key: cord-1051940-b3h72ndl
authors: Richardson, Candice; Phillips, Suzanne; Paslakis, Georgios
title: One year in: The impact of the COVID-19 pandemic on help-seeking behaviors among youth experiencing eating disorders and their caregivers
date: 2021-11-03
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2021.114263
sha: deb85b1fad38ac5ad06e0c4fec1e92e87dec0d13
doc_id: 1051940
cord_uid: b3h72ndl

We analyzed service utilization data from the National Eating Disorder Information Centre's (NEDIC) toll-free helpline/chat to assess the impact of the COVID-19 pandemic on help-seeking behaviors among youth with disordered eating and their caregivers. The number of contacts from affected youth (n = 650) and caregivers (n = 823) was significantly higher in the pandemic year than 2018 and 2019. The proportion of affected youth reporting dieting/restriction, perfectionism, and weight pre-occupation was significantly higher during the pandemic than in 2018 and 2019. Our findings lend support to accounts from expert clinicians reporting an increase in youth presenting with eating disordered symptoms during the pandemic.

Pediatric and mental health experts have reported a spike in eating disorders (EDs) among adolescents and teens amidst the pandemic (Canadian Press, 2021). Canada's largest pediatric hospital has seen 30% and 60% increases in inpatient and outpatient ED treatment referrals, respectively (Canadian Press, 2021) . ED admissions have more than doubled at other pediatric hospitals across the country (Canadian Press, 2021) . The pandemic has exacerbated the already pervasive problem of unmet treatment needs among youth with ED symptoms; this is particularly problematic given evidence that early detection and treatment leads to better outcomes (Couturier et al., 2020; Russell et al., 1987; Treasure and Russell, 2011) .

The National Eating Disorder Information center (NEDIC) is a nonprofit organization that operates Canada's only toll-free helpline and instant chat service. Early on in the pandemic, we found that the number of affected individuals contacting NEDIC had doubled since 2018; compared to 2019, the rates of dieting/restriction, depression, and anxiety had increased by 12%, 15%, and 20%, respectively (Richardson et al., 2020) . The present study is a follow-up to Richardson et al. (2020) , aimed to specifically assess help-seeking behaviors in youth with ED symptoms and their caregivers during the COVID-19 pandemic, and to compare help-seeking behaviors between 2020 and previous years.

Using a retrospective design and Chi-square tests, we statistically analyzed anonymous NEDIC service utilization data comparing the "pandemic year" (01/03/2020-31/12/2020) with corresponding time periods in previous years (01/03/2018-31/12/2018, 01/03/2019-31/ 12/2019). We focused on affected youth (≤19 years) and caregivers, as we have conducted a comprehensive analysis previously (Richardson et al., 2020) .

All individuals who contacted NEDIC between March 1st and December 31st of 2018, 2019, and 2020 were included in the analysis; each contact was analyzed as a separate case. The study was approved by the University Health Network Research Ethics Board; patient consent was waived due to the anonymous nature of NEDIC's services. Statistical analyses were performed using SPSS (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp.).

Abbreviations: NEDIC, National eating disorder information center; ED, Eating disorder. * Corresponding author.

E-mail address: georgios.paslakis@rub.de (G. Paslakis). 

Among affected youth, 89.1% (n = 579) were girls; 65.7% (n = 427) disclosed an ED diagnosis, of which 31.4% (n = 134) reported anorexia nervosa, 7.0% (n = 30) bulimia nervosa, 6.3% (n = 27) binge eating disorder, 1.6% (n = 7) other specified feeding or eating disorder, 0.2% (n = 1) avoidant/restrictive food intake disorder, and 53.4% (n = 228) did not specify the particular type of ED diagnosis.

Data analysis revealed a shift in age distribution of affected individuals contacting NEDIC, see Fig. 1 . Indeed, the number of affected youth contacting NEDIC significantly differed between years (χ2(2)= 310.42, p<.001), with the highest number (n = 650; 27.5%) of affected contacts in 2020, versus n = 273 (19.6%) in 2019, and n = 201 (17.0%) in 2018 (2020>2019>2018).

In the pandemic year, more than half of affected youth (n = 343) reported engaging in dieting/restriction, and 46% (n = 298) reported weight pre-occupation.

In terms of significant differences, the proportion of affected youth who reported dieting/restriction, perfectionism, and weight preoccupation was significantly higher in the pandemic year than 2018 and 2019. While the rate of over-exercising was highest in 2020, it was only significantly higher than 2019 but not 2018. Similarly, anxiety rates were highest in 2020; while rates in 2019 and 2020 were higher than 2018, they were not significantly different from each other. The rates of self-reported over-eating/binge eating, and depression did not vary between years, and purging was highest in 2018.

During the pandemic year, 823 caregivers -including parents, family members, and friends of affected individuals-contacted NEDIC, the majority of which (76.4%, n = 629) were adults (age 26+) and women (76.5%, n = 630). Almost all (98.5%, n = 811) caregivers were contacting NEDIC with regards to a child, family member, or friend affected by an ED or disordered eating. The majority (32.9%, n = 267) of secondary clients were teenagers (age 15-19), 21.5% (n = 174) were adults (age 26+), 15.3% (n = 124) were young adults (age 20-25), 15.8% (n = 128) were adolescents (age 11-14), and 2.6% (n = 21) were children (age ≤10). Among caregivers, the number of contacts differed significantly across the years (χ2(2)=29.95, p<.001); the highest frequency of contacts was in the pandemic period (n = 823), which was significantly higher than the number of contacts in both 2018 (n = 665) and 2019 (n = 630).

The COVID-19 pandemic has significantly disrupted healthcare delivery. We provide evidence for the impact of the pandemic among young individuals affected by disordered eating, as well as their caregivers. The number of contacts from caregivers was significantly higher in the pandemic year than in both 2018 and 2019; with over half of contacts (n = 416) regarding concern for an affected youth. Furthermore, in the pandemic year, over one-third (33.4%, n = 650) of affected individuals contacting NEDIC were youth; the proportion of affected youth reporting dieting/restriction, perfectionism, and weight preoccupation was significantly higher than in 2018 and 2019.

Strengths of this study include: collection of anonymous data, which may facilitate unbiased responses; assessment of a significant number of contacts, including both affected individuals and caregivers; and comparison between corresponding time periods in three consecutive years. Limitations are as follows: we were unable to determine if the same individual(s) contacted NEDIC multiple times given the anonymous nature of their services and therefore considered each contact to be a separate case; symptoms/diagnosis were based on clients' spontaneous self-report which may not accurately reflect their experiences; there is a possibility that the increases in ED symptoms were caused by a trend toward increased symptoms over time rather than the pandemic, specifically.

The increases we observed in help-seeking behavior among caregivers and affected youth in our sample are in line with the currently available reports of increases in ED referrals and admissions during the COVID-19 pandemic. At Canada's largest pediatric hospital, clinicians have not only seen a rise in cases and referrals, but patients are also presenting in more acute physical and mental distress than past cases (Canadian Press, 2021). As a result, these patients require intense monitoring, treatment, and longer lengths of stay than if they had been diagnosed earlier. With COVID-related closures of "non-essential" services, including ED day hospital programs, occurring across Canada, the most severely ill patients with EDs were often left without the intensive treatment that they required (Couturier et al., 2021; Fernández-Aranda et al., 2020; Richardson et al., 2020) .

As experts (Canadian Press, 2021) and studies (Rodgers et al., 2020) have suggested, school disruptions, social isolation, social media exposure, and stress may fuel unhealthy eating and exercise habits. Additionally, pandemic-related social restrictions may deprive youth of social support and adaptive coping strategies thereby removing protective factors which may serve to elevate ED risk and symptoms (Rodgers et al., 2020) . Furthermore, individuals with pre-existing mental health challenges may also be at heightened risk of experiencing deterioration of their mental well-being during the pandemic (Wang et al., 2020) .

Our findings lend support to accounts from expert clinicians reporting an increase in youth presenting with EDs and add to the growing knowledge base regarding help-seeking behaviors in individuals with ED symptoms, as well as their caregivers, during COVID-19. These findings may reflect an increased need for supports in youth 

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

This work was supported by the Loretta Anne Rogers Chair in Eating Disorders Fund at University Health Network and the University of Toronto

Restrictions apply to the availability of these data. Data was obtained from the National Eating Disorder Information center (NEDIC) and are available on re-quest from the corresponding author with the permission of NEDIC.

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