Anorexia in Teens: A Guide for Parents & Caregivers

A recent increase in anorexia in teens

During the first two years of the COVID-19 pandemic, hospitalizations rose sharply as anorexia nervosa diagnoses increased in teens [1]. Lockdowns, social isolation and increased time on social media were cited as possible reasons for this spike. These teens were experiencing life-threatening eating disorder complications as the pandemic raged, and parents puzzled over the best ways to care for their children. Do I let them see their friends? Do I let them go to in-person school? But the most important question these parents asked was, How can I get my child to eat?

In this article, I discuss anorexia nervosa (referred to here as anorexia) and its impacts on teens, from young adolescents to older teens.

How does anorexia impact teens?

Eating disorders do not discriminate. Anorexia affects teens of all ages, genders, races, ethnicities, shapes and sizes [2]. In fact, it is estimated that 6-8% of adolescents have some form of an eating disorder [3], and eating disorder diagnoses are increasingly showing up in younger kids [4,5]. Unfortunately, eating disorders do not come without co-occurring mental health concerns. This means that teens with anorexia often experience depression, anxiety, obsessive-compulsive disorder or other symptoms alongside the eating disorder [2].

A hallmark of anorexia is being greatly concerned about one’s body shape or body image. This can lead a teen to reduce their food intake and/or purge what they eat through excessive exercise, laxative use or other means. Over time, these behaviors can negatively affect all organ systems and lead to long-term medical complications, including:

• Cardiovascular disorders (bradycardia, hypotension)
• Gastrointestinal disorders (constipation)
• Orthopedic disorders (bone density loss, osteoporosis)
• Reproductive disorders (infertility)
• Neurological disorders (decreased brain volume)
• Hair, teeth and skin problems
• Stunted growth

The best way to prevent the health risks associated with anorexia is to seek treatment early. The earlier the disease is identified and treated, the better the teen’s physical and mental health outcomes.

Signs of anorexia in teens

Eating disorders thrive in secrecy. This means that teens with anorexia will go to drastic lengths to keep their eating disorder hidden from friends and family. So, how can you spot the signs of anorexia? I recommend that you watch for both eating disorder behaviors and physical side effects caused by the eating disorder.

Anorexia behaviors to watch for

• Overly focusing on body shape or size
• Refusing to eat certain food groups; eating less than normal
• Exercising more than usual; excessively pacing
• Isolating; withdrawing from friends
• Wearing baggy clothes
• Frequently refusing to attend or stay in school (school refusal)

Side effects of anorexia to watch for

• Abdominal complaints or discomfort
• Fainting, dizziness
• Fine hair on face, arms and torso (lanugo)
• Delayed signs of puberty
• Delayed or halted menstruation
• Lack of appropriate increases in weight or height in a growing child/adolescent

What to do if you spot signs of anorexia

If you spot any of the signs of anorexia above, please reach out to your child’s doctor or a trained eating disorder professional. You can try to talk to your child directly, although younger teens may have a harder time identifying their feelings or talking about body image or eating habits [2]. And, since eating disorders thrive in secrecy, older teens may not want to talk about eating disorder thoughts and behaviors at all. I also want to reassure you that all medical complications related to eating disorders are treatable and reversible, aside from bone density. This is why prevention, early detection and treatment are critical.

Anorexia’s effect on growth and development

We physicians track young people’s growth and follow it closely because young people are expected to grow (both height and weight) at certain rates in puberty. A slowing or halting of growth in puberty, combined with eating disorder behaviors, may indicate malnutrition caused by anorexia [2]. Since anorexia affects sex hormones and sex hormones are tied to puberty and development, anorexia can interrupt growth and pubertal development.

When young adolescents restrict their food intake, their body slows or halts growth/puberty to conserve energy. This is problematic. In older adolescents, puberty has already begun and growth may be nearly complete, so the body does not have the option to halt or slow growth when faced with a lack of nutrients. Instead, the body organs are affected, which I will discuss later.

In summary, teens should be growing, and they tend to grow in predictable ways. Anorexia may inhibit this growth or change the expected growth trajectory.

Anorexia in younger teens

Younger teens and preteens face different risks from anorexia compared to older teens and adults. When anorexia begins at a young age, bone density and brain development can be permanently affected. Young teens are about to hit their most rapid growth spurt at the same age that anorexia is most likely to appear – around age 12. Let’s say a young teen with anorexia starts their growth spurt but then loses weight due to eating disorder behaviors. When weight is lost during a growth spurt, the risk for anorexia-related health complications increases. Down the road, the child’s final adult height may be impacted as there wasn’t enough time to achieve their full growth potential [2.] This shows how serious anorexia can be when it affects developing teens.

Detection of anorexia using growth charts

In a study of patients with anorexia age 9-16, researchers found that nearly half of all patients showed a deviation in the growth curve before the parents even reported eating disorder behaviors or symptoms. Deviations in the growth curve occurred, on average, nearly 10 months before the symptoms were reported [6]. This points to the importance of early screening and early intervention for teens with eating disorders.

Anorexia in older teens

Unlike younger individuals, older adolescents and young adults will not experience stunted growth if anorexia develops later in the teen years. Instead, the eating disorder sets its sights on the body’s multiple organ systems. Seizures, fainting, dehydration and other complications may occur. Despite the damage occurring, an older teen may sometimes still have normal vital signs and normal lab work [2]. Caregivers and physicians must stay vigilant because serious risks can occur if anorexia is left untreated.

View more health risks related to anorexia here.

Anorexia treatment for teens

As I’ve discussed, anorexia can be life-threatening and cause permanent damage. Eating disorder treatment with experienced professionals can help to resolve health complications [2]. Since eating disorders are so complex, a specialized, multidisciplinary eating disorder treatment team (including a psychiatrist, primary care physician, therapist and registered dietitian) is key to recovery. Anorexia treatment for teens typically includes:

• Nutritional rehabilitation and meal support
• Psychological and emotional work
• Body image work 
• Family therapy
• Weight restoration and refeeding, if needed, to reduce the effects of malnutrition 
• Medical monitoring and nursing support, if needed

A family-based treatment (FBT) approach is well documented to help young people recover from eating disorders. This should be the first line of treatment for teens that are medically stable.

Learn more about types of eating disorder treatment.

What is the first step of treatment?

The first step in treating anorexia in teens is to ensure that the individual is receiving proper nutrition. Nutrition must be restored before the brain can recover and before the individual can have insight and start to work on their illness. The intense emotional and therapeutic work involved in eating disorder recovery requires a brain to be well nourished.

Once the brain is nourished, treatment can deepen. The first step in therapy for teens is a family-based treatment approach. Along with FBT, treatment centers integrate multiple therapies including body image work, yoga, art therapy and music therapy. At Eating Recovery Center, we also work with patients using evidence-based eating disorder therapies such as:

• Acceptance and commitment therapy (ACT)
• Dialectical behavior therapy (DBT)
• Cognitive behavioral therapy (CBT)
• Radically open DBT (RO-DBT)
• Exposure and response prevention (ERP)
• Emotion-focused family therapy (EFFT)

Based on your loved one’s unique needs, their treatment team will develop a customized, evidence-based treatment plan, working side-by-side with you throughout the process. 

Read more about our approach to therapy for anorexia here.

If you think your teen may have anorexia

Eating disorders in young people can cause lasting physical, emotional and psychological effects, and even an increased risk of early death. Nonetheless it can be hard to spot the signs of anorexia -- and teens with anorexia may refuse to talk about the eating disorder or go to treatment.

So, what is a caregiver to do? For starters, you may want to ask your pediatrician or family doctor to check the following in your teen:
Vital signs, blood pressure and pulse sitting and standing

• EKG
• Lab testing
• Growth and development
• Further testing of severe medical complications, if indicated (cardiac issues, bone density, etc.)

You can also look for signs of food restriction, food refusal, bingeing or purging and share what you find with the doctor. If you know your teen has anorexia and needs professional help, you are going to face some very tough decisions. Should you consider virtual anorexia treatment? Or would your loved one be better off in an outpatient, partial hospitalization, residential or inpatient program? These are very real and very stressful questions for any parent or caregiver to consider. We recommend that you consult your doctor, a child and adolescent psychiatrist or an eating disorder therapist and weigh the pros and cons of each choice. We also invite you to contact our admissions team to learn more about the differences in types of eating disorder care.

Do families cause eating disorders?

Eating disorders may come as a surprise to some families. Other families may recognize the signs because a family member has also struggled with the illness. While parents and caregivers do not cause anorexia, they can be instrumental in helping their loved one recover [2]. FBT, in particular, is one of the most effective interventions for teens with anorexia. In FBT, parents and caregivers are regularly incorporated into treatment, participating in family therapy, education groups, meal planning, meal preparation and more.

Learn more about the causes of anorexia here.

Can anorexia in teens be prevented?

The American Academy of Pediatrics (AAP) and the Society for Adolescent Health and Medicine (SAHM) have made several recommendations for medical providers in preventing eating disorders. Families may choose to adopt these recommendations in their own households as a way of potentially reducing eating disorder thoughts and behaviors:

1. Discourage talking about diets
2. Discourage skipping meals or using diet pills
3. Promote body acceptance instead of body shaming
4. Have family meals more frequently
5. Avoid talking about weight or appearance

You can also remind your child that there are no “good” or “bad” foods and be on alert if your child starts talking about restrictive diets, such as cutting out entire food groups [2].

Teen anorexia statistics

• The average age that an eating disorder begins has been getting younger over time [2].
• The median age of onset of anorexia is 12.3 years [7].
• One study found that nearly all adolescents with anorexia reported feeling socially impaired (88.9%) [7].
• Teens in higher weight bodies are more likely to be bullied or teased for their appearance [8].
• In young people, the mortality rate of anorexia is 4-11% [9].
• The risk of death in young people with anorexia is 12 times higher than that for the general population of the same age [9].
• Older transgender teens report higher rates of eating disorders compared to cisgender teens [10]. Learn more about how we work with transgender individuals with eating disorders here.

Help for anorexia in teens

Unfortunately, many families may worry about stigma when it comes to eating disorder or mental health concerns. This may cause difficult feelings and may discourage caregivers from speaking up about a teen’s symptoms. But the sooner treatment is started, the more quickly and fully any long-term complications of anorexia can be reversed [2]. Please talk with your child’s doctor if you have concerns that eating disorder behaviors are present. Early detection and early intervention are key. Our team is here to answer any questions you might have. Please call us at 866-622-5914 if you are looking for support or treatment options.

Learn more about:

• Anorexia in Males
• Lanugo & Long-Term Effects of Anorexia
• Anorexia vs. Bulimia: What's the Difference?
• The Two Anorexia Subtypes Explained
• Hair Loss with Anorexia: Why Does it Occur?
• Exercising in Anorexia Recovery: Is It Safe?

Sources

1. Schlissel, A.C., Richmond, T.K., Eliasziw, M., Leonberg, K., & Skeer, M.R. (2023). Anorexia nervosa and the COVID-19 pandemic among young people: A scoping review. Journal of Eating Disorders, 11(1), 122. doi: 10.1186/s40337-023-00843-7
2. Mehler, P.S., & Andersen, A.E. (2022). Eating disorders: A comprehensive guide to medical care and complications. 4th Edition. Johns Hopkins University Press
3. Galmiche, M., Déchelotte, P., Lambert, G., & Tavolacci, M.P. (2019). Prevalence of eating disorders over the 2000-2018 period: A systematic literature review. American Journal of Clinical Nutrition, 109(5), 1402-1413. doi: 10.1093/ajcn/nqy342
4. Favaro, A., Caregaro, L., Tenconi, E., Bosello, R., & Santonastaso, P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa. Journal of Clinical Psychiatry, 70(12), 1715-1721. doi: 10.4088/JCP.09m05176blu
5. Madden, S., Morris, A., Zurynski, Y.A., Kohn, M., & Elliot, E.J. (2009). Burden of eating disorders in 5-13-year-old children in Australia. Medical Journal of Australia, 190(8), 410-414. doi: 10.5694/j.1326-5377.2009.tb02487.x
6. Marion, M., Lacroix, S., Caquard, M., et al. (2020). Earlier diagnosis in anorexia nervosa: Better watch growth charts! Journal of Eating Disorders, 8, 42. https://doi.org/10.1186/s40337-020-00321-4
7. Swanson, S.A., Crow, S.J., Le Grange, D., Swendsen, J., & Merikangas, K.R. (2011). Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723. doi: 10.1001/archgenpsychiatry.2011.22
8. Cheng, S., Kaminga, A.C., Liu, Q., Wu, F., Wang, Z., Wang, X., & Liu, X.. (2022). Association between weight status and bullying experiences among children and adolescents in schools: An updated meta-analysis. Child Abuse & Neglect, Volume 134. doi.org/10.1016/j.chiabu.2022.105833
9. Gravina, G., Milano, W., Nebbiai, G., Piccione, C., & Capasso, A.. (2018). Medical complications in anorexia and bulimia nervosa. Endocrine Metabolic and Immune Disorders Drug Targets, 18(5), 477-488. doi: 10.2174/1871530318666180531094508
10. Connolly, M.D., Zervos, M.J., Barone, C.J. 2nd, Johnson, C.C., & Joseph, C.L. (2016). The mental health of transgender youth: Advances in understanding. Journal of Adolescent Health, 59(5), 489-495. doi: 10.1016/j.jadohealth.2016.06.012