A Review of: Evidence Based Treatment for Eating Disorders: Children, Adolescents, and Adults (Eating Disorders in the 21st Century), 2nd ed., edited by Ida Dancyger and Victor Fornari and The Oxford Handbook of Child and Adolescent Eating Disorders: Developmental Perspectives, edited by James Lock

A mother sits in my office, frantic that her daughter refuses to eat anything except noodles with butter and doesn't seem to be growing taller. Later that day, a father becomes distraught when he describes how his son has been more and more withdrawn, eating less and less, and losing more and more weight. And yesterday, an adolescent girl talked about how she desperately wants to lose weight but can't seem to stop herself from bingeing on any food she can find.

Most child psychiatrists have heard some version of a story of disordered eating, and yet most child psychiatrists (and indeed most physicians) have surprisingly little training in assessing and treating eating disorders in any age group. In children and adolescents, specifically, it is difficult to learn about the epidemiology of eating disorders, as is the case for many psychiatric disorders. In general, fewer studies are conducted in the pediatric population, and there are lower numbers of kids with eating disorders in the general population than, for example, kids with anxiety; therefore, it is more difficult to detect. In addition, there can be a tremendous amount of shame and secrecy associated with having an eating disorder, so our patients often don't present, and even clinical cohorts may be underrepresented.

Despite these difficulties, however, it is quite surprising that child psychiatrists do not have more exposure to eating disorders during their training. Anorexia nervosa is the third most common chronic illness among adolescents (after obesity and asthma) (Herpertz-Dahlmann, 2008). Rates of eating disorders can vary dramatically among studies; the point prevalence for anorexia nervosa lies between 0.3 and 0.9%, and the lifetime prevalence for anorexia nervosa for 20–40-year-old women can be as high as 1.2–2.2%. In more simple terms, 20,000,000 women and 10,000,000 men will have a clinically significant eating disorder at some time in their life. Moreover, 40–60% of elementary school girls (ages 6–12) are concerned about their weight or about becoming too fat, up to 60% of female teens diet regularly, and ∼45% of female teens smoke cigarettes to control weight (National Eating Disorders Association, n.d.).

Perhaps even more important, however, is that the onset for eating disorders is typically between the ages of 10 and 20. As child psychiatrists, we need to be educated about eating disorders (National Eating Disorders Association, n.d.).

Until a few years ago, I was firmly ensconced in the work of general child and adolescent psychiatry, and I saw only the occasional child or adolescent with an eating disorder. Then I had to move to a new city, and I was offered a job on an inpatient eating disorders unit, despite having almost no experience working with patients with eating disorders. Becoming a “subspecialist” in child and adolescent eating disorders proved to be a steep learning curve, one that required a lot of supervision, and a lot of reading. Four years into this work, I have a much firmer grasp on the topic than I did when I started, and my clinical expertise has increased tremendously; however, I still do (and always will) depend upon updates and reviews of evidence-based treatment recommendations. I am particularly partial to reviews that include not only research results, but also practical and concrete recommendations for clinical work.

In the last few years, a number of treatment handbooks for eating disorders have been published, including the 2014 2nd edition of Evidence Based Treatment for Eating Disorders: Children, Adolescents, and Adults (Eating Disorders in the 21st Century) (edited by Ida Dancyger and Victor Fornari), and The Oxford Handbook of Child and Adolescent Eating Disorders: Developmental Perspectives (edited by James Lock). Both books now sit on my bookshelf, each with its own highlights and strengths, and both useful to clinicians at different stages in their career.

In their original preface to the 2009 edition of Evidence Based Treatment for Eating Disorders, Dancyger and Fornari described their book as representing an “opportunity to bring together the current evidence in the treatment of eating disorders throughout the life span.” In the updated 2nd edition, Dancyger and Fornari write, “Several shifts have occurred in the eating disorders field that merit an updated presentation of findings to help inform clinical decision-making.” Of course, the biggest shift in the eating disorders field came with the 2013 publication of Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), including the introduction of a separate eating disorder diagnosis category, redefinitions of anorexia nervosa and bulimia nervosa, as well as several new diagnoses including binge eating disorder and avoidant/restrictive food intake disorder (ARFID) (American Psychiatric Association 2013). Additionally, new research has become available over the ensuing years, including updates regarding both psychotherapies and pharmacological interventions.

The updated edition of Evidence Based Treatment for Eating Disorders is more clearly organized into sections than its predecessor. Part 1 is an introduction to the eating disorder diagnoses, with chapters on the risk factors and underpinnings of anorexia nervosa, bulimia nervosa, and binge eating disorder, as well as a new chapter that provides an overview of changes in DSM-5. The authors of this review of updates to DSM-5 include a brief outline of the history of eating disorder diagnoses, beginning with Catherine of Siena in the Middle Ages, then moving up to Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III) and on until today (American Psychiatric Association 1980). They also review the new diagnostic criteria for existing eating disorders (anorexia nervosa, bulimia nervosa), as well as criteria for revised and new diagnoses (binge eating disorder and ARFID). Overall, Part 1 provides an effective overview of research and evidence that is outlined well and clearly stated, although there is minimal attention paid to the clinical presentation or treatment course of the different disorders. The editors do include a chapter on the tension between research and clinical practice within the field. Essentially a review from an informal survey of members of the Academy for Eating Disorders and a proposed “road map” to bridging this gap, the chapter is an interesting look at a serious issue within the eating disorders field, but may be information that goes beyond the scope of a review of treatment handbook.

The chapters in Part 2 of Dancyger and Fornari's book address intensive treatments of eating disorders, including inpatient and day treatment, medical and nutritional treatment, as well as specific chapters on caring for children and males with eating disorders and a chapter on treatment resistance. This is by far my favorite section of the book, as it includes concrete and practical information, such as criteria for inpatient hospitalization and “how to do” nutritional rehabilitation and medical monitoring. The guidelines set forth provide a good foundation for both new and seasoned clinicians, although for more complicated presentations one would likely need additional references.

In today's treatment settings, evidence has been most supportive of using behavioral strategies in treating eating disorder symptoms. The focus is typically on normalization of eating behaviors (and weight restoration when appropriate) first, and only then moving toward addressing distorted and maladaptive patterns of thinking. In Part 3, Dancyger and Fornari include chapters reviewing some of the psychotherapies most commonly used in treating eating disorders. In anorexia nervosa, there is evidence for the use of cognitive-behavioral therapy (CBT) as well as family-based treatment (FBT, or the Maudsley method), and chapters on each topic provide a good overview of research, treatment goals, and some practical information about how to provide treatment. CBT therapy is widely considered the first line treatment for adults with bulimia nervosa, although interpersonal therapy (IPT) has been shown to be useful as well. Dialectical behavioral therapy (DBT) is presented as a model that might be useful for patients who have not succeeded with the more traditional approaches such as CBT or IPT. Of course, most of the research conducted in eating disorder treatment is in adults, and the jury is still out about definitive, evidence-based treatments for children and adolescents with eating disorders. At this point, CBT and the Maudsley method (family-based treatment) are probably the best-studied therapies in children and adolescents; for more information about these therapies in the younger population, however, clinicians would need to turn to a more treatment-specific reference.

Parts 4 and 5 of Dancyger and Fornari's book address psychopharmacological treatments and future directions, respectively. Again, there is less research available than I would like to admit, and I hope that would-be readers and clinicians new to the field take away an understanding of possible treatments, but also recognize the lack of available evidence.

As a general reference, Dancyger and Fornari's book does do what it sets out to do. It includes up-to-date research whenever possible, it provides overviews of treatment recommendations, and the authors suggest areas for future research. There is little mention of ARFID, most likely because the diagnosis is new, and there is scant evidence for treatment at this time, although it would be useful to include even a very brief chapter addressing it. Additionally, as frequently can occur in compilations, the editors often present information more than once in several different chapters. However, for the most part the information is consistent among chapters by different authors, and for the clinician, this will likely be a nonissue, as most will not read such a book cover to cover in one sitting.

One of the strengths of Dancyger and Fornari's book is its attempt to be an all-inclusive, overarching review of eating disorder treatments in children, adolescents, and adults. At the same time, however, this is also one of the book's greatest limitations. As clinicians working with children and adolescents, the editors are likely familiar with vast differences in presentations, symptoms, treatment course, and treatment recommendations at different ages; their attempt to include all ages in one volume left me feeling overwhelmed with even more unanswered questions. Unfortunately, however, this is also a reflection of the current state of research in eating disorders in children and adolescents; what research does exist is often inconsistent and frequently leads to even more questions.

In 2012, James Lock, one of the leading researchers in the field of child and adolescent eating disorders, edited The Oxford Handbook of Child and Adolescent Eating Disorders: Developmental Perspectives. As the title suggests, Lock's book is dedicated solely to a review of eating disorders in children and adolescents, and each chapter is written with a developmental framework. Lock divides the collection of writings into four parts: Developmental considerations in epidemiology and risk for eating disorders, developmental considerations in assessment, interventions, and developmental translational research. As Lock writes in the very first sentences of Chapter 1, “This book is inspired by the increasing need to consider developmental factors in our understanding of the etiology and treatment of mental diseases, and in particular, eating disorders.” This approach provides a much more cohesive overview and smoother transitions between chapters than Dancyger and Fornari's book; Lock presents a look at eating disorders as they develop over time, and presents information about symptomatology, assessment, and treatment, rather than simply cobbling together articles on different topics within the wider category of eating disorder treatment.

Part One of The Oxford Handbook of Child and Adolescent Eating Disorders includes a review of epidemiology and diagnosis of eating disorders, as well as other developmental considerations such as media exposure, self-regulation, and gender issues. It provides a thorough overview that will be informative whether the reader is a student, an experienced clinician, or a basic science researcher, although the reader does need to keep in mind that this book was written before the publication of the new DSM-5 criteria for eating disorders. Even so, the chapters include useful ways of thinking critically about developmental issues and eating disorders in particular. For example, in Chapter 3 (“Developmental approaches to the diagnosis and treatment of eating disorders”), the authors present a well-thought-out summary of the strengths and weaknesses of a descriptive versus developmental model in thinking about eating disorders. Using a developmental model, rather than a simple disease model, is extremely useful in identifying and assessing psychopathology, especially for those more generally focused clinicians who may not be working in the eating disorders field. For example, the authors point out that “Looking for preoccupation with appearance and weight in an 8-year-old might not help ascertain the presence of a child on a trajectory toward anorexia, but establishing anxious attachment, high levels of avoidance coping, pseudomature defense and personality structures, and rigid maintenance of routines in the area of food choice and daily rhythms might be more to the point.” In other words, as child psychiatrists our primary task is to get to know our patients as people, not just as clusters of symptoms or diagnostic criteria, and this is the way we can best be on the lookout for developing psychopathology.

After Part One's review of epidemiology and risk, Lock moves onto Part Two, section on developmental considerations in assessment of eating disorders. There are clearly challenges in assessing children and adolescents, not only because of our current diagnostic criteria, but also because of the scarcity of available assessment and research instruments. It is also important to point out that, as is true for most pediatric psychopathology, children and adolescents often present very differently than adults and even differently from one another. Chapter 4 (“Developmental perspectives on the physical symptoms of eating disorders in children and adolescents”) summarizes this well. The chapter reviews the most frequent medical sequelae and complications seen in children and adolescents with eating disorders, and also highlights the differences among complications seen in children, adolescents, and adults.

Part Three of Lock's book includes chapters on intervention, and provides a brief summary of empirical support for different treatments and therapies. There is considerably less research available regarding treatment in children and adolescents; therefore, Lock devotes fewer chapters to intervention than did Dancyger and Fornari. Only one chapter addresses psychopharmacological treatment. However, the chapters included in this section are easy to read and give a clear and concise summary of different treatment approaches in different age groups (infancy, early childhood, middle childhood, adolescents, and young adulthood). This section also includes useful chapters on eating disorders in the context of obesity and in the context of the physically ill child.

As The Oxford Handbook of Child and Adolescent Eating Disorders was published in 2012, the most glaring deficiency is the more recent change in diagnostic criteria and diagnoses that came with the publication of DSM-5 in 2013. As I noted, Lock does include a chapter on eating disorders in infancy and early childhood. Readers familiar and unfamiliar with the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) (Zero to Three, 2005) will be happy to see this chapter included, as many books on eating disorders often fail to include any information about feeding and eating problems in infants and very young children.

Lock concludes with Part Four, a single chapter on developmental translational research and a look at neurobiological studies of adolescents with eating disorders. This discussion includes a review of brain development and cognitive process throughout adolescence and the impact of eating disorders on these processes. Some studies have given interesting preliminary findings, but Lock's ultimate conclusion, similar to that of Dancyger and Fornari, is that more research is needed.

I will admit that before I started working within this field, I had a tendency to underestimate both the severity and the extent of eating disorders in children and adolescents. However, despite the fact that eating disorders are far more prevalent than some other illnesses, research funding lags far behind. According to the National Eating Disorders Association, in 2011 “research dollars spent on Alzheimer's Disease averaged $88 per affected individual … For Schizophrenia the amount was $81. For Autism $44. For eating disorders the average amount of research dollars per affected individual was just $0.93 (National Institutes of Health, 2011).” (National Eating Disorders Association, n.d.).

Overall, The Oxford Handbook of Child and Adolescent Eating Disorders is more specifically attuned to children and adolescents, and the developmental perspective provides a valuable organizing tool in thinking about a complex topic. However, information changes quickly in the twenty-first century, and Dancyger and Fornari's Evidence Based Treatment for Eating Disorders: Children, Adolescents, and Adults provides more up-to-date research on the state of treatment of eating disorders. Both books would be excellent additions to any library, although general psychiatrists or primary care providers might lean more toward Dancyger and Fornari, whereas clinicians with a strong developmental focus or those interested in the pediatric population would likely choose Lock.

Both Evidence Based Treatment for Eating Disorders: Children, Adolescents, and Adults and The Oxford Handbook of Child and Adolescent Eating Disorders provide key information to understanding how to recognize, assess, and treat eating disorders in children and adolescents. As more clinicians become familiar with issues in the field, they can better treat patients, work with families, and ultimately we can continue to learn even more where research is needed.

A mother sits in an office, frantic about her daughter, and the child psychiatrist reassures her. A father is distraught in talking about his son, and the therapist collaborates with him. An adolescent girl talks about her struggle with weight and eating disorder symptoms, and the researcher asks questions. And we keep moving forward.

Disclosures

No competing financial interests exist.