Standardized screens for eating disorders in children and adolescents, screening guidance, and follow-up after a positive screen

Eating disorders are complex neurobiological and metabo-psychiatric illnesses with components of biological and temperamental vulnerability tempered by social and environmental factors. [Watson: 2019] Frequently overlooked and difficult to identify, body dysmorphia, maladaptive coping skills, and/or the need for control underlie many eating disorders.

Other Names

• Anorexia nervosa (AN)
• Avoidant restrictive food intake disorder (ARFID)
• Binge-eating disorder (BED)
• Bulimia nervosa (BN)

Screen early for eating disorders
The American Academy of Pediatrics (AAP) recommend that primary care providers routinely screen for eating disorders during annual health supervision visits or sports physicals and ask surveillance questions about eating patterns and body image to all preteens and adolescents. [Hornberger: 2021] The American Academy of Child and Adolescent Psychiatry advise that mental health providers screen all child and adolescent patients for eating disorders. [Lock: 2015]

Importance of recognition
Early recognition can provide the opportunity to intervene before more severe consequences occur.

Malnutrition can occur in patients of any weight
Any concern expressed by a parent or caregiver about a child’s eating behaviors, weight, or shape should heighten concern for a possible eating disorder (current or future), regardless of their weight or BMI.

Increase screening for suicidality
While routine screening for depression and suicidality is recommended at all preventive care visits for youth ages 12-18 [Siu: 2016], suicide rates are increased in patients with eating disorders. [Hornberger: 2021] Consider more frequent screening and vigilance when an eating disorder is suspected or diagnosed.

Avoid weight stigma
Language, weight biases, and discrimination in society and healthcare settings can harm patients physically and psychologically, even when unintentional. Learn about how to recognize and reduce weight bias. See [Rubino: 2020] for an international practice guideline on this topic.

In 2021, the American Academy of Pediatrics (AAP) updated the following guidance on recognizing, evaluating, and managing eating disorders for primary care clinicians.

Hornberger LL, Lane MA.
Identification and Management of Eating Disorders in Children and Adolescents.
Pediatrics. 2021;147(1). PubMed abstract

Eating disorders cause significant medical complications, including metabolic disturbances, nutritional deficiencies, hormone disruption, cardiac arrhythmias, and loss of bone mineral density. Eating disorders are also highly associated with comorbid neuropsychiatric conditions, self-harm, and suicidality. Eating disorders can be severe enough to cause significant morbidity and death. [Herpertz-Dahlmann: 2015]

Potential warning signs of eating disorders:

Growth

• Excessive or rapid weight gain or loss
• Failure to achieve or maintain appropriate increases in weight or height
• Notable fluctuations in weight

Cardiovascular

• Bradycardia or arrhythmia
• Chest pain
• Palpitations
• Orthostatic tachycardia or hypotension
• Shortness of breath
• Edema in the extremities
• Cardiac murmur

Gastrointestinal

• Abdominal and/or epigastric pain
• Bloating
• Early satiety
• Gastroesophageal Reflux Disease
• Vomiting or hematemesis
• Constipation
• Hemorrhoids or rectal prolapse

Skin/Hair

• Brittle or thinning hair or nails, or hair loss,
• Dry, sallow skin
• Lanugo
• Carotenemia or carotenoderma (appearing orange),
• Calloused knuckles
• Poor wound healing
• Bruising on the spine from excessive exercise

HEENT

• Dental erosions or caries
• Palatal abrasions
• Aphthous ulcers
• Angular stomatitis
• Sialoadenitis or parotid gland enlargement

Neurological

• Orthostatic changes/dizziness or Syncope
• Weakness
• Memory loss
• Seizures/Epilepsy

Endocrine/ Genitourinary

• Hypothermia/cold extremities or cold intolerance
• Hot flashes or sweating episodes
• Stress fractures or low bone mineral density
• Primary or secondary amenorrhea or oligomenorrhea

Psychological

• Excessive concern about weight or body image
• Inappropriate dieting, including rigidity about types or quality of foods
• Compulsive exercising
• Fatigue
• Insomnia
• Self-injurious Behavior or Suicidality & Self-Harm
• Depression
• Anxiety Disorders
• Obsessive-Compulsive Disorder (OCD) features
• Attention problems (Attention-Deficit/Hyperactivity Disorder (ADHD))

Eating disorders are found in all ages, genders, sexual orientations, ethnicities, races, socio-economic statuses, and body types. Prevalence is difficult to derive due to under-recognition, changing definitions in the DSM-5, and the inclusion of those meeting criteria for atypical eating disorders. A 2011 cross-sectional survey of more than 10,000 nationally representative US adolescents ages 13-18 years had estimated prevalence rates of AN, BN, and BED at 0.3%, 0.9%, and 1.6%, respectively, with a mean age of onset = 12.5 years. [Hornberger: 2021] Another study demonstrated a higher prevalence of BED, 2-4%. The most common eating disorder in adolescents, BED, more equally affects boys and girls. [Hornberger: 2021] Although more common in older children and adolescents, eating disorders can be present in young children, with an incidence of 1-2.5% of children ages 5-12. Youth with underlying medical conditions requiring dietary control (such as diabetes, celiac disease, inflammatory bowel disease, and metabolic conditions) may be at increased risk of an eating disorder. [Hornberger: 2021] [Herpertz-Dahlmann: 2015] [Rosen: 2010]

Despite the AAP’s recommendation for routine screening of eating disorders in the primary care setting, pediatric eating disorder screens are limited. Studies continue to craft screens with higher sensitivity and specificity for use in different populations. This section includes eating disorder screens that are freely available for pediatric use.

Eating Disorders Screening Tool (NEDA)

Eating Attitudes Test (EAT-26)

Eating Disorder Screen for Primary Care (ESP)

Patient Health Questionnaires (PHQ)

The Sick, Control, One, Fat & Food (SCOFF) Questionnaire

A 5-question screen for eating disorders:

1. Do you make yourself Sick because you feel uncomfortably full?
2. Do you worry you have lost Control over how much you eat?
3. Have you recently lost more than 14 lb (6.3 kg or One stone) in a 3-month period?
4. Do you believe yourself to be Fat when others say you are too thin?
5. Would you say that Food dominates your life?

It is validated in adults and tested widely in different populations internationally, including some adolescents. [Rosen: 2010]

• Ages: Adults (extrapolated for use in adolescents)
• Languages: Translated into many languages for different studies
• Sensitivity/specificity: A 2017 multi-ethnic study in London found 54%/94%, suboptimal for a general population screen. [Solmi: 2015] Prior to that, the SCOFF was found to have 85%/90% relatively in a relatively homogeneous primary care setting in London (not pediatric-specific). [Hill: 2010]
• Scoring: One point should be given for every “yes” answer; a score of 2 or higher indicates a likelihood of an eating disorder. A cutoff point of 2 is advised.

The SCOFF is freely accessible at The SCOFF: A Quick Assessment for Eating Concerns ( 234 KB).

Children’s Eating Disorder Examination-Questionnaire (ChEDE-Q8)

An 8-item self-report to screen for anorexia nervosa, bulimia nervosa, and binge‐eating disorder. [Kliem: 2017] A related version, the Youth Eating Disorder Examination-Questionnaire (YEDE-Q), was studied in 2007. [Goldschmidt: 2007]

• Ages: Best for 8-14 yrs, but studied in ages 7-18
• Language: German, English (the versions vary slightly)
• Sensitivity/specificity: N/A. strong initial validation study.
• Scoring: Scoring is 0-6 for each question. The article provides a table by age and sex to determine cutoff percentiles. >=90%ile considered a critical result.

The author granted permission for the screen to be reproduced freely for research purposes. See Children’s Eating Disorder Examination-Questionnaire (ChEDE-Q8) ( 17 KB).

Adolescent Binge Eating Questionnaire (ADO-BED)

A 10-item questionnaire (Adolescent Binge Eating Scale) developed for the prediction of a binge eating disorder (BED) diagnosis in adolescents seen for obesity.

• Ages: 12-18 years
• Languages: English
• Sensitivity/specificity: 83%/96%
• Scoring: A positive response to questions 1 or 2 plus more than 6 positive responses to questions 3-10 identifies those at high risk for BED; a score of 3 or fewer indicates a low likelihood of BED.

Free to download at Adolescent Binge Eating Scale (ADO-BED) Questionnaire ( 268 KB).

Carefully assess each situation for the possibility of an eating disorder and closely monitor at intervals as frequent as every 1 to 2 weeks until the situation is clarified.

Suspected eating disorders: [Medical: 2016]

• Check CBC, CMP, and electrocardiogram (ECG) in all. See Eating Disorders: A Guide to Medical Care ( 364 KB).
• Selective use of the following tests: leptin level, TSH and T4, amylase and lipase, gonadotropins (LH, FSH) and sex steroids (estradiol, testosterone), Dual Energy X-ray Absorptiometry (DEXA).
• Consider performing a longer diagnostic evaluation using the Eating Disorders: Diagnostic Measures (E-CBT), which is validated in adults and children down to age 9 (considered the gold standard for diagnosis), or a modified version, the children’s EDE (also see Eating Disorders: Diagnostic Measures (E-CBT)), which can be used for younger children down to age 8.
• Consider symptom-based referrals to a pediatric cardiologist, endocrinologist, psychiatrist, behavioral health specialist, and/or pediatric gynecologist.
• Consider hospitalization and/or referral to a multidisciplinary eating disorders program. These usually include some or all of the following: psychiatrist, family therapist, psychologist, pediatrician, nurse, dietician, and other therapists.
• Evaluate for comorbid conditions, such as Depression, Anxiety Disorders, or Obsessive-Compulsive Disorder (OCD).
• Consider symptom-based referrals to a pediatric cardiologist, endocrinologist, psychiatrist, behavioral health specialist, and/or pediatric gynecologist.
• For adolescents with anorexia nervosa, consider referral for family-based treatment; these patients may be less responsive to antidepressants. [Harrington: 2015]
• For adolescents with bulimia nervosa, refer for short-term psychotherapy (e.g., cognitive-behavior therapy) and consider antidepressant medications. [Harrington: 2015]

For extended guidance about diagnosis and treatment, see Resources below.

A multidisciplinary team, coordinated by the primary care clinician or a psychiatric provider, is generally advised for outpatient treatment of eating disorders. The team ideally includes a primary care clinician, a psychiatrist, a dietician with experience in eating disorders, and a therapist. Members of the team should initially plan to see the individual 1-4 times per month, depending on severity. Additional consultants may be advised; guidance for referrals follows:

Psychiatry > … (see NM providers [5])
Refer for difficult-to-manage behavioral problems or consultation on pharmacological management.

Dieticians and Nutritionists (see NM providers [1])
Refer to a registered dietician or nutritionist experienced in eating disorders to implement a nutritional treatment plan, guide a healthy diet and exercise, and discuss behaviors related to food and eating. Look for registered dieticians and other providers specialized in eating disorders who have obtained certification as a Certified Eating Disorder Specialist (CEDS) through the International Association of Eating Disorders Professionals Foundation (iaedp).

Eating Disorders Counseling (see NM providers [0])
Refer for ongoing monitoring and treatment of mental health issues, cognitive behavioral therapy, family therapy, and support.

Pediatric Gastroenterology (see NM providers [2])
Refer for digestive system consequences of disordered eating behaviors.

Obstetrics & Gynecology (see NM providers [1])
Refer for menstrual dysfunction (delayed menarche, oligomenorrhea, and amenorrhea).

Pediatric Sports Medicine (see NM providers [1])
Refer for evaluation and management of the athletes with low energy availability, bone mineral loss, and (when relevant) menstrual dysfunction.

Pediatric Orthopedics (see NM providers [7])
Refer for bone health issues (e.g., stress fractures).

Pediatric Endocrinology (see NM providers [4])
Refer for growth, menstrual disturbance, and concurrent conditions (e.g., thyroid disease or osteopenia/osteoporosis Osteoporosis and Pathologic Fractures).

Adolescent Medicine (see NM providers [1])
Refer for medical care and emotional issues of teens.

Developmental - Behavioral Pediatrics (see NM providers [2])
Refer for medical and emotional issues of children, adolescents, and their families, and for assistance in diagnosing suspected neurodevelopmental disorders like autism spectrum disorder.