Family-Based Treatment for Eating Disorders: Clinical Recommendations for the Pediatrician

AUTHORS:

Jasmine Reese, MD, MPH; Sarah Sobalvarro, PhD, ABPP
Johns Hopkins All Children’s Hospital

REVIEW ARTICLE | PUBLISHED SUMMER 2025 | Volume 45, Issue 3

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Eating Disorders are often chronic, complex, treatment-resistant disorders. For decades, these conditions have earned a reputation as being difficult to treat and as having low recovery rates. Additionally, the patient’s motivation to recover from anorexia nervosa is often low or nonexistent at the start of treatment. Plus, common evidence-based treatments, such as cognitive behavioral therapy, have not been effective for some eating disorders, primarily Anorexia Nervosa. Fortunately, Family-Based Treatment (FBT) has emerged as the gold standard, primary evidence-based treatment for children and adolescents with Anorexia Nervosa.1-3 FBT has evolved from the theoretical model of the “psychosomatic family” (family units that often include enmeshment, overprotectiveness, rigidity, and lack of conflict) during its early development in the late 1970s and 1980s to a robust, family focused model that mobilizes parents/caregivers to play an active and positive role in the child/adolescent’s weight recovery instead of waiting for the adolescent to gain motivation. FBT is comprised of three phases:

  • Phase one involves parents/caregivers being in full control of choosing, preparing, serving, and monitoring the child/adolescent’s meals and snacks to ensure the child/adolescent is obtaining adequate daily calories. Patients continue in this phase until they have restored adequate weight and become less resistant to eating consistent meals and snacks.
  • Phase two involves returning control of nutritional intake to the child/adolescent. This transition must occur gradually, with close monitoring by the family and the patient’s clinical care team, to ensure the patient continues to receive adequate nutrition and calories without the re-emergence of eating disorder behaviors.
  • Phase three focuses on developing a healthy patient identity and healthy family interactions once the eating disorder is well-managed and the patient is weight restored. This is the phase in which individualized, evidence-based treatments (e.g., cognitive behavioral therapy, dialectical behavior therapy, radically open dialectical behavior therapy, trauma-specific therapies) should be utilized to improve body image, anxiety, depression, trauma symptoms, and additional mental health comorbidities.

While an outpatient psychologist or therapist often implements FBT, it has been utilized in medical settings, including primary care offices.4-6 The primary care provider (PCP) plays a vital role in the treatment and recovery journey of an individual challenged with an eating disorder. However, it is well known that numerous barriers exist to feasibility in a busy PCP practice. These include limitations in time, resources, experience, and/or education in diagnosing and treating eating disorders, as well as a lack of confidence and interest in this area.¹ Previous surveys have shown that most providers felt their role was to identify eating disorders in their patients. However, in a study of 70 pediatricians, only 21% endorsed feeling comfortable providing eating disorder treatment. Even less endorsed is having sufficient training in eating disorders.1

Fortunately, a variety of screening tools and guidelines are available to assist pediatricians and family medicine physicians in implementing best practices for early screening and intervention. For example, the American Academy of Pediatrics serves as an indispensable resource in guiding the general pediatrician on how to screen and initiate management for children and teens with eating disorders.7 Early identification and intervention can be essential in achieving recovery. Therefore, it is crucial for primary care providers to routinely screen individuals for disordered eating as they attend their routine office visits. There are many different validated screening tools for disordered eating. Healthcare providers should identify and implement the tool that works best for their clinical practice and workflow. Some examples include the Eating Disorder Examination Questionnaire (EDE-Q), the Eating Attitudes Test (EAT-26), and the Female Athlete Screening Tool (FAST). (https://pmc.ncbi.nlm.nih.gov/articles/PMC8645259/)

PCPs are encouraged to review different screening tools in advance to ensure they know how to utilize, score, and interpret the measure/s to prevent disruption in their clinic efficiency.

One of the primary roles of the PCP is to assess for medical stability, which includes checking for abnormal vital signs, concerning weight changes, abnormal physical exam findings, electrolyte abnormalities, and vitamin deficiencies, among other things. Additionally, understanding when it is appropriate and medically necessary to recommend inpatient hospitalization has been well outlined for the general pediatrician.2 Whether or not a patient requires hospitalization, they should continue to seek care and guidance from the PCP. Therefore, it is in the best interest of the provider to engage in educational opportunities that equip them to provide the best care for their patients and families. Providers should plan to seek out opportunities to learn more about eating disorder care through their national educational forums and annual conferences (i.e., those sponsored by the American Academy of Pediatrics, American Academy of Family Physicians, and ACP Internal Medicine Meeting). These national meetings often offer CME workshops and lectures that highlight evidence-based methods for treating eating disorders.

Especially for children and adolescents, the PCP usually has already established a rapport and trust with families over time, which can serve as a significant catalyst in getting them to initiate treatment. Having a PCP who is knowledgeable and skilled in FBT can lead to improved long-term outcomes and increased compliance with treatment adherence. Studies have shown that a modified FBT approach can be feasible in a primary care setting for patients with eating disorders.4-6 Specifically, pediatricians and PCPs should focus their visits on interventions to help the patient achieve weight restoration. PCPs should meet with the entire family and, most importantly, the caregivers to discuss interventions that will assist with weight restoration. While it can be helpful to meet with the patient alone to assess their current eating behaviors and thoughts, the pediatrician/PCP) should meet with the whole family to discuss interventions that assist with weight restoration. PCPs can utilize the following FBT-specific interventions when meeting with caregivers and the patient together: reviewing meal schedules/content, problem-solving barriers to increased nutrition, setting goals to help caregivers improve the patient’s daily caloric intake, limiting exercise, and guiding parents to present a united front against the eating disorder. A Primary Care Modification of Family-Based Treatment for Adolescent Restrictive Eating Disorders is a helpful resource for further information on how to utilize FBT in primary care settings.4 A summary of clinical recommendations and resources for pediatricians, as well as resources for families, is listed below.

Clinical Recommendations for Pediatricians

  • Offer frequent follow-up visits (i.e., weekly, biweekly, monthly) based on the severity of the eating disorder to ensure medical stability for ongoing outpatient treatment
  • Consider checking blood work, including electrolytes and screening for nutritional deficiencies as needed
  • Coordinate care with therapist/dietitian (i.e., have a plan for care team updates so that providers have a unified message and treatment goal)
  • Empower parents to take an active role in their child/teen’s treatment. Encourage them to communicate closely with their child/teen’s therapist, dietitian, psychiatrist, or eating disorder team if they are in a higher level of care.
  • Encourage parents/caregivers to utilize a family-based treatment approach and recommend parents find an eating disorder therapist or treatment program that utilizes FBT.
  • Encourage parents to prepare, serve, and monitor their child/teen’s meals and snacks when they are in the weight restoration phase. This method should be utilized at any weight if the patient is struggling to eat consistent and adequate meals/snacks independently.
  • Remind parents to use a calm, compassionate, and firm approach to help the child/teen complete their meals and snacks.
  • Remind families that eating disorder treatment should be prioritized, which means they may need to place sports, school, and other activities on hold.
  • Provide encouragement and hope to the patient and family. Individuals can fully recover from an eating disorder. Early diagnosis and intervention are especially helpful in achieving recovery.

Resources for Pediatricians

Resources for Families

  • The Kelty Mental Health Resource Center https://keltyeatingdisorders.ca/
  • Videos discuss and demonstrate meal support based on FBT principles, feature testimonials from parents and youth in recovery, and are subtitled into multiple languages
  • FEAST https://www.feast-ed.org/
  • FEAST is an eating disorder website developed for caregivers and families with loved ones who have an eating disorder. The website provides evidence-based information on eating disorders and shares helpful resources on how to help support someone with an eating disorder.

Books for Caregivers:

  • Help Your Teenager Beat an Eating Disorder by James Locke and Daniel LaGrange
  • When Your Teen Has an Eating Disorder by Lauren Muhlheim
  • Anorexia and Other Eating Disorders by Ava Musby (also has a website: www.anorexiafamily.com)
  • Survive FBT by Maria Ganci

References

  1. Lock, J, Le Grange, D. Family‐based treatment of eating disorders. Int J Eat Disord. 2005;37(S1),S64-S67.
  2. Couturier J, Kimber M, Szatmari P. Efficacy of family‐based treatment for adolescents with eating disorders: A systematic review and meta‐analysis. Int J Eat Disord. 2013;46(1):3-11.
  3. Lock J, Le Grange D. Family‐based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders? Int J Eat Disord. 2019;52(4):481-7.
  4. Lebow, J, O’Brien, JRG, Mattke, et al. A primary care modification of family-based treatment for adolescent restrictive eating disorders. Eat Disord. 2021;29(4),376-389.
  5. Lebow J, Narr C, Mattke A, Gewirtz O’Brien JR, Billings M, Hathaway J, Vickers K, Jacobson R, Sim L. Engaging primary care providers in managing pediatric eating disorders: A mixed methods study. J Eat Disord. 2021;9,1-8.
  6. Forsberg S, Gorrell S, Accurso EC, Trainor C, et al. Family-based treatment for pediatric eating disorders: evidence and guidance for delivering integrated interdisciplinary care. Child Health Care. 2023;52(1),7-22.
  7. Hornberger LL, Lane MA. The Committee on Adolescence. Pediatrics. 2021;147(1), e2020040279.

 

Disclosures: Authors report no conflicts of interest.