Table of Contents
Anorexia nervosa is prevalent among teenagers, especially teenage girls, with 3.8% of girls ages 13 to 18 having an eating disorder (National Institute of Mental Health website, November 2017). Research has found that if the illness starts during adolescence and does not last too long that the patient’s prognosis is fairly good (Herscovici, Kovalskys, & Orellana, 2017).
Treating the illness early on helps shorten the duration of the illness. The treatment method of choice specifically for adolescents with anorexia nervosa is family-based treatment (White et al., 2017). Family-based treatment is based on the Maudsley model of therapy, which was developed as an outpatient treatment in the 1980s. The Maudsley model did not emphasize a family meal during treatment, but instead had smaller meal challenges.
Unlike the Maudsley model, a key component to family-based treatment is the family meal. During the family meal, the role of the therapist is to observe the family interacting during the meal, to coach the parents to help their child eat, and to take back control of their child’s eating (Cook-Darzens, 2016). A main behavior of anorexia is refusal to eat (White et al., 2015). Therefore, the main goal of the family meal is to have the patient be able to take one more bite of food than they would normally have eaten (Godfrey et al., 2015). Besides the family meal, there are five other components to family-based treatment.
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First, parents are supposed to not tolerate any anorexic behaviors their child does. Second, the illness is supposed to be externalized, which should decrease parental criticism towards the child. Next is the family structure where parental unity and sibling support should be maximized. Fourth is consistency by the parents. The fifth and final component is utilizing sibling support of the patient in order to minimize the stress experienced by the patient (Ellison et al., 2012).
The purpose of this literature review is to answer the question “In adolescents diagnosed with Anorexia Nervosa, how does ‘family meal therapy’ and ‘family-based treatment’ affect overall outcomes?” Therapy for adolescents is important because it can affect weight gain, readmission rate, and the well-being of the adolescent going through treatment for anorexia nervosa. Adolescence is a turbulent time for most people but can be especially difficult for those with mental illness.
I chose to research this topic because I believe it is important for nurses to understand the psychological aspects of anorexia nervosa and not just the physical aspects of regaining medical stability. With this understanding, the nurse can have better therapeutic interactions with their adolescent patients. Anorexia nervosa is a complex disease and needs to be understood as a whole to effectively help patients succeed.
Methods
To find the literature used for this literature review the following databases were searched: Google scholar, TRIP database, Science Direct, Ovid, and MEDLINE/PubMed. The following keywords and phrases were searched in varying combinations: adolescent, anorexia, anorexia nervosa, eating disorder, meal, family meal, family meal therapy, Maudsley, family style meal, “treatment for anorexia”, and family-based ‘treatment for anorexia.’ During some searches, exclusion criteria were used only allowing articles from 2014 or later. However, in other searches, there were no exclusion criteria used, but an article from before 2000 was not considered. Articles were read and chosen based on their title, abstract, and the year written. If an article focused only on multi-family therapy it was not used. Once selected the articles were put into a research matrix and relevant information was picked out of the article to be used in the literature review.
Results
There were a total of eight articles used in this literature review. There was a mixture of the types of studies used in the articles. Of the articles, five were randomized control trials (Godfrey et al., 2015; Herscovici, Kovalskys, & Orellana, 2017; Lock et al., 2015; Madden et al., 2015; White et al., 2017). Of the randomized control trials, one was an exploratory longitudinal investigation (Herscovici, Kovalskys, & Orellana, 2017) and another was an exploratory study (Lock et al., 2015). There was one open dissemination trial (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010), one cross-sectional study (White et al., 2015), and one meta-analysis of a randomized control trial (Ellison et al., 2012). Overall, there was a wide variety of research designs utilized.
Samples
Each study and article looked at had small sample sizes, with no study having over 100 participants. The smallest sample consisted of 18 adolescents and their families (White et al., 2017). The largest sample was from a meta-analysis study that looked at the data of 82 adolescents and their families (Madden et al., 2015).
All of the studies had samples that had a majority of female participants. Since adolescents were the focus of the literature review, seven of the eight articles had age ranges of 12 to 18 (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010; Ellison et al., 2012; Godfrey et al., 2015; Lock et al., 2015; Madden et al., 2015; White et al., 2015; White et al., 2017). Only one article extended the definition of adolescent to include 19 and 20-year olds (Herscovici, Kovalskys, & Orellana, 2017). The participants in all of the studies had been diagnosed with anorexia nervosa; however, there were different diagnostic criteria used.
The criteria used were DSM-IV (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2009; White et al., 2015; Madden et al., 2015), DSM-V (Herscovici, Kovalskys, & Orellana, 2017), and DSM-TR-IV (Lock et al., 2015; Godfrey et al., 2015). Two articles did not specify the diagnostic criteria, but simply stated they were diagnosed with anorexia nervosa (Ellison et al., 2012; White et al., 2017). Throughout the articles, the participants were fairly similar in age, illness, and length of illness.
Conceptual Framework
Each of the articles reviewed had the same conceptual framework of family-based treatment. Half of the articles specified that the framework used was Maudsley family-based treatment (Godfrey et al., 2015; Madden et al., 2015; Ellison et al., 2012; Herscovici, Kovalskys, & Orellana, 2017). However, family-based treatment was created from the Maudsley model (Cook-Darzens, 2016). Therefore, all the articles looked at shared the same foundations for their conceptual framework.
Interventions
The common intervention in each study was family-based treatment. However, the exact treatment varied from study to study. While participants in every study had family-based treatment, three studies looked exclusively at the meal session of the family-based treatment model (Godfrey et al., 2015; White et al., 2015; White et al., 2017). Within these three studies, interventions included parents’ strategies used during the meal which had been provided to them by the therapist (White et al., 2017). Other interventions included parental prompts during the family meal and family interactions (Godfrey et al., 2015; White et al., 2015).
Another three studies only used family-based treatment as the intervention, with a range of 15 sessions (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010) to 20 sessions per patient (Ellison et al., 2012; Madden et al., 2015). The remaining studies used two interventions for two different groups (Herscovici, Kovalskys, & Orellana, 2017; Lock et al., 2015). The interventions were family therapy and family therapy combined with a family meal session (Herscovici, Kovalskys, & Orellana, 2017). The other set of interventions was standard family-based treatment and standard family-based treatment with an extra three sessions focusing solely on the family meal (Lock et al., 2015).
Measures and Instruments
Each study used a wide variety of tools to measure effectiveness, track the progress of the participants, and analyze data. Two studies stood out because weight was not measured (Godfrey et al., 2015; White et al., 2015). Measures included analysis of filmed family meal sessions and generation of their own codes to identify common themes among the different sessions (Godfrey et al., 2015). The Family Mealtime Coding System which had been modified for use with adolescents (FMCS-A) was also used to measure interactions during family meals (White et al., 2017; White et al., 2015).
The other six studies all looked at weight, either expected body weight (EBW) or ideal body weight (IBW), as a crucial indicator of progress (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010; Ellison et al., 2012; Herscovici, Kovalskys, & Orellana, 2017; Lock et al., 2015; Madden et al., 2015; White et al., 2017). The Eating Disorder Inventory (EDI) was used to look at the psychological and behavioral aspect of eating disorders as reported by the patient (Ellison et al., 2012; Herscovici, Kovalskys, & Orellana, 2017).
Interestingly, a majority of the studies did not overlap in the tools they used for assessment. Recruitment and attrition rates, EBW, Therapy Suitability and Patient Expectancy, Eating Disorder Examination, Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Yale-Brown-Cornell Eating Disorder Scale, Children’s Yale-Brown Obsessive-Compulsive Scale, Beck Depression Inventory, helping relationship questionnaire, and Parents Versus Anorexia Nervosa were all used to look at various psychological and physical aspects of the participants (Lock et al., 2015). Other tools used were The Morgan-Russell Assessment Schedule, Symptom Check List-90-Revised (Herscovici, Kovalskys, & Orellana, 2017), Core Treatment Objectives Clinician Rating Scale and working alliance inventory (Ellison et al., 2012).
Common Themes
Within the eight studies, there were common themes linking each study to one another. In two of the studies, there was evidence that parental prompts increased food consumption by the patient achieving the goal of the family meal to take one bite more than the patient was willing to take (Godfrey et al., 2015; White et al., 2015). In two studies, they found that early weight gain in the first few sessions of therapy predicted greater weight gain and higher rates of remission (Madden et al., 2015; Doyle et al., 2009). Three studies found that greater use of food prompts by parents or increased control over food by the parents predicted greater weight gain (Ellison et al., 2012; White et al., 2017; White et al., 2015). Two studies found that family therapy and family therapy with a family meal were equally effective forms of treatment (Lock et al., 2015; Herscovici, Kovalskys, & Orellana, 2017).
Discussion
The goal of the literature review was to discover how family meal therapy and family-based treatment affected treatment outcomes of adolescents diagnosed with anorexia nervosa. The results seem to indicate that family-based treatment has a positive effect on the outcomes of adolescents in treatment for anorexia nervosa. The family meal usually went one of two ways; either the patient ate all the food in front of them with no problems or the patient had difficulty eating, but the parents were able to get their child to complete the food or eat more than the patient was willing to eat (Godfrey et al., 2015). Both meals have a positive effect on the patient because they ate, which is an accomplishment when battling anorexia nervosa. Multiple factors of family-based treatment also positively impacted recovery.
One of the big goals of family-based treatment involves giving control back to parents which was shown to have a positive effect on both weight gain and remission (Ellison et al., 2012). Family-based treatment helped patients with early weight gain. Those patients who had a significant amount of weight gain at the beginning of treatment had a higher chance of remission (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010). Overall, utilizing the family of a patient to support and guide them in their recovery had a positive effect on their recovery and ability to achieve remission.
Understanding the effects of family-based treatment on patients with anorexia nervosa can impact the way nurses interact with their patients and the patient’s initial plan of care. When a nurse is caring for a client who is hospitalized for medical complications related to anorexia nervosa, the nurse can involve the parents as much as possible in the patients care. For example, once a patient is eating on their own the nurse could have a parent or family member at meals to encourage the patient to eat. The nurse could try to work with parents on strategies to help their child eat, gain back control in their family, and empower the parents. If the family is not able to be there with their child at meals, the nurse could try to fill the supporter role during meal time.
The findings of this literature review can impact healthcare because there is evidence that family-based treatment is effective in helping adolescents with anorexia nervosa achieve remission. Since family-based treatment is effective, implementing it at hospitals and treatment centers can ultimately cut down on health care costs because there will not be as many readmissions by patients who relapse. Family-based treatment is usually completed as outpatient. Since patients would be discharged once they reach medical stability to start family-based treatment, bed space would free up for other patients who are medically unstable beyond being underweight.
There were numerous limitations to this literature review. A larger sample size of articles could have helped identify more common themes and found stronger results on the effectiveness of the family meal and family-based treatment. When reading the articles, I noticed there seemed to be a good deal of overlap from one study to another. Either data sets were shared or the articles were citing one another.
This is a limitation because it could affect the accuracy of results since it shrinks the sample size even more. Another limitation was the range of how old the articles were. The oldest article was from 2010 and the most recent article was from 2017. That is a seven-year difference between studies as well as an almost ten-year difference from when this literature review was done. Over ten years there have been many changes in technology, research, and viewpoints.
Conclusion
In the future research could be conducted more on the family meal and its specific impact on remission. Altering the family meal could be researched as well. One could compare the traditional family meal studied in this literature review and compare it to a family meal where the environment is less hostile or the patient has more control over what is eaten by being supported to pick out a meal that follows their meal plan.
Control plays a large part in anorexia and looking into the effects of parental and patient control could be beneficial to altering treatment. Future research could be expanded to look at a larger range of patients as well as a more diverse group of patients. Specifically, a study looking at male adolescents with anorexia nervosa could be useful in tailoring treatment to be more effective for them. One could research how family-based treatment could work if the patient comes from a nontraditional household, for example, someone who has foster parents, is being raised by an aunt or uncle, or is being raised by their grandparents.
What I learned from the research process is how difficult it is to find articles pertaining to your topic that are actually measuring what you want to research. I could easily find articles on adolescent anorexia nervosa, but it was much harder to find articles that pertained to the family meal. I learned you need to be creative with your search terms and essentially use as many words as you can think of that all mean the same thing. Creating this literature review gave me a new respect for those doing research and contributing to evidence-based healthcare.
References
- National Institute of Mental Health
- Herscovici, C. R., Kovalskys, I., & Orellana, L. (2017). Clinical outcomes in adolescents with bulimia nervosa: effects of familial eating patterns and communication. Journal of Adolescent Health, 61(4), 424-430.
- White, H. J., Haycraft, E., Madden, S., Rhodes, P., & Miskovic-Wheatley, J. (2017). How to manage adolescent males with anorexia nervosa: a systematic review of the literature. Journal of Clinical Psychology in Medical Settings, 24(4), 385-396.
