By Sarah Rodgers Rosellini, special education teacher, BC Children’s Hospital; Lily Yiu, special education teacher, BC Children’s Hospital; and Jennifer S. Coelho, psychologist, BC Children’s Hospital and clinical associate professor, Department of Psychiatry, UBC

During their careers, teachers will inevitably come across students with eating disorders in their classrooms and school communities. The COVID-19 pandemic has been a perfect storm for an exacerbation in eating disorder symptoms among adolescents.¹ Reduction in social contact, school closures, stay-at-home orders, all compounded by increased internet and social media use, are among the factors thought to have contributed to a global surge in new eating disorder diagnoses.

One of the challenges with identifying and supporting children and youth with eating disorders is that many people with an eating disorder may seem to be healthy, but can be seriously ill. Stereotypes about who is affected by eating disorders may also contribute to difficulties in recognizing eating disorder symptoms. To understand more about the truths about eating disorders, and combatting stereotypes, the Academy for Eating Disorders has shared Nine Truths about Eating Disorders.² One of these truths is that eating disorders affect people of all ages, genders, and backgrounds.

Breaking down stereotypes about gender
Although eating disorders may be perceived as primarily affecting girls and women, in fact eating disorders affect people of all genders. There may be some gender differences in eating disorder symptoms and behaviours, e.g., females may be more likely to pursue weight loss and be concerned about leanness, while males may have more concerns about muscularity.

Some students will have a gender identity that doesn’t match the sex they were assigned at birth. Transgender, non-binary, and gender questioning youth may be at particular risk for the development of disordered eating or symptoms of eating disorders. The onset of puberty can be a particularly distressing time, and some youth may restrict nutritional intake in an effort to delay or stall puberty and the physical changes that accompany it. Access to gender-affirming care has been critical in reducing eating disorder symptoms in trans youth with eating disorders.

Types of eating disorders
Anorexia nervosa (AN) is characterized by restricted intake, extreme weight loss (or, for children/adolescents, failure to gain weight as part of normal development), and typically a fear of gaining weight. There are two distinctive AN subtypes. The restrictive subtype is characterized by restrictive eating and may be accompanied by overexercise. You may also encounter students with the binge-eating/purging subtype. Youth with this subtype are underweight, but also engage in binge-eating (eating large quantities of food and feeling out of control) and/or purging to try to compensate for food intake. Purging can take the form of self-induced vomiting or use of laxatives or diuretics.

Bulimia nervosa (BN) is similar to the binge-eating/purging subtype of AN, where individuals engage in regular binge-eating and behaviours to compensate for their intake during binges (e.g., through purging, fasting, or excessive exercise). Unlike with AN, individuals with BN are not significantly underweight.

Binge-eating disorder (BED) comprises regular episodes of binge-eating (eating large quantities of food and feeling out of control) and is accompanied by embarrassment, guilt, eating until uncomfortably full, or other distressing symptoms.

Other specified eating disorders include eating disorders that are serious and life-threatening, but have different presentations than AN, BN, or BED. This includes atypical AN, where an individual is not underweight, and may be above their suggested body weight range. Individuals with atypical AN restrict intake and typically also have significant weight loss but may have started at a higher weight. Atypical AN is a serious eating disorder that can, for some youth, lead to hospitalization due to medical concerns.

Avoidant restrictive food intake disorder (ARFID) is a newer eating disorder diagnosis. ARFID shares some similarities to AN in that people restrict their food intake and often have a very particular selection of foods they are willing or able to eat. However, people with ARFID do not have fears about weight gain, unlike those with AN. Children with ARFID may appear to be “picky eaters”; however, ARFID is more than just picky eating and is associated with medical problems and/or psychosocial interference due to lack of sufficient nutrition. Youth with ARFID may have textural or flavour sensitivities that limit the types of foods they are able to consume or a general low interest in eating. Other youth with ARFID may worry about the consequences of eating (e.g., choking, nausea, or pain). Youth with ARFID may have trouble at school academically, because of poor nutrition, but also socially as eating and interacting with friends is often affected.

Indicators of eating disorders
These indicators are general in nature, but they can be indicative of eating disorder symptoms. If teachers and support staff notice these indicators, it would be helpful to share this information with the school-based team and the students’ parents/guardians:

• obvious weight loss
• changes in eating habits or not eating at break/lunch
• over-scheduling activities
• over-exercising, constant movement, standing, leg shaking
• perfectionist attitudes
• difficulty with focus
• withdrawal or non-engagement
• drops or jumps in grades or work habits
• intense preoccupation with body image
• evidence of shakiness, dizziness, or feeling faint
• frequent trips to the washroom
• absences from school.

What can educators do if they notice signs of eating disorders?
If you suspect a student is at risk of developing an eating disorder, inquire if your school or district has an intervention protocol in place. Sample protocols, and information about eating disorders in the school context, are available in Understanding Eating Disorders in Schools: A Guide for School Professionals in BC Schools.³

It is important that immediate steps be taken to support a student suspected of developing an eating disorder. Prior to approaching the student, be mindful that the student may react in anger, shut down, or deny that there is anything wrong. If the student is unwilling to engage, acknowledge and validate their discomfort before reassuring them that you are available to listen when they are ready to talk.

For students willing to engage, approach the student through a trauma-informed lens. Avoid using language that could be perceived as judgmental. Express your concerns for their overall well-being and reassure them they have done nothing wrong. Make sure the student is given an opportunity to process their thoughts and feelings. If they are uncomfortable connecting with their family doctor, encourage them to allow the public health clinician assigned to the school to visit them for an assessment. You will also need to inform the student that all health and safety concerns have to be shared with their parents.

The purpose of the initial conversation is not to convince the student that they have a problem or to make a diagnosis. It is simply to initiate support. The good news is that recovery from eating disorders is possible, and there are good outcomes for early intervention in children and adolescents with eating disorders.

Resources
Kelty Mental Health Resource Centre provides information and resources for coping with eating disorders: www.keltyeatingdisorders.ca

Trans Care BC provides education and resources about gender, including information about gender-inclusive language and creating a welcoming gender-affirming environment: www.phsa.ca/transcarebc/gender-basics-education/education-resources/support-tools

1 Katzman, D. K. (2021). The COVID-19 Pandemic and Eating Disorders: A Wake-Up Call for the Future of Eating Disorders Among Adolescents and Young Adults. Journal of Adolescent Health, 69(4), 535-537

2 www.aedweb.org/publications/nine-truths

3 www.keltyeatingdisorders.ca/wp-content/uploads/2016/06/Understanding-Eating-Disorders-in-Schools.pdf