Table 4 Adaptations in action: Clinician attendance at medical appointments with the family

Kyle was a 14-year-old, multiracial, male-identifying patient with atypical anorexia nervosa who completed a 12-week course of home-based FBT. During the first few sessions, the family described having recently learned about Kyle’s patterns of engaging in compulsive and secretive exercise, which the therapist conceptualized as impeding weight gain and further strengthening Kyle’s eating disorder cognitions. The family was initially hesitant to curtail exercise entirely, as it “helps him cope with negative emotions” and they “don’t want to take away all his coping skills.” Kyle had recently increased his energy intake, which further reinforced the family’s belief that his exercise patterns would not be a significant impediment to future weight gain. His therapist had the opportunity to spend some of their allotted therapy hours attending medical appointments with Kyle and his family. This helped to streamline communication with the outpatient eating disorders clinic where he was being seen for ongoing medical monitoring, and unify the messages conveyed by both the FBT therapist and the medical team. For example, during one medical appointment, Kyle’s physician discussed the impact compulsive exercise behaviors could have on Kyle’s bone density (exacerbated by his already low bone density and increased risk for bone fractures) as well as the worsening of electrolyte imbalances. Kyle’s medical provider supported the therapist’s recommendation of complete exercise cessation until Kyle was able to weight restore enough to support increased movement. Following the medical appointment, the family expressed the belief that addressing certain aspects of Kyle’s exercise behaviors (e.g., no longer allowing Kyle to take the dog for daily walks) would resolve the medical provider’s concerns. The therapist reiterated the messages that the medical provider had communicated as additional evidence that more close monitoring of activity patterns and complete cessation of exercise was necessary. The therapist was also able to help parents identify behaviors that the family had not previously considered problematic, such as excessive movement and standing within the home. After several joint medical appointments and FBT sessions focused on limiting exercise alongside increasing energy intake, the family described feeling disappointed that Kyle had not gained as much weight as they had expected. In between sessions, they independently searched Kyle’s phone and found that he had set a recurring alarm in the middle of the night that he was using to wake up and exercise in his room. They described feeling like a “light bulb had turned on” in considering the covert nature of the eating disorder, and how much of a hold it had on Kyle’s functioning. In response, they placed an air mattress in their room for Kyle to sleep on to monitor his activity at night. They continued to closely monitor and limit his movement until he was consistently gaining weight, at which time they gradually reintroduced low-intensity activity such as resuming dog walks in the evening