Oct 01: Eating disorders are widely considered one of the most persistent and difficult-to-treat mental health conditions. Extensive research shows that early intervention is key to giving patients the best chance at a full recovery and fewer serious physical and mental health effects over their lifetime.
In the past, inpatient care paired with individual therapy was the primary treatment for pediatric and adolescent patients. But over the past several decades, a new gold standard emerged: The majority of leading pediatric eating disorders programs now utilize an outpatient treatment method called Family-Based Treatment, or FBT.
Using this method, parents are highly involved in their child’s care. In fact, they’re the primary guide to help their child get better.
Understanding Family-Based Treatment
Originally named the Maudsley method, Family-Based Treatment is most often used as an interdisciplinary intervention for children and adolescents with anorexia and bulimia.
“I think people often assume that eating disorder treatment for adolescents or kids is focused on persuading them out of their eating disorder,” says Sohyun Han, PhD, a clinical psychologist in the Eating Disorders Program at Children’s Hospital Los Angeles. “But that approach is not very effective because, often, we’re working with someone who is ambivalent about getting better.”
This is why in FBT, parents take charge of the child’s eating schedule and food intake.
At CHLA, which receives more than 200 new visits to its Eating Disorders Program each year, parents are guided by medical and mental health specialists to enforce structure and close supervision around their child’s eating—while also showing empathy for how difficult recovery can be.
“This treatment can also coexist with other mental health treatment like cognitive behavioral therapy,” notes Nitika Dhir, MD, a physician in the Eating Disorders Program. “It’s important for youth to receive support for other challenges or life events that may have preceded, or even occurred at the same time as, the eating disorder itself.”
Is Family-Based Treatment a medical or mental health intervention?
It’s actually both.
“Eating disorders have implications that extend far beyond the psychological aspect of a young person’s health,” Dr. Dhir says, noting that these conditions have the 2nd highest mortality rate of any psychiatric illness. “There exists a very significant concern for the medical complications that occur as a result of disordered eating, if left untreated.”
“This is why we take a multidisciplinary approach,” she adds, “Combining psychological and medical expertise helps ensure the safety of our patients while providing families the tools they need to feel empowered.”
How much of a time commitment is Family-Based Treatment?
Family-Based Treatment can take anywhere from 6-12 months depending on how the child or adolescent responds.
While FBT is typically outpatient and much of the patient’s healing happens at home, the highly intensive treatment regimen generally requires a sizeable commitment from both patients and their families.
Phases of Family-Based Treatment
Phase 1 - Full Caregiver Control:
The main goal is to interrupt harmful behaviors like restricting, bingeing, purging and/or exercising compulsively.
Additionally, the child’s care team will work towards weight restoration and addressing any medical or psychiatric comorbidities.
During this phase, parents take charge of all nutrition-related tasks, such as grocery shopping, cooking, and plating the food. Parents additionally provide support and monitoring at every meal and snack to ensure their child makes progress.
Phase 2 – Gradual Return of Control:
Once the child’s weight begins to be restored and their harmful behaviors are well-controlled, treatment focuses on helping gradually foster age-appropriate independence and decision-making.
Therapy focuses on equipping parents to manage setbacks and find the right balance of control and freedom.
Phase 3 – Establishing Healthy Autonomy:
When the child can maintain a healthy weight and make independent food choices in various settings, treatment begins transitioning to promoting regular adolescent development.
Therapy might center on addressing any underlying issues, promoting a positive identity, strengthening peer relationships, and preventing relapse.
What role do parents or caregivers play in Family-Based Treatment?
Parents plan, prepare, and oversee their child’s eating with the guidance of their clinical team and often using any support the child’s school is able to offer.
This sounds simple, but Dr. Han explains that many parents and caregivers feel like they’ve failed or are ready to give up by the time they seek treatment for their child. She often reminds caregivers that they already know how to feed their child and have been doing it for years—but the eating disorder makes that difficult.
“Like chemotherapy for cancer or insulin for diabetes, we help families understand that while their child is malnourished, food is often their only medicine,” says Dr. Han.
Should siblings or other members of the household be involved in family-based treatment?
Ideally, anyone who lives in the household should be involved in treatment sessions and provide support at home.
Who gets involved depends on each family’s unique dynamics and stress levels, which are different for every family. In many situations, a family member or sibling can help care for the person in treatment by helping them relax and have fun, as well as talking to them about their experience.
Why is early intervention for eating disorders important?
Severe malnutrition can affect nearly every part of the body. Long term effects of eating disorders can include cardiovascular damage, weak bones, loss of muscle mass, infertility, and chronic digestive issues, among others.
Years of scientific research also show that eating disorder treatment is actually more effective in childhood and adolescence than in adulthood.
Many factors contribute to this, including the fact that behavioral patterns may be less entrenched early on, kids and teens often have caregivers that are able to ensure they are attending appointments regularly and the malnutrition is treated before some of the mental and physical damage becomes harder to reverse.
Who is a candidate for Family-Based Treatment?
Specialists will work closely with each family to determine which treatment path is right for their child.
Sometimes, eating disorders can be a life-threatening medical or psychiatric emergency and may require inpatient treatment. But for many families and their kids, FBT can offer a structured path to recovery while allowing patients to engage in as many “routine” activities as possible.
“An eating disorder can be all-consuming, and it often makes caregivers feel powerless,” says Dr. Han. “We’re here to help caregivers and their children regain some normalcy around eating. We hope to see youth be able to eat more socially again with their loved ones while also returning to the activities they previously enjoyed.”
