Developmental considerations in measuring children's disordered eating attitudes and behaviors
Introduction
Although prevalence rates for adolescent eating disorders remain low (between 0.3% and 1.0%; Rosenvinge et al., 1999, Steiner and Lock, 1998), and rates for prepubertal children are even lower (Lask & Bryant-Waugh, 2000), there are markedly higher rates for partial syndrome disorders (4–10%; Killen et al., 1994, Shisslak et al., 1995). Furthermore, there is consensus that subclinical forms of eating disturbance are becoming alarmingly common (Hill, 1993, Steiner and Lock, 1998, Thompson and Smolak, 2001). Few studies directly address cohort effects, but one recent Swedish study found that scores on eating disorder measures were significantly higher among 11-year-old girls in 1999 than in 1995 (Halvarsson, Lunner, Westerberg, Anteson, & Sjödén, 2002). In addition, more than 40% of 9- to 16-year-olds reported feeling fat and/or wishing to lose weight, 23% reported being afraid to eat because of the possibility of gaining weight, and 31.4% had dieted previously (Childress, Brewerton, Hodges, & Jarrell, 1993). In a study of 10- to 14-year-old girls, 29.3% were currently trying to lose weight, and 10.5% had scored at or above the clinical threshold for disordered eating attitudes and behaviors (McVey, Tweed, & Blackmore, 2004). This high rate of dieting and related behaviors is especially concerning because childhood and preadolescent dieting is often a precursor for development of an adolescent eating disorder (Hsu, 1996, Killen et al., 1994, Kotler et al., 2001, Marchi and Cohen, 1990, Patton et al., 1999, Stice, 2001, Stice et al., 1998).
Furthermore, disordered eating attitudes and behaviors are affecting girls at younger ages (Hill, 1993, Smolak and Levine, 1994). Although there are limited studies that directly address age trends in disordered eating symptoms, girls as young as 6 and 7 years old have reported engaging in disordered eating behaviors and expressing dieting and weight concerns (Flannery-Schroeder & Chrisler, 1996), and girls as young as 8 have reported being knowledgeable about dieting practices and engaging in some dieting behavior (Schur, Sanders, & Steiner, 2000). In addition, Shapiro, Newcomb, and Loeb (1997) found that 13% to 41% of 8- to 10-year-old girls endorsed some aspect of dysregulated-restrained eating attitudes and behaviors.
A popular screening instrument for measuring the levels of disordered eating in children is the Children's version of the Eating Attitudes Test (ChEAT; Maloney, McGuire, & Daniels, 1988). The ChEAT, which has been widely used to measure levels of disordered eating attitudes and behaviors in children aged 8 to 13, was adapted from the Eating Attitudes Test (EAT; Garner, Olmsted, Bohr, & Garfinkel, 1982) that is utilized with older adolescents and adults. Parallel to the EAT, Maloney et al. (1988) recommended a ChEAT clinical cut-off score of 20 to identify children who may be at risk for problematic eating behaviors.
Concerns about these clinical cut-offs with children began with validity questions of the EAT clinical cut-off with adolescents (Wood, Waller, Miller, & Slade, 1992) and has more recently included concerns about the suitability of the ChEAT cut-off with younger populations (e.g., Rolland et al., 1998, Sasson et al., 1995). Specifically, the validity of the ChEAT threshold of 20 has been criticized by Rolland et al. (1998) who found that 14% of their sample (girls aged 8 to 12 years) scored above the threshold compared with 9% in the Maloney et al. study. Rolland et al. found that the younger girls in their sample (i.e., 8-year-olds) tended to endorse an unusually high number of items, calling into question the ChEAT's validity with young children, and potentially inflating prevalence rates. In fact, 28% of these younger girls scored above the clinical cut-off. Flannery-Schroeder and Chrisler (1996) reported similar concerns with young children (6- and 7-year-olds), suggesting that they may not understand items related to vomiting after eating. Although the ChEAT has not been standardized on children this young, their findings suggest concern regarding comprehension in using the ChEAT with young children. In fact, Smolak and Levine (1994), in their factor analysis of the ChEAT, suggested that this instrument appeared to be more reliable with older children (i.e., their sample with a mean age of 13.2 years compared to Maloney et al.'s sample of 8- to 13-year-olds) and that wording changes may be necessary to make the measure more comprehensible to younger children. Moreover, regardless of age, Lattimore and Halford (2003) questioned the validity of the ChEAT cut-off as an indicator of high risk for disordered eating because girls in their sample (aged 11 to 16 years) who scored above this cut-off appeared to be making relatively healthy eating choices.
As disordered eating is impacting children at younger ages, and because the most widely used screening instrument (i.e., the ChEAT) has received some criticism with younger children, we sought to investigate the discriminant ability of the ChEAT with our sample of ethnically diverse, low/low–middle socioeconomic status third- to sixth-grade girls (aged 8 to 12 years). For this purpose, we employed measures that are theoretically associated with components of the multidimensional nature of disordered eating attitudes and behaviors and for which there are significant data with children in this age range (i.e., body dissatisfaction, body esteem, self-esteem, depressive symptoms, and age-standardized weight).
In the literature addressing associations between preadolescent body dissatisfaction and disordered eating, Gustafson-Larson and Terry (1992) found that a desire for less body fat in 9- to 11-year-old children was significantly associated with an increased frequency of weight-related behaviors and concerns. In addition, body dissatisfaction is associated with many facets of problematic eating in early adolescence, such as emotional eating, binge eating, and abnormal attitudes toward eating and weight (Huon, 1994, Johnson and Wardle, 2005). Moreover, girls exhibiting high levels of dietary restraint report high levels of body dissatisfaction as well as low levels of body esteem (Hill, Oliver, & Rogers, 1992). In fact, there is empirical support for body dissatisfaction at 5 and at 7 years old as a precursor for higher dietary restraint, more maladaptive eating attitudes, and a greater likelihood of dieting at age 9 (Davison, Markey, & Birch, 2003) and for body dissatisfaction in early adolescence as a precursor to eating problems 2 years later (Attie & Brooks-Gunn, 1989). Importantly, disordered eating in adolescence is often linked to weight and body dissatisfaction (French et al., 1997, Koff and Rierdan, 1991, Stice, 2001).
In the literature linking body size discrepancy to disordered eating, Gardner, Stark, Friedman, and Jackson (2000) found that a large discrepancy between ‘perceived’ and ‘ideal’ body shape was a significant predictor of higher eating disorder scores in a longitudinal study of 6- to 14-year-olds and that these body size judgments emerged as predictors around ages 11 and 12. Moreover, Veron-Guidry, Williamson, and Netemeyer (1997) found that body size discrepancy acted as a mediating variable between eating disorder symptoms and such risk factors as societal pressure for thinness, self-esteem, and depression in preadolescent girls. In addition, Hill et al. (1992) found that girls who were highly restrained reported discontent with their body build, weight, and certain regions of their bodies, choosing an ‘ideal’ body shape that was considerably slimmer than that of girls with low levels of dietary restraint and was significantly slimmer than their identified ‘perceived’ body shape.
A related construct, body esteem, is defined as how individuals broadly feel about their bodies. Body esteem has been found to significantly decrease between third and fifth grade (8 and 9 years old vs. 10 and 11 years old) and to be negatively correlated with eating disordered behaviors in first- to fifth-grade girls (6- to 11-years-old) (Flannery-Schroeder & Chrisler, 1996) and middle school girls, ranging in age from 10 to 16 years (Hoare and Cosgrove, 1998, McVey et al., 2002). Furthermore, highly restrained girls have reported lower levels of body esteem compared to unrestrained girls (Hill et al., 1992), and low body esteem was a significant predictor of higher eating disorder scores, emerging as a predictor around age 9 (Gardner et al., 2000).
Although research has shown that body esteem is associated with disordered eating, evidence for a relationship between self-esteem and disordered eating is more equivocal. Self-esteem did not emerge as a significant predictor of higher eating disorder scores in children aged 6 to 14 (Gardner et al., 2000). However, self-esteem, when based on shape and weight, has been associated with greater levels of restrained and/or emotional eating (Hoare & Cosgrove, 1998) and greater attempts to lose weight in adolescents (Muris, Meesters, van de Blom, & Mayer, 2005). Furthermore, global self-worth, similar to self-esteem, was found to be a significant predictor of dieting awareness in 8-year-old girls (Hill & Pallin, 1998), and self-concept was found to predict problem eating for children aged between 8 and 10 (Thomas, Ricciardelli, & Williams, 2000).
Although the empirical literature addressing the relationship between childhood eating disturbance and depressive symptoms is limited, there is some evidence that disordered eating is associated with higher levels of depressive symptoms. For example, Veron-Guidry et al. (1997) found that depressive symptoms were significantly correlated with eating disorder symptoms at ages 8 to 13. A longitudinal study found that depression at age 10 was a significant predictor of higher eating disorder scores at age 11 and persisted through age 14 (Gardner et al., 2000). In fact, when compared with relative weight, body esteem, body dissatisfaction, and teasing, depression was the single most powerful predictor of eating disorder scores in this study. Furthermore, Killen et al. (1994) found that 11- and 12-year-old girls who presented with prominent symptoms of bulimia nervosa approached or exceeded clinical cut-offs on two measures of childhood depression.
In general, overweight children are the most vulnerable to body image concerns, and thus, are at an increased risk for disordered eating. Specifically, overweight children report more concerns about weight, shape, and eating (Burrows & Cooper, 2002), a greater desire for thinness, higher levels of dietary restraint (Ackard and Peterson, 2001, Hill et al., 1994, Vander Wal and Thelen, 2000), lower body esteem (Hill et al., 1994, Vander Wal, 2004), and higher eating-disordered cognitions and behaviors than average-weight children (Gustafson-Larson and Terry, 1992, Tanofsky-Kraff et al., 2004). Regardless of overweight status, body mass index (BMI) has been found to significantly predict eating disorder scores (Gardner et al., 2000, Keel et al., 1997), dieting awareness (Hill & Pallin, 1998), problem eating (Thomas et al., 2000), and stronger attempts to lose weight (Muris et al., 2005). For example, even among 5-year-old girls, higher weight status was associated with greater body dissatisfaction, which in turn was associated with greater weight concerns (Davison, Markey, & Birch, 2000). In our ethnically diverse sample, overweight may be a particularly salient issue as the prevalence of at-risk for overweight and overweight is significantly greater for Hispanic girls than for non-Hispanic white girls (Hedley et al., 2004).
The objective of the present study was to investigate the discriminant ability of the Children's Eating Attitudes Test (ChEAT) clinical cut-off in a low/low–middle socioeconomic status, non-clinical sample of primarily Hispanic and non-Hispanic white (Caucasian) 8- to 12-year-old girls. Specifically, we investigated how age, age-standardized body mass index (z-BMI), body dissatisfaction, body esteem, self-esteem, and depressive symptoms contribute to the clinical determination of disordered eating status. Relatedly, we investigated an alternative threshold for the ChEAT with the intent of increasing sensitivity. A secondary aim was to identify whether age moderates the discriminant ability of these ChEAT thresholds. Age seemed a likely moderator, and we selected age 10 as the cut-off for subsequent analyses because (1) some risk factors for disordered eating, such as depressive symptoms, have been found to emerge at age 10 but not earlier (Gardner et al., 2000); (2) a significant qualitative shift emerges around age 10 regarding the ability to form representational systems and engage in abstract thought (Fischer and Pipp, 1984, Fischer and Silvern, 1985); (3) four of the highest ChEAT scores were reported by the 8- and 9-year-olds; and (4) during the test administration, item content often needed to be explained to these younger participants. A third aim was to determine if an abbreviated version of the ChEAT could yield similar results without compromising sensitivity. This sample was limited to girls because of their greater risk for body image and disordered eating concerns (e.g., Keel et al., 1997, Wood et al., 1996).
Section snippets
Participants
Participants were 152 preadolescent girls from urban and rural public schools in New Mexico. The schools were predominantly in the lower to lower–middle class range, with 56.19% of students qualifying for free or reduced priced meals. The girls ranged in age from 8 to 12 (mean age = 9.76, S.D. = 1.30).1 The sample was composed of 38.8% Caucasian (n = 59), 32.2% Hispanic (n =
Preliminary analyses
BMI scores for this sample ranged from 12.97 to 30.39 (mean = 18.16, S.D. = 3.78). Based on national samples (Kuczmarski et al., 2000), 11.8% of the girls were classified as underweight (BMI ≤ 5%; n = 18); 60.5% were classified as normal weight (BMI between 5% and 85%; n = 92); 11.8% were classified as at risk for overweight (BMI between 85% and 95%; n = 18); and 15.8% were classified as overweight (BMI ≥ 95%; n = 24).
Preliminary between-group ethnic analyses were conducted in order to determine if pooling
Discussion
The present study investigated how age, z-BMI, body dissatisfaction, body esteem, self-esteem, and depressive symptoms contribute to the clinical status of disordered eating behaviors in an ethnically diverse, low/low–middle SES sample of preadolescent girls. The primary aim of this study was to investigate the discriminant ability of the ChEAT clinical cut-off in order to evaluate its clinical utility as a screening measure. We did not include a structured clinical diagnostic interview in this
Acknowledgements
We thank J. Scott Tonigan, Ph.D., and Harold Delaney, Ph.D., who served as statistical consultants.
The authors have no financial relationships to disclose.
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