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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