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Worried your child has an eating disorder? This pediatrician has advice.

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As a pediatrician, I’ve seen how the pandemic has deeply affected our youth; they are suffering from depression and anxiety as they were pulled from routines, school and peers for a year. But one effect I’ve seen that has been surprising: the number of tweens and teens who are suffering from eating disorders, probably brought on by this isolating time.

With the increase in coronavirus vaccinations, the relaxation of strict guidelines and the return to school in some communities, it’s easy to think that the worst of this pandemic is behind us. But the pandemic has given rise to a mental health crisis of monumental proportions among our youth.

“The number of new referrals, along with the amount of hospitalizations for eating disorders, has doubled at the hospital over the last year,” says Lisa Tuchman, chief of adolescent medicine at Children’s National Hospital in D.C.

As a pediatrician, I see the surge myself, and I’ve spoken to many parents about the issue.

So, as we dream about a return to our normal routines and lives, what do teens, parents, caregivers and educators need to know about detecting and battling eating disorders? Here are questions I’ve heard from parents and my answers, so we can address this growing health crisis among young people.

Q: My 16-year-old son has been attending school online for over a year. Over the past few months, he has started exercising compulsively, becoming increasingly picky about the foods he eats and looking thinner than before. He says he’s not worried about his appearance, but we’re concerned about these recent changes. Is it possible he could have an eating issue related to the pandemic, and what should we do?

A: Quite a few kids have experienced anxiety and depression during the pandemic. In some cases, teens may also use overexercising and food restriction as ways to cope with the loss of control in their daily lives. Although eating disorders are more common among adolescent girls, they can certainly occur among boys (sometimes as young as 10). Start by having a conversation with your son about the loss of his normal routines, feelings of isolation, changes in his habits and how he’s coping. Ask specifically whether he is feeling depressed, has tried cutting or is feeling suicidal. Given your description, you should consider having your son talk to his pediatrician to ensure he doesn’t have early signs of compulsive exercising or avoidant/restrictive food intake disorder (ARFID), which involves a high level of pickiness in eating and a general lack of interest in food, which can lead to weight loss and malnutrition. To help him cope with the pandemic, discuss ways for him to stay connected with friends and family. Also, consider focusing on ways he can give back to the community and build an “attitude for gratitude,” both of which have been shown to decrease stress and improve overall well-being.

Q: Our daughter is frequently on Instagram and Snapchat, following sites related to pop singers and models. Her friends are also on the same sites and frequently make comments about looks. She has recently been saying that she’s stressed and snacking on large amounts of food late at night. She uses social media to stay connected to her friends, especially now. So, despite that, should we be limiting her use?

A: Researchers have found that teens who spend more time on social media apps had 2.2 times the risk of poor body image compared with their peers. In a recent study by Jason Nagata and his colleagues at the University of California at San Francisco, the more time 9- and 10-year-old children spent on screens, the more likely they were to engage in uncontrolled or binge eating. For some adolescents, the content of social media and focus on certain body types may reinforce disordered thoughts. Help your daughter to train her lens on her abilities, as opposed to her external appearance. Encourage her to spend time with friends who feel good about their bodies and are not always criticizing themselves or others. Ask her to take a break from Instagram for a short time. Also, chat with her about healthier ways to handle stress and emotions, such as yoga, mindfulness, journaling and exercise. She could take an online eating disorder screening quiz. Finally, encourage your daughter to challenge media norms that are often not realistic. The Dove self-esteem project, for example, has created a wonderful series of resources for parents to promote teen body positivity.

Q: Our 11-year-old daughter has been making comments about her weight and appearance and comparing them with her friends'. She just had a growth spurt and has some acne. What are some signs that she may be struggling with her body image compared with what’s developmentally normal?

A: I often ask teen patients: “When you look at yourself in the mirror, what do you see, and are you happy with it?” If your daughter is having occasional days where she feels unhappy about her body or awkward about pubertal changes, that’s normal. However, if she is consistently dissatisfied about her appearance or comparing herself to others, it’s important to have her refocus on what’s on the inside, such as her unique abilities. You should also consider additional support from a mentor, counselor or pediatrician before her behaviors lead to disordered eating or other unhealthy practices. Parents must be careful of making weight-related comments about themselves or others in front of their children. A study by Common Sense Media showed that more than half of girls and one-third of boys as young as 6 to 8 thought that their ideal weight was thinner than their current size. The good news is that, as a parent, you have more influence than you think to help your child build a healthy self-image. Having regular check-ins about body image, minimizing “fat talk,” celebrating talents and abilities and, if needed, getting support early on are all helpful in ensuring your daughter will feel positive about herself during her teen years and beyond.

Q: The pandemic has been hard for our family, and we have all struggled to stay as active as before. Our preteen was recently told by her doctor at a routine visit that she was overweight. She is now constantly worried about her weight, has tried a wide variety of diets and recently became a vegan. How do we make sure she stays healthy?

A: The pandemic has been tough for many families, and it’s been hard to get kids outdoors or to exercise. It sounds as if your daughter has become overly preoccupied with dieting after being told she was overweight. Put the focus on health, not weight, and encourage her to avoid fad diets, purging, laxatives or other quick fixes. In some cases, suddenly becoming a vegetarian or vegan can be a tip-off for having an eating disorder. I would encourage your daughter to have regular meals, and ensure she’s getting enough vitamin B12 and iron. She may benefit from meeting with a nutritionist. One silver lining of the pandemic is that most providers are meeting virtually. Brainstorm with her about exercise she enjoys and how she can incorporate it regularly into her life. Consider modeling behaviors and exercising together, including having regular family hikes, bike rides or using online fitness workouts from places such as PopSugar or Nike. Finally, ensure that she is turning off devices and getting adequate sleep at night, because doing so can help regulate appetite and metabolism.

Q: Our 15-year-old daughter is an elite ballet dancer. Despite ballet classes being online, she practices several hours each day in preparation for an upcoming virtual performance, for which she has been asked by her coaches to maintain a certain weight. Lately, she has been complaining of feeling cold all the time, having frequent bouts of dizziness, losing hair and being unable to focus. Her doctor mentioned in the past that she has a low heart rate. She has recently lost a few pounds. Our daughter thinks this is all related to the increase in practices and not drinking enough fluids. Is there anything we should consider in preparation for her performance?

A: If your daughter is an elite athlete and exercising several hours a day, it’s important that she’s getting the calories she needs. During the teen years, adolescents are growing taller, their brains are developing and their bodies are building bones and muscles. Your daughter’s symptoms could mean she should be screened for early signs of anorexia (restrictive eating, a strong desire to be thin, fear of gaining weight) or other medical issues. Anorexia can lead to serious medical complications affecting the heart, brain and other organs. You should have a conversation with your daughter’s ballet company about expectations regarding weight. Your daughter should also see her pediatrician for a complete work-up. Treatment for anorexia varies, but it may involve getting a therapist to address weight- and food-related behaviors, often with a focus on family-centered care; a primary care provider to monitor lab tests and weight; and a nutritionist to review a dietary plan. In severe cases, some teens require hospitalization for intensive nutritional treatment or partial/full residential eating disorder care. Your daughter has a wonderful gift with ballet. She needs to receive support early on to ensure she stays healthy and free of injuries.

Anisha Abraham is a pediatrician, teen health specialist, author of the recently published book “Raising Global Teens: A Practical Handbook for Parenting in the 21st Century” and a parent. She is on faculty in the adolescent and young adult medicine division at Children’s National Hospital in Washington, D.C.

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More reading:

Teens are terrible at breaking up. Here are 6 ways parents can help them improve.

Parents can make a plan to decrease suicide risk in their teens. Here’s how.

She was 11, with an eating disorder. It took her mom to figure it out.

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