Written by Judith Banker, MA, LLP, FAED
When your child or adolescent has an eating disorder, the treatment landscape (levels of care, types of treatment, access to treatment etc.) can be overwhelming and confusing. Eating disorders are complex illnesses, therefore the type, course, and level of treatment can vary from child to child, family to family.
This page describes the levels of care and the types of evidence-based treatments available for all eating disorders including anorexia nervosa, bulimia, binge eating disorder, ARFID, OSFED (Other Specified Feeding and Eating Disorders) and related conditions.
Please note: Current levels of care and evidence-based treatments are not standardized across all regions of the world. While every effort was made to gain information about findings and practices from across the globe, the information presented here is derived primarily from research findings and from treatment guidelines developed in North America, Europe, and Australia. Future advances in cross-cultural research and collaboration will help our field understand and develop treatments and practice guidelines that can be culturally adapted and practiced effectively worldwide.
The term “level of care” refers to the therapeutic setting in which treatment is provided. Levels of care can range from a flexibly structured outpatient therapeutic setting where the patient and family participate in weekly hourly treatment sessions while remaining engaged in most of their usual school and work activities, to a highly structured, inpatient hospital medical unit where the child receives round the clock multidisciplinary care and support.
The appropriate level of care is determined by the severity of the illness including degree of medical stability, the ability to progress at the current level of care, and the family’s ability to provide the support or structure needed for their loved one to progress in treatment. Every family and every child has unique needs as well as strengths and limitations (personal or environmental) that impact treatment. All of these factors are taken into consideration when the appropriate level of care is determined.
As a parent, you do not need to – nor should you – make the decision alone as to what the appropriate level of care is for your child. This is a decision that is best made collaboratively with your treatment team based on your child’s needs, your needs as a family, and the recommendations of the team.
If you are just starting out seeking help for your child, an outpatient evaluation with a specialist physician, or specialist mental health team/professional is the first step to determine the best level of care and/or treatment recommendations.
It is important to be aware that treatment guidelines for children and adolescents with eating disorders strongly recommend that treatment should be offered at the least intensive level of treatment feasible, especially for children/adolescents with anorexia nervosa with a duration of illness less than 3 years. In other words, it may be best to start out with outpatient treatment if possible, and increase gradually to higher levels of care if and when needed.
In most cases the initial level of care recommended will be outpatient. Outpatient treatment is the least disruptive to your child’s life and allows your child and you and your family to stay engaged in their usual day to day activities and home life while they participate in treatment.
Treatment usually consists of weekly sessions (around 60 minutes in length, more or less) with a licensed mental health professional experienced in eating disorder diagnosis and treatment, a dietitian or nutrition specialist, and a medical provider. The frequency of these sessions may vary depending on symptom severity and the modality of treatment that is recommended. As your child progresses, session frequency will gradually reduce.
Length of treatment is highly variable, again depending on symptom severity and the complexity of the symptomatology (that is, the presence of co-occurring factors including mood disorders, obsessive compulsive disorder, trauma, autism spectrum disorder, or complicating physical conditions).
Your treatment team will be able to discuss potential length of care, frequency of sessions and types of treatment involved with you as part of the initial evaluation/intake process.
Treatment for children and teens is often approached more aggressively due to the physiological demands of growth and development. Growing children and adolescents can be more quickly destabilized physically and mentally by the dietary/nutritional dysregulation that accompanies an eating disorder.
If your child is not making progress in outpatient care, a step up in level of care to Intensive Outpatient Treatment (IOP) can provide the additional support or structure needed to promote momentum toward symptom reduction and physical and mental restoration.
Treatment takes place in the IOP setting, between three to 5 days per week and can include therapy groups, family sessions, weight and behavioral monitoring, a daily meal and snacks,
and weekly sessions with a mental health professional, a dietitian, and medical management by a physician and a psychiatrist. Program structures can vary from region to region.
If further structure and supervision is needed to help your child, participation in a PHP or “day treatment” program may be recommended. The schedule can vary from program to program and region to region, but generally participants participate from six to 10 hours each day, five to seven days a week. A certified teacher may be provided for children and teens. Parents/families can be involved more or less intensively depending on the need and the design of the program.
The structure can include multiple group therapy sessions a day, therapeutic meals and snacks, medical monitoring of weight, vital signs, and bloodwork, family therapy/education/support, regular sessions with a psychiatrist, an individual therapist, and with a registered dietitian and other associated therapy professionals such as art or music therapy, and occupational therapy.
Involvement in a PHP can place greater demands on families, in particular if it is necessary to commute a significant distance to transport your child and/or to attend family sessions. In addition, most PHPs do not have accommodations for families or the child/teen to spend the night. Some parents may arrange for temporary housing near the facility during their child’s term of treatment, but for many families this is not an option.
Length of participation can vary based on geographic location and regional insurance practices.
Residential treatment provides a 24/7 live-in support and treatment environment. This is often a non-medical unit in a hospital, or a large home-like setting that offers medical management and psychiatric care, individual and family therapy and nutrition sessions, along with multiple daily groups. All meals and snacks are provided. Length of stay can vary based on geographic location and regional insurance practices.
Inpatient hospitalization is the highest level of eating disorder treatment. This level of care comes into play when the child’s medical or psychiatric status is so compromised, either in the short or long term, that 24/7 medical management is required; in particular when life-threatening conditions like severe depression or suicidal ideation, acute dehydration, cardiac abnormalities, fainting/dizziness, or extreme lethargy and other conditions related to severe malnutrition or eating dysregulation are involved.
The goal of inpatient hospitalization is medical and psychiatric stabilization so the child can step down to residential or PHP level of care and gradually return to or begin outpatient treatment to progress toward recovery.
Research on the effectiveness of treatments for eating disorders is more commonly carried out with adult patients. Available findings for effective treatments with child and adolescent eating disorders are more limited.
Working with a multi-disciplinary eating disorder specialist team treatment is strongly recommended whenever possible – including a psychologist/social worker, a dietitian or nutritionist, and medical management with a pediatrician and, if indicated, a psychiatrist.
The general aim of the treatment team is to work together with the family and patient to address symptom management and physical restoration while also addressing any co-occurring or pre-existing psychological and physical conditions, as well as effects or reactions to current treatment. Toward the end of treatment, the focus is on relapse prevention.
Research on the effectiveness of treatments for eating disorders is more commonly carried out with adult patients. Available findings for effective treatments with child and adolescent eating disorders are more limited.
Working with a multi-disciplinary eating disorder specialist team treatment is strongly recommended whenever possible – including a psychologist/social worker, a dietitian or nutritionist, and medical management with a pediatrician and, if indicated, a psychiatrist.
The general aim of the treatment team is to work together with the family and patient to address symptom management and physical restoration while also addressing any co-occurring or pre-existing psychological and physical conditions, as well as effects or reactions to current treatment. Toward the end of treatment, the focus is on relapse prevention.
FBT, also known as the Maudsley Method, is widely viewed as the first line treatment of choice for children and adolescents with eating disorders. This approach was developed based on the recognition that parents/families are critical resources for the care and feeding of their children, and thus are essential to the treatment process.
The whole family is directly involved in this treatment approach, taking an active role in re-feeding and other Interventions to help their child recover. Studies on the effectiveness of FBT have most frequently addressed the delivery of the treatment to children and adolescents with anorexia nervosa and bulimia. However, more recent studies are beginning to demonstrate FBT has potential for the treatment of BED (binge-eating disorder) and ARFID (avoidant/restrictive food intake disorder) as well.
FBT is a manualized treatment approach that is broken down into three phases: re-feeding, weight restoration, and interruption of compensatory behaviors; returning age appropriate control of eating to the child; and establishing age appropriate autonomy over food intake. The role of the professional/s is to provide guidance and support to the family as they work to help their child progress through the phases of the program.
FBT is most often delivered in an outpatient or partial outpatient setting where the interventions can be practiced at home, but efforts to adapt the delivery of FBT at higher levels of care are producing promising results.
In situations involving an adolescent where FBT has been attempted but was ineffective, or if FBT is contraindicated, not possible, or simply not available, AFT may be a reasonable alternative. AFT is not a manualized treatment which makes it more difficult to assess by empirical research, but the essential elements of AFT include: the use of a strong, effective therapeutic relationship to achieve symptom management; psychoeducation; and the development of more positive coping mechanisms and self-understanding to foster autonomy from the eating disorder. The parents or other family members may be involved in this form of treatment when possible or recommended. AFT can also address co-occurring mood disorders, trauma, and other psychological conditions that often accompany eating disorders.
This form of therapy, widely considered to be a second line treatment of choice for children and adolescents with eating disorders targets the beliefs, thoughts, and behaviors associated with disordered eating, body image, and related issues.
The objective of CBT or CBT-ED is to practice interventions that challenge and modify those thoughts/beliefs/actions that lead to the development and/or perpetuation of the eating disorder. CBT principles and interventions can also be applied to the management of co-occurring mood disorders and other psychological conditions that often accompany eating disorders. CBT and CBT-ED can be delivered across all levels of care.
DBT is based on an affect or emotion regulation model. When applied to the treatment of eating disorders the principles of DBT address the episodes of emotional dysregulation that trigger or reinforce disordered eating. Further, DBT skills can be applied to mood disorders and other psychological conditions that often accompany eating disorders. DBT can be delivered across all levels of care.
Again, it is important to keep in mind that treatment for eating disorders can often be a trial and error process. In some cases, families start out with a professional team and treatment approach that is a good fit. In other cases, due to lack of access to treatment or other variables, it can be more difficult to arrange the type of treatment your child needs. While you are figuring things out, lean on us at F.E.A.S.T. for support and information.
F.E.A.S.T. does not recommend specific treatment providers or treatment centers.
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