Advances in Psychotherapy for Children and Adolescents with Eating Disorders
Lock, James, Fitzpatrick, Kathleen Kara, American Journal of Psychotherapy
There is a significant lag in the development of evidence based approaches for eating disorders in children and adolescents despite the fact that these disorders typically onset during these developmental periods. Available studies suggest that psychotherapy is the best available approach to these disorders. Specific studies support the use of family based interventions, adolescent focused individual therapy, and developmentally adapted cognitive behavioral therapy in this age group. The current report summarizes the available evidence supportive of each of these treatment modalities, as well as, provides a description of the rationale and principle therapeutic targets and intervention types. Future directions in psychotherapy research in child and adolescent eating disorders are discussed.
KEYWORDS: anorexia; bulimia; psychotherapy; adolescents
Eating disorders typically onset during late childhood and early adolescence (Hoek & Hoeken, 2003; van Son et al., 2006). These disorders are relatively common, both as full and partial syndromes (Hoek & Hoeken, 2003). The incidence rate for anorexia nervosa (AN) is just under 1%, similar to schizophrenia, while the incidence rate for bulimia nervosa (BN) is between 2% to 3%. Partial or subthreshold cases, sometimes referred to as Eating Disorder Not Otherwise Specified, account for another 2% to 5%. In addition to being common, these disorders often lead to physical health problems, including bone loss, amenorrhea, hypokalemia, and death (Golden et al., 2003; Rome & Ammerman, 2003). Mortality rates for anorexia nervosa are among the highest for any psychiatric disorder averaging 8% to 12% of patients (Herzog et al., 2000; Sullivan, 1995). Deaths are most often due to cardiac arrest and suicide. Eating disorders, especially anorexia nervosa, are expensive to treat because of the high use of hospitalization (Lock, Couturier, & Agras, 2008; Streigel-Moore, Leslie, Petrin, Garvin, & Rosenheck, 2000).
Strangely, given these facts, eating disorders in children and adolescents have resided on the peripheries of child and adolescent psychiatry and psychology. Instead of child and adolescent psychiatric and psychological experts focusing on these disorders, for the most part, these young patients have been treated by adult psychiatrists, adolescent medicine specialists, and nutritionists (Lock, 2002). In many cases, these clinicians provide exceptional and well-informed care; however, at other times, the lack of a developmentally informed psychological approach has lead to an overemphasis on adolescent autonomy, a neglect of the importance of families and parents in particular, an overemphasis on the medical aspects of treatment, and an ignorance of the psychological and cognitive limits of children and adolescents (Crisp, 1980).
In addition to much of the clinical care being offered by providers with a limited developmental understanding of children and adolescents, most of the psychiatric treatment research in eating disorders has focused on adults for both anorexia nervosa and bulimia nervosa (Le Grange & Lock, 2005; Lock & Gowers, 2005). This would not be surprising if these disorders did not so clearly onset during the adolescent years (Flament, Ledoux, Jeammet, Choquet, & Simon, 1995; Hoek & Hoeken, 2003). At the same time, results of these studies likely have limited applicability for adolescents with eating disorders because adult cases typically represent more chronic and resistant forms of eating disorders (Herzog et al., 1993). This has lead, especially in anorexia nervosa, to a kind of therapeutic nihilism regarding treatment response. Further, approaches using an adult model have tended to focus on individual therapy, motivation, and cognitive approaches suitable for adult levels of interpersonal, legal, and psychological maturity (Geller, Cocksell, & Drab, 2001; Pike, Walsh, Vitousek, Wilson, & Bauer, 2004). …