A Pilot Study of an Acceptance-Based Separated Family Treatment for Adolescent Anorexia Nervosa

Probably not a substantial claim: may not pass S3 (load-bearing).

In OCD, parental anxiety is associated with illness accommodation.

“For example, in obsessive-compulsive disorder, parental anxiety has been associated with illness accommodation (i.e., allowing the child to engage in checking compulsions; Caporino et al., 2012; Flessner et al., 2011).”

• cites Caporino et al., 2012 sourceSupported
• cites Flessner et al., 2011 sourceSupported

May combine two claims.

FBT-M leads to weight restoration to 95% ideal and EDE scores within one SD of normative samples in 40-50% of adolescents.

“Almost half of the adolescents who receive FBT-M (40% to 50%) restore weight to 95% of ideal for height, age, and sex, and Eating Disorder Examination (EDE) scores are reduced to within one standard deviation of normative samples (Lock et al., 2010).”

• cites Lock et al., 2010 sourceSupported

May combine two claims.

Severe weight loss leads to biological adaptations of starvation that may attenuate somatic constituents of emotion and decrease intensity of anxious state.

“Further, because severe weight loss leads to the biological adaptations of starvation, it may also attenuate the somatic constitutes of emotion (e.g., heart rate; Damasio, 1995) and thereby decrease the experienced intensity of the anxious state (Pollatos, Gramann, & Schandry, 2007).”

• cites Damasio, 1995 sourceNot checked — no full text of the source
• cites Pollatos, Gramann, & Schandry, 2007 sourcePartly supported

  The Discussion (page not provided) reports that participants with greater awareness of bodily states experienced more intense feelings while viewing pleasant and unpleasant pictures. This supports a general link between bodily perception and emotional intensity, but the paper does not establish that severe weight loss or starvation attenuates bodily responses or decreases the intensity of anxiety. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

Parents generally found the treatment credible and anticipated improvement in their child.

“Overall, parents rated the treatment as credible and expected improvement in their child's condition.”

May combine two claims.

ASFT expectancy subscale scores exceeded CBT-E, averaging 27.25 ± 4.74 versus 19.06 ± 5.52.

“Parent expectancy subscale scores for ASFT were higher than CBT-E, with a mean of 27.25 ± 4.74 (range 19–32) compared to 19.06 ± 5.52 (Byrne et al.).”

• cites Byrne et al.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

With the Byrne et al. method, credibility ratings spanned 16 to 27 and averaged 23.5 ± 3.66.

“Using this method, parent credibility scores ranged from 16 to 27, with a mean of 23.5 ± 3.66.”

• cites Byrne, Fursland, Allen, and Watson (2011) sourceNot checked — no full text of the source

May combine two claims.

Parent treatment credibility scores were neutral to positive, with mean .345 and SD 3.66.

“Parent treatment credibility scores, on average, were neutral to positive, M = .345, SD = 3.66 (ranged from −7.15 to 3.85)”

May combine two claims.

Most adolescents demonstrated a clear reduction in attempts to restrain eating and increases in adaptive functioning, including interpersonal relations, self-reliance, self-esteem, and personal adjustment.

“Most adolescents demonstrated a clear reduction in attempts to restrain eating and increases in adaptive functioning, including: interpersonal relations, self-reliance, self-esteem, and personal adjustment.”

May combine two claims.

Broad effects were seen in the mental health and functioning of caregivers; for many caregivers, anxiety decreased and negative experiences of caregiving decreased.

“Broad effects were also seen in the mental health and functioning of the caregiver. For many caregivers, anxiety decreased as did negative experiences of caregiving.”

May combine two claims.

Some adolescents reported improvements in quality of life and comorbid symptomatology, as well as decreased avoidance and fusion, although the effect of treatment on comorbid anxiety and depression cannot be parsed from the effects of renourishment on mood.

“Some adolescents reported improvements in quality of life and comorbid symptomatology (although the effect of treatment on comorbid anxiety and depression cannot be parsed from the effects of renourishment on mood), as well as decreased avoidance and fusion.”

May combine two claims.

The majority of adolescents in ASFT had increases in BMI and made important steps towards increasing participation in valued life domains despite the presence of aversive thoughts of weight and shape.

“Consistent with the emphasis of acceptance-based behavioral therapies, the majority of adolescents in ASFT had increases in BMI and made important steps towards increasing participation in valued life domains (e.g., improving relationships) despite the presence of aversive thoughts of weight and shape.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Adolescent 1 identified her eating disorder as the one thing that was 'working' to diminish feelings of ineffectiveness and isolation.

“She identified the ED as the one thing that was “working” to diminish feelings of ineffectiveness (i.e., losing weight was something she could do well) and isolation (she no longer cared about time with friends and whether she was accepted by them).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Adolescent 1 was a 15-year-old female whose illness at its worst involved a diet of only one vegetable and condiment.

“Adolescent 1 was a 15 year-old female who, at the worst point in illness, had adopted a diet that included only one vegetable and condiment.”

May combine two claims.

Adolescent 1's family withdrew from treatment at Session 8 due to early symptom remission; at that point her weight was fully restored and her menses were regular.

“The family withdrew from treatment at Session 8 due to early symptom remission. At this point, the adolescent's weight was fully restored and her menses were regular.”

May combine two claims.

Two adolescents (33%) were removed from treatment for reasons other than remission: one needed a higher level of care, and one requested a male therapist.

“Two adolescents (33%) were removed for other reasons: need for a higher level of care, and reported desire for a male therapist.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Adolescent 4 requested a male therapist at midtreatment.

“Despite progress, Adolescent 4 requested a male therapist at midtreatment.”

May combine two claims.

Parents reported decreased anxiety and caregiver burden, indicating broad effects.

“There was evidence of broad effects, with parents reporting decreased anxiety and caregiver burden.”

May combine two claims.

Adolescent 1's anxiety and depression decreased to within normal limits, and her interpersonal relations and social stress scores were no longer clinically significant.

“Her anxiety and depression decreased, falling within normal limits; her interpersonal relations and social stress scores were no longer clinically significant.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

At treatment initiation, Adolescent 1 had increased intake to 8-10 safe foods but remained very restrictive, not gaining weight, and socially isolated and withdrawn.

“At the time of treatment initiation, Adolescent 1 had increased her intake and was consuming 8 to10 safe foods, but was still very restrictive, not gaining weight, and socially isolated and withdrawn.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Adolescent 1's BMI at study entry was 17.5 (16.4 percentile), up from her lowest BMI of 16 (3.3 percentile).

“Adolescent 1's BMI at study entry was 17.5 (16.4 percentile), up from her lowest BMI of 16 (3.3 percentile).”

May combine two claims.

One adolescent was referred to a higher level of care; this adolescent was highly socially anxious, uninterested in participating, and nearly nonverbal in session, and her caregivers had the lowest credibility and expectancy scores for treatment and the highest criticism.

“One adolescent was referred to a higher level of care. This adolescent was highly socially anxious, uninterested in participating in treatment, and nearly nonverbal in session. The caregivers of the adolescent had the lowest credibility and expectancy scores for treatment. They also had the highest criticism, although emotional overinvolvement was similar to several other families with good outcom”

May combine two claims.

In the current study, parent ratings of treatment credibility and expectancy for recovery seemed to be a prognostic indicator; families with caregivers with low to negative scores ended treatment prematurely, before 20 sessions and before adequate change had occurred (Adolescents 4 and 5).

“In the current study, parent ratings of treatment credibility and expectancy for recovery seemed to be a prognostic indicator. Families with caregivers with low to negative scores ended treatment prematurely, before 20 sessions and before adequate change had occurred (Adolescents 4 and 5).”

May combine two claims.

One of six families terminated treatment midtreatment because of early symptom remission, which the authors considered a positive outcome.

“Of the 6 families, one terminated midtreatment due to early symptom remission. This was considered a positive treatment outcome.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Adolescent 1 gained weight steadily over the course of treatment.

“She gained weight steadily over the course of treatment.”

May combine two claims.

All but one adolescent restored weight and were menstruating at the end of treatment.

“All but one adolescent restored weight and were menstruating at the end of treatment.”

May combine two claims.

Over the course of treatment, Adolescent 1 became increasingly skilled at approaching uncomfortable interpersonal situations, was less withdrawn, and more genuine in expressing emotion.

“Over the course of treatment, Adolescent 1 became increasingly skilled at approaching uncomfortable interpersonal situations and was less withdrawn and more genuine in her expression of emotion.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

One adolescent on birth control restored weight to ideal, but her menses remained regular throughout treatment.

“One adolescent, who was on birth control, restored weight to ideal; however, menses remained regular throughout treatment.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

During the time-line exercise, Adolescent 1 described a shift in peer relationships and an end to dance, both of which increased feelings of insecurity and self-doubt.

“During the time-line exercise, Adolescent 1 described a shift in peer relationships and an end to dance (which had been self-defining). Both events increased feelings of insecurity and self-doubt regarding whether she was good at things, liked by others, and generally acceptable.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Six adolescents participated in the initial pilot study.

“Six adolescents participated in this initial pilot study and each presented unique challenges.”

May combine two claims.

Adolescent 1's self-reliance and personal adjustment improved.

“Self-reliance and personal adjustment improved.”

May combine two claims.

Parental anxiety could generate inconsistent responses to illness behavior, with caregivers freezing or panicking when witnessing restriction.

“Parental anxiety could also generate inconsistent responses to illness behavior; caregivers may freeze (underrespond) or panic (overrespond) when witnessing their child restrict.”

Classified as probably not a substantial claim.

FBT-M might reduce clinical focus on maintaining factors or other influences that limit improvement.

“However, it may also decrease therapeutic attention to factors that either maintain illness behaviors or otherwise limit treatment outcome among some adolescents.”

May combine two claims.

The treatment used ACT rather than DBT because ACT emphasizes acting effectively despite compelling thoughts and feelings instead of reducing arousal, and it explicitly incorporates values.

“Therapeutic components were grounded in ACT (Hayes, Strosahl, & Wilson, 1999) rather than dialectical behavior therapy or other acceptance-based approaches. This is because ACT focuses exclusively on effective action in the presence of compelling thoughts and feelings rather than on strategies to down-regulate arousal (which individuals with AN may have already mastered with their symptoms) and”

• cites Hayes, Strosahl, & Wilson, 1999Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Lundgren, Dahl, & Hayes, 2008 sourceNot checked — no full text of the source

May combine two claims.

Parental frustration or guilt might prompt harsh, emotional communication aimed at forcing change, which could worsen conflict and reinforce symptoms.

“Frustration with symptoms or guilt regarding their child's illness, for example, may lead to negative and affectively laden parental communication to compel the child to change. While this behavior may be aimed at reducing painful affect for all family members, such a critical approach would be expected to further escalate a challenging situation and promote “power struggles” that maintain sympto”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Expanding treatment beyond nutritional status should make it more acceptable to adolescents with AN and promote long-term health and well-being.

“Broadening treatment to other domains of functioning (rather than just nutritional status, the primary focus in FBT-M) would be expected to improve treatment acceptability among adolescents with AN and support long-term health and well-being.”

May combine two claims.

Parents might worry or experience sadness and unintentionally collude with AN.

“Similarly, parents might worry or experience sadness regarding their child's condition, and in an effort to remediate this experience, unintentionally collude with AN (e.g., not insist on additional food intake at meals for fear of making things worse).”

May combine two claims.

Strict rule following may broadly impair functioning by weakening the use of dynamic internal experience for action and hindering navigation of developmental challenges.

“Rigid rule following would also be expected to impact functioning more generally by reducing skill in the use of ongoing, dynamic internal experience to guide action; interfering with the adolescent's ability to navigate other developmentally appropriate challenges (e.g., complex social situations; Zucker et al., 2007).”

• cites Zucker et al., 2007 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Caring for a child with a severe psychiatric illness is highly stressful, and parents commonly feel strong emotions.

“Having a child with a severe psychiatric illness is extremely stressful (Zabala, MacDonald, & Treasure, 2009), and parents often experience an array of intense emotions.”

• cites Zabala, MacDonald, & Treasure, 2009 sourceNot checked — no full text of the source

May combine two claims.

Harsh communication and emotional overinvolvement are components of expressed emotion, which prior work links to eating disorder outcomes.

“Indeed, critical communication and emotional overinvolvement are aspects of expressed emotion (EE), a parental factor that has been found to impact ED prognosis (Eisler et al., 1997; Kyriacou, Treasure, & Schmidt, 2008).”

• cites Eisler et al., 1997 sourceNot checked — no full text of the source
• cites Kyriacou, Treasure, & Schmidt, 2008 sourceNot checked — no full text of the source

May combine two claims.

Helping parents notice and handle hard emotions better might improve their management of the child's illness and reduce caregiver burden.

“Improving parents’ ability to recognize and respond effectively to understandable but difficult emotions might allow them to more successfully manage their child's illness with less caregiver burden (Treasure, Murphy, Szmukler, Gavan, & Joyce, 2001).”

• cites Treasure, Murphy, Szmukler, Gavan, & Joyce, 2001 sourceNot checked — no full text of the source

May combine two claims.

Acceptance-based CBT targets avoidance of emotion and encourages acting effectively even when upset, so it fits the negative reinforcement processes that sustain illness.

“These approaches are well-suited to address negative reinforcement contingencies that maintain illness as they target emotional avoidance and emphasize effective action despite emotional upset or competing cognitions.”

May combine two claims.

A notable proportion of adolescents receiving FBT-M show limited or no improvement, so alternatives are needed.

“While significant, this leaves a substantial subset of adolescents treated with FBT-M making more modest or no gains; thus, there is a need for treatment alternatives.”

Classified as probably not a substantial claim.

A structured diagnostic interview administered by an experienced master's-level clinician determined each diagnosis.

“Diagnosis was determined by a structured diagnostic interview conducted by a master's-level clinician with extensive experience in the assessment and treatment of adolescents with an ED.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

FBT-M is a practical, nonetiological family-based approach to undernourishment that focuses most treatment on reversing weight loss through parents initially controlling the adolescent's eating and then returning control when appropriate.

“FBT-M is a nonetiological, practical family-based solution to undernourishment. The majority of treatment is devoted to reversing weight loss via the parents taking initial control over the adolescent's eating and transferring that control back to the adolescent when appropriate.”

• cites Lock et al., 2001Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Lock, Agras, Bryson, & Kraemer, 2005 sourceNot checked — no full text of the source
• cites Loeb, Lock, Greif, & le Grange, 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Adhering to strict eating rules might ease distress indirectly by causing severe weight loss, which is prized and can produce positive feelings.

“Following rigid dietary rules might also reduce discomfort indirectly via severe weight loss, which is highly valued and thus a source of positive feelings (e.g., pride).”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Such an approach should help adolescents eat adequately even with fear or uncertainty and improve overall functioning by allowing actions that conflict with unhelpful self-imposed rules.

“This approach would be expected to not only improve adolescents’ ability to eat healthfully despite fear or uncertainty, but also their overall functioning by permitting them to behave in ways that are contrary to ineffective self-imposed rules (e.g., social scripts).”

May combine two claims.

Studies suggest acceptance-based treatments are helpful for ED symptomatology but might be enhanced with inclusion of the family.

“Studies suggest that acceptance-based treatments are helpful for ED symptomatology, but might be enhanced with inclusion of the family (Baer, Fischer, & Huss, 2005; Berman, Boutelle, & Crow, 2009; Heffner, Sperry, Eifert, & Detweiler, 2002; Juarascio, Shaw, Forman, Timko, & Herbert, 2012; Wildes & Marcus, 2011).”

• cites Baer, Fischer, & Huss, 2005 sourceNot checked — no full text of the source
• cites Berman, Boutelle, & Crow, 2009 sourceNot checked — no full text of the source
• cites Heffner, Sperry, Eifert, & Detweiler, 2002 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A few studies have identified predictors of remission and treatment completion in adolescent AN; for example, older adolescents and those with comorbid psychiatric conditions tend to drop out of treatment prematurely.

“A few studies have identified predictors of remission and treatment completion in adolescent AN. For example, studies have found older adolescents and those with comorbid psychiatric conditions tend to drop out of treatment prematurely (Lock, Couturier, Bryson, & Agras, 2006).”

• cites Lock, Couturier, Bryson, & Agras, 2006 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Parental belief in the treatment may have affected adolescent willingness to participate.

“Parental belief in the treatment may have affected adolescent willingness to participate, and this is a potentially important area in need of further study.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

It may be that other factors not targeted in ASFT are equally or more important in facilitating recovery from AN.

“Thus, it may be that other factors not targeted in ASFT are equally or more important in facilitating recovery from AN.”

• AssumptionRests on an assumption: The etiology of anorexia nervosa is multifaceted, involving biological vulnerabilities, sociocultural influences, and biobehavioral maintenance factors such as starvation effects.

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

Although acceptance was observed in session and in parent reports of evocative situations outside of session, a standardized measure of this change is important.

“Although acceptance was observed in session and in parent reports of evocative situations outside of session, a standardized measure of this change is important.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

It may be that ASFT is best suited for adolescents who have achieved some degree of weight stabilization prior to initiation of this outpatient intervention.

“Alternatively, it may be that ASFT is best suited for adolescents who have achieved some degree of weight stabilization prior to initiation of this outpatient intervention.”

May combine two claims.

Despite these limitations, the acceptability, feasibility, and preliminary outcomes of this treatment development study are encouraging and suggest additional research testing the efficacy of an acceptance-based treatment for adolescents with AN.

“Despite these limitations, the acceptability, feasibility, and preliminary outcomes of this treatment development study are encouraging and suggest additional research testing the efficacy of an acceptance-based treatment for adolescents with AN.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Adolescent 4's request for a male therapist was conceptualized as related to her initial difficulty being with other females and a core issue for future therapeutic work.

“This was conceptualized as related to her initial difficulty of being with other females and a core issue for future therapeutic work.”

May combine two claims.

ASFT seeks to enhance the effectiveness and generalizability of parent-facilitated exposure by embedding exposures within an ACT framework and broadening the targets of exposure beyond food/eating.

“However, ASFT seeks to enhance the effectiveness and generalizability of parent-facilitated exposure (Loeb et al., 2010) by embedding exposures within an ACT framework and broadening the targets of exposure beyond food/eating.”

• cites Loeb et al., 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Preliminary outcomes for ASFT were promising, although not entirely uniform.

“Although not entirely uniform, preliminary outcomes for ASFT were promising.”

May combine two claims.

Missing data was an issue; most notably, only a few parents completed the AAQ-II at multiple time points, making it impossible to provide meaningful information about whether treatment affected their acceptance of difficult thoughts and feelings.

“Second, as with many treatment studies, missing data was an issue. Most notably, only a few parents completed the AAQ-II at multiple time points, thus making it impossible to provide any meaningful information (data not shown) and discern whether the treatment affected their acceptance of difficult or compelling thoughts and feelings.”

Classified as probably not a substantial claim.

The intervention specifically targets negative reinforcement contingencies (attenuation of negative affect in parents and adolescents).

“First, this intervention specifically targets negative reinforcement contingencies (attenuation of negative affect in parents and adolescents).”