Educational continuity in intensive treatment for eating disorders: Homebound Instruction as a component of intensive CBT-E

 

1. Introduction

Eating disorders are complex conditions characterised by medical, psychological, and psychosocial impairment. In children and adolescents, prolonged interruption of school attendance represents an additional risk factor, as it may be associated with social isolation, loss of developmental roles and a reduction in quality of life

The residential intensive CBT-E programme (Dalle Grave, 2018; Fairburn, 2008) implemented at the Centro Terapeutico Villa del Principe in Genoa (Italy) places particular emphasis on the recovery of global functioning. Within this framework, ensuring continuity of education is not only a legal requirement but also a clinically relevant component of treatment. This paper describes the integration of Homebound Instruction (Italian: Istruzione Domiciliare), the formal provision of the Italian Ministry of Education for students who are unable to attend school because of a medical condition, within the Nutritional Rehabilitation Unit, outlining its theoretical rationale, organisation, and clinical implications.

2. Regulatory framework

In Italy, Homebound Instruction (Istruzione Domiciliare) is regulated by the Ministry of Education through a consolidated set of provisions, including Ministerial Note no. 2939 (April 28, 2015), Ministerial Note no. 1865 (October 10, 2017), and the National Guidelines issued on June 6, 2019 (Ministero dell’Istruzione, 2019). These regulations define the criteria for activation of the service for students who are unable to attend school for at least 30 days, even if non-consecutively. The service is managed by the student’s school and provides a variable number of weekly teaching hours (usually 4–6), delivered either at home or within the treatment setting.

In a 20-week residential programme for eating disorders, the implementation of HI is essential to ensure continuity of the educational pathway. Its activation requires structured collaboration between the healthcare team and the school system and therefore represents a complex, intersectoral intervention.

3. Clinical rationale for the integration of Homebound Instruction

The available literature, although not specifically focused on eating disorders, indicates that educational support for children and adolescents with chronic medical conditions is associated with improved school engagement and quality of life (Barnett et al., 2023). Similarly, hospital-based schooling has been linked to reduced emotional distress and improved emotional regulation (Ciucci et al., 2024).

To date, no studies have specifically examined the structured integration of educational interventions within intensive treatment programmes for eating disorders.

The experience described in this paper was developed within a specialised residential CBT-E programme. All school-age patients admitted to the unit were included in the HI activation procedure due to their prolonged absence from school. The data presented derive from routine clinical practice and are merely observational.

4. Clinical and educational objectives of Homebound Instruction

Within an intensive CBT-E programme, HI can be conceptualised as an intentional and structured therapeutic component.

From this perspective, the school activity is not an accessory element but contributes to the restoration of a broader and more functional system of self-evaluation.

HI can be organised around clinical objectives consistent with the CBT-E model. This approach appears to be consistent with the limited available evidence on school-based interventions in healthcare contexts (Efthymiou et al., 2023), although this evidence derives predominantly from a generalist perspective:

• Enhancing engagement and personal agency: students are actively involved in planning their study activities and defining educational goals, promoting self-efficacy and responsibility.
• Addressing clinical perfectionism: the educational context allows the implementation of specific CBT-E strategies aimed at developing realistic standards and increasing tolerance of mistakes, particularly when the broad form of CBT-E is indicated.
• Providing graded exposure to cognitive and interpersonal demands: schoolwork represents a structured and protected exposure to performance-related and relational stressors.
• Preventing school dropout and maintaining developmental roles: patients are supported in studying despite the presence of disorder-related symptoms, maintaining contact with their class group and their identity as students.

In this context, HI functions as a cognitive decentring intervention, promoting investment in alternative domains and facilitating the expansion of self-evaluation areas, a core therapeutic target in CBT-E.

5. Educational continuity, nutritional rehabilitation, and cognitive functioning

Cognitive impairments are frequently observed in conditions of malnutrition and may interfere with the implementation of treatment procedures. In eating disorders, cognitive rigidity, deficits in executive functioning, and reduced action monitoring can act as maintaining factors.

In the integrated model adopted at Villa del Principe, nutritional rehabilitation and HI operate synergistically: clinical stabilisation supports cognitive recovery, while the continuity of school activity provides a structured context for the stimulation of executive functions.

In line with previous findings (Ciucci et al., 2024), maintaining school activity during admission also appears to contribute to emotional regulation and to the reduction of distress.

6. Results and clinical observations

The most relevant finding is that all school-age patients who completed the residential programme maintained educational continuity.

Clinically, a progressive reduction in school-related anxiety, improved tolerance of frustration, and increased adherence to the therapeutic programme were observed. In several cases, the maintenance of the student role facilitated the transition to discharge and the return to everyday life.

These observations were not based on standardised outcome measures and therefore do not allow causal interpretations. The aim of this contribution is descriptive: to present an integrated model of care and to provide a basis for future systematic research.

7. Conclusions and clinical implications

The structured integration of Homebound Instruction within residential intensive programmes for eating disorders represents a clinically meaningful practice that is consistent with the CBT-E model.

The experience at the Centro Terapeutico Villa del Principe shows how the collaboration between the healthcare team and the school system can enhance engagement in treatment and support the recovery of global functioning and quality of life.

When systematically integrated into intensive CBT-E, the healthcare–school collaboration becomes not only an organisational model but an active therapeutic factor that supports continuity of care and promotes clinical change.

Within this framework, the structured collaboration between the healthcare and educational systems described by Hong et al. (2025) should not be viewed merely as an organisational model consistent with child and adolescent mental health approaches; when systematically integrated into intensive CBT-E programmes, as in the present experience, it becomes an active clinical factor capable of strengthening continuity of care, supporting therapeutic change, and improving outcomes.

Acknowledgements

I would like to thank Marco Massa for his supervision and for his valuable contribution to the preparation of this article.

References

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