Screening for Eating Disorders in Children and Adolescents: A Guide for Providers

Countless studies over recent years add up to a concerning reality: eating disorders are becoming increasingly prevalent among young people. According to a JAMA Pediatrics review released in early 2023, one out of every five children worldwide displays symptoms of disordered eating. Not only are patients being diagnosed with eating disorders at ages younger than ever before, but they’re also coming into eating disorder-related health visits with more severe mental and physical symptoms (CDC). We know that childhood and adolescence are critical periods of growth and development, adding gravity to the role of providers in screening and intervening effectively and early to limit the eating disorder’s potential for irreversible consequences.

Given this urgency, as a provider, what should you be looking out for when meeting with child or adolescent patients? How can you ensure that your eating disorder screening is informed, comprehensive, and age-appropriate? Here, we hope to equip you with a deeper understanding of the importance of early intervention, common signs of eating disorders in children and adolescents, and how to respond if you suspect your young patient is struggling with an eating disorder or disordered eating.

The Importance of Early Eating Disorder Intervention

Eating disorders have become an illness of younger and younger patients. Newer evidence indicates that the average age of onset is 12 years old (down from a previous median age of 14), and we see this age decreasing with each subsequent generation.

Despite the pervasive eating disorder stereotype – white, thin, teenage, cisgender girls – eating disorders can affect children and young adolescents of diverse genders, ethnicities, races, sexual orientations, socio-economic backgrounds, and body weights. In fact, BIPOC, LGBTQ+, and trans and non-binary youth develop eating disorders at even higher rates, according to research. That said, eating disorders are far less likely to be detected among these underrepresented groups.

Even with clear data, the healthcare field is still missing opportunities to connect the youngest patients to care. Only a minority of children and adolescents receive services specifically for eating and/or weight concerns. When disordered eating goes unaddressed, harmful thoughts and behaviors can take deeper root, leading to greater risk or damage to health, substantial psychological distress, and/or significant impairment to one’s quality of life.

While all types of eating disorders can affect children and adolescents, studies suggest higher prevalence rates of restrictive-type eating disorders among younger patients, including anorexia nervosa, atypical anorexia nervosa, and Avoidant/Restrictive Food Intake Disorder (ARFID). The medical complications and management of eating disorders are generally considered from an age-neutral perspective. However, children and young adolescents may have unique medical complications that can be harder to detect. Energy needs for growth and development create a period of nutritional vulnerability for younger patients. Some malnutrition-related complications, including stunted linear growth, bone development, and brain maturation, can be irreversible if not detected early and addressed with effective and swift intervention. Additionally, it’s worth noting that eating disorders are among the most life-threatening of all mental health conditions. According to research, people with anorexia between the ages of 15 and 24 are ten times more likely to die than their peers.

Children and adolescents with eating disorders often present first to medical providers. As scientific literature affirms, improving medical and clinical outcomes for children and adolescents with eating disorders must be a primary care priority. Heightened recognition of the age of onset, additional risks associated with marginalized identities, developmentally based medical concerns, and an increased understanding of best-practice screening practices are essential for preventing and disrupting the harmful course of these serious illnesses.

Signs of Eating Disorders in Children and Adolescents

Regular healthcare visits are essential to a young person’s overall health. As a provider, you are well-positioned to monitor ongoing physical and mental health and screen for a range of conditions, including eating disorders.

Behaviors associated with an onset of an eating disorder may manifest differently in children and young adolescents than in someone older. The American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry advise screening young people through longitudinal height and weight monitoring and looking for symptoms of disordered eating, followed by further questioning.

Look for these signs and symptoms in your patient:

• Significant weight gain or loss, or failure to gain weight/height according to growth pattern
• Electrolyte abnormalities, including low potassium and high blood alkaline levels
• Low blood pressure
• Low body temperature
• A slow or irregular heartbeat
• Amenorrhea
• Cold intolerance
• Complaints of nausea, stomachaches, bloating, or constipation
• Complaints of dizziness, weakness, or fatigue
• Swollen salivary glands
• Dry, pale skin
• Fine hair growth on body and thinning hair on head
• Brittle nails and blue nail beds

When talking to children and young adolescents with known or suspected eating disorders, make sure to keep your interview developmentally appropriate. Bright Futures, an eating disorder prevention initiative from the American Academy of Pediatrics, recommends the following screening questions to pinpoint concerns that warrant further evaluation:

• How do you feel about your present weight?
• How much would you like to weigh?
• How much do you worry about eating?

In children and young adolescents, the patient or their parent may note:

• Excessive concerns about their weight
• Engaging in inappropriate dieting
• A pattern of weight loss
• Avoiding social situations involving food
• An aversion to tastes, smells or textures
• A fear of vomiting or choking
• Hiding or hoarding food, or eating in secret
• A failure to achieve appropriate increases in weight or height
• Delayed or interrupted puberty, which may include amenorrhea

How to Proceed if You Suspect Your Child or Adolescent Patient Has an Eating Disorder

A medical evaluation must follow if patients are presenting with reported dieting, body image dissatisfaction, experiences with weight-based stigma, and/or changes in exercise or eating patterns.

During an initial medical evaluation, medical providers can assist in early identification and management by:

• Ruling out other disorders or undiagnosed pre-existing conditions, such as:
  • Crohn’s disease
  • Thyroid disease
  • Prolactinoma
  • Diabetes
  • Celiac disease
  • Food allergies
  • Eosinophilic esophagitis
• Evaluating the patient’s medical, nutritional, and psychosocial status
• Determining the severity of the condition
• Making a plan of care

Eating disorder behaviors are often less obvious in children. Children and adolescents may be less likely to have overt weight loss, abnormal vital signs, and/or abnormal lab values. As such, monitoring your patient’s growth charts can be vital to earlier diagnosis. What’s more, because restrictive intake may be surreptitious, medical complaints may present first, leading to potential misdiagnoses. It’s important to be vigilant and suspicious of indications of disordered behaviors and intervene accordingly.

Due to the potentially irreversible effects on physical and emotional growth and development, the high mortality rate, and evidence suggesting improved outcomes with early treatment, the threshold for eating disorder intervention is lower in children and adolescents.

Support your patient as they take the next step toward healing. If you suspect your patient has an eating disorder, please talk to one of Veritas Collaborative’s professionals at 612-402-3061 or refer a patient through our online form so we can schedule an eating disorder assessment.

At Veritas Collaborative, our program was specifically built with children and adolescents in mind. Treatment at Veritas stands out in our ability to provide age-appropriate, best-practice care tailored to the unique medical, nutritional, and psychosocial needs of young people and their families, across a full continuum of care. You can trust that your patients will be well-situated for recovery alongside a multidisciplinary team of professionals who innately understand their needs and challenges.

To learn more about the unique considerations for eating disorders in children and adolescents, watch Dr. Anna Tanner’s presentation titled “Not Just a Phase: Eating Disorders in Children and Adolescents” on our Recorded Presentations page.