One aspect of treatment that is unique to adolescents is the involvement and authority of the family in the treatment process. The development of a therapeutic relationship between care providers and parents can be critical to success, but also challenging if parents deny the existence of a problem or blame the adolescent for the problem. Conversely, if the care providers attribute blame or fault to the parents, it will be difficult to foster a collaborative relationship with the parents.

Especially for anorexia nervosa, treatment often begins with a specialist in adolescent medicine because of the physical symptoms associated with weight loss (e.g., amenorrhea, fatigue, cold intolerance, weakness, fainting). Adolescents with anorexia nervosa tend to be more willing to be evaluated for these “medical problems” than for any associated psychological symptoms. In addition to addressing the presenting medical symptoms, primary care providers can suggest the need for additional mental health services. By focusing on the signs and symptoms that precipitated a medical evaluation and emphasizing healthy meal planning and completion, the primary care provider can shift the focus away from the presence of an eating disorder and toward the behaviors needed to improve health, thereby enhancing motivation for treatment. In the case of continuing medical instability or significant eating problems, adolescent patients can be referred for additional specialist services. Appropriately trained health-care professionals can usually treat bulimia nervosa on an outpatient basis, but some patients with bulimia nervosa need to be monitored for potential medical complications.

In the United Kingdom, the National Institute for Clinical Excellence has completed a compre hensive and rigorous evaluation of the literature on eating disorders. A guideline that makes recommendations for the identification, treatment, and management of anorexia nervosa, bulimia nervosa, and atypical eating disorders (including binge eating disorder) was published in January 2004 (NICE, 2004). The guidelines contains specific recommendations regarding the treatment of adolescents with anorexia nervosa and bulimia nervosa (see http://www.nice.org.uk/ ).

Although not based on empirical studies addressing the appropriate timing, location, and provider of treatment for adolescents with eating disorders, several professional organizations have developed guidelines for the treatment of anorexia nervosa and bulimia nervosa.

The American Psychiatric Association (APA) published its first practice guideline for the treatment of patients with eating disorders in 1993, with a revision in 2000. In this guideline, presentation of the disorder in the younger child and older adult were described, but the specific treatment needs of adolescents were not addressed. A strength of this guideline is the advice provided to practitioners on the medical management of anorexia nervosa. The choice of a treatment site and the potential collaborative arrangements among different health care professionals are similarly addressed. The APA practice guideline notes that bulimia nervosa patients rarely require hospitalization. Family therapy is said to be especially useful for adolescents, according to the Russell et al. (1987) study (see our analysis of this research above, under Psychological Treatments for Adolescents with Anorexia Nervosa).

In 2003, the Society for Adolescent Medicine (SAM) published guidelines that are similar to the 2000 APA recommendations (Golden et al., 2003) with five major positions on the treatment of adolescents with eating disorders:

The American Academy of Pediatrics (AAP) also published a statement about the treatment of adolescents with eating disorders in 2003, noting the potential role for primary care providers in the identification and treatment of these disorders (Rome et al., 2003). The AAP emphasized the unique position of primary care pediatricians in detecting the onset of eating disorders and stopping their progression at the earliest stages of the illness as part of routine, preventive health care. Additionally, because of their existing re lationship with a patient, primary care providers already have an established trusting relationship with the patient and the family, and usually have the necessary knowledge and skills to monitor health. The AAP policy statement also advocated rapid and aggressive treatment of eating disorders, and noted that hospitalization might be required in the case of emerging medical or psychiatric needs or failure to respond to intensive outpatient treatment.

There are no scientific studies to indicate the optimal treatment for adolescents, in terms of when treatment should begin, where that treatment should be delivered, or who should provide the treatment. The consensus view is that therapy should begin as soon as possible after a clinically significant eating problem has been identified, with the treatment provider, parents, and patient working to individualize treatment. The setting for the treatment is partially determined by availability, but the severity and duration of illness, especially with regard to medical complications, must also be considered. The optimal professional to treat an adolescent with an eating disorder is again determined in part by availability. Eating disorders can be effectively managed by a variety of different professionals, including physicians (psychiatrists, primary care providers, or adolescent medicine specialists), psychologists, social workers, and nutritionists who are familiar with efficacious treatment of eating disorders.