In general, the studies comparing the efficacy of the interventions did not find statistically significant differences between groups.
In the second, it was found that, despite the comparison of the end of treatment for FBT vs. AFT not producing statistically significant differences, these differences were found in the follow-up period for the cases. In only one study no methodological limitations were found The results indicated the lack of published research in the southern hemisphere, with the exception of Brazil and Australia. This is an important gap in evidence-based psychotherapies for the treatment of AN in childhood and adolescence, to the extent that sociocultural differences, especially in Latin American countries 33 , such as stronger and more lasting family ties with the family of origin, parenting styles and socio-educational skills may influence patient adherence to treatment and the efficacy of the intervention.
The concentration of articles published in the last decade was verified, which indicates that, although in an incipient manner, studies in the field of ED in childhood and adolescence have recently emerged. In the present review 9 RCTs were found, a number higher than that found in a systematic review conducted for AN treatment in childhood and adolescence, published in , which found only five studies with this design Although the RCT design is considered to be the gold standard for evaluating the efficacy of treatments, among the studies analyzed, several methodological limitations have decreased the quality of the scientific evidence produced.
All these factors imply low adherence to treatment and a high number of participants being lost after treatment and during follow-up. Girls represented the vast majority in all studies analyzed. However, recent research points to an increase in the number of boys with AN , which indicates the need to assess their particularities in terms of clinical presentation, history of being overweight, impact of culture and media on eating behavior, as well as gender and sexuality.
These variables have been addressed in qualitative studies 38 and in case studies 35 , however, to date, there are few clinical trials with samples of children with AN. In this sense, samples composed by boys are recommended for future studies in order to explore their peculiarities and assess the response to treatment, for the purpose of increasing the efficacy of the services offered to this population.
In Psychodynamic Therapy 26,29,30 it is the patients with AN were considered to present egoic fragilities associated with difficulty with situations of uncontrollability, alexithymia and intolerance to emotional discomfort, in addition to difficulties with individuation and transitioning from childhood to adulthood. They use the eating control and food restriction, whether consciously or unconsciously, to reduce the contact with negative affections.
The food restriction may also serve as a way of communicating through the body, unconscious affects that could not be transmitted via language. At the beginning of the psychotherapy process, behavioral goals are established for reducing food restriction and increasing weight, while these objectives are worked on in parallel with those described previously.
In the studies assessed 26,29,30 the psychodynamic psychotherapy protocol was offered during 32 sessions, 24 of which were made available to the adolescent individually and eight sessions were given to the parents, without the presence of the adolescent, with the objective being to assess the parental egoic functions, approach to parental behaviors that could assist in the process of changing the their child and to update the parents regarding the progress and difficulties of the psychotherapy process.
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In Systemic Psychotherapy, AN is considered to be the expression or attempt to solve a family problem rather than an individual one. The objective of this modality of psychotherapy is to produce a new family functioning in which there is no need for one of its members to be chronically ill. There is no specific focus on decreasing behaviors such as food restriction or weight recovery goals.
However, when the family spontaneously brings these aspects up, they must be addressed by the psychotherapist. In the systemic psychotherapy all 16 sessions are performed with the parents and the adolescent with AN together. Siblings or other people who live in the house are invited to participate in the psychotherapy sessions. After regaining weight, the focus is on its maintenance.
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When the adolescent reaches a BMI that poses no risk to his or her life, issues relating to adolescence such as autonomy and new challenges, as well as issues regarding family dynamics are addressed. None of the psychotherapy protocols described assessed the efficacy of the treatment group. A significant number of assessment instruments were used to assess the behavioral profile of the patients, their parents and the ED symptoms. An even greater diversity was used to assess family functioning and family characteristics, such as perceived family support, level of autonomy, and degree of differentiation among the members.
The wide variety of instruments used to assess the same family variables makes it difficult to compare the studies. In this sense, an attempt to standardize the instruments used in different research sites can be a promising measure; which would allow, in addition to the comparison between results from different samples, the development of meta-analyses. Most studies did not find a statistically significant difference when comparing the different treatment modalities 18,20,25,29, This can be justified by the reduced sample size of most of the studies, resulting in a possible type II error not finding differences between groups when they exist.
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The two studies 26,30 that found significant differences between groups, compared individual treatment, focusing on the adolescent vs treatment of the adolescent and the family members. It was found that the second modality was more promising, which suggests that interventions that include the family in the treatment have a greater reach than those only involving the adolescent.
This finding is corroborated by previous studies 13,14, Apparently, in terms of cost-benefit ratio, FBT is superior to the other treatment modalities, as it is associated with faster regaining of weight and, therefore, less days of hospitalization. Even in FBT, the complete remission rates are not encouraging. This finding points to the need to develop and assess the efficacy of new modalities of research protocols in psychotherapy that integrate FBT interventions with the approach for AN maintaining factors associated with family dynamics, which are already established in the literature.
The combining of good and intermediate outcomes without the presentation of the gross numbers was found, along with the creation of alternative remission criteria, and the presentation of only the participants who finished the treatment, rather than presenting the drop-out percentage; thus making it difficult to compare the results between the studies assessed. Sometimes exercise may be carried out in secret in the privacy of the bedroom or bathroom.
Laxative abuse: This is not as common as in adult populations partly because children have less access or opportunity to obtain laxatives, but nevertheless, it still occurs. Many children with anorexia nervosa will report that they consider themselves fat even when severely underweight, which is similar to the clinical observation seen in adult patients with the same condition. Preoccupation with weight: Children with anorexia nervosa tend to be preoccupied by their own body weight and are often experts at calorie counting.
This preoccupation is closely related to fear of fatness.
The majority of physical changes in anorexia nervosa are predominantly related to the effects of starvation and dehydration. This includes slow pulse rate, low blood pressure and poor circulation leading to cold hands and feet. Teeth may be pitted, eroded and decayed from gastric acid during vomiting. A wide range of biochemical changes have been described in anorexia nervosa, although there is little information specifically relating to children. These include low haemoglobin and white cell count, low levels of potassium and chloride, raised liver enzymes such as alanine transaminase and alkaline phosphatase, and low levels of plasma zinc and serum iron.
A number of endocrine changes appear in anorexia nervosa and evidence suggests that this is due to the secondary effects of starvation. Changes include increased cortisol, growth hormone and cholecystokinin, and decreased luteinizing hormone, follicle stimulating hormone, oestrogen, triodothyronine and thyroid stimulating hormone. Purging Type: During the current episode of bulimia nervosa, the person regularly engages in self-induced vomiting or laxative misuse, diuretics or enemas. Non-purging Type: During the current episode of bulimia nervosa, the person has used other inappropriate compensating behaviours such as fasting or excessive exercise, but not regularly used purging behaviour.
Eating Disorders in Children and Adolescents : A Clinical Handbook
Self-induced vomiting can lead to complications such as fluid and electrolyte disturbance and gastro-intestinal bleeding. Other physical complications include dental erosions, enlargement of the salivary glands, and muscle weakness. This term was first introduced by Higgs et al 9 , to describe a group of underweight children presenting with inadequate food intake and emotional disturbance who did not meet the criteria for anorexia nervosa.
The operational definition we use has evolved from Higgs and colleagues original description together with clinical experience and is as follows:. Selective eaters are a group of children who present with very restricted eating habits in terms of the range of foods they will accept.
This term was first described by Lask et al Initially these children present with features fairly typical of anorexia nervosa, but the food avoidance is gradually followed by a more generalised avoidance with a marked fear response. Children with this condition generally present with complaints of difficulty or pain on swallowing. Features include:. For a number of reasons, the incidence and prevalence of childhood-onset anorexia are not known.
There have been no epidemiological studies which have focussed specifically on this age group and the strict diagnostic criteria used in wider epidemiological studies may lead to a substantial underestimate of the true incidence. Although debatable, an increase in actual referral rate of anorexia nervosa in children has been reported. At present, there is little epidemiological information on the other eating disorders in children.
Comprehensive assessment should include physical, psychological and social components. Those with low to moderate risk should be managed as an outpatient. Those who are severely emaciated, with serious risk of self harm, with severe deterioration or with poor response to treatment are deemed high risk and should be considered for inpatient treatment or urgent referral to specialist services.
Pharmacological interventions have a very limited evidence base for the treatment of anorexia nervosa.
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Normal BMI range is BMI below 17 is a concern and GPs should consider referral to specialist services. However, BMI below 15 is serious and inpatient care should be considered. Anorexia nervosa carries considerable risk of serious physical morbidity. Awareness of the risk, careful monitoring and, where appropriate, close liaison with an experienced physician, are important in the management of the physical complications of anorexia nervosa.
This requires about to extra calories a week. The right to confidentiality of children and adolescents with eating disorders should be respected. Family members, including siblings, should normally be included in the treatment of children and adolescents with eating disorders. Interventions may include sharing of information, advice on behavioural management and facilitating communication.
They should also balance the need for treatment and urgent weight restoration with the educational and social needs of the young person. This may be sufficient treatment for a limited subset of patients. If treated, one third have full recovery, one third partial recovery and one third have chronic problems.
Poor prognostic factors for anorexia nervosa include: chronic illness, late age of onset, bulimic features such as vomiting and purging, anxiety when eating with others, excessive weight loss, poor childhood social adjustment, poor parental relationships and male sex. Prognosis for Bulimia nervosa is generally good, unless there are significant issues of low self esteem or evidence of severe personality disorder. Chapter Chapter 9.
Eating Disorders in Children and Adolescents: A Clinical Handbook
Author Index. Subject Index. Le Grange was a member of the team at the Maudsley Hospital in London that developed family-based treatment for anorexia nervosa. Over his career, he has treated numerous adolescents and families struggling with eating disorders. The author of over articles, books, book chapters, and published abstracts, Dr.