J. DRUG EDUCATION, Vol. 22(3)223-240,1992

DRUG ABUSE AND EATING DISORDERS: PREVENTION IMPLICATIONS*

W. DAVID WAlTS Southeastern Louisiana University ANN MARIE ELLIS Southwest Texas State University

ABSTRACT

This article explores the relationship between drug and alcohol abuse and eating disorders in a sample of adolescent females using a self-report methodology. An Eating Disorders Risk (EDR) Scale is adopted and correlated with drug and alcohol use, other forms of deviance, family and peer relationships, and depression. The findings support the concept of a generalized theory of addictions based on psychosocial, family, and peer factors. Family and peer prevention applications and a need for further research on the correlates of depression are discussed.

The clinical prevalence of alcohol and drug abuse and eating disorders has raised questions regarding the etiological and epidemiological features of each, their possible relationship to one another, and the implications for prevention. Affecting a much larger proportion of females than males, eating disorders are clinically thought to be associated with drug and alcohol abuse [l, 21. The same impulsivness and need to control that is thought to underlie eating disorders is believed to be associated with drug abuse. The purpose of this article is to identify prevention applications based on the similarities, differences, and relationships between the two behaviors in an adolescent female population. *A previous version of this article was presented at the Southwestern SociologicalAssociation. This research was supported in part by a grant from the U.S. Department of Education Drug Free Schools and Communitiesprogram.

223 0 1992, Baywood Publishing Co.,Inc.

doi: 10.2190/CUD9-LJA4-98J6-H799 http://baywood.com

224 I WAlTSANDELLlS

REVIEW OF THE LITERATURE Reports of drug abuse and eating disorders as related phenomena are increasing along with other problem behaviors, such as shoplifting and sexual promiscuity [3]. The clinical reports are based on women who are under treatment for eating disorders, primarily bulimia, or abuse of alcohol and other drugs, or both [4]. The samples reported are often small, and an intensive view of the patient with multiple presenting symptoms is provided [5-lo]. The epidemiological studies of alcohol, other drug use, and eating disorders also focus on the relation of bulimia to substance abuse, but they rely primarily on self-report surveys of various populations, predominantly college students [11-13], including graduate and professional students [14]. Timmerman et al. have examined eating disorders and alcohol abuse among secondary school students [ 151. Using self-report data, significant associations between bulimia, alcohol abuse, high socioeconomic status, and high maternal vocational status were reported. Two percent of the girls met DSM-I11 criteria for bulimia, and 12.5 percent of the females were alcohol abusers. This study recommended further examination of the development of eating disorders and alcohol use in early adolescence. The frequency of the existence of both bulimia and alcohol abuse among women is within a fairly consistent range according to the literature. Women treated for eating disorders, principally bulimia, have been reported as presenting alcohol problems in the range of twenty to more than fifty percent, while female patients treated for alcohol abuse are reported with eating disorder symptoms in the range from 6 percent to approximately 30 percent. For patients presenting both bulimia and alcohol abuse, eating disorder symptoms tend to appear earlier in adolescence or young adulthood, with alcohol symptoms occurring later. In some cases in which both behaviors are reported, alcohol abuse has occurred after the eating disorder has ceased. While studies of substance abuse and eating disorders have focused on alcohol, Gold and his colleagues have examined the association between cocaine use and eating disorders, finding a prevalence rate of 32 percent for anorexia, bulimia, or both disorders among male and female callers to the National Cocaine Hotline [16-181. While only 22 percent of the eating disordered callers said they used cocaine to ameliorate their eating disorder symptoms, they were more likely to do so than callers without an eating disorder. Like substance abuse, much of the eating disorder literature is grounded in the concept of addiction. While the sources of the addiction may vary from genetic predisposition to family factors to personality dimensions for both eating disorders and alcoholism, addiction is theorized to be the underlying dimension. Irrespective of the etiology, both behaviors are interpreted as addictions: for the anorexic, an addiction to food restriction; for the bulimic, an addiction to food binges and, most often, a mixture of purging, diuretics and laxatives; and for the

DRUG ABUSE AND EATING DISORDERS / 225

alcoholic and other substance abusers, a lack of control over the consumption of drugs. A global theory of addictive disorders, capable of producing prevention applications, must include genetic, psychological, and environmental/experimental factors. While there is evidence to support a genetic predisposition to alcoholism among males [191, the research record for females is unclear. Self-report methodology is not equipped to address the specifically genetic dimension of a theory of addictive disorders. However, social, psychological, and environmental factors may be tested with self-report data. Psychological factors posited to affect the development of addictive disorders include depression, which has been identified as a correlative factor in both alcohol use and bulimia in at least one study [7]. Drug and alcohol abuse and eating disorders may be coping mechanisms for young women who are having difficulty with depression, family, and peer relationships. Drug and alcohol use can be seen as self-medicating, while eating disorders, like other behaviors such as suicide attempts, provide forms of release that are reinforcing and self-destructive. Whether depression precedes drug abuse, eating disorders, and other dysfunctional behaviors can only be tested with longitudinal data. It may be, as Nathan has argued, that depression is a response to drug and alcohol abuse and its consequences [20]. Similarly, young women afflicted with eating disorders may develop depression in response to eating disorder behaviors. Social factors that impact the development of addictive disorders include the family and peer group. The family forms the basic values and attitudes of the child, including those that impact most directly on addictive disorders. Family attitudes toward alcohol, drugs, food, and thinness are thought to contribute to substance abuse and eating disorders. The evidence suggests that family impact is greater in early childhood, while peer groups have more effect in early adolescence [21]. Experiences that young people have with family members and other contribute to the risk of treating depression and pain with addictive and self-destructive behaviors. Children who live in alcohol and other drug dependent families and who are physically or sexually abused or neglected, are at high risk of depression, addictive disorders, and suicidal behaviors. An understanding of the relationships among alcohol, drugs, eating disorders, and depression is needed in order to develop effective education and prevention programs. Given the range of factors involved with both substance abuse and eating disorders, this study was undertaken with the purpose of developing prevention applications. HYPOTHESES

Based on the literature and the theoretical framework presented, the following hypotheses are proposed:

226 / WATTSANDELLIS

1. Eating disorders are positively correlated with drug use. a. Eating disorders and alcohol abuse are correlated. b. Eating disorders and drug abuse are correlated. c. The association of eating disorder with drug and alcohol abuse increases with grade level. 2. Eating disorders are correlated with other forms of deviance. a. Eating disorders are correlated with externally directed deviance, e.g., theft and violence. b. Eating disorders risk are correlated with internally directed deviance, e.g., suicidal thoughts and tendencies. 3. Eating disorders are correlated with family dysfunction and peer deviance. a. Eating disorders are correlated with family rejection. b. Eating disorders are correlated with family drinking and drug use. c. Eating disorders are correlated with peer deviance and drug use. 4. Depression is correlated with eating disorders and drug use.

METHOD

Early in the fall of 1989, a universe self-report survey of an affluent, Texas suburban school system was undertaken consistent with the requirements of a drug abuse prevention project. Although the survey included grades four through twelve, only the data gathered in grades seven through twelve are relevant for this study. The survey questionnaire consisted of 106 items which included agreement to participate in the survey, gender, age, and grade information. In order to be included in the data analysis, the respondents had to give permission for their responses to be used, and respond positively to a question about whether they had answered truthfully. They could not report any use of a false drug included in the study for validation purposes. Finally, respondents had to mark one of the two choices for gender on the answer sheet. The questionnaires were distributed by classroom teachers and school counselors during regularly scheduled class periods. Respondents were instructed to read the questions and place their anonymous answers on the machine-readable answer sheets provided. The answer sheets were collected and read into a computer via an optical scan device, and the data were analyzed using SPSS procedures. Forty-nine of the questions assessed the respondents’ use of drugs, including questions on when and where drugs were used. Modeled on both the annual senior survey conducted by the Monitoring the Future Project [22] and the statewide drug and alcohol abuse survey [23], the data were comparable to both state and national trends. Perceived parents’ attitudes toward drinking and drug abuse were measured, as was the perceived use of drugs and alcohol by peers. Additionally, four questions measured depression, two questions assessed suicidal ideation, four

DRUG ABUSE AND EATING DISORDERS / 227

questions measured delinquency, and two questions measured sexual activity, including date rape. Due to the age range and naivete of this adolescent population, the decision was made not to include any questions that would provide information to respondents as to the specific behaviors individuals with eating disorders use. This was done to insure that respondents would not learn new, deviant behaviors. No questions were asked about eating disorder behavior, such as food restriction, binging, laxatives, or vomiting. A four-item scale regarding eating and self-image was adapted from the Eating Disorders Inventory [24] and the Eating Attitudes Test [25]. The items are: “I feel extremely guilty after over-eating;’’ “I am terrified of gaining weight;” “I feel satisfied with the shape of my body;” “I think my thighs are just right.” Respondents could answer “always,” “frequently,” “sometimes,” “rarely,” or “never.” After reverse coding the first and second statements, the four items were combined to create a single Eating Disorders Risk (EDR) scale with a possible variance from 4 to 20. The higher the score the respondent received, the greater the likelihood of an eating disorder. Using Cronbach’s alpha, this scale produced a reliability coefficient of .827. It is important to keep in mind that this scale does not measure either bulimia or anorexia, but the respondent’s propensity toward developing or currently practicing eating disorder behaviors. It is a scale that measures eating disorder risk, not eating disorder behavior. The validity of the scale is supported by the intercorrelations that exist between these attitudes and feelings regarding eating, and the actual eating disorder behaviors reported elsewhere [25]. The drugs, measured for use in the lifetime, last year, and last month, were marijuana, hallucinogens, designer drugs, cocaine, steroids, amphetamines, barbiturates, and inhalants. Lifetime alcohol use, drinking in the last year, and drinking in the last month were also measured. Respondents were also asked to report the number of drinks that they normally have when they drink. This measure was taken as an indication of heavy drinking and possible problem drinking. Drugs other than alcohol were collapsed into three scales: lifetime drug use, drug use in the last year, and drug use in the last month. Reliability coefficients were calculated on the three scales, producing Cronbach’s alphas of 2354 for lifetime drug use, 328 for drug use in the last year, and .789 for drug use in the last month. FINDINGS Usable responses to the survey were evenly divided between males (50.6%) and females (49.4%), and totaled 1,715. Since eating disorders are disproportionately female, only the results from the females in grades seven through twelve will be reported in this article. Demographic and more complete drug use data are reported elsewhere [26]. In grades seven and eight, 273 females responded: 45.8 percent were eleven to twelve years of age; 53.1 percent were thirteen to fourteen

228 I WATTSANDELLIS

years old; and 1.0 percent were fifteen or sixteen years of age. For grades nine through twelve, less than one half of one percent were less than thirteen years old, while 25.8 percent were thirteen to fourteen years of age. Forty-eight percent were fifteen to sixteen years of age, and 23.5 percent were seventeen or eighteen years old. Only one female reported being over eighteen years of age. No data were gathered on ethnicity, since this school district is 99 percent whitehon-hispanic and the anonymity of the few minorities would have been violated by collecting such data. Prevalence of Eating Disorders Risk

For the sample of 826 females who completed the scale, the EDR scores ranged from 4 (3.5%of respondents) to 20 (4.4%of the respondents). The mean score for all grades was 12.12 with a standard deviation of 4.36, as shown in Table 1. Examining the means and standard deviations for all the grades shows a similar pattern of variance; however, tenth-grade students have a mean two points above the lowest in the other grades. To emphasize the distribution of scores in this sample, the scale was collapsed (see Table 2), using the standard deviation as a criterion for setting the upper limit of the scale. In other words, respondents with scores of 17 or more are in the second standard deviation of eating disorder risk scores variability. Respondents with scores of 17 or more have answered “always” to at least one of the eating disorder risk questions; those with scores of 18 or more have answered “always” to at least two of the questions; and those with scores of 20 have answered “always” to all of the questions. For grades seven and eight, five students gave the extreme response to all four of the eating disorder risk questions; for ninth grade, six; tenth grade, 9; for eleventh and twelfth grades, eight in each grade answered all the eating disorder items with the greatest at-risk response. Table 2 shows the EDR scores in a collapsed scale. Examining the percentage of respondents in each grade with a score of 17 or more, the prevalence of high scores peaks in the tenth grand, almost doubling from the ninth to the tenth. It

Table 1. Means and Standard Deviations for the Eating Disorders Risk Scale (EDR) by Grade for Females Grades

7-8 9th 10th 11th 12th

All

N 258 156 147 133 132 826

x 11.01 11.65 13.18 12.53 13.24

12.12

SD 3.97 4.34 4.47 4.41 4.36 4.36

DRUG ABUSE AND EATING DISORDERS / 229

Table 2. Distribution of Collapsed Eating Disorder Risk Scale (EDR) Scores by Grade for Females (Percent) Eating Disorder Scale Scores 4-6 7-9 10-12 13-16 17-20

7-8

9th

10th

11th

12th

Grades

Grade

Grade

Grade

Grade

12.8 25.6 25.2 26.4 10.1

13.5 19.2 24.4 28.2 14.7

10.2 12.2 17.7 32.7 27.2

9.0 21.8 15.0 30.8 23.3

9.8 12.1 17.4 36.4 24.2

levels off in grades eleven and twelve but remains high. While it is not possible to make a clinical diagnosis based on this brief scale, it is prudent to conclude that young women scoring in the higher ranges of the EDR scale are at risk for the development of eating disorders. Prevalence of Alcohol and Drug Abuse As shown in Table 3, the prevalence of alcohol and drug use in this female school population is displayed by grade from junior high through high school, and compared to a statewide sample of females surveyed in 1988. The prevalence of alcohol and drug use increased almost 100 percent from grades seven and eight to twelfth grade for alcohol, amphetamines, barbiturates, and inhalants. Marijuana use increased by eight times, while hallucinogen use increased by over ten times. For seniors, 14.4 percent of respondents reported that they had been drinking three or more times in the last two weeks. Many of these young women were consuming multiple drinks at a sitting. While only 4 percent of seventh and eighth graders report drinking three or more drinks at a time, that percentage increases to 22.4 percent for the ninth grade and to over 37 percent for the tenth, eleventh, and twelfth grades. Lifetime alcohol use was reported by over 90 percent of the seniors, and over half of the senior women had used alcohol in the last month. Within this high school culture, frequent, multiple drinking occasions are common and are an accepted part of social life. Illicit drugs show a lower rate of lifetime use. Marijuana continues to be the most commonly used lifetime drug, with one third reporting use, followed by inhalants, with one quarter of the female students reporting use. Seventeen percent of the female respondents report using designer drugs in their lifetimes, while 16.9 percent of seniors have used hallucinogens. Lifetime cocaine use increases remarkably in the senior year to 12.0 percent, compared to 5.9 percent by juniors. Juniors use more drugs in the last month than seniors. While only 6.8 percent of seniors report marijuana use in the last month, almost 12 percent of juniors have

230 / WATTSANDELLIS

Table 3. Prevalenceof Alcohol and Drug Use for Females by Grade (Percent) Compared to Texas (TX) Females 7-8

9th

9TX

10th

lOTX

11th

11 TX

12th

12TX

Alcohol Lifetime Last year Last month More than 3 drinks

53.0 40.8 16.5 4.1

76.3 64.2 29.6 14.6

73.7 NA 36.9 NA

89.8 76.4 43.9 37.1

82.6 NA 46.6 NA

88.1 82.2 59.5 40.7

81.3 NA 50.2 NA

91.7 82.0 51.9 40.1

84.7 NA 51.8 NA

Cigarettes last year

14.4

22.4

NA

37.2

NA

37.0

NA

37.6

NA

Marijuana Lifetime Last year Last month

4.4 2.6 1.1

8.8 8.2 4.4

22.9 NA 8.7

19.6 16.9 6.8

33.1 NA 12.1

29.6 25.9 11.9

35.5 NA 10.2

33.1 18.0 6.8

40.2 NA 11.1

Hallucinogens Lifetime Last year Last month

1.5 1.1 0.4

5.2 4.4 0.6

3.4 NA 0.9

8.4 8.8 2.0

5.1 NA 1.4

14.8 13.4 2.2

8.3 NA 2.7

16.9 9.8 1.5

8.9 NA 2.8

0.4 0.7

2.5 1.9 0.6

NA NA NA

8.8 5.4 1.4

NA NA NA

14.1 12.7 2.2

NA NA NA

17.3 11.3 2.3

NA NA NA

3.6 NA 1.2 NA

1.4 2.0 1.4 0.7

5.7 NA 2.2 NA

5.9 3.7 0.7 0.7

6.3 NA 1.7 NA

12.0 5.3 1.5 3.8

8.6 NA 2.2 NA

Designer drugs Lifetime Last year Last month

0.0

Cocaine Lifetime Last year Last month Crack lifetime

0.7 0.7 0.0 0.0

3.8 2.5 0.6 2.5

Steroid lifetime

0.0

3.2

NA

0.7

NA

0.0

NA

1.5

NA

Amphetamines Lifetime Last year Last month

7.7 7.4 3.7

13.8 6.3 3.2

16.0 NA 5.1

10.9 8.8 1.4

22.7 NA 8.6

14.9 11.9 4.4

22.6 NA 6.2

13.5 7.5 0.8

24.0 NA 6.7

Barbiturates Lifetime Last year Last month

5.1 7.4 3.7

2.5 6.3 3.2

12.1 NA 3.7

4.8 8.8 1.4

17.1 NA 4.7

8.9 11.9 4.4

14.5 NA 2.7

9.8 7.5 0.8

15.1 NA 6.7

Inhalants Lifetime Last year Last month

12.5 9.5 4.8

12.7 9.5 3.8

21.2 NA 6.3

11.5 6.8 2.0

20.9 NA 5.1

29.1 20.0 7.5

15.8 NA 3.7

25.6 7.5 0.8

14.0 NA 2.1

DRUG ABUSE AND EATING DISORDERS / 231

used it. Over four percent of the junior women, but less than one percent of seniors, have used amphetamines in the last month. Inhalant use in the last month is high for juniors (7.5%), and low for seniors (0.8%). Barbiturates and amphetamines show similar use rates in the last month for juniors and seniors, approximately 2 percent. In comparison to the state sample of females, lifetime alcohol use in the tenth through the twelfth grades is higher, as is use in the last month for tenth-graders. Another area that is higher than the state is lifetime inhalant use in the eleventh and twelfth grades. Lifetime cocaine use by the twelfth grade is three times higher for the district females than the statewide reported prevalence rates. The drugs that have a higher use rate than the state, particularly alcohol, are also associated with eating disorders. Eating Disorders and Alcohol Use

Hypothesis l(a) predicts that alcohol use and eating disorders will be correlated. Examining Table 4, we find that the frequency of lifetime alcohol use is correlated across all grade levels with the EDR scale. Although the correlations between frequency of lifetime alcohol use and the EDR are weak,' they are consistent and in the predicted direction. For alcohol use in the last year, the correlations are significant for the seventh to eighth (.200 p s .Ol), eleventh (.271 p s .Ol), and twelfth (.253 p I; .01) grades, and in the predicted direction. For use in the last month, only the eleventh (.272 p s . O l ) and twelfth (.206 p s .05) grades have significant correlations with the EDR in the predicted direction. For three of the five grade categories, there are significant associations between the number of drinks the respondent reports at a sitting and the risk of eating disorders. The strongest correlation is with the eleventh grade (.272p 5 .Ol), but the correlations are significant for the tenth grade (.169 p s .05) and the seventh to eighth grade ( . l 8 3 p s . O l ) respondents. Clearly, for most of the respondents, the risk of eating disorders is associated with alcohol consumption, both in frequency and in the amount of alcohol consumed at a sitting. With regard to the association of alcohol use with eating disorders tending to increase by grade level, only partial support can be found. While EDR scores tend to increase with age, peaking in grade ten, the association with alcohol abuse occurs most consistently in grades seven to eight and eleven. For seniors, the EDR and alcohol use over the lifetime, last year, and last month are associated; however, for this grade, eating disorders risk is not associated with the number of drinks in the last year. Overall, there is a consistent, clear association between

'

The correlations in Table 4 measure the extent of the relationship between alcohol and drug use and EDR. Statistical significance measurcs the probability that the relationship is not due to chance, while the value of the correlation coefficient measures the strength of the relationship. For example, a correlation of .200 accounts for only 4 percent of the variance.

232 I WATTSANDELLIS

Table 4. Eating Disorder Risk (EDR) Scale Correlations with Alcohol and Drug Abuse Variables for Females by Grade Alcohol and Drug Use Variables

7-8 Grades

.I 86" Lifetime alcohol use Last year alcohol use .200" .042 Last month alcohol use .I 83" Number drinks at a sitting Last year cigarettes .151* .179" Lifetime drug use Last year drug use .141" Drug use last month .I 63" .055 Lifetime marijuana use -.045 Last year marijuana use Last month marijuana use -.072 .213" Lifetime amphetamine use .261" Last year amphetamine use Last month amphetamine use .I 72" .202" Lifetime inhalant use .253* Last year inhalant use .203" last month inhalant use

9th Grade

10th Grade

.210" .I 49 -.077 .094 .027 -.I 89 -.I 13 -.I 44 -.027 -.058 -.085

.242" .140 .I14 .169* .111 .080 -.049 -.144 -.007 -.018 -.039 .049 .066 .014 .020 .153 -.051

.005 -.061 -.I 16 -.011 -.037 -.061

11th

12th

Grade

Grade

.284* .271" .272" .272" .128 .157 .I34 .I39 .080 .069

.197*

.051

.089 .139 ,167 .174* .221* .135 ~

.253" .206* .149 .088 .150 .178" .I 92* .lo8 .215* .166 .lo4 .182* .116 .I60 .092 ,116

~.

*p s .05. "p s .01.

EDR scores and alcohol use that increases as the respondents become older. It is important to note that the girls in the seventh and eighth grades are also vulnerable to both the use of alcohol and the threat of eating disorders. Prevention implications are that by the time children enter junior high school, clear educational efforts should be in place to assist children in avoiding these dual addictive behaviors. Eating Disorders and Drug Use

While the risk of eating disorders is associated with drug use as predicted, the association is not as consistent as that found with alcohol. First, examining the composite drug use for lifetime (.179 p < .Ol), last year (.141 p s .05), and last month (.163p 5 .Ol), we find that all three are associated with the EDR for grades seven and eight. Drug use in the last year (.178 p s .01) is correlated with eating disorders risk in the senior year, but none of the composite drug-use measures are correlated with the EDR in grades nine, ten, and eleven.

DRUG ABUSE AND EATING DISORDERS / 233

When the composite scales are broken down to their component drugs and periods of use, only a few drugs are significantly correlated with the EDR scale. For seniors, marijuana use in the last year is significantly correlated with the risk of eating disorders (.215 p s .01). While it is an illicit drug with much lower prevalence rates than alcohol, marijuana use is widespread but apparently deferred or delayed until the upper grades in high school. Of all the illicit drugs, amphetamine and inhalant use show the most consistent correlations across the grades and in the different periods of use reported. Amphetamine use in the last year is correlated with the EDR for both grades seven and eight (.261 p s .Ol), and the twelfth grade (.182 p 5 .05). Lifetime (.202 p s .Ol) and last year (.253 p s .Ol) inhalant use are correlated for both grades seven and eight and the eleventh grade. What is most striking about these patterns is that in the seventh and eighth grades, all measures of amphetamine and inhalant use are correlated with eating disorders risk. To repeat an earlier observation, vulnerability to both eating disorders and drug abuse occurs much earlier than high school. The pattern of association of eating-disorder symptoms among seventh and eighth graders with amphetamines, inhalants, all of the composite drug scales, cigarette use in the last year, and lifetime and last year alcohol use suggests that for young women, deviance may be expressed more globally without the clear definition that occurs for older adolescents. These data suggest that eating disorders may be accompanied by drug use at an early age. Eating Disorders and Other Deviant Behaviors

As suggested in the literature, eating disorders are thought to be related to other forms of deviance. Table 5 displays the correlations between a number of measures of deviance and the EDR scale. Only one other form of deviance, suicidal thoughts, is consistently related to eating disorders across all grade levels. Hypothesis 2@) predicted that eating disorders are associated with internally directed deviance, like suicidal tendencies, and is supported by the data. Hypothesis 2(a), however, predicts that eating disorders will be associated with externally directed deviance. Only one variable, vandalism, is positively correlated with the EDR, and only for grades seven and eight. While selling drugs and threatening with a gun are associated with the EDR for grade ten, they are correlated in the opposite direction than that predicted. In other words, tenth grade females who are prone to eating disorders are less likely to engage in drug sales or threatening others with a gun. Therefore, hypothesis 2(a) is not supported. Another form of deviance reported in the clinical literature related to eating disorders is sexual activity. The questionnaire included two measures of sexual activity, date rape and the number of partners with whom the respondent has had sex without the use of a condom. While the date rape question in particular does not measure sexual permissiveness or number of sexual partners, it indirectly measures vulnerability to sexual exploitation, which has been associated with

234 / WAlTSANDELLlS

Table 5. Eating Disorder Risk Scale (EDR) Correlations with Other Deviant Behaviors for Females by Grade

7-8 Deviant Behaviors

Grades

Selling drugs Theft over $50 Threaten with gun Vandalism Date rape Unprotected sex Suicidal thoughts

.06a .002 .098 .I 56* .I 13 .I 13 .293*

9th Grade

10th Grade

11th Grade

12th Grade

-.M

-.1a2* -.I41 -.168* .02a -.03a -.043 .I 90*

.053 .097

.I40 .I13 .039 .096

-.023 -.079 ,041 -.oa5 -.051

, I 96*

-.009

.I 16 -.015

.046 .21I*

.oa6

.247* .259*

*p s .05. "p s .01.

eating disorders, alcohol abuse, and drug abuse. Date rape shows no correlation with the EDR for any of the grades, but the reported number of sexual partners without condom protection is positively correlated with the EDR for twelfth graders (.274p 5.01). In their senior year, young women prone to eating disorders are more likely to have multiple sexual partners and to engage in unsafe sex. Further epidemiological research is needed to clarify the nature of the relationship between sexual permissiveness, drugs, and eating disorders. These findings suggest that for older adolescent girls, unsafe sexual activity is positively associated with attitudes characteristic of eating disorders. Eating Disorders: Family, Friends and Depression

Hypothesis 3 predicts that eating disorders are correlated with family dysfunction and peer deviance. Dysfunctional family relationships are thought to contribute to the prevalence of eating disorders. A number of questions on the instrument measured the respondent's perception of family relationships. Many of those were not significant for specific grades, but almost all of them correlated significantly at some grade level with the EDR (see Table 6). For grades seven and eight, feeling unwanted by parents was moderately correlated with the EDR (.309p 5 . Ol), while parents knowing who the respondent was with is weakly correlated with the EDR (.158p s .05). Other family variables are not significant. For the ninth grade, only one family variable was correlated-a composite family drinking and drug use problem (.245 p 5 .Ol). For tenth grade students, the amount of time spent with parents is negatively correlated with vulnerability to an eating disorder (-.191 p s .05). For this grade, which had the highest mean eating disorder risk score, the amount of time spent with parents

DRUG ABUSE AND EATING DISORDERS / 235

Table 6. Family, Friends, and Eating Disorder Risk: Correlations for Females by Grade Family and Friends

7-8 Grades

9th Grade

10th Grade

1l t h Grade

12th Grade ____

Feeling unwanted .309* Parents know where .084 Parents know who with .158* Time with parents -.084 Parents alcohol advice .023 Family drink/drug problems .096 Friends’ tobacco use .180” Friends’ alcohol use .203* .171” Friends’ drug use Friends’ suicide .238*

.145 -.024 .067 -.125 .064 .245* .052 ,098 .052 .050

-.084 .131 .074 -.191* -.056 -.044 .158 .232* .090 .198*

-.033 .268* .189* -.035 -.051 .077 .158 .295* .287* .215*

-.121 .204* .140 -.124 .176*

.150 .039 .165 .138 .155

*p s .05. “p s .01.

may impact eating disorders. For grades seven through ten, EDR scores are correlated with the respondent’s view of her relationship with her parents, and the possibility of family dysfunction as expressed through family drinking and drug use problems. For grades eleven and twelve, a different picture emerges. In the later grades, respondents are not as concerned about their parents’ relationships with them as they are about their peers, and are hence less affected by their parents’ control of them. Respondents who believe that their parents know where they are when they’re away from home are less likely to be vulnerable to an eating disorder for juniors (.268 p s .01) and seniors (.204 p s .01). Parents knowing who the respondent is with when away from home is weakly correlated for eleventh graders (.189 p 5 .05). Parents advice about alcohol use is positively correlated with the EDR for seniors; the more parents approve of beer drinking by teenagers, the more likely they are to score higher on the eating disorders risk scale (.176 p s .05).For the older high school student, perceived effectiveness of control and direction are the critical family variables that impact the likelihood of both eating disorders and drug abuse. While there is clear evidence that family variables are correlated with the risk of eating disorders scale, the perception of what one’s friends are doing exercises a more pervasive role. For the seventh- to eighth-grader, even the perception that one’s friends smoke is associated with the EDR (.180p s .01). However, friends’ alcohol and drug use is more likely correlated with the EDR across grades. The belief that one’s friends use alcohol is associated with the EDR in the seventh and eight grades (.203 p s .Ol), the tenth grade (.232p 5 .Ol), and the eleventh grade

236 / WAlTSANDELLlS

(.295p 5.01). Friends’ drug use is correlated with eating-disorders risk in both the seventh and eighth grades (.171p 5.01) and the eleventh grade (.287p 5.01). The risk of eating disorders, while not always directly associated with drug use in this study, is associated with reported involvement in peer groups that are engaging in a wide variety of addictively-oriented deviant behaviors. The key social link for the relationship between eating disorders and other forms of deviance is likely made through the peer group; for young women, the peer group appears to be the social learning group for eating disorders and other deviant behaviors. Not only are the young women at risk for eating disorders involved with drug-using peer groups, they are involved with friends who have higher levels of suicidal ideation. One question asked the respondents how many of their friends told them they were considering suicide. For many of the grades, the higher the number of friends the respondent reported thinking of suicide, the more likely she was to score higher on the eating disorder scale. As shown in Table 6, eatingdisorders risk and number of friends considering suicide are correlated for seventh- and eighth-graders (.238 p 5 .Ol), tenth-graders (.198 p 5 . Ol), and eleventh-graders (.215 p 5 .05). Addictive behaviors, such as eating disorders and drug use, are associated with psychosocial factors in addition to the social correlates of family and peer group. The most consistent correlate with the EDR, and for some grades the strongest, is depression. A depression scale was created by combining five variables: the extent of emotional pain, the extent of disappointment in self, the sense of success or failure, whether the future looks bright or dim, and whether the respondent is happy or very unhappy. As a scale, depression is correlated with the EDR as shown in Table 7. The correlations for all grades are significant, ranging from .196 (p 5 .01) for the eleventh grade to .432 (p 5 .01) for the tenth grade. As shown in Table 7, depression is consistently correlated with both alcohol and drug use over the lifetime, last year, and last month for almost all grades. Only the eleventh and twelfth grades for alcohol use in the last month are not significantly correlated with depression. The number of drinks at a sitting, a measure of heavy drinking, is also correlated with depression for all grades but the twelfth. The twelfth-grade correlates are not significant since drinking is so widespread in this grade that there is little variance. The women with depression drink as much as the women without depression; in other words, female seniors all drink a lot. When drug use is examined, seniors with depression use drugs over the lifetime (.210 p 5 .01) and the last year (.218 p 5 .01) more than those who are not depressed. Perhaps what is of greatest concern is that the seventh- and eighthgraders, the youngest in the study, are showing a pattern of correlation suggesting that depression may underlie eating disorders, drug and alcohol use, and suicide (see Table 7). The same pattern exists in the ninth grade, with some reduction in the tenth. While the focus of this study is not on suicide, depression is highly and systematically correlated with suicidal thoughts. With correlations ranging from

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Table 7. Depression: Eating Disorders Risk and Drug Use Correlations for Females by Grade

Eating disorders Lifetime drug use Last year drug use Last month drug use Lifetime alcohol use Last year alcohol use Last month alcohol use Number drinks at a sitting Suicidal thoughts

7-8 Grades

9th Grade

.335* .297* .311* .197* .323* .285* .200* .299* .619*

.323* .377* .375* .319* .279* .290* .206* .340* .632*

10th Grade .432* .125 .014 -.044 .201* .237* .250* .205* .634*

11th Grade

12th Grade

.196* .254* .245* .161 .187* .232* .089 .240* .511"

.360* .21o* .218* .160 .129 .156 .142 .loo .377*

*p s .05. "p s .01.

.634 (p s .01) for tenth-graders to .377 (p s .01) for seniors, the connection between depression and self-destructive thoughts and wishes is explicit and profound. Depression is a factor that cuts across and is associated with eating disorders, drug and alcohol abuse, and suicide.

DISCUSSION These findings reinforce the importance of examining and preventing drug abuse in the context of a range of behaviors. The young women in this study who are at greatest risk of eating disorders are depressed, considering suicide, and likely to be involved with friends who use drugs and alcohol. Whether they are involved with friendship groups that use drugs and drink, or manifest their depression and loneliness by discussing suicide with their friends, these young women are in deep pain. Their eating disorders and related behaviors may be coping mechanisms to deal with that pain. The data suggest that preventive programs in the grades preceding and including the seventh and eighth grades are needed and have the potential to be successful in teaching young women the concomitant risks of addictive behaviors, including drug abuse and eating disorders. While young women at this age are already experimenting, engaging in drug use and other troubling behaviors, it is better to teach alternatives to ameliorating pain then leaving it up to adolescents to devise their own self-destructive strategies. Counselors, parents, and others responsible for adolescents need to take a proactive stance regarding these threats to health. A pattern has emerged in the seventh and eighth grades of young women turning to a number of adaptive strategies including drugs, alcohol, and eating

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disorders, whether as a cause of or in reaction to feelings of rejection from parents, depression, and peer attachment. Two prevention strategies are suggested by the data. First, there is clearly family involvement with the eating disorders and drug abuse. Given the priority in time of family relationships, family problems are an etiological factor. The data suggest that two types of family interventions may be appropriatefor specific ages. The eleven- to thirteen-year-olds in this study are affected by their own perceptions that their parents do not want them. In other words, the emotional tenor in the home affects them. School-based interventions designed to maximize this sensitivity may relieve some of the compelling need to use eating disorder and drug-based adaptive behaviors. Older adolescents, in the junior and senior high school years, are affected by their own perceptions that their parents are aware of and exercising parental control: the greater the perceived control by parents, the lower the involvement in alcohol and drug abuse and eating disorders. Young women prone to eating disorders and drug abuse appear to need more direct parental supervision in order to feel secure enough not to use eating disorders as an adaptive response. Second, given the association between eating disorders and peers with addictive adaptations, a preventive strategy suggested by the data is the implementation of peer prevention groups that include eating disorders as a focus. The success of peer prevention with drug and alcohol abuse suggests that eating disorders, as another addictive behavior, may be prevented using a similar strategy [27]. Coupled with a strategy that is designed to intervene with parents, at least through an educational format, peer prevention may contribute to a reduction in eating disorders, alcohol abuse, and drug abuse behaviors. Finally, more research is badly needed on the relationship of depression to eating disorders, suicidal tendencies, and drug and alcohol abuse. While it seems to be the case that eating disorders are another addictive response by individuals for self-treatment of depression, we still know very little of the etiology of depression. While Bulik argues that depression may be genetically grounded, much like alcoholism [7], more research is needed on the social, familial, and peer factors that, on the one hand, contribute to depression and, on the other, mitigate against it. Nathan maintains that depression is a response to alcohol/drug abuse and, by implication, eating disorders [20]. Whether depression is an antecedent, a consequence, or both, it cuts across drug and alcohol abuse, eating disorders, and other self-destructive behaviors. By understanding these forces, drug and deviance prevention specialists will be in a better position to affect both eating disorders and drug and alcohol abuse. REFERENCES 1. J. Lacey and E. Mourelli, Bulimic Alcoholics: Some Features of a Clinical Sub-group, British Journal ofAddictiort, 81, pp. 381-395,1986.

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2. S. Fechner-Bates, Coexistence of Eating Disorders and Substance Abuse: A Spectrum of Eating Disorders Based on the Dimension of Severity, Dissertation Abstracts International, 15:2-B, p. 982,1990. 3. N. A. Slater, Connections: An Integrated Literature Analysis of Publications Examining the Relationships among Substance Abuse, Eating Disorders, Sexual Abuse and Physical Abuse, Dissertation Abstracts International, 50:8-B, p. 3679, 1990. 4. J. L. Katz, Eating Disorders: A Primer for the Substance Abuse Specialist, Journal of Substance Abuse Treatment, 73, pp. 143-149,1990. 5. M. D. Beary, J. H. Lacey, and J. Merry, Alcoholism and Eating Disorders in Women of a Fertile Age, British Journal of Addiction, 81, pp. 685-689, 1986. 6. E. Mitchell, R. Pyle, D. Eckert, and D. Hatsukami, The Influence of Prior Alcohol and Drug Abuse Problems on Bulimia Nervosa Treatment Outcome, Addictive Behaviors, 15, pp. 169-173,1990. 7. C. Bulik, Alcohol Use and Depression in Women with Bulimia, American Journal of DrugAbuse, 13:3, pp. 343-355, 1987. 8. C. Bulik, Drug and Alcohol Abuse by Bulimic Women and Their Families, American Journal of Psychiatry, 144:12, pp. 1604-1606, 1987. 9. D. Hatsukami, E. Mitchell, D. Eckert, and R. Pyle, Characteristics of Patients with Bulimia Only, Bulimia with Affective Disorder, and Bulimia with Substance Abuse Problems, Addictive Behaviors, 11, pp. 399-406, 1986. 10. P. P. Root, Treatment Failures: The Role of Sexual Victimization in Women’s Addictive Behaviors, American Journal of Ortlropsychiatry, 59:4, pp. 542-549, 1989. 11. P. Claydon, Self-Reported Alcohol, Drugs, and Eating Disorder Problems among Male and Female Collegiate Children of Alcoholics, College Health, 36, pp. 111-116, September, 1987. 12. K. Lundholm, Alcohol Use among University Females: Relationship to Eating Disordered Behavior, Addictive Behaviors, 15, pp. 169-173,1990. 13. G. Morgan and 0. Solloway, Gender Role Attitudes, Religiosity and Food Behavior: Dieting and Bulimia in College Women, Social Science Quarterly, 71:1, pp. 142-151, 1990. 14. B. Herzog, F. Borus, J. Hamburg, L. Ott, and A. Concus, Substance Abuse, Eating Disorders, and Social Impairment of Medical Students, Journal of MedicalEducation, 62, pp. 651-657, August 1987. 15. G. Timmerman, A. Wells, and S. Chen, Bulimia Nervosa and Associated Alcohol Abuse among Secondary School Students, Journal of the American Academy of Child andAdolescent Psychiatry, 29:1, pp. 118-122,1990. 16. M. S. Gold, A. M. Washton, and C. A. Dackis, Cocaine Abuse: Neurochemistry, Phenomenology, and Treatment, National Institute of Drug Abuse Research, Monograph No. 61, p. 985. 17. J. M. Jonas and M. S. Gold, Cocaine Abuse and Eating Disorder, Lancet, 123477, p. 390, 1986. 18. J. Gold, S. Gold, D. Sweeney, and A. L. C. Potash, Eating Disorders and Cocaine Abuse: A Survey of 259 Cocaine Abusers, Journal of Clinical Psychiatry, 48:2, pp. 47-50,1987. 19. D. W. Goodwin, Alcoholism and Heredity: A Review and a Hypothesis, Archives of General Psychiatry, 36, pp. 57-61,1979.

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20. P. E. Nathan, The Addictive Personality is the Behavior of the Addict, Journal of Consulting and Clinical Psychology, 56:2, pp. 183-189,1988. 21. R. Jessor and S. L. Jessor, Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth, Academic Press, New York, 1977. 22. L. Johnston, P. M. O’Malley, and J. G. Bachman, Drug Use Among American High School Students, College Students, and Other Young Adults: National Trends Through 1985, U.S. Department of Health and Human Services, U.S. Government Printing Office, Washington, D.C., 1986. 23. E. Fredlund, T. Spence, and J. Maxwell, Substance Abuse among Students in Texas Secondary Schools-I 988, Texas Commission on Alcohol and Drug Abuse, Austin, 1989. 24. M. Gamer, M. P. Olmstead, and .I.Polivy, The Eating Disorders Inventory: A Measure of Cognitive-Behavioral Dimensions of Anorexia Nervosa and Bulimia, in Anorexia Nervosa Recent Developments in Research, P. L. Darby (ed.), Alan R. Liss, New York, 1983. 25. M. Garner and P. Garfinkel, The Eating Attitudes Test: An Index of the Symptoms of Anorexia Nervosa, Psychological Medicine, 9, pp. 273-279,1979. 26. W. D. Watts and A. M. Ellis, Drug and Alcohol Use in the Eanes Independent School District: Grades 4-12 Fall 1989, Southwest Texas State University, San Marcos, 1990. 27. N. Tobler, A Meta-Analysis of 143 Adolescent Drug Prevention Programs: Quantitative Outcome Results of Program Participants Compared to a Control or a Comparison Group, Journal ofDrug Issues, 16, pp. 537-567, Fall, 1986.

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