Abstract BackgroundThere is a critical need to disseminate efficacious psychosocial treatments for mental disorders because there is a significant gap between evidence-based treatment (EBT) approaches and usual clinical practice. To address this gap, cost-effective, efficient, and scalable methods of training mental health clinicians in EBT are needed. One example of the need to improve dissemination and implementation of psychosocial treatments is for adolescents with anorexia nervosa (AN), a serious mental disorder with an incidence rate of about 1% that can become life-threatening. Based on outcomes from a series of randomized controlled trials (RCTs), an EBT for adolescents with AN is family-based treatment (FBT); however, few therapists are trained in the approach. Some studies suggest that online training is feasible for training clinicians treating eating disorders, including pilot data related to FBT specifically, but RCTs examining different training formats for FBT to improve fidelity and patient outcomes are needed. ObjectiveThis study compared 2 different formats for delivering online training in FBT to therapists treating adolescents with AN and planned to assess the feasibility of the 2 training formats, as well as to examine whether either approach was superior in improving fidelity to FBT or patient outcomes. MethodsParticipants were 123 mental health therapists licensed in the United States in private practice with no previous FBT training. Therapists were randomized to either (1) a webinar training lecture series or (2) an interactive e-training on-demand program (ET-FBT) with an additional focus on key FBT interventions. Both groups were offered up to 12 one-hour group-based clinical case consultation (CCC) sessions posttraining. We examined the feasibility and acceptability of the online training programs and posttraining outcomes in fidelity to key components of FBT, self-efficacy, and working alliance. We explored rates of patient early response (weight gain of 2.4 kg at session 4) in adolescent patients with AN treated after FBT training during CCC. ResultsBoth online trainings had a high completion rate of 95% (117/123), with CCC completion at 38% (47/123). Both programs showed significant improvements within randomized groups in therapists’ fidelity, self-efficacy, and working alliance. Working alliance improved significantly more in the ET-FBT group, but there were no other significant differences between training groups. Early response rates doubled posttraining and CCC (16%-34%), regardless of randomized training format, a rate that is similar to that achieved by therapists in RCTs examining FBT treatment outcomes. ConclusionsIt is feasible to deliver online training in FBT to clinicians in private practice in 2 different formats, and both trainings led to significant improvements in fidelity, self-efficacy, working alliance, and patient outcomes. Future studies should address challenges in patient recruitment for posttraining CCC and refine CCC implementation to maximize training effects and efficiency.

OBJECTIVE:To examine the efficacy of family-based treatment for avoidant/restrictive food intake disorder (FBT-ARFID) compared with individual psychoeducational motivational therapy (PMT) for underweight children with ARFID between 6 and 12 years of age. The main outcome evaluated was the difference between groups on change in percent estimated body weight (%EBW) from baseline to end of treatment (EOT). METHOD:A total of 98 children with ARFID were randomized to 14 sessions of telehealth FBT-ARFID or PMT conducted over 4 months. Assessments of weight/height, eating-related cognitions, and behaviors associated with ARFID were collected online at baseline, 1 month, 2 months, and EOT by assessors masked to treatment condition. RESULTS:FBT-ARFID was superior to PMT at EOT in promoting increased %EBW. There were no differences between groups regarding improvements in overall severity of ARFID symptoms or other related ARFID symptoms; however, baseline severity of ARFID symptoms moderated the effect, with children who were most symptomatic improving significantly more in FBT-ARFID than in PMT (exploratory analyses). CONCLUSION:FBT-ARFID is superior to PMT for promoting weight gain in low-weight children with ARFID, especially children with greater severity of ARFID symptoms. CLINICAL TRIAL REGISTRATION INFORMATION:Confirming the Efficacy/Mechanism of Family Therapy for Children With Low Weight ARFID. https://clinicaltrials.gov/study/NCT04450771.

OBJECTIVE:Although international treatment guidelines for eating disorders recommend varying psychological approaches for adolescents with anorexia nervosa (AN), most existing reviews have combined adolescent and adult samples, leaving the overall evidence base for this population poorly defined. This systematic review is the first to synthesize randomized controlled trials (RCTs) of psychological treatments for adolescents with AN across outpatient, inpatient, and day-patient settings. METHOD:A systematic search of databases (e.g., PubMed, APA PsycINFO) identified 22 relevant studies through June 2025. Eligible studies focused on adolescents (ages 8-18 years) with AN undergoing psychological treatment. RESULTS:Evidence from the nine RCTs consistently indicates that family therapy produces significant positive effects on somatic parameters (e.g., weight) and short-term eating-disorder symptoms. In four, mostly underpowered comparative RCTs, outpatient family therapy showed small-to-moderate effect sizes over individual therapy, though these were restricted to outcomes related to medical recovery. For inpatient care, a limited evidence base suggests that shorter inpatient treatment followed by outpatient care may achieve outcomes comparable to extended hospitalization. Psychological modules delivered during inpatient treatment (e.g., Cognitive Remediation Therapy, CBT-Insomnia) showed some improvements confined to narrow symptom domains but did not translate into broader recovery. CONCLUSION:The evidence base remains limited, with few RCTs in adolescents with AN and a geographically narrow, demographically homogeneous sample, predominantly girls from Western settings. Family therapy is supported as the first-line treatment, yet substantial uncertainties persist. Larger and more inclusive RCTs are needed to clarify mechanisms of change, long-term outcomes, and the effectiveness of individual-focused approaches.

Objective:Avoidant/restrictive food intake disorder (ARFID) is characterized by an avoidance or restriction of food intake due to a lack of interest in eating or foods, sensory sensitivities, and/or fear of adverse consequences, resulting in physical, medical, or psychosocial impairment. While previous studies in other eating disorders have found correlations between parental hostility, critical comments, and treatment outcomes, the ways that parents display their emotions and thoughts have not been evaluated in families of children with ARFID. Method:This study coded parental emotions and responsiveness in therapist-guided family meals during session two of manualized Family-Based Treatment (FBT) for ARFID to examine what types of comments were made. Thirty-one recorded meals were randomly selected from a randomized clinical treatment trial for children 6-12 years old with low-weight ARFID receiving FBT. The videos were double-coded with consensus and scoring guidelines developed in alignment with expressed emotion constructs (warmth, positive comments, hostility, critical comments, and emotional overinvolvement) but modified to fit the age range of ARFID children and the setting of the family-meal. Results:The study found that parents tended to make more positive comments than critical comments, with low scores of hostile comments and emotional overinvolvement. Discussion:Overall, these findings may suggest that some families enter treatment with relational strengths that can be leveraged therapeutically to reduce mealtime conflicts and improve treatment outcomes. The findings also support the establishment of a coding framework for parental emotions during mealtimes of families of children with low-weight ARFID and highlight the need for further research.

Background:Anorexia nervosa is a severe psychiatric disorder with high morbidity and mortality, particularly among adolescents. Family-based treatment (FBT) is the leading evidence-based intervention for adolescent anorexia nervosa, involving parents in renourishment and behavior interruption. Despite its effectiveness, challenges in distress tolerance and emotion regulation during high-stress situations, such as mealtimes, contribute to suboptimal treatment outcomes, with only 35% to 50% of adolescents achieving full recovery. Enhancing distress tolerance skills during FBT may improve treatment responses and recovery rates. The BALANCE mobile app was developed to address this need, offering real-time, dialectical behavior therapy (DBT)-based distress tolerance skills to support adolescents and families during mealtimes. Objective:Our aim was to explore the feasibility and acceptability of a mobile app designed to deliver distress tolerance skills to adolescents with and adolescents without anorexia nervosa. When fully programmed and optimized, we plan to use the mobile app to improve distress tolerance during mealtimes for adolescents with anorexia nervosa undergoing FBT. Methods:BALANCE was developed collaboratively with Stanford University's Center for Biodesign, leveraging the expertise of clinical psychologists and using biodesign student input and the Stanford Spezi ecosystem. The app underwent an iterative development process, with feedback from adolescent users. The initial feasibility and acceptability of the app were assessed through self-reported questionnaires and structured interviews with 24 adolescents aged 12 to 18 years, including 4 diagnosed with anorexia nervosa and 20 healthy controls. Adolescents with anorexia nervosa specifically used the app during mealtimes, and healthy controls used it as needed. Participants assessed the app's usability, perceived effectiveness, and its impact on their distress tolerance. Results:The app demonstrated high usability and acceptability. Of 24 participants, 83% (n=20) reported enjoying the app, 88% (n=21) would recommend it to peers, and 100% (n=24) found it user-friendly. Adolescents with anorexia nervosa reported that BALANCE helped them manage stressful mealtimes more effectively, highlighting features such as guided meditation, breathing exercises, and gamification elements as particularly effective. Healthy controls provided additional feedback, confirming the app's broad appeal to the target audience and potential scalability. Preliminary findings suggest that BALANCE may enhance distress tolerance in adolescents with and adolescents without anorexia nervosa. Conclusions:BALANCE shows promise as an innovative mobile health intervention for enhancing distress tolerance in adolescents with anorexia nervosa. Its user-friendly design and tailored DBT-based skills make it a feasible tool for integration into FBT. Future research should explore its integration into clinical practice and its impact on treatment outcomes. As distress tolerance skills are relevant to a range of mental health conditions, future research may also expand BALANCE's application to broader adolescent populations.

Online training programs offer accessible, cost-effective solutions to disseminate evidence-based interventions. Yet, online training is typically insufficient without additional clinical case consultation (CCC). This is particularly salient in adolescent eating disorders treatment, where clinical demand far outstrips capacities of providers trained in evidence-based treatment approaches. This study seeks to better understand attitudes and barriers to receiving CCC among private practice clinicians treating adolescent eating disorders. Licensed private practice clinicians (n = 47; 100

OBJECTIVE:Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents. METHODS:Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT). RESULTS:Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT. DISCUSSION:The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes. PUBLIC SIGNIFICANCE:Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

BACKGROUND:The leading evidence-based treatment for anorexia nervosa (AN) in adolescents is Family-based Treatment (FBT). However, due to the intensive training requirements and lack of practitioners, it is often difficult for families to access FBT. Thus, innovations that improve access to care are needed. A pilot randomized study of a guided self-help version of Family-based Treatment (GSH-FBT) that utilized approximately 1/4 the amount of therapist time compared to FBT found that the approach was acceptable and appeared to achieve similar outcomes. The study protocol detailed in this manuscript compares the efficiency (clinician time) of GSH-FBT to Family-based Treatment via Videoconferencing (FBT-V) in a fully powered study in achieving clinical outcomes through a multi-site randomized clinical trial across the US and Ontario, Canada. METHODS:This study will randomize the families of adolescents ages 12-18 (n = 200) who meet DSM-5 criteria for AN to receive either GSH-FBT or FBT-V. Participants will be randomized to 15 sixty-minute sessions of FBT-V or to 10 twenty-minute sessions of online GSH-FBT. Major assessments will be conducted by a masked assessor at baseline, within treatment, at the end of treatment (EOT), and 6 and 12 months after the end of treatment (EOT). The primary outcomes of this study are changes to body weight and eating disorder cognitions relative to clinician time used (relative efficiency of treatment modality). CONCLUSIONS:The findings of this study may help increase access to care by providing a time efficient, affordable, more scalable intervention for adolescent AN compared to standard FBT.

OBJECTIVE:Research on treatments for children with avoidant restrictive food intake disorder (ARFID) is needed. This pilot case series describes outcome data for 20 children ages 6-12 years old with a diagnosis of ARFID and who are low-weight. METHOD:Participants were recruited nationwide as part of an ongoing randomized clinical trial. All participants in this study received a 14-session psychoeducational and motivational treatment (PMT) protocol. Parents completed measures of ARFID severity (the Pica, ARFID, Rumination Disorder Interview) and parental self-efficacy (Parents vs. ARFID scale). Height and weight were self-reported by parents and percent of estimated body weight (%EBW) was calculated. Assessments occurred at baseline, 1-month within treatment, 2-months within treatment, end-of-treatment (EOT), and 6-month follow-up. RESULTS:Twenty children (10.34 ± 1.76 years; 85% Non-Hispanic; 75% White; 70% female; 84.16 ± 4.66% EBW) with low-weight ARFID and their parents received PMT-ARFID with a clinician specializing in eating disorders. By EOT, PARDI severity scores decreased (large effect size) parental self-efficacy increased (medium effect size), but %EBW remained unchanged. DISCUSSION:Additional research evaluating PMT in adequately powered clinical trials for youth with ARFID is needed.

This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12-18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced.