Anorexia nervosa is a serious mental disorder with a lifetime prevalence of approximately 2% in females and 0.16-0.3% in males. Research on the effectiveness and practice of family treatment of anorexia nervosa in adolescents has continued over the past 40 years, and research evidence of effective treatment continues to emerge. Dr. Blessitt of Moseley Hospital, London, UK, reviewed the literature on the use of (multiple) family treatments for anorexia nervosa in adolescents over the past 12 months and summarizes the latest findings and perspectives in the November 2015 issue of Current Opinion Psychiatry. Family therapy-anorexia nervosa (FT-AN) is also known as family-based treatment (FBT) or Maudsley family therapy (MFT). As the subject of numerous empirical studies, the most recent evidence suggests that approximately 50-85% of adolescents treated with FT-AN achieve good regression within 12 months.The early stages of FT-AN treatment focus on supporting parents in guiding their children to manage their eating, and then once eating and weight have stabilized, the focus shifts to dealing with the factors that perpetuate the condition by interfering with the normal growth of the adolescent and working towards achieving the family’s daily living style goals. The goal is to achieve the family’s daily lifestyle. Key Points 1, Systematic family treatment of adolescent anorexia nervosa results in good levels of recovery, although the specific mechanisms by which this treatment is effective remain unclear. 2. In FT-AN, family meal intervention, treatment coordination, and family functioning are some of the elements that deserve in-depth study of their importance. 3. Recent studies have shown high acceptance of multifamily treatment and significant improvements in participants’ weight, symptoms, and family health. 4. Multidisciplinary collaboration in FT-AN can be challenging, but is effective in reducing the need for hospitalization, shortening the length of stay, improving symptoms, and achieving high rates of treatment completion. 5. Further well-designed and well-resourced studies are needed. The Role of Eating Disorder Management in the Home Treatment of Anorexia Nervosa in Adolescents Most studies of home treatment for eating disorders have focused specifically on eating disorder management, but it is unclear how this factor determines the effectiveness of home treatment.Goart et al. demonstrated that home treatment is used as a complement to treatment as usual (TAU), focusing on intrafamilial dynamics to enable improvement. . This also questioned whether there was a potential impact of family therapy beyond eating behavior. This issue was explored in a comparative study of two manualized approaches to treating anorexia nervosa in adolescents, including the Family Therapy Manual for Eating Disorders (FT-AN) and Systemic Family Therapy (SyFT). The studies showed that the two treatment responses were very similar, with no statistically significant differences in end-of-treatment remission rates or expected body weight (EBW). Interestingly, overall, the FT-AN group gained weight faster early in the treatment period and had a shorter hospital stay if hospitalization was required, resulting in a significantly lower overall treatment cost than the SyFT group. In addition, exploratory moderator analyses indicated that individuals in the SyFT group with high obsessive-compulsive co-morbidity scores gained more weight than those in the FT-AN group. The authors concluded that although the two treatment manuals were clearly different, the actual treatment differences may be less than expected. As both treatments become widely available and therapists gain experience, it can be expected that families themselves will focus on eating problem management. The Role of Family Meals in the Treatment of Anorexia Nervosa Family meals have a long history of treating anorexia nervosa in adolescents, and they are an important intervention in the second FT-AN diagnostic and treatment process, with a significant impact on early weight gain. As a supportive intervention, family meals can help parents facilitate their children’s eating and develop parenting strengths, and they also provide therapists with the opportunity to learn about family relationships, beliefs, behaviors, and structures. Several recent studies have described the family meal process. Godfrey et al. analyzed records of 30 family meals and showed that 90% of patients were able to eat adequately when their parents either struggled after adamant demands to eat (15/30 families), or agreed to eat without resistance (12/30 families). Furthermore, Godfrey et al. suggest that it is not always appropriate to make adolescents eat more food after they have eaten adequately, but that the focus is on ‘one more bite’, which is the point at which parents feel they are winning the battle against the disease, and at which point adolescent participation can be gradually reduced. The authors propose that family meals be conceptualized as an empowering intervention for parents and an opportunity for family integration that promotes a sense of parental efficacy and caregiving, while creating a family consensus to fight the disease. The authors suggest that the family meal also allows for a broader exploration of: family barriers; what parents can do when the patient is not eating or has an eating disorder; and what families and adolescents are doing well when the patient is eating and what needs to be improved. Therapeutic Fit Therapeutic fit has been a focus of research in the field of family therapy and general psychotherapy, but the authors found that the literature on the treatment of eating disorders consisted of only four studies on therapeutic fit. The research data, although very limited, on the role of therapeutic fit in adolescent anorexia nervosa appear to be consistent with findings outside of eating disorders that adolescent and parent fit scores are not interchangeable and that each of the two scores correlates with different levels of treatment outcome. Parental fit scores were mostly associated with patient persistence in treatment as well as initial behavioral changes (i.e., early weight gain), whereas adolescent scores were more predictive of physiological variables and changes in long-term outcomes, such as post-treatment weight gain. The role of treatment fit in the treatment of adolescent anorexia nervosa was explored in a study by Forsberg et al. They concluded that the complexity of the study included the difficulty of controlling for symptom change interacting with the formation of a treatment fit. The study measured fit at the fourth clinic visit, but since almost a quarter of the patients were in remission by then (>95% desired weight). That is, estimates of the impact of treatment fit were highly conservative, and thus the study did not find that parental fit was associated with complete remission at the end of treatment.Forsberg et al. also list elements for further study, including family member fit, exploring “consensus of purpose” in patient, parent, and therapist fit, and focusing on clarifying the relationship and dynamics of symptomatic change and early treatment fit. Family functioning and treatment regression The focus of research on the assessment of family functioning in adolescents with anorexia nervosa has shifted from the role of disease formation to the potential role of regulating treatment regression, as reported by Ciao et al. who reported on changes in family functioning in a randomized controlled trial (RCT) using the McMaster Family Functioning Rating Scale (FFRS). Ciao et al. reported changes in family functioning in a randomized controlled trial (RCT) that used the McMaster Family Assessment Device (FAD) to compare FT-AN and adolescent-focused treatment from the perspectives of different family members at baseline and at the end of treatment. While family functioning was less impaired at baseline and relatively unchanged overall after treatment, two subscales (Communication and Behavioral Control) showed bidirectional therapeutic effects, i.e., improvement with FT-AN treatment but partial exacerbation with individual treatment. Thus, the authors concluded that there is a need to explore in depth the effect of treatment on family functioning and the role of family functioning on the treatment and recovery process. Recently, there have been several studies in the literature reporting favorable outcomes of MFT in the treatment of anorexia nervosa in adolescents.Gabel et al. in a retrospective cohort study compared 25 adolescent cases who received MFT and TAU with matched cases who received only TAU and found that there was a greater increase in weight gain in the MFT group.Marzola et al. followed 54 adolescents who received the MFT intervention for 30 months and showed that the remission rate (>1%) was higher than the remission rate (>1%). Marzola et al. followed 54 adolescents who received MFT intervention for 30 months and showed a remission rate (>95% EBW) of 59.3% and a partial remission rate (>85% EBW) of 27.7%. Two other case-series studies showed high family acceptance of MFT-AN, treatment completion of more than 90%, significant improvements in weight and other symptoms, improved patient affect and better family relationships. A small qualitative study also suggested increased parental empathy, self-efficacy and hope, increased patient introspection, and increased motivation for early treatment. Advances in FT-AN for the treatment of anorexia nervosa in adolescents Research interest in FT-AN for the treatment of anorexia nervosa in adolescents by multidisciplinary teams of specialists is growing, and Hughes et al. found that the advantages of FT-AN included a significant reduction in the need for hospitalization, a shorter hospital stay, an improvement in the patient’s weight, and a high rate of completion of treatment. Of course many challenges exist including professional role transitions, preconceived dilemmas, and team members’ apprehension of the model. Team training and supervision, team meetings, and open dialog about issues can increase a specialist’s confidence in delivering FT-AN therapy.Hughes et al. suggest that a multidisciplinary approach increases team communication and reduces isolation. Formal meetings and supervision are necessary to promote the support, development, and adherence model, and training ensures treatment credibility. Although family therapy for adolescent anorexia nervosa is now recognized as an effective treatment, in looking forward the authors note that future research needs to explore the specific dimensions of improvement with family therapy, identifying the potential best-responding populations and the extent to which patients benefit from this treatment. Well-designed studies with appropriate tests of efficacy and comparisons of home treatment with other treatments are also needed in the future.