What helps children with anorexia nervosa gain weight?

What helps children with anorexia nervosa gain weight?  How can you tell whose child will do well and whose may not?  Can you tell?

At Kartini Clinic we have always felt that three factors determine outcome in children with anorexia nervosa:  

1. severity of illness  
2. parental unity with treatment team 
3. parental ability to enforce the meal plan/re-nutrition.  

And of those three, we think we have noticed over the years that #2 and #3 can trump severity of illness.  In other words, even if your child’s illness is very severe, as long as you are on the same page as your treatment team and you are able to enforce adequate eating, you child can do well.

So I was excited to see an article in the International Journal of Eating Disorders Vol 45 Issue 4 May 2012 by one of our favorite groups of colleagues, from Sydney Australia, including Drs. Michael Kohn and Sloane Madden, who think very much as we do.  This group, Ellison R, Rhodes P et al., took a systematic look at this very issue and titled it:  “Do the Components of Manualized Family-based Treatment for Anorexia Nervosa Predict Weight Gain?”

59 children under age 19 who had been ill for less than three years were followed.  The children were first admitted to the hospital for medical stabilization and were fed via nasogastric tube (done somewhat more routinely in Australia than here), supported meals, individual supportive therapy as well as treatment of any co-morbid psychiatric illnesses (including the use of medication).  After discharge from the hospital they were treated with twenty sessions of manualized family based treatment (FBT).

The authors analyzed the five features considered “key treatment features” of manualized FBT treatment plus one unique to this study, to try and see whether or not any of these features predicted weight restoration (outcome).  The five features were:

1. parents taking and keeping control over the food (“control”)
2. unity between the parents (“unity”)
3. parents able to keep from criticizing the patient (“criticism”)
4. parents able to externalize the illness (e.g. “it’s the eating disorder talking not my daughter” called “externalization”)
5. sibling support of the patient (“sibling support”).  

A sixth, and in my opinion extremely important, factor they examined was what they called “parent therapeutic alliance” and we have always called “parental unity with team.”

Of the core components, this team reports, parental control over AN behavior was found to be the strongest predictor of outcome. And parental control was the only core treatment variable that had a significant relationship to the dropout rate: higher parental control was associated with lower rates of dropout from treatment.  The only core component that did not predict weight gain was sibling support  BUT, in the way these things are inextricably entwined in human relationships and families, sibling support was one of the factors that predicted parental control.

Therapeutic alliance or “parental unity with team” (Kartini-speak) did predict weight restoration.  Oh how I like it when what we think we see turns out to be what we really see…

So take-home pearls of wisdom from this excellent study:

1. absolutely critical to success, the conditio sine qua non of treatment, is that parents take charge of food
2. parents: get close to your team.  Find a team you can trust and respect and who trust and respect you, and stick with them
3. parents: even if you are divorced and/or you agree about nothing else, for your child to do well you will have to find agreement around their food and treatment
4. it isn’t just politically correct and a little silly sounding to speak consistently about the eating disorder as a thing separate from your child; the ability to do so actually helps predict whether or not they will be able to gain weight.  This is the so-called “externalization” but also helps lower the child’s perception of being criticized (see above about “criticism”).
5. sibling support may not predict weight restoration but since it does influence parents’ ability to stay in control over food, it remains important
6. treatment teams need to understand that, to the extent certain interventions support parents in their quest to remain in control of the food, such interventions will likely help the child

So thanks, Team Sydney: good work.