Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders

About This Program

Target Population: Adolescents (12-19) with eating disorders

For children/adolescents ages: 12 – 19

Program Overview

Enhanced Cognitive Behaviour Therapy (CBT-E) for Adolescents with Eating Disorders has a transdiagnostic scope of the treatment which allows it to be used to treat the full range of disorders that occur in adolescent patients including anorexia nervosa (AN) and bulimia nervosa (BN). It can be used as an alternative to Family-Based Treatment.

Program Goals

The goals of Enhanced Cognitive Behaviour Therapy (CBT-E) for Adolescents with Eating Disorders are:

  • Engage in the treatment and be actively involved in the process of change.
  • Eliminate the eating disorder psychopathology (i.e., the dietary restraint and restriction, and low weight if present; extreme weight control behaviors; and preoccupation with shape, weight, and eating).
  • Learn how to recognize and counteract the mechanisms maintaining the eating disorder psychopathology.
  • Experience lasting change.

Logic Model

The program representative did not provide information about a Logic Model for Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders.

Essential Components

The essential components of Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders include:

  • Step One - Starting well and deciding to change
    • The aims are to engage the patient in treatment and change, including addressing weight regain.
    • The appointments are twice weekly for 4 weeks and involve the following:
      • Jointly creating a formulation of the processes maintaining the eating disorder
      • Establishing real-time self-monitoring of eating and other relevant thoughts and behaviors
      • Educating about:
        • Body weight regulation and fluctuations
        • The adverse effects of dieting
        • The ineffectiveness and physical complications of self-induced vomiting and laxative misuse as a means of weight control, if applicable
      • Introducing and establishing weekly in-session weighing, and becoming proficient in interpreting and coping with weight fluctuations
      • Introducing and adhering to a pattern of regular eating, with planned meals and snacks
      • Thinking about addressing weight regain (if indicated)
      • Involving parents to facilitate treatment
  • Step Two - Addressing the change
    • The aim is to address weight regain (if indicated) and the key mechanisms that are maintaining the patient’s eating disorder.
    • The appointments are twice a week until the rate of weight regain stabilizes, at which time they are held once a week. This Step involves the following CBT-E modules:
      • Underweight and Undereating:
        • Creating a daily positive energy balance of about 500 kcal to achieve a mean weekly weight regain of about 0.5 kg
      • Overvaluation of Shape and Weight:
        • Providing education on overvaluation and its consequences
        • Nurturing previously marginalized domains of self-evaluation
        • Reducing unhelpful body checking and avoidance
        • Re-labelling unhelpful thoughts or feelings such as “feeling fat”
        • Exploring the origins of the overvaluation
        • Learning to identify and control the eating disorder mindset
      • Dietary Restraint:
        • Changing inflexible dietary rules into flexible guidelines
        • Introducing previously avoided foods
      • Events and Mood-related Changes in Eating:
        • Developing proactive problem-solving skills to tackle such triggering events
        • Developing skills to accept and modulate intense moods
      • Setbacks and Mindsets:
        • Providing education about setbacks and mindsets
        • Identifying eating‐disorder mindset reactivation triggers
        • Spotting setbacks early on
        • Displacing the mindset
        • Exploring the origins of the overvaluation.
  • Review sessions
    • These are held one week after Step One and then every four weeks, for the purposes of:
      • Identifying barriers to change, both general (e.g., school pressures) and features of the eating disorder itself (e.g., difficulties in weight regain, presence of dietary restraint)
      • Adjusting the initial formulation in light of progress and/or emerging issues
      • Deciding to continue with the focused form of CBT-E rather than the broad form
        • The broad form of CBT-E includes four additional modules (i.e., clinical perfectionism, low self-esteem, interpersonal difficulties, or mood intolerance), one of which may be added to the focused modules in Step Two. This form of treatment is indicated if clinical perfectionism, low self-esteem, interpersonal difficulties, or mood intolerance are marked, and appear to be maintaining the disorder and obstructing change.
  • Step Three – Ending well
    • The aims are to ensure that progress made during treatment is maintained, and that the risk of relapse is minimized. There are three appointments, 2 weeks apart, covering the following:
      • Addressing concerns about ending treatment
      • Devising a short-term plan for continuing to implement changes made during treatment (e.g., reducing body checking, introducing further avoided foods, eating more flexibly, maintaining involvement in new activities) until the post-treatment review session
      • Phasing out treatment procedures, in particular self-monitoring and in-session weighing
      • Education about realistic expectations and identifying and addressing setbacks
      • Devising a long-term plan for maintaining body weight, and averting and coping with setbacks
  • Posttreatment review session
    • Reviewing the long-term maintenance plan around 4, 12, and 20 weeks after treatment has finished

Program Delivery

Child/Adolescent Services

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders directly provides services to children/adolescents and addresses the following:

  • Eating disorder psychopathology such as over-evaluation of shape, weight and eating control, strict dieting, binge eating, self-induced vomiting, laxative misuse, diuretic misuse, excessive exercising, food checking, body checking, body avoidance, feeling fat, low weight and starvation syndrome; and/or co-existing psychopathology (in a subgroup of patients) such as clinical perfectionism, core low self-esteem, marked interpersonal difficulties, and/or mood intolerance
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: The role of parents is to support the implementation of the one-to-one treatment. Parental involvement includes two short joint sessions with the adolescent during the assessment and preparation phase, one parent-alone session in the first week of treatment, and then several joint sessions with the adolescent and the therapist at the end of the individual patient’s session. The joint sessions typically last about 15 minutes. Additional joint sessions can be scheduled under unusual circumstances, such as family crises, extreme difficulties during meals, or parental criticism towards the adolescent. The main goals of these joint sessions are to keep parents informed and involved in the treatment process and up to date on the progress of their child. These sessions are also used to discuss how parents might help their child in creating an optimal family environment which is supportive of change and help them to implement some key procedures of the treatment.

Recommended Intensity:

Not underweight patients have 20 sessions of 50 minutes (twice a week in the first four weeks, then once a week; in the last 6 weeks there are three appointments, 2 weeks apart) with Posttreatment review at 4-, 12-, and 20-week follow-up. Underweight patients (BMI < 18.5) have 40 sessions (duration depends by the amount of weight that has to be regained). The appointments are twice a week until the rate of weight regain stabilizes, at which time they are held once a week. in the last 6 weeks there are three appointments, 2 weeks apart) with posttreatment review at 4-, 12-, and 20-week follow-up. Events and circumstances may influence the duration of treatment (e.g., life crisis, development of clinical depression).

Recommended Duration:

Non-underweight patients: 20 weeks; Underweight patients: 40 weeks

Delivery Settings

This program is typically conducted in a(n):

  • Outpatient Clinic
  • Group or Residential Care

Homework

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders includes a homework component:

In common with other forms of CBT, monitoring and success in completing strategically planned homework tasks are of paramount importance. Therapist and patient agree on specific homework tasks to do between sessions. These are of fundamental importance and must be given absolute priority, as it is what patients do between the sessions that will determine the benefits or limitations of the treatment. Examples include real-time self-monitoring, regular eating, evaluating the pros and cons of weight regain, etc.

Languages

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders has materials available in a language other than English:

Italian

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Typical psychotherapy office

Manuals and Training

Prerequisite/Minimum Provider Qualifications

The minimum qualification to deliver the training depend on the rules to deliver psychological treatments, which varies from one country to another.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Dalle Grave, R., & Calugi, S. (2020). Cognitive behavior therapy for adolescents with eating disorders. Guilford Press. https://www.guilford.com/books/Cognitive-Behavior-Therapy-for-Adolescents-with-Eating-Disorders/Grave-Calugi/9781462542734

Dalle Grave , R., & el Khazen, C. (2022). Cognitive Behaviour Therapy for Eating disorders in young people: Parents' guide. Routledge. https://www.routledge.com/Cognitive-Behaviour-Therapy-for-Eating-Disorders-in-Young-People-A-Parents/Grave-Khazen/p/book/9780367775049

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

The online training program in CBT-E is now available to any eligible therapist who wants to receive training at no cost. Access to the training is funded by Health Education England in partnership with Oxford Health NHS Foundation Trust.

https://www.cbte.co/for-professionals/training-in-cbt-e/

It is also recommended that they receive expert clinical supervision that may be available via videoconferencing (or face-to-face, if local) by a member of the CBT-E Training Group. For further information please contact: credoenquiries@psych.ox.ac.uk

Number of days/hours:

Varies dependent on personal pace through the training

Relevant Published, Peer-Reviewed Research

Dalle Grave, R., Calugi, S., Doll, H. A., & Fairburn, C. G. (2013). Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: An alternative to family therapy? Behaviour Research and Therapy, 51(1), R9-R12. https://doi.org/10.1016/j.brat.2012.09.008

Type of Study: One-group pretest–posttest study
Number of Participants: 49

Population:

  • Age — Adolescents: 13-17 years (Mean=15.5 years); Parents: Not specified
  • Race/Ethnicity — Adolescents: 100% White; Parents: Not specified
  • Gender — Adolescents: 100% Female; Parents: Not specified
  • Status — Participants included adolescents with marked anorexia nervosa.

Location/Institution: A community-based eating disorder clinic

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to establish the immediate and longer-term outcome following Enhanced Cognitive Behavior Therapy (CBT-E). Measures utilized include the Eating Disorder Examination Questionnaire (EDE-Q6.0) and the Symptom Checklist-90. Results indicate there was a substantial increase in weight together with a marked decrease in eating disorder psychopathology. Over the 60-week posttreatment follow-up period, there was little change despite minimal subsequent treatment. Limitations include lack of a control group, generalizability due to gender and ethnicity, and small sample size.

Length of postintervention follow-up: 60 weeks.

Calugi, S., Dalle Grave, R., Sartirana, M., & Fairburn, C. G. (2015). Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa. Journal of Eating Disorders, 3, Article 21. https://doi.org/10.1186/s40337-015-0057-z

Type of Study: One-group pretest–posttest study
Number of Participants: 46 Adolescents and 49 Adults

Population:

  • Age — Adolescents: Mean=15.5 years; Adults: Mean=24.6 years
  • Race/Ethnicity — Adolescents: Not specified; Adults: Not specified
  • Gender — Adolescents: 100% Female; Adults: 98% Female
  • Status — Participants included adolescents and adults recruited from consecutive referrals to a specialist eating disorder clinic.

Location/Institution: Verona area of Italy

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to provide benchmark data on the duration of treatment required to restore body weight in adolescents and adults with anorexia nervosa treated with outpatient Enhanced Cognitive Behaviour Therapy (CBT-E). Measures utilized include the Eating Disorder Examination Questionnaire (EDE-Q6.0). Results indicate 29 (63.1%) of the adolescents and 32 (65.3%) of the adults completed all 40 sessions of treatment. Significantly more adolescents reached the goal BMI than adults (65.3% vs. 36.5%). The mean time required by the adolescents to restore body weight was about 15 weeks less than that for the adults (Mean=14.8 weeks vs. Mean=28.3 weeks). Limitations include lack of control group, lack of follow-up, small sample size, and generalizability due to gender.

Length of postintervention follow-up: None.

Dalle Grave, R., Calugi, S., Sartirana, M., & Fairburn, C. G. (2015). Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight. Behaviour Research and Therapy, 73, 79-82. https://doi.org/10.1016/j.brat.2015.07.014

Type of Study: One-group pretest–posttest study
Number of Participants: 68

Population:

  • Age — Adolescents: 13-19 years (Mean=16.5 years); Parents: Not specified
  • Race/Ethnicity — Adolescents: Not specified; Parents: Not specified
  • Gender — Adolescents: 13-19 years (Mean=16.5 years); Parents: Not specified
  • Status — Participants were adolescent patients with an eating disorder and body mass index centile corresponding to an adult BMI >/= 18.5.

Location/Institution: A community-based eating disorder clinic in Verona area of Italy

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the effects of Enhanced Cognitive Behavioral Therapy (CBT-E) on non-underweight adolescents with an eating disorder. Measures utilized include the Eating Disorder Examination Questionnaire (EDE-Q6.0) and the Symptom Checklist-90. Results indicate three-quarters completed the full 20 sessions. There was a marked treatment response with two-thirds having minimal residual eating disorder psychopathology by the end of treatment. Limitations include lack of follow-up, lack of control group, and generalizability due to gender.

Length of postintervention follow-up: None.

Dalle Grave, R., Sartirana, M., & Calugi, S. (2019). Enhanced cognitive behavioral therapy for adolescents with anorexia nervosa: Outcomes and predictors of change in a real‐world setting. International Journal of Eating Disorders, 52(9), 1042-1046. https://doi.org/10.1002/eat.23122

Type of Study: One-group pretest–posttest study
Number of Participants: 49

Population:

  • Age — Adolescents: 11-18 years (Mean=15.5 years), Parents: Not specified
  • Race/Ethnicity — Adolescents: 100% White; Parents: Not specified
  • Gender — Adolescents: 100% Female; Parents: Not specified
  • Status — Participants were adolescents with anorexia nervosa.

Location/Institution: An outpatient eating-disorder service located in Verona, Italy

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to establish the outcomes and predictors of change in a cohort of adolescents with anorexia nervosa treated via Enhanced Cognitive Behavioral Therapy (CBT-E) in a real-world clinical setting. Measures utilized include the Eating Disorder Examination Questionnaire, the Brief Symptom Inventory, and the Clinical Impairment Assessment. Results indicate 35 patients (71.4%) who finished the program showed both considerable weight gain and reduced scores for clinical impairment and eating disorder and general psychopathology. Changes remained stable at 20 weeks. No baseline predictors of drop-out or treatment outcomes were detected. Limitations include small sample size, generalizability due to gender and ethnicity, and lack of control group.

Length of postintervention follow-up: 20 weeks.

Le Grange, D., Eckhardt, S., Dalle Grave, R., Crosby, R. D., Peterson, C. B., Keery, H., Leser, J., & Martell, C. (2020). Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: a non-randomized effectiveness trial. Psychological Medicine. Advance online publication. https://doi.org/10.1017/S0033291720004407

Type of Study: Pretest-posttest study with a nonequivalent control group (Quasi-experimental)
Number of Participants: 97

Population:

  • Age — Adolescents: 12–18 years (Mean=14.6 years), Parents: Not specified
  • Race/Ethnicity — Adolescents: 89% Caucasian, 4% Multiracial/Other, 3% Asian, 3% Not reported, and 1% African American; Parents: Not specified
  • Gender — Adolescents: 83% Female; Parents: Not specified
  • Status — Participants were adolescents with a with a DSM-5 eating disorder diagnosis and their parents.

Location/Institution: The Center for the Treatment of Eating Disorders (CTED) at Children’s Minnesota, MN, a pediatric specialty clinic in the USA.

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare the relative effectiveness of family-based treatment (FBT) and Enhanced Cognitive-Behavior Therapy (CBT-E). Participants and their parents chose between FBT and CBT-E treatments. Measures utilized include the Eating Disorder Examination (EDE) or the Eating Disorder Examination Questionnaire (EDE-Q), the Clinical Impairment Assessment (CIA), the Beck Anxiety Inventory (BAI), the Child Depression Inventory (CDI-2), the Rosenberg Self-Esteem Scale (RSE), the Child Behavior Checklist (CBCL), the Brief Symptom Inventory (BSI), the McMaster Family Assessment Device (FAD) and the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-Kid). Results indicate slope of weight gain at end of treatment was significantly higher for FBT than for CBT-E, but not at follow-up. There were no differences in the EDE Global Score or most secondary outcome measures at any time-point. Several baseline variables emerged as potential treatment effect moderators at end of treatment. Choosing between FBT and CBT-E resulted in older and less-well participants opting for CBT-E. Limitations include an a priori power calculation to guide recruitment efforts was not conducted, participants were not randomly allocated to either FBT or CBT-E, compliance with postbaseline assessments was less than optimal, and diversity was limited.

Length of postintervention follow-up: 6 months and 1 year.

Additional References

Dalle Grave, R., Eckhardt, S., Calugi, S., & Le Grange, D. (2019). A conceptual comparison of family-based treatment and enhanced cognitive behavior therapy in the treatment of adolescents with eating disorders. Journal of Eating Disorders, 7, Article 42. https://doi.org/10.1186/s40337-019-0275-x

Dalle Grave, R., Sartirana, M., Sermattei, S., & Calugi, S. (2021). Treatment of eating disorders in adults versus adolescents: Similarities and differences. Clinical Therapeutics, 43(1), 70-84. https://doi.org/10.1016/j.clinthera.2020.10.015

Dalle Grave, R. (2019). Cognitive-behavioral therapy in adolescent eating disorders. In J. Hebebrand & B. Herpertz-Dahlmann (Eds.), Eating disorders and obesity in children and adolescents (pp. 111-116). Elsevier.

Contact Information

Riccardo Dalle Grave, MD
Agency/Affiliation: Department of Eating and Weight Disorders, Villa Garda Hospital, Garda (VR), Italy
Website: www.dallegrave.it/en/cbt-e-multistep
Email:
Phone: +390456208611

Date Research Evidence Last Reviewed by CEBC: July 2021

Date Program Content Last Reviewed by Program Staff: December 2021

Date Program Originally Loaded onto CEBC: December 2021