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The most highly recommended treatments were family-based.
By any measure, it was a daunting project: establishing Canadian practice guidelines for treating children and adolescents with eating disorders. A panel headed by Dr. Jennifer Couturier at McMaster University, Hamilton, Canada, along with a panel of clinicians, researchers, parents, and those who had real-life experience with eating disorders recently took on the country-wide task.
The panel developed a list of suggestions, including strong recommendations for Family-Based Treatment (FBT), as well as care provided in the least-intensive environment (J Eat Disord. 2020; 8:4). Other types of treatment, including Multi-Family Therapy, Cognitive Behavioral Therapy, Adolescent-focused Psychotherapy, Adjunctive Yoga and use of atypical antipsychotics had weaker recommendations.
The investigators noted that despite the seriousness and prevalence of EDs and the need for earlier diagnosis, no Canadian practice guidelines existed to help clinicians make treatment decisions. When they evaluated clinical guidelines developed by the National Institute of Health and Care Excellence, the guidelines did not include any form of grading of the evidence. Guidelines from the Academy of Eating Disorders focused on medical management, not on psychotherapeutic/psychopharmacologic interventions.
Family-based treatment
Of all the treatments examined for AN, the group found that FBT had the most evidence to support its use in teens and children (see also “When Family-Based Treatment Fails,” elsewhere in this issue). As for bulimia nervosa, when FBT was compared to CBT, remission rates were significantly better in the FBT group (39% vs. 20%) (Child Adolesc Psychiatry. 2015; 54:886).
Recommendations
The group strongly recommended FBT for most children or adolescents with AN or BN, especially those who had been ill for fewer than three years. The group recognized that there are challenges when implementing FBT, including the need for specialized, well-trained staff members, access to care and costs of training, adding that Parent-Focused Family Therapy, where the patient is seen separately from the family, may be just as effective as traditional FBT, where the family is seen together. They concluded that Structural and Systemic Family Therapy might be helpful for children and adolescents with AN but evidence doesn’t show that it is superior to FBT, especially when costs are considered.
The group also listed some promising therapies that have some data but need more research before definitive recommendations can be made, including:
- FBT for children with atypical AN
- FBT for children with Avoidant/Restrictive Food Intake Disorder (ARFID)
- FBT for children across the gender spectrum, including those who are gender-variant or gender non-conforming
- Cognitive Remediation therapy, art therapy, and CBT for children and teens with AN
- Emotion-focused family therapy for BN and AN
- Other forms of family therapy, including Multi-family therapy, and CBT.
A few potential medications identified
According to the panel, use of olanzapine or aripiprazole might be reasonable options for certain populations of teens and children with AN, especially when monitored carefully. Some promising medications, which need further research, include selective serotonin reuptake inhibitors (such as fluoxetine for BN), risperidone and quetiapine for AN, atypical antipsychotics for use in ARFID, and mirtazapine for patients with AN. Some medications have no evidence of effectiveness or (in one instance) could be harmful, including selective norepinephrine reuptake inhibitors, mood stabilizers, and buproprion (elevated risk of seizures).
It is important to note that the review did identify the scant nature of the psychopharmacology literature in this area.
Parents and patient representatives weigh in
Parents and patient representatives pointed out the critical importance of peer support (parents and patients), especially during transition to different levels of care and during the transition from pediatric to adult systems of care. The panel also stressed the importance of a coordinated continuum of care from outpatient to residential care. This group noted a lack of services, especially the lack of residential care centers across Canada, and the great need for individuals with skill in working in intensive inpatient and residential services. This becomes especially essential for those patients who are medically stable and who also have psychiatric co-morbidities, who need longer-term treatment in a highly structured environment. For example, in Canada (as seems to be the case in many other places) there are no services for patients with substance abuse comorbidity.
The guidelines panel encountered several gaps that they feel need future study, including treatments for complex presentations of eating disorders and co-morbidities such as borderline personality disorder, obsessive-compulsive disorder, and substance use disorder. The panel also had difficulty recommending inpatient levels of care, noting that these services deserve further study and expansion throughout Canada. One important area for future study includes identifying and giving attention to transition-age youth (young adults 16 to 24 years of age), an important group with unique needs.