Andrea Goldschmidt Hi, my name’s Andrea  Goldschmidt and I’m a Clinical Psychologist   and Associate Professor of Psychiatry at the  University of Pittsburgh School of Medicine.   Today, I’ll be talking to you about  family-based treatment for adolescents   with restrictive eating disorders [pause]. So, family-based treatment is a very specific form  of behavioural treatment for adolescents who have   restrictive eating disorders, such as anorexia  nervosa, including atypical anorexia nervosa.   And unlike other treatments, it involves a heavy  emphasis on caregivers actually taking charge of   the adolescent’s eating. So, the underlying  treatment model assumes that adolescents who   have restrictive eating disorders are not able  to make healthy decisions about their eating   because of starvation brain, and that they  need their parents and other caregivers to   make healthy decisions for them, to get them  back on track with their eating and weight. It is delivered in three phases. In the  first phase, parents or other caregivers are   instructed to take complete control  of the adolescent’s eating behaviour,   including deciding how much and what the  adolescent should eat and at what times,   to get them back on track with their eating and  weight. Once the adolescent is eating well and is   on a consistent weight gain trajectory, parents  will gradually revisit the feeding plan and   hand back control of the eating to the  adolescent. And the adolescent will be   gradually making more and more decisions about  their eating. In the third and final phase,   the focus is more on repairing the adolescent and  child relationship, assuring that parents are in   an appropriate hierarchy relative to the children  in the family, and addressing any general   adolescent issues that may have been put to the  wayside by the child’s eating disorder [pause]. So, family-based treatment is a very efficacious  intervention for adolescents with restrictive   eating. About 50-60% of adolescents will have a  good response to family-based treatment. However,   a large proportion of adolescents in the community  have difficulties accessing this treatment.   In addition to general issues accessing mental  health treatment, such as insurance barriers   or transportation issues, many families who  have a lower income might have difficulties   accessing treatment in particular. And  specifically with family-based treatment,   there are not a large numbel – number of providers  in the community who are trained in this specific   approach. So, unless you happen to live in a dre  – geographic area of the country where there are   lots of providers or have enough income to  support travelling to and from treatment,   it might be very, very difficult for  you to find a family-based treatment   provider who can deliver treatment to  your child who might need it [pause]. So, in our research, we have worked on  adapting home-based treat – adapting   family-based treatment to be delivered in  the home setting by novice community-based   Therapists. And this addressing two types  of barriers that people might encounter in   receiving family-based treatment for  their adolescent’s eating disorder. One   is difficulties getting to treatment. So, some  families might have – be working multiple jobs   or might not have reliable transportation and  might have difficulties just literally getting   from their home to the treatment setting.  In home-based treatment, the Therapist will   come to you in your home and deliver the  treatment there, with your entire family   present. Which addresses one major barrier to  treatment, especially for lower income families. The other major barrier is that it’s  delivered through community settings,   which means that a provider does not  need to have a specific expertise in   eating disorders to be trained in delivering  this treatment. And so, we can, ideally,   get a larger number of providers who are trained  to deliver the treatment with high fidelity and   be available to be a resource for families  living in the community. And in addition to   training novice providers, many families  that have insurance constraints around,   for example, seeing Therapists that operate  in private practice settings, might have an   easier time with insurance coverage for treatment  that’s delivered in a community setting [pause].  So, as the name implies, family-based treatment  involves the entire family and that can include   both the caregivers, and mainly parents who  are living in the home with the adolescent,   as well as siblings, and other key family  members who might have a large role in   the day-to-day life of the adolescent with the  eating disorder. That often includes grandparents   who may be living in the home with the family,  or may live nearby and have a lot of caretaking   responsibilities, including being with the  adolescent for a lot of meals and snacks. So, the parents are typically the primary  caregivers responsible for intervention and   as I alluded to earlier, what this  often looks like is deciding what,   how much and when the adolescent needs to eat  to support their full recovery. So, deciding on   target foods that are going to be energy dense  and get the adolescent weight restored as soon   as possible. Making sure that the adolescent  is eating at regular intervals and eating   those energy dense foods at regular intervals to  support weight gain. The adolescents and other   family members involved in the day-to-day life of  the adolescent also have important roles to play.   Depending on how frequently grandparents,  for example, are with the adolescent,   they may actually take on more of a caregiver  role too, in supporting the adolescent and   getting adequate nutrition to support  nutritional restoration and weight gain. The siblings will often take on a role of  being supportive people to the adolescent. So,   as you can imagine, a teenager with a restrictive  eating disorder often experiences a lot of   distress around the re-feeding process, and  having supportive siblings in the home can   make the process a little bit easier for them. So,  adol – siblings can do things like distracting the   adolescent when they’re struggling with negative  feelings about eating or their weight and shape.   Just sitting with the child during mealtimes  and reminding them, you know, that they can   play a game or do something fun after dinner  is done and just being general supportive   persons in the adolescent’s life. And  in addition to siblings, friends that   the adolescent may have in the community or  school can also take on this role [pause]. So, one of the key things that I have been really  interested in in my research is understanding how   families learn to deliver FBT in their natural  environments. So, as you might’ve gleaned from   my discussion so far, most of the intervention  is actively happening in the adolescent’s home   or other settings where the adolescent may  be eating. And so, you can imagine, learning   a new intervention skill in a Therapist’s  office setting and then figuring out how   to translate it to the places and times where  the family is actually eating together can be   quite difficult for some families. So, one of the  things that we’re really interested in studying   as part of adapting FBT to be delivered in  the home, is how families might be able to   better learn in the setting where they’re  actually going to be delivering treatment. So, in home-based treatment, obviously,  the Therapist is delivering much of the   intervention in the family’s home, but they  can also participate in delivering treatment   in other settings, where the adolescent  may be experiencing a lot of mealtimes,   such as school, restaurants, where they may  be doing more exposure-based interventions   around foods that the adolescent might’ve been  afraid to eat previously. And the Therapist   can also go to the fam – with the family to  Doctors’ appointments to support consistent   messaging across providers. So, having the  Therapist actually travel to the locations   where the family is going to be delivering  the intervention might be a more effective   way to support learning and implementation  on the family’s part, as well [pause]. So, some of the key adaptations that we’ve  considered in delivering FBT in the home setting.   Obviously, we’ve had to be really thoughtful about  ways that the Therapist could be more effective in   promoting re-feeding in the home environment.  So, the Therapist really, actually, has a lot   more leeway to be creative with intervention  and problem-solving in the home environment,   in a way that they couldn’t do in a regular  office setting. So, in the office setting,   you’re really reliant on hearing what the family  tells you about how the week has gone or how their   adolescent is responding to re-feeding. Whereas  in the adolescent’s home, the Therapist can   survey the refrigerator or the pantry to identify  with the family foods that would be effective for   re-feeding and can actually also participate in  meal preparation and grocery shopping with the   family. As I mentioned earlier, the Therapist  could also support meal exposures in restaurant   settings or other places where the adolescent  might have a particularly tough time re-feeding. So, one of the other main differences between  FBT delivered in an outpatient setting and FBT   delivered him a home-based level of care,  is that FBT delivered in the home setting   is often a little bit more constrained in terms  of the duration and intensity of treatment. So,   home-based treatment in general,  not just for eating disorders,   but for any psychiatric condition,  is designed to be an intermediate   level of care between hospital-based  treatment and outpatient treatment.   Which means that families that are receiving  home-based treatment likely need more intensive   treatment than what a regular, once a week,  hour long of outpatient therapy can provide. So, the Therapist is often in the family’s  home for two to three times a week,   maybe two plus hours at a time, which  is significantly longer and more intense   than what an outpatient Therapist might be  delivering in an office setting. And so,   we really had to identify creative ways to deliver  FBT in this type of duration and intensity level.   FBT was originally designed to be a once a week  outpatient therapy delivered about – over about   six to 12 weeks. So, we really had to figure  out how to deliver the most potent forms of   the intervention quickly in the family’s home, in  a way that they can then sustain over the entire   duration of treatment in the home-based level of  care. And that can range anywhere from six to 32   weeks of treatment. It really just depends on the  geographic region of the country where the care is   being delivered and constraints of whoever  is funding the treatment, as well [pause]. So, there are some significant challenges  associated with delivering FBT in a home-based   setting that don’t often arise in outpatient FBT.  As I alluded to earlier, home-based treatment is   designed to be a bridge between outpatient and  hospital-based treatment. So, this means that   adolescents participating in home-based treatment  have often not responded well to an outpatient   level of care and might be presenting with a  more severe and/or complex course of – a more   severe and/or complex form of anorexia nervosa  than those who present in a regular outpatient   setting. So, that presents one unique challenge. The other unique challenge in terms of home-based   treatment is that the Therapist, because they’re  participating so intimately in the day-to-day   lives of their families, sometimes they can  actually take too much charge of re-feeding,   which ends up undermining the families in terms of  their delivering the re-feeding intervention. So,   we have to be really careful in supervision  to make sure that Therapists are maintaining   appropriate boundaries with families and not  taking over re-feeding for the caregivers,   which could decrease their – the parents’  self-efficacy to deliver the intervention [pause]. So, right now, we are in the process of testing  out the effectiveness of home-based FBT through a   randomised controlled trial. We’re comparing it to  a home-based treatment as usual, which integrates   components of cognitive behavioural therapy and  dialectical behaviour therapy to improve distress   tolerance and address some of the mechanisms  that might be maintaining the eating disorder   in the adolescent. And we hope to have some  preliminary findings pretty soon and update the   literature to see if this is – can be a feasible  and effective form of treatment for adolescents.