Table 1 An overview of the key tenets of family-based treatment and planned adaptations for Medicaid-insured youth and their families

Agnostic view on the potential causes of EDs

No assumptions are made about eating disorder causes. The cause(s) cannot be determined for a particular individual and are not needed to inform steps towards recovery, but rather might detract from the need for urgent action towards swift recovery

Tailoring/tweaking: Additional emphasis on assessing and acknowledging other issues outside the eating disorder to minimize likelihood that the family feels dismissed or misunderstood by the clinician, while emphasizing that most of the critical issues unrelated to the eating disorder cannot be effectively addressed while the patient is malnourished

Increase the acceptability and appropriateness of the intervention at the clinician and patient/family level (enabling greater cultural sensitivity for Latino, Asian, and Black/African American patients/families)

Externalizing the illness

The eating disorder is viewed as having “taken over” the patient around issues related to food/eating, shape/weight, and physical activity, with the patient having little (if any) control over eating disorder-related thoughts, feelings, or behaviors. Externalizing the illness is critical to increase compassion and reduce criticism/blame towards the patient

Tailoring/tweaking: Given potentially less parental supervision and greater expectations for self-sufficiency/independence and greater need for their child to be able to achieve independence faster, training emphasized finding repeated opportunities to externalize the illness. Given varying levels of mental health literacy, medical analogies were emphasized as potentially more relatable and concrete ways to assist with externalization and build compassion for why their child may not want to recover (or why they would struggle to recover without support, even if motivated)

Increase appropriateness of language at the patient/family level due to higher levels of mental health stigma and barriers mental health service engagement, as well as possibly greater parental expectations for children to take responsibility for their own health

Nonauthoritarian therapeutic stance

Therapist serves as a consultant to the family (eating disorders expert) while family is the expert on their child; therapist guides the family through treatment but does not tell them exactly to how support their child to recover (e.g., not providing meal plan or directives on how to manage return to exercise, once medically cleared)

Tailoring/tweaking: Clinicians (given their advanced education and position) may have more difficulty achieving a nonauthoritarian stance with socioeconomically and racially/ethnically diverse families (who face systemic challenges, such as language barriers, racism) than with more privileged families, where the perceived power differential might be smaller. Because families might perceive clinicians as unnecessarily withholding expertise per the manual, this adaptation allowed for offering more concrete guidance and support to caregivers on the treatment process (when needed). The therapeutic stance was maintained by eliciting caregivers’ thoughts about which suggestions might work for their family, if any, and inquiring about other ideas that might work

Increase acceptability and feasibility for clinicians who are used to being more directive; increase acceptability and appropriateness for patients/caregivers who may need and/or want more concrete guidance

Parental empowerment and alignment

Clinicians convey confidence in caregivers' capacity to effectively manage the recovery process (e.g., longstanding knowledge of their child, success in feeding this child or other children previously). Caregivers are not to blame for the disorder and are the most important part of the solution. It is essential that they are aligned so that the eating disorder does not divert their efforts

Tailoring/tweaking: For caregivers who had been separated from their child for a period of time, particularly if only recently reunited, this adaptation proactively advised caution in using caregivers’ history of effective feeding practices with or knowledge of their child (when unhelpful) to empower caregivers. Instead, clinicians could focus on caregiver strengths in navigating other challenges. In addition, clinicians were trained to be more available to support caregivers in navigating systems (medical care, school) and the way in which they could do this to support caregiver empowerment, rather than undermine it. In addition, caregiver roles and cultural beliefs around caregiver responsibilities are more explicitly discussed and addressed to assist with parental alignment

Increase appropriateness and acceptability for patients/families, particularly those who may have experienced extended separations and/or for whom caregiver responsibilities are shared with multiple caregivers. Increase cultural sensitivity and acceptability for caregivers who may experience systemic and linguistic barriers in advocating within health and school systems, or caregivers with highly defined responsibilities/role by gender or other personal characteristic

Pragmatic and exclusive focus on eating disorder symptoms

Early exclusive focus on interrupting eating disorder behaviors for prompt weight restoration and return to physical health, to the exclusion of other problems (e.g., depressed mood, trauma, social withdrawal), the treatment of which is delayed until eating disorder treatment and weight restoration is well underway

Loosening structure: Additional emphasis on assessing and acknowledging other issues outside the eating disorder, in order to ensure that the family does not feel dismissed or misunderstood by the clinician, while emphasizing that most of the critical issues unrelated to the eating disorder cannot be effectively addressed while the patient is malnourished. Additional latitude was given to address other issues that might interfere with parental success in renourishment (e.g., housing, employment, finances, caregiver health), and thoughtfulness around how to address other issues (social work referral if possible, or scheduling additional sessions to assist with other issues)

Increase the acceptability and appropriateness of the intervention at the clinician and patient/family level, given socioeconomic challenges faced by populations with lower incomes and multiple psychosocial stressors, and clinicians’ training in addressing these issues (and their importance for professional satisfaction)