Intensive Family-Based Therapy During an Acute Medical Admission for Anorexia Nervosa

1 Theoretical and Research Basis for Treatment

Anorexia nervosa (AN) is a significant public health concern affecting 4% of women cross-nationally (Smink, van Hoeken, & Hoek, 2013), with the highest incidence rates among adolescents, aged 15 to 19 (Herpertz-Dahlmann, 2009). AN has the highest mortality rate of any psychiatric disorder at 6% (Arcelus, Mitchell, Wales, & Nielsen, 2011). Characterized by high rates of relapse, less than 50% of adult AN patients fully recover (Steinhausen, 2009). Individuals with AN and their families often suffer significant financial burden associated with medical costs, as chronic AN is associated with multiple inpatient admissions (Steinhausen, Grigoroiu-Serbanescu, Boyadjiva, Neumarker, & Winkler Metzke, 2008) and an average cost of treatment upward of US$80,000 (Lock, Couturier, & Agras, 2008).

Factors associated with a positive prognosis of AN include early age at illness onset, short treatment duration, and supportive family involvement in the treatment process (Steinhausen, 2009). These findings highlight the need for efficacious short-term treatment and family engagement in therapy interventions. Consistently, family-based treatment is the gold standard treatment for pediatric AN. FBT is a short-term, behaviorally oriented intervention in which parents are actively involved in their child’s recovery (Lock & Le Grange, 2012). The treatment approach draws on the neurobiological underpinnings of AN, highlighting brain impairments associated with malnutrition that hinder one’s motivation to recover (Kaye, Fudge, & Paulus, 2009). As such, sufferers are considered incapable of making sound nutritional decisions and parents are enlisted as the primary resource in their child’s care. Emphasis is placed on parental assumption of control of the child’s nutritional intake and ultimate weight restoration. Treatment success is contingent upon parental capabilities in this task (Lock & Le Grange, 2012).

Standard FBT occurs within the context outpatient care for 9 to 12 months and is characterized by three treatment phases (Lock & Le Grange, 2012). Phase 1 prioritizes weight restoration of which caregivers are given primary responsibility. Parents are asked to assume control of all of their adolescents eating behaviors via meal planning, preparation, and supervision. Therapy sessions serve as a problem solving platform, with the clinician guiding the family to determine means of helping the adolescent achieve weight gain. Phase 2 of FBT represents the period during which caregivers return control of eating to the adolescent, with the goal of developmentally appropriate independence in eating-related tasks. Finally, Phase 3 emphasizes the resolution of adolescent challenges associated with identity formation and normal developmental tasks that are often impeded by eating disorder symptoms (Lock & Le Grange, 2012).

The effectiveness of outpatient FBT for adolescent AN has been consistently illustrated in randomized controlled studies and case reports (Couturier, Kimber, & Szatmari, 2013; Le Grange et al., 2014; Krautter & Lock, 2004; Lock et al., 2010; Loeb, Hirsch, Greif, & Hildebrandt, 2009). Importantly, outpatient FBT is associated with faster recovery rates, higher sustained remission rates, and a significant decrease in hospital readmissions and associated treatment costs as compared with individual psychotherapy (Couturier et al., 2013; Lock et al., 2008; Lock et al., 2010). A recent longitudinal study examining the 5-year outcomes of outpatient FBT revealed a 56% decrease in hospital admissions, 75% decrease in readmissions, and 51% decrease in total hospital admission days. Furthermore, upward of 90% of adolescents were weight restored at therapy completion (Hughes et al., 2013).

More recently, FBT interventions have been extended beyond the adolescent outpatient treatment realm with encouraging results (Lock, Le Grange, Forsberg, & Hewell, 2006; Rockwell, Boutelle, Trunko, Jacobs, & Kaye, 2011). Specifically, implementation of outpatient FBT has demonstrated effectiveness in children (Lock et al., 2006). Furthermore, intensive treatment has also been promising, with an intensive 40-hr, 1-week FBT-guided intervention associated with sustained weight gain at 9-month follow-up (Rockwell et al., 2011).

To our knowledge, there are no studies examining the efficacy of FBT-guided interventions within the context of an acute medical hospitalization for adolescents with AN. At our institution, a large children’s hospital in an urban setting, the majority of medically hospitalized adolescents with AN have no prior history of psychological care for an eating disorder. With an average length of stay ranging 8 to 10 days, the admission offers an invaluable period of time to commence intensive FBT interventions.

Herein, we describe the use of an FBT-guided intervention in the context of an acute medical admission for AN. Whereas the short length of acute hospital stay prevents the implementation of standardized FBT (i.e., three phases of treatment), we hypothesized that providing families with a brief intervention emphasizing basic FBT principles to empower parents could improve the treatment outcome in medically compromised youth with AN. Thus, the presented case study highlights the use of this protocol in an adolescent with severe AN who was medically hospitalized for bradycardia secondary to malnutrition and risks associated with refeeding disorder. Of note, the efficacy of this intervention is currently being examined in the context of a large-scale, institutional review board (IRB)–approved study at our institution.

2 Case Introduction

“Sheila,” a 15-year-old Caucasian female, was referred for an outpatient eating disorders evaluation by her community pediatrician for weight loss concerns. At the evaluation, eating disorders symptoms and medical vitals were assessed. Sheila reported consumption of 300 to 500 kcals daily and exercised for 30 to 90 min per day (i.e., running, dancing, or performing calisthenics). Over the past year, her weight had declined from 51.3 kg (112.9 lbs; 19.8 kg/m² body mass index [BMI]) to 42.3 kg (93.1 lbs; 16.3 kg/m² BMI). Upon physical examination, Sheila was found to be bradycardic, with a heart rate of 44 bpm on electrocardiogram (EKG). A medical hospitalization was recommended, and she was admitted that evening.

3 Presenting Complaints

Sheila’s eating disorder symptoms began approximately 14 months prior to her hospitalization. At that time, her family gave up “unhealthy” foods for Lent. Whereas family members resumed normal eating behaviors after Lent concluded, Sheila continued to avoid “junk” foods. Over the following months, her diet became more and more restrictive; she cut out carbohydrates and fats until she was consuming no more than 500 kcal per day. Although she expressed beliefs that she was too thin, she noted an intense fear of gaining weight.

Sheila denied concerns with her body shape and weight prior to symptom onset. However, as her restriction exacerbated, she negatively compared herself with her two older sisters, believing that she was “chubbier” than them and needed to lose weight. Of note, both of Sheila’s sisters engaged in regular exercise and “watched what they ate.” According to Sheila’s mother, her sisters did not have eating disorders, but they did monitor their weight and Sheila compared her weight with theirs. Sheila had always worked hard in school and described having to work hard for As while her older sister (aged 16) did not have to exert as much effort at getting As. Her mother noted that as she became more preoccupied with weight and shape, she also became more driven and perfectionistic about school. Sheila also reported difficulties paying attention due to thoughts about food, weight, and shape. She enjoyed going to the grocery store, where she would look over food labels and expressed a new found interest in cooking. With respect to mood, Sheila experienced significant mood lability in the weeks leading up to her hospitalization. She vacillated between feeling down, irritable, and anxious.

4 History

Sheila lived with her parents and two older sisters, aged 16 and 19. She was in the ninth grade, with above average grades. She had a number of close friends and participated in dance and drill team. She had no prior history of mental health diagnoses or treatment and had no major medical problems. Her parents denied any family history of mental health concerns. However, both of her parents presented with moderate to significant levels of anxiety. There were no reported significant household stressors.

5 Assessment

At admission, Sheila’s mother completed the Brief Illness Perceptions Questionnaire (B-IPQ; Broadbent, Petrie, Main, & Weinman, 2006) and the Parents Versus Anorexia Scale (PVA; Rhodes, Baillie, Brown, & Madden, 2005). These questionnaires evaluate one’s beliefs about AN and assess parental self-efficacy in the context of providing care within the FBT model, respectively. We hypothesized that these assessments capture key messages targeted in FBT interventions that facilitate treatment engagement.

The B-IPQ is a nine-item self-report measure of cognitive and affective illness representations among eight dimensions. The B-IPQ is a brief version of the Illness Perception Questionnaire–Revised (IPQ-R; Moss-Morris et al., 2002). The IPQ-R has demonstrated good test–re-test reliability (with subtests ranging from 0.48 to 0.70) and convergent validity with the IPQ-R (Broadbent et al., 2006). Illness perceptions are implicated in treatment engagement, coping, and outcomes (Hagger & Orbell, 2003). Given the caregiver’s role in FBT interventions, it is plausible that parental beliefs about their child’s eating disorder will likely impact their ability to implement recommended, evidence-based interventions. At intake, Sheila’s mother rated her understanding of AN as 5 out of 10 (with 0 = no understanding and 10 = a clear understanding of the illness), believed AN severely affected Sheila’s life (10 out of 10), believed that Sheila’s illness would last at a duration of 9 out of 10 (with 0 = a very short time and 10 = forever), believed that Sheila had control over her AN symptoms at 9 out of 10 (with 0 = absolutely no control and 10 = an extreme amount of control), believed that treatment would be extremely helpful in her daughter’s recovery (10 out of 10), expressed extreme concern with her daughter’s illness (10 out of 10), and reported that Sheila’s illness affected her emotionally at an 8 out of 10 (with 0 = not at all affected emotionally and 10 = extremely affected emotionally).

The PVA was developed to assess a caregiver’s efficacy in the context of Maudsley Family-Based Treatment for AN. The scale is comprised of seven self-report items rated in a five-point Likert-type scale with scores ranging from 35 (highest self-efficacy) to 5 (lowest self-efficacy). Acceptable reliability (α = .78) has been established (Rhodes et al., 2005). At intake, Sheila’s mother’s total score on the PVA was a 15. She expressed feeling unequipped to use specific strategies to bring about Sheila’s recovery.

In addition to parent questionnaires, Sheila completed the Eating Disorders Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994). The EDE-Q is a self-report version of the Eating Disorder Examination (EDE) interview, which assesses the frequency of eating disorder attitudes and behaviors over the previous 28 days (Fairburn, 2008; Luce & Crowther, 1999). It yields four subscale scores: Dietary Restraint (DR), Shape Concern (SC), Weight Concern (WC), and Eating Concern (EC) as well as a Global Score (GS). Higher scores indicate greater symptom severity and impairment. Research suggests that the EDE-Q shows good reliability (Luce & Crowther, 1999) and validity (Fairburn & Beglin, 1994). Sheila completed the EDE-Q at admission and at 5 months following hospital discharge. At intake, her results were the following: 5.0 on DR, 5.0 on SC, 4.5 on WC, 3.2 on EC, and 4.5 on GS. Compared with normative data of a community sample of adolescent females aged 12 to 15, Sheila’s responses on the EDE-Q were elevated (Mond et al., 2014).

Finally, Sheila’s weight, BMI, and percent of ideal body weight (IBW) were measured at hospital admission, discharge, and at 5-month follow-up. IBW was determined by historical growth charts obtained from her childhood pediatrician. At intake, Sheila’s weight was 42.3 kg (93.1 lbs; 16.3 kg/m² BMI) and percent IBW was 82.0%.

6 Case Conceptualization

It is likely that a combination of biological and environmental factors contributed to the development of AN for Sheila. Temperamentally, Sheila was high achieving, driven, perfectionistic, and a “people-pleaser.” She avoided conflict, prided herself on her achievements, and was described as being the most compliant and “good-natured” of her parents’ three children. Anxiety also played a notable role in her eating disorder. Sheila’s parents both struggled with anxiety symptoms, and Sheila self-identified as a “worrier,” often worrying about her school performance, her future, and most recently, her weight and shape. For Sheila, giving up junk food for Lent appeared to act as an environmental trigger for the development of her eating disorder, as this directly preceded symptom onset. It is plausible that Sheila applied her perfectionistic and anxious tendencies to this endeavor, which served to exacerbate and maintain her eating disorder. Reinforcement also played a large role in symptom engagement. Specifically, Sheila was initially met with positive comments from her siblings and peers about her weight loss and her drive to be “healthy.” Furthermore, her sisters, who were both very weight and diet focused, likely reinforced her desire to restrict and lose weight. She feared that resuming a normal diet and potentially gaining weight would promote criticism and judgment by others. Given her developmental level (early adolescence) and her diagnosis of AN, a family-based therapy approach was appropriate. Her parents were both engaged in her treatment and were judged to be able to follow through with therapy recommendations associated with FBT.

7 Course of Treatment and Assessment of Progress

Using standard FBT as a guide, four treatment sessions were provided over the course of Sheila’s 10-day medical hospitalization. Each session ranged from 60 to 90 min in length and was conducted by a trained psychologist in her hospital room. Both parents were included in all four sessions as both were present for the majority of Sheila’s hospitalization and would be sharing responsibility for refeeding. Although it would have been ideal to involve siblings as recommended by FBT, logistically it was not possible on an inpatient unit because the siblings had school during the day. Individual and group therapy was not provided to Sheila during the admission.

Session 4: Behavioral Contracting (60 Min)

The final session occurred on the morning of Sheila’s discharge. The psychologist and family created a clear contingency plan that would be implemented in the home environment, with the goal of motivating Sheila to meet nutritional goals in the refeeding process. Upon completion, the plan was recorded and provided to the family and Sheila’s outpatient care team.

Consistent with FBT tenets, the plan reiterated that Sheila’s parents would be in control of all meal planning and preparation. Sheila would not be allowed in the kitchen during meal preparation and could not go grocery shopping with parents, as these activities prompted family conflict prior to the hospitalization. All meals and snacks would be supervised by parents, unless at school, where Sheila would eat with a guidance counselor. If Sheila was unable to complete 100% of a given meal or snack, she was expected to drink a commensurate amount of liquid supplement. If she chose not to drink the supplement, Sheila would be expected to rest in bed to conserve energy, without any privileges (e.g., technology use, homework). She would be required to stay home from school to rest if food refusal occurred at breakfast on school days. At the next scheduled meal, Sheila was expected to “make-up” any missed nutrition. (If refusal occurred while under the guidance counselor’s supervision, the counselor would notify Sheila’s parents and she would be expected to make this up at her after school snack.) If successful, she could resume normal activities, including returning to school. If unsuccessful, she was expected to return to bed and rest, where she would have a chance to get back on track at the next scheduled meal. If Sheila was unable to meet nutritional expectations after two consecutive days, an emergency family therapy appointment would be scheduled, during which problem solving would occur. Outcomes could potentially include re-hospitalization or consideration of a higher level of mental health care (e.g., partial hospitalization program, inpatient).

Given Sheila’s tendency to be perfectionistic, the use of bed rest and staying home from school appeared to be strong motivators to eat. To Sheila, lying in bed was equated with laziness, which prompted significant distress. Furthermore, missing school or not being allowed to work on homework was perceived as a consequence that she hoped to avoid. Finally, the possibility of admission to a higher level of care with food refusal was an important component of this plan, as avoiding more intensive care was a strong motivator for Sheila to be compliant with her meal plan. Of note, these contingencies are not suitable for all youth, emphasizing the need for a family discussion to delineate appropriate motivators in developing a suitable behavioral contract.

Assessment of progress

A re-assessment of parent self-report questionnaires was conducted immediately following completion of Session 4 and again at 5 months following hospital discharge (see Table 1). Prior to discharge, Sheila’s mother completed the B-IPQ and PVA. The EDE-Q was not re-administered to Sheila due to the time frame assessed by the measure (i.e., the past 28 days), which would be redundant with the initial administration, 9 days prior. Notable positive changes were evident on the parent measures. At discharge, Sheila’s mother endorsed a positive change in beliefs about her ability to care for Sheila (i.e., parental self-efficacy). She expressed an improved understanding of AN, less belief in Sheila’s ability to control her symptoms, and greater hope that Sheila would recover. These changes were in line with psychoeducation and skills targeted by our FBT treatment and, we believe, would facilitate improved ability to implement and adhere to recommended interventions on an outpatient basis. Of note, no changes were apparent in her mother’s beliefs about how much AN affected Sheila’s life, the beneficial nature of treatment, degree of symptoms experienced by Sheila, and the emotional impact of the illness on Sheila’s mother.

OPEN IN VIEWER

Table 1.

Changes After FBT-Based Intervention.

	Admission	Discharge a	5-month follow-up b	Healthy control norms c	+ improved= no change− worse
BMI	16.32	17.5	20.0		+
% IBW	82	85.8	97.7		+
HR (bmp)	38	48	NA		+
EDE-Q Global d	4.5	NA	2.5	1.6	+
EDE-Q Restraint d	5.0	NA	0.4	1.3	+
EDE-Q Eating Concern d	3.2	NA	1.6	1.1	+
EDE-Q Shape Concern d	5.0	NA	4.4	2.1	+
EDE-Q Weight Concern d	4.5	NA	3.8	2.1	+
PVA e	15	22	NA		+
Understanding of AN e	5	9	5		=
Child control over AN e	9	5	9		=
Affect child life e	10	10	5		+
Emotional impact on parent e	8	7	3		+

Note. FBT = family-based therapy; BMI = body mass index; % IBW = percentage of ideal body weight; HR (bmp) = overnight low heart rate (beats per minute); EDE-Q = Eating Disorder Examination Questionnaire; PVA = Parents Versus Anorexia; Understanding of AN = parent report of understanding anorexia nervosa; child control over AN = parent report of how much control child has over anorexia nervosa; affect child life = parent report of how much the illness affects their child’s life; emotional impact on parent = parent report of the emotional impact of the illness on themselves; NA = nonapplicable.

a

The EDE-Q was not administered at discharge because the admission was 10 days and the EDE-Q assesses a 28-day period.

b

HR (bmp) and PVA were not administered at 5-month follow-up.

c

Based on normative data for adolescent girls, 12-15.

d

Child report.

e

Parent report.

At 5 months post-discharge, following a course of standard outpatient FBT, Sheila’s mother was re-administered the IPQ, and Sheila completed the EDE-Q at the outset of an outpatient therapy visit. Sheila was weight restored at this point, maintaining a BMI of 20.0 and at 97.7% of her IBW. On the IPQ, compared with hospital admission and discharge, positive changes were evident in her mother’s perception of how much AN symptoms affected Sheila’s life, the degree to which Sheila experienced AN symptoms, concern experienced by Sheila’s mother about her daughter’s illness, and the emotional impact of the illness on Sheila’s mother. Compared with hospital discharge, her mother reported less understanding of AN and beliefs that Sheila had more control over AN symptoms. Lessened understanding could be associated with ongoing challenges experienced by Sheila, such as negative body image and ongoing distorted cognitions, despite weight restoration. Her parents struggled to make sense of these enduring symptoms because they anticipated that her psychological distress would dissipate upon weight restoration. With respect to beliefs that Sheila had more control over her symptoms, we believe that this is a positive change. At 5 months post-discharge, Sheila was making independent food choices and appropriately managing her nutritional intake without parental supervision.

On the EDE-Q, Sheila’s responses were consistent with improvements in all subscales as compared with hospital admission. Scores on the Global, Restraint, Weight Concern, and Eating Concern scales were no longer clinically elevated. Although improved, her Shape Concern score was still elevated compared with a normative group, suggesting ongoing difficulties in this domain.

8 Complicating Factors

Sheila’s mother and father both exhibited moderate to significant anxiety. Her father noted difficulties sleeping and frequent panic attacks triggered by anxiety about Sheila’s eating disorder, and her mother displayed significant anxiety during sessions. Their anxiety occasionally impeded their ability to recognize Sheila’s progress in treatment, as they tended to focus on additional areas for needed improvement as opposed to progress made. To manage this in session, the therapist often modeled praise of Sheila’s progress as well as emotion validation (e.g., “It seems like you feel guilty about skipping snack this week, let’s discuss ways to address that this week and help you to be more successful”). Parents’ anxiety also created barriers in transitioning between phases of FBT. Therapy discussions about transferring control over eating back to Sheila were met with significant parental concern, resulting in many sessions processing and managing these worries. To address this, the therapist built a hierarchy of steps to shift control of eating back to Sheila in a developmentally appropriate way. Parents were reassured that if Sheila lost weight over a week where she had more control over eating, the control would be shifted back to parents. Parents increased their confidence in Sheila managing her meals more independently when they saw that she was continuing to gain weight throughout these exposures. Finally, Sheila’s two sisters were very weight conscious and were often dieting and exercising. Sheila frequently compared herself with her sisters, creating additional conflict and anxiety during the refeeding process. The therapist emphasized to parents that this was a sign that the eating disorder was very strong, and why Sheila needed improved nutrition. As she neared weight restoration in outpatient therapy, the therapist implemented more cognitive behavioral strategies to identify and restructure automatic, negative thoughts.

9 Access and Barriers to Care

The use of FBT in the context of inpatient medical care is contingent upon both trained therapists and the ability for parents to be readily present during the admission process. First, FBT is a specialized treatment intervention requiring extensive training and competency to administer. Access to FBT may be limited by the dearth of clinicians with this competency, particularly for individuals with AN who reside in rural settings with limited access to mental health care. Second, adaptation of FBT to the inpatient medical setting requires that the caregiver is present for intensive therapy sessions and at the majority of the child’s meals and snacks throughout the admission. Some parents may not be able to meet this demand, given work and family responsibilities. In the case of Sheila, her mother was a schoolteacher and was on summer break, so she had the ability to be present during her daughter’s hospitalization. However, Sheila’s father was unable to attend all sessions. In this case, accommodations were offered, such as telephoning in for therapy sessions. Although this modification may not provide the same degree of support as face-to-face FBT, we believe that it offered a feasible alternative. Finally, barriers may exist in transferring the family from inpatient to outpatient levels of care. Whereas our institution can accommodate both inpatients and outpatients, facilitating in-house referrals that maximize care continuity, referring to an external outpatient provider could present challenges. Specifically, if the team refers to an outpatient provider without competence in FBT, the inpatient intervention will not be reinforced, and the family will receive mixed messages. It is important to identify community-based therapists who provide evidence-based FBT to bridge inpatient and outpatient care. It is also critical for the inpatient therapist to communicate with the anticipated outpatient clinician to determine goodness-of-fit and to maximize care.

10 Follow-Up

Sheila and her parents have attended 22 sessions (6 months) of outpatient therapy since hospital discharge. The family was able to continue working with the inpatient psychologist for outpatient care, which provided a seamless transition. Sheila has maintained her weight at or above 95% IBW for 3 months. She is currently in Phase 3 of FBT where she is planning, preparing, and managing the majority of her own meals and snacks. In line with normal adolescent development, her parents prepare her dinner and she eats this meal with her family. Sheila continues to struggle with eating disorder cognitions and therapy has shifted to include cognitive behavioral interventions to target these thinking patterns. Sheila appears motivated to implement these strategies and has reported a subsequent decline in distorted thinking patterns. With respect to eating behaviors, she tends to exhibit inflexible food choices, typically eating the same foods and limiting variety in her diet. Although she is able to eat challenging foods when it is a parental expectation, she is unmotivated to increase variety on her own. Despite these challenges, Sheila has maintained her weight in a healthy range. She recently started dating and is socializing more with her friends. Whereas family conflict has recently increased, it is related to normal developmental issues (e.g., Sheila wanting increased autonomy, disagreements about dating rules), as opposed to eating disorder symptoms.

11 Treatment Implications of the Case

In the case of Sheila, findings were noteworthy. Compared with baseline, Sheila’s parents expressed a higher level of self-efficacy and understanding of the illness immediately following the intensive, four-session FBT intervention. This is critical because parental self-efficacy in caring for one’s adolescent with AN is a central tenet in successful refeeding (Lock & Le Grange, 2012). They also indicated more hope that their daughter would recover and perceived Sheila to have less control over her illness, facilitating their motivation to take control of her eating behaviors. We believe that these factors positively impacted their ability to engage in treatment recommendations, which can be counterintuitive to developmentally appropriate parenting.

It is also noteworthy that Sheila’s BMI increased from 16.3 to 20.0 over the 5-month period, illustrating an increase in percent IBW from 82.0% to 97.7%. This finding is consistent with randomized controlled trials (RCTs) demonstrating FBT’s superiority to individual psychotherapy in terms of increased weight gain (Lock et al., 2010). It is unclear if, and to what extent, our inpatient intervention facilitated an improved outpatient treatment response for Sheila. It is conceivable that receiving this intensive FBT-based intervention allows parents a better understanding of AN and treatment, which, in turn, helps parents feel more equipped to refeed their adolescent and save them from this debilitating illness. It is also possible that receiving an FBT intervention at the inpatient medical stabilization phase of treatment shortens the time frame of outpatient FBT. Future studies are needed to answer these important questions.

Additional psychological benefits were apparent over the 5-month time period. Sheila’s mother expressed reduced emotional burden associated with her daughter’s illness. On the EDE-Q, Sheila no longer endorsed AN symptoms to a clinical degree (with the exception of concerns with body shape), indicating that important benefits were achieved beyond weight restoration.

It is noteworthy that despite treatment gains, Sheila continues to display eating disorder behaviors and cognitions, as evidenced by limited variety of foods consumed, negative body image, and eating disorder cognitions. This is not a surprise; it is common for these symptoms to persist beyond the point of weight restoration (Goldstein et al., 2011).

In summary, this case provides preliminary support for the use of an intensive FBT-guided intervention for adolescents with AN during an inpatient medical hospitalization before transitioning to traditional outpatient FBT. Possible mechanisms of action in these improvements include faster weight gain, improved understanding of the illness, and increased parental self-efficacy. Future studies are needed to evaluate the effectiveness of this intervention and its generalizability.

12 Recommendations to Clinicians and Students

This case report provides preliminary acceptability and effectiveness for the use of an intensive FBT-based intervention in the context of an inpatient medical admission for an adolescent with AN. In this regard, a number of recommendations for clinicians and students can be generated.

First, clinicians and students interested in conducting FBT for adolescents with AN should consult Lock and Le Grange’s (2012) treatment manual and seek specialized training in this modality. It is crucial to receive training in this intervention prior to its administration (Couturier et al., 2014). Second, application of FBT in the context of inpatient medical care requires the clinician to have a flexible schedule. Given the acute nature of a medical admission for AN, the clinician must provide a very intensive intervention in a limited period of time. In the case of Sheila, four lengthy sessions were provided over the course of seven weekdays. For clinicians and students with time-limited schedules, this intervention may not be feasible. Third, this intervention will not be effective if the patient’s family is not able or willing to be present during the hospitalization. We recommend that the intervention be described at admission outset to assess whether or not caregivers are capable of participating throughout the hospitalization. This sets the expectation that parents’ presence is critical for their child’s recovery and encourages their attendance at every therapy session throughout the hospitalization. In our experience, parents are often uncertain whether or not their presence during inpatient sessions will be helpful or harmful to their child. Informing parents that they are a critical part of care and are expected to be present during therapy sessions seems to lift a burden off of parents and instill confidence that they will be able to help their child. Fourth, it is important to individually tailor interventions to the family’s needs and to do so without judgment or criticism. For example, many parents are unable to be present for all meals and snacks following hospital discharge due to work schedules or other family commitments. In this case, it is important to assess the feasibility of the caregivers’ ability to take on this role in the outpatient realm. If parents are unable to prepare and supervise 100% of the child’s meals, it is critical for the clinician to be understanding of this. We suggest that the therapist use problem solving with the caregivers to determine alternate adults who can help care for the child, such as extended family members or close friends. We encourage these to attend inpatient therapy sessions to help prepare for their supervisory role following the hospitalization. Similarly, when creating a behavioral contract, it is important to assess potential motivators by garnering family input. A “one size fits all” approach is not appropriate for this treatment, and attempts to implement such an approach can quickly alienate families. Finally, working with a multidisciplinary team is critical, given the complexities of AN (Watson & Bulik, 2013). Although the psychologist was responsible for the intensive FBT sessions, interventions were reinforced by collaborative staff, including team physicians, dietitians, and nurses. For example, the hospital dietitian worked with parents to plan all meals without the youth’s input, and nurses provided parents with additional support at meals and snacks. This collaborative approach further bolsters parents’ abilities to manage their child’s illness in the framework of FBT during an inpatient medical admission.