Michele G. Sullivan

NEW ORLEANS – Female victims of sexual and physical assault show a high rate of postassault alcohol abuse, which is associated with a more severe course of posttraumatic stress disorder.

Compared with nondrinking women, those with alcohol use disorders (AUD) were significantly more likely to have severe PTSD symptoms, especially intrusion symptoms. Even past alcohol users showed more severe symptoms than did nonusers, Debra Kaysen, Ph.D., said at the annual meeting of the Association for the Advancement of Behavioral Therapy.

Her findings suggest that all assault victims should be carefully screened for both past and present AUD.

“My experience is that this is not necessarily done in all cases,” said Dr. Kaysen, of the University of Washington, Seattle. “It's not enough just to ask about current use, because past use is apparently also a risk factor.”

Dr. Kaysen saw 189 women within 2 weeks of either a sexual or physical assault, and 66% (124) of them returned for a 3-month follow-up. The women were young (mean 31 years), and most were black, single, and poor, with 50% making less than $5,000 a year. The women were recruited through local emergency departments, police departments, and community victim services agencies.

Alcohol use and abuse were assessed with the Structured Clinical Interview for DSM-III-R, and PTSD was assessed with the Clinician-Administered PTSD Scale (CAPS)

No symptoms of PTSD were present in 22% of the group. Thirty-five percent of the group showed acute PTSD symptoms 2 weeks after the assault but not at follow-up. Thirty-eight percent showed a chronic course; they were symptomatic at both 2 weeks and 3 months. Delayed onset occurred in 5% of the women; they showed no symptoms at 2 weeks but were symptomatic by the 3-month follow-up.

Most of the women (71%) had no AUD, either current or past. A past history but no acute drinking was found in 17%. Acute AUD occurred in 3%. These women, previously nondrinkers, began drinking at 2 weeks but had stopped by 3 months. Two percent of the group experienced a delayed onset of AUD, 4% had quit drinking in the past but experienced a relapse after the assault, and 2% had a chronic course of AUD.

At the initial visit, women with AUD had the most severe intrusive symptoms–indicated by an average CAPS score of about 26. Women with a past history had a CAPS score of about 22, whereas nondrinkers had a score of about 18.

Symptoms improved at almost the same rate in all of the women over the study period. By 3 months, however, women with current AUD still had more severe intrusive symptoms (CAPS score of 18) than those with a past history of AUD (CAPS score of 15) and those without AUD (CAPS score of 12).

“The women who were drinking got better but never made up the ground they had lost at the very beginning,” Dr. Kaysen said.

She saw a trend toward even worse results in avoidance symptoms among current drinkers. Their average CAPS score fell from about 27 to only 25 by 3 months, compared with a fall from 29 to 23 for those with a past history. The score for nondrinkers fell from 23 to 15.

Because the number of women with current AUD was small, Dr. Kaysen said her results must be interpreted with caution. The combination of PTSD and alcohol use, however, is “clearly potentially devastating” and should spark proactive intervention.

It's important to protect women with acute posttraumatic alcohol use from developing a full-blown alcohol use disorder. “We might think about teaching relapse-prevention skills or using motivational enhancement therapy to prevent the development of alcohol use disorders in those with high-risk drinking” she said.

NEW ORLEANS – Female victims of sexual and physical assault show a high rate of postassault alcohol abuse, which is associated with a more severe course of posttraumatic stress disorder.

Compared with nondrinking women, those with alcohol use disorders (AUD) were significantly more likely to have severe PTSD symptoms, especially intrusion symptoms. Even past alcohol users showed more severe symptoms than did nonusers, Debra Kaysen, Ph.D., said at the annual meeting of the Association for the Advancement of Behavioral Therapy.

Her findings suggest that all assault victims should be carefully screened for both past and present AUD.

“My experience is that this is not necessarily done in all cases,” said Dr. Kaysen, of the University of Washington, Seattle. “It's not enough just to ask about current use, because past use is apparently also a risk factor.”

Dr. Kaysen saw 189 women within 2 weeks of either a sexual or physical assault, and 66% (124) of them returned for a 3-month follow-up. The women were young (mean 31 years), and most were black, single, and poor, with 50% making less than $5,000 a year. The women were recruited through local emergency departments, police departments, and community victim services agencies.

Alcohol use and abuse were assessed with the Structured Clinical Interview for DSM-III-R, and PTSD was assessed with the Clinician-Administered PTSD Scale (CAPS)

No symptoms of PTSD were present in 22% of the group. Thirty-five percent of the group showed acute PTSD symptoms 2 weeks after the assault but not at follow-up. Thirty-eight percent showed a chronic course; they were symptomatic at both 2 weeks and 3 months. Delayed onset occurred in 5% of the women; they showed no symptoms at 2 weeks but were symptomatic by the 3-month follow-up.

Most of the women (71%) had no AUD, either current or past. A past history but no acute drinking was found in 17%. Acute AUD occurred in 3%. These women, previously nondrinkers, began drinking at 2 weeks but had stopped by 3 months. Two percent of the group experienced a delayed onset of AUD, 4% had quit drinking in the past but experienced a relapse after the assault, and 2% had a chronic course of AUD.

At the initial visit, women with AUD had the most severe intrusive symptoms–indicated by an average CAPS score of about 26. Women with a past history had a CAPS score of about 22, whereas nondrinkers had a score of about 18.

Symptoms improved at almost the same rate in all of the women over the study period. By 3 months, however, women with current AUD still had more severe intrusive symptoms (CAPS score of 18) than those with a past history of AUD (CAPS score of 15) and those without AUD (CAPS score of 12).

“The women who were drinking got better but never made up the ground they had lost at the very beginning,” Dr. Kaysen said.

She saw a trend toward even worse results in avoidance symptoms among current drinkers. Their average CAPS score fell from about 27 to only 25 by 3 months, compared with a fall from 29 to 23 for those with a past history. The score for nondrinkers fell from 23 to 15.

Because the number of women with current AUD was small, Dr. Kaysen said her results must be interpreted with caution. The combination of PTSD and alcohol use, however, is “clearly potentially devastating” and should spark proactive intervention.

It's important to protect women with acute posttraumatic alcohol use from developing a full-blown alcohol use disorder. “We might think about teaching relapse-prevention skills or using motivational enhancement therapy to prevent the development of alcohol use disorders in those with high-risk drinking” she said.

NEW ORLEANS – Female victims of sexual and physical assault show a high rate of postassault alcohol abuse, which is associated with a more severe course of posttraumatic stress disorder.

Compared with nondrinking women, those with alcohol use disorders (AUD) were significantly more likely to have severe PTSD symptoms, especially intrusion symptoms. Even past alcohol users showed more severe symptoms than did nonusers, Debra Kaysen, Ph.D., said at the annual meeting of the Association for the Advancement of Behavioral Therapy.

Her findings suggest that all assault victims should be carefully screened for both past and present AUD.

“My experience is that this is not necessarily done in all cases,” said Dr. Kaysen, of the University of Washington, Seattle. “It's not enough just to ask about current use, because past use is apparently also a risk factor.”

Dr. Kaysen saw 189 women within 2 weeks of either a sexual or physical assault, and 66% (124) of them returned for a 3-month follow-up. The women were young (mean 31 years), and most were black, single, and poor, with 50% making less than $5,000 a year. The women were recruited through local emergency departments, police departments, and community victim services agencies.

Alcohol use and abuse were assessed with the Structured Clinical Interview for DSM-III-R, and PTSD was assessed with the Clinician-Administered PTSD Scale (CAPS)

No symptoms of PTSD were present in 22% of the group. Thirty-five percent of the group showed acute PTSD symptoms 2 weeks after the assault but not at follow-up. Thirty-eight percent showed a chronic course; they were symptomatic at both 2 weeks and 3 months. Delayed onset occurred in 5% of the women; they showed no symptoms at 2 weeks but were symptomatic by the 3-month follow-up.

Most of the women (71%) had no AUD, either current or past. A past history but no acute drinking was found in 17%. Acute AUD occurred in 3%. These women, previously nondrinkers, began drinking at 2 weeks but had stopped by 3 months. Two percent of the group experienced a delayed onset of AUD, 4% had quit drinking in the past but experienced a relapse after the assault, and 2% had a chronic course of AUD.

At the initial visit, women with AUD had the most severe intrusive symptoms–indicated by an average CAPS score of about 26. Women with a past history had a CAPS score of about 22, whereas nondrinkers had a score of about 18.

Symptoms improved at almost the same rate in all of the women over the study period. By 3 months, however, women with current AUD still had more severe intrusive symptoms (CAPS score of 18) than those with a past history of AUD (CAPS score of 15) and those without AUD (CAPS score of 12).

“The women who were drinking got better but never made up the ground they had lost at the very beginning,” Dr. Kaysen said.

She saw a trend toward even worse results in avoidance symptoms among current drinkers. Their average CAPS score fell from about 27 to only 25 by 3 months, compared with a fall from 29 to 23 for those with a past history. The score for nondrinkers fell from 23 to 15.

Because the number of women with current AUD was small, Dr. Kaysen said her results must be interpreted with caution. The combination of PTSD and alcohol use, however, is “clearly potentially devastating” and should spark proactive intervention.

It's important to protect women with acute posttraumatic alcohol use from developing a full-blown alcohol use disorder. “We might think about teaching relapse-prevention skills or using motivational enhancement therapy to prevent the development of alcohol use disorders in those with high-risk drinking” she said.

STOCKHOLM – In Sweden, there is no evidence of an association between suicide and the use of selective serotonin reuptake inhibitors among children or adolescents; instead, these drugs appear to be associated with a decreased risk of suicide in the general population.

About 95% of suicides in Sweden are investigated in a process that includes a forensic toxicology screen, and antidepressants are among the drugs identified, Göran Isacsson, M.D., said at the annual congress of the European College of Neuropsychopharmacology.

Dr. Isacsson compared the toxicologic results from 14,857 suicides that occurred from 1992 to 2000 with those of 26,422 natural or accidental deaths during the same period.

His analysis indicated a decreased association with suicide for three serotonin reuptake inhibitors (SSRIs): fluoxetine (relative risk of 0.91), paroxetine (RR 0.87), and citalopram (RR 0.76). Sertraline showed a slightly increased association with suicide (RR 1.05), while fluvoxamine showed a significantly increased association (RR 3.04).

“This increased risk can probably be explained by the fact that fluvoxamine was the first SSRI introduced in Sweden and was prescribed for patients who didn't respond to other medications,” Dr. Isacsson suggested.

The association between SSRIs and suicide was even lower among children and adolescents, he said. There were 52 suicides among children up to 15 years old. Of those children, seven were taking antidepressants: five, a tricyclic antidepressant; one, venlafaxine; and one, mianserin. “None of these children were taking an SSRI–the most commonly prescribed antidepressant in this age group,” Dr. Isacsson said. There were 356 suicides among children aged 15-19 years; 13 children had been taking an antidepressant, but only 6 of that group had been taking an SSRI. “That was not significant when compared to the controls,” he said.

STOCKHOLM – In Sweden, there is no evidence of an association between suicide and the use of selective serotonin reuptake inhibitors among children or adolescents; instead, these drugs appear to be associated with a decreased risk of suicide in the general population.

About 95% of suicides in Sweden are investigated in a process that includes a forensic toxicology screen, and antidepressants are among the drugs identified, Göran Isacsson, M.D., said at the annual congress of the European College of Neuropsychopharmacology.

Dr. Isacsson compared the toxicologic results from 14,857 suicides that occurred from 1992 to 2000 with those of 26,422 natural or accidental deaths during the same period.

His analysis indicated a decreased association with suicide for three serotonin reuptake inhibitors (SSRIs): fluoxetine (relative risk of 0.91), paroxetine (RR 0.87), and citalopram (RR 0.76). Sertraline showed a slightly increased association with suicide (RR 1.05), while fluvoxamine showed a significantly increased association (RR 3.04).

“This increased risk can probably be explained by the fact that fluvoxamine was the first SSRI introduced in Sweden and was prescribed for patients who didn't respond to other medications,” Dr. Isacsson suggested.

The association between SSRIs and suicide was even lower among children and adolescents, he said. There were 52 suicides among children up to 15 years old. Of those children, seven were taking antidepressants: five, a tricyclic antidepressant; one, venlafaxine; and one, mianserin. “None of these children were taking an SSRI–the most commonly prescribed antidepressant in this age group,” Dr. Isacsson said. There were 356 suicides among children aged 15-19 years; 13 children had been taking an antidepressant, but only 6 of that group had been taking an SSRI. “That was not significant when compared to the controls,” he said.

STOCKHOLM – In Sweden, there is no evidence of an association between suicide and the use of selective serotonin reuptake inhibitors among children or adolescents; instead, these drugs appear to be associated with a decreased risk of suicide in the general population.

About 95% of suicides in Sweden are investigated in a process that includes a forensic toxicology screen, and antidepressants are among the drugs identified, Göran Isacsson, M.D., said at the annual congress of the European College of Neuropsychopharmacology.

Dr. Isacsson compared the toxicologic results from 14,857 suicides that occurred from 1992 to 2000 with those of 26,422 natural or accidental deaths during the same period.

His analysis indicated a decreased association with suicide for three serotonin reuptake inhibitors (SSRIs): fluoxetine (relative risk of 0.91), paroxetine (RR 0.87), and citalopram (RR 0.76). Sertraline showed a slightly increased association with suicide (RR 1.05), while fluvoxamine showed a significantly increased association (RR 3.04).

“This increased risk can probably be explained by the fact that fluvoxamine was the first SSRI introduced in Sweden and was prescribed for patients who didn't respond to other medications,” Dr. Isacsson suggested.

The association between SSRIs and suicide was even lower among children and adolescents, he said. There were 52 suicides among children up to 15 years old. Of those children, seven were taking antidepressants: five, a tricyclic antidepressant; one, venlafaxine; and one, mianserin. “None of these children were taking an SSRI–the most commonly prescribed antidepressant in this age group,” Dr. Isacsson said. There were 356 suicides among children aged 15-19 years; 13 children had been taking an antidepressant, but only 6 of that group had been taking an SSRI. “That was not significant when compared to the controls,” he said.

A new group skills-training program is exploring the vital role of parents as part of the treatment team for adolescents with eating disorders.

“Most families have neither the skills nor the support to address eating disorders at home,” said Nancy Zucker, Ph.D., director of the eating disorders program at Duke University, Durham, N.C.

“Parents don't have the skills to reinforce behaviors consistently at each and every meal, and they don't have a lot of information, even on parenting in general, or a forum to talk about what is happening to them and their children,” she said.

The need for a skills-building program has become even more apparent as reimbursement issues interfere with inpatient treatment for these adolescents. “Parents are now getting their children back at lower and lower weights, and the only validated treatment is renourishment,” she noted. But even after initial treatment, the task of renourishment is not an easy one for families.

Given the amount of eating necessary and the conflict they can arouse, it became increasingly obvious that families needed to be more involved in the child's recovery and “that parents needed a lot more support and guidance than they could get in a 1-hour therapy visit,” Dr. Zucker said.

Three years ago, she began meeting with some of her patients' parents in a structured, weekly group. The format was based on other successful parent-training models, such as those used with attention-deficit hyperactivity disorder, in which skills are taught in an atmosphere of support and accountability.

“We try to engage in a process-focused, rather than outcome-focused approach,” said Dr. Zucker, who directs the group. “It is without bias or judgment. That's the philosophy that underpins everything we do.”

Although there are dozens of support groups for parents whose children have eating disorders, Dr. Zucker's is one of the few with a set agenda of developing specific parenting skills aimed at helping modify eating behavior. “We teach what we call an 'off-the-cuff' approach to managing the behaviors of eating disorders,” she said.

Parents are asked not to enter into conflict with the child regarding eating, she explained: “These disorders are a metaphor for the child's emotional state. When they are at the peak of their anger, they can't hear anything. The parent needs to stay calm. Ninety-nine percent of the time, when they don't engage at the top of that emotional wave, the kids will come down, and the power struggle resolves.”

Parents in the group address three barriers that potentiate mealtime conflict: negative perfectionism, expressed negative emotion, and poor self-efficacy. Parents target negative perfectionism within themselves and learn how to create a home environment that doesn't foster that in them or in their children. They also work diligently on emotional regulation, learning to avoid the negative verbal communication that makes working with their children even more difficult.

Each session includes a three-part homework assignment. “They're assigned an eating disorder behavior to target, an adaptive skill in the child that they work on increasing by modeling a positive coping strategy, and a self-care assignment,” Dr. Zucker said. Parents are expected to present the results of that homework during the next group session, where they receive praise and advice from Dr. Zucker and their peers. Unconditional support is key. “It's a no-criticism environment, because our philosophy is, there are no mistakes.”

The group provides a critical stress-relief valve for parents up against a frightening and frustrating disorder, but the assignments aimed at improving parents' skills and their own sense of self-worth aren't easy, said Patty Hernandez, a group member.

Ms. Hernandez's 15-year-old daughter was diagnosed with anorexia nervosa after her weight dropped from 116 to 82 pounds in a 4-month period. The girl's primary care physician failed to recognize the problem, but her mother knew the signs all too well. “I'm anorexic, so I could see very early what was going on,” she said. “First, I saw her dropping out the after-school snacks that she really loved, and then one day I saw a piece of paper where she'd written, 'Nothing tastes as good as being thin.'”

After an unsuccessful hospitalization in a psychiatric ward and a protracted battle with an insurance company, Ms. Hernandez's daughter entered the Duke eating disorders program, and Ms. Hernandez and her husband entered the parent group. “It has been a savior for us,” she said. “It's so invaluable to listen to other parents every week going through the same thing and realize that you're not the only one, you're not crazy, you're not horrible parents,” she said.

Still, being in the group isn't easy, she said. Her own eating issues “became very loud” when she saw her daughter refusing to eat. “It's incredibly hard to remember that I have to take care of myself by getting my three meals and snacks in every day, in order to set a good example for my child.”

Mrs. Hernandez isn't alone in expressing her positive experiences with the group. Dr. Zucker recently presented the results of the first of several studies on the group skills-training model. Fourteen caregivers and 10 adolescents were interviewed before and after the parents' 4 months of group work

Among the patients, weight concern scores fell from 3.16 to 1.40, shape concern scores fell from 3.48 to 2.03, and restraint scores fell from 2.88 to 1.20. The patients' body mass indexes increased a mean of 2 kg/m2, from 16.72 kg/m2 to 18.62 kg/m2.

Among the parents, 91% strongly agreed that the group was essential for their children's improvement and 82% strongly agreed that their children would not be doing as well if they had not participated in the group.

Last spring, Dr. Zucker received a $10,000 grant from the National Eating Disorders Association (NEDA) for further research into the group model. Her ongoing studies compare the skills-training model to a parent education-only model, and she is investigating different methods of delivering the group content, perhaps via a Web-based program.

Dr. Zucker is now analyzing preliminary data from these studies, and the results will provide a key insight into the usefulness of her model in other practices, said James Mitchell, M.D., professor and chair of the department of neuroscience at the University of North Dakota and chairman of the NEDA grant awards committee that evaluated Dr. Zucker's program.

Sometimes, he said, group therapy models accomplish wonderful results under the hand of a particularly enthusiastic and inspiring leader, but those results are not reproducible with a different leader. “Like everything else, initial results can look very good at the first pass, but sometimes don't stand up under scrutiny,” he said. “She needs to show that her results are due to the model itself and that others can use it just as well. Those questions need to be answered. But it looks like it has a lot of promise.”

The parent group model is just one facet of a comprehensive eating disorders treatment program that could include psychiatrists and other M.Ds., psychologists, dietitians, and exercise physiologists committed to working with both patient and family, Dr. Mitchell noted. “Research shows quite clearly that you have a better success rate if you involve the family of an adolescent. One question, however, is how to involve that family. Should it be included in the treatment as a unit, or should you work with the family separately? Dr. Zucker's program is one that's trying to answer that question.”

Dr. Zucker has applied her model's general tenets to two new pilot eating disorder programs: an intensive weekend parent training group for parents who live out of town and a prevention program aimed at high school freshmen. Presented as part of the school's health curriculum, the program focuses on building good mental health, including healthy attitudes about eating, within the family unit.

“We don't give information about eating disorders,” she said. “The key things we focus on are the importance of quality family interaction during consistent meals, separating the negative aspects of perfectionism from the positive, and taking the shame away from making mistakes.”

A new group skills-training program is exploring the vital role of parents as part of the treatment team for adolescents with eating disorders.

“Most families have neither the skills nor the support to address eating disorders at home,” said Nancy Zucker, Ph.D., director of the eating disorders program at Duke University, Durham, N.C.

“Parents don't have the skills to reinforce behaviors consistently at each and every meal, and they don't have a lot of information, even on parenting in general, or a forum to talk about what is happening to them and their children,” she said.

The need for a skills-building program has become even more apparent as reimbursement issues interfere with inpatient treatment for these adolescents. “Parents are now getting their children back at lower and lower weights, and the only validated treatment is renourishment,” she noted. But even after initial treatment, the task of renourishment is not an easy one for families.

Given the amount of eating necessary and the conflict they can arouse, it became increasingly obvious that families needed to be more involved in the child's recovery and “that parents needed a lot more support and guidance than they could get in a 1-hour therapy visit,” Dr. Zucker said.

Three years ago, she began meeting with some of her patients' parents in a structured, weekly group. The format was based on other successful parent-training models, such as those used with attention-deficit hyperactivity disorder, in which skills are taught in an atmosphere of support and accountability.

“We try to engage in a process-focused, rather than outcome-focused approach,” said Dr. Zucker, who directs the group. “It is without bias or judgment. That's the philosophy that underpins everything we do.”

Although there are dozens of support groups for parents whose children have eating disorders, Dr. Zucker's is one of the few with a set agenda of developing specific parenting skills aimed at helping modify eating behavior. “We teach what we call an 'off-the-cuff' approach to managing the behaviors of eating disorders,” she said.

Parents are asked not to enter into conflict with the child regarding eating, she explained: “These disorders are a metaphor for the child's emotional state. When they are at the peak of their anger, they can't hear anything. The parent needs to stay calm. Ninety-nine percent of the time, when they don't engage at the top of that emotional wave, the kids will come down, and the power struggle resolves.”

Parents in the group address three barriers that potentiate mealtime conflict: negative perfectionism, expressed negative emotion, and poor self-efficacy. Parents target negative perfectionism within themselves and learn how to create a home environment that doesn't foster that in them or in their children. They also work diligently on emotional regulation, learning to avoid the negative verbal communication that makes working with their children even more difficult.

Each session includes a three-part homework assignment. “They're assigned an eating disorder behavior to target, an adaptive skill in the child that they work on increasing by modeling a positive coping strategy, and a self-care assignment,” Dr. Zucker said. Parents are expected to present the results of that homework during the next group session, where they receive praise and advice from Dr. Zucker and their peers. Unconditional support is key. “It's a no-criticism environment, because our philosophy is, there are no mistakes.”

The group provides a critical stress-relief valve for parents up against a frightening and frustrating disorder, but the assignments aimed at improving parents' skills and their own sense of self-worth aren't easy, said Patty Hernandez, a group member.

Ms. Hernandez's 15-year-old daughter was diagnosed with anorexia nervosa after her weight dropped from 116 to 82 pounds in a 4-month period. The girl's primary care physician failed to recognize the problem, but her mother knew the signs all too well. “I'm anorexic, so I could see very early what was going on,” she said. “First, I saw her dropping out the after-school snacks that she really loved, and then one day I saw a piece of paper where she'd written, 'Nothing tastes as good as being thin.'”

After an unsuccessful hospitalization in a psychiatric ward and a protracted battle with an insurance company, Ms. Hernandez's daughter entered the Duke eating disorders program, and Ms. Hernandez and her husband entered the parent group. “It has been a savior for us,” she said. “It's so invaluable to listen to other parents every week going through the same thing and realize that you're not the only one, you're not crazy, you're not horrible parents,” she said.

Still, being in the group isn't easy, she said. Her own eating issues “became very loud” when she saw her daughter refusing to eat. “It's incredibly hard to remember that I have to take care of myself by getting my three meals and snacks in every day, in order to set a good example for my child.”

Mrs. Hernandez isn't alone in expressing her positive experiences with the group. Dr. Zucker recently presented the results of the first of several studies on the group skills-training model. Fourteen caregivers and 10 adolescents were interviewed before and after the parents' 4 months of group work

Among the patients, weight concern scores fell from 3.16 to 1.40, shape concern scores fell from 3.48 to 2.03, and restraint scores fell from 2.88 to 1.20. The patients' body mass indexes increased a mean of 2 kg/m2, from 16.72 kg/m2 to 18.62 kg/m2.

Among the parents, 91% strongly agreed that the group was essential for their children's improvement and 82% strongly agreed that their children would not be doing as well if they had not participated in the group.

Last spring, Dr. Zucker received a $10,000 grant from the National Eating Disorders Association (NEDA) for further research into the group model. Her ongoing studies compare the skills-training model to a parent education-only model, and she is investigating different methods of delivering the group content, perhaps via a Web-based program.

Dr. Zucker is now analyzing preliminary data from these studies, and the results will provide a key insight into the usefulness of her model in other practices, said James Mitchell, M.D., professor and chair of the department of neuroscience at the University of North Dakota and chairman of the NEDA grant awards committee that evaluated Dr. Zucker's program.

Sometimes, he said, group therapy models accomplish wonderful results under the hand of a particularly enthusiastic and inspiring leader, but those results are not reproducible with a different leader. “Like everything else, initial results can look very good at the first pass, but sometimes don't stand up under scrutiny,” he said. “She needs to show that her results are due to the model itself and that others can use it just as well. Those questions need to be answered. But it looks like it has a lot of promise.”

The parent group model is just one facet of a comprehensive eating disorders treatment program that could include psychiatrists and other M.Ds., psychologists, dietitians, and exercise physiologists committed to working with both patient and family, Dr. Mitchell noted. “Research shows quite clearly that you have a better success rate if you involve the family of an adolescent. One question, however, is how to involve that family. Should it be included in the treatment as a unit, or should you work with the family separately? Dr. Zucker's program is one that's trying to answer that question.”

Dr. Zucker has applied her model's general tenets to two new pilot eating disorder programs: an intensive weekend parent training group for parents who live out of town and a prevention program aimed at high school freshmen. Presented as part of the school's health curriculum, the program focuses on building good mental health, including healthy attitudes about eating, within the family unit.

“We don't give information about eating disorders,” she said. “The key things we focus on are the importance of quality family interaction during consistent meals, separating the negative aspects of perfectionism from the positive, and taking the shame away from making mistakes.”

A new group skills-training program is exploring the vital role of parents as part of the treatment team for adolescents with eating disorders.

“Most families have neither the skills nor the support to address eating disorders at home,” said Nancy Zucker, Ph.D., director of the eating disorders program at Duke University, Durham, N.C.

“Parents don't have the skills to reinforce behaviors consistently at each and every meal, and they don't have a lot of information, even on parenting in general, or a forum to talk about what is happening to them and their children,” she said.

The need for a skills-building program has become even more apparent as reimbursement issues interfere with inpatient treatment for these adolescents. “Parents are now getting their children back at lower and lower weights, and the only validated treatment is renourishment,” she noted. But even after initial treatment, the task of renourishment is not an easy one for families.

Given the amount of eating necessary and the conflict they can arouse, it became increasingly obvious that families needed to be more involved in the child's recovery and “that parents needed a lot more support and guidance than they could get in a 1-hour therapy visit,” Dr. Zucker said.

Three years ago, she began meeting with some of her patients' parents in a structured, weekly group. The format was based on other successful parent-training models, such as those used with attention-deficit hyperactivity disorder, in which skills are taught in an atmosphere of support and accountability.

“We try to engage in a process-focused, rather than outcome-focused approach,” said Dr. Zucker, who directs the group. “It is without bias or judgment. That's the philosophy that underpins everything we do.”

Although there are dozens of support groups for parents whose children have eating disorders, Dr. Zucker's is one of the few with a set agenda of developing specific parenting skills aimed at helping modify eating behavior. “We teach what we call an 'off-the-cuff' approach to managing the behaviors of eating disorders,” she said.

Parents are asked not to enter into conflict with the child regarding eating, she explained: “These disorders are a metaphor for the child's emotional state. When they are at the peak of their anger, they can't hear anything. The parent needs to stay calm. Ninety-nine percent of the time, when they don't engage at the top of that emotional wave, the kids will come down, and the power struggle resolves.”

Parents in the group address three barriers that potentiate mealtime conflict: negative perfectionism, expressed negative emotion, and poor self-efficacy. Parents target negative perfectionism within themselves and learn how to create a home environment that doesn't foster that in them or in their children. They also work diligently on emotional regulation, learning to avoid the negative verbal communication that makes working with their children even more difficult.

Each session includes a three-part homework assignment. “They're assigned an eating disorder behavior to target, an adaptive skill in the child that they work on increasing by modeling a positive coping strategy, and a self-care assignment,” Dr. Zucker said. Parents are expected to present the results of that homework during the next group session, where they receive praise and advice from Dr. Zucker and their peers. Unconditional support is key. “It's a no-criticism environment, because our philosophy is, there are no mistakes.”

The group provides a critical stress-relief valve for parents up against a frightening and frustrating disorder, but the assignments aimed at improving parents' skills and their own sense of self-worth aren't easy, said Patty Hernandez, a group member.

Ms. Hernandez's 15-year-old daughter was diagnosed with anorexia nervosa after her weight dropped from 116 to 82 pounds in a 4-month period. The girl's primary care physician failed to recognize the problem, but her mother knew the signs all too well. “I'm anorexic, so I could see very early what was going on,” she said. “First, I saw her dropping out the after-school snacks that she really loved, and then one day I saw a piece of paper where she'd written, 'Nothing tastes as good as being thin.'”

After an unsuccessful hospitalization in a psychiatric ward and a protracted battle with an insurance company, Ms. Hernandez's daughter entered the Duke eating disorders program, and Ms. Hernandez and her husband entered the parent group. “It has been a savior for us,” she said. “It's so invaluable to listen to other parents every week going through the same thing and realize that you're not the only one, you're not crazy, you're not horrible parents,” she said.

Still, being in the group isn't easy, she said. Her own eating issues “became very loud” when she saw her daughter refusing to eat. “It's incredibly hard to remember that I have to take care of myself by getting my three meals and snacks in every day, in order to set a good example for my child.”

Mrs. Hernandez isn't alone in expressing her positive experiences with the group. Dr. Zucker recently presented the results of the first of several studies on the group skills-training model. Fourteen caregivers and 10 adolescents were interviewed before and after the parents' 4 months of group work

Among the patients, weight concern scores fell from 3.16 to 1.40, shape concern scores fell from 3.48 to 2.03, and restraint scores fell from 2.88 to 1.20. The patients' body mass indexes increased a mean of 2 kg/m2, from 16.72 kg/m2 to 18.62 kg/m2.

Among the parents, 91% strongly agreed that the group was essential for their children's improvement and 82% strongly agreed that their children would not be doing as well if they had not participated in the group.

Last spring, Dr. Zucker received a $10,000 grant from the National Eating Disorders Association (NEDA) for further research into the group model. Her ongoing studies compare the skills-training model to a parent education-only model, and she is investigating different methods of delivering the group content, perhaps via a Web-based program.

Dr. Zucker is now analyzing preliminary data from these studies, and the results will provide a key insight into the usefulness of her model in other practices, said James Mitchell, M.D., professor and chair of the department of neuroscience at the University of North Dakota and chairman of the NEDA grant awards committee that evaluated Dr. Zucker's program.

Sometimes, he said, group therapy models accomplish wonderful results under the hand of a particularly enthusiastic and inspiring leader, but those results are not reproducible with a different leader. “Like everything else, initial results can look very good at the first pass, but sometimes don't stand up under scrutiny,” he said. “She needs to show that her results are due to the model itself and that others can use it just as well. Those questions need to be answered. But it looks like it has a lot of promise.”

The parent group model is just one facet of a comprehensive eating disorders treatment program that could include psychiatrists and other M.Ds., psychologists, dietitians, and exercise physiologists committed to working with both patient and family, Dr. Mitchell noted. “Research shows quite clearly that you have a better success rate if you involve the family of an adolescent. One question, however, is how to involve that family. Should it be included in the treatment as a unit, or should you work with the family separately? Dr. Zucker's program is one that's trying to answer that question.”

Dr. Zucker has applied her model's general tenets to two new pilot eating disorder programs: an intensive weekend parent training group for parents who live out of town and a prevention program aimed at high school freshmen. Presented as part of the school's health curriculum, the program focuses on building good mental health, including healthy attitudes about eating, within the family unit.

“We don't give information about eating disorders,” she said. “The key things we focus on are the importance of quality family interaction during consistent meals, separating the negative aspects of perfectionism from the positive, and taking the shame away from making mistakes.”