ref61">1</reflink>]). Our own RCT of family therapy vs. individual supportive therapy following weight restoration in hospital ([<reflink idref="bib27" id="ref62">27</reflink>]; [<reflink idref="bib6" id="ref63">6</reflink>]) showed that adolescents with a short history of illness did well in family therapy and continued to do well at 5 years.</p> <p>Overall, there were no differences in the long‐term outcome between the two treatment groups. The patients in the conjoint family therapy group were on average somewhat lighter than those in the separated family therapy group, but this difference was not statistically significant and also reflected a lower initial weight at the start of the study. However, a moderator analysis revealed that there was a significant interaction between type of treatment, EE and time. For this reason the results were examined separately for the high and low EE families, and these showed some important differences.</p> <p>Of particular interest was the difference found in patients from families with raised levels of maternal criticism. At the end of treatment this group of patients had done less well in terms of improvement in core eating disorder symptoms if the treatment was CFT. At follow‐up this subgroup continued to have done least well, shown in the lack of weight gain since the end of outpatient treatment and persistence of amenorrhoea. Our end‐of‐treatment findings, as well as two earlier studies, have indicated that families where there are raised levels of criticism are difficult to engage in conjoint family therapy ([<reflink idref="bib35" id="ref64">35</reflink>]) and those that do engage may not always benefit from the treatment ([<reflink idref="bib14" id="ref65">14</reflink>]; [<reflink idref="bib5" id="ref66">5</reflink>]). The fact that this effect is still noticeable 5 years later is somewhat surprising and raises questions about mechanisms of change brought about by the family interventions.</p> <p>To explain the relative lack of progress post treatment in the high EE group treated with CFT, two alternatives need to be considered. From a theoretical point of view the most parsimonious explanation would be that the lack of progress is an example of the negative effects of living in an environment where there are raised levels of criticism. However, one of two additional mechanisms would need to be postulated to explain why the SFT‐treated high EE group continued to improve significantly after the treatment ended. Either the treatment had changed the nature of the family environment or the adolescent was less influenced by parental criticism. Neither of these options, however, is consistent with the end‐of‐treatment data ([<reflink idref="bib5" id="ref67">5</reflink>]). Reduced levels of criticism (both from parents to child as well as between parents) were found at the end‐of‐treatment assessment but there were no significant differences between the two treatments and the adolescents in the CFT group made greater improvements on individual psychological measures such as depression and self‐esteem. The alternative explanation is that what underlies the poorer response of the high EE group to CFT is simply a reflection of the difficulties that we encounter in trying to develop an effective therapeutic alliance with high EE families, particularly if the treatment involves conjoint family meetings.</p> <p>In our clinical experience we find that there is a small group of families with whom we do not engage well. The parents in these families often feel particularly burdened by the problem and are generally self‐blaming. One parent (often the mother) may alternate between being intensely involved in trying to help her daughter and then feeling overwhelmed by the enormity of the task and trying to back off completely. The other parent may try to play down the seriousness of the problem in an attempt to reduce the pressure on his/her partner or alternately become more distant and absorbed in work. The sense of helplessness and anxiety generated by the situation will often lead to increased criticism or hostility. Our usual focus of trying to identify the strengths and potential resourcefulness of the family is often experienced negatively by the family. We have suggested that conjoint meetings in such families, early on in treatment, can be counterproductive, partly, perhaps, because they can be experienced by the family as an indication that the clinicians see the family as the cause of the problem. The risk is that premature conjoint meetings simply reinforce a sense of ineffectiveness and helplessness in the family, particularly if the meetings are acrimonious or hostile. The resulting lack of a positive therapeutic alliance may have a lasting effect, as the results of our follow‐up indicate.</p> <hd id="AN0025182222-16">Conclusion</hd> <p>The findings from this study are in keeping with the evidence from other studies of a long‐term efficacy of family therapy in adolescent anorexia nervosa and highlights that those who respond well to family therapy generally stay well. Although the two methods of treatment (CFT and SFT) did not appear to differ as regards the long‐term outcome, the results support the conclusion that CFT is less effective in families with high levels of expressed emotion. This has practical implications, indicating that it may be inadvisable to use conjoint family meetings, at least early on in treatment, when raised levels of parental criticism are evident. Our clinical experience would suggest that later on in treatment, once the family is well engaged, conjoint meetings may still have a useful role to play even with this group of families.</p> <ref id="AN0025182222-17"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref61" type="bt">1</bibl> <bibtext> Conflict of interest statement: No conflicts declared.</bibtext> </blist> </ref> <ref id="AN0025182222-18"> <title> References </title> <blist> <bibtext> Ametller, L., Castro, J., Serrano, E., Martinez, E., & Toro, J. (2005). Readiness to recover in adolescent anorexia nervosa: Prediction of hospital admission. Journal of Child Psychology and Psychiatry, 46, 394 – 400.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Casper, R.C., & Jabine, L.N. (1996). An eight‐year follow‐up: Outcome from adolescent compared to adult onset anorexia nervosa. Journal of Youth and Adolescence, 25, 499 – 517.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref31" type="bt">3</bibl> <bibtext> Child Growth Foundation. (1990). BMI charts. UK cross‐sectional reference data: 1990. London: Child Growth Foundation.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref18" type="bt">4</bibl> <bibtext> Eisler, I. (2005). The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27, 104 – 131.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref16" type="bt">5</bibl> <bibtext> Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E., & Le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. 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(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.</bibtext> </blist> <blist> <bibtext> 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.</bibtext> </blist> <blist> <bibtext> Martin, F.E. (1985). The treatment and outcome of anorexia nervosa in adolescents: A prospective study and five year follow‐up. Journal of Psychiatric Research, 19, 509 – 514.</bibtext> </blist> <blist> <bibtext> Minuchin, S., Rosman, B.L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press.</bibtext> </blist> <blist> <bibtext> Morgan H.G., & Hayward A.E. (1988). Clinical assessment of anorexia nervosa. The Morgan–Russell outcome assessment schedule. 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Russell and Christopher Dare</p> <p>Reported by Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib30" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib33" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib24" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib36" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib28" firstref="ref7"></nolink> <nolink nlid="nl6" bibid="bib20" firstref="ref9"></nolink> <nolink nlid="nl7" bibid="bib19" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib27" firstref="ref12"></nolink> <nolink nlid="nl9" bibid="bib26" firstref="ref14"></nolink> <nolink nlid="nl10" bibid="bib15" firstref="ref15"></nolink> <nolink nlid="nl11" bibid="bib17" firstref="ref17"></nolink> <nolink nlid="nl12" bibid="bib16" firstref="ref21"></nolink> <nolink nlid="nl13" bibid="bib14" firstref="ref22"></nolink> <nolink nlid="nl14" bibid="bib22" firstref="ref23"></nolink> <nolink nlid="nl15" bibid="bib21" firstref="ref24"></nolink> <nolink nlid="nl16" bibid="bib11" firstref="ref27"></nolink> <nolink nlid="nl17" bibid="bib10" firstref="ref29"></nolink> <nolink nlid="nl18" bibid="bib29" firstref="ref30"></nolink> <nolink nlid="nl19" bibid="bib23" firstref="ref33"></nolink> <nolink nlid="nl20" bibid="bib31" firstref="ref34"></nolink> <nolink nlid="nl21" bibid="bib37" firstref="ref35"></nolink> <nolink nlid="nl22" bibid="bib12" firstref="ref36"></nolink> <nolink nlid="nl23" bibid="bib25" firstref="ref37"></nolink> <nolink nlid="nl24" bibid="bib38" firstref="ref44"></nolink> <nolink nlid="nl25" bibid="bib34" firstref="ref45"></nolink> <nolink nlid="nl26" bibid="bib18" firstref="ref51"></nolink> <nolink nlid="nl27" bibid="bib32" firstref="ref52"></nolink> <nolink nlid="nl28" bibid="bib13" firstref="ref53"></nolink> <nolink nlid="nl29" bibid="bib35" firstref="ref60"></nolink>
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  Data: A Randomised Controlled Treatment Trial of Two Forms of Family Therapy in Adolescent Anorexia Nervosa: A Five-Year Follow-Up
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  Data: <searchLink fieldCode="AR" term="%22Eisler%2C+Ivan%22">Eisler, Ivan</searchLink><br /><searchLink fieldCode="AR" term="%22Simic%2C+Mima%22">Simic, Mima</searchLink><br /><searchLink fieldCode="AR" term="%22Russell%2C+Gerald+F%2E+M%2E%22">Russell, Gerald F. M.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Child+Psychology+and+Psychiatry%22"><i>Journal of Child Psychology and Psychiatry</i></searchLink>. Jun 2007 48(6):552-560.
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  Data: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp
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  Data: 9
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  Data: 2007
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  Data: Journal Articles<br />Reports - Evaluative
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  Data: <searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Eating+Disorders%22">Eating Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Mothers%22">Mothers</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Child+Relationship%22">Parent Child Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Questionnaires%22">Questionnaires</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Family+Counseling%22">Family Counseling</searchLink><br /><searchLink fieldCode="DE" term="%22Therapy%22">Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Interviews%22">Interviews</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink>
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  Label: DOI
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  Data: 10.1111/j.1469-7610.2007.01726.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0021-9630
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: There is growing evidence that family therapy is an effective treatment for adolescent anorexia nervosa. This study aimed to ascertain the long-term impact of two forms of outpatient family intervention previously evaluated in a randomised controlled trial (RCT). Method: A five-year follow-up was conducted on a cohort of 40 patients who had received either "conjoint family therapy" (CFT) or "separated family therapy" (SFT). All patients were traced and 38 agreed to be reassessed (29 interviewed in person, 3 completed telephone interviews, 6 completed questionnaires and/or agreed for parents/GP to be interviewed). Results: Overall there was little to distinguish the two treatments at 5 years, with more than 75% of subjects having no eating disorder symptoms. There were no deaths in the cohort and only 8% of those who had achieved a healthy weight by the end of treatment reported any kind of relapse. Three patients developed bulimic symptoms but only one to a degree warranting a diagnosis of bulimia nervosa. The one difference between the treatments was in patients from families with raised levels of maternal criticism. This group of patients had done less well at the end of treatment if they had been offered conjoint family meetings. At follow-up this difference was still evident, as shown in the relative lack of weight gain since the end of outpatient treatment. Conclusions: This study confirms the efficacy of family therapy for adolescent anorexia nervosa, showing that those who respond well to outpatient family intervention generally stay well. The study provides further support for avoiding the use of conjoint family meetings at least early on in treatment when raised levels of parental criticism are evident.
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  Data: 2008
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  Group: ID
  Data: EJ813260
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ813260
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/j.1469-7610.2007.01726.x
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 9
        StartPage: 552
    Subjects:
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Eating Disorders
        Type: general
      – SubjectFull: Mothers
        Type: general
      – SubjectFull: Parent Child Relationship
        Type: general
      – SubjectFull: Questionnaires
        Type: general
      – SubjectFull: Patients
        Type: general
      – SubjectFull: Family Counseling
        Type: general
      – SubjectFull: Therapy
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Interviews
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Outcomes of Treatment
        Type: general
    Titles:
      – TitleFull: A Randomised Controlled Treatment Trial of Two Forms of Family Therapy in Adolescent Anorexia Nervosa: A Five-Year Follow-Up
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Eisler, Ivan
      – PersonEntity:
          Name:
            NameFull: Simic, Mima
      – PersonEntity:
          Name:
            NameFull: Russell, Gerald F. M.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 06
              Type: published
              Y: 2007
          Identifiers:
            – Type: issn-print
              Value: 0021-9630
          Numbering:
            – Type: volume
              Value: 48
            – Type: issue
              Value: 6
          Titles:
            – TitleFull: Journal of Child Psychology and Psychiatry
              Type: main
ResultId 1