Cognitive-behavioral therapy for weight management and eating disorders in children and adolescents

Eating disorders and obesity in children and adolescents involve harmful behavior and attitude patterns that infiltrate daily functioning. Cognitive-behavioral therapy (CBT) is well suited to treating these conditions, given the emphasis on breaking negative behavior cycles. This article reviews the current empirically supported treatments and the considerations for youth with weight control issues. New therapeutic modalities (ie, enhanced CBT and the socioecologic model) are discussed. Rationale is provided for extending therapy beyond the individual treatment milieu to include the family, peer network, and community domains to promote behavior change, minimize relapse, and support healthy long-term behavior maintenance.     

Cognitive-behavioral theories of eating disorders

This article presents an integrated cognitive-behavioral theory of eating disorders that is based on hypotheses developed over the past 30 years. The theory is evaluated using a selected review of the eating disorder literature pertaining to cognitive biases, negative emotional reactions, binge eating, compensatory behaviors, and risk factors for eating disorders. In general, hypotheses derived from cognitive-behavioral theories have been supported by a variety of research studies. The implications of these findings for treatment and prevention of eating disorders are discussed. This review of the literature serves as a conceptual base for some of the other articles that are included in this special issue of Behavior Modification. The article concludes with an introduction to six articles that discuss issues related to psychiatric classification, assessment, treatment, and prevention of eating disorders.     

Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review

OBJECTIVE: To review the literature on the cognitive-behavioral treatment of children and adolescents with anxiety and depressive disorders within the conceptual framework of evidence-based medicine. METHOD: The psychiatric and psychological literature was systematically searched for controlled trials applying cognitive-behavioral treatment to pediatric anxiety and depressive disorders. RESULTS: For both anxiety and depression, substantial evidence supports the efficacy of problem-specific cognitive-behavioral interventions. Comparisons with wait-list, inactive control, and active control conditions suggest medium to large effects for symptom reduction in primary outcome domains. CONCLUSIONS: From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents. Future research in this area will need to focus on comparing cognitive-behavioral psychotherapy with other treatments, component analyses, and the application of exportable protocol-driven treatments to divergent settings and patient populations.     

Intensive outpatient group treatment for adolescents with eating disorders

We present an intensive outpatient group treatment for girls with eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder) additionally to/instead of inpatient treatment or individually treatment by psychotherapists. The therapy concept is primarily behaviour therapy oriented, encouraging the self-management-abilities of the patients thereby learning self-determination and responsibility in dealing with their illness. The slow-open group concept provokes group cohesion, solidarity and support among girls, who share similar age-related development-stages and eating disorders. Other than cognitive behaviour therapy and the principles of self-management we use client-centered therapy, art-, dance- and nutritional therapy. For each patient an individual treatment plan is adapted depending on age, individual symptoms, problems and motivation. Each member of the group has to accept defined group rules during the group sessions. The group takes place twice a week and on one Saturday per month. The adolescents stay in their social environment. Transfer of therapeutic success into daily life therefore is immediate and longlasting. Duration of therapy is between four months and one year, longer only in complex cases. Parallel to the parent/patient cooperation a parental psycho-educative group is available.     

Risk factors for eating disorders in adolescents

OBJECTIVE: The aim of this study was to identify psychopathological, social and family variables that, measured at the age of 13, might predict the development of eating disorders 2 years later, using a standardized interview and controlling the effect of initially abnormal eating behavior. METHOD: At age 13 and 15, 1076 adolescents completed questionnaires for the screening of psychiatric morbidity, abnormal eating attitudes and family dysfunction. Probable cases of eating disorders [159] and 150 controls were assessed with standardized interviews (SCAN). RESULTS: Controlling the effect of previous eating psychopathology, pathological body dissatisfaction, measured with the Body Shape Questionnaire (BSQ), and a negative perception of parental attitudes were predictors of eating disorders 2 years later. Self-esteem was a protective factor for body dissatisfaction. CONCLUSIONS: Preventive actions should focus on self-esteem as a protective factor for body dissatisfaction, a strong predictor for eating disorders. The significance of family perception should be explored more in detail in future research.     

Cognitive-behavioral therapy for bipolar disorders in adolescents: a pilot study

Objectives:  To develop a cognitive behavioral intervention for adolescents with bipolar disorders, test its feasibility and preliminary efficacy.
Methods:  Based on existing research, a manualized, individually delivered cognitive behavioral intervention was developed and tested with adolescents with bipolar disorders as an adjunct to pharmacological treatment. Using existing data, baseline characteristics and outcome were compared to a matched group of eight adolescents with bipolar disorders who did not receive any psychosocial intervention.
Results:  Preliminary results support the feasibility and efficacy of this manualized cognitive behavioral intervention.
Conclusions:  Individually delivered cognitive-behavioral therapy (CBT) as an adjunct to pharmacological treatment is feasible and associated with symptom improvement in adolescents with bipolar disorders. Randomized controlled studies are needed.     

Multimodal arts psychotherapy with adolescents suffering from conduct disorders

We explore the mode of action of multimodal arts psychotherapy through a longitudinal study with 56 adolescents suffering from conduct disorders and treated by means of arts psychotherapies, based on literary and musical production.Original rating scales for the literary production as well as observational frames for active music therapy, allow us going from qualitative analysis to quantification and the use of inferential and multidimensional statistics.The pretest–posttest analysis of the data of the rating scales and the observational frames has shown significant changes in form and contents of the literary productions, as well as in style and communication mode during musical production. A correlational study on Delta values has given further insight into the psychological meaning of changes. A detailed investigation of the psychotherapeutic process, has allowed us to distinguish different recurring phases that we will illustrate through the presentation of typical literary productions.The discussion is about the differences between this combined treatment methodology and traditional active or receptive music therapy, about the contribution to the psychological diagnosis of stories written under musical mood induction as well as about more fundamental epistemological considerations regarding the construction of knowledge in arts psychotherapies.Our clinical and experimental data led to a modelling of the mode of functioning of multimodal arts psychotherapy in the treatment of conduct disorders in adolescence. Possibilities of tertiary prevention can be derived from this, as well as approaches for future research.     

Health-related quality of life among adolescents with eating disorders

Objective

Health-related quality of life (HRQoL) is an emerging area of research in eating disorders (EDs) that has not been examined in adolescents in detail. The aim of the current study is to investigate HRQoL in an adolescent ED sample, examining the impact of ED symptoms on HRQoL.

Methods

Sixty-seven treatment-seeking adolescents (57 females) with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (EDNOS) completed self-report measures of HRQoL and ED symptoms.

Results

Participants reported poorer HRQoL in mental health domains than in physical health domains. Disordered attitudes, binge eating, and compensatory behaviors were associated with poorer mental health HRQoL, and body dissatisfaction was associated with poorer physical health HRQoL.

Conclusion

The current study assessed HRQoL among adolescents with EDs, finding several consistencies with the literature on adults with EDs. Future research should compare adolescents and adults with EDs on HRQoL.     

Efficacy of psychodynamic short-term psychotherapy for children and adolescents with anxiety disorders

Anxiety disorders can be regarded as one of the most prevalent disorders in children and adolescents. Although psychodynamic psychotherapies are frequently carried out in this field, the evaluation of its efficacy for anxiety disorders is still deficient. Therefore the aim of the study was to evaluate psychodynamic short-term psychotherapy (PSTP) comprising 25 therapy sessions for children and adolescents with anxiety disorders. In a controlled trial PSTP was compared to a waiting list control condition. 26 children and adolescents with anxiety disorders were included in the study. Treatment outcome was measured by the Impairment-Score for Children and Adolescents (IS-CA). Moreover, the Child Behavior Checklist (CBCL) and the Psychic and Social-Communicative Findings Sheet for Children and Adolescents (PSCFS-CA) were administered at the beginning and end of the treatment. The statistical and clinical significance of changes in these measures was evaluated. A significant advantage of the treatment group compared to the waiting control group for the IS-CA was shown. For the IS-CA total score, an effect size of 1.6 was found. Whereas 62% of the patients in the treatment group showed clinically significant and reliable improvement at the end of therapy, this was the case for only 8% of the subjects in the waiting list condition. Effect sizes comparable to the IS-CA were found for the PSCFS-CA. In the CBCL significant improvement could be shown for the treatment and control group. The findings support the evidence that psychodynamic short-term psychotherapy (PSTP) is an effective treatment for children and adolescents with anxiety disorders. However, some of the studied children and adolescents seem to be in need of more intensive treatment.     

Efficacy of psychodynamic short-term psychotherapy for children and adolescents with behavioral disorders

Behavioral disorders represent one of the most frequent mental disorders in children and adolescents. Even though psychodynamic psychotherapies are often used to treat behavioral disorders, to date, its efficacy has rarely been empirically evaluated. The aim of the study therefore was to evaluate psychodynamic short-term psychotherapy (PSTP) for children and adolescents with behavioral disorders. By means of a waiting-list controlled study, 26 children and adolescents fulfilling diagnosis of behavioral disorders were examined. The treatment group received 25 sessions of psychodynamic psychotherapy. Primary criterion of outcome was the Impairment-Score for Children and Adolescents (IS-CA). Furthermore, the Child Behavior Checklist (CBCL) and the Psychic and Social-Communicative Findings Sheet for Children and Adolescents (PSCFS-CA) were administered at the beginning and end of the treatment. The statistical as well as the clinical significance of changes during treatment were analysed. It could be shown, that the treatment group improved significantly more in the Impairment-Score for children and adolescents (IS-CA) compared to the waiting group. The effect size of the IS-CA total score was 0,6. 31% of the children in the treatment group improved clinically significantly or according to the criterion of Reliable Change, whereas that was the case only for 8 % of the subject in the waiting list condition. A significant advantage was found for the therapy group in the PSCFS-CA. Effect sizes were between 0.8 and 1.4. In the CBCL significant improvement could be shown for the treatment and control group however only with small effects. These results substantiate that psychodynamic short-term psychotherapy (PSTP) is an effective intervention for children and adolescents with behavioral disorders. However, the findings also show that some of the children and adolescents are in need of a more intensive or long-term treatment.     

The quality of randomized controlled trials of psychotherapy for eating disorders

Objective

We investigated the quality of randomized controlled trials (RCTs) that included direct comparisons of psychotherapy for adults with an eating disorder (ED).

Method

Thirty‐five direct comparison RCTs of psychotherapy for adults diagnosed with an ED were rated using the Randomized Controlled Trials Psychotherapy Quality Rating Scale (RCT‐PQRS).

Results

The mean total RCT‐PQRS score (mean = 28.26; SD = 7.04) was in line with those that were reported for RCTs of psychotherapy for depression and anxiety disorders. Several standards of quality were unfulfilled by over half of the RCTs of treatment for EDs, including therapist supervision while treatment was being provided (62.9% unfulfilled); outcome assessment performed by raters blind to treatment group/condition (54% unfulfilled); and adequate sample size (66% unfulfilled). More recent RCTs were of higher quality, and higher quality was moderately associated with lower effect sizes.

Conclusions

To improve the quality of RCTs of psychotherapy of EDs, we recommend that researchers address the quality criteria listed in the RCT‐PQRS. Psychotherapy trials should be registered, have a published protocol, and be reported following the Consolidated Standards of Reporting Trials guidelines. Authors should take into account the quality of the research when using that research to inform ED treatment guidelines.

     

Prevention of eating disorders in argentine adolescents

ABSTRACT

In the last few decades much effort has been devoted to developing prevention programs for eating disorders, as most individuals with these pathologies do not receive treatment and tend to become chronic. The purpose of this study was to evaluate a cognitive dissonance and media literacy intervention aimed at preventing eating disorders in female adolescents. Eighty-eight female students (aged 12–17) from Argentina, participated in a 3-session program. Adolescents completed a baseline, post-intervention and a 6-month follow-up survey. A significant decrease in thin-ideal internalization, body image concerns, influence of advertising, drive for thinness and bulimic attitudes was found at post-intervention. In addition, the number of participants with disturbed eating attitudes and behaviors decreased at post-intervention. Results for body image concerns and drive for thinness were maintained at follow-up.     

The prevalence of eating disorders in adolescents with idiopathic scoliosis

This study examines the hypothesis of an association between adolescent idiopathic scoliosis (AIS) and eating disorders (EDs). A population of young females affected by AIS has been interviewed for a possible diagnosis of EDs. The proportion of individuals with EDs resulted significantly larger than normative epidemiological data: Prevalences were 9.2% for anorexia nervosa (AN), 7.7% for bulimia nervosa (BN) and 5.3% for eating disorders not otherwise specified (EDNOS). The relationship between EDs and AIS was further tested through a second analysis. Severity of the rachides pathology was correlated with the presence of AN. Our study supports the hypothesis of a comorbidity between AIS and EDs: Some possible clinical explanations for this association are discussed.     

Psychological education as a group process for parents of adolescents with eating disorders

Psychoeducation is a well-established component of cognitive-behavioral therapy in adult patients with eating disorders. This paper describes a group model of psychoeducation that has been offered by our department for the past two years to parents of adolescent patients with anorexia and bulimia nervosa. According to their own reports, parents appreciate this means of support to help them cope with their child's illness.     

Group psychoeducation for parents of adolescents with eating disorders: the Aachen program

Family-based treatment in adolescents and individual psychoeducation in adults are accepted components in a multimodal treatment of eating disorders. However, only few studies have been conducted on the use of parent-based psychoeducation. This paper presents the structure and content, as well as a preliminary evaluation, of a group psychoeducation program for parents of adolescent patients with eating disorders. The program is limited to five 90-minute sessions and aimed at increasing the parents' understanding of the disorder and promoting high transparency with regard to our treatment principles. The vast majority of parents rated the group psychoeducation as helpful in coping with their child's disorder and would recommend others to take part in the program.     

Individual psychotherapy for children and adolescents with an eating disorder from historical precedent toward evidence-based practice

This article reviews the place of individual therapy in the suite of treatment services required by children and adolescents with an eating disorder. Individual therapy is defined and traced from historical origins in psychoanalytic practice with later important modifications by Hilda Bruch and Arthur Crisp. More recent developments, based primarily on cognitive and learning theory are discussed, as is the timing of individual therapy with respect to illness stage and patient motivation. Evidence for therapy effectiveness is reviewed where possible. At present, treatment evidence in the pediatric mental health field must be inferred from adult research.     

Parent psychoeducation groups in the treatment of adolescents with eating disorders

Parents of adolescents with eating disorders show high levels of emotional distress, which may contribute to less functional coping with the illness of their child. In our department a psychoeducational group program is been offered to the parents of 153 children and adolescents with anorexia and bulimia nervosa. According to their own reports parents are highly interested in gaining information about the eating disorder and appreciate this means of support to help them to cope with the illness of their child.