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A Comparison of Short- and Long-Term Family Therapy

for Adolescent Anorexia Nervosa


JAMES LOCK, M.D., PH.D., W. STEWART AGRAS, M.D., SUSAN BRYSON, M.A.,
AND HELENA C. KRAEMER, PH.D.

ABSTRACT
Objective: Research suggests that family treatment for adolescents with anorexia nervosa may be effective. This study
was designed to determine the optimal length of such family therapy. Method: Eighty-six adolescents (12–18 years of age)
diagnosed with anorexia nervosa were allocated at random to either a short-term (10 sessions over 6 months) or long-term
treatment (20 sessions over 12 months) and evaluated at the end of 1 year using the Eating Disorder Examination (EDE)
between 1999 and 2002. Results: Although adequately powered to detect differences between treatment groups, an in-
tent-to-treat analysis found no significant differences between the short-term and long-term treatment groups. Although
a nonsignificant finding does not prove the null hypothesis, in no instance does the confidence interval on the effect size on
the difference between the groups approach a moderate .5 level. However, post hoc analyses suggest that subjects with
severe eating-related obsessive-compulsive features or who come from nonintact families respond better to long-term
treatment. Conclusions: A short-term course of family therapy appears to be as effective as a long-term course for ado-
lescents with short-duration anorexia nervosa. However, there is a suggestion that those with more severe eating-related
obsessive-compulsive thinking and nonintact families benefit from longer treatment. J. Am. Acad. Child Adolesc. Psychi-
atry, 2005;44(7):632–639. Key Words: anorexia nervosa, family therapy.

Anorexia nervosa usually first presents in adolescence. ies, this superiority was maintained 5 years after treat-
Despite the severity of this condition both medically ment was completed (Eisler et al., 1997).
and psychologically, it is still unclear how to treat this Among the treatment trials employing family therapy
disorder (American Academy of Pediatrics, 2003). for adolescents, treatment intensity averaged 20 sessions
However, the few existing controlled studies suggest (range 9–36), whereas treatment duration averaged ap-
that family therapy that initially promotes parental con- proximately 12 months (range 6–36) (Lock and Le
trol over refeeding may be effective for this age group Grange, 2001). Comparison of patient outcomes among
(Dare and Eisler, 1997). Results of two of these trials these studies suggests that there was little difference in
provide preliminary evidence that this form of family outcome as a result of having more treatment sessions or
treatment is superior to individual therapy for adoles- longer treatment. However, no study has evaluated the
cents with anorexia nervosa (Robin et al., 1999; Russell relationship between the dose of therapy and outcome
et al., 1987) Further, on follow-up in one of these stud- (Le Grange et al., 1992; Robin et al., 1999; Russell
et al., 1987). To advance our understanding of the ef-
Accepted December 21, 2004.
fectiveness of family therapy for adolescents with an-
From the Department of Psychiatry and Behavioral Sciences, Stanford orexia nervosa, we undertook a study to determine the
University School of Medicine, Stanford, CA. optimal length of treatment. Specifically we wished to
Dr. Lock’s work on this project was supported by NIH Career Development
Award MH01457.
determine whether patients treated for only 6 months
Correspondence to Dr. James Lock, Department of Psychiatry and Behavioral (short-term) would do as well at the end of 1 year as
Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, those who were treated for the entire period (long-
CA 94305; e-mail: Jimlock@stanford.edu. term). We hypothesized that there would be no differ-
0890-8567/05/4407–0632Ó2005 by the American Academy of Child
and Adolescent Psychiatry. ence in outcome between the short- and long-term
DOI: 10.1097/01.chi.0000161647.82775.0a groups.

632 J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA

METHOD anorexia nervosa available at the time to estimate effect size (Le Grange
et al., 1992; Robin et al., 1999; Russell et al., 1987). For change
Participants in body mass index (BMI), the primary outcome, a sample of 86
subjects yields 80% power (assuming a conservative moderate
Eighty-six adolescents (between the ages of 12 and 18 years; 77 effect size, a standardized mean difference of 0.5, and a 5% two-
females and 9 males) were entered into the study. All subjects com- tailed test of significance) to detect group differences (Kraemer and
pleted human subjects informed consent processes as approved by Thienemann, 1987).
the institutional review board at the study site. These adolescents Baseline characteristics of participants in the study are summa-
met DSM-IV criteria for anorexia nervosa except that some partially rized on Table 1. The mean BMI at the initial point of identification
weight restored participants were entered and for postmenarchal fe- of the subjects for the study was 16.0 ± 1.6 kg/m2. The mean BMI at
males, those who had missed a minimum of one menstrual period the point of randomization to treatments was 17.1 ± 1.4 kg/m2. This
instead of the usual three required by DSM-IV criteria. This sample mean increase in BMI before randomization was a result of weight
represents the typical range of adolescents presenting for outpatient gain in those adolescents (30% [26 patients]) briefly hospitalized
treatment for anorexia nervosa. (average length of stay was 12.3 days) for acute medical instability
Participants were recruited by referral from pediatricians and before starting treatment. In addition, 31 (36%) had comorbid psy-
therapists to a specialty evaluation clinic for child and adolescent chiatric illness at baseline. Twenty-one (24%) had major depression
eating disorders (Fig. 1). Screening of all referrals to this clinic (n or dysthymia, 12 (14%) had an anxiety disorder including obsessive-
= 241) from September 1999 to April 2002 yielded 141 eligible par- compulsive disorder, and four (5%) had other psychiatric disorders.
ticipants over a 32-month period, of whom 86 (61%) agreed to ran- Of these subjects, 12 (14%) received medications during the trial
domization. Subjects screened for the study included many patients (selective serotonin reuptake inhibitors and atypical antipsychotics),
with other eating disorders (e.g., bulimia nervosa), which accounts five in long-term treatment and seven in short-term treatment.
for the high proportion of potential subjects screened out initially. There were no significant differences at the pretreatment evaluation
Reasons for nonparticipation were (1) distance to treatment site between treatment groups on any baseline measures.
(27%), (2) preferred individual treatment (22%), (3) did not want to
participate in research (6%), and (4) no reason given for refusal (45%).
Measures
Our plan called for exclusion of participants with severe physical
health problems likely to affect weight (e.g., diabetes mellitus) or psy- Participants were assessed pretreatment and at 6 and 12 months
chiatric illnesses that would interfere with treatment (e.g., psychosis) using the Eating Disorder Examination (EDE), an interview that
and those who had failed family treatment using the model em- measures height, weight, and the severity of the characteristic psy-
ployed in the study, but no potential participants were excluded chopathology of eating disorders (Cooper et al., 1989). The adult
based on these criteria. Psychotherapy in addition to that offered version of this interview was used because we found that adolescent
in the study protocol was not permitted. However, psychotropic participants were able to understand and respond to questions as
medications used to treat common comorbid psychiatric illnesses formulated in this iteration (Passi et al., 2003).
(e.g., depression, obsessive-compulsive disorder, generalized anxiety General psychopathology was assessed with structured interviews
disorder) were allowed. using the Schedule for Affective Disorders and Schizophrenia for
The sample size for this study was developed using data from School-Age Children (6–18 years) (Kaufman et al., 1997). The
the previously published controlled trials of family treatment for Yale-Brown-Cornell Eating Disorder Scale (YBC-ED) was employed

Fig. 1 Flow diagram of subject progress during the randomized clinical trial.

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LOCK ET AL.

TABLE 1 procedures by a research assistant not involved in assessments to ei-


Baseline Sample Demographics ther a short-term (6 months and 10 sessions) or a long-term (12
months and 20 sessions) treatment (Efron, 1971). The latter con-
Long- Short-
dition was designed to replicate a standard family treatment package
Term Term similar to the usual duration and intensity of sessions provided in
(N = 42) (N = 44) most studies (Dare et al., 2001; Eisler et al., 2000; Russell et al.,
1987). Randomization resulted in 42 subjects in intensive treatment
Age (yr) 15.2 (1.7) 15.2 (1.6)
and 44 subjects in less intensive treatment.
Duration of illness (mo) 12.0 (9.9) 11.3 (10.4) Assessments were conducted by trained assessors who were not
Ethnicity involved with the treatment of patients in the study and who were
Asian 2 (5%) 6 (14%) not told which group that the patient was randomized to for treat-
White 32 (76%) 32 (73%) ment. The assessments were undertaken before randomization and
Hispanic 6 (14%) 4 (9%) at 6 and 12 months. Questionnaires were completed by the partic-
Native American 0 (0%) 1 (2%) ipants at home. All therapists (including the principal investigator)
Other 2 (5%) 1 (2%) as well as patients and their family members were blinded to the
Gender randomization status of patients until after the seventh session
Male 4 (9%) 5 (11%) (the point of delineation between the two arms in terms of treatment
session frequency). There were no instances in which either the
Female 38 (91%) 39 (89%)
therapists or patients were ‘‘unblinded’’ before the seventh treatment
Family incomea session. This prevented therapists and families from responding to
<50K 4 (10%) 4 (9%) the knowledge that they had either a short- or long-term treatment
50–100K 18 (43%) 14 (33%) by either intensifying or relaxing treatment procedures during these
>100K 20 (48%) 24 (57%) early sessions.
Maximum parental education Four therapists treated participants in both treatment condi-
High school or less 3 (7%) 6 (14%) tions. The therapists were all trained in the manual-based version
College 21 (50%) 20 (46%) of family-based treatment for anorexia nervosa using a written text,
Graduate school 18 (43%) 18 (41%) videotaped sessions, and role-playing (Lock and Le Grange, 2001;
Hospitalization before treatment 14 (34%) 12 (27%) Lock et al., 2001). During the treatment phase of the study, there
Average no. of hospital days for those was weekly supervision of cases. Three of the therapists were master’s
degree level psychologists and one was a child and adolescent
hospitalized before treatment 12.4 (7.0) 12.2 (6.7)
psychiatrist (J.L.).
Psychotropic use for comorbid 5 (12%) 7 (16%) The manual-based treatments were conducted on an outpatient
conditions basis. In the shorter treatment, sessions were initially held weekly for
Previous treatment (excluding 7 weeks, then monthly for 2 months, and a final session 2 months
hospitalization immediately later at the 6-month mark. In the longer treatment, sessions were
before treatment) 36 (90%) 39 (89%) initially held weekly for 7 weeks, then biweekly through session
Purgers 9 (21%) 7 (16%) 13 (at 5 months), and the remaining seven sessions were monthly
Restrictors 33 (79%) 37 (84%) until the end of the treatment year. None of the participants received
Intact families 31 (74%) 36 (82%) any other psychotherapy during the treatment phase of the study.
All participants were required to be medically stable before and
a
Missing two subjects. during treatment, employing criteria similar to those of published
recommendations (Lock, 1999). To be medically stable, participants
were required to meet the following criteria: heart rate more than 45
as a measure of severity of obsessionality and compulsiveness about beats per minute, orthostatic blood pressures changes of fewer than
eating behaviors, weight, and exercise (Mazure, et al., 1994, 1995). 35 points, body temperature higher than 36.4°C, no evidence of
It was administered immediately after each EDE assessment. electrolyte abnormalities or prolonged QTc on electrocardiogram,
The Child Behavior Checklist (CBCL) and Youth Self-Report and weight greater than 75% of that expected for height.
were used to assess global problems of interpersonal functioning Brief hospitalization for medical instability was occasionally needed
(Achenbach, 1991). The CBCL was completed by one of the parents for participants in both conditions. Treatment in hospital consisted
pretreatment and 6 and 12 months. The Youth Self-Report was com- of medical monitoring, nutritional supplementation, and nonspecific
pleted by the adolescent participant at the same intervals as the CBCL. supportive therapies.
Family functioning was assessed using the Family Environment On discharge, participants re-entered the treatment condition to
Scale (Moos, 1974; Moos and Moos, 1994). The same parent com- which they were randomized and completed the allotted treatment
pleted the FES pretreatment and at 6 and 12 months. duration (not including the days of hospitalization) with no change
in the allocated number of treatment sessions.
Medical treatment during the study consisted of brief (10–
Design and Procedures
20 minute) medical checks by pediatricians, most of whom had sig-
Because duration of illness has been shown to predict a negative nificant expertise in the medical presentations of adolescents with
outcome using this treatment (Russell et al., 1987), randomized sub- eating disorders. These physicians were blinded to the randomiza-
jects were stratified on this variable with balance being sought for tion status of the participants. Medical visits were scheduled at in-
those with more than 1 year of illness before treatment. Participants tervals determined by these physicians and ranged from twice-
were randomized within each stratum using the Efron biased coin weekly visits to monthly visits, depending on their assessment of

634 J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA

medical acuity, with an overall average of approximately 35 brief the baseline response (which, given randomization, should not dif-
contacts per patient during the year. Patients were followed by the ferentiate the two groups), and the slope represents the rate of re-
physician group throughout the 1-year study period regardless of sponse for each individual subject. This approach uses the repeated
the treatment group assigned. A nutritionist was also available for brief measures for each subject to reduce the unreliability of the response
consultations with participants and their parents during these visits as measure and is helpful in dealing with missing data and dropout.
a part of the overall medical service; however, no structured program Effect sizes (ES) are reported using the mean difference between
of nutritional counseling was provided for subjects in the study. groups divided by the pooled within-group SD. In a post hoc ex-
ploratory analysis of possible moderators of treatment outcome, we
employed a linear regression model using the measures at 1 year as
Treatments the dependent measure and controlling for baseline values. Indepen-
dent variables were centered (Kraemer et al., 2002). For the analysis
The family treatment used is based on treatment developed by of the use of hospitalization during treatment, we used a Mann-
Dare and colleagues at the Maudsley Hospital in London (Dare Whitney U (a nonparametric test) to account for nonnormally dis-
and Eisler, 1997). The treatment was manual based and piloted be- tributed values associated with this variable.
fore initiating the controlled trial (Lock and Le Grange, 2001; Lock
et al., 2001). This form of family treatment is highly focused on the
behaviors and thoughts associated with anorexia nervosa and sees the
RESULTS
adolescent as incapacitated mostly in terms of his or her eating dis-
order specifically in the inability to maintain an optimal weight for Of the 86 participants, nine (10%) did not complete
age and height. In the first phase, the therapist strives to unite the
parents in developing a consistent approach to refeeding. The ther- treatment (defined before the start of study as attending
apist explicitly disclaims the notion that the parents have caused the 80% of assigned treatment sessions, i.e., eight of 10 ses-
eating problem and instead expresses sympathy for the parents’ sions in the short-term treatment group and 16 of 20 in
plight in trying to find a way to help their child. In addition, the
therapist attempts to recruit the sibling subsystem to support their the long-term treatment group). Two (4%) dropped
affected sibling. Parents work out for themselves how best to refeed out of the short-term allocation and seven (16%) drop-
their child with anorexia nervosa with the therapist’s ongoing sup- ped out of the long-term allocation. The reasons for
port and consultation.
Once steady weight gain is evident and the family experiences re-
dropping out included a perception by the parents that
lief that they are being effective in taking charge of the eating dis- the treatment offered was not effective (n = 1), a wish for
order, the second phase of treatment begins. During this phase, a different form of treatment (n = 1), living too far away
symptoms of anorexia nervosa remain central in the discussions, (n = 1), need for other psychiatric treatment (n = 1), and
but other issues that are perceived to interfere with the parents in
their task of ensuring steady weight gain can be brought forward participant refusal (n = 1). In the remaining cases (n =
(e.g., eating at school or at parties, level of activity, sports partici- 4), the reason for dropout was unknown because the
pation). participant could not be contacted. In addition, eight
When the patient achieves a stable weight and there are no strug-
gles with eating, the third phase of treatment is initiated. The goal of treatment completers (three from the long-term treat-
this phase is to identify and briefly address other adolescent concerns ment group and five from the short-term group) did
that have been ignored because of the development of anorexia nerv- not complete the final assessment (Fig. 1).
osa. Depending on the age of development, this entails, among other
things, working toward increased personal autonomy for the adoles-
cent, more appropriate family boundaries, and the need for the pa- Treatment Outcome
rents to reorganize their life together as their children mature. Comparison of intent-to-treat outcomes between the
Regardless of the treatment phase, each session begins with a 10–
15 minute check-in with the adolescent and is followed by a 45- to two groups can be found in Table 2 and Figs. 2 and 3.
50-minute meeting with the entire family. Occasional brief tele- Despite the fact that multiple testing increases the prob-
phone calls (less than 10 minutes in duration) are allowed when ability of a false positive, no statistically significant dif-
problems arise that require consultation with the therapist.
In the current study, the short-term treatment focused on the first ference between the treatment groups was detected on
and second phases of treatment, although at least one session, usually the primary outcomes (BMI, EDE) or on any of the
the last, examined more general adolescent issues. On the other secondary outcomes. Indeed there were only two out-
hand, the long-term treatment group allowed for more time in each
treatment phase and in particular more time to focus on general ad-
comes, EDE eating and CBCL Internalizing subscale,
olescent concerns during the third phase. for which the long-term treatment has results better
than those of the short-term treatment (indicated by
positive signs on the ES of the slope, the standardized
Data Analysis
mean difference between the slopes in the long-term
The primary analysis was by intention-to-treat. A random regres- versus short-term treatments).
sion model was used to compare the response trajectories (based on
the EDE outcome data) of the two groups. This assumes a linear Clearly, a nonsignificant difference does not prove
model for each subject’s trajectory, such that the intercept represents the null hypothesis, even when the study is adequately

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LOCK ET AL.

TABLE 2
Comparison of Long-Term and Short-Term Treatments
Long-Term Treatment Short-Term Treatment
(N = 42) Mean (SD) (N = 44) Mean (SD) Effect Size of
12 mo 6 mo Slope (95%
(End of (End of Confidence
Baseline 6 mo Treatment) Baseline Treatment) 12 mo Interval) AUC

Eating Disorder
Examination: Eating
Concerns Subscale 1.04 (1.33) 0.75 (1.00) 0.52 (0.83) 1.35 (1.13) 0.86 (1.01) 0.71 (0.92) +0.09 (–0.33 to +0.51) 53%
Eating Disorder
Examination:
Restraint Subscale 2.64 (1.96) 1.64 (1.70) 1.42 (1.63) 2.76 (1.97) 1.84 (1.77) 1.62 (1.80) –0.08 (–0.51 to +0.34) 48%
Eating Disorder
Examinations:
Shape Concerns
Subscale 2.41 (1.67) 1.96 (1.55) 1.76 (1.69) 2.61 (1.73) 2.25 (1.63) 2.08 (1.70) –0.12 (–0.54 to +0.31) 47%
Eating Disorder
Examinations: Weight
Concerns Subscale 1.96 (1.52) 1.62 (1.48) 1.39 (1.44) 2.32 (1.51) 2.01 (1.50) 1.97 (1.60) –0.11 (–0.53 to +0.31) 47%
Body mass index 17.3 (1.5) 19.0 (1.8) 19.5 (2.1) 17.0 (1.3) 19.0 (2.3) 19.5 (2.2) –0.26 (–0.68 to +0.17) 43%
Weight (kg) 46.7 (7.2) 51.4 (7.5) 53.2 (8.0) 44.6 (5.5) 50.6 (8.1) 52.0 (7.6) –0.21 (–0.63 to +0.22) 44%
Youth Self-Report
Externalizing Scale 9.2 (6.5) 8.6 (6.7) 8.5 (6.0) 9.4 (6.6) 9.5 (6.8) 9.6 (6.6) –0.19 (–0.62 to +0.25) 45%
Internalizing Scale 16.6 (11.7) 14.6 (10.7) 14.0 (10.8) 19.2 (12.3) 19.6 (12.6) 18.2 (12.2) –0.15 (–0.58 to +0.29) 46%
Total score 40.6 (25.6) 36.1 (23.7) 35.7 (23.1) 45.0 (27.7) 46.1 (28.3) 44.9 (27.6) –0.24 (–0.67 to +0.20) 43%
Child Behavior
Checklist
Externalizing Scale 7.71 (6.6) 6.05 (5.8) 6.0 (5.2) 8.5 (6.3) 7.3 (5.5) 7.3 (5.9) –0.04 (–0.47 to +0.39) 49%
Internalizing Scale 15.6 (10.5) 12.6 (9.0) 11.2 (9.0) 18.7 (10.5) 15.7 (9.5) 13.8 (9.8) +0.04 (–0.40 to +0.47) 51%
Total Score 36.4 (25.4) 28.3 (17.7) 26.1 (19.1) 41.2 (21.3) 35.5 (20.7) 32.3 (22.6) –0.06 (–0.49 to +0.37) 48%
Yale-Brown Cornell
Eating Disorder Scale:
total score 12.2 (8.4) 8.8 (6.6) 6.4 (6.4) 13.4 (7.9) 10.9 (9.7) 9.2 (9.6) –0.28 (–0.70 to +0.15) 42%

AUC = area under the curve (probability that a long-term subject will have better outcome than a short-term subject).
Means and SD are presented. Significance tests and effect sizes compare the slopes in the two groups.

powered. However, all the confidence intervals for the nalizing Scale, the only two variables in which the ES
ES indicate that the true ES is unlikely to be anywhere favored longer term treatment. In short, there is no ev-
near moderate (d = 0.5) (Cohen, 1988. Another method idence supporting that, in general, long-term treatment
for examining ES, the area under the curve (Grissom, will produce more favorable results than the short-term
1994; McGraw and Wong, 1992) uses the probability treatment.
that a long-term treatment subject has an outcome pref- Another outcome of interest relates to the use of hospital-
erable to that of a short-term treatment subject. In this ization. A total of 19 participants (22%) were medically
case, area under the curve calculations (with a null value hospitalized according to study criteria after beginning
of 50%) is at best 53% for EDE Eating Concerns. The treatment. Of these, nine (21%) of the participants in the
number needed to treat (NNT) (Cook, 1995), which is long-term group were hospitalized after the study treat-
the number of subjects needed to be treated with long- ment had begun for an average of 16 days. Ten (23%) of
term treatment to have one more success than if all had those in the short-term group were hospitalized after the
been treated with short-term treatment is 20 subjects for study treatment had begun for an average of 20 days.
EDE Eating Concerns and 44 subjects for CBCL Inter- There was no significant difference between the groups.

636 J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA

Fig. 2 Change in weight (kg) by treatment group.


Fig. 4 Change in body mass index by treatment and Yale-Brown-Cornell
Eating Disorder Scales.
Moderators of Outcome
Because there may be some subjects for whom one or DISCUSSION
the other length of treatment might be more effective,
we examined possible moderators of outcome for both The present study was designed to determine the op-
BMI and global EDE. The variables explored were age, timal length of family-based treatment for anorexia
session attendance, baseline BMI (including low qual- nervosa in adolescents, a treatment that has been sug-
ifying BMI), comorbidity, duration of illness, EDE re- gested to be effective in controlled trials (Eisler et al.,
straint subscale scores, gender, intact family, principal 2000; Le Grange et al., 1992; Russell et al., 1987).
investigator being the therapist, purging status, medica- The results of this study can be regarded as reliable
tion use, hospitalization, YBC-ED total score, internal- for the following reasons. First, the study was designed
izing score on the Youth Self-Report and the CBCL, to have adequate power to detect a moderate difference
and family income. between the two treatments (Kraemer and Thienemann,
Two moderators of treatment outcome were found. 1987). Second, treatment manuals were used for the
For BMI, the total score on the YBC-ED moderated two levels of therapy (Lock and Le Grange, 2001).
outcome (Fig. 4) in favor of longer treatment for those Third, the quality of the therapy was closely monitored
with the most severe symptoms (t 81 = 2.7, p = .008). For to ensure fidelity to the treatment type and to the in-
global EDE, those with nonintact families (Fig. 5) did tensity and duration of its application. Fourth, the main
better in longer treatment (t 81 = 2.9, p = .004).

Fig. 3 Change in global eating disorder examination by treatment group. Fig. 5 Change in global eating disorder examination by family status.

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LOCK ET AL.

outcome measures (BMI and EDE) were independently by an excellent medical staff with expertise in the treat-
assessed by interviewers trained and experienced in its ment of adolescent anorexia nervosa.
use. Therefore, it seems likely that both the therapy
and the assessment of eating-disordered psychopatho-
logical processes were carried out with high fidelity, Clinical Implications
lending credibility to the results obtained. Overall, the results of this study suggest that for ado-
The results of the study suggest that many adolescents lescents with anorexia nervosa, a short-term treatment
with anorexia nervosa can be as effectively treated with with family therapy is as effective as long-term family
a relatively short-term family therapy as with long-term therapy for the majority of such patients when their out-
family therapy. It appears, however, that participants comes are assessed at the end of 1 year. A follow-up
with more severe and persistent eating-related obses- study to determine whether the effects of treatment were
sive-compulsive thinking or those who come from non- maintained would be a useful future study. However,
intact families did significantly better in long-term although there is no clear definition of remission or re-
treatment. Both of these potential moderators make covery in anorexia nervosa, using BMI of greater than
clinical sense. Those with the highest degree of obses- 17.5 alone (the DSM-IV diagnostic threshold for an-
sional concern and most intractable compulsive behav- orexia nervosa), 96% of the sample are remitted at
iors are more challenging for parents to redirect and the end of treatment, whereas using a stricter criterion
thereby might take longer to change. Intact families of a BMI of 20 and a global EDE score within 2 SDs of
have an advantage in taking on the tasks of changing normal, 67% would be considered remitted.
behaviors related to anorexia nervosa because both pa- Clinicians interested in using family-based therapy
rents are more likely to be available and invested sim- for anorexia nervosa should consider the possibility that
ilarly in their child’s recovery. Because family-based a short-term course will benefit the patients; however, if
treatment for anorexia nervosa depends heavily on this there are exceptionally high levels of eating-related ob-
parental resource, any compromise in it would likely sessionality and compulsiveness or the patient comes
lead to the need for additional assistance. Thus, longer from a single-parent or divorced family, it is probably
term treatment might be expected. These findings pro- more likely that a longer course will be required. The
vide preliminary evidence to guide therapists when se- increase in the EDE scores for this subgroup (Fig. 5)
lecting patients for long- or short-term treatment. may portent future relapse. This might suggest that the-
rapists consider alternative treatments (e.g., individual
treatment) in addition to more family therapy. Longer
Limitations term follow-up and additional treatment studies may
There are important qualifications relevant to the help to shed light on this important subject. Clinicians
current study that may limit its generalizability. The using this approach may not generally have the avail-
study sample consisted of participants who agreed to ability of medical experts to support their treatment
family treatment from referrals to a tertiary treatment as such a resource is not always or commonly available.
center for eating disorders. The conclusions therefore At the same time, in the United Kingdom, where this
may pertain to help-seeking families willing and able treatment originated, adolescents treated with this ap-
to participate in family-based therapy. The socioeco- proach generally are not provided with this level of med-
nomic status of the sample and education of the parents ical support and appear to have similar outcomes (Eisler
were on average higher than expected in the general et al., 2000). It is also important to remember that in
community, although similar to many samples of par- both arms of the study, treatments were titrated upward
ticipants with anorexia nervosa. Additional variables from a base of weekly sessions for approximately 2 months
that might have played a role in the overall outcome at the start. Getting patients started in the right way ap-
include the availability of medical hospitalization for pears to be key in the success of this approach. The de-
acutely ill patients both before and during the study, creased frequency of sessions later in therapy may serve
use of medications, and expectation effects of participa- to boost and continue the impact of the earlier sessions.
tion in a treatment study. It should also be emphasized While these findings provide encouragement for the
that treatments provided in this study were supported use of this form of treatment for the majority of such

638 J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA

patients, albeit combined with hospitalization and psy- Kaufman J, Birmhaher B, Brent D et al. (1997), Schedule for affective dis-
orders and schizophrenia for school-age children–present and lifetime
chotropic medications when needed, further research is version (KSADS-PL): initial reliability and validity data. J Am Acad Child
needed to determine definitively whether this type of Adolesc Psychiatry 36:980–988
Kraemer H, Thienemann S (1987), How Many Subjects? Statistical Power
family therapy is superior to other forms of treatment Analysis in Research. Newbury Park, CA: Sage
for adolescent anorexia nervosa. Kraemer H, Wilson GT, Fairburn G, Agras WS (2002), Mediators and mod-
erators of treatment effects in randomized clinical trials. Arch Gen Psy-
chiatry 59:877–884
Disclosure: The authors have no financial relationships to disclose. Le Grange D, Eisler I, Dare C, Russell G (1992), Evaluation of family treat-
ments in adolescent anorexia nervosa: a pilot study.Int J Eat Disord
12:347–357
Lock J (1999), How clinical pathways can be useful: an example of a clinical
REFERENCES pathway for the treatment of anorexia nervosa in adolescents Clin Child
Psychol Psychiatry. 4:331–340
Achenbach T (1991), Manual for the Child-Behavior Checklist/4-18 and 1991 Lock J, Le Grange D (2001), Can family-based treatment of anorexia nervosa
Profile. Burlington: University of Vermont, Department of Psychiatry be manualized? J Psychother Pract Res 10:253–261
American Academy of Pediatrics (2003), Identifying and treating eating dis- Lock J, Le Grange D, Agras WS, Dare C (2001), Treatment Manual for An-
orders: policy statement. Pediatrics 111:204–211 orexia Nervosa: A Family-Based Approach. New York: Guilford
Cohen J (1988), Statistical Power Analysis for Behavioral Science. Hillsdale, Mazure S, Halmi C, Einhorn A (1995), The Yale-Brown-Cornell Eating Dis-
NJ: Erlbaum order Scale: a new scale to assess eating disorder symptomatology. Int J
Cook R (1995), The number needed to treat: a clinically useful measure of Eat Disord 18:237–245
treatment effect. BMJ 310:452–454 Mazure S, Halmi S, Sunday S, Romano S, Einhorn A (1994), The Yale-
Cooper Z, Cooper PJ, Fairburn C (1989), The validity of the eating disorder Brown-Cornell Eating Disorder Scales: development, use, reliability,
examination and its subscales. Br J Psychiatry 154:807–812 and validity. J Psychiatr Res 28:425–445
Dare C, Eisler I (1997), Family therapy for anorexia nervosa. In: Handbook of McGraw K, Wong S (1992), A common language effect size statistic. Psychol
Treatment for Eating Disorders, Garner D, Garfinkel D, eds. New York: Bull 111:361–365
Guilford, pp 307–324 Moos R (1974), The family environment scale, Form R. Palo Alto, CA: Con-
Dare C, Eisler I, Russell G, Treasure J, Dodge E (2001), Psychological ther- sulting Psychologists Press
apies for adults with anorexia nervosa: randomized controlled trial of out- Moos R, Moos B (1994), Family Environment Scale Manual, Palo Alto, CA:
patient treatments. Br J Psychiatry 178:216–221 Consulting Psychologists Press
Efron B (1971), Forcing a sequential experiment to be balanced. Biometrika Passi V, Bryson S, Lock J (2003), Assessment of eating disorders in adoles-
58:403–417 cents with anorexia nervosa: self-report versus interview. Int J Eat Disord
Eisler I, Dare C, Hodes M, Russell G, Dodge E, Le Grange D (2000), Family 33:45–54
therapy for adolescent anorexia nervosa: the results of a controlled com- Robin A, Siegal P, Moye A, Gilroy M, Dennis A, Sikand A (1999), A con-
parison of two family interventions. J Child Psychol Psychiatry 41:727–736 trolled comparison of family versus individual therapy for adolescents
Eisler I, Dare C, Russell G, Szmukler G, Le Grange D, Dodge E (1997), with anorexia nervosa. J Am Acad Child Adolesc Psychiatry 38:1482–
Family and individual therapy in anorexia nervosa: a five-year follow- 1489
up. Arch Gen Psychiatry 54:1025–1030 Russell G, Szmukler G, Dare C, Eisler I (1987), An evaluation of family
Grissom R (1994), Probability of the superior outcome of one treatment over therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry
another. J Appl Psychol 79:314–316 44:1047–1056

J. AM. ACAD. CH ILD ADO LESC. PSY CH IATRY, 44:7, JULY 200 5 639