Parental Expressed Emotion During Two Forms of Family‐Based Treatment for Adolescent Anorexia Nervosa

Abstract

High parental expressed emotion (EE), reflected by criticism or emotional over-involvement, has been related to poorer outcome in family-based treatment (FBT) for adolescent anorexia nervosa. This study assessed EE in 89 mothers and 64 fathers at baseline and end of treatment in a randomised trial comparing conjoint FBT to parent-focused FBT (PFT). Compared with conjoint FBT, PFT was associated with a decrease in maternal criticism, regardless of adolescent remission. Furthermore, an increase in maternal criticism was more likely to be observed in conjoint FBT (80%) than PFT (20%, p = 0.001). Adolescents of mothers who demonstrated an increase in EE, or remained high in EE, were less likely to remit compared with adolescents for whom EE decreased or remained low (33% and 0% vs. 43% and 50%, p = 0.03). There were no significant effects for paternal EE. The results highlight the importance of considering EE when implementing FBT for adolescents with anorexia nervosa. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association. Family-based treatment (FBT; Lock & Le Grange, 2013) is currently the most efficacious outpatient treatment for medically stable adolescents with anorexia nervosa (AN) (Lock, 2015) and is considered first-line outpatient treatment (Ciao, Accurso, Fitzsimmons-Craft, Lock, & Le Grange, 2015; Couturier, Kiymber, & Szatmari, 2013). Despite this, FBT is not effective for all patients, thus prompting exploration of factors that might enhance, or hinder, patient recovery. One such factor is expressed emotion (EE).Expressed emotion characterises the quality of interpersonal interactions and the relationship between a caregiver and an unwell relative (Brown & Rutter, 1966;Hodes, Dare, Dodge, & Eisler, 1999;Vaughn & Leff, 1976). Family members characterised as having high EE are generally critical or hostile towards the unwell family member and/or emotionally overinvolved (Rienecke, Accurso, Lock, & Le Grange, 2016). In assessing EE within families, the attitudes, emotions and feelings expressed by family members towards an unwell relative is evaluated (Rein et al., 2006). The most common face-to-face methods used to assess EE are the Camberwell Family Interview (Vaughn & Leff, 1976), Standardised Clinical Family Interview (SCFI;Kinston & Loader, 1984) and the Five Minute Speech Sample (FMSS; Magana, Goldstein, Karno, & Miklowitz, 1986).Early studies have suggested that parental EE predicts treatment response in family therapy for adolescents with AN. Specifically, high parental EE has been associated with treatment dropout (Szmukler, Eisler, Russell, & Dare, 1985) and poor treatment outcomes (Le Grange, Eisler, Dare, & Russell, 1992;van Furth et al., 1996). For instance, in a small (n = 18) randomised clinical trial (RCT) of conjoint family therapy (CFT) versus separated family therapy (SFT), parents of adolescents who had a poor response to treatment made significantly more critical comments during the SCFI (i.e., high EE) at baseline compared with those who had a good or inte...

Family‐based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders

“…More recently, in a RCT comparing manualized conjoint FBT versus a separated version of the same treatment (PFT 1 ) (Le Grange et al, 2016), EE was measured at baseline and posttreatment. Interestingly, findings from the earlier investigations which seemed to favor a separated format of this treatment when parental criticism is high were amplified here (Allan et al, 2018). Regardless of remission, PFT rather than conjoint FBT was associated with a decrease in maternal criticism.…”

“…Thus, if there was a way to improve early response, recovery rates could also improve. Other studies suggest that parental criticism, as measured by expressed emotion (EE) (Leff & Vaughn, ), may limit the effectiveness when manualized FBT is delivered in conjoint format, while remission is enhanced when delivered in a separated format (e.g., PFT) (Allan, Le Grange, Sawyer, McLean, & Hughes, ; Le Grange et al, ). Therefore, approaches to minimize parental criticism in the therapeutic setting might be another way to improve remission rates.…”

“…Nor has the limited number of exploratory moderator analyses identified any family characteristics as potential moderators. Notwithstanding, at least four studies (Allan et al, 2018;Eisler et al, 2000;Le Grange, Eisler, Dare, & Hodes, 1992; Le Grange, Eisler, Dare, & Russell, 1992;Szmukler, Eisler, Russell, & Dare, 1985) have shown that the presence of parental criticism at the start of family interventions, as measured via EE (Leff & Vaughn, 1985), does seem to impact treatment outcome. In the first of these studies, high levels of parental criticism toward the unwell offspring predicted premature treatment drop-out (Szmukler et al, 1985), while a pilot investigation, comparing a conjoint versus separated format of family therapy for adolescent AN, showed that outcomes were poorer for the conjoint rather than separated family therapy when baseline parental criticism is elevated (Le Grange, Eisler, Dare, & Hodes, 1992; Le Grange, Eisler, Dare, & Russell, 1992).…”

“…Other studies suggest that parental criticism, as measured by expressed emotion (EE) (Leff & Vaughn, 1985), may limit the effectiveness when manualized FBT is delivered in conjoint format, while remission is enhanced when delivered in a separated format (e.g., PFT) (Allan, Le Grange, Sawyer, McLean, & Hughes, 2018;Le Grange et al, 2016).…”

Identifying and responding to child maltreatment when delivering family‐based treatment—A qualitative study

“…These indicators should signal practitioners to consider the possibility that maltreatment may be occurring and that a more detailed clinical inquiry of family dynamics is needed. If a practitioner becomes aware of or suspects any form of child maltreatment to be happening, one intervention avenue to explore might be FBT in its separated format, at least for highly critical or conflictual families (Allan, Le Grange, Sawyer, McLean, & Hughes, ); although this emerging evidence does not speak directly to the case of child maltreatment and has focused on adolescents with anorexia.…”