Implementation, Outcome and Mechanisms of Family-Based Treatment for Adolescent Anorexia Nervosa Adapted for the Home Setting: A Pilot Effectiveness Trial

项目摘要/摘要 神经性厌食症(AN)是一种严重的精神疾病，影响约1%的青少年，并与 高发病率和高死亡率。以家庭为基础的治疗(FBT)，涉及授权照顾者 控制再喂养以使青少年恢复到正常的体重和饮食轨迹，假设 通过增加与再喂养相关的照顾者自我效能来运作，并通过以下方式减少青少年痛苦 反复暴露在与饮食和体重相关的刺激下。尽管自由贸易协定目前被认为是“第一条线” 对青少年AN的治疗，在社区环境中未得到充分利用，许多家庭在一年内无法获得 多种实际原因(例如，治疗费用、许多地区受过培训的提供者有限) )，特别是来自代表性不足的社会人口群体的人。此外，一个实质性的 部分家庭对FBT反应不佳，这可能是由于新获得的干预措施失败所致 在(通常是基于办公室的)治疗环境之外进行泛化的技能。基于家庭的治疗是一种 传统办公室门诊治疗的替代方案，可以减少许多实用的治疗障碍 吸收和参与，并可能增强治疗技能的普适性，因为它以多种方式提供 经常发生再喂食的自然主义环境(例如，家庭、学校、社区)。虽然以家庭为基础 模型已经成功地应用于其他精神疾病，家庭治疗HAD 从未被测试过。此外，FBT在国外的“真实世界”环境中经历了有限的调查 致力于饮食失调的专业学术和临床环境。因此，已知的许多东西 关于FBT是基于相对同质的样本，来自较低水平的个人的代表性有限 收入和种族/少数民族背景。此外，尚不清楚假定的FBT机制是否适用于 有效性上下文。拟议的R34试点有效性试验将评估结果、实施情况、 以及青少年家庭适应和适应家庭环境的FBT机制(FBT-HB)，在 两家以社区为基础的行为健康机构，主要服务于低收入、种族和民族 多样化的客户群。患有谱系障碍的青少年(n=50)和他们的照顾者将随机 被分配到FBT-HB或以家庭为基础的常规护理(综合家庭治疗方法)。护理者和 青少年将提供有关体重、饮食和可能的治疗机制的数据，包括照顾者自我 治疗技能的有效性、青春期苦恼和概括性。实现构造将是 在提供者和参与家庭中进行衡量。总体目标是评估FBT的初步影响- Hb对青少年饮食和体重结果的影响；FBT-Hb的可接受性、适当性、可行性和保真度； 以及照顾者和青少年层面的变革机制。这项拟议的研究显然有可能 促进对FBT对AN真实世界有效性的科学和临床理解，包括是否 使其适应家庭环境可能会改善其可及性和对治疗结果的影响。

PROJECT SUMMARY/ABSTRACT Anorexia nervosa (AN) is a serious psychiatric illness that affects ~1% of adolescents and is associated with high rates of morbidity and mortality. Family-based treatment (FBT), which involves empowering caregivers to take control of refeeding to restore the adolescent to a normative weight and eating trajectory, is postulated to operate via increasing caregiver self-efficacy related to refeeding, and decreasing adolescent distress through repeated exposure to eating- and weight-related stimuli. Although FBT is currently considered the “first line” treatment for adolescent AN, it is underutilized in community settings and is unavailable to many families for a multitude of practical reasons (e.g., costs of treatment, limited availability of trained providers in many regions of the country), particularly those from underrepresented sociodemographic groups. Furthermore, a substantial subset of families do not optimally respond to FBT, which may be due to failure of newly acquired intervention skills to generalize outside of the (typically office-based) treatment context. Home-based treatment is an alternative to traditional office-based outpatient treatment that can reduce many pragmatic barriers to treatment uptake and engagement, and may enhance generalizability of treatment skills as it is delivered in multiple naturalistic settings where refeeding often occurs (e.g., home, school, community). Although home-based models have been successfully applied to other psychiatric conditions, home-based treatments for AN have never been tested. Moreover, FBT has undergone limited investigation in “real world” settings outside of specialty academic and clinical environments dedicated to eating disorders. As a result, much of what is known about FBT is based on relatively homogeneous samples with limited representation from individuals from lower income and racial/ethnic minority backgrounds. Furthermore, it is unclear if putative FBT mechanisms apply in the effectiveness context. The proposed R34 pilot effectiveness trial will assess outcomes, implementation, and mechanisms of FBT for adolescent AN adapted for the home setting (FBT-HB), delivered in the context of two community-based behavioral health agencies that serve a primarily lower-income, racially and ethnically diverse clientele. Adolescents with AN-spectrum disorders (n=50) and their caregivers will be randomly assigned to either FBT-HB or home-based usual care (integrated family therapy approach). Caregivers and adolescents will provide data on weight, eating, and putative treatment mechanisms, including caregiver self- efficacy, adolescent distress, and generalizability of treatment skills. Implementation constructs will be measured among providers and participating families. Overall aims are to assess preliminary effects of FBT- HB on adolescent eating and weight outcomes; FBT-HB acceptability, appropriateness, feasibility, and fidelity; and caregiver- and adolescent-level mechanisms of change. The proposed study has clear potential to advance scientific and clinical understanding of the real-world effectiveness of FBT for AN, including whether adapting it for the home setting may improve its accessibility and effects on treatment outcome.