Eating Disorders in Teens with ADHD: Red Flags and Recovery Steps

Eating disorders disproportionately impact teens with attention deficit hyperactivity disorder (ADHD) ^{1 2} – and we don’t fully understand why. A growing body of research links ADHD to a higher incidence of anorexia nervosa, bulimia nervosa, and binge-eating disorder during puberty and adolescence – a time when a mix of factors, including social media use, can contribute to negative body image and low-self-esteem. New studies also show that the pandemic triggered eating disorders among teens and worsened symptoms for those with existing eating disorders.^{3 4}

We are just beginning to understand how ADHD influences the development of eating disorders and disordered eating in teens, however it stands to reason that the low self-esteem associated with ADHD, particularly when undiagnosed, could be at least partially to blame, among other ADHD-related factors.

Regardless of root cause, eating disorders are serious but treatable conditions. Prevention efforts and support for teens in recovery must center on challenging appearance ideals and societal pressures that force youth to question their worth in relation to their body.

Eating Disorders Prevalent in ADHD

Individuals with ADHD are four times more likely to develop eating disorders than are non-ADHD individuals.⁵ The most common eating disorders are the following.

Binge-eating disorder is characterized by recurrent episodes of eating large quantities of food in a short time span, often much more rapidly and with less control than normal and to the point of discomfort. Binge eating usually occurs in secrecy, as episodes are associated with feelings of shame, embarrassment, and guilt.

[Is Your Child Showing Signs of an Eating Disorder? Take This Symptom Test]

Bulimia nervosa describes recurrent episodes of binge eating accompanied by unhealthy, harmful behaviors to compensate for binge eating, including self-induced vomiting, excessive exercise, and laxative abuse, among others. Teen girls with ADHD may be at particular risk for this eating disorder.⁶

Anorexia nervosa is associated with difficulty sustaining enough energy for the body’s needs due to persistent food restriction. It is often drive by an intense fear of being fat and of gaining weight, along with significant body image issues. Food restriction in anorexia nervosa along with other harmful weight loss methods can cause extreme thinness. Individuals who display all symptoms of anorexia except significantly low body weight have what is known as atypical anorexia nervosa.

Disordered Eating vs. Eating Disorders

Disordered eating describes abnormal eating patterns and behaviors that may not fit clinical criteria for an eating disorder diagnosis but are nonetheless concerning. Disordered eating is associated with poor self-esteem and a preoccupation with food and body image that takes a toll on quality of life. Possible signs and examples of disordered eating include but are not limited to:⁷

• using food to cope with negative feelings and stressors
• assigning “good” and “bad” labels to food
• feeling like food must be earned
• “making up” for food intake through food restriction or exercise to “work off” food
• yo-yo dieting; chronic weight fluctuations

[Read: “How My Eating Disorder Consumed Me”]

Eating Disorders in Teen Girls vs. Teen Boys

Research shows that eating disorders are more prevalent in girls, but it is important to recognize that they can occur in all kinds of people, regardless of gender, size, race, ethnicity, sexual orientation, or age. Among males, eating disorders remain under-researched, underdiagnosed, and undertreated due to stigma, misperceptions, and stereotypes.⁸ Eating disorders and disordered eating behaviors present differently in teen boys and teen girls, which explains under recognition in males.⁹ While girls may focus on thinness, boys may focus more on muscularity and muscle-building.¹⁰ Recent research also shows that boys and girls are equally likely to engage in disordered eating.¹¹

In my experience as an eating disorders specialist, I’ve seen firsthand how my adolescent patients, regardless of gender, deal with the same issues underlying EDs, like low self-esteem and poor body image.

What Drives Eating Disorders in Teens with ADHD?

The drivers behind eating disorders in teens, ADHD or not, are complex. Eating disorders run in families, suggesting a genetic factor.¹² Outsized sociocultural pressures often take a toll, as our culture undeniably values thinness and stigmatizes people in larger bodies. Many teens, especially girls and those with low self-esteem, internalize these messages. Dieting behaviors often follow, which predispose teens to disordered eating and eating disorders.¹³

Adolescence and Social Comparison

The transition to adolescence is a risky period for developing eating disorders and disordered eating.¹⁴ Social comparison — a normative part of adolescent development that helps teens understand themselves and the world around them — is thought to play a role. As teens try to be liked and approved by peers, they tune in to society’s appearance ideals and see that people who don’t meet those ideals are stigmatized.

Social Media

Social media is associated with eating disorders and poor body image issues in teens, according to research. Opportunities for social comparison on social platforms trigger body dissatisfaction and low self-esteem. Studies have found that teens who frequently check social media are more likely to experience body dissatisfaction than are teens who don’t spend as much time on these networks.¹⁵ Common body image concerns cited after social media use include dissatisfaction with thinness, body shape, and attractiveness.

Teens also feel pressured to appear perfect on social media platforms, which can trigger perfectionism – a known risk factor for eating disorders.^{16 17 18}

What’s more, platforms like TikTok and Instagram have been found to expose teens to pro-eating disorder content. According to Fairplay, a child advocacy group, Instagram’s algorithms promote content to teens that encourages restrictive diets and extreme weight loss.¹⁹ The platform’s own internal study also found that the app makes body image issues worse in girls.²⁰

ADHD-Related Factors

Impulsivity & Other ADHD Symptoms

Most studies on eating disorders and ADHD have focused on binge eating, and researchers have long pointed to impulsivity as a possible factor behind this behavior (though hyperactivity and inattention have also been linked to binge eating).^{5 21} Other ADHD symptoms and traits, like disorganization and emotional dysregulation, may increase susceptibility to disordered eating.²²

Altered Reward Processing

The connection between food, appetite, satiation, and weight is complicated – perhaps more so in the ADHD brain. In a recent study of individuals with high- and low-level ADHD symptoms, researchers detected increased neural activity in the former group when its members looked at pictures of food compared to the latter group, which may provide insight into the condition’s link to binge-eating behaviors.²³

Comorbid Conditions

Eating disorders share a strong relationship with anxiety and depression – which frequently co-occur with ADHD.^{24 25} Substance use problems, also associated with ADHD, are common in eating disorders as well.^{26 27}

Eating Disorder Symptoms in Teens: Early Warning Signs

Changes in behavior and mood, as indicated by the following, mark early signs of eating disorders in teens:

• anxiety, depression, irritability
• sudden weight loss or weight gain
• increased isolation; lack of engagement; withdrawing from others
• a sudden drop in academic performance
• difficulty feeling satiated
• food avoidance; making excuses not to eat
• secretiveness around food; hiding food or wrappers
• preoccupation with food and body image
• inflexible thinking around food and dieting; strict adherence to food and/or exercise schedules
• excessive exercise
• frequent weighing and measuring of body parts; body checking

Help for ADHD Teens with Eating Disorders and Disordered Eating Behaviors

If you are concerned about or recognize eating disorder symptoms in your child, contact their pediatrician for an evaluation and to understand treatment options. Chances for recovery increase the earlier a disorder is detected.

Speak with your teen’s doctor if you notice disordered eating behaviors, which may be more subtle but no less mentally torturing. They require intervention, too. Request an evaluation, even if you’re not fully convinced that your child’s thoughts, behaviors, and food-related issues are serious.

Eating Disorders: Treatment & Recovery

Treatment for active eating disorders generally includes a combination of psychotherapy, medications, nutritional counseling, and medical monitoring, depending on a patient’s needs. The goal of treatment is to restore a patient’s health, improve their relationship with food and with themselves, and build coping and self-regulation skills that don’t center on food or manipulating body size.

Full recovery is absolutely possible, though it may be a long-term process. Signs that someone is making progress include healthier behaviors and thinking around food, consistency in reaching nutritional needs, and re-engaging with the world around them, among others.

ADHD-Specific Treatment Considerations

Patients with ADHD and an eating disorder need care from a medical professional who understands both conditions, especially when they co-occur. ADHD and eating disorders must be addressed at the same time.

Stimulant medication requires careful attention in eating disorder recovery. Though stimulants are considered the first-line treatment for ADHD, they are also known to suppress appetite and affect weight. It may also be unsafe for malnourished patients or those dealing with medical complications from their eating disorder, like cardiovascular problems, to take stimulants until they enter a healthier state. At the same time, stimulants help individuals with ADHD function better, which may improve eating disorder recovery. But as the saying goes, pills don’t teach skills. Compensatory skills and strategies to manage ADHD symptoms are just as important in recovery.

How Parents Can Help Teens at Risk for Eating Disorders & Disordered Eating

Pressures to attain appearance ideals drive body dissatisfaction, eating disorders, and disordered eating. To protect youth from these outcomes, or to help teens in recovery, we need to challenge and dismantle the cultural assumption that “thinner is better” and help them focus on accepting people of all sizes and shapes, among other steps.

1. Examine and monitor your thoughts and language around food and appearance.

Children are highly impressionable and absorb the behaviors and language of adults around them. You may not be aware of the messages you’ve internalized about the thin-ideal and the ways you and others inadvertently uphold unrealistic and unhealthy beliefs. Telling someone that they “look good” after weight loss, for example, even if well-meant, reinforces the “thinner is better” ideal.

• Avoid talking negatively about your body, especially in the presence of your child.
• Avoid commenting on or judging other people’s bodies. Compliment someone’s spirit, energy, spark, sense of humor, and other traits that are not based on physical appearance.
• Identify and address disordered eating patterns in yourself.

It takes lots of work to notice and unlearn deeply ingrained beliefs. Give yourself grace as you rewire.

2. Remain vigilant and approach sensitive topics with care.

If you notice concerning behaviors in your teen, like emotional eating or food avoidance, gently check in from a place of compassion and support. Listen without judgment, assure your child that they are not doing anything wrong, and ask how you can best support them. Find a time when your child is most relaxed and open to talking. Car talks work well for many families, but you can also try approaching your teen as they’re winding down for bed.

3. Help your child find balance and structure.

Your teen needs structure to live a healthy, balanced life. Help your child build routines that reduce stress and facilitate healing. Focus on anchor points: restful sleep; three nutritious meals a day with snacks in between; joyful movement; connection time; “me” time.

Regulation, moderation, and intent are key as you help your teen find balance. Be careful not to enforce a diet/restriction mentality as you provide structure around food. Instead, focus on helping your teen connect with and honor their hunger and fullness cues.

Your teen may have a fixed definition of exercise in mind, and they may associate it with obligation, punishment, and “making up” for their eating. Encourage your teen to move their body for the joy of it, without the goal of manipulating body size. Movement comes in so many forms: dancing; playing motion-based video games; walking the dog; roller skating; swimming.

4. Talk about social media and limit screen time.

Have open conversations with your teen about social media, how they spend their time on it, and how it makes them feel. These conversations will help your child become aware of their stressors and give them the ability to step back to self-regulate. Validate your child’s feelings as they open up to you, especially about body image concerns. Coming from a place of fear, worry, anger, or judgment will only cause your teen to shut down. Approach these conversations with an open heart.

Set expectations around screen time at home, like what time phones should be put away and when the Wi-Fi will turn off. Blockers and parental control features can ensure that your teen doesn’t have access to certain apps past a fixed time.

5. Foster and protect your child’s self-esteem.

• Celebrate your child’s unique self and their values. Your teen must understand that their worth and value as a person are not determined by their weight, body shape, and other superficial qualities. They are enough as they are.
• Focus on building a positive, supportive bond with your child.
• Help your child experience success.
• Encourage your child to build connections with peers through hobbies and extracurriculars.
• Foster resiliency, or the ability to adapt during difficult situations and bounce back. Showing gratitude, practicing mindfulness, lending a helping hand, and tapping into a growth mindset all help.

If you or a loved one are coping with an eating disorder, contact the National Eating Disorder Association (NEDA) for support, resources, and treatment options. Call or text NEDA at 800-931-2237 or visit www.nationaleatingdisorders.org to reach a NEDA volunteer.

Eating Disorders in Teens: Next Steps

• Self-Test: Eating Disorders in Children and Teens
• Watch: How to Encourage Healthy Nutrition Among Teens with Eating Disorders
• Read: “My Appearance Is the Only Thing I Can Control.”

 The content for this article was derived, in part, from the ADDitude Mental Health Out Loud episode titled, “Eating Disorders and Body Image Among Teens” [Video Replay and Podcast #428] with Dena Cabrera, Psy.D., CEDS, which was broadcast live on October 27, 2022.

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