A Nurse Is Assessing a Family's Dynamics During a Counseling Session

Introduction

Restrictive eating disorders (REDs) are a heterogeneous group of potentially severe psychopathological conditions that have shown an increased incidence among young people in recent years, peculiarly in the loftier-risk group of 15- to 19-yr-sometime girls (1–3). REDs are thought to take a multifactorial etiology involving individual vulnerability factors influenced past biological, psychological, environmental, and family-related factors (4–eight).

Among the latter, previous inquiry has highlighted that family relations are frequently dysfunctional in the families of individuals afflicted by REDs (9–11). Cerniglia and his grouping (12), for example, underlined difficulties in respecting interpersonal boundaries, poor tolerance of conflict, and depression satisfaction. Utilise of the clinical version of the Lausanne Trilogue Play (LTPc) (13)—a semi-structured method for observing family dynamics—may help to identify specific characteristics of a family's triadic interactions that may be linked to the patient's clinical condition. Previous LTPc studies accept in fact highlighted dysfunctional interaction patterns in the families of individuals with REDs (14–16). For case, fathers were found to experience specific difficulties in maintaining a scaffolding part in relation to their daughters' development, and in providing them with back up and guidance (xiv, 15, 17). This is line with current literature (18, nineteen) showing that fathers tend to disengage from caregiving. Accordingly, it has been suggested that greater affective engagement and participation in the healthcare procedure on the part of fathers should be encouraged (xx, 21). During the concluding decade, the focus of family unit functioning research in this specific expanse has shifted abroad from the role of family unit-related factors in maintaining REDs to enhancement of protective family factors that may improve interventions (22). In these families, parents oft tend to adapt their ain lives to the Crimson symptoms of their daughters; for case, they may accept repast rituals in society to avoid conflicts (23). Not surprisingly, therefore date of the whole family in the adolescent'southward treatment and care procedure is now recognized as a key prognostic factor (4, vii, 17, 24–29).

Family-centered approaches [eastward.g., family-based therapy (FBT)] (xxx, 31) are amongst the most effective (type I evidence) interventions for the psychiatric care of patients with REDs (20, 32); in particular, they are considered the showtime-line treatment for severe cases in boyhood (25, 33, 34). Recently, FBT has likewise been establish to exist effective in the treatment of avoidant/restrictive food intake disorder (ARFID) (35). Nonetheless, the efficacy may be partial when family members are not properly engaged in the treatment and care process (26, 27), and a significant number of patients may non reply well to FBT. Another family therapy approach that has shown good evidence of effectiveness is the psychodynamic model based specifically on intrafamily relationships developed by the French group at the Montsouris Establish in Paris (18). This model focuses more on psychological bug than on eating beliefs symptoms. It has been shown to be effective in reducing feeding symptoms and improving general psychopathological operation, as measured by the Morgan–Russell Result Assessment Schedule (MROAS) (36) adapted for boyish patients (37). These results suggest that improving family functioning may be an intermediate goal, important in promoting better clinical outcomes in the adolescent herself (17, 38, 39). Individual approaches, such as adolescent-focused therapy (40), tin also be effective when patients are afflicted by more severe psychopathological conditions and when their autonomy is severely compromised. Reinstating adaptive psychological development trajectories should be considered a pivotal aim to target inside the recovery process (39, 41). However, when family relationships are highly dysfunctional, individual psychotherapy tin can achieve only partial results; dysfunctional parenting may negatively impact the handling and care procedure of adolescents with REDs, and may represent a pregnant obstruction to the effectiveness of private psychotherapy (xviii, 41).

On the basis of these premises, and with a view to identifying a suitable treatment for patients with severe REDs, a multidisciplinary family therapy approach integrating the models by Godart et al. (eighteen) and Fitzpatrick et al. (40) was developed at two university tertiary care services in Italy. The treatment program we developed combines principles from diverse models of intervention (i.e., psychodynamic psychotherapy, parental role intervention, and triadic or family-centered interventions). We also provided nutritional counseling and neuropsychiatric monitoring of the overall procedure, including the effects of any pharmacological therapy. The aim of the nowadays written report was to await for pregnant pre-post differences in family unit functioning in the families of adolescent patients with severe REDs who underwent a 6-month (± two) multidisciplinary treatment program. Family functioning was assessed before and after the handling using the LTPc procedure (13). Greater understanding of how family functioning may improve subsequently a relatively brief multidisciplinary family treatment plan may further inform constructive interventions for these patients and their families. LTPc score changes are related to changes in family members' abilities to get involved in the game, to adhere to their assigned role in the different phases of it (and therefore, when necessary, to stand back), and to back up others' ideas. Score changes may also be linked to greater emotional participation and substitution, too as improved gaze triangulation.

Materials and Methods

Population

Sixty-vii families of adolescent patients diagnosed with REDs were assessed for eligibility between July 2017 and October 2020 at the Kid Neurology and Psychiatry Unit of measurement of the IRCCS Mondino Foundation (Pavia, Italy) and at the Child and Adolescent Neuropsychiatry Unit of the Bambino Gesù Children's Infirmary (Rome, Italy). Patients were considered eligible for the study if they were 11–xviii years old and if they had a diagnosis of Cherry (including restrictive and binge-eating/purging subtypes of anorexia nervosa, ARFID, singular anorexia nervosa, other specified feeding or eating disorders with restrictive characteristics). Diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria (42). Patients were excluded from the study if they presented at least 1 of the following: psychotic disorders, intellectual inability, neurological disorders (e.chiliad., epilepsy), or other psychiatric comorbidities with an organic substrate (e.g., celiac disease, Wilson's disease). Unmarried-parent families and individuals partially unable to sympathise Italian were too considered ineligible. Finally, to avoid interrupting or modifying ongoing therapies, nosotros also excluded patients who were already receiving psychotherapy at a secondary-level service. The study was approved by the Ethics Committee of the Policlinico San Matteo in Pavia, Italia (P-20170016006). All the enrolled patients and their parents provided written informed consent to participate in the study. Figure 1 illustrates the flow nautical chart of the participant option procedure.

Figure one. Period chart of the study population.

Procedures

The patients were interviewed by a trained child neuropsychiatrist, who nerveless clinical and socio-demographic information. To ostend the RED diagnosis and verify the presence of any comorbidities, the semi-structured DSM-based Yard-SADS interview (43) was administered to the patients and their parents. Furthermore, the absence of intellectual disabilities was verified through administration of the age-appropriate Wechsler intelligence scale: WISC-IV (44) or WAIS-IV (45). To evaluate family functioning, the LTPc process (13) was used twice, before (T₀) and after the handling (T₁). Every LTPc session, performed in a dedicated room, was videotaped and subsequently coded independently past two raters, who had first received specific preparation.

Treatment

The treatment lasted half dozen (±2) months and involved a multidisciplinary squad (Effigy ii), as the main international guidelines suggest that the care of patients afflicted past REDs should be entrusted to a squad of medical, social, and rehabilitation healthcare professionals (24, 46).

Effigy 2. Overview of the multi-disciplinary intervention.

Our multidisciplinary squad comprised an practiced neuropsychiatrist, a neuropsychiatry resident, psychotherapists, a psychiatric rehabilitation specialist, an educator, and a nurse.

The integrated handling model (see Supplementary Material) consisted of at least 24 sessions of psychodynamic psychotherapy for the adolescent patient, scheduled once a week and conducted in an private or grouping setting (xl, 47, 48), at least 12 parental role intervention sessions (49, fifty), and at least 12 treatment sessions focusing on triadic or family interaction. The parental role sessions took place every other week, alternating with the triadic or family interventions. The first session with the parents e'er involved the utilize of video feedback, which allows parents to work directly on their own limits and resources, favors the evolution of the ability to reflect on the relationship (mentalization), and significantly improves the therapeutic alliance (51–53).

Finally, nutritional counseling was provided, besides as neuropsychiatric monitoring of the progress of the handling, to allow introduction or adjustment of pharmacological therapy as needed, as in the case of comorbid depressive or broken-hearted symptoms. Further details on the intervention are reported in Supplementary Textile.

The LTPc: Procedure and Coding

The LTPc is a standardized and well-validated observation-based method used in clinical and research settings to appraise dysfunctional patterns in triadic or family interactions (13). The procedure requires parents and daughter to pretend that they are planning a weekend where the adolescent daughter stays abode alone. The pretend play is divided into four phases. In phase 1, the mother interacts with the patient while the father assumes the part of observer. In phase two, the father plans the activity with the patient while the mother observes. In stage three, all the family members interact with each other. Finally, in phase 4, the parents talk together, while the boyish assumes the role of observer. The unabridged process is videotaped and lasts ~15 min.

The LTPc coding system used in this study has been explained in previous publications (14, 52, 54, 55). Essentially, information technology considers four aspects of interaction (i.e., participation, organisation, focal attention, melancholia contact), which are rated, in each stage, on a iii-indicate Likert scale (0 = dysfunctional; 1 = partially functional; 2 = functional). On this ground, descriptions of each family member'south interactive contribution and of the overall family functioning are obtained. The total family unit score, which identifies i of four types of family brotherhood, is the sum of the scores recorded by each family member in each stage (13).

Statistical Analyses

The statistical analyses were conducted using IBM SPSS Version 21 for Windows. Descriptive statistics were calculated for each variable. To test for stability, we adopted the hateful-level alter method (56) and rank-guild consistency method (57). To assess mean differences in LTPc scores, divide paired sample t-tests were computed for each LTPc phase (1, female parent-daughter; 2, father-daughter; 3, triadic interaction; 4, parental pair).

Results

Tabular array 1 reports the descriptive statistics for this sample. Xviii 11- to 17-year-old girls (Thou = 14.64 years, SD = 1.47) who were existence cared for in day-infirmary settings participated in the study with their parents. Eleven girls came from the Child Neurology and Psychiatry Unit of the IRCCS Mondino Foundation in Pavia (61.11%) and seven from the Child and Boyish Neuropsychiatry Unit of the Bambino Gesù Children'due south Hospital in Rome (38.89%). Two of the 18 pairs of parents were divorced (xi.10%). The boilerplate duration of symptoms prior to clinical referral was 13.32 months (SD = eleven.33). The severity of the patients' clinical atmospheric condition was assessed using the MROAS and coded as: 0 = good event, 1 = intermediate issue, and 2 = poor upshot. These outcomes were distributed every bit follows: 25.4% good, 44.1% intermediate, and xxx.v% poor. At baseline (T₀), the boilerplate percentage of weight loss reported by the patients was 22.02% (SD = 11.xv), and their average BMI was 13.1 kg/m² (SD = 18.74) (range: 11.91–32.eleven kg/m²). The median pre-handling percentile BMI was i.2. Within the sample, 28 of 67 patients were using medications before T₀ (i.e., 6.9% were taking antipsychotics, 58.6% antidepressants, 6.9% benzodiazepines, and 27.6% a combination of antipsychotics and antidepressants). The total family unit score in phase 2 (male parent–girl) showed a statistically significant positive change from T₀ to T₁ (see Table 2). No significant differences emerged for the other LTPc phases.

Table 1. Descriptive statistics: patients' baseline diagnoses and therapies both before and during the multidisciplinary treatment programme.

Table two. Descriptive statistics for the LTPc phases and mean comparisons.

Discussion

The aim of the present study was to assess post-treatment changes in family unit performance among families of adolescents with astringent REDs who underwent a multidisciplinary vi-calendar month handling program. We observed a significant change in the family functioning score for the LTPc stage two, in which the father interacts with his girl while the mother acts equally a silent observer. This suggests that the fathers, when playing an active role, could improve dyadic family functioning. This finding is consistent with the thought, emerging from previous pioneering studies, that encouraging paternal interest tin can improve patient outcomes (20, 21). In the families of girls affected by REDs, fathers tend to be disengaged from the caregiving office. Although this may be merely a defensive reaction to their daughter's illness, information technology can pb to a less affective bond and influence the quality of family interactions and the patient's outcome (xv, 58). Information technology tin be speculated that the treatment model hither proposed had more effect on the fathers than on the other members of the triad. In line with the current literature (59, 60), the results of our study therefore support the clinical indication of promoting melancholia engagement and participation of all family unit members, including fathers, in the care of adolescent patients, especially those with REDs (xviii, 19). A growing body of literature indeed suggests that therapeutic approaches to severe REDs in adolescence should include the promotion of paternal—and non simply maternal—participation (20, 21, 61), in order to raise the parents' alliance and better the quality of triadic interactions. Paternal interest and warmth take been shown to be primal for patient outcomes, and fathers who tend to depict back and remain emotionally and concretely discrete need to be encouraged and supported (18, 20, 21, 62).

We did not find a similar alter in maternal interactive beliefs afterwards the treatment. As others take pointed out (63–65), mothers are usually more involved in their daughters' afflictions. It is likely that a more prolonged family unit handling would exist needed in lodge to change dysfunctional interactive patterns in mothers. However, information technology can as well exist speculated that when fathers evidence able to play a more agile office, this may be due in office to mothers managing to requite them more than space (15).

Nosotros also institute no post-treatment modify in the performance of the parental pair. This is in line with the fact that our treatment model, based on a psycho-pedagogical approach, was designed to strengthen the parental function rather than accost relational dynamics (such as conflict and conflict management) betwixt the parents themselves (66). Consequently, we were not surprised that the functioning of the parental pair remained unchanged afterward the handling.

Finally, the treatment was non found to change triadic operation. We tin can assume that a 6-calendar month handling is not long enough to modify interactions at the triadic level.

The lack of impact of the treatment on triadic functioning could too exist explained by the fact that dyadic relations were highly impaired in our sample of adolescents; these were indeed patients whose psychopathological weather were astringent plenty to warrant intervention past tertiary-level services.

This study has some limitations. Offset, the relatively small sample size (due to the demand to include merely triads with consummate data and to the exclusion of patients already receiving psychotherapy) limits the generalizability of the findings. Time to come research in larger samples is needed. 2d, nosotros focused on REDs because the families of patients affected past these weather condition frequently testify dysfunctional family relations (15, 67). Time to come studies should investigate whether our results extend to other eating disorders. Finally, in line with the descriptive aim of this written report, no command groups were included. Hereafter research is warranted to address the relative effect of this multidisciplinary treatment plan compared with care every bit usual and with other family unit- or patient-centered interventions.

Conclusions

Since the psychopathological organisation underlying REDs can vary, the therapeutic arroyo should exist tailored to the specific features of the single patient. In item, in the almost severe cases, particular attention should be paid to parental (dyadic) and triadic or family interactions, but psychotherapy for patients only (individual or group) may also exist very useful. We strongly suggest that a flexible therapeutic approach allowing integrated interventions (psychodynamic psychotherapy for patients, back up for the parental part, and triadic or family intervention) might better meet the needs of the almost dumb patients referred to third intendance services. The LTPc may assistance clinicians to improve their agreement of dysfunctional family interactions and even uncover potential protective factors that might exist further exploited to enhance the efficacy of the family unit intervention in Ruby-red patients (fifteen). In addition, performing the LTPc subsequently the handling may help the clinical decision-making procedure. For example, its findings may support the decision to continue with the current treatment or let the treatment to be tailored to the needs of the family, perhaps suggesting a less-intensive program of treatment in order to obtain a better balance of family psychological and economical resources.

Data Availability Statement

The raw data supporting the conclusions of this commodity will be fabricated available upon reasonable requests to the respective author.

Ideals Statement

The present report was reviewed and canonical by Ethics Committee of the Policlinico San Matteo in Pavia, Italy (P-20170016006). Written informed consent to participate in this study was provided by the participants' legal guardian/adjacent of kin.

Writer Contributions

MM designed the written report. MO, CR, MCr, MCC, and VZ collected data. LP conducted statistical analyses. MCh and RB provided scientific supervision. All authors contributed to the drafting of the manuscript and agreed on the final version to be submitted for publication.

Funding

This study was supported by Italian Ministry building of Health (Ricerca Corrente 2020).

Conflict of Interest

The authors declare that the research was conducted in the absence of whatsoever commercial or financial relationships that could exist construed as a potential conflict of interest.

Acknowledgments

Authors are thankful to the colleagues of the Child Neurology and Psychiatry Unit and to the patients and their parents who took part in this written report.

Mondino Foundation Eating Disorders Clinical and Research Group

Luca Capone, Chiara Coci, Elisabetta Zerbi, Alice Busca, Maria Sabella, Lucia Racioppi.

Supplementary Fabric

The Supplementary Textile for this commodity tin be plant online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.653047/full#supplementary-material

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