While the efficacy of family therapy for adolescents with anorexia nervosa is well documented, the process of change across treatment is less well understood. Emerging research has looked at the young person experience, however, little is known about the parent/caregiver perspective. This study aimed to understand factors that parents/caregivers perceive as facilitating change in family therapy for anorexia nervosa (FT-AN). Twenty-three parents/caregivers of young people (age 12–18 years) with anorexia nervosa who had completed FT-AN participated in individual semi-structured interviews online. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. Five interconnected themes were generated: Not alone, Strong foundations, Commitment, Both/and rather than either/or, and Strengthening family connection. Parents /caregivers highlighted the importance of collaboration—both within the family and with the clinical team—in building a support network. This collaborative foundation was seen as central to facilitating change, initially through structure and boundaries, and later through increased flexibility and safe risk-taking. Maintaining a life outside the illness and ensuring a balance between physical and emotional needs across all stages of treatment emerged as critical to the recovery journey. This qualitative study explored parental experiences of supporting a young person through FT-AN. Themes generated in this study closely mirror the change processes reported by young people and align with the theoretical underpinnings of FT-AN. Parents reported that change was supported through collaboration with knowledgeable clinicians, setting clear expectations and reduced isolation. A holistic, person-centred approach to treatment that considered life outside the illness was considered as key in promoting change and building commitment from the young person and family. Additionally, finding the right balance in safe risks taking, flexibility within the approach and gradual spacing out of sessions were all described as key to promoting change. Family therapy for anorexia nervosa (FT-AN) is a first-line recommended treatment for adolescents with anorexia nervosa. While it is helpful for most, there are many who require more or something different to reach recovery. This study aimed to understand factors that parents/caregivers perceive as impacting change in FT-AN. Twenty-three parents/caregivers of young people (age 12-18 years) with anorexia nervosa who had completed FT-AN participated in individual semi-structured interviews. Analysis of transcripts using reflexive thematic analysis generated five interconnected themes: 1) Not alone, 2) Strong foundations, 3) Commitment, 4) Both/and rather than either/or, and 5) Strengthening family connection. Parents/caregivers highlighted the importance of collaboration—both within the family and with the clinical team—in building a support network. This collaborative foundation was seen as central to facilitating change, initially through structure and boundaries, and later through increased flexibility and safe risktaking. Parents/caregivers reported that change was supported through collaboration with knowledgeable clinicians, setting clear expectations and reduced isolation. A holistic, person-centred approach to treatment that considered life outside the illness was considered as key in promoting change and building commitment from the young person and family.

OBJECTIVE:Family therapy for anorexia nervosa (FT-AN) is the first-line recommended treatment for young people with anorexia nervosa. There is variability in treatment length across studies and evidence suggests treatment length and outcome are not necessarily linearly related. This makes it difficult to identify the optimum length of treatment in clinical practice. This study aimed to explore young people's perspectives on the timing of discharge and how this relates to recovery. METHOD:Twenty three young people (age 12-18) diagnosed with anorexia (or atypical anorexia) nervosa participated. All had completed FT-AN with or without adjunctive multi-family therapy. Semi-structured individual qualitative interviews were conducted. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS:Four inter-connected themes were generated; (1) who decides?, (2) knowing what's coming, (3) things that need to be in place, (4) discharge is a necessary step towards recovery. DISCUSSION:Young people said that remaining in treatment for longer than necessary may impede recovery. Establishing clear expectations about discharge and recovery, helping young people to commit to ongoing behaviour change, and building their support network were all described as important components in helping them to feel confident about discharge and to take ownership of continuing the recovery journey post-discharge.

Various forms of eating disorder focused family therapy (FT-ED) have been developed and evaluated for adolescents. FT-ED for adolescent anorexia nervosa (AN) focuses on empowering parents/carers with the knowledge and skills required to facilitate recovery for their child. The recent trend and increased awareness of the period between adolescence and adulthood during ages 18-25, known as 'emerging adulthood', has brought into question whether the traditional treatment approach for adults with AN, that is, individual therapies, is the most appropriate approach for this age group. This paper briefly outlines the current forms FT-ED for emerging adults with AN and examines the evidence for each. We then present considerations for tailoring FT-ED for emerging adults with AN across three broad domains: structure and set-up, process, and content. Finally, we present suggestions on how to troubleshoot common pitfalls that may be encountered, such as reluctance to include parents in treatment. Future research should examine which forms of FT-ED are best for which emerging adults and families and under what contexts. There is also a need to explore the incorporation of technology into sessions with families who live apart.

This review aims to report on recent evidence for multi-family therapy for eating disorders (MFT) across the lifespan. It is a narrative update of recent systematic, scoping and meta-analytic reviews. There has been a recent increase in published theoretical, quantitative and qualitative reports on MFT in the past few years. Recent and emerging data continues to confirm MFT can support eating disorder symptom improvement and weight gain, for those who may need to, for people across the lifespan. It has also been associated with improved comorbid psychiatric symptoms, self-esteem and quality of life. Data are also emerging regarding possible predictors, moderators and mediators of MFT outcomes, as well as qualitative data on perceived change processes. These data suggest families with fewer positive caregiving experiences at the start of treatment may particularly benefit from the MFT context. Additionally, early change in family functioning within MFT may lead to improved outcomes at end of treatment. MFT is a useful adjunctive treatment across the lifespan for people with eating disorders. It helps to promote change in eating disorder and related difficulties. It has also been shown to support and promote broader family and caregiver functioning.

Background: Despite dietitians being important members of the multidisciplinary team delivering family therapy for anorexia nervosa (FT-AN), their specific responsibilities and roles are unclear and their involvement in the treatment can be a contentious issue. Methodology: Clinicians (n = 20) experienced in the delivery of FT-AN who were working at a specialist child and adolescent eating disorder service responded to an online survey about their experience of including a dietitian in FT-AN and how they understand the role. Both categorical and open-ended questions were used. Reflexive thematic analysis was used to analyse the qualitative free-text responses of clinician perspectives on the role of the dietitian in FT-AN. Results: All clinicians agreed that dietetics had a role within FT-AN and most frequently sought dietetic involvement in the early phases of FT-AN. Reflexive thematic analysis of responses identified three main themes. These were (1) collaboration is key, (2) confidence as a core consideration and (3) case-by-case approach. These themes evidenced the role of the dietitian within FT-AN and highlighted both the benefits and concerns of this involvement. Conclusions: This study demonstrated that dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counselling should be offered in joint sessions with the therapist rather than separately. The findings of the study were limited by the small sample size of participants recruited from a single centre and heterogeneity in the professional background of respondents. Although the integration of dietetics within the multidisciplinary team and the ability of dietitians to individualise patient care can enhance FT-AN treatment, potential benefits and disbenefits should be considered for each case.

Multi-family Therapy (MFT) is being increasingly used in specialist eating disorder services internationally. Despite evidence of its efficacy, little is understood about the treatment mechanisms and what specifically promotes change. This study aimed to understand clinician perspectives on how change occurs during MFT. Clinicians with (a) 5 or more years’ experience facilitating MFT and (b) who had facilitated a minimum of two MFT groups were eligible for this study. Two individual interviews and four semi-structured focus groups were conducted online. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. Twelve clinicians (five systemic/family psychotherapists, five clinical psychologists, and two consultant child and adolescent psychiatrists) from six different specialist services in the UK participated. Four main inter-connected themes describing how change is perceived to occur were generated; (1) Intensity and immediacy, (2) Flexibility, (3) New ideas and channels of learning and (4) Containment. Current data matches closely with young person and parent experiences of MFT and intensive day treatment and how they perceive change to occur. Quantitative data are now needed to evaluate the impact of these factors on outcome. Plain English Summary Multi-family Therapy (MFT) is being increasingly used in specialist eating disorder services internationally. While there is evidence that it is helpful, little is understood about how the treatment works and what specifically promotes change. This study aimed to understand how clinician believe change to occur during MFT for young people and their family members. Clinicians with (a) five or more years’ experience facilitating MFT and (b) who had facilitated a minimum of two MFT groups were eligible for this study. Two individual interviews and four semi-structured focus groups were conducted online. Recordings were written out word-for-word and analysed using reflexive thematic analysis, a commonly used method for analysing this type of data. Twelve clinicians (five systemic/family psychotherapists, five clinical psychologists, and two consultant child and adolescent psychiatrists) from six different specialist services in the UK participated. Four related themes describing how change is perceived to occur were generated; (1) Intensity and immediacy, (2) Flexibility, (3) New ideas and channels of learning and (4) Containment. Current data matches closely with young person and parent experiences of MFT and intensive day treatment and how they perceive change to occur. These factors now need to be tested in future research.

Background Family therapy for anorexia nervosa (FT-AN) is the first line recommended treatment for child and adolescent anorexia nervosa. Despite evidence of its efficacy, little is understood about the treatment mechanisms. This study aimed to understand how young people who have received FT-AN perceive change to occur across treatment. Method Fifteen adolescents (age 12–18 years) completed individual semi-structured interviews online. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. Results Four inter-connected themes describing the process of change during treatment were generated; (1) relationships as the vehicle for change, (2) an awakening, (3) through, not around – no way out, (4) the life beyond. Conclusions Current data match relatively closely with theoretical models of FT-AN and emphasise the importance of building trust with all family members, including the young person. Additionally, supporting the family to create a trusting context in which there is a sense that the only way out of the illness is by going through it (rather than avoiding it) is critical. Empirical investigation of each of the described mechanisms is needed.

OBJECTIVE:To summarise existing evidence on bonding and parent-child quality of interaction in parents with eating disorder (ED). METHODS:A scoping review was conducted. Seven databases (PsycInfo, Embase, Medline, Pubmed, OpenGrey, ProQuest and Google Scholar) were examined and studies exploring research into bonding and quality of interaction in parents with ED were included. RESULTS:Seventeen quantitative studies were included in the review. Reviewed literature suggests that parents with ED tend to be more intrusive, may exhibit more negative expressed emotions and may be involved in higher levels of mealtime conflicts during mealtimes. Additionally, they may be less sensitive and may offer less structured in non-feeding interactions. Children of parents with ED may have a more difficult temperament, may display greater internalisation and externalisation problems, may be less responsive to their parents and exhibit more behavioural difficulties. CONCLUSION:Overall, we found that parents with ED are more likely to have difficulties during interactions with children, compared with controls, both in feeding and non-feeding contexts which might impact children's mental health. Proposals for future research are suggested to enhance our understanding of the intergenerational transmission of ED, holding the potential to pinpoint therapeutic and preventative targets for both parents with ED and their children.

OBJECTIVE:Multi-family therapy (MFT-AN) is a promising group-based treatment for adolescent anorexia nervosa. This study aimed to explore how young people and parents perceived change to occur during MFT treatment.METHODS:Young people (10-18 years) diagnosed with anorexia nervosa or atypical anorexia nervosa and their parents who completed MFT-AN alongside family therapy for anorexia nervosa within the preceding 2 years were eligible for this study. Semi-structured qualitative interviews were conducted. Recordings were transcribed verbatim and analysed using reflexive thematic analysis.RESULTS:Twenty-three participants (8 young people, 10 mothers and 5 fathers) completed interviews. Five main themes were identified; (1) Powerful connection, (2) Intensity, (3) New learning and perspective shifts, (4) Comparisons, and (5) Discharge is not recovery. There was a strong sense that being with others in a similar position in an intense environment were key factors in promoting change. Comparisons were inevitable and could promote insight and foster motivation, but could also be unhelpful at times. Participants spoke about how recovery continues beyond service use and requires ongoing attention and support.CONCLUSIONS:Through the mechanisms of connection, intensity, new learning and comparisons change is perceived to occur in MFT-AN. Some of these are considered unique to this treatment format.

INTRODUCTION Multi-family therapy for anorexia nervosa (MFT-AN) is a novel, group-based intervention that intensifies single-family therapy for anorexia nervosa (FT-AN), with the aim of improving outcomes. The current study explored treatment moderators in a randomised controlled trial (N = 167) of FT-AN and MFT-AN for young people (adolescents/emerging adults aged 13-20 years) with anorexia nervosa. METHODS Data were analysed using multiple linear regression. Six hypothesised baseline participant and parent factors were tested as possible moderators of treatment effect on end-of-treatment and follow-up percentage of median Body Mass Index (%mBMI); age, eating disorder symptom severity, perceived family conflict (young person and parent ratings) and parent-rated experiences of caregiving (positive and negative). RESULTS Greater parent-rated positive caregiving experiences moderated treatment outcomes at follow-up (β = -0.47, 95%CI: -0.91, -0.03, p = 0.04), but not end-of-treatment. Participants who had fewer parent-rated positive caregiving experiences at baseline had higher weight at follow-up if they had MFT-AN compared to FT-AN. No other hypothesised baseline factors moderated treatment outcome (p's > 0.05). DISCUSSION The current study suggests MFT-AN may be indicated for families who present with fewer positive caregiving experiences to treatment. The MFT-AN group context may help to promote mentalisation and hope for these families, which may be harder to achieve in single-family treatment. Future research is needed to empirically evaluate how and why MFT-AN supports this group more. TRIAL REGISTRATION ISRCTN registry: ISRCTN11275465, registered 29 January 2007.

ObjectiveEating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch. MethodIn October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap. ResultsSeveral key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal. ConclusionsProgramme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.

Doel: In deze studie is onderzoek gedaan naar de kwantitatieve en kwalitatieve bewijsbasis voor multi-family therapy (MFT) voor eetstoornissen, wat betreft de veranderingen in fysieke en psychische symptomen, bredere individuele en gezinsfactoren en de ervaring van de behandeling. Methode: Er is een systematisch scoping review uitgevoerd. Vier databases (PsycInfo, Medline, Embase, CENTRAL) en vijf databases voor grijze literatuur zijn op 24 juni 2021 doorzocht op relevante, intercollegiaal getoetste artikelen uit tijdschriften, hoofdstukken uit boeken en proefschriften. Er is geen begindatum opgegeven. Alleen artikelen met kwantitatieve en kwalitatieve gegevens zijn opgenomen. Er waren geen beperkingen wat betreft leeftijd of diagnose. De studies zijn eerst geïnventariseerd; waarbij gekeken is naar de opzet van de studie, de leeftijd van de deelnemers en de behandelsetting. Daarna is het narratief gesynthetiseerd. Resultaten: De uitkomsten van 714 mensen die MFT hebben gevolgd in 27 studies (1 gemengde methode, 17 kwantitatief en 9 kwalitatief) zijn gesynthetiseerd. MFT wordt in verband gebracht met verbeteringen van de symptomatologie van de eetstoornis en met gewichtstoename voor degenen met ondergewicht. MFT wordt ook in verband gebracht met verbeteringen van andere individuele- en gezinsfactoren zoals comorbiditeiten, zelfvertrouwen, de kwaliteit van leven en een aantal aspecten van de ervaring van de zorg. Echter, deze laatste bevindingen zijn wisselend. MFT wordt doorgaans tegelijkertijd als nuttig en als lastig ervaren, vanwege de thematiek en het intensieve groepsproces. Bespreking: MFT wordt in verband gebracht met significante verbeteringen van de eetstoornissymptomen gedurende het gehele leven, alsmede met verbeteringen van bredere individuele en gezinsfactoren. De bewijsbasis is echter klein en de studies hebben meestal niet voldoende sterkte. Er is behoefte aan omvangrijkere, meer kwalitatieve studies en aan onderzoek naar de specifieke invloed die MFT kan hebben op de behandeluitkomsten; omdat het bij MFT nu meestal een aanvullende behandeling gaat.

OBJECTIVE Individuals with eating disorders are known to have higher rates of insecure attachment compared to community controls, but the factors underlying this finding are poorly understood. We conducted the first meta-analysis comparing attachment in eating disorder samples compared to community controls that included quality assessment, publication bias and moderation analysis. METHOD We pre-registered our meta-analysis (CRD42019146799) and followed PRISMA guidelines. We searched PsychINFO, Embase, Medline, CINAHL, and Scopus for publications. Attachment scores were extracted, and Cohen's d calculated for each study using a random effects model. RESULTS In total, 35 studies were included in the meta-analysis and six studies were summarized in a narrative review. Eating disorder samples showed higher rates of insecure attachment compared to community controls, with a large effect size, across measurement methods and different attachment dimensions. Blinding of assessors moderated effect sizes for attachment interview studies, but no other moderators were significant. DISCUSSION Risk of insecure attachment is elevated in individuals with eating disorders, albeit heterogeneity is high and largely unexplained. Clinicians may need to take this into account in their work, particularly given the association between attachment insecurity and challenges to therapeutic alliance. Future studies comparing eating disorder samples with community samples should control for general psychopathology. PUBLIC SIGNIFICANCE Attachment is a broad concept referring to a person's thoughts, feelings and behaviors in relation to close others. This systematic review and meta-analysis found that individuals with eating disorders are lower in attachment security than community controls, regardless of attachment construct or measurement approach. Attachment may be relevant in influencing eating disorder recovery, the development of therapeutic alliance, and potentially clinical outcomes, although more research is needed.

AbstractAimsThis study aims to investigate the effect of maternal eating disorders (ED) on mother‐infant quality of interaction at 8 weeks and bonding and child temperament at 1 and 2 years postnatally. We also aimed to explore the relationship between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother‐infant quality of interaction and bonding in women with ED. Women were recruited to a prospective longitudinal study. By the time of giving birth, the sample consisted of 101 women of the initial 137 (73.7%). Overall, 62 women (ED = 36; HC = 26) participated in the 8‐week assessment, 42 (ED = 20; HC = 22) at 1 year, and 78 (ED = 34; HC = 44) at 2 years. Mann‐Whitney U Test was used to explore association between maternal ED and mother‐infant quality of interaction and between maternal ED and bonding. Spearman correlations were used to explore associations between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother‐infant quality of interaction and bonding.ResultsWe found no differences between early mother‐infant interaction and bonding in mothers with ED in comparison to HC. High levels of maternal ED psychopathology were correlated with high anxiety levels, higher negative affectivity, and lower extraversion in children of ED mothers both at 1 and 2 years. Furthermore, high levels of ED psychopathology were also associated with lower effortful control at 1 year.ConclusionsFindings imply that maternal ED have an impact on child temperament. Future research should focus on resilience and on which protective factors might lead to positive outcomes. These factors can be then used as therapeutic and preventative targets.

This study explored the experience of having a sibling with anorexia nervosa and the sibling perspectives on service provision. Four focus groups were conducted with 14 siblings (8 female, 6 male, age 11–19 years) of adolescents with anorexia nervosa or related restrictive eating disorders. Group discussions were transcribed and analysed using thematic analysis. Four themes and eight sub-themes were generated. These illustrated siblings feel greatly affected by the way the family needs to change to support someone with anorexia nervosa. Feelings of ambivalence and acceptance were also evident. They described silencing their own emotions and needs so as not to trouble others, and distancing themselves from their families in order to cope. Some female (but no male) siblings identified an impact on their own perceptions of eating and body image. Siblings generally felt that services had not attended to their needs, and that they had not been appropriately included in treatment. Data from this study suggest the sibling experience needs to be more carefully considered and included in treatment. This may include a more explicit invitation to sessions and a more active discussion about their own needs and useful involvement in treatment sessions. Findings point to ways siblings may be better supported, such as peer support groups. This study investigated the experience of having a sibling with anorexia nervosa, and the sibling perspectives on the treatment they get. Four focus groups were held with siblings (11–19 year-olds) of adolescents with anorexia nervosa. Group discussions were written down word-for-word and analysed using thematic analysis. Four themes and eight sub-themes were identified. These illustrated siblings feel very affected by the way the family needs to change to support someone with anorexia nervosa. Feelings of ambivalence and acceptance were also evident. Siblings said they silenced their own emotions and needs so as not to trouble others, and distanced themselves from their families in order to cope. Siblings generally felt that services had not attended to their needs, and that they had not been appropriately included in treatment. Findings from this study point to ways siblings may be better supported, such as peer support groups.

BACKGROUND:Randomized controlled trials showed the efficacy of family therapy for anorexia nervosa during adolescence, but studies examining its long-term beneficial effect are still needed. This article presents the results of a 54-month post-randomization follow-up of a previously reported randomized controlled trial that compared two post-hospitalization outpatient treatment programs: Treatment As Usual alone versus Systemic Family Therapy added to Treatment As Usual.METHODS:A consecutive series of 60 female adolescents with anorexia nervosa (DSM-IV) were randomized (30 per group). During the first 18 months, in the Treatment As Usual group, subjects received a multidisciplinary treatment. In the other group, Systemic Family Therapy sessions targeting intra-familial dynamics were added to Treatment As Usual. At 54 months, the primary outcome was defined using the Morgan and Russell global Outcome Categories (Good or Intermediate versus Poor). Secondary outcomes were the Global Outcome Assessment Schedule score, body mass index, amenorrhea, number of hospitalizations, eating disorder symptoms, psychopathological features, and family functioning. Analyses were carried out using an Intention-To-Treat with the Last Observation Carried Forward procedure. Data of 59/60 subjects were available.RESULTS:At 54 months, significant effects in favor of adding Systemic Family Therapy to Treatment As Usual were shown for the Global Outcome Categories (60% of Good/Intermediate versus 31% in the control group, p = .026), mean body mass index (p = .048), resumption of menses (70.0% vs. 40% p = .020), and mental state score (p = .010). Family cohesion scores were lower in the Systemic Family Therapy group (p = .040).CONCLUSIONS:Adding Systemic Family Therapy focusing on intra-familial dynamics to a multidimensional outpatient treatment program appeared to lead to a better long-term outcome in young women who suffered from severe anorexia nervosa during adolescence.

Randomized controlled trials showed the efficacy of family therapy for anorexia nervosa during adolescence, but studies examining its long-term beneficial effect are still needed. This article presents the results of a 54-month post-randomization follow-up of a previously reported randomized controlled trial that compared two post-hospitalization outpatient treatment programs: Treatment As Usual alone versus Systemic Family Therapy added to Treatment As Usual. A consecutive series of 60 female adolescents with anorexia nervosa (DSM-IV) were randomized (30 per group). During the first 18 months, in the Treatment As Usual group, subjects received a multidisciplinary treatment. In the other group, Systemic Family Therapy sessions targeting intra-familial dynamics were added to Treatment As Usual. At 54 months, the primary outcome was defined using the Morgan and Russell global Outcome Categories (Good or Intermediate versus Poor). Secondary outcomes were the Global Outcome Assessment Schedule score, body mass index, amenorrhea, number of hospitalizations, eating disorder symptoms, psychopathological features, and family functioning. Analyses were carried out using an Intention-To-Treat with the Last Observation Carried Forward procedure. Data of 59/60 subjects were available. At 54 months, significant effects in favor of adding Systemic Family Therapy to Treatment As Usual were shown for the Global Outcome Categories (60% of Good/Intermediate versus 31% in the control group, p  = .026), mean body mass index ( p  = .048), resumption of menses (70.0% vs. 40% p  = .020), and mental state score ( p  = .010). Family cohesion scores were lower in the Systemic Family Therapy group ( p = .040). Adding Systemic Family Therapy focusing on intra-familial dynamics to a multidimensional outpatient treatment program appeared to lead to a better long-term outcome in young women who suffered from severe anorexia nervosa during adolescence.

Background: Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial. Overview of paper: This paper describes a large-scale transformation programme following a major government investment (initially 30 pound million/year, since then increased to over 50 pound million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

INTRODUCTION:Prior to the COVID-19 pandemic, research in virtual care for young people with eating disorders was preliminary and implementation rare. This study explored the experience of young people, parents and clinicians when therapy was transitioned to virtual provision as a result of the UK lockdown in March 2020.METHODS:A mixed-method approach was used in this study. Online questionnaires that included a mixture of rating (Likert scale) and free-text response questions were completed by 53 young people with any eating disorder, 75 parents and 23 clinicians. Questions focused on the experience of online treatment as well as the impact on engagement, perceived treatment efficacy and preferences around treatment mode in the future. Likert scale questions were analysed using a summary approach. Free-text responses were analysed qualitatively using reflexive thematic analysis.RESULTS:Responses to rating scale questions indicate satisfaction with treatment, good engagement and ability to manage technology. Young people who had transitioned care, rather than started care virtually in lockdown, rated therapy as less effective. However, individual accounts of experience were more varied. Reflexive thematic analysis of free-text responses identified key themes of 1) Making it work, 2) Home as a therapeutic space, and 3) Disrupted connection and 4) Into the future.CONCLUSIONS:These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and therapeutic engagement and depth and need for consideration of equal access to treatment in socially unequal societies.