CBT has been adjusted for adolescents with bulimia nervosa with the addition of a focus on adolescent developmental issues, parental involvement, using age-appropriate examples, and improving the therapeutic alliance.15 Although no randomized clinical trials using these additional foci have been conducted, case series data suggest that CBT adjusted for adolescents who have bulimia nervosa was effective and led to recovery rates of approximately 50% in a clinical sample.
A number of medication treatment studies for adults with bulimia nervosa suggest that some antidepressant medications are useful for managing bulimia nervosa.16 However, when compared with CBT, medications are less effective but are more cost-effective.17 The single study of antidepressant treatment in adolescents with bulimia nervosa was a pilot study of 10 participants that found that the medication was well tolerated and led to clinical improvements in binge eating and purging.18
Table 2 presents a summary of treatment options for children and adolescents with anorexia nervosa or bulimia nervosa. There are no systematic studies of treatment for children and adolescents who received selective eating, FAED, or another EDNOS diagnosis. A report on the use of behavioral desensitization and shaping in an inpatient milieu for the management of a somatization disorder similar to FAED suggests that this approach may be useful in severe cases.19
There are few systematic studies that compare the relative merits of different types of treatment settings for children and adolescents with eating disorders.20 Two randomized clinical trials in adolescents compare inpatient treatment with outpatient treatment.21,22 The first study compared an inpatient stay of several months in a specialty service with outpatient family and individual therapy.21 At the end of treatment and follow-up, there were no differences in outcome. A more recent study compared specialized inpatient treatment for adolescents with anorexia nervosa with specialized outpatient CBT for adolescents with anorexia nervosa and usual outpatient care.22 Again, no differences were found at 1-year follow-up; however, specialized CBT was the most cost-effective.23
There are no systematic studies that compare day programs or other intensive outpatient treatments with outpatient care, although there is evidence that such programs are becoming more common.24 However, one study compared a high dose with a low dose of outpatient family treatment for adolescents with anorexia nervosa and found that at the end of treatment and at 4-year follow-up, those adolescents who received the lower dose did as well as those who received twice as much treatment for twice as long.25,26 Taken together, these findings suggest that treatment for adolescents with anorexia nervosa does not require intensive intervention for psychiatric improvement.
Although the psychiatric treatment of adolescents with anorexia nervosa may generally be conducted on an outpatient basis, management of the medical consequences of severe malnutrition as a result of anorexia nervosa often requires medical hospitalization.27 A number of academic and medical associations have published guidelines for the medical management of these disorders in children and adolescents, and they identify acute medical complications associated with significant weight loss, including bradycardia, hypotension, and refeeding syndrome.28
Current studies of treatment
There are a number of treatment studies of child and adolescent eating disorders that are under way. It is hoped that these studies will provide important guidance on how to improve outcomes in this population.
At the University of Chicago and Stanford University, a study of 120 adolescents with anorexia nervosa that compares a developmentally focused individual treatment (adolescent-focused therapy [AFT]) with family therapy is nearing completion. This study is a large-scale comparison of 2 major and divergent approaches to managing anorexia nervosa. AFT concentrates on individuation, autonomy, and self-mastery to overcome the preoccupations and inappropriate avoidance that characterize the symptoms of anorexia nervosa.29 Family therapy, in contrast, employs parents to directly manage the adolescent’s weight restoration and only secondarily examines adolescent developmental issues in the family context.30 The results of this study should be available soon.
Another large study of adolescent anorexia nervosa is being conducted at 7 sites in the US and Canada. The study compares family therapy (as described above) with a systemic family approach aimed at family dynamics rather than empowering parents to effect weight change in their anorexic child.31 Results will shed light on the specific role of family involvement in the treatment of adolescents with anorexia nervosa.