Skip to main content

Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review



Recommended first line treatment for children and adolescent eating disorders is outpatient therapy. However, a significant number of children and adolescents with eating disorders continue to require inpatient treatment during the course of their illness. The effect of psychological treatments in an inpatient setting on outcomes at the time of discharge remains unclear. This paper presents the results of a review of the literature on outcomes at the time of discharge following inpatient psychological treatment for children and adolescents with eating disorders.

Main body

The majority of studies found were observational and of low quality. The most consistently reported positive outcome of inpatient treatment is weight gain. Results related to symptom change and motivation vary between studies. Within the inpatient setting, there is considerable heterogeneity in the types of treatments offered, goals of treatment, length of stay and outcomes measured.


There remains a paucity of high-quality studies examining the effect of psychological treatments provided to children and adolescents in an inpatient setting. The significant heterogeneity between studies makes it not possible to compare across studies. Future research should aim to resolve these deficiencies in order to better determine the specific factors that contribute to positive outcomes of inpatient treatment for children and adolescents with eating disorders.

Plain English summary

For children and adolescents with eating disorders, outpatient treatment is the type of treatment with the most support in the scientific literature and should be the basis of most treatment plans. However, many children and adolescents will require inpatient treatment at some point in their illness. The effect of inpatient treatment on eating disorder symptoms remains unclear. This paper aims to review the available literature on psychological treatments provided to children and adolescents with eating disorders in an inpatient setting in order to understand what is known to date. Unfortunately, there remain very few studies designed in such a way to be able to answer the question ‘what is the best psychological treatment to provide in an inpatient setting to children and adolescents with eating disorders?’ and due to considerable variability in the studies available, the only consistent positive result in the studies available is that inpatient treatment is effective in producing weight gain. Further research is needed in order to optimize treatment for children and adolescents with eating disorders in the inpatient setting.


Eating disorders (EDs) are complex disorders that typically appear during childhood and adolescence [1]. Current ED guidelines and expert consensus support outpatient family-based treatment as the first-line recommended treatment for children and adolescents [2,3,4]. Despite this recommendation, a proportion of patients with potentially life-threatening severe EDs will require higher levels of support, including inpatient stabilization and treatment [5].

Unfortunately, inpatient lengths of stay (LOS) for ED treatment tend to be long in comparison to other medical and psychiatric disorders, with the average LOS in studies from Germany, Japan, Switzerland and Scotland being greater than 7 weeks [6,7,8,9]. Modifying factors for LOS in adolescent patients include treatment under the Mental Health Act and nasogastric feeding, both of which appear to be associated with longer LOS [9]. Prolonged LOS is concerning, as it can disrupt adolescent development and engagement in school, family and social life. Further, inpatient treatment is expensive in terms of economic costs and intensive medical resource requirement [10]. In 2013, a review of admissions with a mean length of stay 37.9 days (standard deviation [SD] 19.7 days) to a Canadian tertiary care center for medical stabilization and initial weight rehabilitation for adolescents with AN found that the mean total hospital cost was $51,349 Canadian Dollars (CAD) (SD $26598) with a mean total societal cost of $54,932 CAD (SD $27864) per admission [10]. Similar studies from Portugal and Germany found comparable high costs for eating disorders treatment, in that the average cost per admission in those countries was 5202 to 5883€ and 13,367€ respectively [11, 12].

While three recently published studies examining outcomes across varying treatment settings supports the least intensive management as first line treatment for EDs [13,14,15], the evidence base that examines best practice for patients who do require inpatient treatment remains scant. The goal of this review is to further explore the scope and benefits of psychological treatments provided to children and adolescents with EDs in inpatient settings at the time of hospital discharge.


PRISMA systematic review methodology was used to capture all articles on inpatient treatment for EDs in children and adolescents [16]. Our search utilized the following databases: Medline, PsycINFO, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL, and included the following search terms: Anorexia Nervosa (AN) OR Bulimia Nervosa (BN) OR Binge Eating Disorder (BED) OR Other Specified Feeding and Eating Disorder (OSFED) OR Eating Disorder Not Otherwise Specified (EDNOS) OR Avoidant/Restrictive Food Intake Disorder (ARFID) AND Inpatient Treatment. The search string was developed further and was modified for each database as appropriate (see Additional file 1). Inpatient treatment was defined for the purposes of this review as treatment that involves 24 h/day care in a hospital setting. Reference lists were reviewed for any additional articles. Two reviewers had to agree for inclusion of articles in our review, with a third reviewer resolving any disputes. The initial database search included all years up until March 2017. In November 2018 a forward citation chaining process was completed to search each included article to examine if it had been cited by any additional articles since March 2017 up until November 2018. Newly found articles were then screened to decide whether they matched the inclusion criteria. The forward chaining process involved the use of Google Scholar to locate all articles citing our included articles from the primary search. Inclusion criteria included original peer-reviewed research articles that focused on children and adolescents up to age 18 years, provided a description of an ED-specific treatment as well as weight and/or psychological outcomes at the time of discharge, and were published in English or French. Studies of all different types of methodology were included (randomized controlled trials [RCTs], open trials, case reports). Studies were excluded if they did not distinguish between outcomes for children and adolescents and outcomes for adults, or if they focused only on medical interventions, pharmacotherapy or refeeding protocols aimed at restoring medical stability to facilitate discharge to outpatient treatment.

For each included study, the study type (e.g. prospective or randomised control trial), number of participants included in the analysis, treatment method, primary outcome variable(s), and observed results were summarized.

Given the low quality of the studies, quantitative analysis was not possible. Qualitative review of all included studies was performed, summarizing the outcomes at end of inpatient treatment. We distinguish outcomes across various types of treatment frameworks as well as the evidence supporting the use of adjunctive therapies as part of inpatient treatment.

Two reviewers (LI and JC) independently assessed the risk for bias in the articles using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system [17]. The GRADE system incorporates analysis of risk of bias based on various limitations of the studies, including lack of concealment of allocation, blinding, accounting of all participants, and selective reporting of outcomes for RCTs, and lack of an adequate control population, flawed measurement of outcomes, failure to adequately control for confounding factors and incomplete or inadequately short follow-up for observational studies.


The database search initially provided n = 7136 citations, as reported in the PRISMA flowchart (Fig. 1). An additional 49 citations were added through review of references and forward citation chaining. After removing duplicates, n = 6426 records remained, of which n = 5881 were eliminated given that they did not meet the inclusion criteria. Of the 545 full text articles assessed for eligibility, n = 479 studies were excluded because they were longitudinal follow-up studies with no information on outcome at the time of discharge, were primarily adult studies, were review or secondary analysis papers, book chapters or guidelines, or did not provide sufficient description of the treatment provided, did not focus on inpatient treatment, or otherwise did not meet the inclusion criteria. Ultimately, n = 66 studies were selected for inclusion in this review (See Fig. 1). Quantitative analysis of the results was not possible due to the varying outcome measures used, the low quality of the studies and the high heterogeneity in methods used amongst the studies. Instead a narrative summary of the results is presented below. The risk of bias as assessed by the GRADE system was deemed as high for all included studies.

Fig. 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of study selection

Inpatient ED programs for anorexia nervosa

Primary outcome – weight gain

We failed to identify any RCTs exploring outcomes of inpatient treatment specifically for pediatric AN, including atypical anorexia nervosa. We identified twenty studies (total n = 1091) describing inpatient treatment based on an integrative approach for AN, including psychiatric, medical, nutritional, and pharmacologic management, as well as individual, group and family therapy along with skilled nursing support [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37]. None of these studies included control or comparison groups. Various measures of change in weight were used across these studies. Mean change in weight was positive in all studies. Mean LOS ranged widely between studies (Table 1).

Table 1 Studies of inpatient treatment for children and adolescent patients with anorexia nervosa

Three studies (total n = 39) examined inpatient treatment utilizing a family-based approach [38,39,40], and three papers (total n = 296) reported on inpatient treatment utilizing a cognitive behavioural (CBT) approach [41,42,43]. In all studies patients gained weight in hospital, although measures by which weight changes were reported varied, as did LOS (Table 1).

Fourteen additional studies reported on a behaviour therapy approach (total n = 218) [44,45,46,47,48,49,50,51,52,53,54,55,56,57]. Various approaches to reporting change in weight were used, and all studies reported a positive change in weight from admission to discharge (Table 1). Of interest, Collins et al. (1983) reported that LOS was correlated to admission weight and feeding mode (i.e. oral vs nasogastric tube (NGT) feeds), and reported that the highest LOS was in those < 75% Treatment Goal Weight (TGW) at admission and requiring NGT feedings [49]. Another cohort study, by Solanto et al. (1994), reported weight gain under two types of behaviour contracts, varying only with regards to the expected rate of weight gain as measured every 4 days (q4d) (i.e. 0.36 kg/q4d vs 0.55 kg/q4d) [56]. Those treated under the contract with higher weight targets gained weight at a faster rate and gained more weight overall.

Two reports (total n = 6) were included in which patients were treated within an inpatient program using a psychodynamic approach [58, 59]. The LOS and weekly weight gain for these patients varied substantially (Table 1).

Finally, two reports examined the effect on weight of admission to a general pediatrics unit with supportive psychotherapy [37, 60, 61]. In both studies patients gained weight (Table 1).

Symptom change

While all of the observational studies of patients with AN using an integrative framework for inpatient treatment reported on change in weight, fewer reported on change in ED symptoms or psychopathology (Table 1). Four studies reported on changes in the Eating Disorder Examination-Questionnaire (EDE-Q) [22, 24, 35, 36]. In only one of these studies, Fennig et al’s (2015) [36], a significant pre-post difference (n = 51, p < 0.05) was found and attributed predominantly to changes in restraint and eating concerns subscales. Of note, BMI at discharge was higher in the Fennig et al. (2015) study than the other three studies that reported on EDE-Q scores. Three studies (total n = 126) reported change in Eating Attitude Test (EAT) scores at admission and discharge [21, 30, 32]. The difference in EAT scores was noted to improve in two of the studies [21, 32]. Fennig et al. (2015), compared scores on the Eating Disorder Inventory-2 (EDI-2) at admission and discharge and found no significant change in total or subscale scores [36].

Schlegl et al. (2016), used a CBT framework for treatment and reported on symptom change using EDI-2 scores [42]. All subscales showed significant improvements (Table 1).

Several studies using a behaviour therapy approach reported on symptom change during admission (Table 1). Cinciripini et al. (1983) described a case report in which purging after meals decreased from 48% of meals/week to 0% of meals per week [47]. Two other studies reported on EAT scores, both of which showed a reduction in scores during admission [44, 57]. Of note, Alessi et al. (1989) reported that EAT scores remained high for the first 7 weeks of treatment (with weight gain of 4.5 kg over the first 7 weeks) and scores then dropped (from total score of 60 to 10) during the last 3 weeks of a 10-week admission. Steinhausen et al. (1985) reported symptom change through EDI scores and noted that the mean “Drive for Thinness” scores decreased significantly over the course of admission (p = 0.02) [57].

Measures of change in motivation

Castro-Fornieles et al. (2007) measured motivation for change using the Anorexia Nervosa Stage of Change Questionnaire (ANSOCQ) at admission and discharge in an inpatient program utilizing an integrative framework [21]. Change in mean ANSOCQ score was noted to be statistically significant; however, both admission and discharge scores were characterized as within the “preparation” phase of motivation, and wide confidence intervals were reported (Table 1).

Inpatient programs for mixed ED diagnoses

Weight gain

Three studies using an integrative approach (total n = 239) were included and reported on weight gain during inpatient treatment for patients with mixed ED diagnoses [9, 28, 30] (Table 2). The studies included in this section reported outcomes for various eating disorders (ie AN, BN, OSFED and EDNOS) as a combined group rather than differentiating outcomes by diagnosis. In all 3 studies patients gained weight from admission to discharge. Not surprisingly, in the 2 studies that differentiated anorexia nervosa-restricting subtype (AN-R) from other ED diagnoses, there was a significantly greater increase in Body Mass Index (BMI) for the group containing AN-R patients [28, 30].

Table 2 Studies of inpatient treatment for children and adolescents mixed eating disorder diagnoses

Symptom change

Rothschild-Yakar et al. (2013) compared symptom change from admission to discharge in an integrative inpatient treatment program for mixed ED diagnoses, using the EAT-26 in a group of patients with AN-R vs anorexia nervosa binge-purge subtype (AN-BP) or bulimia nervosa (BN) [30]. Overall there was a statistically significant improvement in EAT-26 scores over the course of the admission (p < 0.001), and no significant difference in change in EAT-26 scores by diagnosis.

Inpatient programs for bulimia nervosa

We identified only one study that reported outcomes of inpatient treatment specifically for youth with BN [62]. The treatment provided was based on behaviour therapy and outcomes focused primarily on changes from admission to discharge in serotonin levels, as measured by 5-hydroxytriptamine induced calcium release from platelets. As such, this study was limited in that the only reported ED-specific outcome was change in BMI, and weight decreased slightly over admission (Table 3).

Table 3 Studies of inpatient treatment for children and adolescent with bulimia nervosa

Inpatient programs for ARFID


Three case reports or case series were identified which described inpatient treatment of a total of eight children with ARFID treated using either a family-based or CBT or behavioural therapy approach [63,64,65]. Weight gain was reported in two studies (Table 4).

Table 4 Studies of inpatient treatment for children and adolescents with avoidant restrictive food intake disorder

Change in Oral intake

Singer et al. (1992) reported on change in caloric intake in kcal/day for three patients with ARFID using a CBT inpatient treatment [64]. Oral intake rose for all three patients over the course of admission (Table 4).

Pitt and Middleman (2018) reported on two cases of adolescents with ARFID [65]. After admission, nasojejunal (NJ) tubes were placed to initiate refeeding when oral feeding was not tolerated. The authors reported that the use of an individualized behaviour plan for each patient providing reinforcements for eating was the critical factor which helped these patients to tolerate oral intake without vomiting and allowed for the removal of the NJ tubes (Table 4).

Combined inpatient and day treatment programs

Weight gain

Five studies summarized the experience of 264 adolescents with AN treated as inpatients followed immediately by day treatment (DTP), utilizing either an integrative or CBT approach [66,67,68,69,70]. Studies considered as providing combined inpatient and day treatment programs reported on change from the point of admission to an inpatient program through the end of their involvement in day treatment. In these studies, all patients received inpatient treatment directly followed by day treatment services. All five studies included inpatient treatment for medically unstable patients followed by transfer to a DTP once medical stability was attained (Table 5). Total mean LOS (i.e. inpatient and DTP combined) varied substantially between studies. Weight increased in all studies (Table 5).

Table 5 Studies of inpatient treatment followed by day treatment for children and adolescents with eating disorders

Symptom change

Symptom change was reported using various scales in two studies of combined inpatient and DTP [66, 68]. Hillen et al. (2015) failed to demonstrate a significant change in EDI-2 scores. Dalle Grave et al. (2014) reported a significant decrease in EDE-Q scores pre to post treatment for global score and for all subscales other than Shape Concern. The percentage of patients with Global EDE-Q scores < 1 SD above the community mean at admission was 2% (+/− 7.7) and at discharge it was 10% (+/− 38.5), suggesting a decrease in ED thoughts and urges with treatment (Table 5).


Hillen et al. (2015) reported on change in motivation as measured by the ANSOCQ in 35 patients [68]. Overall mean scores increased by 21.7 points which signified moving from contemplation to preparation phases. Overall, 29.4% (up from 0% at admission) of patients were classified as being in “maintenance phase” and 26.5% (up from 15% at admission) in “action phase” at time of discharge from DTP (Table 5).

Overall outcome

Treat et al. (2008) included 71 patients who combined inpatient and DTP and reported on “overall outcome” [70]. At the end of DTP 35.2% were deemed to have an excellent outcome, 26.8% were deemed to have good outcome,14.1% were deemed below average outcome and 23.9% were described as having a poor outcome, according to definitions assigned by the authors which included a combination of % ideal BMI, maintenance of weight and compensatory behaviours (Table 5).

Adjunctive treatments

Adjunctive cognitive remediation therapy (CRT)

Four studies reported on the addition of CRT to integrative inpatient treatment for patients with AN (total n = 127) [71,72,73,74] (Table 6). Herbrich et al. (2017) described no difference in the change in weight between adolescent patients who received 10 sessions of CRT over 10 weeks compared to those who received treatment as usual (TAU) in a quasi-experimental design (n = 24 in each group) [74]. The other three studies did not include a control group. Patients (total n = 79) gained weight, but it was not possible to determine whether CRT had an impact on weight gain above and beyond what would have been expected by inpatient treatment [71,72,73].

Table 6 Studies of adjunctive treatments in addition to inpatient treatment for children and adolescents with eating disorders

Three studies of CRT added to inpatient treatment for AN reported on symptom change (Table 6). A report of two cases by Asch et al. (2014) described that total scores on the EAT decreased for one patient and increased in the other patient and Eating Behavior Rating Scale (EBRS) scores decreased slightly for both patients, by the end of 10 weeks [71]. Another study by Harrison et al. (2018), included 70 hospitalized patients who received individual CRT, and noted no change in EDE-Q scores [73].

In a study by Harrison et al. (2018), patients reported on change in motivation as measured by the MSCARED before and after the course of CRT [73]. There was a statistically significant shift in motivation noted (p < 0.001), with 42.9% in preparation, action or maintenance stages of change at initiation of CRT, and with 95.7% in one of those stages of change after receiving CRT (Table 6). Due to the design of this study it was not possible to differentiate the effect of inpatient treatment alone from inpatient treatment plus CRT.

Adjunctive multi-family/parent group therapy

A study by Depestele et al. (2017) reported on 112 patients with various ED diagnoses admitted to an inpatient ED unit providing an integrative therapy approach to treatment, who also received either adjunctive multi-family group therapy (MFT, n = 62) or adjunctive multi-parent group therapy (MPT, n = 50) [75]. Both MPT and MFT interventions “promoted an autonomy-supportive parental attitude and the adolescents’ autonomy and self-determination.” Results reported a main effect of time on drive for thinness (p < 0.001) and body dissatisfaction (p < 0.001) as measured by EDI-2. Both scales improved independent of the type of intervention (Table 6).

Adjunctive bright light therapy

A study by Janas-Kozik et al. (2011) examined patients with AN and depressive symptoms (> 17 on Hamilton Depression Rating Scale) who were admitted to a CBT-based inpatient program and treated adjunctively with Bright Light Therapy [76]. In this study patients were randomized to receive either daily 30 min of Bright Light Therapy (BLT) + inpatient treatment (n = 12) × 6 weeks, or inpatient treatment only × 6 weeks (n = 12). Patients in both groups had a significant change in their BMI during the 6-week study; however, weight change from baseline was statistically significant by week 3 (p = 0.038) in the BLT group but only at week 6 (p = 0.048) in the TAU group (Table 6).

Adjunctive meal support

Three studies examined the effect of meal support/supervision as part of inpatient treatment for groups of patients with mixed ED diagnoses [77,78,79] (Table 6). In the two studies examining weight gain, there were no significant differences between cohorts who received meal support (total n = 77) and those who did not (total n = 78) on the rate of weight gain per day, although there was a trend towards greater weight gain per day in the group who received meal support [78, 79]. In these two studies, the approach to meals for patients who did not receive meal support was not documented. A separate study by Couturier & Mahmood (2009) reported a significant decrease in the rate of nasogastric tube feeds in the cohort of patients treated on an inpatient unit after the institution of consistent meal support [77].

Selective versus non-selective menus

Leacy & Cane (2012) (n = 22) compared the rate of weight gain and EDE-Q scores in patients with AN who received non-selective menus (i.e. meals chosen by a dietician) or selective menus (i.e. meals chosen by the patient, under the direction of a dietician) as part of their inpatient treatment [80]. The non-selective menu group gained weight significantly faster than those in the selective menu group (p = 0.02) (Table 6). No significant differences were found on any of the EDE-Q items related to eating concern. Overall change in EDE eating concern scores in this study were low, ranging from − 0.6 to 1.1 (Table 6).


The aim of the present review was to identify the scope and benefits of psychological treatment provided to children and adolescents with EDs in inpatient settings. We identified 66 studies that demonstrated considerable heterogeneity in the types of treatment provided and the outcomes reported. While all studies focused on inpatient treatment, in some studies this treatment was provided on a pediatric unit and in other studies it was provided on a psychiatric unit, either designed specifically for the treatment of patients with EDs or not. The treatment provided also varied with regards to the therapeutic modalities utilized, length of stay in intensive treatment, and the goals or expectations of treatment.

Despite the presence of substantial biases, and lack of control groups, each of the specialized ED inpatient programs and non-specialized general pediatric wards reported success in helping underweight patients with restrictive eating disorders gain weight. Beyond this finding, given the overwhelming heterogeneity of methods described, there is little that can be concluded from the various studies contained within.

Similarly, it is impossible to draw any conclusions as to which adjunctive treatments might be most helpful when treating youth with AN in hospital. While adjunctive treatments were examined, i.e. the use of meal support, selective versus non-selective menus, bright light therapy, CRT, and multi-family versus multi-parent group, the quality of the studies does not allow us to draw any conclusions about the effectiveness of these treatments. There are also some interesting omissions from this literature on adjunctive inpatient treatments, including no papers looking at outcomes of adjunctive yoga, exercise programs, art therapy, journaling, mindfulness, dialectical behaviour skills groups, or individual or group motivational enhancement therapy. Furthermore, there are insufficient studies of inpatient treatment for EDs other than AN, such that no conclusions can be drawn about the effectiveness of inpatient programs for the treatment of BN, ARFID or BED.

Finally, none of these studies serve to identify the specific factors most associated with a successful inpatient program for the treatment of children and adolescents with EDs. Clinical experience often points to a number of factors that appear to have clinical relevance, including a specialized, experienced multidisciplinary treatment team that combines confidence, compassion, consistency and the ability to create a safe environment where it is assumed that patients will take the nutrition they need to recover. These units typically provide skilled meal support and attend to patients’ medical, nutritional and psychological needs, with a focus on weight gain, renourishment and symptom interruption. It is widely recognized that families need to be supported and educated, and patients benefit from therapy which helps them to separate from and externalize the illness, thereby improving their motivation for recovery. Unfortunately, few of these factors have been identified, studied or discussed in the literature, there are no RCTs to provide guidance, and it is impossible to compare one inpatient program to another based on studies to date. It is also impossible to discern the optimal LOS, which combination of individual, group or family therapy is essential, or to determine the ideal group therapy content.

Limitations of this review include the inability to complete a meta-analysis or quantitative analysis due to the low quality and high heterogeneity of the studies available, the lack of inclusion of the search term “unspecified feeding and eating disorder” which could have yielded additional studies on this topic, a lack of studies specifically reporting on particular diagnoses including EDNOS, OSFED or atypical anorexia nervosa, and an inability to disaggregate findings based on subgroup such as gender or age (ie children vs adolescents).

Future research should focus on resolving these deficiencies through the use of studies based on high quality research methods, standardized operation of reporting treatment variables and outcomes, and multi-site designs to gather data on larger numbers of participants. Given the paucity of research in this field, the prolonged LOS (and associated costs) often observed, as well as the substantial variability by which treatments are delivered, it is critical that basic indicators of admission and treatment are standardized and reported, in order to continue to move the field forward. Only with improved research methods and reporting will it be possible to identify the key components of successful inpatient treatment and to improve outcomes for children and adolescents with EDs.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.



Anorexia nervosa


Anorexia nervosa – restricting subtype


Anorexia nervosa – binge/purge subtype


Anorexia nervosa stages of change questionnaire


Avoidant restrictive food intake disorder


Binge eating disorder


Bright light therapy


Body mass index


Bulimia nervosa


Cognitive behaviour therapy


Cognitive remediation therapy


Day treatment program


Eating attitude test


Eating disorder


Eating disorder examination – questionnaire


Eating disorder inventory


Eating disorder not otherwise specified


Grading of Recommendations, Assessment, Development and Evaluations


Multi-parent group therapy


Multi-family group therapy


Nasogastric tube




Other specified feeding and eating disorder


Preferred Reporting Items for Systematic Reviews and Meta-analyses


Randomized control trial


Treatment as usual


  1. 1.

    Le Grange D, Lock J, editors. Childhood and adolescence: looking at eating disorders when they start. New York: Guildford Press; 2011.

    Google Scholar 

  2. 2.

    Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, et al. Royal Australian and new Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014;48(11):977–1008.

    PubMed  Google Scholar 

  3. 3.

    Lock J, La Via MC. American Academy of C, adolescent psychiatry committee on quality I. practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015;54(5):412–25.

    PubMed  Google Scholar 

  4. 4.

    Wilson GT, Shafran R. Eating disorders guidelines from NICE. Lancet. 2005;365(9453):79–81.

    PubMed  Google Scholar 

  5. 5.

    Jauregui-Garrido B, Jauregui-Lobera I. Sudden death in eating disorders. Vasc Health Risk Manag. 2012;8:91–8.

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Kastner D, Lowe B, Weigel A, Osen B, Voderholzer U, Gumz A. Factors influencing the length of hospital stay of patients with anorexia nervosa - results of a prospective multi-center study. BMC Health Serv Res. 2018;18(1):22.

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Nozoe SSY, Yoshioka M, Naruo T, Masuda A, Nagai N, Tanaka H. Clinical features of patients with anorexia nervosa: assessment of factors influencing the duration of in-patient treatment. J Psychosom Res. 1995;39(3):271–81.

    PubMed  Google Scholar 

  8. 8.

    Warnke I, Rossler W. Length of stay by ICD-based diagnostic groups as basis for the remuneration of psychiatric inpatient care in Switzerland? Swiss Med Wkly. 2008;138(35–36):520–7.

    PubMed  Google Scholar 

  9. 9.

    Morris J, Simpson AV, Voy SJ. Length of stay of inpatients with eating disorders. Clin Psychol Psychother. 2015;22(1):45–53.

    PubMed  Google Scholar 

  10. 10.

    Toulany A, Wong M, Katzman DK, Akseer N, Steinegger C, Hancock-Howard RL, et al. Cost analysis of inpatient treatment of anorexia nervosa in adolescents: hospital and caregiver perspectives. CMAJ Open. 2015;3(2):E192–7.

    PubMed  PubMed Central  Google Scholar 

  11. 11.

    AM C, M G-P, JV S, F C, I B, A. F. Eating disorders-related hospitalizations in Portugal: a nationwide study from 2000 to 2014. Int J Eat Disord. 2017;51(10):1201–6.

    Google Scholar 

  12. 12.

    Stuhldreher N, Wild B, Konig HH, Konnopka A, Zipfel S, Herzog W. Determinants of direct and indirect costs in anorexia nervosa. Int J Eat Disord. 2015;48(1):139–46.

    PubMed  Google Scholar 

  13. 13.

    Gowers SG, Clark AF, Roberts C, Byford S, Barrett B, Griffiths A, et al. A randomised controlled multicentre trial of treatments for adloescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial. Health Technol Assess. 2010;14(15):1.

    PubMed  Google Scholar 

  14. 14.

    Herpertz-Dahlmann B, Schwarte R, Krei M, Egberts K, Warnke A, Wewetzer C, et al. Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial. Lancet. 2014;383(9924):1222–9.

    PubMed  Google Scholar 

  15. 15.

    Madden S, Miskovic-Wheatley J, Wallis A, Kohn M, Lock J, Le Grange D, et al. A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents. Psychol Med. 2015;45(2):415–27.

    PubMed  Google Scholar 

  16. 16.

    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006–12.

    Google Scholar 

  17. 17.

    Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–15.

    PubMed  Google Scholar 

  18. 18.

    Anis N, Isomaa R, Kaltiala-Heino R. Adolescent psychiatric inpatients with first hospitalization due to anorexia nervosa: can rehospitalization be predcited by clinical features. Psychiatr Fenn. 2016;47:76–94.

    Google Scholar 

  19. 19.

    Ayton A, Keen C, Lask B. Pros and cons of using the mental health act for severe eating disorders in adolescents. Eur Eat Disord Rev. 2009;17(1):14–23.

    PubMed  Google Scholar 

  20. 20.

    Bourion-Bedes S, Baumann C, Kermarrec S, Ligier F, Feillet F, Bonnemains C, et al. Prognostic value of early therapeutic alliance in weight recovery: a prospective cohort of 108 adolescents with anorexia nervosa. J Adolesc Health. 2013;52(3):344–50.

    PubMed  Google Scholar 

  21. 21.

    Castro-Fornieles J, Casula V, Saura B, Martinez E, Lazaro L, Vila M, et al. Predictors of weight maintenance after hospital discharge in adolescent anorexia nervosa. Int J Eat Disord. 2007;40(2):129–35.

    PubMed  Google Scholar 

  22. 22.

    Goddard E, Hibbs R, Raenker S, et al. A multi-centre cohort study of short term outcomes of hospital treatment for anorexia nervosa in the UK. BMC Psychiatry. 2013;13:287:1–14.

  23. 23.

    Heinberg LJ, Haug NA, Freeman YL, Ambrose D, Guarda AS. Clinical course and short-term outcome of hospitalized adolescents with eating disorders: the success of combining adolescents and adults on an eating disorders unit. Eat Weight Disord. 2003;8(4):326–31.

    PubMed  Google Scholar 

  24. 24.

    Hetman I, Brunstein Klomek A, Goldzweig G, Hadas A, Horwitz M, Fennig S. Percentage from target weight (PFTW) predicts re-hospitalization in adolescent anorexia nervosa. Isr J Psychiatry Relat Sci. 2017;54(3):28–34.

    PubMed  Google Scholar 

  25. 25.

    Kalisvaart JL, Hergenroeder AC. Hospitalization of patients with eating disorders on adolescent medical units is threatened by current reimbursement systems. Int J Adolesc Med Health. 2007;19(2):155–65.

    PubMed  Google Scholar 

  26. 26.

    Leon GR, Lucas AR, Colligan RC, Ferdinande RJ, Kamp J. Sexual, body-image, and personality attitudes in anorexia nervosa. J Abnorm Child Psychol. 1985;13(2):245–57.

    PubMed  Google Scholar 

  27. 27.

    Strik Lievers L, Curt F, Wallier J, Perdereau F, Rein Z, Jeammet P, et al. Predictive factors of length of inpatient treatment in anorexia nervosa. Eur Child Adolesc Psychiatry. 2009;18(2):75–84.

    PubMed  Google Scholar 

  28. 28.

    Mekori E, Halevy L, Ziv SI, Moreno A, Enoch-Levy A, Weizman A, et al. Predictors of short-term outcome variables in hospitalised female adolescents with eating disorders. Int J Psychiatry Clin Pract. 2017;21(1):41–9.

    PubMed  Google Scholar 

  29. 29.

    Nova E, Lopez-Vidriero I, Varela P, Casas J, Marcos A. Evolution of serum biochemical indicators in anorexia nervosa patients: a 1-year follow-up study. J Hum Nutr Diet. 2007;21:23–30.

    Google Scholar 

  30. 30.

    Rothschild-Yakar L, Lacoua L, Stein D. Changes in patient measures as predictors of therapists' ratings of treatment collaboration and change in eating disorder subgroups. Assessment. 2013;20(6):752–63.

    PubMed  Google Scholar 

  31. 31.

    Roux H, Ali A, Lambert S, Radon L, Huas C, Curt F, et al. Predictive factors of dropout from inpatient treatment for anorexia nervosa. BMC Psychiatry. 2016;16(1):339.

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Shugar G, Krueger S. Aggressive family communication, weight gain, and improved eating attitudes during systemic family therapy for anorexia nervosa. Int J Eat Disord. 1995;17(1):23–31.

    PubMed  Google Scholar 

  33. 33.

    Tasaka K, Matsubara K, Takamiya S, Ishikawa SI, Iwata A, Nigami H. Long-term follow up of hospitalized pediatric anorexia nervosa restricting type. Pediatr Int. 2017;59(4):482–9.

    PubMed  Google Scholar 

  34. 34.

    Toms DA, Crisp AH. Weight phobia in an adolescent male with stunted development. J Psychosom Res. 1972;16(4):289–95.

    PubMed  Google Scholar 

  35. 35.

    Vall E, Wade TD. Predictors and moderators of outcomes and readmission for adolescent inpatients with anorexia nervosa: a pilot study. Clin Psychol-Uk. 2017;21(2):143–52.

    Google Scholar 

  36. 36.

    Fennig S, Brunstein Klomek A, Shahar B, Sarel-Michnik Z, Hadas A. Inpatient treatment has no impact on the core thoughts and perceptions in adolescents with anorexia nervosa. Early Interv Psychiatry. 2015;11(3):200–7.

    PubMed  Google Scholar 

  37. 37.

    Lock J, Litt I. What predicts maintenance of weight for adolescents medically hospitalized for anorexia nervosa? Eat Disord. 2003;11(1):1–7.

    PubMed  Google Scholar 

  38. 38.

    Goldfield GS, Boachie A. Delivery of family therapy in the treatment of anorexia nervosa using telehealth. Telemed J E-Health. 2003;9(1):111–4.

    PubMed  Google Scholar 

  39. 39.

    Halvorsen I, Reas DL, Nilsen JV, Ro O. Naturalistic outcome of family-based inpatient treatment for adolescents with anorexia nervosa. Eur Eat Disord Rev. 2018;26(2):141–5.

    PubMed  Google Scholar 

  40. 40.

    Matthews A, Peterson CM. Intensive family-based therapy during an acute medical admission for anorexia nervosa: a case report. Clin Case Stud. 2016;15(4):313–25.

    Google Scholar 

  41. 41.

    Salbach-Andrae H, Schneider N, Seifert K, Pfeiffer E, Lenz K, Lehmkuhl U, et al. Short-term outcome of anorexia nervosa in adolescents after inpatient treatment: a prospective study. Eur Child Adolesc Psychiatry. 2009;18(11):701–4.

    PubMed  Google Scholar 

  42. 42.

    Schlegl S, Diedrich A, Neumayr C, Fumi M, Naab S, Voderholzer U. Inpatient treatment for adolescents with anorexia nervosa: clinical significance and predictors of treatment outcome. Eur Eat Disord Rev. 2016;24(3):214–22.

    PubMed  Google Scholar 

  43. 43.

    Paul P, Mehta S, Coffey BJ. Anorexia nervosa in a 14-year-old second-generation Hispanic adolescent boy. J Child Adolesc Psychopharmacol. 2013;23(4):295–9.

    PubMed  PubMed Central  Google Scholar 

  44. 44.

    Alessi NE, Krahn D, Brehm D, Wittekindt J. Prepubertal anorexia nervosa and major depressive disorder. J Am Acad Child Adolesc Psychiatry. 1989;28(3):380–4.

    PubMed  Google Scholar 

  45. 45.

    Blanchet-Collet C, Sider A, Gal B, Hanachi-Guidoum M, Melchior JC, Bouscary D, et al. Anorexia nervosa hyperactivity-induced ischemic colitis (ANHIC): a new cause of anaemia. Eat Weight Disord-St. 2016;21(3):507–10.

    Google Scholar 

  46. 46.

    Blinder BJ, Freeman DM, Stunkard AJ. Behavior therapy of anorexia nervosa: effectiveness of activity as a reinforcer of weight gain. Am J Psychiatry. 1970;126(8):1093–8.

    PubMed  Google Scholar 

  47. 47.

    Cinciripini PM, Kornblith SJ, Turner SM, Hersen M. A behavioral program for the management of anorexia and bulimia. J Nerv Ment Dis. 1983;171(3):186–9.

    PubMed  Google Scholar 

  48. 48.

    Clark DB, Munford PR. Behavioral consultation to pediatrics. Child Behavior Therapy. 1981;2(3):25–33.

    Google Scholar 

  49. 49.

    Collins M, Hodas GR, Liebman R. Interdisciplinary model for the inpatient treatment of adolescents with anorexia nervosa. J Adolesc Health Care. 1983;4(1):3–8.

    PubMed  Google Scholar 

  50. 50.

    Garfinkel PE, Kline SA, Stancer HC. Treatment of anorexia nervosa using operant conditioning techniques. J Nerv Ment Dis. 1973;157(6):428–33.

    PubMed  Google Scholar 

  51. 51.

    Halmi KA, Powers P, Cunningham S. Treatment of anorexia nervosa with behavior modification. Effectiveness of formula feeding and isolation. Arch Gen Psychiatry. 1975;32(1):93–6.

    PubMed  Google Scholar 

  52. 52.

    Leitenberg H, Agras WS, Thomson LE. A sequential analysis of the effect of selective positive reinforcement in modifying anorexia nervosa. Behav Res Ther. 1968;6(2):211–8.

    PubMed  Google Scholar 

  53. 53.

    Nygaard JA. Anorexia nervosa. Treatment and triggering factors. Acta Psychiatr Scand Suppl. 1990;361:44–9.

    PubMed  Google Scholar 

  54. 54.

    Pertschuk M, Edwards N, Pomerleau O. A multiple-baseline approach to Behavioural intervention in anorexia nervosa. Behav Ther. 1978;9:368–76.

    Google Scholar 

  55. 55.

    Poole AD, Sanson-Fisher RW, Young P. A behavioural programme for the management of anorexia nervosa. Aust N Z J Psychiatry. 1978;12(1):49–53.

    PubMed  Google Scholar 

  56. 56.

    Solanto MV, Jacobson MS, Heller L, Golden NH, Hertz S. Rate of weight gain of inpatients with anorexia nervosa under two behavioral contracts. Pediatrics. 1994;93(6 Pt 1):989–91.

    PubMed  Google Scholar 

  57. 57.

    Steinhausen HC. Evaluation of inpatient treatment of adolescent anorexic patients. J Psychiatr Res. 1985;19(2–3):371–5.

    PubMed  Google Scholar 

  58. 58.

    Groen JJ, Feldman-Toledano Z. Educative treatment of patients and parentsin anorexia nervosa. Br J Psychiatry. 1966;112(488):671–81.

    PubMed  Google Scholar 

  59. 59.

    Kronenberg J, Nachshoni T, Neumann M, Gaoni B. The treatment of anorexia-nervosa in a general-hospital - a case vignette of a multidisciplinary general hospital-based approach. J Adolesc. 1994;17(2):163–71.

    Google Scholar 

  60. 60.

    Jenkins ME. An outcome study of anorexia nervosa in an adolescent unit. J Adolesc. 1987;10(1):71–81.

    PubMed  Google Scholar 

  61. 61.

    Maxmen JS, Siberfarb PM, Ferrell RB. Anorexia nervosa. Practical initial management in a general hospital. JAMA. 1974;229(7):801–3.

    PubMed  Google Scholar 

  62. 62.

    Wockel L, Zepf FD, Koch S, Meyer-Keitel AE, Schmidt MH. Serotonin-induced decrease of intracellular ca(2+) release in platelets of bulimic patients normalizes during treatment. J Neural Transm (Vienna). 2009;116(1):89–95.

    Google Scholar 

  63. 63.

    Spettigue W, Norris ML, Santos A, Obeid N. Treatment of children and adolescents with avoidant/restrictive food intake disorder: a case series examining the feasibility of family therapy and adjunctive treatments. J Eat Disord. 2018;6:20.

    PubMed  PubMed Central  Google Scholar 

  64. 64.

    Singer L, Ambuel B, Wade S, Jaffe A. Cognitive-Behavioural treatment of health-impairing food phobias in children. J Am Acad Child Adolesc Psychiatry. 1992;31(5):847–52.

    PubMed  Google Scholar 

  65. 65.

    Pitt PD, Middleman AB. A focus on behavior Management of Avoidant/restrictive food intake disorder (ARFID): a case series. Clin Pediatr (Phila). 2018;57(4):478–80.

    Google Scholar 

  66. 66.

    Dalle Grave R, Calugi S, El Ghoch M, Conti M, Fairburn CG. Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: immediate and longer-term effects. Front Psychiatry. 2014;5:14:1–7.

  67. 67.

    El Ghoch M, Milanese C, Calugi S, Muller MJ, Pourhassan M, Ruocco A, et al. Regional fat distribution in adolescent and adult females with anorexia nervosa: a longitudinal study. Clin Nutr. 2014;34(6):P1224–32.

  68. 68.

    Hillen S, Dempfle A, Seitz J, Herpertz-Dahlmann B, Buhren K. Motivation to change and perceptions of the admission process with respect to outcome in adolescent anorexia nervosa. BMC Psychiatry. 2015;15:140.

    PubMed  PubMed Central  Google Scholar 

  69. 69.

    Strober M, Freeman R, Lampert C, Diamond J, Teplinsky C, DeAntonio M. Are there gender differences in core symptoms, temperament, and short-term prospective outcome in anorexia nervosa? Int J Eat Disord. 2006;39(7):570–5.

    PubMed  Google Scholar 

  70. 70.

    Treat TA, McCabe EB, Gaskill JA, Marcus MD. Treatment of anorexia nervosa in a specialty care continuum. Int J Eat Disord. 2008;41(6):564–72.

    PubMed  Google Scholar 

  71. 71.

    Asch M, Esteves J, De Hautecloque D, Bargiacchi A, Le Heuzey MF, Mouren MC, et al. Cognitive remediation therapy for children and adolescents with anorexia nervosa in France: an exploratory study. Encephale. 2014;40(3):240–6.

    PubMed  Google Scholar 

  72. 72.

    Kuge R, Lang K, Yokota A, Kodama S, Morino Y, Nakazato M, et al. Group cognitive remediation therapy for younger adolescents with anorexia nervosa: a feasibility study in a Japanese sample. BMC Res Notes. 2017;10(1):317.

    PubMed  PubMed Central  Google Scholar 

  73. 73.

    Harrison A, Stavri P, Ormond L, McEnemy F, Akyol D, Qureshi A, et al. Cognitive remediation therapy for adolescent inpatients with severe and complex anorexia nervosa: a treatment trial. Eur Eat Disord Rev. 2018;26(3):230–40.

    PubMed  Google Scholar 

  74. 74.

    Herbrich L, van Noort B, Pfeiffer E, Lehmkuhl U, Winter S, Kappel V. Follow-up assessment of cognitive remediation therapy in adolescent anorexia nervosa: a pilot study. Eur Eat Disord Rev. 2017;25(2):104–13.

    PubMed  Google Scholar 

  75. 75.

    Depestele L, Claes L, Dierckx E, Colman R, Schoevaerts K, Lemmens GMD. An adjunctive multi-family group intervention with or without patient participation during an inpatient treatment for adolescents with an eating disorder: a pilot study. Eur Eat Disord Rev. 2017;25(6):570–8.

    PubMed  Google Scholar 

  76. 76.

    Janas-Kozik M, Krzystanek M, Stachowicz M, Krupka-Matuszczyk I, Janas A, Rybakowski JK. Bright light treatment of depressive symptoms in patients with restrictive type of anorexia nervosa. J Affect Disord. 2011;130(3):462–5.

    PubMed  Google Scholar 

  77. 77.

    Couturier J, Mahmood A. Meal support therapy reduces the use of nasogastric feeding for adolescents hospitalized with anorexia nervosa. Eat Disord. 2009;17(4):327–32.

    PubMed  Google Scholar 

  78. 78.

    Kells M, Davidson K, Hitchko L, O'Neil K, Schubert-Bob P, McCabe M. Examining supervised meals in patients with restrictive eating disorders. Appl Nurs Res. 2013;26(2):76–9.

    PubMed  Google Scholar 

  79. 79.

    Kells M, Schubert-Bob P, Nagle K, Hitchko L, O'Neil K, Forbes P, et al. Meal supervision during medical hospitalization for eating disorders. Clin Nurs Res. 2016;26(4):525–37.

    PubMed  Google Scholar 

  80. 80.

    Leacy KA, Cane JN. Effect of non-select menus on weight and eating concern in adolescents hospitalized with anorexia nervosa. Eat Disord. 2012;20(2):159–67.

    PubMed  Google Scholar 

Download references


The authors would like to acknowledge the contribution of Neera Bhatnagar (library scientist) who supported the initial abstract search, as well as Cheryl Webb and Dr. Natasha Snelgrove who contributed to this work through screening of abstracts.


This study did not receive any funding.

Author information




All authors contributed to the screening of articles for inclusion/exclusion. LI and JC assessed the risk of bias for the articles included. The authors contributed to and approved the final manuscript.

Corresponding author

Correspondence to Leanna Isserlin.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Additional file 1.

Database Search Strategies.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Isserlin, L., Spettigue, W., Norris, M. et al. Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review. J Eat Disord 8, 32 (2020).

Download citation


  • Child
  • Adolescent
  • Humans
  • Inpatients
  • Hospitalization
  • Feeding and eating disorders