Family-Based Treatment (FBT) for Eating Disorders in Children and Teens
Eating disorders are severe, complex mental illnesses that intersect physical health, mental health, emotional health, relationships, and body image (though not always). These experiences deeply impact individuals, their families and loved ones. At SBSN, our team of dietitians often connect with family members who are inquiring about their child/teen who was recently diagnosed, or has been up against an eating disorder/disordered eating behaviors for some time. Navigating next steps in support, treatment, and care can feel overwhelming, confusing, and at times, scary. It is natural to feel concern and have questions about where to turn and how to navigate treatment approaches.
What is Family-Based Treatment for Eating Disorders?
Family Based Treatment (FBT), also known as the Maudsley method, is an evidence- based, 3-phase treatment approach for eating disorders that takes place in the home environment, and incorporates active participation of the parents/caregivers in the child’s/teens treatment process, while being guided and supervised by trained professionals.
When did therapists begin to use FBT as a treatment option for eating disorders?
FBT was first developed at Maudsley Hospital in London in 1985 as a treatment method for anorexia nervosa in adolescents. It is currently considered the gold standard for treating eating disorders in adolescents and teens and has since expanded into the treatment of various eating disorders such as other specified feeding and eating disorders (OSFED), binge eating disorder (BED), and bulimia nervosa (BN). Additionally, it can be used for the treatment of eating disorders in young adults as well.
When is FBT appropriate for treating eating disorders?
FBT is most commonly used at lower levels of eating disorder care, such as at the intensive outpatient (IOP) and outpatient (OP) treatment level. In both scenarios, individuals are navigating their eating disorder recovery while still living (partially or full time) at home. FBT encompasses the “treatment at home” model and aims to support the child’s/teen’s treatment through the role of parents/caregivers who implements treatment approach strategies and helps to create a healing environment at home in which the child/teen can fully recover. Although not common, some higher levels of care can use an FBT - informed approach in their treatment models. Family based treatment often takes several months or longer, depending on the individual.
5 Core Pillars of FBT
Parental empowerment and confidence- The main goal in FBT is to empower parents/caregivers as agents in change to support and nourish their child/teen confidently throughout their eating disorder recovery journey.
Agnostic View of the Illness - The eating disorder is viewed as separate from the individual themselves to reduce parental hostility, criticism, and blame.
Additionally, FBT focuses on treating the eating disorder vs finding the cause. FBT does not involve investigation of causation, pathologizing family, or figuring out “why” the eating disorder began. It also does not place guilt, blame, shame, judgement, or criticism towards the parent/caregiver.
Collaborative approach with family members - FBT encompasses non-negotiable active family participation and engagement that occurs in the home environment. This method relies on a collaborative and multifaceted teamwork approach that fosters open communication and collaboration between family members, team members, and the child/teen. This helps the family’s awareness, response and management while supporting their child/teen recover from an eating disorder.
Prioritize Physical Recovery First - FBT focuses on weight restoration and nutritional rehabilitation, as well as the rapid reduction of symptoms. Physical healing and adequate renourishment are required to occur before deeper cognitive and emotional recovery are possible
Gradual Reintroduction of Independence - FBT utilizes a non-authoritarian therapeutic approach in which the child/teen continues to gain empowerment, knowledge and independence as they progress throughout the three phases of FBT. Families are needed in the early stages of behavior change at the beginning, when eating disorders are strongest. The goal of FBT is for the child/teen to be renourished, weight restored, and gain independence in their eating behaviors to help reduce the risk of relapse and gain skills that they need to be successful in long term recovery.
Structure + Phases of Family Based Treatment
All Eating Related Responsibilities on the Parent/Caregiver + Focus on Weight Restoration
Parents/caregivers take complete, 100% responsibility of supporting initial behavior change through making all food/eating related decisions for their child/teen. This includes planning, purchasing, cooking, plating and supervising all foods and eating moments. This phase is not meant to be punitive, diminishing or infantilizing towards the child/teen. Instead, parents are using compassionate approaches in helping to lead by example by role modeling various food groups, types of foods, appropriate portion sizes, appropriate length to complete each eating moment, and support in the frequency of eating that is needed throughout the day to meet the child’s/teens individual meal plan. Parents use non-negotiable, concrete, and consistent support in helping the child/teen complete each eating moment.
The child/teen’s only role is to show up and complete each eating moment. This approach is a temporary phase as we prioritize renourishing and medically restabilizing your child/teen.Integration and use of safe foods, as well as challenging to incorporate other high-energy & nutrient dense foods. In early phases of eating disorder treatment, humans are typically underweight, underfed, and undernourished as an effect of their eating disorder. This is when eating disorders are strongest, and do everything they can to ‘stay alive’ and thrive. By disrupting their decision making around food and eating choices, we prevent the child/teen from re-instilling strong disordered eating/eating disorder behaviors and patterns and begin the process of creating new neural-pathways that foster behavior change.
Note: 100% completion of eating moments are required. If the child/teen is unable to complete the eating moment, appropriate liquid supplementation is mandatory to ensure the child/teen is meeting their nutritional needs throughout the day and keeping their weight trajectory goals on track for best treatment and long term recovery outcomes.
Note: Inability or unwillingness of the child/teen to incorporate supplements is often indicative of needing treatment through higher levels of care, above the outpatient level, as it becomes extremely difficult to support a child/teen in meeting their meal plan without having a plan B, especially on the hardest of days. This phase can also be done at higher levels of care first, before moving into phase 2. A higher level of care at any movement in recovery does not mean you or the child/teen are failing at recovery. Rather, it means the individual and/or family can deeply benefit from more support than what can be offered in the outpatient setting, and can best support long- term recovery.
Child/Teen Gradually Begins to Practice the Basic Foundations
While parent/caregiver involvement is still the main component of treatment, the child/teen begins to take incremental steps in re-establishing independence in their eating-related responsibilities with continued role modeling, guidance and supervision by the parent/caregiver and treatment team. If needed, continued weight restabilization goals must still continue.
Nutrition psychoeducation and body image counseling are strongest in this phase.
While Family-Based Treatment (FBT) is widely recognized as the gold standard for treating eating disorders in children and teens—supported by extensive research—it’s important to understand that it’s not a one-size-fits-all solution. Deciding if FBT is the right fit for your situation is a key step, and one that your treatment team can help guide you through.
At Side By Side Nutrition, our experienced dietitians perform comprehensive assessments to develop and adjust individualized plans tailored to each family’s unique needs. We take into account a range of factors, including the type and severity of the eating disorder, family dynamics, and the ability to implement FBT effectively. We also prioritize personal preferences and specific needs throughout the process.
In the next blog post, we’ll discuss the roles of families in eating disorder recovery.