The teen’s perception of family function was a key to treatment success.
Family-based therapy (FBT), the approach of choice for adolescents with anorexia nervosa (AN) being treated as outpatients, uses the family as the key agent during therapy.
In a recent study at the Sydney (Australia) Children’s Hospital Network and the University of Sydney, the adolescent patient’s view of the family and its function was critical to success of FBT (J Eat Disord. 2017; 5:55). Dr. Andrew Wallis and colleagues explored the relationship between family functioning, teen-parent attachment, and remission, as well as changes over time, for a group of adolescents with severe AN being treated with FTB.
The authors pointed out that while FBT works for most, it doesn’t work for everyone. Length of illness, prior hospitalizations, and older age, cannot be modified once treatment begins. In contrast, if family functioning could be modified during treatment, this might improve response (Eur Eat Disorders Rev. 2016; 24:43). Some positive elements in family function have been tied to the outcome in previous FBT studies—particularly positive relationships between parents and adolescents, parental warmth, and family cohesion, for example (J Fam Ther. 2005;2:104; J Ment Health. 2005;14:575). Better family organization and control early in treatment often predicts a good outcome from treatment. In contrast, a negative communication style, including critical comments, has the opposite effect.
The 57 teens were a subgroup from a previously reported randomized controlled trial by the authors that investigated the role of inpatient weight restoration prior to entry into outpatient FBT (Psychol Med. 2015; 45:415). Those participating in the original study had met DSM-IV criteria for AN of less than 3 years duration, and were medically unstable when admitted. Eligible subjects were then divided in to two treatment groups, either to medical stabilization or to minimum weight restoration before they went on to outpatient FBT.
A three-stage process helps parents take responsibility 
The study used type 3-stage FBT, in which parents initially take responsibility for their child’s weight gain and return to normal eating patterns, to reverse the starvation caused by AN. As treatment moves into its second and third phrases, responsibility for eating is slowly but surely handed back to the adolescent, helping him or her progress independently with food and normal adolescent life. The therapy team included three psychologists and a social worker.
The teens were assessed at baseline, at the 20th session of FBT, and 12 months after session 20. Remission outcome was defined as percent of expected body weight (%EBW) using Centers for Disease Control and Prevention growth charts, and EDE global scores. Family function and adolescent-parent attachment were evaluated with the Family Assessment Device and the Inventory of Parent and Peer Attachment. The Family Assessment Device is a self-report measure including 60 items divided into 7 subscales (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, and a general scale that measures family function). Just as its name implies, the Inventory of Parent and Peer Attachment is a 45-item questionnaire that seeks to probe the affective cognitive expectancies associated with the quality, rather than the categories, or attachment relationships between the young person and his or her mother and father.
The importance of the teen’s perception of family function
Teens who reported poorer general family functioning had more comorbid psychiatric features and were more likely to have binge-purge type AN. In contrast, better adolescent–reported family functioning was associated with higher adolescent self-esteem and stronger adolescent attachment to both parents
Few or no changes in the quality of the parent-teen relationship were reported during treatment or at follow-up.  No elements of mother-reported family functioning at the beginning of treatment were related to better outcome from FBT; however, higher levels of father-reported behavior control (for example, establishment of rules and expected behaviors) at the beginning of treatment were positively related to remission in the long term.
Dr. Wallis and colleagues stress the importance of family functioning for people receiving FBT, for the adolescent’s perception of family functioning at the beginning of treatment did predict remission. Teens who perceived better family communication and ability to solve problems were more likely to respond to FBT.