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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [280]-[284]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [280]-[284]
icine recommends a dietary intake of 1,300 mg/day of calcium for healthy girls aged 9–18 years (Standing Committee on the Scientific Evaluation of Dietary Reference Intakes for Calcium, 1997) and the American Academy of Pediatrics recommends a calcium intake of 1,200–1,500 mg/day for adolescents (American Academy of Pediatrics Committee on Nutrition, 1999). Without scientific evidence demonstrating the efficacy of calcium supplementation in adolescents with anorexia nervosa, it may be most prudent to suggest calcium supplementation for patients whose dietary intake contains less than the recommended amount. A number of studies have shown that body weight, and particularly lean body mass, is a significant determinant of bone mineral density in healthy subjects (Glastre et al., 1990; Henderson, Price, Cole, Gutteridge, & Bhagat, 1995; Southard et al., 1991) and in those with anorexia nervosa (Bachrach et al., 1990; Goebel, Schweiger, Kruger, & Fichter, 1999; Golden et al., 2002; Gordon, Goodman, et al., 2002; Grinspoon et al., 1999; Soyka et al., 2002). Although bone mineral density increases with weight gain, even with weight restoration, osteopenia is not entirely reversible (Bachrach et al., 1991; Golden et al., 2002; Hartman et al., 2000; Rigotti et al., 1991). Both weight-bearing and resistance exercise programs increase bone mineral density of the spine in children and young women (McKay et al., 2000; Snow-Harter, Bouxsein, Lewis, Carter, & Marcus, 1992), but exercise programs for patients with anorexia nervosa have not been studied. Excessive exercise, commonly used by patients with anorexia nervosa to control weight, could interfere with weight gain and produce amenorrhea. Therefore, any exercise should be undertaken cautiously. Hormone replacement therapy is frequently prescribed to treat osteopenia in adolescents with anorexia nervosa (Robinson, Bachrach, & Katzman, 2000), on the assumption that estrogen deficiency contributes to the bone loss. The only randomized controlled trial published to date (Klibanski, Biller, Schoenfeld, Herzog, & Saxe, 1995) found no significant increase in bone mineral density for adult subjects with anorexia nervosa randomly assigned to receive es
trogen treatment, in comparison to those who did not receive hormone treatment. The only suggestion of benefit was for those who were very malnourished (<70% of ideal body weight); hormone treatment may have provided a protective effect. In that subgroup, spinal bone mass increased 4% in those who received estrogen, but decreased 20.1% in those who did not. Golden et al. ( 2002) found that estrogen-progestin treatment in adolescents did not significantly increase bone mineral density, compared with standard treatment at 1-year follow-up. In subjects followed for 2–3 years, osteopenia was persistent and in some cases progressive, despite weight gain, in both experimental treatment groups (estrogen-progestin treatment and standard care). Thus, there is currently no evidence of efficacy of hormone replacement therapy for the treatment of osteopenia in anorexia nervosa. Furthermore, prescribing estrogen to a young adolescent may cause premature closure of the epiphyses, which might result in further growth arrest. Ongoing randomized controlled trials are evaluating the use of new modalities such as IGF-l (Grinspoon et al., 1996, 2002), dehydroepiandrosterone (DHEA; Gordon et al., 1999; Gordon, Grace et al., 2002), and the bisphosphonates for the treatment of osteopenia in anorexia nervosa. Current treatment recommendations include weight restoration with resumption of menses, calcium (1,300–1,500 mg/day) and vitamin D (400 IU/day) supplementation, and carefully monitored weight-bearing exercise (Golden, 2003).
Treatments to Increase Weight in Adolescents
The goal weight should be set in treatment on an individual basis, taking into account pubertal stage, prior growth percentiles, and height and age. For adolescents, the goal weight is a “moving target,” and normal growth and development necessitate a recalculation of this number every 6 months. Height and weight tables used for adults are inappropriate for adolescents. The National Center for Health Statistics (NCHS) tables provide a useful resource of normative height and weight data for children and adoles
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cents in the United States (National Center for Health Statistics, 1973); however, the tables provide only normative weight data, not specific guidance for what is an “ideal body weight.” The goal, or “ideal,” weight should be the weight at which normal physical and sexual development occurs; for girls this is the weight at which menstruation and ovulation are restored. In postmenarcheal girls, a weight approximately 90% of ideal body weight (the median weight for age and height according to the NCHS tables) is a reasonable goal weight, since 86% of patients who achieve that weight will resume menses within 3 to 6 months (Golden et al., 1997). For those who were previously overweight, treatment goal weight may need to be higher. In a premenarcheal girl or an adolescent boy whose growth and development are not yet complete, treatment goal weight should be 100% of ideal body weight to maximize growth potential.
Most of the medical consequences of eating disorders are secondary to malnutrition and are reversible with nutritional rehabilitation and interruption of binge–purge activity. Heart rate returns to normal after approximately 12 days, vital sign instability resolves after approximately 21 days, and resting energy expenditure increases slowly and normalizes after approximately 6 weeks (Schebendach et al., 1997; Shamim et al., 2003). The amount of time needed for weight gain varies, and resumption of menses usually occurs within 3–6 months after achieving treatment goal weight. Difficulties with body image distortion and preoccupation with weight and shape, however, may take longer to resolve. Although most of the medical complications are reversible, growth retardation, osteopenia, and, possibly, structural brain changes may not be entirely reversible.
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CHAPTER 14 Treatment of Eating Disorders
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Ideally, treatment efficacy should be evaluated by means of randomized control trials (RCTs) (National Institute for Clinical Excellence, 2004; Wilson & Fairburn, 2002). Surprisingly, for adolescents with eating disorders, only a handful of relatively small RCTs have been completed. In the absence of the requisite empirical base, the evaluation and recommendations described in this chapter are derived from the following sources: extrapolation from evidence-based treatments for eating disorders in adults, generalizations from closely related psychological and pharmacological treatments of anxiety and mood disorders in adolescents, and consensus views of clinicians who are experienced in the treatment of eating disorders.
PSYCHOLOGICAL TREATMENTS FOR ADOLESCENTS WITH EATING DISORDERS
Psychological interventions are a mainstay of the treatment of eating disorders in adults. Despite the need for effective treatment of eating disorders in affected adolescents, there are remarkably few controlled studies of psychological interventions in this age group. There have been only five RCTs of outpatient-based psychological treatments for adolescents with anorexia nervosa (National Institute for Clinical Excellence, 2004) and no studies of adolescents with bulimia nervosa (Weisz & Hawley, 2002). The lack of research in the treatment of adolescents with eating disorders is not unique, as relatively less attention has been paid to treatment outcome studies of adolescent psychiatric disorders in general than to those of either adults (Weisz & Hawley, 2002) or younger children (Kazdin, Bass, Ayers, & Rodgers, 1990). Because symptoms of both anorexia nervosa and bulimia nervosa generally begin in adolescence (Mitchell, Hatsukami, Eckert, & Pyle, 1985; Schmidt, Hodes, & Treasure, 1992), it is difficult to explain the complete lack of research done with adolescent bulimia nervosa patients and the relatively low number of bulimia nervosa patients who present for treatment. It is possible that adolescents with anorexia nervosa are more easily identified by parents and professionals and are therefore encouraged to seek treatment, whereas adolescents
with bulimia nervosa can more easily hide their behaviors, thus their disorder escapes detection.
Psychological Treatments for Adolescents with Anorexia Nervosa
Randomized Controlled Trials of Treatment of Anorexia Nervosa
Russell and colleagues, from the Maudsley Hospital in London (Russell, Szmukler, Dare, & Eisler, 1987), published the first RCT of the treatment of adolescents with anorexia nervosa. The aim of this study was to evaluate two treatment approaches, family therapy and individual treatment for the management of patients who had initially been treated in a hospital. The average duration of the patients' hospital stay was 10 weeks, and the mean weight on discharge was 88.9 ± 7.4% average body weight. Although patients are typically still symptomatic at the end of hospitalization, the next stage of treatment, is sometimes described as “relapse prevention.” This study was an evaluation of treatment at this stage. The study did not consist of a single RCT; rather, there were four separate RCTs, each involving slightly different groups of patients. One of these groups (subgroup 1) was composed of 21 adolescents with anorexia nervosa who had a mean age of 16.6 ± 1.7 years and a mean duration of illness of 1.2 ± 0.7 years. These 21 patients were randomized to receive either 1 year of family therapy or 1 year of individual psychotherapy. The form of family therapy used has since come to be known as the “Maudsley method,” described in a recently published manual (Lock, Le Grange, Agras, & Dare, 2001). The Maudsley method, a specific form of family therapy designed for adolescent patients with anorexia nervosa, is quite unlike more generic family-based treatments. As described by Lock and colleagues ( 2001), this treatment has three stages: refeeding the patient, negotiating for a new pattern of relationships, and addressing adolescent issues and treatment termination. In the initial implementation of the Maudsley treatment (Russell et al., 1987), there are two main phases. The first phase occurs after the patient and family have been engaged in therapy
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doi:10.1093/9780195173642.003.0015
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