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. Author manuscript; available in PMC: 2025 Oct 1.
Published in final edited form as: Int J Eat Disord. 2024 Jul 15;57(10):2117–2127. doi: 10.1002/eat.24257

Trauma-focused cognitive-behavioral therapy for adolescents bullied because of weight: A feasibility study

Janet A Lydecker 1, Elise V Ozbardakci 1, Raissa Lou 1, Carlos M Grilo 1
PMCID: PMC11622608  NIHMSID: NIHMS2021802  PMID: 39007703

Abstract

Objective:

To test the feasibility and acceptability of a treatment for weight bullying.

Method:

Participants who had experienced weight-related bullying and were currently experiencing traumatic stress were recruited and enrolled in a feasibility trial of trauma-focused cognitive behavioral therapy combined with cognitive-behavioral therapy for eating disorders (TF-CBT-WB). Thirty adolescents (aged 11-17) were determined eligible and 28 began treatment (12 weeks).

Results:

This study demonstrated treatment feasibility and acceptability of TF-CBT-WB for adolescents with traumatic stress following weight-bullying experiences. Overall retention and treatment satisfaction were good. Within-subjects improvements were observed for intrusion symptoms of traumatic stress, global eating-disorder severity, overvaluation of weight/shape, dissatisfaction with weight/shape, dietary restraint, and depression. Clinically-meaningful improvements were attained for several patient outcomes. Clinically-meaningful decreases in functional impairment were attained by more than half of participants.

Conclusions:

Overall, this clinical trial testing TF-CBT-WB for adolescents experiencing traumatic stress following weight-bulling experiences demonstrated therapy feasibility, acceptability, and initial evidence that clinically-significant improvements in patient outcomes were feasible. However, some patient outcomes thought to be more central to how the youth viewed the world failed to show improvements, suggesting that additional content related to these constructs might yield greater benefit.

Keywords: adolescents, weight stigma, bullying, trauma, eating disorder, treatment

INTRODUCTION

Bullying is commonly experienced during childhood. A meta-analysis yielded an estimate that 36% of youth are bullied (Modecki et al., 2014). Bullying can be physical, verbal, or relational (Vaillancourt et al., 2008) and occurs when an individual with more power intentionally causes harm to a victim, often repeatedly (Modecki et al., 2014; Olweus, 1994). Among other reasons for bullying, youth living in larger bodies are targeted because of their size (Puhl et al., 2016). Notably, youth living in larger bodies are more likely to experience bullying than peers not living in larger bodies (Boswell et al., 2024; Haines et al., 2008; Janssen et al., 2004; Launius & Lydecker, 2024; Sutin et al., 2016).

Bullying can have problematic health consequences and be highly distressing (Lyznicki et al., 2004; Puhl & Luedicke, 2012). Victims of bullying are more likely than non-bullied peers to experience social and academic impairment (Hayden-Wade et al., 2005; Krukowski et al., 2009; Lydecker et al., 2023; Puhl & Luedicke, 2012), anxiety and depression (Copeland et al., 2013; Wolke & Lereya, 2015), eating disorders and weight/shape concerns (Copeland et al., 2015; Lydecker et al., 2023), weight gain (Sutin et al., 2016), and poorer overall health (Gini & Pozzoli, 2009; Takizawa et al., 2015; Wolke & Lereya, 2015; Wolke et al., 2001). Bullying is also associated with self-harm and suicide (Holt et al., 2015; Wang et al., 2018; Wolke & Lereya, 2015). Childhood bullying also has long-term associations with adult health problems: anxiety, depression, self-harm and suicide, poorer overall health, poorer academic achievement, and poorer social functioning (Copeland et al., 2013; Takizawa et al., 2015; Takizawa et al., 2014; Wolke & Lereya, 2015).

Children who are bullied can develop post-traumatic stress disorder (PTSD); approximately 41% of girls and 28% of boys who experienced bullying have clinical levels of traumatic stress (Idsoe et al., 2012). The nature of bullying (that it occurs as events, leaves children feeling unsafe, and engenders emotional distress) fits criteria for stressors addressed by trauma treatment (Lydecker, 2022; National Institute for Health and Care Excellence, 2018), and experts recommend considering bullying as a potential trauma experience (American Psychiatric Association, 2013; Kaess, 2018; Lydecker, 2022; National Child Traumatic Stress Network, n.d.).

Weight (or body size) is the most common reason children are bullied (Puhl et al., 2016). As with general bullying, weight-related bullying has negative consequences (Puhl & Luedicke, 2012), including binge eating (Neumark-Sztainer et al., 2002), extreme weight-control behaviors such as vomiting or fasting (Neumark-Sztainer et al., 2002), weight and shape concerns (Puhl et al., 2017), and weight gain and obesity (Puhl et al., 2017; Takizawa et al., 2015). Bullied youth say they use extreme weight-control behaviors and binge eating to cope with bullying (Puhl & Luedicke, 2012), and to attempt desperately to avoid future victimization by losing weight (Reece et al., 2016). Childhood weight-related bullying also has long-term associations with extreme weight-control behaviors, disordered eating, and weight/shape concerns in adulthood (Copeland et al., 2015; Puhl et al., 2017).

Taken together, weight status, disordered eating, and bullying appear to be complexly interrelated: children living in larger bodies are more likely to experience bullying, and bullying has consequences including eating-disorder psychopathology and weight gain (Sutin et al., 2016) (Figure 1). Because weight-related bullying in childhood is both a precursor to adult disordered eating and obesity and a distinct source of health problems and psychosocial impairment, treating bullying during childhood could improve immediate and long-term health (Lydecker, 2022). While there are policy initiatives and school-level programs aimed at preventing and reducing the occurrence of bullying (Hatzenbuehler et al., 2017; Schuster & Bogart, 2013), there are currently no established individual-level treatments for the negative consequences of weight-related bullying. This is despite recommendations suggesting that treatments for the consequences of bullying could improve children’s health (Idsoe et al., 2012; Lancaster et al., 2009; Lydecker, 2022) and despite individuals’ beliefs that healthcare providers are important sources of help for youth who have been bullied (Puhl et al., 2016).

Figure 1.

Figure 1.

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Conceptual Relationship between Bullying and Disordered Eating

Because there is no evidence-based treatment for youth who have experienced bullying (Idsoe et al., 2012; Lydecker, 2022), a feasibility study is a critical first step in the treatment development process (Carroll & Nuro, 2002; Onken et al., 2014; Rounsaville et al., 2001). The current study tested the feasibility of a treatment for weight-related bullying because weight-related bullying is the most common form of bullying. Additionally, youth who are bullied because of their weight may have a particular need for treatment because of complex needs including traumatic stress from bullying and co-occurring or developing problems with disordered eating and weight/shape concerns. Specifically, the current study tested the feasibility of adapting trauma-focused CBT (TF-CBT) (Ascienzo et al., 2020; Morina et al., 2016; National Institute for Health and Care Excellence, 2018) with elements of CBT for eating disorders (CBT-ED) (Grilo, 2017; Hilbert et al., 2020; Lock, 2015; National Institute for Health and Care Excellence, 2017; Wilson et al., 2007) to treat traumatic stress and eating-disorder psychopathology among those who experienced weight-related bullying (TF-CBT-WB). TF-CBT helps children regulate emotions surrounding a highly-distressing stressor and enhance safety to prevent further victimization. CBT-ED reduces unhealthy weight-control behaviors (such as vomiting and fasting), disordered eating (such as binge eating and emotional eating), and weight/shape concerns, and improves healthy eating patterns and coping with weight-related thoughts and emotions.

The primary aim of this study was to test the feasibility of TF-CBT-WB in a single-arm clinical trial. The secondary aim was to test whether clinically-significant improvements in patient outcomes were feasible to obtain with TF-CBT-WB. We hypothesized that youth would experience clinically-significant improvements in two key clinical outcomes, traumatic stress and weight/shape concerns. We also explored whether youth experienced clinically-significant improvements in additional clinical outcomes: reductions in binge eating, extreme weight-control behaviors, depression, and internalized weight bias, and increases in self-esteem and self-compassion.

METHODS

This study was approved by the Yale Human Investigations Committee and was pre-registered at ClinicalTrials.gov (NCT04587752). Parents provided consent and permission and adolescents provided assent prior to study activities.

Treatment Development

The current study piloted a novel treatment addressing weight-related bullying with TF-CBT, supplemented with CBT-ED; we refer to our new treatment as TF-CBT-WB in this manuscript. We conducted a non-randomized pilot study in which adolescents who reported having been bullied because of their weight or size all received TF-CBT-WB. The treatment involved three months of weekly, 60-min, telehealth sessions between the clinician and adolescent (12 sessions), with parents attending monthly with their child. Patients and clinicians provided feedback on each treatment session (how helpful they found it, how much they liked it, how likely they were to use the strategies covered). TF-CBT-WB conceptualized the bullying as the stressor at the center of TF-CBT and used CBT-ED’s weight and eating problem-solving and cognitive processing content. Session content can be viewed in more detail in Supplemental Table 1.

Sample Size

The study design allowed for 80% power to detect clinically-meaningful within-subject effects (d=0.64) with a sample size of 30 (assuming 20% dropout).

Measures

Treatment feasibility and acceptability was measured by participant recruitment and retention, as well as ratings of credibility and satisfaction.

Patient outcomes were measured by instruments with established reliability and validity. Traumatic stress symptoms of intrusion, arousal, and avoidance were assessed with the Children’s Impact of Event Scale-13 interview (CRIES) (Horowitz et al., 1979; Perrin et al., 2005; Smith et al., 2003) clinicians anchored adolescents to consider weight bullying as the event. We tested whether participants experienced clinically-significant improvements in traumatic stress by examining scores above and below the clinical cut-off for the CRIES, which is considered to be a score of 17 on the sum of the intrusion and avoidance subscales (Perrin et al., 2005). Eating disorder symptoms of weight/shape concerns and eating-disorder behaviors (unhealthy weight-control and binge eating) were assessed with the Eating Disorder Examination (EDE) interview for children and the questionnaire version (EDEQ) (Berg et al., 2012; Bryant-Waugh et al., 1996; Fairburn & Beglin, 1994; Fairburn & Cooper, 1993; Glasofer et al., 2007; Tanofsky-Kraff et al., 2004). We tested whether participants experienced clinically-significant improvements in weight/shape concerns by examining scores above and below the clinical threshold of 4 (i.e., at least moderate) (Fairburn & Cooper, 1993) on the EDE Interview scores on overvaluation of weight/shape and dissatisfaction with weight/shape. We also examined whether participants experienced clinically-significant improvements in disordered eating behaviors by assessing objective binge-eating episode frequency and total binge-eating episode frequency (objective and subjective binge-eating episodes), and purging episode frequency (vomiting, diuretics, laxatives, excessive exercise) using the EDE interview, considering a change from “any” (i.e., at least one episode) behavior to “no” (i.e., zero episodes) behavior to be clinically-significant. Finally, we used the EDEQ global score, which has an established threshold of 2.77 (Fairburn et al., 2009; Hart et al., 2024), to determine whether there were clinically-significant improvements in overall eating-disorder psychopathology over the course of treatment. The Clinical Impairment Assessment (CIA) assessed impairment related to eating behaviors (Bohn et al., 2008; Bohn & Fairburn, 2008); the threshold for clinically-significant impairment is 16 (Bohn et al., 2008). Despite being designed with adult patients, the CIA and its threshold have been used with adolescent patients (He et al., 2022; Neipp et al., 2024; Sahlan et al., 2022). The Patient Health Questionnaire-9 (PHQ) assessed depression (Kroenke et al., 2001; Richardson et al., 2010). The Rosenberg Self-Esteem Scale (RSES) assessed self-esteem (French et al., 1995; Rosenberg, 1965). The Self-Compassion Scale (SCS) assessed self-compassion, which includes mindfulness, self-kindness, and common humanity (Neff, 2003). The Weight Bias Internalization Scale-Modified (WBIS) assessed the internalization of weight stigma, or the application of societal bias related to weight to the self; the modified version is does not assume that the respondent has a larger body (Durso & Latner, 2008; Pearl & Puhl, 2014).

Participants

Participants (N=28) were middle/high school-aged adolescents who had experienced weight-related bullying (i.e., verbal, relational, physical, or cyberbullying related to having a larger or otherwise non-ideal body size). Adolescents were eligible if they lived at home, were 11-17 years old, reported experiencing weight-related bullying, and reported current distress about weight-related bullying (reporting at least “sometimes” experiencing at least one symptom on the CRIES). Participants could not have medical or psychiatric conditions requiring intensive care or hospitalization (e.g., severe anorexia, psychosis, suicidality), developmental disorders, uncontrolled medical conditions requiring intensive care (e.g., cancer), avoidant/restrictive food intake disorder, pregnancy, or concurrent treatments that influenced trauma-related stress. Individuals with avoidant/restrictive food intake disorder were excluded because weight/shape concerns are a contraindication for the diagnosis and clinically-significant change in weight/shape concerns was our secondary outcome. Other conditions not listed, including current and past eating disorders, were not exclusionary. Participants were referred by providers or parents, or self-referred. Recruitment efforts included social media advertisements, research trial registries, and soliciting referrals from healthcare providers. Participants were eligible if they lived in the United States.

Data Analysis

Feasibility was descriptive, including treatment ratings (clinician/patient) and total/last sessions attended. Descriptive statistics also quantified patient outcome variables. Paired t-tests tested change in variables from baseline to end of treatment.

RESULTS

Feasibility

55 participants were assessed for eligibility, of whom 30 were eligible and 28 began treatment. Seven dropped or were withdrawn from treatment after starting (75% treatment retention. Participants attended a mean number of 9.96 out of 12 sessions. 71.4% of participants completed all sessions and 82.1% completed the end of treatment assessment. Participant recruitment and flow throughout the pilot study are depicted in Figure 2.

Figure 2. Participant flow.

Figure 2.

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*Psychiatric condition: participants reporting serous mental illness such as blpolar disorder and conditions requiring a higher level of care (e.g., suicidality, restrictive eating disorder).

**Treatment for trauma or higher level of care

Participant Demographic Characteristics

The average age of enrolled participants was 13.71 years (SD=2.12; range 11-17 years old). 16 participants were in middle school, 10 participants were in high school, 1 participant had finished their high school degree, and 1 participant was pursuing their high-school equivalence degree outside of formal schooling. Approximately two-thirds of participants self-identified as girls (n=19, 67.9%); 32.1% identified as boys. 60.7% (n=17) identified as non-Hispanic White, 21.4% identified as non-Hispanic Black/African American (n=6), 14.3% identified as Hispanic/Latinx White (n=4), and 3.6% identified as Hispanic/Latinx Black (n=1). 78.6% identified as heterosexual (n=22) and 21.4% identified as bisexual (n=6).

Acceptability

Participants completed a treatment credibility survey at the end of the first treatment session. All participants thought the program made at least moderate sense (M=5.10, SD=1.04; scale range 0-6, participant score range 3-6) and that their clinician seemed at least moderately helpful (M=5.14, SD=1.11; scale range 0-6, participant score range 3-6).

Teens, parents, and clinicians had high overall satisfaction with sessions (all means ≥4.99 on a scale of 0 through 6). They rated materials helpful (teen: M=5.06, SD=0.97; parent: M=5.42, SD=0.89; clinician: M=5.08, SD=0.87), useful (teen: M=4.99, SD=1.05; parent: M=5.28, SD=1.09), and reported that they liked the materials (teen: M=5.22, SD=0.96; parent: M=5.50, SD=0.91; clinician: M=5.08, SD=0.94).

Patient Outcomes

Baseline and end of treatment clinical measures are summarized in Table 1, along with tests of change from baseline to end of treatment.

Table 1.

T-tests and ANOVAs comparing treatment outcomes from baseline to end of treatment

Baseline End of
Treatment
N M SD M SD t p d [95% CI]3
CRIES Interview
  Intrusion 22 6.41 5.99 4.45 5.96 2.71 .01 0.33 [0.06–0.60]
  Avoidance 22 9.18 6.04 7.55 6.99 1.11 .28 0.25 [−0.23–0.73]
  Arousal 22 9.41 5.57 8.55 8.42 0.54 .59 0.12 [−0.33–0.57]
EDE Interview
  Binge-eating Episode Frequency1 21 4.81 7.71 3.38 6.26 - - -
  Purging Episode Frequency1,2 21 0.00 0.00 0.00 0.00 - - -
EDEQ Brief 2
  Restraint 20 1.82 1.64 1.05 1.09 2.24 .04 0.53 [.002–1.05]
  Overvaluation 20 3.55 2.12 1.93 1.83 4.81 <.001 0.81 [0.36–1.26]
  Dissatisfaction 20 3.70 1.94 2.85 2.08 2.84 .01 0.42 [0.05–0.76]
  Global 20 2.85 1.49 1.81 1.42 5.02 <.001 0.71 [0.33–1.09]
CIA total 21 14.71 12.54 12.57 13.28 0.98 .34 0.17 [−0.19–0.52]
WBIS mean 20 −0.07 1.82 −0.34 1.73 1.31 .21 0.15 [−0.09–0.39]
PHQ total 20 8.20 6.82 5.65 5.64 2.38 .03 0.40 [0.02–0.77]
RSES total 20 16.25 6.61 18.15 6.34 −1.80 .09 −0.29 [−0.65–0.06]
SCS total 20 22.90 7.55 24.35 7.55 −0.65 .52 −0.19 [−0.81–0.43]
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Note. CRIES=Children’s Revised Impact of Events Scale, EDE=Eating Disorder Examination, EDEQ=Eating Disorder Examination Questionnaire, CIA=Clinical Impairment Assessment, WBIS=Weight Bias Internalization Scale (Modified Version), PHQ=Patient Health Questionnaire; RSES=Rosenberg Self-Esteem Scale; SCS=Self-Compassion Scale. Highlighted rows denote significant t-tests.

1

Variable not normally distributed; t-test not conducted.

2

Two participants reported purging episodes at baseline but did not complete the end-of-treatment assessment. All other participants reported no purging episodes (sum of vomiting, laxative misuse, diuretic misuse, driven exercise, other extreme weight control behaviors) at baseline and end of treatment.

3

We report Cohen’s d with adjustment for correlated data

Traumatic Stress Symptoms.

At baseline, 71.4%[n=15/21] of teens met the clinical threshold for PTSD following weight-bullying experiences on the CRIES; 46.7%[n=7/15] of these teens no longer met the clinical threshold at end of treatment. Paired t-tests compared the interview version of the CRIES from baseline to end of treatment. Intrusion, but not avoidance or arousal or the total traumatic stress score, significantly decreased (t(21)=2.71, p=.01, d=0.33 [95% CI: 0.06 – 0.60]).

Weight/Shape Concerns.

For overvaluation, 59.1%[n=13/22] of teens had clinically-significant overvaluation at baseline; 30.8%[n=4/13] of these teens no longer had clinically-significant overvaluation at end of treatment. For dissatisfaction, 47.6%[n=10/21] of teens had clinically-significant dissatisfaction at baseline; 20%[n=2/10] of these teens no longer had clinically-significant dissatisfaction at end of treatment.

There was significant within-subject changes in overvaluation of weight/shape (t(19)=4.81, p<.001, d=0.81 [95% CI: 0.36 – 1.26]) and body dissatisfaction (t(19)=2.84, p=.01, d=0.42 [95% CI: 0.05 – 0.76]).

Eating-Disorder Psychopathology.

At baseline, 31.8%[n=7/22] of teens engaged in objective binge-eating episodes; 42.9%[n=3/7] of these teens fully remitted. At baseline, 57.1%[n=12/21] of teens engaged in binge-eating episodes (objective and subjective binge-eating episodes together); 33.3%[n=4/12] of these teens fully remitted. Two participants reported purging episodes at baseline, but neither completed an assessment at end of treatment. No other teens reported purging episodes at baseline or end of treatment. For dietary restraint, 31.8%[n=7/22] of teens had clinically-significant restraint at baseline; 42.9%[n=3/7] of those teens no longer had clinically-significant restraint at end of treatment.

Regarding overall eating-disorder psychopathology, 45.0%[n=9/20] had clinically-significant global EDEQ scores at baseline, and 44.4%[n=4/9] of those teens no longer had clinically-significant global EDEQ scores at end-of-treatment.

There were significant within-subject changes in dietary restraint (t(19)=2.24, p=.04, d=0.53 [95% CI: 0.002 – 1.05]) and the global severity score (t(19)=5.02, p<.001, d=0.71 [95% CI: 0.33 – 1.09]). Changes in dietary restraint, overvaluation of weight/shape, body dissatisfaction, and global eating disorder severity over treatment are depicted descriptively in Figure 3.

Figure 3.

Figure 3.

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Change in eating disorder psychopathology from baseline to end of treatment.

Impairment.

At baseline, 33%[n=7/21] of teens reported clinical impairment related to their eating behaviors; 57.1%[n=4/7] of these teens were no longer experiencing clinically-significant impairment at end of treatment. T-tests using the continuous score revealed no significant within-subject difference (t(20)=0.98, p=.34, d=0.17 [95% CI: −0.19 – 0.52]).

Self-esteem, self-compassion, internalized bias, and depression.

We also tested whether psychosocial variables changed with treatment, with particular attention to variables that related to how individuals see themselves and the world. Depression significantly decreased (t(19)=2.38, p=.03, d=0.40 [95% CI: 0.02 – 0.77]). Self-compassion (t(19)= −0.65, p=.52, d= −0.19 [95% CI: −0.81 – 0.43]), self-esteem (t(19)= −1.80. p=.09, d= −0.29 [95% CI: −0.65 – 0.06]), and internalized weight bias (t(19)=1.31, p=.21, d=0.15 [95% CI: −0.09 – 0.39]) did not change significantly.

DISCUSSION

This was the first test of a novel approach to mitigate the negative consequences of weight bullying, trauma-focused cognitive behavioral therapy combined with elements of cognitive behavioral therapy for eating disorders. This study followed a rigorous treatment development model (Carroll & Nuro, 2002; Onken et al., 2014; Rounsaville et al., 2001) and aimed to examine the feasibility, acceptability, and initial evidence of efficacy of TF-CBT-WB to inform a larger-scale and adequately-powered test of efficacy.

This study demonstrated feasibility and acceptability for TF-CBT-WB. Nearly all participants who were determined to be eligible began treatment and 75% completed treatment, with 71.4% attending all sessions. While retention was better than in other clinical trials testing trauma therapies (Wamser-Nanney & Walker, 2022), and on par with clinical trials testing eating disorder therapies (Linardon et al., 2018), there is room for improvement. Thus, future research should examine retention strategies and reasons for drop out to refine TF-CBT-WB further. Considering bullying as a trauma and using a trauma treatment is novel because bullying is typically considered to be a psychosocial stressor or a normative childhood experience, yet some individuals experience full or subthreshold PTSD after being bullied (Idsoe et al., 2012). In our study, despite a low threshold as inclusion criteria, more than seventy percent of participants met the PTSD threshold on the CRIES. From other work, we know that childhood maltreatment might predispose individuals to subsequent stressors and maltreatment, including increased vulnerability to weight discrimination experiences throughout the lifespan (Udo & Grilo, 2016). However, it is notable that our measure of traumatic stress specifically tied symptoms to weight-related bullying. Treating bullying is also novel because work focused on bullying is typically prevention, to prevent bullying occurring or reduce the frequency of bullying. While this is crucial work, attention is also needed for the individual victim of bullying, to mitigate the plethora of negative consequences of bullying, which include a variety of psychological problems (Doom et al., 2024), metabolic medical problems (Udo et al., 2016), and impairment (Lydecker et al., 2023).

Our pilot study demonstrated initial evidence of efficacy for TF-CBT-WB by examining the feasibility of attaining clinically-significant outcomes over the course of treatment. We found that several key patient outcomes improved, including intrusion symptoms of traumatic stress, depression, global eating-disorder severity, overvaluation of weight/shape and dietary restraint. Notably, all key patient outcomes had at least some individuals who attained clinically-significant outcomes (above to below the measure-specific clinical threshold; some behaviors to no behaviors). Of interest are the weight/shape concern findings. Overvaluation and dissatisfaction both decreased from baseline to end-of-treatment. Broadly, dissatisfaction with weight/shape is thought to be more closely impacted by fluctuations in mood than other body image constructs (Cooper & Fairburn, 1993) as demonstrated empirically (Masheb et al., 2006; Wade et al., 2011). Further, dissatisfaction tends to be a particularly common body-image concern even to the point of being a “normative discontent” (Rodin et al., 1984). In contrast, overvaluation of weight/shape is considered a core aspect of eating disorders (Fairburn et al., 2003; Grilo, 2013), central to eating-disorder psychopathology but unrelated to weight (Wang et al., 2019), and associated with the persistence of disordered eating (Grilo et al., 2024).

This study was an important demonstration of the feasibility of attaining clinically-meaningful outcomes. Our outcomes were comparable to those achieved in eating disorder treatments (i.e., EDEQ global scores below clinical threshold 45% at baseline to 70% at end of treatment, compared to other work that has documented 32% at baseline to 68% at end of treatment (Hart et al., 2024) and 26% at baseline to 82% at end of treatment (Dalle Grave et al., 2015)). An important next step is a definitive extension and test of the efficacy of TF-CBT-WB in a larger, adequately-powered randomized controlled trial that includes a control group, including tests of putative mechanisms of change. Conceptually, mechanisms of change that could be tested include cognitive appraisals of the bullying experiences (Kleim et al., 2013) and beliefs about how to cope effectively with the bullying experiences, particularly as they relate to eating disorder behaviors. Additionally, as noted previously, weight/shape concerns in general and overvaluation in particular should be tested as a mechanism of change. While we did not assess formally whether adolescents were experiencing ongoing bullying, or whether the bullying was exclusively in the past, anecdotally, participants in the study had both experiences, including some adolescents who went to the extreme of changing school districts to escape the bullying. While TF-CBT-WB addressed safety concerns to prevent revictimization (StopBullying.Gov, n.d.), the primary focus of TF-CBT-WB was to address how adolescents responded to the bullying experiences internally. Future research should address whether ongoing bullying experiences might impact the course or efficacy of treatment.

Also notable for future study are the patient outcomes that did not show significant improvements. In this study, there were no participants who reported purging behaviors at baseline or at the end of treatment in our clinician-administered interviews. It is possible that those who engage in extreme or inappropriate weight control or compensatory behaviors represent a potential group who either do not seek treatment or seek other forms of help or treatment. It is well-established that people with eating disorders seek treatment at low rates, particularly evidence-based treatments (Coffino et al., 2019; Sanzari et al., 2021; Sanzari & Liu, 2019) and it is possible that those experiencing traumatic stress following weight-bullying experiences who engage in purging behaviors might not seek treatment because of high distress or shame. We did not see significant decreases in weight bias internalization nor significant increases in self-esteem or self-compassion. Taken together, this suggests that these variables, which are more integral to how the adolescent sees the world and themselves in it, may need more time to realize changes, or may need additional content in the intervention. Moreover, compared to eating disorder treatments delivered to adolescents (5 months; e.g., (Dalle Grave et al., 2015)) and pediatric obesity interventions (6 months; e.g., (Wilfley et al., 2017)), TF-CBT-WB in the current study (3 months), was shorter, although this length is consistent with TF-CBT therapy protocols (2 to 4 months; e.g., (Deblinger et al., 2011)). The last part of trauma-focused cognitive behavioral therapy includes making meaning out of the trauma and consolidating coping skills and the trauma narrative; with the inclusion of eating disorder content in TF-CBT-WB, it is possible that there was insufficient time for consolidation and making meaning. Future iterations of TF-CBT-WB should consider including additional content on practicing skills and post-traumatic growth.

The findings of our study should be interpreted with caution and in light of our study design. First, this was a feasibility study; as previously discussed, this study did not have a control group and did not have sufficient power to detect the efficacy of the treatment. Second, as this was the first treatment for any kind of bullying, and—in particular—for weight-related bullying. Given the novelty of this treatment, the individuals who self-referred or were referred by their provider to participate may not be representative of the participants who would be recognized and/or treated in community clinics. Additionally, individuals who sought treatment in our research study needed to have a parent provide consent for treatment. In community settings, parental consent is not always required, and thus, our sample may not generalize to youth who do not disclose their experiences being bullied to their parents, or to those youth who do not have parents supportive of psychological treatment. Finally, while we had some demographic diversity in our small sample, it is unknown whether our outcomes are moderated by demographic characteristics. In particular, diversity in race/ethnicity, gender, socioeconomic status, and sexual identity is highly relevant because of disparities in eating disorder prevalence and treatment in minoritized groups. It is essential for future, large-scale research testing the efficacy of TF-CBT-WB to include demographically-diverse participants to test for potential predictors and moderators of treatment outcomes. Another limitation of the current study was that inclusion criteria focused on trauma symptoms rather than eating-disorder symptoms/behaviors. We required trauma symptoms because this was a feasibility test of a trauma-treatment. Future research should also require eating disorder symptoms or stratify randomization by the presence of eating-disorder symptoms to increase rigor in testing the efficacy of TF-CBT-WB in reducing eating-disorder symptoms. Existing longitudinal research suggests that trauma symptoms may develop prior to eating-disorder symptoms following weight-related bullying, thus, TF-CBT-WB could also be tested as a prevention protocol. Another primary limitation of the current study was that there was no follow-up period. Future research should evaluate participants for a year following the intervention to test the durability of improvements and any relapse.

In conclusion, the current study was a novel, initial test of trauma-focused cognitive behavioral therapy for adolescents experiencing traumatic stress following weight bullying. Our sample included youth with racial/ethnic and gender diversity, and clinical presentations were severe. Feasibility, acceptability, and evidence supporting the feasibility of attaining clinically-significant patient outcomes was promising. Future research should develop this protocol further, particularly around self-compassion, self-esteem, and internalized weight bias and testing potential mechanisms of change, and test whether the protocol could be an alternative treatment for eating disorders, prevention for eating disorders, and/or a treatment for traumatic stress stemming from weight bullying and other forms of bullying.

Supplementary Material

1

Clinical Trials:

This pilot study was registered on clinicaltrials.gov: NCT04587752, Cognitive-Behavioral Therapy for Weight-related Bullying.

Public Significance.

Bullying has serious consequences to youth’s mental and physical health, including longitudinal associations with eating-disorder psychopathology, mood problems, and weight gain. This study demonstrated feasibility of the first treatment for weight-related bullying. In this study, teens who received trauma-focused cognitive behavioral therapy for weight bullying experienced improvements in global eating-disorder severity, weight/shape concerns, and depression.

Funding:

This research was supported, in part, by National Institutes of Health grant K23 DK115893 (Lydecker) and UL1 TR001863. Funders played no role in the content of this paper.

Footnotes

Disclosure: The authors declare no conflict of interest relevant to this article. Dr. Lydecker reports broader interests, which did not influence this research, including Honoraria for lectures, consultation around continuing medical education activities, and consultation to Novo Nordisk. Dr. Grilo reports broader interests, which did not influence this research, including Honoraria for lectures, and Royalties from Guilford Press and Taylor & Francis Publishers for academic books.

Data availability statement:

Data from the pilot study, including the study protocol, statistical analysis plan, and informed consent form, are posted on clinicaltrials.gov. Deidentified participant data (including data dictionaries) will be made available to researchers who make a reasonable request and provide a methodologically-sound proposal and IRB-approved protocol for use in achieving the goals of the approved proposal.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS2021802-supplement-1.pdf (546.3KB, pdf)

Data Availability Statement

Data from the pilot study, including the study protocol, statistical analysis plan, and informed consent form, are posted on clinicaltrials.gov. Deidentified participant data (including data dictionaries) will be made available to researchers who make a reasonable request and provide a methodologically-sound proposal and IRB-approved protocol for use in achieving the goals of the approved proposal.

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