Early Childhood Eating Behaviors and Adolescent Eating Disorders MARGARET MARCHI, PH.D., AND PATRICIA COHEN, PH.D. Abstract. Maladaptive eating patterns were traced longitudinally in a large random sample of children. Pickiness and concern with weight were more common in girls than in boys, and the prevalence of pickiness declined with age. No age or sex differences in family contention around meals nor in bingeing were shown. All problem behaviors showed significant stability over the 10-year span studied, beginning at ages 1 to 10. Certain eating and digestive problems in early childhood were predictive of symptoms of bulimia nervosa and anorexia nervosa in adolescence. Findings regarding prospective risks implicate pica and problem meals in early childhood for later bulimia nervosa; suggesting problems in self-control of eating behavior as well as eating-related family struggles. Risks in early childhood for subsequent symptoms of anorexia nervosa include picky eating and digestive problems. J. Am. Acad. Child Adolesc. Psychiatry, 1990, 29,1:112-117. Key Words: eating disorders, epidemiology, risk factors.
Only very little empirical information is available on the relationship between troublesome eating behaviors in early childhood and the subsequent development of eating disorders. No previous studies have gathered data on eating problems over a period of years prior to the development of diagnosable anorexia or bulimia nervosa. In a retrospective study, parents of 20 bulimic women were interviewed, but few recalled significant feeding problems (Mitchell et a1., 1986). Another study found that mothers of children with prepubertal anorexia nervosa reported more premorbid feeding problems than did mothers of postpubertal children with anorexia nervosa or mothers of prepubertal neurotic children (Jacobs and Isaacs, 1986). Even the prevalence of specific eating problems among young children is not well documented, although parental and professional experiences suggest that such problems are not uncommon. In older age groups, certain rates of disordered eating are so high as to lead to the contention that it is, to some extent, the norm in our society (Polivy and Herman, 1987). More than half of all adolescent girls and young women diet at least occasionally (Polivy and Herman, 1983; Rodin et a1., 1985; Polivy et a1., 1986). Disordered eating along the bulimic spectrum in adolescents and college students has been found with varying rates, depending on the definition of the problem. Between 26 and 79% of college women and between 41 and 60% of college men report binge eating of some description (Hawkins and Clement, 1980; Clarke and Palmer, 1983; Pyle et a1., 1983; Katzman et a1., 1984; Moss et a1., 1984; Hart and Ollindick, 1985).
Some kind of purging behavior has been reported in 13% of adolescents (Killen et a1., 1986). When combinations of eating behaviors are considered, rates drop dramatically. Between 1 and 5% of adolescent or college women and less than 1% of adolescent or college men binge along with self-induced vomiting or laxative abuse (Johnson et a1., 1983; Pope et a1., 1984; Pyle et a1., 1986). Two percent of adolescents have been estimated to show serious bingeing, highly restrictive dieting, emotional eating, or purging (Kagan and Squires, 1984). Incidence rates of anorexia nervosa have been variously estimated at 0.64 (Jones et a1., 1980),4.06 (Szmukler, 1985), and, most recently 7.3 cases per 100,000 adults (Lucas et a1., 1988). Bulimia nervosa has been estimated as occurring in between 1 and 5% of women and less than 1% of men (Mitchell and Eckert, 1987). Rates vary with socioeconomic status: about 4 to 5% in college women and about one-fifth as many in working women (Hart and Ollendick, 1985; Zuckerman et a1., 1986). The present study investigates problematic eating behaviors in children over a lO-year interval from early and middle childhood to late childhood and adolescence. The development and stability over a 2-year interval of eating disorders in early and middle adolescence is described. The study focuses on three major questions: (1) How common and long lasting are troublesome childhood eating behaviors? (2) What is the prevalence of eating disorders in a general population sample of young persons, ranging in age from 11 to 21? (3) Are early troublesome eating behaviors related to the later development of eating disorders? These questions are answered by data including a prospective assessment of observable eating, digestion, and meal-related behaviors by mothers, gathered by parallel questions answered over an approximately l l-year span. Data on eatingrelated behaviors, including all criteria for DSM-IlI-R diagnoses of anorexia nervosa and bulimia nervosa were gathered from both children and adolescents, ages about 10 to 20, and their mothers.
Accepted March 15, 1989. From the New York State Psychiatric Institute and Columbia University School of Public Health. This work is a product of the Children in the Community Project, supported by NIMH Grants MH36971 and MH30906 and by the New York State Office of Mental Health. The original sampling and data collection were conducted by Leonard Kogan and colleagues, to whom we are much indebted. Reprint requests to Dr. Cohen, Box 47, New York State Psychiatric Institute, 722 West 168 St., New York, NY 10032. 0890-8567/90/2901-0112$2.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
Sample As part of along-term study of psychopathology in an epidemiological sample of over 800 children, children and
112
EARLY CHILDHOOD EATING TABLE
1. 1985 Characteristics of the Study Sample
Female White Median family income Means years maternal education Urban or suburban residence Catholic Intact families School attendance: Public school Private school Post-high school None
T ABLE
Ages 1-10 Ages 9-18 Ages 11-21 (%) (%) (%)
49% 91%
$30,000 12.6 76% 54%
66% 65% 9%
13% 14%
their mothers were interviewed regarding eating behaviors , as well as the presence of specific eating disorders. Families were interviewed three times , when the children were ages 1 through 10, when they were 9 through 18, and 2.5 years later when they were predominately 12 through 20 . The sample was originally drawn as a representative random sample of families living in two upstate New York counties ; at the follow-up intervals they lived primarily in New York State but also in 26 other states, where they were traced and interviewed. A description of the original sampling procedures is provided in Kogan et al. (1977), and interviewing procedures and reinterview rates are given in Cohen and Brook (1987). Characteristics of the families correspond roughly to the general population of families in eastern states, with the full range of parental education and income and urban and rural residence (See Table 1). They are , however, somewhat more Catholic and include fewer minority families than a more general reference population , both characteristics of the areas from which they were sampled. The present sample consists of 659 children, 326 girls and 333 boys , whose families were interviewed at all three ages. Ages ranged from 1 to 10 at Time 1, with a mean of about 6 years, from 9 to 19 at Time 2, with a mean of about 14, and from 11 to 21 at Time 3, with a mean of about 16 years. Because the original interviews were based on arandom sample of families with children in the 1- to 1O-year age range , the distribution of children's ages at each assessment period is roughly rectangular.
Eating Behaviors Six eating behaviors were assessed by maternal interview at all three ages. These behaviors were (1) meals unpleasant (hardly ever, sometimes, usually); (2) struggle over eating; (3) amount eaten (not enough, right amount, too much); (4) picky eater (hardly ever, sometimes, often, every often); (5) speed of eating (slowly , average, quickly); and (6) interest in food. In order to reduce the number of variables, the six eating behaviors were factor analyzed, using a principle components analysis and varimax rotation . At each age a twofactor solution was indicated by the latent root> 1.0 criterion . The early childhood and late adolescence factor structures were closely similar. Unpleasantness at meals and struggle over eating loaded on one factor, accounting for l.Am.Acad. ChildAdolesc. Psychiatry, 29:1 ,lan.1990
2. Prevalence of Troublesome Eating Behaviors"
Problem meals Pickiness Pica (two or more nonfood substances) Digest ive problems Food avoidance Multiple weight reduction efforts Frequent binging
3.8 29 1.7
6.1 NA NA NA
2.6
2.4
28 0
27 NA
NA NA 18
NA
5.4
6.3 21
5.3
-N = 659 .
31.1 % of the variance at Time 1 and 22 .8% of the variance at Time 3. This cluster will be referred to as "problem meals." Eating little, pickiness, eating slowly, and a low interest in food loaded on a second factor , referred to as "pickiness," accounting for 30.8% of the variance at Time 1 and 28.1 % at Time 3. The factor structure in early adolescence had a less clearly defined simple structure but was generally consistent with the item grouping indicated by the other analyses. Therefore, items in these two clusters were unit weighted and summed to produce pickiness and problem meals scores. For purposes of prevalence estimates, pickiness was defined by the presence of three of the following four behaviors: does not eat enough, is often or very often choosy about food , usually eats slowly, and is usually not interested in food . Problem meals was indicated if meals were hardly ever pleasant and there were frequent struggles about eating. In Table 2 it can be seen that, so defined, pickiness was quite common at all three ages, whereas problem meals were relatively rarely characteristic of the children in the sample. Three other measures of eating-related problems were also available. Data on pica-eating dirt, clay, laundry starch, paint or plaster, or other nonfood material-was available from the maternal interviews. Data on digestive problems, including frequent vomiting, diarrhea, constipation, or stomach aches were also collected in the early childhood interview of mothers. Youths were also asked in the later adolescent interviews about foods they completely avoided. Food avoidance was defined as avoiding two or more groups of common food, such as meats, dairy products, or processed foods . In late childhood and adolescence, children and mothers were interviewed with the Diagnostic Interview Schedule for Children (DISC) (Costello et al., 1984; Cohen et al., 1987) covering DSM-III-R criteria for anorexia and bulimia nervosa . In both interviews questions were expanded somewhat from the original DISC, and in the later interview questions were included to cover DSM-Ill-R. The 30 questions included in each interview (mother and child) covered issues of overconcern with weight , trying to lose weight, using vigorous methods of weight control such as strict dieting, exercising, fasting, purging or laxative use, frequent bingeing and negat ive or unusual behavior in connection with bingeing, and feeling out of control when
113
MARCHI AND COHEN TABLE
3. Age" and Sex Differences in Problematic Eating Behaviors Age
Boys
Girls
SE
(X)
(X)
-0.043** -0.047** -0.126** -0.010
0.007 0.012 0.029 0.009
0.450 0.294 7.59 1.28
0.457 0.313 8.06** 1.28
0.040 0.065 0.163 0.050
-0.062* -0.001 0.224** 0.16 0.185**
0.026 0.008 0.085 0.092 0.062
7.35 1.25 0.06 4.90 2.66
7.87** 1.31 3.89** 9.92** 5.78**
0.163 0.044 0.456 0.494 0.334
-0.021 -0.007 0.503** -0.139 0.371** -0.017
0.025 0.008 0.151 0.090 0.109 0.010
7.29 1.27 5.05 4.90 6.3 0.297
7.99** 1.26 13.79** 9.06** 12.56** 0.362
0.138 0.042 0.846 0.504 0.610 0.057
Annual Change Ages 1-10 Pica Digestive problems Pickiness Problem meals Ages 9-18 Pickiness Problem meals Weight reduction efforts Anorexia symptoms Bulimia symptoms Ages 12-20 Pickiness Problems meals Weight reduction efforts Anorexia symptoms Bulimia symptoms Food avoidance
SE
-Analyses carried out by multiple regression of age, sex, and interactive terms on scaled measures of eating problems. Coefficients reported are B weights (unstandardized). *p < 0.05; **p < 0.01.
bingeing. In order to estimate prevalence, weight concern was defined as a positive response to more than half of the questions regarding weight concern and reduction efforts; bingeing was defined as a positive response to more than half of the questions regarding bingeing. Among 9- to 18year-olds, 18% of children showed weight reduction concerns and activities .and for 12- to 20-year-olds the figure was 21%. As shown in Table 2, the prevalence of frequent bingeing was also very similar in the two surveys, at about 5%.
Age and Sex Differences in Problematic Eating Behavior Analyses of the relationship of age and sex to problematic eating and of relationships among the measures of problematic eating were carried by multiple regression analyses for scaled measures of eating problems and by multiple logistic regression analyses for dichotomous measures such as diagnoses. As shown in Table 3, younger children in the age range of 1 to 10 were more likely to ingest nonfood substances, but pica did not differ between boys and girls. Digestive problems were also more common among younger children in the age range 1 to 10. Pickiness was more common among the younger children prior to adolescence but did not differ significantly by age in the older group. Picky eating was more common among girls than boys at all ages. There was no evidence that the prevalence of problem meals varied for boys as compared to girls or among children of different ages across the range from age 1 to age 20. By late childhood and adolescence girls were much more concerned about weight reduction than were boys, and these concerns and behaviors increased significantly with age. Bingeing did not differ for age or sex groups in either interview. 114
Counts of symptoms of anorexia and bulimia nervosa were both much more common in girls than in boys in the age range 9 toll. Although anorexic behavior did not vary across this age range, bulimic behavior gradually increased.
The Stability of Problematic Eating Behaviors The relationships between early and later eating behaviors, controlling for age and sex difference, are given in Table 4. All variables showed significant stability across the entire study span although, as expected, stabilities were higher across the 2-year span in adolescence than across the larger intervals from the early childhood assessment. Although problem meals were not as stable over time as was pickiness, later problem meals were very significantly more likely among those who had exhibited this problem earlier, possibly because the stability comes not only from the child's behavior but also from stability in the family interaction patterns.
Early Risks for Later Problematic Eating Behavior The investigation of potential early signs of later probTAIlLE
4. Stability of Problematic Eating Behaviors
Pickiness Problem meals Weight reduction Bingeing Anorexia symptoms Bulimia symptoms
Age 1~10 to 9-18
Age 1-10 to 12-20
Age 9-18 to 12-20
0.321 a 0.171
0.123 0.237
0.632 0.343 0.587 0.230 0.312 0.547
a Correlation coefficient, partialling age and sex; .all coefficients are significant p < 0.01.
J.Am.Acad. ChildAdolesc.Psychiatry, 29:1, Jan. 1990
EARLY CHILDHOOD EATING TABLE
5. Prospective Risks for Later Problematic Eating Behavior
Anorexia nervosa symptoms
B Problems age 9 to 18 Risks age 1 to 10 Digestive problems Pica Pickiness Problem meals Problems age 12 to 20 Risks age 1 to 10 Digestive problems Pica Pickiness Problem meals Risks age 8 to 18 Pickiness Problem meals Reducing
Reducing efforts
Bulimia nervosa symptoms B
SE
B
SE
0.778** -0.264 0.258* 0.453
0.295 0.474 0.132 0.427
0.278 0.505 - 0.153 0.417
0.203 0.326 0.091 0.294
0.233 0.275 -0.231 0.233
0.277 0.445 0.125 0.277
0.482 -0.250 0.241 -0.115
0.305 0.490 0.138 0.443
0.781* 1.715** -0.155 0.447
0.367 0.590 0.165 0.532
0.330 0.664 -0.758** 0.682
0.510 0.820 0.230 0.740
0.154 0.497 0.045
-0.159 0.476 0.667**
0.161 0.516 0.047
-1.50** 0.708
0.246 0.801
0.496** 0.065 0.082
-All regression coefficients are estimated with controls for age, sex, and prior manifestation of symptoms. *p < 0.05;**p < 0.01.
lematic eating behaviors was done by adding earlier measured behaviors to the equations predicting later problems from age and sex. Because of the number of tests carried out from this investigation was large, multiple regression analysis was preceded by set correlational analyses (Cohen and Cohen, 1983) of the multiple dependent variable to ensure that significant findings were beyond the chance expected level. These analyses employed the Sector module of the SYSTAT computer program (Cohen, 1989; Wilkinson, 1988). All multivariate relationships were significant (p < 0.01). Therefore, analyses proceeded to identify the specific early predictors of later problematic eating behaviors other than earlier measures of these same behaviors (see Table 5). In Table 5 it can be seen that two of the four measures from the early childhood assessment predicted levels of symptoms of anorexia nervosa in the 9- to I8-year group. Both digestive problems in early childhood and picky eating were harbingers of later elevated symptoms of anorexia nervosa. In later adolescence symptoms of bulimia nervosa were related both to early digestive problems and pica in early childhood. On the other hand, being a picky eater in early childhood was a protective factor for reducing behavior and concerns, both in the 9- to 18-year group in and the 12- to 20-year group. Presumably this effect is mediated by resulting slimness in these adolescents. Fighting with one's family over meals in early childhood was associated with elevated rates of food avoidances in adolescence. In the investigation of prospective predictors of eating problems within adolescence, pickiness was strongly predictive of symptoms of anorexia nervosa and of reducing concerns and efforts more generally. Reducing efforts were a risk factor for subsequent elevated symptoms of bulimia nervosa, as well as for the development of food fads. l.Am.Acad. Child-Adolesc.Psychiatry, 29:1 .Jan. 1990
Prevalence and Stability of Diagnoses of Anorexia and Bulimia Nervosa On the basis of youth and mother responses to the DISC, DSM-III-R diagnoses of anorexia nervosa, anorexia without amenorrhea and bulimia nervosa were made. There were no identified cases of anorexia nervosa with amenorrhea. Estimated prevalences per 1,000 youth are shown in Table 6. Because there has been a good deal of disageement about appropriate diagnostic criteria for these disorders, we also investigated risk factors for "diagnoses" defined as scores in the top 5% (about 2 standard deviations above the mean) and the anorexia and bulimia symptom scales (all DSM diagnosed cases also met this criterion). As can be seen, the rates for girls as compared to boys were much larger for all definitions and diagnoses, although the relative risk was greater for the DSM-III-R-defined diagnoses than for the severe behavior measures. Age differences were investigated for girls on the diagnoses and for both sexes on the extreme behavior measures. The increase in prevalence with age was significant only for the severe symptoms of bulimia nervosa. TABLE
6. Prevalence of Eating Disorders in Late Childhood and Adolescence Estimated Cases per 10000 Ages 9-18
Age 11-21
Boys Girls Boys Girls (N = 333) (N = 326) (N = 333) (N = 326) Anorexia Bulimia Severe anorexic behaviors Severe bulimic behaviors
3 (1) 3 (1) 39 (13)
17 (5) 9 (3) 55 (18)
3 (1) 3 (1) 36 (12)
28 (4) 25 (8) 61 (20)
15 (5)
64 (31)
15 (5)
88 (28)
-No. of cases in parentheses.
115
MARCHI AND COHEN
Prospective Risk Factors for Adolescent Eating Disorder ' Youth with extreme bulimic and anorexia behavior and those who had obtained a DSM-Il/-R diagnosis of bulimia or anorexia nervosa (without amenorrhea) were examined to determine risk factors 'among the early problematic eating behavior. For those with diagnoses the data are too sparse to constitute a statistically meaningful test. Nevertheless , two prospective risks did reach conventional levels of significance . Pica in early childhood was a risk for bulimia nervosa in the 9 to 18 year group (odds ratio 6.66, SE 2.20). And elevation on the measure of anorexic symptoms was predictive of DSM-Il/-R diagnosis of anorexia nervosa 2 years 'later. The prospective risks associated with extreme levels of bulimic and anorexic symptoms were identified by logistic regression analysis. Problem meals in early childhood were a significant risk for extreme symptoms of bulimia nervosa in the 9 to 18 year olds, and reducing concerns and behavior, bulimic symptoms, and extreme bulimic symptoms were all predictive of extreme symptoms for bulimia nervosa 2 years' later in adolescence. Extreme symptoms of anorexia nervosa in adolescence were foreshadowed by picky eating in early and later childhood, and extreme symptoms in the 12 to 20 age group were associated with elevated symptoms 2 year earlier.
Summary and Discussion In this study three questions were addressed. The first of these was whether 'e ating problems in childhood are longlasting . As shown in the stabilities of these problems over a lO-year interval , we may say that children showing problem in early childhood are definitely at increased risk of showing parallel problems in later childhood and adolescence. The second inquiry was with regard to the prevalence of these problems in a general population sample of children and adolescents. Rates of DSM-III-R diagnoses of anorexia and bulimia nervosa were shown to be somewhat smaller than might have been expected on the basis of previous estimates, and anorexia with amenorrhea was not identified at all. On the other hand, more significant numbers of children and adolescents had levels of symptoms of these disorders high enough to be of concern. And symptoms and diagnoses increased in prevalence with age and in girls as compared to boys . Perhaps the most interesting findings were those regarding risk factors for problems of bulimia and anorexia nervosa in adolescence. All four of the problems measured in early childhood were predictive of at least one problem 8 to 10 years later, net of any possible spurious relationship attributable to age or sex differences in these problems. Although rare in this population, pica in early childhood was related to elevated, extreme, and diagnosable problems of bulimia nervosa in adolescence, strongly suggesting that pica may be a symptom of a more general tendency to indiscriminant or uncontrolled eating behavior. This suggestion is also supported by the finding that picky eating in early childhood was a protective factor for bulimic symptoms in the 12- to
I16
20-year~0Ids.Fights
at mealtime in -early childhood were predictive only of extreme symptoms of bulimia nervosa. Although this relatively -weak finding needs replication in future studies even more than some .of the other findings , if confirmed it suggests that the extreme behavior characterizing diagnosable bulimia may include riot only elements of indiscriminant eating but also aspects of rebellion and problem s between parents and child. Other investigators have also implicated family environment as a factor in the etiology of eating disorders (Strober and Humphrey , 1987) , although true causal statusfor thes,evariables is far from established. We will be investigating this issue in a subsequent paper. Digestive problems in early childhood, on the other hand, were predictive of elevated symptoms of anorexia nervosa in adolescence, and picky eating even more so. These symptoms, taken together, suggest abiological substrate .predisposing the child to'refrainfrom eating. We do not have data that would indicate whether this mechanism is associated with lesser feelings of hunger, increased ability to ignore hunger, or learned patterns of food avoidance .following discomfort. A role for a general tendency to eat less is supported by the finding that weight concerns and weight reduction efforts were not a risk factor for subsequent anorexia nervosaor for elevated symptoms of anorexia. ' Food avoidances arean interesting example of an .increasingl y common .adole scent pattern;,Because these were first measured-in the third wave of interviews, they could not be used as a prospective risk factor. However,greater food avoidances were found among the adolescents with an early childhood history of problem meals . They were not related to earlier problems of the digestive system, although they may often be rationalized on such a basis by ' their adherents. They were predicted by higher levels of weight concern and reduction efforts 2 years earlier. They were also significantly related to symptoms of bulimia nervosa, both as measured contemporaneously and as measured 2 years earlier. These findings suggest that in at least some adolescents food avoidances may be used as a method of controlling their own eating. The relationship with early family fights at meals also suggests some element of rebellious control may motivate food avoidances in some adolescents. Finally, diagnosable levels of anorexia and bulima nervosa were presaged by elevated symptoms of these disorders 2 years earlier, suggesting both an insidious onset and an opportunity for secondary prevention. Future work tracing the origins and development of aberrant eating behaviors in early childhood, and particularly work that investigates alternative constitutional contributors to these behaviors, is needed .
References Clarke, M. G. & Palmer, R. L. (1983), Eating attitudes and neurotic symptoms in university students. Br. J. Psychiatry , 142:299-304. Cohen, J. (1989), SEICOR: A supplementary modeule for SYSTAT. Evanston, IL: SYSTAT , Inc . Cohen,1. & Cohen, P. (1983), Applied MultipleCorrelation/Regression for the Behavioral Sciences, Revised Edition. Hillsdale , NJ: Lawrence Erlbaum Associates. J.Am.Acad. Child Adolesc.Psychictry.Zvtl .Jan. 1990
EARLY CHILDHOOD EATING
Cohen, P. & Brook, J. S. (1987), Family factors related to the persistence of psychopathology in childhood and adolescence. Psychiatry. 50:332-345. - - Velez, C. N., Kohn, M., Schwab-Stone, M. & Johnson, 1. (1987), Child psychiatric diagnosis by computer algorithm. JAm A.cad. Child Adolesc. Psychiatry 26:631-638. Costello, A., Edelbrock, C. S., Dulcon, M. K.,Kalas, R. & Klaric, S. H. (1984), Report on the NIMH Diagnostic Interview Schedule for Children (DISC). Pittsburgh: Dept. of Psychiatry, University of Pittsburgh. Hart, K. J. & Ollindick, T. H. (1985), Prevalence of bulimia in working and university women. Am. J. Psychiatry, 142:851-854. Hawkins, 1. 1. & Clement, P. F. (1980), Development and construct validation of a self-reported measure of binge eating tendencies. Addictive Behaviors, 5:219-226. Jacobs, B. W. & Isaacs, S. (1986), Pre-pubertal anorexia nervosa. J. Child Psychol, Psychiatry ,27:237-250. Johnson, C. L., Lewis, G., Love, S., Stuckey, M., & Lewis, L. (1983), A descriptive survey of dieting and bulimic behavior in a female high school population. In: Understanding anorexia nervosa and bulimia. Columbus, OH: Rose Laboratories, pp. 14-18. Jones, D. J., Fox, M. M., Babigian, H. M. & Hutton, H.E. (1980), Epidemiology of anorexia nervosa in Monroe County, New York: 1960-1976. Psychosom, Med., 42:551-558. Kagan, D. M. & Squires,R. L. (1984), Eating disorders among adolescents. Adolescence, 19:15'-29. Katzman, M. A., Wolchik, S. A. & Braver,S. L. (1984), The prevalence of frequent binge eating and bulimia in a nonclinical college sample. International Journal of Eating Disorders, 3:53c...62. Killen, J. D., Taylor, C. B., Teich, M. J., Saylor, K.E., Maron, D. 1. & Robinson, T. N. (1986), Self-induced vomiting and laxative and diuretic use among teenagers. JAMA, 225:1447-1449. Kogan, L. S., Smith, J. & Jenkins, S. (1977), Ecological validity of indicator data as predictors of survey findings. J. Social Service Research, 1:117-132. Lucas, A. R. et at (1988), The incidence of anorexia nervosa. Mayo Clinic Proceedings, 63:433-442. Mitchell, J. E., Boutacoff, L. & Wilson D. (1986), Absence of early feeding problems among bulimic women. Am. J. Orthopsychiatry, 56:313-316.
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- - Eckert, E. D. (1987), Scope and significance of eating disorders. J. Consult. Clin. Psychol, 55:628-634. Moss, R. A., Jennings, G., McFarland, J. H. & Carter, P. (1984), Binge-eating, vomiting and weight fear in a female high school population. J. FamilyPractice, 18:313-320. Polivy, J., Garner, D. M, & Garfinkel, P. E. (1986), Causes and consequences of current preference for thin female physiques. In: Physical Appearance, Stigma, and Social Behavior. The Third Ontario Symposium in Personality and Social Psychology, ed, C. P. Herman, M. P. Zanna & E.T. Higgins, Hillsdale, NJ: Lawrence Erlbaum, pp. 89-112. - - Herman, C. P. (1983), Breaking the Diet Habit. New York: Basic Books. - - -_. (1987), Diagnosis and treatment of normal eating. J. Consult. Clin. Psychol. 55:635-644. Pope, H. F., Jr., Hudson, J. 1., Yurgelun-Todd, D. & Hudson, M. S. (1984), Prevalence of anorexia nervosa and bulimia in three student populations. International Journal of Eating Disorders, 3:4551. Pyle, R. L., Halvorson, P. A., Neuman, P. A. & Mitchell, J. E. (1986), The increasing prevalence of bulimia in freshman college students. International Journal of Eating Disorders, 5:631-647. - - Mitchell, J. E:, Eckert, E. D., Halvorson, P. A., Neurman, P. A. & Goff, G. M. (1983), The incidence of bulimia in freshman students. International Journal of Eating Disorders, 2:75-85. Rodin, J., Siberstein, L. R. & Streigel-Moore, R. H. (1985), Women and weight: a normative discontent. In: Nebraska Symposium on Motivation: Vol. 32. Psychology and Gender, ed. T. B. Senderegger. Lincoln, NE: University of Nebraska Press, pp. 267-307. Strober, M. & Humphrey, L. L. (1987), Familial contributions to the etiology and course of anorexia nervosa and bulimia, J. Consult. Clin. Psychol. 55:654-659. Szmukler, 1. I. (1985) The epidemiology of anorexia nervosa and bulimia. P. Psychiat. Res. 19:143-153. Wilkinson, L. (1988), SYSTAT IV. Evanston, IL: SYSTAT, Inc. Zuckerman, D. M., Colby, A., Ware, N. C. & Lazerson, J. S. (1986), The prevalence of bulimia among college students. Am. J. Public. Health, 76:1135-1137.
117
Only very little empirical information is available on the relationship between troublesome eating behaviors in early childhood and the subsequent development of eating disorders. No previous studies have gathered data on eating problems over a period of years prior to the development of diagnosable anorexia or bulimia nervosa. In a retrospective study, parents of 20 bulimic women were interviewed, but few recalled significant feeding problems (Mitchell et a1., 1986). Another study found that mothers of children with prepubertal anorexia nervosa reported more premorbid feeding problems than did mothers of postpubertal children with anorexia nervosa or mothers of prepubertal neurotic children (Jacobs and Isaacs, 1986). Even the prevalence of specific eating problems among young children is not well documented, although parental and professional experiences suggest that such problems are not uncommon. In older age groups, certain rates of disordered eating are so high as to lead to the contention that it is, to some extent, the norm in our society (Polivy and Herman, 1987). More than half of all adolescent girls and young women diet at least occasionally (Polivy and Herman, 1983; Rodin et a1., 1985; Polivy et a1., 1986). Disordered eating along the bulimic spectrum in adolescents and college students has been found with varying rates, depending on the definition of the problem. Between 26 and 79% of college women and between 41 and 60% of college men report binge eating of some description (Hawkins and Clement, 1980; Clarke and Palmer, 1983; Pyle et a1., 1983; Katzman et a1., 1984; Moss et a1., 1984; Hart and Ollindick, 1985).
Some kind of purging behavior has been reported in 13% of adolescents (Killen et a1., 1986). When combinations of eating behaviors are considered, rates drop dramatically. Between 1 and 5% of adolescent or college women and less than 1% of adolescent or college men binge along with self-induced vomiting or laxative abuse (Johnson et a1., 1983; Pope et a1., 1984; Pyle et a1., 1986). Two percent of adolescents have been estimated to show serious bingeing, highly restrictive dieting, emotional eating, or purging (Kagan and Squires, 1984). Incidence rates of anorexia nervosa have been variously estimated at 0.64 (Jones et a1., 1980),4.06 (Szmukler, 1985), and, most recently 7.3 cases per 100,000 adults (Lucas et a1., 1988). Bulimia nervosa has been estimated as occurring in between 1 and 5% of women and less than 1% of men (Mitchell and Eckert, 1987). Rates vary with socioeconomic status: about 4 to 5% in college women and about one-fifth as many in working women (Hart and Ollendick, 1985; Zuckerman et a1., 1986). The present study investigates problematic eating behaviors in children over a lO-year interval from early and middle childhood to late childhood and adolescence. The development and stability over a 2-year interval of eating disorders in early and middle adolescence is described. The study focuses on three major questions: (1) How common and long lasting are troublesome childhood eating behaviors? (2) What is the prevalence of eating disorders in a general population sample of young persons, ranging in age from 11 to 21? (3) Are early troublesome eating behaviors related to the later development of eating disorders? These questions are answered by data including a prospective assessment of observable eating, digestion, and meal-related behaviors by mothers, gathered by parallel questions answered over an approximately l l-year span. Data on eatingrelated behaviors, including all criteria for DSM-IlI-R diagnoses of anorexia nervosa and bulimia nervosa were gathered from both children and adolescents, ages about 10 to 20, and their mothers.
Accepted March 15, 1989. From the New York State Psychiatric Institute and Columbia University School of Public Health. This work is a product of the Children in the Community Project, supported by NIMH Grants MH36971 and MH30906 and by the New York State Office of Mental Health. The original sampling and data collection were conducted by Leonard Kogan and colleagues, to whom we are much indebted. Reprint requests to Dr. Cohen, Box 47, New York State Psychiatric Institute, 722 West 168 St., New York, NY 10032. 0890-8567/90/2901-0112$2.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
Sample As part of along-term study of psychopathology in an epidemiological sample of over 800 children, children and
112
EARLY CHILDHOOD EATING TABLE
1. 1985 Characteristics of the Study Sample
Female White Median family income Means years maternal education Urban or suburban residence Catholic Intact families School attendance: Public school Private school Post-high school None
T ABLE
Ages 1-10 Ages 9-18 Ages 11-21 (%) (%) (%)
49% 91%
$30,000 12.6 76% 54%
66% 65% 9%
13% 14%
their mothers were interviewed regarding eating behaviors , as well as the presence of specific eating disorders. Families were interviewed three times , when the children were ages 1 through 10, when they were 9 through 18, and 2.5 years later when they were predominately 12 through 20 . The sample was originally drawn as a representative random sample of families living in two upstate New York counties ; at the follow-up intervals they lived primarily in New York State but also in 26 other states, where they were traced and interviewed. A description of the original sampling procedures is provided in Kogan et al. (1977), and interviewing procedures and reinterview rates are given in Cohen and Brook (1987). Characteristics of the families correspond roughly to the general population of families in eastern states, with the full range of parental education and income and urban and rural residence (See Table 1). They are , however, somewhat more Catholic and include fewer minority families than a more general reference population , both characteristics of the areas from which they were sampled. The present sample consists of 659 children, 326 girls and 333 boys , whose families were interviewed at all three ages. Ages ranged from 1 to 10 at Time 1, with a mean of about 6 years, from 9 to 19 at Time 2, with a mean of about 14, and from 11 to 21 at Time 3, with a mean of about 16 years. Because the original interviews were based on arandom sample of families with children in the 1- to 1O-year age range , the distribution of children's ages at each assessment period is roughly rectangular.
Eating Behaviors Six eating behaviors were assessed by maternal interview at all three ages. These behaviors were (1) meals unpleasant (hardly ever, sometimes, usually); (2) struggle over eating; (3) amount eaten (not enough, right amount, too much); (4) picky eater (hardly ever, sometimes, often, every often); (5) speed of eating (slowly , average, quickly); and (6) interest in food. In order to reduce the number of variables, the six eating behaviors were factor analyzed, using a principle components analysis and varimax rotation . At each age a twofactor solution was indicated by the latent root> 1.0 criterion . The early childhood and late adolescence factor structures were closely similar. Unpleasantness at meals and struggle over eating loaded on one factor, accounting for l.Am.Acad. ChildAdolesc. Psychiatry, 29:1 ,lan.1990
2. Prevalence of Troublesome Eating Behaviors"
Problem meals Pickiness Pica (two or more nonfood substances) Digest ive problems Food avoidance Multiple weight reduction efforts Frequent binging
3.8 29 1.7
6.1 NA NA NA
2.6
2.4
28 0
27 NA
NA NA 18
NA
5.4
6.3 21
5.3
-N = 659 .
31.1 % of the variance at Time 1 and 22 .8% of the variance at Time 3. This cluster will be referred to as "problem meals." Eating little, pickiness, eating slowly, and a low interest in food loaded on a second factor , referred to as "pickiness," accounting for 30.8% of the variance at Time 1 and 28.1 % at Time 3. The factor structure in early adolescence had a less clearly defined simple structure but was generally consistent with the item grouping indicated by the other analyses. Therefore, items in these two clusters were unit weighted and summed to produce pickiness and problem meals scores. For purposes of prevalence estimates, pickiness was defined by the presence of three of the following four behaviors: does not eat enough, is often or very often choosy about food , usually eats slowly, and is usually not interested in food . Problem meals was indicated if meals were hardly ever pleasant and there were frequent struggles about eating. In Table 2 it can be seen that, so defined, pickiness was quite common at all three ages, whereas problem meals were relatively rarely characteristic of the children in the sample. Three other measures of eating-related problems were also available. Data on pica-eating dirt, clay, laundry starch, paint or plaster, or other nonfood material-was available from the maternal interviews. Data on digestive problems, including frequent vomiting, diarrhea, constipation, or stomach aches were also collected in the early childhood interview of mothers. Youths were also asked in the later adolescent interviews about foods they completely avoided. Food avoidance was defined as avoiding two or more groups of common food, such as meats, dairy products, or processed foods . In late childhood and adolescence, children and mothers were interviewed with the Diagnostic Interview Schedule for Children (DISC) (Costello et al., 1984; Cohen et al., 1987) covering DSM-III-R criteria for anorexia and bulimia nervosa . In both interviews questions were expanded somewhat from the original DISC, and in the later interview questions were included to cover DSM-Ill-R. The 30 questions included in each interview (mother and child) covered issues of overconcern with weight , trying to lose weight, using vigorous methods of weight control such as strict dieting, exercising, fasting, purging or laxative use, frequent bingeing and negat ive or unusual behavior in connection with bingeing, and feeling out of control when
113
MARCHI AND COHEN TABLE
3. Age" and Sex Differences in Problematic Eating Behaviors Age
Boys
Girls
SE
(X)
(X)
-0.043** -0.047** -0.126** -0.010
0.007 0.012 0.029 0.009
0.450 0.294 7.59 1.28
0.457 0.313 8.06** 1.28
0.040 0.065 0.163 0.050
-0.062* -0.001 0.224** 0.16 0.185**
0.026 0.008 0.085 0.092 0.062
7.35 1.25 0.06 4.90 2.66
7.87** 1.31 3.89** 9.92** 5.78**
0.163 0.044 0.456 0.494 0.334
-0.021 -0.007 0.503** -0.139 0.371** -0.017
0.025 0.008 0.151 0.090 0.109 0.010
7.29 1.27 5.05 4.90 6.3 0.297
7.99** 1.26 13.79** 9.06** 12.56** 0.362
0.138 0.042 0.846 0.504 0.610 0.057
Annual Change Ages 1-10 Pica Digestive problems Pickiness Problem meals Ages 9-18 Pickiness Problem meals Weight reduction efforts Anorexia symptoms Bulimia symptoms Ages 12-20 Pickiness Problems meals Weight reduction efforts Anorexia symptoms Bulimia symptoms Food avoidance
SE
-Analyses carried out by multiple regression of age, sex, and interactive terms on scaled measures of eating problems. Coefficients reported are B weights (unstandardized). *p < 0.05; **p < 0.01.
bingeing. In order to estimate prevalence, weight concern was defined as a positive response to more than half of the questions regarding weight concern and reduction efforts; bingeing was defined as a positive response to more than half of the questions regarding bingeing. Among 9- to 18year-olds, 18% of children showed weight reduction concerns and activities .and for 12- to 20-year-olds the figure was 21%. As shown in Table 2, the prevalence of frequent bingeing was also very similar in the two surveys, at about 5%.
Age and Sex Differences in Problematic Eating Behavior Analyses of the relationship of age and sex to problematic eating and of relationships among the measures of problematic eating were carried by multiple regression analyses for scaled measures of eating problems and by multiple logistic regression analyses for dichotomous measures such as diagnoses. As shown in Table 3, younger children in the age range of 1 to 10 were more likely to ingest nonfood substances, but pica did not differ between boys and girls. Digestive problems were also more common among younger children in the age range 1 to 10. Pickiness was more common among the younger children prior to adolescence but did not differ significantly by age in the older group. Picky eating was more common among girls than boys at all ages. There was no evidence that the prevalence of problem meals varied for boys as compared to girls or among children of different ages across the range from age 1 to age 20. By late childhood and adolescence girls were much more concerned about weight reduction than were boys, and these concerns and behaviors increased significantly with age. Bingeing did not differ for age or sex groups in either interview. 114
Counts of symptoms of anorexia and bulimia nervosa were both much more common in girls than in boys in the age range 9 toll. Although anorexic behavior did not vary across this age range, bulimic behavior gradually increased.
The Stability of Problematic Eating Behaviors The relationships between early and later eating behaviors, controlling for age and sex difference, are given in Table 4. All variables showed significant stability across the entire study span although, as expected, stabilities were higher across the 2-year span in adolescence than across the larger intervals from the early childhood assessment. Although problem meals were not as stable over time as was pickiness, later problem meals were very significantly more likely among those who had exhibited this problem earlier, possibly because the stability comes not only from the child's behavior but also from stability in the family interaction patterns.
Early Risks for Later Problematic Eating Behavior The investigation of potential early signs of later probTAIlLE
4. Stability of Problematic Eating Behaviors
Pickiness Problem meals Weight reduction Bingeing Anorexia symptoms Bulimia symptoms
Age 1~10 to 9-18
Age 1-10 to 12-20
Age 9-18 to 12-20
0.321 a 0.171
0.123 0.237
0.632 0.343 0.587 0.230 0.312 0.547
a Correlation coefficient, partialling age and sex; .all coefficients are significant p < 0.01.
J.Am.Acad. ChildAdolesc.Psychiatry, 29:1, Jan. 1990
EARLY CHILDHOOD EATING TABLE
5. Prospective Risks for Later Problematic Eating Behavior
Anorexia nervosa symptoms
B Problems age 9 to 18 Risks age 1 to 10 Digestive problems Pica Pickiness Problem meals Problems age 12 to 20 Risks age 1 to 10 Digestive problems Pica Pickiness Problem meals Risks age 8 to 18 Pickiness Problem meals Reducing
Reducing efforts
Bulimia nervosa symptoms B
SE
B
SE
0.778** -0.264 0.258* 0.453
0.295 0.474 0.132 0.427
0.278 0.505 - 0.153 0.417
0.203 0.326 0.091 0.294
0.233 0.275 -0.231 0.233
0.277 0.445 0.125 0.277
0.482 -0.250 0.241 -0.115
0.305 0.490 0.138 0.443
0.781* 1.715** -0.155 0.447
0.367 0.590 0.165 0.532
0.330 0.664 -0.758** 0.682
0.510 0.820 0.230 0.740
0.154 0.497 0.045
-0.159 0.476 0.667**
0.161 0.516 0.047
-1.50** 0.708
0.246 0.801
0.496** 0.065 0.082
-All regression coefficients are estimated with controls for age, sex, and prior manifestation of symptoms. *p < 0.05;**p < 0.01.
lematic eating behaviors was done by adding earlier measured behaviors to the equations predicting later problems from age and sex. Because of the number of tests carried out from this investigation was large, multiple regression analysis was preceded by set correlational analyses (Cohen and Cohen, 1983) of the multiple dependent variable to ensure that significant findings were beyond the chance expected level. These analyses employed the Sector module of the SYSTAT computer program (Cohen, 1989; Wilkinson, 1988). All multivariate relationships were significant (p < 0.01). Therefore, analyses proceeded to identify the specific early predictors of later problematic eating behaviors other than earlier measures of these same behaviors (see Table 5). In Table 5 it can be seen that two of the four measures from the early childhood assessment predicted levels of symptoms of anorexia nervosa in the 9- to I8-year group. Both digestive problems in early childhood and picky eating were harbingers of later elevated symptoms of anorexia nervosa. In later adolescence symptoms of bulimia nervosa were related both to early digestive problems and pica in early childhood. On the other hand, being a picky eater in early childhood was a protective factor for reducing behavior and concerns, both in the 9- to 18-year group in and the 12- to 20-year group. Presumably this effect is mediated by resulting slimness in these adolescents. Fighting with one's family over meals in early childhood was associated with elevated rates of food avoidances in adolescence. In the investigation of prospective predictors of eating problems within adolescence, pickiness was strongly predictive of symptoms of anorexia nervosa and of reducing concerns and efforts more generally. Reducing efforts were a risk factor for subsequent elevated symptoms of bulimia nervosa, as well as for the development of food fads. l.Am.Acad. Child-Adolesc.Psychiatry, 29:1 .Jan. 1990
Prevalence and Stability of Diagnoses of Anorexia and Bulimia Nervosa On the basis of youth and mother responses to the DISC, DSM-III-R diagnoses of anorexia nervosa, anorexia without amenorrhea and bulimia nervosa were made. There were no identified cases of anorexia nervosa with amenorrhea. Estimated prevalences per 1,000 youth are shown in Table 6. Because there has been a good deal of disageement about appropriate diagnostic criteria for these disorders, we also investigated risk factors for "diagnoses" defined as scores in the top 5% (about 2 standard deviations above the mean) and the anorexia and bulimia symptom scales (all DSM diagnosed cases also met this criterion). As can be seen, the rates for girls as compared to boys were much larger for all definitions and diagnoses, although the relative risk was greater for the DSM-III-R-defined diagnoses than for the severe behavior measures. Age differences were investigated for girls on the diagnoses and for both sexes on the extreme behavior measures. The increase in prevalence with age was significant only for the severe symptoms of bulimia nervosa. TABLE
6. Prevalence of Eating Disorders in Late Childhood and Adolescence Estimated Cases per 10000 Ages 9-18
Age 11-21
Boys Girls Boys Girls (N = 333) (N = 326) (N = 333) (N = 326) Anorexia Bulimia Severe anorexic behaviors Severe bulimic behaviors
3 (1) 3 (1) 39 (13)
17 (5) 9 (3) 55 (18)
3 (1) 3 (1) 36 (12)
28 (4) 25 (8) 61 (20)
15 (5)
64 (31)
15 (5)
88 (28)
-No. of cases in parentheses.
115
MARCHI AND COHEN
Prospective Risk Factors for Adolescent Eating Disorder ' Youth with extreme bulimic and anorexia behavior and those who had obtained a DSM-Il/-R diagnosis of bulimia or anorexia nervosa (without amenorrhea) were examined to determine risk factors 'among the early problematic eating behavior. For those with diagnoses the data are too sparse to constitute a statistically meaningful test. Nevertheless , two prospective risks did reach conventional levels of significance . Pica in early childhood was a risk for bulimia nervosa in the 9 to 18 year group (odds ratio 6.66, SE 2.20). And elevation on the measure of anorexic symptoms was predictive of DSM-Il/-R diagnosis of anorexia nervosa 2 years 'later. The prospective risks associated with extreme levels of bulimic and anorexic symptoms were identified by logistic regression analysis. Problem meals in early childhood were a significant risk for extreme symptoms of bulimia nervosa in the 9 to 18 year olds, and reducing concerns and behavior, bulimic symptoms, and extreme bulimic symptoms were all predictive of extreme symptoms for bulimia nervosa 2 years' later in adolescence. Extreme symptoms of anorexia nervosa in adolescence were foreshadowed by picky eating in early and later childhood, and extreme symptoms in the 12 to 20 age group were associated with elevated symptoms 2 year earlier.
Summary and Discussion In this study three questions were addressed. The first of these was whether 'e ating problems in childhood are longlasting . As shown in the stabilities of these problems over a lO-year interval , we may say that children showing problem in early childhood are definitely at increased risk of showing parallel problems in later childhood and adolescence. The second inquiry was with regard to the prevalence of these problems in a general population sample of children and adolescents. Rates of DSM-III-R diagnoses of anorexia and bulimia nervosa were shown to be somewhat smaller than might have been expected on the basis of previous estimates, and anorexia with amenorrhea was not identified at all. On the other hand, more significant numbers of children and adolescents had levels of symptoms of these disorders high enough to be of concern. And symptoms and diagnoses increased in prevalence with age and in girls as compared to boys . Perhaps the most interesting findings were those regarding risk factors for problems of bulimia and anorexia nervosa in adolescence. All four of the problems measured in early childhood were predictive of at least one problem 8 to 10 years later, net of any possible spurious relationship attributable to age or sex differences in these problems. Although rare in this population, pica in early childhood was related to elevated, extreme, and diagnosable problems of bulimia nervosa in adolescence, strongly suggesting that pica may be a symptom of a more general tendency to indiscriminant or uncontrolled eating behavior. This suggestion is also supported by the finding that picky eating in early childhood was a protective factor for bulimic symptoms in the 12- to
I16
20-year~0Ids.Fights
at mealtime in -early childhood were predictive only of extreme symptoms of bulimia nervosa. Although this relatively -weak finding needs replication in future studies even more than some .of the other findings , if confirmed it suggests that the extreme behavior characterizing diagnosable bulimia may include riot only elements of indiscriminant eating but also aspects of rebellion and problem s between parents and child. Other investigators have also implicated family environment as a factor in the etiology of eating disorders (Strober and Humphrey , 1987) , although true causal statusfor thes,evariables is far from established. We will be investigating this issue in a subsequent paper. Digestive problems in early childhood, on the other hand, were predictive of elevated symptoms of anorexia nervosa in adolescence, and picky eating even more so. These symptoms, taken together, suggest abiological substrate .predisposing the child to'refrainfrom eating. We do not have data that would indicate whether this mechanism is associated with lesser feelings of hunger, increased ability to ignore hunger, or learned patterns of food avoidance .following discomfort. A role for a general tendency to eat less is supported by the finding that weight concerns and weight reduction efforts were not a risk factor for subsequent anorexia nervosaor for elevated symptoms of anorexia. ' Food avoidances arean interesting example of an .increasingl y common .adole scent pattern;,Because these were first measured-in the third wave of interviews, they could not be used as a prospective risk factor. However,greater food avoidances were found among the adolescents with an early childhood history of problem meals . They were not related to earlier problems of the digestive system, although they may often be rationalized on such a basis by ' their adherents. They were predicted by higher levels of weight concern and reduction efforts 2 years earlier. They were also significantly related to symptoms of bulimia nervosa, both as measured contemporaneously and as measured 2 years earlier. These findings suggest that in at least some adolescents food avoidances may be used as a method of controlling their own eating. The relationship with early family fights at meals also suggests some element of rebellious control may motivate food avoidances in some adolescents. Finally, diagnosable levels of anorexia and bulima nervosa were presaged by elevated symptoms of these disorders 2 years earlier, suggesting both an insidious onset and an opportunity for secondary prevention. Future work tracing the origins and development of aberrant eating behaviors in early childhood, and particularly work that investigates alternative constitutional contributors to these behaviors, is needed .
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EARLY CHILDHOOD EATING
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