Eating disorders in young people: early warning signs families should know

Eating disorders are serious psychiatric conditions with significant physical consequences. Anorexia nervosa has the highest mortality rate of any mental health condition, estimated at approximately five to ten per cent over twenty years when untreated. Yet the early stages are frequently dismissed as faddy eating, dieting, or normal adolescent concern about appearance. The window between symptom onset and effective treatment is critical: outcomes are substantially better when intervention occurs early in the illness. Understanding what to look for, and acting on it promptly, is not overcautious. It is medically appropriate.

Types of eating disorder in young people

Anorexia nervosa involves restriction of food intake driven by a distorted relationship with weight and body image. It is characterised by a persistent refusal to maintain a healthy body weight and an intense fear of weight gain. Bulimia nervosa involves cycles of binge eating followed by compensatory behaviours: typically self-induced vomiting, laxative use, or excessive exercise. Avoidant restrictive food intake disorder (ARFID) is distinct from anorexia in that it is not driven by weight and shape concerns. Instead, it involves severe restriction based on sensory properties of food, fear of vomiting or choking, or profound lack of interest in eating. ARFID is particularly common in children with autism or ADHD. Binge eating disorder, less frequently diagnosed in young people but not uncommon, involves recurrent episodes of bingeing without compensatory behaviours.

Early warning signs of anorexia

Early anorexia rarely announces itself. Initial signs include increasing interest in food content, calories, and 'healthy eating'; cutting out food groups; eating significantly less at mealtimes while denying hunger; becoming reluctant to eat with others; exercising more than usual, particularly after eating; wearing loose or layered clothing; and becoming preoccupied with weight, body shape, or the body weight of others. Physical signs appear later and include fatigue, feeling cold, hair thinning, and in girls, the cessation of periods. By the time physical signs are visible, the eating disorder is already established. The behavioural and psychological signs are the ones that create the opportunity for early intervention.

Early warning signs of bulimia and ARFID

Bulimia is often harder to detect than anorexia because body weight may remain within a normal range. Signs include disappearing to the bathroom shortly after meals, food disappearing from the household in unexplained quantities, swollen glands at the sides of the jaw, dental enamel erosion, and calluses on the knuckles of the dominant hand from self-induced vomiting. The young person may appear preoccupied with weight but is less likely to be visibly underweight than someone with anorexia. ARFID presents as extreme selectivity: a child who will only eat a very small number of foods and experiences genuine distress when presented with other foods. In young children, ARFID may be present for years before being identified as a clinical condition rather than fussiness.

How to talk to a young person you are concerned about

The most important principle is to focus on what you have observed rather than on weight or appearance. Saying 'I've noticed you've been eating much less at dinner. I'm worried about you' is more likely to open a conversation than 'you look too thin'. Avoid commenting on weight loss positively, as 'you look slim' can reinforce the behaviour. Do not threaten, bribe, or express disgust at the eating pattern. Do not issue ultimatums about food at mealtimes. The goal of an early conversation is to communicate concern and create the conditions for a clinical assessment. It is not to persuade the young person that they have an eating disorder. Denial is a defining feature of anorexia in particular, and argument typically strengthens it.

What to do next

If you are concerned about your child's eating, the appropriate first step is to see your GP. The GP will assess physical health markers (weight, BMI, blood tests including electrolytes and full blood count) and can make a referral to the appropriate NHS service. CAMHS eating disorder teams exist in most areas, though waiting times are variable. Given that early treatment is strongly associated with better outcomes, many families pursue private assessment and treatment in parallel with NHS referral. A specialist eating disorder assessment will identify which type of eating disorder is present, assess physical risk, and produce a formulation and treatment plan. If there is concern about immediate physical risk (rapid weight loss, fainting, very low weight), a medical assessment the same day is appropriate.

What treatment involves

Treatment for eating disorders in young people is typically multi-modal and always involves the family. Family-based treatment (sometimes called the Maudsley approach) is the most evidence-based intervention for adolescent anorexia and involves parents taking active responsibility for nutritional rehabilitation while the young person's relationship with food and their body is gradually restored. Individual therapy addresses the underlying psychological drivers once weight is medically stable. CBT-E (enhanced cognitive behavioural therapy) is the recommended approach for bulimia in adolescents. ARFID treatment typically involves behavioural approaches to food exposure, often with occupational therapy input. All eating disorder treatment requires close physical health monitoring throughout.