FBT across Developmental Stages and the Diagnostic Spectrum of Eating Disorders
FBT was specifically developed as an intervention for adolescents as opposed to other treatments that have been adapted for the treatment of adolescents. Several reasons can be put forward to explain the development of FBT specifically for adolescents with eating disorders, but the main driving force that gave rise to this therapy is probably twofold. First, the Maudsley team of clinical researchers in London (e.g., Dare, 1983) argued that hospitalization of one’s child for any reason is almost always experienced as traumatic and therefore should be avoided if possible. Second, such hospitalizations often cause the parents to feel disempowered, that is, that they have “failed” in taking care of their child. This places parents at a considerable disadvantage when they are presented with the crisis of the eating disorder and the need to take care of their offspring once she or he is discharged from inpatient care. FBT aims to prevent hospitalization if it is medically appropriate and instead seeks to bolster parental skills to take charge of their adolescent’s weight restoration and/ or to curtail binge eating and purging. From a developmental perspective these strategies may come across as out of place given that patients seen in FBT are mostly teens. However, these interventions are temporary, and the ultimate goal is to encourage adolescents’ independence and to support them on their developmental trajectory unencumbered by the eating disorder.
Most adolescents are embedded in their families and, in many respects, are dependent on their parents, a situation that provides the parents with considerable leverage over their adolescent. Consequently, it would seem appropriate to expect parents to utilize this advantageous position, in conjunction with their caretaking skills and affection for their child, to “arrest” the eating disorder from their child. As stated earlier, this intervention is time-l imited, as FBT is ultimately most respectful of the adolescent and her or his nascent independence. A key tenet of FBT is to separate the illness from the adolescent (externalization) and is perhaps the most tangible way in which respect for the adolescent is demonstrated. In addition, this process of externalization also helps parents to view the eating disorder as something that has overtaken their teen and in turn allows them (the parents) to be effective in their interventions.
FBT is consistent in the application of its core strategies and therapeutic interventions across the developmental spectrum of childhood through adolescence. This consistency often surprises parents and clinicians alike, who assume that prescriptions such as parental control over eating should be modulated to reflect chronological age. Although developmental stage must be respected with regard to the patient’s general life and broad psychosocial domains, the eating disorder is a leveling force that renders the child or adolescent regressed with regard to ability to appropriately self-regulate food intake. Thus parental control should be (1) focused only on the eating disorder symptoms, (2) temporary until sufficient weight is restored for the cognitive symptoms of the eating disorder to improve and motivation for wellness to set in, and (3) only as extreme as the eating disorder is ego-syntonic, with low-weight eating disorder presentations generally requiring more initial parental control and normal-weight binge eating and purging clinical profiles allowing for more collaboration between parents and child in navigating symptom management. As discussed previously, the one FBT-application exception to this algorithm is for pediatric obesity, a nonpsychiatric disorder. Unlike eating disorders, obesity does not affect insight and judgment, although it may be associated with or exacerbated by disordered eating patterns. For this medical condition, degree and intensity of parental control should precisely match developmental stage, attenuating as the child ages, even in early phases of treatment.
The distinctions between FBT for AN, BN, EDNOS, and pediatric obesity, for which there are separate manuals (Le Grange & Lock, 2007; Lock et al., 2001; Loeb et al., 2006, 2011), can be resolved within a transdiagnostic framework by combining weight status (low vs. normal to high) and specific behavioral symptoms (restriction vs. restriction plus binge eating and/or purging vs. other forms of excessive eating), yielding the following algorithm:
• Low-weight patients will benefit from principles and practices in the AN treatment that are more categorically defined, especially in terms of the allocation and timing of autonomy and control over eating.
о Low-weight patients with bulimic symptoms will benefit more from the behavioral techniques drawn from the BN protocol, which target binge eating and purging behaviors.
- • For normal- to higher-weight adolescents, for whom symptoms may be experienced as more ego-dystonic, the more collaborative parent- child approach described in the BN manual is appropriate.
- • For EDNOS, especially for those children and adolescents in whom a more serious eating disorder may be in the process of unfolding, severity, chronicity, and breadth of the eating disorder symptoms must also be considered. Such symptom-driven guidelines may be more useful than age- or developmentally based ones, as clinical observations suggest that a low-weight eating disorder renders a regressed state with regard to selfcare that is fairly equivalent across childhood, adolescence, and even adulthood. For individuals above a minimally normal weight threshold, and especially for overweight patients without an eating disorder, matu- rational stages will serve as a better guide for the intensity and quality of parental involvement in Phase I of FBT.