Parents are encouraged to find solutions to the problems of food refusal and weight loss-inducing behaviors. Usually this entails helping the parents agree on a strategy to increase the amounts and types of food their child is eating and to limit the child's physical activity. Thus, in the first part of the FBT program, parents learn to get organized, become consistent, and be persistent without getting angry and frustrated with their child.

At the beginning of treatment, FBT is highly focused on eliminating food refusal and promoting weight gain. Issues related to family or individual processes are deferred unless they directly interfere with weight restoration. Once weight is restored and the adolescent is eating more regularly, control of eating is returned to the adolescent. After the adolescent demonstrates sufficient ability to eat normally and maintain a normal weight, therapy turns to more general issues of adolescent development and family process.

The major innovation of putting parents in control of weight restoration sets FBT apart from other therapies for AN. Like parents of children with autism, schizophrenia, and other illnesses, parents of children with AN have long felt blamed, responsible, and guilty for their children's illness. As a result, they felt powerless to help their children.

FBT aims to diminish these sentiments and powerlessness in several ways. First, parents are reminded that there is no known cause for AN. The approach further empowers parents by encouraging them to directly challenge and disrupt the severe dieting and overexercise associated with AN as they would any other dangerous adolescent behavior (eg, alcohol(Drug information on alcohol) or drug use, truancy, or recklessness). The issue of adolescent control is reformulated to help parents see that extreme dieting and the resulting malnutrition are evidence that their child needs help and should not be left to his or her own devices regarding eating behavior.

What the studies show

There are only 5 randomized controlled outpatient trials of psychological treatment for adolescents with AN (Table).^9,13-16

	TABLE Trials of psychological treatment for adolescents with anorexia nervosa
	Study		No. of subjects		Study design		Main findings
	Russell (1987)9		21		FBT vs supportive individual therapy		Adolescents with short-duration illness did better with FBT
	Le Grange (1992)13		18		FBT-whole family vs FBT-separated		Adolescents with critical families did better in the separated form of FBT
	Robin (1999)14		37		Family therapy vs active individual therapy		Family therapy more rapid in effects, but no differences at follow-up
	Eisler (2000)15		40		FBT-whole family vs FBT-separated		Adolescents with critical families did better in the separated form of FBT
	Lock (2005)16		86		FBT-short (1 month) vs FBT-long (12 months)		FBT-short is as effective as FBT-long
FBT, family-based treatment.

These trials were conducted over the past 20 years and comprised about 200 participants. All of these trials involved FBT in some form. Taken together, these studies suggest that family therapy is acceptable, feasible, and effective. In fact, dropout rates were modest (between 10% and 15%), in contrast to treatment studies of adults with AN, where dropout rates of 40% or more effectively made randomized outcomes difficult to analyze and interpret.¹⁷ Outcomes of adolescents in these studies suggest that between 70% and 80% do well in FBT in terms of weight restoration, normalization of eating-related thoughts and behaviors, and psychosocial functioning. In comparison, outcomes in adult studies report 30% to 40% recovery rates.⁴

Studies comparing FBT with other approaches are few and small in scale. Although the results available suggest that FBT may be superior in adolescent participants, definitive conclusions about comparative outcomes await further study.^9,14 Interestingly, studies of adults with AN who were treated with FBT are less convincing; in such cases, FBT may be no better than individual therapy.^9,18,19

Long-term outcomes of adolescent patients treated with FBT suggest that the improvements obtained during treatment are enduring. Two studies have demonstrated that both weight restoration and eating-related thoughts and behaviors continue to be improved at follow-up 4 to 5 years later.^20,21 However, although the majority of these adolescents have recovered from their eating disorder and are working or are in school, about a quarter of them have other mental health problems, including depression and anxiety disorders.

Because of the high cost of managing AN, one of the more exciting findings is that FBT can be a remarkably efficient therapy. In its chronic form, AN is highly intractable to known interventions, often requiring long-term and intensive interventions.²² However, many younger and less chronically ill adolescent patients appear to respond favorably with the relatively short treatment protocols of family therapy.