Emergency room visits for eating disorders among 12- to 17-year-old girls doubled during the coronavirus pandemic, according to new research from the US Centers for Disease Control and Prevention – a troubling existing trend that was likely worsened by the stress of living through the prolonged crisis.

“​​We are seeing such a high volume of patients in need of eating disorder care as well as worsening severity,” said Tracy Richmond, a physician and the director of the eating disorder program at Boston Children’s Hospital, who was not involved in the CDC study. “It feels really clear for those of us who take care of teenagers that there is an absolute second pandemic of mental health needs in adolescents.”

After a decade of increasing concern, the American Academy of Pediatrics declared a national mental health emergency among children and teens in 2021, and the US surgeon general warned in December of a youth mental health crisis that began building before the pandemic.

In 2020, kids actually made fewer visits to emergency departments than the year before – a decline of 21%, the CDC report found. In 2021, there was a decrease of 8% compared to 2019.

But the reason for those visits changed dramatically during the early months of the pandemic, with the proportion of emergency visits for mental health among kids rising by 24% in 5- to 11-year-olds and 31% in 12- to 17-year-old, as compared with the year before.

There are also marked differences in gender.

Among teen girls, aged 12 to 17, visits for eating disorders and tic disorders increased in both 2020 and 2021. There were also more visits for depression and obsessive-compulsive disorder among teen girls in 2021.

Another CDC study published the same day found that overall visits to the emergency room declined in this same time, falling by 51% in 2020, 22% in 2021, and 23% in the first month of 2022, compared to 2019.

Covid-19 remained the predominant reason for ER visits among kids – particularly among children too young to be vaccinated during the Omicron wave, when visits for that age group increased.

There were also increases in visits related to behavioral health conditions among children five to 17, including self-harm, drug poisonings, socioeconomic and psychosocial concerns, and – among adolescents only – symptoms of mental health conditions and substance use.

“The results point to the importance of increased awareness for health concerns that could arise due to delayed medical care and heightened emotional distress during the pandemic, especially among adolescents,” said Lakshmi Radhakrishnan, a health scientist at the CDC and the lead author of both studies.

The reasons for the rise in distress among teen girls are complex and various, she added, making it difficult to pinpoint their cause.

Richmond said that inpatient visits at her center have nearly tripled and the need for outpatient care has also increased.

“As patients are coming in with higher needs, they’re coming in with more severe presentation, and they’re often coming in with comorbid mental illness, like depression, anxiety, suicidality,” Richmond said.

Potential reasons include changes in routine and schedule, including spending more time at home and new habits around eating and exercise, as well as the stress of living through the pandemic – losing parents and caregivers to the virus or to other related causes, watching parents worry about their jobs and their own mental health.

Social isolation can be particularly challenging in the teenage years, when it’s important for kids to form close relationships with peers and build their own identities.

“They’re meant to be individuating from parents and family, and really be striking out on their own and developing their own individuality,” Richmond said. “Instead, in the early parts of the pandemic, they were driven back into the home and closer to their families.”

Kids have also had disruptions to their regular activities and extracurricular interests – sports teams, theater groups, newspapers.

The isolation may have accelerated an existing tendency to spend time on social media, where they are flooded with increasingly precise algorithms that may lead to the rapid rise in eating disorders.

“As our adolescents have been spending more time with social media, we also are uncovering that the content that they’re being served is just getting more and more extreme,” Richmond said.

The tic disorders seen were particularly unusual because boys of the same age didn’t see an increase – and tic disorders tend to be diagnosed at earlier ages and are more common in boys than in girls.

The increase in tic disorders may also be linked to social media – specifically TikTok, where cataloging tics has become its own genre of videos.

But social media can also provide support and socialization, as well as a creative outlet, for many kids – and nuanced discussions of the role of social media are very important, said Tyler Black, a child and adolescent psychiatrist and suicidologist at BC Children’s Hospital in Vancouver.

“Kids were online and connecting virtually and Snapchatting before we were Zooming – they were doing virtual teleconferences before we even knew what Zoom was – and they were very prepared for online interaction.”

The return to school, for those who attended remotely or on a hybrid schedule, may have also contributed to stress, Black said.

School is a major cause of stress for kids with anxiety, according to a 2014 study from the American Psychological Association. Kids are about twice as likely to die of suicide in the United States on school days versus non-school days.

“People naively say things like ‘if we send kids back to school, we’ll restore their mental health.’ And I keep wanting to remind everybody that prior to the pandemic, we had a lot of concerns about school and kids’ mental health,” Black said, including bullying, racism and a lack of mental health curriculum or support services for kids.

Eating disorders can affect everyone, Richmond said – “all genders, all ages, all socioeconomic groups, all racial and ethnic groups – and I do think we’ve seen more of that during the pandemic than ever before.”

Every wave of Covid-19 has also brought destabilization, she said.

“There’s just continued uncertainty, and a feeling of loss – you sort of feel like you’re getting your footing under you, and then a new variant comes and shakes everything up,” Richmond said. “I do think there’s some sense of kids wanting to control things … and for many of them, it just spirals out of control in a way that they didn’t expect.”