Eating Disorders in High School: What Parents Miss

A guide for parents of 14–18 year olds on recognizing eating disorders before they become medical emergencies. Covers all disorder types, hidden behaviors, high-risk groups, and the family-based treatment that works.

By TherapyExplained Editorial TeamApril 25, 202611 min read

What You Are Up Against

Your teen comes home from practice, eats a salad, and tells you she is "eating clean." Your son tracks every macro on an app but explains it away as "getting gains." Your daughter has lost fifteen pounds, looks tired, and when you ask if she is okay, she says she is fine.

Eating disorders are among the most lethal mental illnesses that exist. According to research published in the journal Current Psychiatry Reports and summarized by the Academy for Eating Disorders, anorexia nervosa has the highest mortality rate of any psychiatric diagnosis — an estimated 5 to 10 percent of those with the illness will die from it, from medical complications or suicide. Bulimia and binge eating disorder also carry significant medical risk. Yet parents routinely miss eating disorders for months or years, because everything about the cultural moment makes them easy to hide and hard to name.

This guide is for parents who suspect something is wrong, parents who should suspect it but do not yet, and parents who have just found out. The goal is not to alarm you. The goal is to give you enough to act before the medical timeline catches up.

Why Parents Miss Them

The culture rewards what eating disorders look like. When a teenager loses weight, eats "healthy," skips junk food, runs five miles every morning, and refuses dessert, adults around her often say: good for you. Coaches say: you look faster. Relatives say: wow, you look great. The behaviors that signal an eating disorder to a clinician are the same behaviors our culture praises in teenagers. This is not a minor obstacle. It is the central reason eating disorders escalate to medical emergencies before families realize what is happening.

Kids become expert concealers. Teens with eating disorders are often high-achieving, people-pleasing, and extremely skilled at managing how they appear to others. They learn which lies hold up. They eat dinner at home and quietly restrict every other meal. They run the water in the bathroom. They wear layers. They know which topics to avoid. This is not manipulation for its own sake — it is the disorder protecting itself. But it means the absence of obvious warning signs means nothing.

Body shame keeps kids quiet. A teenager who is convinced her body is disgusting is unlikely to volunteer that information. Shame is one of the central emotions driving every eating disorder subtype. For boys and athletes, add the layer of feeling like they should be able to handle it — asking for help feels like weakness. For kids in larger bodies, there is the fear — often confirmed by experience — that adults will respond to weight concerns with diet advice rather than concern.

The myth that eating disorders look a certain way. There is a cultural image: white, female, visibly underweight. That image is wrong in almost every dimension, and it costs kids their lives. According to the National Eating Disorders Association (NEDA), people of all genders, races, body sizes, and socioeconomic backgrounds develop eating disorders. An estimated 1 in 3 people with an eating disorder is male. People in larger bodies develop anorexia. Black and Latinx teenagers are diagnosed at comparable rates to white teenagers but receive treatment far less often. LGBTQ+ youth face disproportionately higher rates. The image in your head may be the very reason you are missing your own kid.

28.8 million

Americans will experience an eating disorder in their lifetime, yet fewer than 1 in 10 receive treatment (NEDA)

The Disorders You Need to Know

Anorexia Nervosa — and the Version You Have Never Heard Of

Anorexia involves severe restriction of food intake, an intense fear of gaining weight, and distorted perception of body size. The behavioral signs parents often notice: skipping meals, making excuses around food, eating tiny portions, extreme food rules ("I only eat before 6pm," "no carbs after noon"), compulsive exercise, wearing bulky clothes to hide weight loss, mood changes around mealtimes.

But here is what most parents do not know: atypical anorexia. A teenager who has lost forty pounds over eight months — and now has the cardiac risk, the bone density loss, the electrolyte abnormalities, and the cognitive distortion of anorexia — may still appear to be in the "normal" weight range. The medical danger is identical to classic anorexia. The weight loss is clinically significant relative to where that person started, not relative to a height-weight chart. Pediatricians using standard BMI charts sometimes reassure parents when they should be ordering an EKG. If your child has lost significant weight rapidly, the number on the scale is not the whole picture.

The Academy for Eating Disorders' medical care standards make this explicit: weight thresholds are not appropriate criteria for determining medical severity in adolescents with restrictive eating disorders.

Bulimia Nervosa — and Purge Methods That Do Not Involve Vomiting

Bulimia involves episodes of binge eating followed by compensatory behaviors. Most parents know about vomiting. Fewer know about the other methods:

Laxative misuse: Your teen may have a stash you do not know about. Chronic laxative use causes dangerous electrolyte imbalances — dangerously low potassium levels can produce cardiac arrhythmia.
Diuretic misuse: Water pills used to "flush weight" carry the same cardiac risk.
Compulsive compensatory exercise: Runs that cannot be skipped regardless of injury, illness, or weather. Exercise that produces visible distress if prevented. Exercise used not for fitness but to undo eating.
Fasting after eating: Days of restriction after a binge that parents never see because the binge happened privately.

The bathroom timing observation is worth noting specifically. If your teen consistently disappears to the bathroom within fifteen to twenty minutes after every meal — particularly if the toilet runs or the water runs — that pattern deserves attention. Stomach aches after every dinner are another cover.

Unlike anorexia, people with bulimia are often at a typical body weight. The disorder is frequently invisible for years. Dental erosion from stomach acid is one of the few physical signs that develops over time; ask your teen's dentist if they have noticed anything.

Binge Eating Disorder — the Most Common ED, and the Most Missed

Binge eating disorder (BED) is the most common eating disorder in the United States, more prevalent than anorexia and bulimia combined, according to NEDA. It involves recurrent episodes of eating large amounts of food in a short time, with a sense of loss of control and significant distress afterward — and without the compensatory behaviors of bulimia.

Parents miss BED for several reasons. There is no purging to stumble across. Weight gain may be gradual. The behaviors happen in secret: eating after everyone goes to bed, food hidden in the bedroom, evidence of large amounts of food consumed in a short window. The emotional signature is shame and self-disgust after eating, not satisfaction. The teen who eats a full dinner with the family and then consumes a substantial quantity of food alone at 1am is not just "a growing kid with a big appetite."

BED is not about willpower or self-discipline. It has the same neurobiological underpinning as other eating disorders, and it responds to the same evidence-based treatments. Left untreated, it causes medical harm and enormous psychological suffering.

ARFID — When "Picky Eating" Is Something More Serious

Avoidant/Restrictive Food Intake Disorder (ARFID) involves severe restriction of food intake, but without the body image distortion that characterizes anorexia. Kids with ARFID avoid food based on sensory characteristics (texture, color, smell, appearance), fear of choking or vomiting, or a generalized lack of interest in eating. The food list may be extremely narrow — sometimes fewer than ten accepted foods.

ARFID is frequently misidentified as autism, as "picky eating" a kid will outgrow, or as sensory processing issues with no eating-disorder framing. It can co-occur with autism and anxiety — the presence of another diagnosis does not rule out ARFID. When ARFID leads to significant nutritional deficiency, weight loss, or impaired functioning (teens who cannot attend school events, eat at restaurants, or participate in social situations involving food), it requires clinical intervention. CBT-AR (cognitive behavioral therapy for ARFID) is the evidence-based treatment.

The Disorder You Have Never Heard of: Diabulimia

Type 1 diabetics can manipulate insulin to lose weight — restricting or skipping doses causes glucose to spill into the urine rather than be stored as energy. This practice, called diabulimia, carries extreme medical risk including accelerated diabetic complications, kidney damage, and DKA (diabetic ketoacidosis), which can be fatal. Parents of teens with type 1 diabetes who notice consistently elevated A1C despite apparent medication compliance, or who notice unexplained weight changes, should raise this specifically with their child's endocrinologist.

High-Risk Groups

Athletes. Sports with weight classes (wrestling, rowing, weightlifting), aesthetic scoring (gymnastics, figure skating, diving), or lean-body emphasis (distance running, swimming, dance) have significantly elevated eating disorder rates. The culture in many of these sports normalizes restriction, cutting weight, and overtraining. A coach saying "you'd be faster if you lost five pounds" is not unusual — and it is also potentially the sentence that starts an eating disorder. Do not assume your teen's sport is protecting them. Research published by the American College of Sports Medicine identifies the female athlete triad (low energy availability, menstrual dysfunction, low bone density) as a significant risk — and equivalent patterns exist in male athletes.

Kids with anxiety, OCD, or depression. The overlap between eating disorders and anxiety disorders is high — anxiety often precedes the eating disorder and provides the psychological substrate (need for control, perfectionism, intolerance of uncertainty) that the disorder then occupies. OCD can show up as eating-related rituals that look like anorexia. Depression can manifest as appetite suppression that shifts into restriction. If your teen is already in treatment for anxiety or depression, ask the therapist directly whether they are monitoring for eating disorder behaviors.

Post-puberty. For girls, the period immediately after puberty — when the body changes in ways that do not match cultural ideals of thinness — is a peak risk window. For boys, the equivalent is often around the age when peer and media pressure around muscularity intensifies.

LGBTQ+ teens. Research consistently finds elevated eating disorder rates in LGBTQ+ youth. Body dysphoria, social rejection, minority stress, and the specific dynamics of gender dysphoria in trans and nonbinary teens all create elevated risk.

The Recognition Checklist

You do not need to diagnose your teen. You need to recognize enough to act. Look for patterns, not single incidents.

Food and eating behaviors

Skipping meals consistently, or eating very little at family meals
Rigid food rules that expand over time (no fat, no sugar, specific foods only, eating only at certain times)
Cutting food into unusually small pieces, rearranging food without eating it, hiding food in napkins
Excuses to avoid family meals ("I ate already," "I'm not hungry," "I have practice")
Disappearing to the bathroom after meals
Evidence of large amounts of food consumed secretly
Obsessive reading of nutrition labels, calorie counting, food tracking apps
Increased interest in cooking for others while eating little themselves

Body and physical signs

Significant or rapid weight changes — loss or gain
Feeling cold all the time; wearing layers in warm weather
Dizziness, fainting, chronic fatigue
Hair thinning or falling out
Missed or stopped menstrual periods
Dental problems or swollen jaw/cheeks
Calluses on knuckles (from induced vomiting)
Frequent stomach complaints

Exercise and activity

Compulsive exercise that cannot be interrupted for illness, injury, or social events
Distress, guilt, or anxiety if they miss a workout
Exercise that functions as compensation ("I ate dinner so I have to run")

Social and emotional signs

Withdrawal from social events involving food (birthday parties, restaurants, school lunch)
Significant increase in body-related comments, self-criticism, or appearance anxiety
Mood changes around mealtimes — irritability, anxiety, withdrawal
Declining school performance, trouble concentrating (often a sign of malnutrition)
Increased rigidity, control-seeking, perfectionism
Secretiveness, disappearing to the bathroom, hiding behaviors

No single item on this list is diagnostic. A cluster of these, or any single item that feels persistent and escalating, is reason to consult a professional.

How to Talk to Your Teen About This

This conversation is not one you should delay because you are afraid of getting it wrong. A conversation that goes imperfectly is better than no conversation. A few guidelines:

Do not comment on weight or appearance. Not "you look too thin," not "I've noticed you've lost weight," not "you used to look healthier." Comments about the body — even well-intentioned ones — are consistently reported by people in recovery as harmful. They create shame, increase body focus, and do not lead to help-seeking.

Do talk about behaviors you have observed. "I've noticed you're not eating much at dinner" or "I've noticed you seem anxious about eating lately" or "I've noticed you go to the bathroom right after meals." Be specific about what you have seen, not what you have concluded.

Expect denial. Most teenagers with eating disorders will deny there is a problem. This is not a reason to drop it. Say: "I hear you that you don't think anything is wrong. I love you and I'm worried, so I'm going to make a doctor's appointment anyway. We can let the doctor weigh in."

Do not negotiate about getting help. Getting medical and clinical evaluation is not optional. Frame it as a parental decision, not a debate. You would not let your teenager decline to see a doctor for a suspected bone fracture.

Do not make it about food. The dinner table is not the place to problem-solve an eating disorder. Keep mealtimes as calm as possible. The treatment will address the eating — not you.

Do not remove their phone or internet access as an initial response unless specific, identifiable pro-eating-disorder content is making things worse and your teen's clinician recommends it. Punitive responses increase shame and secrecy, which is the opposite of what you need.

Treatment: What Actually Works

Family-Based Treatment (FBT) — the Gold Standard for Adolescents

For adolescents with anorexia nervosa — and increasingly for adolescent bulimia — family-based treatment (FBT, also called the Maudsley approach) is the most extensively researched and most effective intervention available. Research by Dr. James Lock and Dr. Daniel Le Grange at Stanford and UCSF, including multiple randomized controlled trials, demonstrates that FBT leads to full remission in approximately 40 to 50 percent of adolescent patients at end of treatment, with recovery rates continuing to increase at follow-up.

The counterintuitive feature: FBT puts parents in charge of refeeding, not the teenager. Phase 1 of FBT is weight restoration, during which parents externalize the eating disorder — treating it as a separate force attacking their child — and take charge of all food decisions: what is served, how much, when, where. This is uncomfortable. It will feel controlling. But the clinical reasoning is sound: a malnourished brain cannot reason its way out of anorexia, and the eating disorder's core function is to undermine the teen's own recovery efforts. Parents are not being controlling. They are being the external nervous system their teen's malnourished brain cannot currently provide.

Phase 2 of FBT returns food autonomy to the teen gradually as weight is restored and cognition improves. Phase 3 addresses the developmental tasks the eating disorder has interrupted.

For a deeper look at how FBT works, see our guide to family-based treatment and the Maudsley approach.

CBT-E for Older Adolescents

Enhanced cognitive behavioral therapy (CBT-E), developed by Dr. Christopher Fairburn at Oxford, is the leading evidence-based treatment for bulimia nervosa, binge eating disorder, and anorexia in older adolescents and adults who are medically stable. CBT-E directly addresses the core psychological maintenance mechanisms: overvaluation of weight and shape, dietary restraint, binge-purge cycles, and perfectionism. It is typically 20 sessions in the standard version, with a longer version for more complex presentations. Look specifically for therapists trained in CBT-E rather than general CBT — the eating disorder-specific version has meaningfully different components.

When Outpatient Is Not Enough

For many adolescents, outpatient therapy with a specialized eating disorder therapist is the right starting point. But eating disorders frequently require higher levels of care, and the decision to step up is time-sensitive. Signs that outpatient is not sufficient:

Weight loss is continuing despite treatment
Medical instability: low heart rate (below 50 bpm), low blood pressure, electrolyte abnormalities
Your teen cannot maintain minimal nutritional intake even with parental support
Outpatient sessions are not producing change after 4 to 6 weeks
Suicidality or self-harm as co-occurring behaviors

The levels of care above outpatient:

Intensive outpatient (IOP): 3 to 5 days per week, 3 hours per day, typically includes supervised meals and group therapy. Teen returns home nightly.
Partial hospitalization (PHP): Full treatment days (6 to 8 hours) 5 to 7 days per week. Teen lives at home or in a step-down residence. Appropriate when outpatient has failed but the teen is medically stable.
Residential treatment: 24-hour care in a non-hospital therapeutic setting. Appropriate for teens who cannot be safe or cannot eat at home. For a detailed guide to residential programs, see our teen residential treatment guide.
Medical inpatient/medical stabilization: When cardiac instability, severe electrolyte abnormalities, or dangerously low weight require hospitalization before psychiatric/behavioral treatment can begin. This is not the same as a psychiatric hospitalization and is typically brief — the goal is medical stability before transferring to a higher-level eating disorder program.

See our eating disorder treatment centers and levels of care guide for a detailed breakdown of how to evaluate programs.

Yes, and this is one of the most important things for parents to understand. Most people with eating disorders are not underweight. People with bulimia nervosa are typically at a normal or above-average weight. Binge eating disorder often involves weight gain. Atypical anorexia — which carries the same medical risk as classic anorexia — occurs in people who have lost significant weight relative to their own baseline but may still appear 'normal' on a weight chart. The Academy for Eating Disorders explicitly states that weight and BMI are not reliable indicators of eating disorder severity. If the behaviors and psychological markers are present, medical evaluation is warranted regardless of what the scale says.

Keep mealtimes as calm and normal as possible. Do not comment on what your teen is or is not eating. Do not comment on their body. Do not negotiate, bargain, or argue about food at the table — that battle cannot be won and will increase both conflict and secrecy. If you are already in FBT, follow your clinician's guidance exactly. If you have not yet started treatment, your job at the table is to keep the emotional temperature low and the relationship intact. Save the harder conversations for a non-mealtime moment, and save the clinical interventions for the clinical team.

This is a situation where you need clinical guidance rather than a parental policy. Taking a phone away as punishment typically increases secrecy and shame without reducing access to the content (teens find other devices). However, if specific accounts or communities are actively reinforcing the eating disorder — pro-ana communities, accounts glorifying restriction — and your teen's clinician agrees that the harm is demonstrable and significant, a targeted and explained limitation on specific content, done collaboratively with the treatment team, can be appropriate. Blanket phone removal usually makes things worse. The underlying eating disorder, not the phone, is the problem to treat.

Go to the emergency room — or call 911 — if your teen: faints or nearly faints; has a heart rate below 50 beats per minute (check on a smartwatch or manually); has chest pain or palpitations; is too weak to stand; has not eaten or drunk anything in 24 hours; or expresses active suicidal intent with a plan. Electrolyte emergencies and cardiac arrhythmias can happen quickly and without much warning in teens who have been purging or severely restricting. When in doubt, go. A false alarm costs you a few hours. Not going costs you everything.

Yes. General practitioners and pediatricians often miss eating disorders, particularly atypical presentations or patients who are not visibly underweight. If your teen's weight is in a 'normal' range but has dropped significantly from their personal baseline, your doctor may not be alarmed when they should be. Ask specifically: 'Can you check orthostatic vitals?' (blood pressure and heart rate lying vs. standing — abnormal orthostatics indicate cardiovascular compromise). Ask: 'Can you order labs to check electrolytes?' Ask for a referral to an adolescent medicine specialist or an eating disorder-specialized clinician. Parental instinct that something is wrong deserves clinical attention.

FBT is structured, parent-directed refeeding — it is not punitive, and it is done within a therapeutic framework with a trained FBT therapist guiding the process. Parents are not screaming at their kid to eat more. They are providing meals with a firm, calm, loving expectation that their teen will eat, and staying at the table until the meal is complete. This is difficult and emotionally charged, and the FBT therapist prepares you for it specifically. The research is clear that this approach — externalizing the eating disorder and empowering parents — produces better outcomes in adolescents than treatments that leave the teen in charge of their own recovery. For more, see our [FBT guide](/blog/family-based-treatment-maudsley-approach).

In some ways, yes. Boys with eating disorders are less likely to talk about wanting to be thin and more likely to focus on muscularity, leanness, or athletic performance. Restriction may be framed as 'clean eating' or 'getting cut.' Exercise compulsion is common and may be harder to identify in a culture that praises boys for working out hard. Boys are significantly less likely to be referred for evaluation because clinicians, parents, and coaches do not expect the diagnosis. If your son is showing behavioral signs — food rules, compulsive exercise, social withdrawal around eating, dramatic body changes — those signs deserve the same response you would give a daughter.

General therapists, even good ones, often lack eating disorder expertise — this is a highly specialized field. Look for therapists who list FBT or CBT-E as specific training, not just 'eating disorders' as a population they see. Certifying directories include the Training Institute for Child and Adolescent Eating Disorders (TICAED) for FBT providers, and Dr. Fairburn's CREDO training network for CBT-E. The NEDA treatment finder at nationaleatingdisorders.org/find-treatment and the ANAD provider directory at anad.org are also useful starting points. Ask any potential provider: 'How many teens with anorexia/bulimia are you currently treating?' and 'What specific evidence-based model do you use?'

The Stakes Are Specific

Eating disorders do not resolve on their own. They get quieter and more entrenched. The teenagers who recover do so because an adult in their life recognized something, said something, and kept pushing for help even when the teen said everything was fine. You do not need to be certain. You need to be concerned enough to act.

If something feels wrong about how your teen is eating, exercising, or relating to food and their body — that feeling is worth a doctor's appointment. It is worth a conversation with a specialized clinician. It is worth being the parent who was too cautious rather than the parent who waited.

The gap between noticing and acting is where this illness lives.

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