Family-Based Treatment, known widely as FBT, has become the first-line therapy for children and adolescents diagnosed with anorexia nervosa or atypical anorexia nervosa, the latter a condition in which a young person meets all the psychological and behavioural criteria of anorexia without falling below the standard weight threshold. Yet despite its status as the gold standard, remission rates remain stubbornly modest, and a substantial proportion of young patients either do not complete the programme or fail to respond to it. That gap between the best available treatment and the outcomes families actually experience has pushed clinicians around the world to improvise, adjusting the manualised protocol in dozens of different ways. A new systematic review published in the Journal of Eating Disorders has now catalogued those improvisations and, more importantly, assessed how much scientific evidence actually stands behind each one.
The review, led by Alexandra Cussen of the University of Melbourne and Murdoch Children’s Research Institute together with colleagues including Michele Yeo, Janet Conti, Andrew Wallis and Phillipa Hay, followed the PRISMA reporting guidelines and was prospectively registered with PROSPERO. The team searched three major databases, APA PsycINFO, Embase and Web of Knowledge, covering publications from 2005 through to the fourth of August 2025, and supplemented the search with citation tracking. After removing duplicates from 1,794 identified records, the researchers applied strict inclusion criteria: studies in any language that examined adaptations to outpatient, manualised FBT for young people aged eighteen or under with anorexia nervosa or atypical anorexia nervosa. Quality was appraised using the Joanna Briggs Institute critical appraisal tools, a standard framework for judging methodological rigour across diverse study designs.
The final evidence base comprised thirty-one papers, of which twenty-five were primary studies and six were secondary analyses, encompassing a total of 2,332 participants. Within that body of work the reviewers identified twenty-one distinct adaptations to FBT, which they organised into three broad categories. The first, add-ons, involved bolting supplementary components onto the standard protocol and appeared in thirteen studies; examples include cognitive remediation therapy, dialectical behaviour therapy skills, art therapy and guided self-help elements. The second category, in-model modifications or flexibility, described in nine studies, kept the FBT framework intact but altered how it was delivered, such as changing session frequency, separating the adolescent from parents during parts of treatment, or shifting the primary focus onto parents alone. The third category, adaptations beyond the FBT manual, appeared in six studies and involved more fundamental departures from the published protocol.
A central question driving the review was whether these modifications are grounded in what the field already knows about why young people drop out of treatment or fail to recover. The answer, in many cases, was no. Only eight of the included studies explicitly targeted a factor with established links to treatment non-response, such as high expressed emotion within the family, early non-response during the critical first weeks, low parental self-efficacy, or older adolescent age. The remaining adaptations were largely driven by clinical intuition, local service constraints or theoretical preference rather than by evidence about the mechanisms that derail recovery. For a field that has spent two decades building the case for FBT through randomised trials, the reviewers suggest, this disconnect between theory and modification practice represents a significant blind spot.
Methodological weaknesses compounded the problem. Fifteen of the thirty-one studies, roughly fifty-eight percent, had no comparator group at all, meaning that any improvement observed could not be attributed with confidence to the adaptation itself rather than to the passage of time, the natural course of the illness, or the underlying FBT framework. Sample sizes were frequently small, outcome measures varied widely from one study to the next, and few trials used the standardised remission definitions that would allow findings to be pooled or compared across research groups. The Joanna Briggs Institute appraisals reflected these limitations, with many studies scoring poorly on key quality criteria. In practical terms, the review found a literature that is rich in clinical creativity but poor in the controlled evidence needed to separate genuinely useful innovations from well-intentioned noise.
Against that backdrop, three adaptations stood out as showing preliminary evidence of benefit over standard FBT. The first is a separated treatment model, in which the therapist meets with the adolescent and the parents in separate sessions rather than conducting every session with the whole family together. This structure, exemplified by approaches such as Acceptance-based Separated Family Treatment, appears to ease the intense interpersonal pressure that can arise when weight restoration is negotiated in front of the patient, while still equipping parents to take charge of refeeding. The second promising adaptation is parent emotion-coaching, which trains caregivers to recognise, validate and help regulate their child’s emotional distress rather than focusing solely on eating behaviour, directly addressing the high expressed emotion that predicts poorer outcomes. The third is flexible or extended treatment duration, allowing the number and pacing of sessions to respond to how quickly a patient progresses instead of adhering to a fixed schedule.
The mechanistic logic behind these three winners is instructive. Separated models and emotion-coaching both target the emotional climate of the household, which decades of family research have identified as a modifiable predictor of outcome in adolescent anorexia. Extended duration, by contrast, addresses the temporal mismatch between a fixed treatment calendar and the highly variable pace of weight and psychological recovery, particularly for older adolescents or those presenting with atypical anorexia who may start treatment at a higher weight and therefore face different restoration trajectories. In each case the adaptation is not a random departure but a targeted response to a specific, evidence-linked barrier to recovery, which is precisely the approach the reviewers argue the field should take more systematically.
The authors are careful about what their findings can and cannot support. They conclude that while some promising adaptations exist, the evidence base remains limited by the predominance of small, uncontrolled studies and the absence of standardised outcome measures, and they call for adequately powered, controlled trials of the most promising modifications to demonstrate clear benefit over standard FBT before clinical practice changes wholesale. The research was funded by the Australian Government’s Medical Research Future Fund under its Childhood Mental Health programme, with additional support from an Australian Government Research Training Program Scholarship. The team also disclosed several competing interests, including editorial roles held by some authors at the Journal of Eating Disorders and co-authorship of two of the included papers, transparency that matters when the review touches on a treatment model closely associated with several of the investigators.
For clinicians and families, the practical message is one of cautious optimism. FBT remains the treatment of first choice, and nothing in this review undermines that position. But for the roughly half of young patients who do not fully remit with standard care, the review suggests that clinicians are not simply guessing when they adjust the protocol: separated formats, emotion-focused parent coaching and flexible treatment length now carry the strongest preliminary signals of added benefit. For researchers, the message is sharper. The field has generated twenty-one ideas for improving a therapy that helps many but not all, and it now needs the large, controlled, consistently measured trials that can tell families which of those ideas genuinely work, turning two decades of clinical improvisation into a tested roadmap for better recovery rates in adolescent anorexia nervosa and atypical anorexia nervosa.
Subject of Research: Systematic review of adaptations to family-based treatment for children and adolescents with anorexia nervosa or atypical anorexia nervosa
Article Title: Treatment adaptations to family-based treatment for children and adolescents with anorexia nervosa or atypical anorexia nervosa, and their evidence-base: a systematic review
Article References: Cussen, A., Yeo, M., Conti, J., Alford, C., Donnelly, B., Jackman, B., Krug, I., Kushner, Y., McCormack, M., Rankin, R., Turner-Revach, M., Wallis, A., & Hay, P. (2026). Treatment adaptations to family-based treatment for children and adolescents with anorexia nervosa or atypical anorexia nervosa, and their evidence-base: a systematic review. Journal of Eating Disorders. https://doi.org/10.1186/s40337-026-01776-7
Image Credits: AI Generated
DOI: 10.1186/s40337-026-01776-7
Keywords: family-based treatment, anorexia nervosa, atypical anorexia nervosa, adolescent eating disorders, systematic review, treatment adaptation, psychotherapy, parent emotion-coaching, separated family treatment, treatment non-response, Journal of Eating Disorders, PRISMA
News Source: Ophelia Keating. (October 7, 2026). Scientists Map 21 Ways Doctors Tweak the Leading Therapy for Teen Anorexia. Scienmag.
