Schools, this is how you spot an eating disorder

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The earlier an eating disorder is detected, the easier and swifter the treatment. And the pupil is spared the damage created  by malnutrition and over-exercise.

If you’re only flagging up concerns with very thin pupils, you’re missing a majority of (equally urgent) cases.

You don’t have to be sure that it’s an eating disorder

Your job is not to diagnose, and you can’t be expected to tell the difference between a diagnosable eating disorder and what might just be an issue with disordered eating or with body dissatisfaction.

* Link: The main eating disorders: binge eating, bulimia, anorexia, ARFID and OSFED *

* Link: Not an eating disorder but just as serious: orthorexia, bigorexia and others *

I recommend you flag up concerns when:

• the pupil seems to be missing meals, or is eating less or cutting out some types of food
• the pupil seems obsessive about exercising
• the pupil is suspected of vomiting after a meal
• the pupil might have a compulsion to binge – bingeing means consuming unusually large quantities in an out-of-control (and usually secretive) way
• the pupil is supremely interested in food, cooking, fitness, and diets
• the pupil seems to have gained weight very suddenly (be careful with this one – it might be their body preparing them for growth)
• the pupil seems to have lost weight (always a medical concern with a growing child)
• the pupil’s mood has darkened – they seem anxious, depressed, withdrawn (but this may only be evident at home – the pupil may continue to be high-performing in school)
• there is a greater incidence of eating disorders among pupils who self-harm, suffer from depression, anxiety, have obsessive-compulsive disorder (OCD) or have autistic spectrum disorder (ASD)

That’s the short version that I recommend you make all staff aware of. Below are more signs that it would be useful for a few designated members of staff to be able to refer to.

Signs that someone may be suffering from an eating disorder

Some of the signs below don’t mean much on their own, and some would describe the behaviour of many ordinary young people. Nobody expects you to diagnose these complex illnesses, but you may bring important pieces to the jigsaw, especially with behaviours that are not happening at home. Many young people begin restricting in school while still eating well at home. Conversely, some people show their worst behaviours at home, maintaining a show of normality in public.

Behaviour around food

• The pupil is leaving food uneaten, slipping it into the bin or pockets
• The pupil brings lovely food in for others without eating any of it
• On a school trip, or when someone brings in celebration food, the pupil eats nothing or very little
• The pupil has become vegetarian or vegan, or is avoiding gluten or fats or some other major food group. Or they always eat the same small number of things.
• The pupil does a lot of baking or cooking and is very skilful at it. They may have a hobby or job related to food. (This is why it’s useful to have well-informed home economics staff.)
• The pupil nibbles very slowly (they’re making the food last because they’re hungry)
• The pupil dissects the food, leaving some parts for later, or leaving aside anything oily or calorie-dense. They wipe their fingers to remove any traces of fat.
• The pupil takes a very long time to complete a meal (possibly because eating is hard and scary)
• The pupil has signed up to so many lunchtime activities that there is little opportunity to eat
• The pupil is drinking large amounts of water or zero-calorie drinks (for those who vomit, it’s to help vomit; for those who restrict, it’s to ward off hunger)
• The pupil is often chewing gum (anorexia: this is to hold off hunger; vomiting: to help disguise the smell – they may use mint sweets too)
• The pupil is hardly drinking at all (because fluids are just as scary as food)
• The pupil is anxiously taking a very long time to make food choices at the servery, possibly also looking up calories on their phone
• Pupils who are prone to binge eating may eat large amounts fast and may justify this with accounts of how much they’ve exercised or how little they ate before. At other times they may eat very little.
• Pupils who vomit are likely to visit the toilet after eating. You may hear flushing multiple times. The vomiting itself may be silent, or the person may run taps or play music to cover the noise. You may detect a smell of vomit in the bathroom or find a lot of perfume has been sprayed. Sometimes people vomit into bags that they later try to hide.
• For those who binge-eat: large quantities of food may disappear; the person surreptitiously eats many helpings and tries to eat these in secret.

Behaviours around exercise

• The pupil has signed up for many exercise classes
• The pupil is moving a lot, takes extra-long routes to get from A to B, does not sit back in the seat, uses any opportunity to stand instead of sit

Behaviours around mood

• This may be a model pupil – bright, studious, smart, helpful, getting consistently high grades, engaging in school life. They may have many friends and appear happy. (Meanwhile at home parents may be seeing anxiety, tears, suicidality, panic attacks, obsessionality, body-checking, difficulty sleeping. It depends if school is providing a welcome distraction from the eating-disordered thoughts, or is an extra source of stress)
• At the opposite end there are eating-disorder sufferers who are wild and impulsive. They have rapid mood swings and engage in high-risk behaviours (around drink, drugs, sex, self-harm). This is less likely in those with restricting anorexia and more likely with people who binge and purge.
• The pupil seems pre-occupied, listless, anxious or depressed
• A normally calm pupil gets irritable and has mood swings (think of how you are when you’ve not eaten for a while)
• The pupil studies obsessively for long hours
• The pupil’s thinking is inflexible, rigid, black-and-white (common in anorexia)
• The pupil comes to life when discussing diet, exercise, obesity and body shapes
• The pupil has poor self-esteem, is very critical of himself or herself, suffers from guilt, shame and self-disgust. May be suicidal.
• The pupil is certain they are fat
• The pupil doesn’t engage with others and turns down social events (this may be to avoid eating in public, or it may be about self-hate and the take-over of obsessive thoughts)

Physical signs

• The pupil has boundless energy and seems on a high (especially with anorexia, while untreated)
• The pupil looks weak, tired, lethargic and may be dizzy or even faint (because they may not have eaten for many hours)
• The pupil wears more than others because they are cold (this is the starving body diverting resources to essential functions)
• Some feel the cold but wear very little because they believe that being cold will burn more calories.
• Hands are cold
• The pupil wears baggy clothes to hide weight loss
• The pupil is not growing like their peers (malnutrition)
• The pupil is losing weight
• Hands look bony, the mouth and eyes look tight over the skull (a sign of being underweight)
• Hair is thinning, falling out, lifeleless
• Fine furry down (lanugo) cover the body – visible on arms, face and the back of the neck (a sign of an undernourished body trying to stay warm)
• The skin is very dry (especially for those who are restricting fluids)
• The person is underweight, normal weight or high weight: do not rule out any of the eating disorders purely on the basis of weight
• The person’s weight fluctuates fast (periods of restriction alternate with periods of eating large amounts)
• The pupil is body-checking: you may see them feeling their belly, or feeling for the girth of their wrist or arm
• In a room with mirrors, the pupil’s eyes are often drawn to his or her tummy
• Any signs of self-harm (cuts on the arms) or of OCD (obsessive-compulsive behaviours like long hand-washing) would add to the possibility of an eating disorder
• Often ill (e.g. colds) as the immune system cannot cope with malnutrition

Physical signs that might indicate vomiting

• A swollen or puffy face (swollen glands between the ear and jaw line)
• There are red marks, scars or callouses on the knuckles or the back of the hand (though some are capable of hands-free vomiting)
• The person keeps their nails short (to not scratch inside their mouth)
• The skin is dry and blotchy
• There are mouth sores
• Tooth damage: the teeth may look grey or ragged
• Redness around the eyes (or a lot of makeup to conceal it) because of burst blood vessels
• A sore throat

* Next page: What to do when a pupils shows signs of an eating disorder * 

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