Evidence-based psychotherapy for treatment of anorexia nervosa in children and adolescents: systematic review

Alckmin-Carvalho, Felipe; Vega, Juliana Bergamo; Cobelo, Alicia Weisz; Fabbri, Alessandra Donzelli; Pinzon, Vanessa Dentzien; Melo, Márcia Helena da Silva

doi:10.1590/0101-60830000000154

person Felipe Alckmin-Carvalho

schoolEating Disorders Outpatient and Inpatient Program, Child and Adolescent Psychiatry Division (PROTAD/SEPIA), Department of Psychiatry, Institute of Psychiatry, University of Sao Paulo (USP), São Paulo, SP, BrazilschoolClinical Psychology Program, Institute of Psychology, University of Sao Paulo (USP), São Paulo, SP, Brazil

person Juliana Bergamo Vega

schoolEating Disorders Outpatient and Inpatient Program, Child and Adolescent Psychiatry Division (PROTAD/SEPIA), Department of Psychiatry, Institute of Psychiatry, University of Sao Paulo (USP), São Paulo, SP, Brazil

person Alicia Weisz Cobelo

schoolEating Disorders Outpatient and Inpatient Program, Child and Adolescent Psychiatry Division (PROTAD/SEPIA), Department of Psychiatry, Institute of Psychiatry, University of Sao Paulo (USP), São Paulo, SP, Brazil

person Alessandra Donzelli Fabbri

schoolEating Disorders Outpatient and Inpatient Program, Child and Adolescent Psychiatry Division (PROTAD/SEPIA), Department of Psychiatry, Institute of Psychiatry, University of Sao Paulo (USP), São Paulo, SP, Brazil

person Vanessa Dentzien Pinzon

schoolEating Disorders Outpatient and Inpatient Program, Child and Adolescent Psychiatry Division (PROTAD/SEPIA), Department of Psychiatry, Institute of Psychiatry, University of Sao Paulo (USP), São Paulo, SP, Brazil

person Márcia Helena da Silva Melo

schoolClinical Psychology Program, Institute of Psychology, University of Sao Paulo (USP), São Paulo, SP, Brazil

Address for correspondence: Felipe Alckmin-Carvalho. Institute of Psychology of the Universidade de São Paulo, Department of Clinical Psychology. Av. Professor Mello Moraes, 1721, Cidade Universitária, Building F, Room 19 – 05508-030 – São Paulo, SP, Brazil. Telephone:
(11) 3091-1961 E-mail:
felipealckminc@gmail.com

Conflict of interest

The authors have no conflict of interest related to the topic of this article. The funding agency had no role in the study design or in the decision to submit the paper for publication.

Authors/Country	Objective	N	Age	Theoretical perspective	Design	Sessions	Instruments	Results
Authors/Country	Objective	N	Age	Theoretical perspective	Design	Sessions	Instruments	End of treament	Follow-up
Le Grange et al. (1992)²⁰ (England)	To assess the effects of two modalities of family therapy: CFT and SFT for adolescents with AN in outpatient treatment.	18	15.33 (SD = 1.81)	CFT vs. SFT	RCT	9	MRAOS, EAT, RSE, SCFI, FACES-III	Of the 18 participants, 12 (67%) had a good/intermediate outcome, considering both treatments together, and 6 (33%), had a poor outcome. Both treatments showed improvement in terms of weight gain and relief of psychological symptoms, with no differences between groups (p > 0.05).	Period: Two years after baseline. Result: There were no changes.
Robin et al. (1994)²⁹ (United States)	Assess the impact on family relations for BFST vs. EOIT.	22	BFST: 14.7, (SD = 2.7) EOIT: (13.9) SD = 2.1)	BFST vs. EOIT (Current name: ASF)	RCT	48	PARQ OFC	55% of the BFST participants and 46% of the IOTR participants recovered in terms of weight and menstruation (p > 0.05). Descriptive analysis indicates better results from BFST.	Period: 12 months. Results: 82% of the BFST participants and 50% of the IOTR participants recovered in terms of weight and menstruation (p > 0.05).
Robin et al. (1999)³⁰ (United States)	To compare the effectiveness of BFST vs. EOIT in the treatment of adolescents with AN.	37	11-20 years	BFST vs. EOIT (Current name: ASF)	RCT	40	EAT, EDI, MFPS, BDI YSR, CBCL, PARQ	52.6% of BFST patients and 41.2% of patients in the EOIT group reached a 50th percentile in terms of weight (p > 0.05). 94% of the BFST group and 64% of the EOIT group were menstruating regularly (p < 0.05).	Period: 12 months. Results: 66.7% of the BFST group and 68.8% of the EOIT group reached the 50th percentile of weight (p > 0.05). 92.9% of the girls undergoing BFST and 80% of the EOIT group were menstruating regularly (p > 0.05).
Eisler et al. (2000)¹⁸ (England)	To assess and compare the efficacy of two psychological interventions for AN: CFT vs. SFT.	40	15.5 SD = 1.6	CFT vs. SFT	RCT	15-16	SMFQ, RSE, EAT, EDI, MOCI, FACES III, SCFI	CFT: 5 (26.3%) patients had a good outcome, 4 (21%) intermediate and 10 (52.7%) were poor. SFT: 10 (47.6%) patients had a good outcome, 6 (28.5%) intermediate and 5 (23.8%) were poor. There were no differences between groups (p > 0.05).	Did not exist.
Ball & Mitchell (2004)²⁵ (Australia)	To compare CBT with BFT in the treatment of adolescents with AN.	25	CBT: 18.45 (SD = 2.57) BFT: 17.58 (SD = 3.37)	CBT vs. BFT	RCT	21-25	MRS, EDE, ABOS, EDI, BDI, STAI-YI	69.2% of CBT participants completed treatment vs. 75% undergoing BFT. 77.8% of those who completed CBT and BFT treatment, had a “good” or “intermediate” outcome (p < 0.05).	Period: 6 months There were no changes.
Lock et al. (2005)²⁷ (United States)	To assess the effects of short term (ST) and long term (LT) of FTB in the treatment of adolescents with AN.	86	15.2 (SD = 1.7)	FBT	RCT	ST: 10 LT: 20	YSR, CBCL, EDE, K-SADS, YBC-ED, FES	There were no differences in primary outcomes (BMI and EDE) in the ST and LT interventions (p > 0.05). The indicators of internalizing behavioral problems (CBCL) and the subscale for eating behavior (EDE) were lower in the participants undergoing LT intervention.	Did not exist.
Gowers et al. (2007)²⁸ (England)	To assess the effectiveness of three treatment modalities for AN available in the British healthcare system: CAMHS vs. hospitalization in psychiatric ward vs. outpatient specialty care.	167	12-18 years	CBT and FBT	RCT	20-24	EDI, MRAOS, HoNOSCA, FAD, MFQ	CAMHS: 10 (18.2%) had a good results, 31 (56%) intermediate and 13 (24%) were poor. Specialized outpatient clinic: 8 (15%) had a good outcome, 22 (40%) intermediate and 24 (44%) were poor. Inpatient ward: 12 (21%) had a good results, 18 (32%) intermediate and 26 (46%) were poor.	Period: 2 years after baseline. Results: CAMHS 20 (36%) had a good outcome, 20 (36%) intermediate and 14 (26%) were poor. Specialized outpatient clinic: 13 (24%) had a good outcome, 28 (51%) intermediate and 12 (22%) were poor. Inpatient ward: 19 (33%) good, 17 (30%) intermediate and 17 (30%) were poor.
Paulson-Karlsson et al. (2009)¹² (Sweden)	To assess the effects of FTS + CFT for adolescents with AN undergoing outpatient treatment.	32	15.4 (SD = 1.4)	SFT + CFT	Open Trial	20-25	RAB, EDI, YSR, FSC	No results were reported at the end of treatment.	Period: 36 months. Results: 25 (78%) of the participants achieved complete remission, with reduction of eating symptoms, internalizing problems and improvement of family situation. No results were reported in terms of good, intermediate or poor outcomes, nor the results at the end of treatment.
Lock et al. (2010)²⁶ (United States)	To compare the impact of FBT vs AFT (former EOIT) on complete remission in the treatment of adolescents with AN.	121	14.4 (DP = 1.6)	FBT vs. AFT	RCT	24	EDE, K-SADS	Complete remission in 22.6% undergoing AFT and 41.8% undergoing FBT, (p > 0.05).	Period: 12 months. Results: complete remission in 23.2% undergoing AFT and 49.3% undergoing FBT (p < 0.05).
Turkiewicz et al. (2010)²² (Brazil)	To assess the viability, acceptance and efficacy of FBT for AN in adolescents in Brazil.	9	14.64 (DP = 1.63)	FBT	Open Trial	10-12	EDE-Q CGAS	7 (78%) completed the treatment. Six (86%) re-established the target weight, 4 (44%) returned to menstruating regularly. There was no statistically significant reduction in the EDE-Q or CGAS scores.	Period: 6 months. Results: 7 (100%) were assessed. They all regained their weight and returned to menstruating regularly. There was improvement in CGAS (p < 0.05), but not in the EDE-Q.
Dalle-Grave et al. (2013)²³ (Italy)	To assess the effects of the CBT-e intervention in adolescents with AN and to determine if this type of intervention can be an alternative to FBT.	46	15.5 (SD = 1.3)	CBT-e	Open Trial	44	EDE-q GSI	29 (63%) completed treatment, 9 (32%) reestablished 95% of ideal weight and 28 of those who completed treatment (96.6%) reduced symptoms of eating disorders and other psychiatric disorders compared to the baseline of the treatment.	Period: 12 months. Results: 29 (63%) were assessed at follow-up. Of these, 13 (44.8%) reestablished 95% of the ideal weight. Psychiatric symptoms remained stable.
Agras et al. (2014)²⁴ (United States)	vs	158	15.3 (SD = 1.8)	FBT vs. SyFT	RCT	16	EDE, BDI, RSES, QLES (short form), SAI, CYBOCS YBCEDS	All participants completed both treatment modalities. Remission rate of 33.1% for FBT and 25% for SyFT (p > 0.05) in all endpoints, except for the self-esteem scale, in favor of SyFT.	Period: 12 months. Results: 114 (72%) were assessed. Remission of 40.7% for FBT and 39.0% for SyFT (p > 0.05). Faster weight gain in the FBT group, and fewer days of hospitalization, which makes intervention less costly.
Timko et al. (2015)⁹ (United States)	To assess the feasibility, acceptability and effectiveness of ASFT.	47	14.02 (SD = 1.58)	ASFT	Open Trial	20	CEQ, EDE, EDEq, ABOS, famQ, DERS, AFQ-Y and AAQ-2	of the participants who started treatment, 49% had complete remission and 29.8% had partial remission. The proportion of patients who completed treatment with total remission was 67.7% and, with partial remission, 32.3%.	Did not exist.
Accurso et al. (2015)³¹ (United States)	To compare FBT-based intervention results achieved in a study with a RCT design, of those obtained in a traditional clinical setting (SCC)	84	14.5 (SD = 2.2)	FBT	Mixt (Open Trial + RCT)	18	EDE-12.0, KSADS, BDI	57% of the total participants had reestablished their weight: RCT (62.5%) and SCC (53.8%). There were no differences between groups (p > 0.05). Patients with BMI < 81% of expected had better RCT results (p < 0.05).	Did not exist.

[TFN1] ASFT: Acceptance-based Separated Family Treatment; ACT: Acceptance and Commitment Therapy; FBT: Family-Based Treatment; RCT: randomized clinical trial; EDE: Eating Disorder Examination, EDE-q: Eating Disorder Examination questionnaire; ABOS: Anoretic Behavior Observation Scale; famQ: Family Questionnaire; DERS: Difficulties in Emotional Regulation Scale; AFQ-Y: Action and Fusion Questionnaire-Youth; AAQ-2: Acceptance and Action Questionnaire; BDI: Beck Depression Inventory; BFST: Behavioral Family Systems Therapy; EOIT: Ego Oriented Individual Therapy; PARq: Parent Adolescent relationship questionnaire; OFC: Observed Family Conflicts; CBT-E: Cognitive Behaviour Therapy Enhanced; GSI: Global Severity Index; CGAS: Children's Global Assessment Scale; SyFT: Systemic Family Therapy; RSES: Rosenberg Self-Esteem Scale; QLES: Quality of Life and Enjoyment Scale (short form); SAI: State-trait Anxiety Inventory; CYBOCS: Child Yale Brown obsessive Compulsive Scale; YBCEDS: Yale Brown Cornell Eating Disorder Scale; EAT: Eating Attitudes Test; EDI: Eating Disorder Inventory; MFPS: Maturity Fears and Perfectionism Scale; YSR: Youth Self Report; CBCL: Child Behavior Checklist; CAMHS: treatment as usual; KSADS: Kiddie Schedule for Affective Disorders and Schizophrenia; CFT: Conjoint Family Therapy; RAB: Rating of Anorexia and Bulimia Nervosa; FSC: The Family Climate self-rating scale; SMFQ: Short Mood and Feeling Questionnaire; MOCI: Maudsley Obsessional Compulsive Index; FACES III: Family Adaptability and Cohesion Evaluation Scale; SCFI: Standardized Clinical Family Intervention; HoNOSCA: Health of the Nation Outcome Scale for Children and Adolescents; FAD: Family Assessment Device; MFQ: Mood and Feeling Questionnaire; FES: Family Environment Scale; MRAOS: Morgan-Russell Average Outcome Scale.