Cognitive Behavioral Therapy: Family-Based or Not?

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In the areas of weight management and eating disorders in kids and teens, several different components are involved. Negative behavior cycles need to be broken, and patterns need to be restructured. Some behaviors need to be eliminated, and others put in their place. Equally important is the long-term maintenance of both elements — the permanent extinction of some behaviors and the perpetual repetition of others. If all this can be accomplished, the likelihood of relapse is minimized.

Two major problem categories are anorexia nervosa (AN) and bulimia nervosa (BN). Cognitive behavioral therapy achieved some early successes with those. Basically, all eating disorders have something in common — a constant concern with food, eating, and weight. AN and BN are about the obsessive need to eat less and weigh less. Even though it seems on the surface to be the diametrical opposite, BED or binge eating disorder leading to obesity comes from the same roots — constant concern with food, eating, and weight. BED is included, along with some other diagnoses, in a category dubbed EDNOS, or “eating disorder not otherwise specified.”

It looked promising

Ten years ago, the United Kingdom’s Health Development Agency (using sources from everywhere) issued a report called The Management of Obesity and Overweight. Authored by Caroline Mulvihill and Robert Quigley, the report was subtitled “An analysis of reviews of diet, physical activity and behavioural approaches.” Among many other useful explorations of the literature, it offered a comparison between behavioral modification programs that were family-based and those that were not family-based. Reviewing family-based modalities that had been tried so far, the researchers wrote:

These programmes included behaviour modification, dietary and exercise education, with a mix of sessions involving the child, parent(s) and, in some cases, the entire family. The review concluded that while some findings appear promising, the small size of some of the studies and the disparate nature of the interventions mean there is ‘at present insufficient evidence to recommend any specific programme’.

Although family-based programs were regarded favorably, there was not at the time enough solid evidence for the authors to recommend any specific one. They also looked at reports about behavior modification programs without parental involvement — well, one, actually, because that’s all they could find in the literature, and it involved kids from 9 to 19 years of age. The report says:

This compared a three-part cognitive–behavioural ‘obesity-training’ programme combined with a calorie-reduced diet and an exercise programme, against a group that received the same diet and exercise component but received muscle relaxation training instead of the psychological component. The intervention lasted for six weeks. Both groups significantly reduced their percentage overweight over the course of a year. No statistically significant differences were found between the two treatment groups.

Progress

Almost a decade later, the U.S. National Institutes of Health issued a report titled Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents. Despite the development of successful treatment programs, relapse and non-recovery still were prominent occurrences. In fact, AN patients were noteworthy for dropping out before the end of the structured treatment programs, and because of non-completion, could not even be counted in the relapse vs. non-relapse statistics.

Family-based behavioral treatment for obesity still looked promising because of short-term successes, but once the intervention was over, patients would revert to old behaviors and gain weight. Families are especially crucial because for the most part children and youth cannot avoid living with them. For a kid, the family home and the people in it are the most significant and influential features of the environment, and if they don’t change, the outcome of any intervention that involves only the child is apt to be dismal. The report puts it this way:

The persistence of weight-related problems may occur because environmental stimuli, which had fostered the previously learned, maladaptive behaviors, have not been modified.

This is reminiscent of a famous quotation attributed to Albert Einstein (though he probably didn’t say it), the one about how doing the same thing over and over again, and expecting different results, is the definition of insanity.

Your responses and feedback are welcome!

Source: “The Management of Obesity and Overweight,” Prevenzione PDF, October 2003
Source: “Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents,” NIH.gov, 04/01/12
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