Introduction
Evidence-based practice is integral to improving patient outcomes and enhancing safety. To offer holistic nursing care founded on the best evidence, it is important to interpret research and address the complexities associated with mental disorders. Holistic Nursing care is based on the use of evidence to transform patients' health care. Holistic nurses and health care professionals have the “capacity to accept the potential validity of medical therapies that may not have undergone the rigorous testing necessary to be considered standard of care". Thus, evidence-based practice has emerged as the foundation for the provision of care by nurses. Evidence-based practice is the standard for care in nursing specialties, especially mental disorders. The primary focus of this essay is on a child's mental health presentation, which is anorexia, ways to care for and manage the complexities associated with the disorder, and the reasons why current guidelines do not address the complexities of anorexic patients. The paper also discusses evidence-based holistic care for a patient with anorexia nervosa, a mental and eating disorder that affects girls and young women. The essay is organized into four parts: an introduction, Part A, Part B, and a conclusion, which is a summary of the paper.
Part A
The focus of this section is on anorexia nervosa, which is a mental health disorder affecting girls and young adult women. Additionally, the evidence-based holistic care of patients presenting with anorexia nervosa will be hypothetically and critically discussed. An evaluation of why current assessment and treatment guidelines do not always consider the complexity of an individual’s case and how this complexity may have to be managed is also carried out.
Mental disorders are part of a large portion of the disease burden among young people in the United Kingdom. The majority of mental disorders start in adolescents and youth (12–24 years of age), but they can also continue later in life. The problems associated with poor mental health include lower educational achievements, violence, substance abuse, and poor reproductive and sexual health. Eating disorders such as anorexia are mental disorders that affect children and adolescents as well as young adults. Bernstein (2017) has described Anorexia nervosa (AN) as a potentially life-threatening eating disorder, which is characterized by the inability of a person to maintain a minimally normal weight, fear of gaining weight, disturbance in the manner in which body shape and weight are perceived, and unrelenting dietary habits that inhibit weight gain. It is a mental disorder that affects people of all ages, sexual orientations, sexes, ethnic origins, and races. Nonetheless, Anorexia nervosa is more prevalent among young adult women and adolescent girls. The typical age for the start of anorexia is early adolescence between 12 to 15 years, whereas bulimia is more prevalent in middle adolescence between 15 to 17 years (Lock, 2009). Thus, although both are experienced at the adolescent stage, the onset varies whereby anorexia starts early, especially among girls.
Anorexic individuals show a disturbed body image and intense fear of weight gain that motivate them to uphold severe dietary restrictions and weight loss behaviors, including excessive physical activity and purging. People with this type of eating and mental disorder are disturbed by cognitive and emotional functioning. Subsequently, medical morbidity and psychiatric comorbidity are commonly prevalent among young adult women and adolescent girls. Anorexia nervosa experienced by adults and older adolescents has a protracted or relapsing course, with high levels of mortality and disability, particularly without treatment. Subsyndromal anorexia nervosa is also linked with adverse health outcomes and potential death. Anorexia nervosa is different from Bulimia Nervosa in that the latter entails recurrent episodes of binge eating, while the former is associated with restriction of energy intake as a requirement to have a low body weight.
In terms of epidemiology, anorexia nervosa is prevalent in high-income countries, and it affects around 1% of women compared to less than 0·5% of men. Nonetheless, accurate point prevalence is difficult to calculate because studies have failed to identify cases of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)-defined anorexia nervosa. In case the DSM-5 criteria A and C are applied, then the prevalence point is estimated to be around 0·3–0·5%. However, studies conducted have shown that there has been an increase in anorexia nervosa among adolescents over the last twenty years. Zipfel et al. (2015) have contended that anorexia nervosa starts early to mid-adolescence but it can arise at any age. Nicholls, Lynn, and Viner (2011) posited that the sex ratio in adults to prevalence of anorexia nervosa is 1:8, whereby more females are affected in comparison to males. In children, the distribution of anorexia nervosa in terms of sex is less skewed. Across the age groups, the rates of full recovery are higher,r and mortality rates lower in adolescents in comparison to adults. The differences result from age differences whereby early treatment for adolescents could result to full recovery, thus reducing the mortality rate.
In the UK, eating disorders affect 1.6 million people, where 11 are males, while the rest are females. In addition, t14-25-year-oldscompared to older people, are most affected by anorexia nervosa statistics further show that 1 in 100 women aged between the ages of 15 and 30 experience affected anorexia nervosa (Micali et al., 2013). Of the 1.6 million people, 10% of people are anorexic compared to 40% who are bulimic. Early diagnosis and treatment of anorexia nervosa improve the efficacy of recovery. This has been supported by Zipfel et al. (2015) findings that when anorexia nervosa when diagnosed and treated early, the recovery rate for this eating disorder declines. Despite the prevalence and death rates, Arcelus et al. (2011) noted that even when the mortality and morbidity rates among patients with eating disorders remain high, there is no single study that has provided the exact rates. Thus, a clarification of the mortality and morbidity rates among anorexic patients could play an integral role in the future of nursing.
Patients diagnosed with anorexia nervosa usually display a broad range of somatic complications that affect the organ systems of the affected. For instance, in the acute state, patients diagnosed with anorexia nervosa complain of dizziness, syncope, and fatigue. Additionally, patients with a chronic course could experience organ failure as a result of malnutrition and show signs of osteoporosis and osteopenia of the lumbar spine (Zipfel et al., 2015). Furthermore, patients with anorexia nervosa are at the risk of an increased lifetime prevalence of type 1 diabetes, which is a result of poor glycaemic control, insulin purging, diabetic complications, and high mortality.
According to the American Psychological Association [APA] (2011), there are specific psychological factors accompanied by personality traits that predispose persons to developing anorexia nervosa. Most of the girls and young women with eating disorders such as anorexia nervosa usually suffer from low self-esteem, intense dissatisfaction with their body, and feelings of helplessness. Additionally, there are also particular personality traits linked to this form of mental disorder. Adolescents with anorexia nervosa tend to be perfectionistic and self-centered (APA, 2011). Physical factors on the other hand are such as genetic risk. Family members as well as friends are reported to cause this disorder as they could repeatedly tease adolescents about their bodies. This could subsequently create negative emotions and traumas (APA, 2011). Also, environmental influences such as societal idealizations on matters related to weight and body shape risk children to develop anorexia Nervosa (Micali et al., 2013).
Regarding the diagnosis of anorexia nervosa, the DSM-5 diagnostic criteria – as provided by the American Psychiatric Association (2013) is adopted. According to this criterion, the classification is based on three requirements that must be met. For instance, DSM-5 diagnostic criteria A states that to be anorexic, a person has restricted energy intake compared to the required amount, and this results in low body weight. A significant low body weight is that which is below the minimally normal. Kakhi and McCann (2016) added that criteria B is that the person must have an intense fear of gaining weight, and ultimately becoming fat. Criteria C is the disturbance in a manner that the individual’s body weight, as well as shape, is disturbed. After these requirements have been met, the person is diagnosed with anorexia nervosa, and treatment must be sought. According to the NICE recommendations, during the assessment of a person to determine if they have Anorexia nervosa, attention must be paid to the general clinical assessment including growth rates in children, rate of weight loss, appropriate laboratory tests, and objective physical signs (APA, 2013). Additionally, adolescents and children with Anorexia nervosa must be provided personal appointments with a healthcare professional, which are separate from those of the family members. As part of providing holistic evidenced care, therapeutic involvement of siblings as well as other family members is recommended because the disorder also has effects on other family members.
Eddy et al. (2010) established that the phenomenology of anorexia nervosa among children and adolescents is not only understudied but also poorly understood. The present classification system of eating disorders DSM-IV-TR has classified anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS) under the same platform. Although children and adolescents are the ones majorly linked with anorexia nervosa, the DSM-IV-TR has not made specific provisions for the diagnosis (Eddy et al., 2010). Thus, to inform DSM-V, additional research is required to establish if the same diagnostic presentations and symptom clusters observed in adults could also be identified in adolescents and children. There is limited empirical work that has examined the suitability and applicability of the DSMIV-TR among adolescents and children, and therefore, different diagnostic thresholds could be required for younger populations (Eddy et al., 2010). According to Bravender, Bryant-Waugh, and Herzog (2009), the Workgroup for Classification of Eating Disorders in Children and Adolescents reviewed the literature and identified potential complexities linked with the diagnostic criteria for adolescents and children. For instance, growth and weight gain in children and adolescents are expected as they grow and this could be a challenge when applying a strict weight criterion needed for the anorexia nervosa diagnosis. Bravender et al. (2007) contended that children and adolescents could be premenarcheal and this implies that the anorexia nervosa diagnosis could be irrelevant.
The application of the cognitive eating disorder criteria that includes extreme fear of weight gain, overvaluation of share and weight, and body image disturbance, are according to Eddy et al. (2010) complex and hard to assess and apply among younger patients. Eddy, Doyle, Hoste, Herzog, and, Le Grange (2008) established that there is an absence of clinically meaningful differences between children and adolescents with anorexia nervosa and bulimia nervosa. Thus, the current classification system of eating disorders remains inadequate in terms of categorizing eating pathology among children and adolescents. Bravender et al. (2007) further pointed out that developmental differences between children, adolescents, and adults resulted in unique sets of complexities linked to the applicability of the DSM-IV-TR. Given that anorexia nervosa starts mostly in adolescence, the failure to classify younger patients with this disorder is problematic. Because of these classification problems, certain revisions have been carried out on DSM-IV for Anorexia Nervosa. This has been necessary because of major complexity resides in the high number of patients who fail to meet the A, B, and C criteria for anorexia nervosa. The patients diagnosed with Anorexia Nervosa may be confused with those with other eating disorders in terms of depressive symptoms, pathology, and self-esteem.
Developmental factors have to be considered when classifying eating disorder diagnoses and subtypes. Eddy et al. (2008) contend that clinical and epidemiologic studies have demonstrated the frequent crossover from anorexia nervosa to bulimia (8–54%) within the first five years of illness. Additionally, during adolescence, children with anorexia nervosa could infrequently present a purging subtype and the diagnosis of the restricting subtype could not assist in differentiating the clinical presentations of the disorder at this stage of development. The diagnosis and assessment criteria rely on age, and children and adolescents have to develop the cognitive capacity to perceive and reason about the long-term negative effects, before fear of weight gain body image, or distortion. Eddy et al. (2010) established that the absence of not paying attention to developmental factors could result in a wrong diagnosis. Instead, the inclusion of developmental changes and capturing them adequately could reduce the complexity of diagnosis and assessment.
Under the DSM-5, Knoll et al. (2011) noted that the term ‘‘restriction of energy intake relative to requirements’’, poses some complexities. For instance, the term could be used to describe behavior as active and deliberate acts of the patient. According to Hebebrand and Bulik (2010), the phrase ‘‘restriction of energy intake’’ fails to adequately address if the energy intake is clinically too low regarding requirements Also, there is no simple method to measure energy intake, and this could hinder healthcare professionals from establishing whether the patient has anorexia nervosa. The DSM-V term ‘‘markedly low body weight’’ is described ‘‘as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected for age and height’’ (Knoll et al., 2011, p. 96). The omission of a body weight percentage of less than 85% of the expected in DSM-V has created uncertainty because it remains hard to formalize the weight criterion for adolescents and children. Thus, based on the current guidelines for diagnosis, assessment, and treatment of adolescents and children with anorexia nervosa do not at all address the complexity and nature of individual cases, but instead delve into the DSM-V criteria for eating disorders. Children and adolescents are at risk of being diagnosed with anorexia nervosa.
For a patient with anorexia nervosa to be treated, it is necessary to diagnose early and provide holistic care. Zipfel et al. (2015) have noted that with the treatment provided, forty percent of the patients diagnosed with anorexia nervosa make a full recovery. Thus, access to evidence-based holistic care from a specialist service in the treatment of anorexia nervosa is linked with better outcomes. Therefore, healthcare practitioners must be competent enough to be in a position to identify anorexia nervosa and subsequently have early access to both the secondary level and tertiary levels of care. Hay, Touyz, and Sud (2012) posited that early access was evidence that effective intervention for patients with anorexia nervosa at the early stages of illness was important because it improved outcomes. On the other hand, late access to holistic care makes it much harder to realize full recovery. Despite this critical window, those who develop severe as well as enduring anorexia nervosa are at a high risk for death or disability.
It is widely believed that the treatment of adolescents with anorexia nervosa is supported by family-based treatment (FBT) is supported by empirical evidence. Nonetheless, Fairburn (2005) noted that the available evidence is based on a past study by Russell and colleagues that depended on the treatment of 21 adolescent patients. Thus, on whether evidence-based treatment of anorexia nervosa is possible Fairburn (2005) concluded that it is good with adolescents but poor with adults. Kass, Kolko, and Wilfley (2013) established that cognitive-behavioral therapy CBT) and interpersonal psychotherapy (IPT) were specialist psychological treatments that were used to address anorexia nervosa symptomatology. In the same study, the efficacy of both CBT and IPT for adults with anorexia nervosa was evaluated against a contrast of treatment by specialist supportive clinical management and established that 49% of patients showed a good outcome. Nonetheless, none of the treatments was more efficacious than the other. The use of Cognitive remediation therapy (CRT) could address the impaired cognition associated with the maintenance of anorexia nervosa and could minimize dropout and enhance outcomes via increased treatment engagement and better-quality cognitive flexibility. Nonetheless, Lock, Agras, Fitzpatrick, Bryson, Jo, and Tchanturia (2013) established that there is not enough evidence to show that CRT was effective after it was applied after the use of CBT and resulted in improved quality of life.
Other than nutritional rehabilitation, medication can also be used to treat patients with anorexia nervosa. For instance, adolescents and children with anorexia nervosa could be provided with antidepressants such as fluoxetine and citalopram are effective in terms of weight gain compared to those using a placebo (Chakraborty & Basu, 2010). Nonetheless, low doses of second-generation antipsychotic medications can improve weight gain, but controlled studies must be undertaken to improve (Barbarich et al., 2004). When treatment is being provided to children and adolescents with anorexia nervosa, it is important to include family members. Families can benefit from being part of counseling and family therapy sessions as they provide support to the child, hence improving the intervention process.
Part B
This section critically discusses the broader service issues and how specialist services may be designed to help patients diagnosed with anorexia nervosa. In addition, the section also provides a discussion of how professionals need to work together to ensure a patient receives individualized seamless care. Lastly, a critical discussion of the strengths of current specialist service provision and the current gaps in service delivery for anorexia nervosa was provided.
As indicated in Part A, FBT and CBT are applicable in the treatment of patients with anorexia nervosa. However, drawing from Espie and Eisler (2015), the FBT could be challenging when used for the treatment of anorexia nervosa in children and adolescents. For instance, it is used to imply a wide range of family-oriented counseling approaches or treatments, and it requires a specialist to establish the most appropriate one for the patient. Nonetheless, Family therapy for anorexia for children and adolescents is suitable for anorexia nervosa and it is evidenced as an efficacious treatment. Treatments for anorexia nervosa must be designed and evaluated to establish their ability to be distributed and implemented in the UK across various settings. Partnering with stakeholders is also needed to evaluate the uptake, sustainability, and cost-effectiveness of evidence-based treatments (Kass, Kolko & Wilfley, 2013). Honing the understanding of specialists could enhance them to predict patient treatment response and aid in the development of novel treatment solutions.
The other issue related to service provision to patients with anorexia nervosa is related to ethical issues. The issues of consent and treatment refusal remain complex, especially when dealing with children and adolescents because a third party such as a parent or a guardian must be involved in the discussion (National Collaborating Centre for Mental Health, 2004). Although different kinds of psychological treatment such as FBT, CBT, and IPT are linked with improvements in terms of recovery after treatment in comparison to the ‘standard care’ for specific populations, it is hard to sustain long-term benefits. The National Collaborating Centre for Mental Health (2004) further added that evidence on the effectiveness of family interventions that explicitly focus on anorexia nervosa is limited. In addition, there is insufficient evidence to establish if conjoint or separated kinds of family therapy are more effective than other forms of intervention.
Anorexia nervosa is a both mental disorder and an eating disorder that has clear and documentable symptoms and behavioral features and cognitions. The challenge faced by service specialists is that the behavioral and symptoms of anorexia nervosa vary depending on the age of the disorder and the age of the patient (Knoll et al., 2011). The current DSM-5 tends to classify anorexia nervosa-like subtypes as EDNOS. Additionally, the DSM-5 criterion insufficiently resolves the problems found in DSM-IV, and this hampers both clinical practices for service specialists. This implies that the assessment of patients, especially children, and adolescents with anorexia nervosa remains challenging because seriously ill patients with an anorexia nervosa-like phenotype would only fulfill one AN criterion (Knoll et al., 2011). From a developmental point of view, the DSM-V D criterion remains inapplicable to prepubescent females because it is during this stage that they experience amenorrhea. Amenorrhea is associated with starvation, but developmental changes in adolescents could make females seem anorexic. Furthermore, preadolescents have challenges in perceiving the risk associated with eating disorders, and this could hinder service specialists from providing individualized seamless care.
Royal College of Psychiatrists (2012) recommended that “An integrated quality network for eating disorder services across the age range covering all service components of eating disorders services and involving patients and carers should be set up to provide external quality control and accreditation of services (p. 6). Thus, specialist services may be designed to help anorexia nervosa patients by formation of integrated quality network in all regions in the UK. In addition, the network must entail a multidisciplinary staff to ensure that all the needs of the patients are met and for them to receive individualized seamless care. The NICE guidelines (National Collaborating Centre for Mental Health) recommendations for anorexia nervosa stipulate that people with this disorder must be managed on an outpatient basis, whereby psychological treatment is offered at the service by a competent and skilled team. For children, the Royal College of Psychiatrists (2012) noted that therapeutic approaches for anorexia nervosa included CBT (84%), family-based treatment (77%), and nutritional advice and monitoring (82%). The strength of these approaches could assist in improving the understanding of how treatments work. This could subsequently inform questions related to the most efficacious treatments.
A cohesive multidisciplinary team approach is widely recognized as the best practice when dealing with patients with anorexia nervosa. According to Joy, Wilson, and Varechok (2003), team members are such as a physician, a mental health professional, and a nutritionist, and they all must be experienced and knowledgeable on how to care for persons with disordered eating. Additionally, each treatment team member has special skills and responsibilities required for patient care. Nonetheless, the current guidelines do not offer the roles and responsibilities of each member of the treatment team to enhance recovery. It is therefore important to note eating problems such as anorexia nervosa may not necessarily meet the DSMD- V criteria, especially for adolescents who are influenced by different developmental factors (Joy et al., 2003). Despite the multi-disciplinary treatment efforts, the prognosis for anorexia nervosa remains poor, whereby only 40% -50% of patients progress to full recovery. All practitioners must therefore undertake continued efforts to enhance early, comprehensive intervention (Joy et al., 2003). In determining the level of treatment of a patient, assessment must comprise physical condition, eating disorder behaviors, psychology, and social circumstances, which are realized via a multidisciplinary approach. It is thus unsafe for care providers and professionals to depend on a single parameter, such as minimal body weight, when determining the kind and level of treatment needed. Treatment guidelines for anorexia nervosa have recommended the regular monitoring of the patient’s mental and physical status, till full recovery.
Professionals need to work together to ensure that a patient receives individualized seamless care. The initial assessment of the patient with anorexia nervosa entails the use of an in-depth interview, investigations, and a physical examination, to establish the nature and the severity of eating disorder diagnosis and symptoms, comorbid physical and psychological symptoms, risks and diagnoses, past treatments, present motivation for treatment, and any accessible supports (Zipfel et al., 2015). These undertakings require the efforts of a multidisciplinary team composed of nurses, nutritionists, caregivers, and physicians. When dealing with a patient with anorexia nervosa, the requirement is to build a rapport because of the fearful perception of treatment. It is also important to involve partners and family members in assessment and consequent treatment. Healthcare professionals are required to include families because they play a fundamental role in the recovery of patients from anorexia nervosa, and education is significant across the developmental continuum. The nature and level of involvement and maximum way of engaging families in therapy, nonetheless, varies based on the patient's developmental status as well as the family functioning level. In FBT, parents learn how to engage their children and adolescents and practice the same psychological and behavioral strategies used by care providers’ weight restoration programs (Fairburn, 2005). For patients transitioning from adolescence to adulthood, the service providers must consider several factors such as the patient’s developmental status, family functioning, and living situation.
When various professionals are involved in providing patient care to anorexic individuals, it is beneficial to share an understanding and establish therapeutic boundaries put into place. This is necessary to ensure that all team members involved implement consistently, hence promoting evidence-based holistic care (Kuyken, Padesky & Dudley, 2009). Good communication is also important as it ensures that healthcare providers make the necessary referrals that lead itosuitable therapeutic programsto meets the needs of a specific patient (Yager, 2007). Excellent communication among care providers establishes and maintains healthy relationships among care providers. It also ensures that defined roles for care providers are established when patients are transitioning between levels of care. When working in teams, effective communication is required to avoid challenges with engagement and relapse in anorexia nervosa treatment (Kuyken et al., 2009). Also, mismatches between the behavioral expectations found with a level of care and patient as well as the family readiness for change are reduced when there is excellent communication. Communication between patients, families, and care providers ensures that seamless individualized services are provided. This is achieved by tailoring relevant patient characteristics and needs at each level of primary and secondary care.
The NHS (2006) has recommended the use of a multidisciplinary model of care to provision of services to patients with anorexia nervosa. For appropriate management of this disorder to be undertaken input from several disciplines, and working together is required to ensure coordination. The NHS has further recommended that anorexia nervosa in most patients could effectively be managed on an outpatient basis via medical monitoring, psychological component, and dietetic advice offered by a multidisciplinary team. After a patient seeks medical attention, the initial step is to develop a therapeutic rapport with the patient, and at the same time establish the motivation needed for change, and combat any further weight loss.
About the strengths of current specialist service provision, the NICE guidelines ensure that the services provided to patients with anorexia are patient-centred. In addition, the guidelines recommended patients with anorexia nervosa be treated in secondary care but be allowed to choose between in, out, or day-patient provision (Knoll et al., 2011). Also, people with severe and chronic anorexia nervosa must seek treatment in specialist eating disorder services. According to Chakraborty and Basu's (2010) findings, CBT significantly reduces relapse risk and increases the chance for good outcomes in comparison to nutritional counseling.
In respect to service provision, some gaps may hinder assessment and treatment, and full recovery from anorexia nervosa. National Eating Disorders Collaboration [NEDC] (2013) has defined a gap as the difference between an agreed standard and actual practice and the perceived need for eating disorder services. Accordingly, the current guidelines do not address how person and family-centered care could be used to address the needs of children and adolescents (Kass et al., 2013). In support, the Joint Commissioning Panel for Mental Health (2013) noted that currently there are no quality comprehensive services for persons with anorexia disorders in many parts of England, and subsequently majority of people seek treatment in non-specialist settings. Thus, there is a need to ensure that people diagnosed with eating disorders such as anorexia disorder have access to specialist treatment to promote complete recovery.
The other gap or issue is relayed to the DSM-5 criteria used by service specialists in the diagnosis and assessments of patients with eating disorders. Based on Surgenor and Maguire's (2013) study, the cross-over between anorexia nervosa subtypes is common, and this implies that those with anorexia nervosa -Restricting Type and anorexia nervosa -Binge-Eating/Purging Type could be phases of the similar condition instead of different groups. Other issues related to diagnostic variability include the inability of specialists to fully assess some features of anorexia nervosa which are similar to other eating disorders. This may be a challenge in identifying patients with severe anorexia nervosa. The issues of assessment in both children and adolescents are complex and may limit the level of intervention and treatment provided to the patients (Surgenor & Maguire, 2013).
Conclusion
Anorexia nervosa affects young adult women and adolescent girls more compared to males. Additionally, anorexia nervosa begins in early adolescence and it is associated with the inability of an individual to maintain a minimally normal weight, fear of weight gain, disturbance because of body shape and weight increase, and unrelenting dietary habits used to inhibit weight gain. The DSM-5 diagnostic criteria are not adequate in the diagnosis and assessment of anorexia nervosa in adolescents and children. From a developmental perspective,e it is easy for specialists to mistake EDNOS for anorexia nervosa, hence poor treatment. Phenomenology of anorexia nervosa among children and adolescents is understudied and poorly understood. For instance, the DSM-IV-TR does not make any specific provisions for the diagnosis of anorexia nervosa among children and adolescents. Thus, empirical work examining the suitability and applicability of the DSMIV-TR among adolescents and children is limited and this possesses potential complexities linked with the diagnostic criteria. Both FBT and CBT are effective in the treatment of patients with anorexia nervosa, but further study is required on their effectiveness in adolescents and children. The issues faced by specialists in the provision of treatment include the inability of DSM-5 criteria to insufficiently resolve the problems in DSM-IV. The multi-disciplinary model could be used to enhance the effective treatment of persons with anorexia nervosa because it promotes communication between different professionals. The primary gap is that the current guidelines by NICE do address how person and family-centered care could be used to address the needs of children and adolescents.
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