Cognitive Remediation Therapy for Children with Anorexia Nervosa
Abstract
Abstract.Objective: Evidence-based treatment programs for children with anorexia nervosa (AN) are scarce, while their prognosis is negative and the incidence rate rises. A new therapeutic approach recently received positive attention: cognitive remediation therapy (CRT). This intervention targets inflexibility and the inability to perceive the bigger picture in persons with AN. So far, studies and case reports have focused on either adolescent or adult patients and less on young children with AN. This case report therefore describes and evaluates the implementation of CRT with a child with AN. Method: A 12-year-old girl with severe chronic AN was treated with 10 sessions of CRT. Her clinical and neuropsychological evaluations before, directly after and 7 months after CRT are reported. Additionally, the patient’s written and verbal feedbacks are reviewed. Results: At the 7-month follow-up the patient showed a stable healthy weight and reported a reduced presence of psychopathology. Her neuropsychological performance directly after CRT and after 7 months did not improve. Conclusions: The clinical evaluation of our case report suggests that CRT may be a promising add-on therapy in the clinical treatment of young girls with AN.
Zusammenfassung.Fragestellung: Trotz negativer Prognose und steigender Inzidenzrate der Anorexia nervosa (AN) bei Kindern unter 14 Jahren, liegen wenige empirisch belegte wirksame Behandlungsprogramme vor. In den letzten Jahren hat die Cognitive Remediation Therapy (CRT) als Therapieansatz viel Aufmerksamkeit bekommen. Die Intervention zielt darauf ab, kognitive Flexibilität und zentrale Kohärenz bei PatientInnen mit AN zu stärken. Bisherige Studien und Fallbeschreibungen untersuchen lediglich PatientInnen im Jugend- oder Erwachsenenalter. Die vorliegende Kasuistik beschreibt und evaluiert daher erstmalig den Einsatz der CRT bei Kindern mit AN. Methodik: Mit einem 12-jährigen Mädchen mit schwerer chronischer AN wurden zehn Sitzungen CRT durchgeführt. Diverse klinische und neuropsychologische Merkmale wurden sowohl vor und direkt nach der Intervention, als auch sieben Monate nach Abschluss der Intervention erhoben. Zusätzlich wurde das Feedback der Patientin einbezogen. Ergebnisse: Zum Katamnesezeitpunkt zeigt die Patientin ein stabiles und gesundes Gewicht sowie eine reduzierte Psychopathologie. Auf neuropsychologischer Ebene ist hingegen keine Verbesserung nach Abschluss der CRT zu beobachten. Schlussfolgerungen: Die Kasuistik deutet an, dass die CRT auf klinischer Ebene möglicherweise eine vielversprechende Zusatztherapie in der Behandlung von Mädchen mit AN ist.
Introduction
In the last decade, an increase in the number of children suffering from anorexia nervosa (AN) has been reported (Favaro, Caregaro, Tenconi, Bosello, & Santonastaso, 2009; Nicholls, Lynn, & Viner, 2011). Due to the sensitive developmental stage in childhood, AN can have severe and enduring consequences for both brain and hormonal development (Mainz, Schulte-Ruther, Fink, Herpertz-Dahlmann, & Konrad, 2012). Early onset of AN is associated with a negative prognosis, a chronic disease course, and hospitalization (Favaro et al., 2009; Knoll, Föcker, & Hebebrand, 2013). Additionally, these young patients often present with distinct comorbidities, such as anxiety and/or depression (Nicholls et al., 2011). Currently, besides family-based therapy for adolescents (Lock et al., 2010), there are no evidence-based therapeutic interventions for patients with AN (NICE, 2004; Knoll et al., 2013), and treatment programs are especially scarce in young children.
A recent addition to the therapeutic interventions for patients with AN is cognitive remediation therapy (CRT; Lindvall Dahlgren & Rø, 2014; Tchanturia, Lloyd, & Lang, 2013). Cognitive inflexibility and the inability to perceive the bigger picture, i.e. reduced central coherence, are typically observed weaknesses in adults with AN (Lopez, Tchanturia, Stahl, & Treasure, 2009; Tenconi et al., 2010). CRT attempts to improve these cognitive weaknesses via a wide range of materials combined with reflective thinking (Lindvall, Owen, & Lask, 2011; Tchanturia & Davies, 2010). The first randomized studies examining the effects of CRT in adults with AN suggest that it could be an effective add-on intervention, particularly in chronic and treatment-resistant AN (Brockmeyer et al., 2014; Lock et al., 2013; Tchanturia, Lounes, & Holttum, 2014). Randomized controlled studies with adult AN patients report neuropsychological improvements in flexibility and central coherence (Brockmeyer et al., 2014; Lock et al., 2013). In line with the adult literature, a case series in adolescent patients reports improvements on several neuropsychological measures, such as visuospatial memory and central coherence, after CRT (Dahlgren, Lask, Landrø, & Rø, 2013). Moreover, adults with AN show clinical improvements, for example in the form of increased quality of life (Dingemans et al., 2014) and stronger therapy adherence (Lock et al., 2013).
Case Description
Cleo1 is a 12-year-old native German girl who was referred to our clinic for the third time. She started presenting eating disorder symptoms at age 10, at which time she was on the 70th BMI-percentile. Over the course of her illness, she withdrew more and more from her friends and stopped playing her musical instruments despite being very gifted. Her first admission took place at age 11, after which she was placed in a residential treatment group due to severe psychosocial stress at home, including parent separation and on-going psychological problems of her father, e.g. recurrent depression and alcoholism.
At her current admission Cleo was underweight with a BMI of 14 (1st BMI-percentile). She presented with a great fear of weight gain, a disturbed body-image, depressed mood, and blunted affect. Notably, she exhibited drastically reduced eye contact. Cleo was diagnosed with AN restrictive subtype and a moderate depression. Her pharmacological treatment consisted of an atypical antipsychotic (olanzapine) and an antidepressant (venlafaxine), both of which are off-label prescription drugs. Due to prolonged refusal of food and fluid intake, she received a percutaneous endoscopic gastrostomy (PEG) tube and was force-fed while being fixated for a period of 3 weeks. After a 1-week stay in a closed ward in another clinic, she agreed to receive her food via a PEG-tube and fixation was not necessary. Weekly visits to her residential treatment group were halted after Cleo increasingly reported suicidal thoughts prior to these visits and performed recurrent self-injurious behavior, i.e. hair pulling which led to bald patches on her head.
Overall, Cleo was a young patient with extremely severe and chronic AN characterized by rigid and inflexible behavior. Therefore, when she requested to partake in CRT, it was deemed meaningful to let her participate.
Methods
Before participation in this case study, informed consent was obtained from the patient and her parents. Ethical approval was obtained from the ethical committee of the Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum. Comments and suggestions from the patient and her parents were incorporated into the final manuscript.
CRT Intervention
One month after her admission Cleo started her CRT sessions twice a week, over a time period of 5 weeks, in addition to a multimodal treatment program. At this point, she still refused voluntary food and fluid intake, experienced suicidal thoughts and was severely underweight with a BMI of 15.06 on the 3rd BMI-percentile (Table 1). The slight weight increase that had taken place since admission was largely due to her PEG-tube.
Before each of the ten sessions, the clinical psychologist (VK) who conducted CRT with Cleo chose from a wide range of available materials (Lindvall et al., 2011; Tchanturia & Davies, 2010) to find tasks tailored to Cleo’s abilities and inabilities. Some of the materials chosen were a city map, geometric figures, puzzle ball, and a creative memory game. The city map and puzzle ball mostly targeted central coherence ability and the creative memory game focused on cognitive flexibility. After reflecting on her approach in each task, Cleo was asked to find similarities to her behavior outside the therapy (e.g. with homework, friendships or when learning to play a musical instrument). In general, patients are not requested to address problems related to their eating disorder pathology during CRT sessions; they are however free to bring it up on their own accord. At the end of the session the patient can be challenged to suggest a small change they would like to make in any area of their everyday life. These small exercises are intended to promote the implementation of different thinking styles and flexibility into their behavior outside of the CRT sessions.
Evaluation
Before and directly after the intervention, as well as at a 7-month follow-up, several psychopathological (Table 1) and neuropsychological (Table 2) outcome measures were used (Rose, Davis, Frampton, & Lask, 2011; van Noort, Pfeiffer, Lehmkuhl & Kappel, 2013). The last session was used to verbally evaluate the intervention, as well as exchange written feedback letters. Finally, her clinical records assembled during the course of CRT were extensively studied.
Results
Treatment course
From the first session onwards, Cleo seemed eager to participate in CRT; in contrast to her other treatment modules, she would be waiting for the CRT therapist at least 10 minutes before every session. She was very engaged and participated well during the sessions. The first two to three sessions focused on making Cleo familiar with CRT and the session structure, as well as practicing giving everyday life examples of areas where she would like to use more flexible or bigger-picture thinking. The tasks and games largely focused on training flexibility.
By session 4, Cleo was well able to give everyday life examples, and one example she gave for inflexibility was her wearing the same pieces of clothing all the time. At the end of the session, she decided to make a small change in her everyday life by planning to wear a top she had not worn very often. Her experience was very positive and she concluded that “it is good sometimes to try something new.” Following this session, she started experimenting more with her outfit, i.e. wearing different earrings and head bands.
Despite not putting the focus on eating disorder pathology, Cleo frequently brought up her eating disorder-related problems in the CRT sessions, both as everyday-life examples and as a potential area for change. In session 5, she noted her refusal for voluntary feeding as an example of an area in her everyday life where she was not flexible and rather stuck. During this session, she practiced “seeing the bigger picture” with her CRT therapist and she came to the conclusion that if she wanted to be discharged and live with her mother, she needed to start eating again. Following this, Cleo decided to read her notes from the session before the afternoon snack to help her remember the advantages of being flexible and seeing the bigger picture (as experienced during the tasks in the sessions) during snack-time. Despite an extreme internal struggle, she managed to eat a piece of apple that day; her first voluntary food intake in several weeks.
By session 7, a clear change had occurred in Cleo: she was making significantly more eye contact both during her CRT sessions and outside of the sessions. Moreover, she was showing more emotional expression, both facially and verbally.
Another everyday-life example of her inflexibility came up in session 8: her inability to ask for help. She realized that her tendency to solve problems on her own, e.g. school assignments, sometimes proved difficult for her and made her feel tense or strained. This reflection came about after playing a game with different difficulty levels. She experienced problems solving the highest level, but instead of changing her approach and potentially asking for help, she got stuck and could not move forward.
In the final session, she mostly practiced bigger-picture thinking. As an exercise she decided to draw the different goals that she wanted to reach on her path of life (e.g. living at home) and the different approaches there were to reaching them. During her verbal feedback, she mentioned that she had started to play her musical instrument again, something she partly allotted to her experiences in CRT.
Clinical and Neuropsychological Evaluation of CRT
As can be seen in Table 1, Cleo’s weight did not improve over the course of CRT. Due to the chronic nature of her illness, it can be assumed that 6 weeks was too short to significantly gain weight. Her reported eating disorder pathology was high at all three timepoints. However, at follow-up she was able to maintain a healthy and stable weight. Cleo’s scores suggested the presence of obsessive compulsive (OCD) symptoms, both directly after CRT and at 7-month follow-up. Cleo’s trait anxiety levels remained in the average range at all three timepoints. She reported significant depression levels both pre- and post-CRT. At follow-up her scores suggested a significant reduction in depression symptoms.
Overall, the ten CRT sessions seem to have had no effect on Cleo’s neuropsychological performance (see Table 2). With an IQ of 117, Cleo showed a consistent set-shifting performance (Trail Making Test) at an average level in comparison to the normative data for her age group. Her central coherence ability (CCI) was weak at all three timepoints and suggests a preference for a detail-focused processing style rather than a globally-oriented approach. Cleo’s style index (SI) was the only neuropsychological measure that showed an overall improvement after CRT, suggesting a slight increase in the level of continuity while drawing the different elements of the figure. Cleo’s other cognitive abilities, such as planning (Tower Test) and inhibition (Color Word Test), remained stable over time either at an average or clearly above average level, respectively.
Written and Verbal Patient Feedback
The materials used in CRT, in addition to the focus on thinking style, as opposed to focusing on thinking content were very well received by Cleo. She wrote that she took with her from the intervention, among other things, “that [she] should look at the bigger picture more often.” She reported having discovered several new thinking styles, such as a trial-and-error approach, comparing different options, and learning to distract herself. Moreover, in her written feedback she concluded that, due to CRT, she is now more conscious and reflective of the different thinking styles she uses in her everyday life. Cleo evaluated CRT very positively and even requested additional CRT sessions. She was able to participate in three additional sessions, before her discharge after 7 months of hospitalization with a weight on the 12th BMI-percentile.
Follow-Up
At the 7-month follow-up, Cleo showed a very positive disease course. Her weight was stable and remained at an age-appropriate healthy range (BMI = 19.45, 50th BMI-percentile). Moreover, she reported a reduced presence of depression symptoms and an increase in self-esteem (see Table 1). Cleo successfully integrated into a new school. She is not institutionalized and currently lives with her mother and her two pets.
Discussion
This description of Cleo’s sessions shows that CRT can be successfully implemented in the treatment of a young AN patient. Similarly, it provides insight into the themes that can be discussed and changes that can be reached within CRT.
Although the positive disease course of this patient is not solely due to CRT or is separable from the other interventions she received during her hospitalization, it can be said that the patient had previously participated in the same multimodal treatment program minus CRT, with no apparent positive long-term effects and followed by severe short-term relapses. The current disease course of our young patient after years of chronic AN suggests that CRT may provide a meaningful addition to regular treatment of severe childhood AN.
On a clinical level, Cleo’s treating psychiatrist and Cleo herself report that CRT was a vital part of finding a pathway to recovery. Her neuropsychological performance however, except for one measure of central coherence (SI), shows no clear improvement after CRT. In line with our opposing clinical and neuropsychological findings, there is currently an active debate in the field of CRT as to what the correct measures are to evaluate the effectiveness of CRT and whether, especially in children and adolescents, CRT is more effective on a clinical level, e.g. treatment attrition or quality of life, as opposed to a neuropsychological level (Lindvall Dahlgren & Rø, 2014).
It should also be noted that our patient had several years of experience with psychotherapy, so that her metacognitive abilities were well developed for her age. In general, these abilities are still developing in young children. Therefore, this positive implementation may not be generalizable to all children with AN. CRT therapists should be aware of the developmental level and therapy experience of their patients.
Overall, Cleo’s case supports the notion to further examine the clinical relevance of CRT for the treatment of young children with AN.
Conflicts of interest: None
This work is funded by the Charité-Universitätsmedizin Berlin. The authors would like to thank the patient and her family for their participation in the intervention, the accompanying extensive evaluation, and their helpful suggestions for the final version of the manuscript.
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1The patient’s name has been altered.
