WONDERLICH, STEPHEN A. Ph.D.; CROSBY, ROSS D. Ph.D.; MITCHELL, JAMES E. M.D.; ROBERTS, JENNIFER A. M.S.; HASELTINE, BETH M.S.; DeMUTH, GAIL R.N.; THOMPSON, KEVIN M. Ph.D.
Objective: To test the hypothesis that childhood sexual abuse increases the risk of eating disturbance in children.
Method: Data obtained from 20 sexually abused children were compared with data obtained from 20 nonabused control children. All subjects were female and between the ages of 10 and 15 years. Subjects completed a battery of tests assessing eating disorder behaviors, body image concern, and childhood trauma history.
Results: Comparison of the 2 groups revealed that the abused children had higher levels of weight dissatisfaction and purging and dieting behavior. Furthermore, abused children reported eating less than control children when they felt emotionally upset. Abused children were less likely than control children to exhibit perfectionistic tendencies, but more likely to desire thinner body types.
Conclusions: This is the first controlled study to examine the relationship between childhood sexual abuse and eating disturbance which relied on children as subjects. The results support previous findings with adult subjects which indicate that a history of childhood sexual abuse is associated with weight and body dissatisfaction, along with purging and dietary restriction.
The relationship between childhood sexual abuse and eating disorders is a topic that has generated considerable research in the past decade. Although there have been inconsistencies in the results (e.g., Kinzl et al., 1994; Pope et al., 1994), studies of individuals with eating disorders (e.g., Steiger and Zanko, 1990), abuse victims (e.g., Pribor and Dinwiddie, 1992; Wonderlich et al., 1996a), community-based samples (e.g., Bushnell et al., 1992; Garfinkel et al., 1995), and nationally representative samples (e.g., Dansky et al., 1997; Wonderlich et al., 1996b) have all found significant associations between a history of childhood sexual abuse and disturbances in eating. In the most recent and comprehensive review of this literature, the authors concluded that childhood sexual abuse represents a general risk factor for bulimia nervosa, particularly when high degrees of psychiatric comorbidity are present, but its relationship to anorexia nervosa remains unsubstantiated (Wonderlich et al., 1997). Although the relationship of eating disturbances and other forms of child maltreatment has not received the amount of empirical attention seen in the childhood sexual abuse literature, there is evidence that eating disturbances may be linked to a history of childhood physical abuse (e.g., Rorty et al., 1994) and emotional abuse (e.g., Kent et al., 1999).
Although these findings provide evidence that childhood sexual abuse may indeed be a risk factor for eating disorders, studies are frequently limited by measurement strategies for both eating disorders and sexual abuse, as well as inadequate research designs. Also, all of these studies have been conducted with adults who are asked to recall histories of childhood sexual abuse and eating behavior. Such a design leaves open the possibility of a retrospective recall bias which could limit accuracy of measurement. Several recent studies have attempted to minimize the length of the recall interval by studying adolescent samples (e.g., Perkins and Luster, 1999; Thompson et al., in press), but these survey-based studies may also be biased by retrospective recall and limited depth of assessment characteristic of large-scale surveys.
To overcome these limitations, prospective longitudinal designs with abused and nonabused children are needed. Empirical studies that have used abused children as subjects have consistently revealed elevated rates of psychopathology and behavioral problems, including anxiety disturbances, posttraumatic stress disorder, sexualized behaviors, and poor self-esteem (Green, 1993; Kendall-Tackett et al., 1993). Furthermore, an increasing number of longitudinal studies of sexually abused children have attempted to identify change in psychopathology across time, as well as mediators and moderators of such change (e.g., Cohen and Mannarino, 1996; Mannarino and Cohen, 1996; Tebbutt et al., 1997). These studies suggest that the child's cognitive construal of the abuse situation, locus of control, parental reaction, and family functioning may all have an impact on the child's adjustment following the abuse. To date, no empirical studies have used children as subjects in a controlled, prospective, longitudinal design to examine the relationship between disturbances in eating and a history of child maltreatment, although one uncontrolled study revealed high rates of eating disturbance in maltreated children (Brewerton et al., 1998).
The present study attempts to fill this deficit by assessing eating disturbance in a group of sexually abused children and control children. It represents the first wave in a longitudinal study that will attempt to identify possible mediators and moderators of the relationship between childhood sexual abuse and disturbances in eating. In this study, we compared sexually abused children with nonabused children on a variety of measures of eating disturbance. The objective of the study was to examine the association between childhood sexual abuse and eating disturbances. The following hypotheses were tested:
1. Sexually abused girls would report more body image disturbance and eating disorder behaviors than non-abused girls.
2. Childhood sexual abuse would interact with other forms of child abuse (i.e., physical abuse, emotional abuse) such that children who experience multiple forms of abuse would show greater levels of eating disturbance than children who were sexually abused only.
Two groups of girls who were 10 to 15 years old participated in the study. The sexually abused girls (n = 20) were identified by therapists in a local specialized treatment center for abused children. These children were referred by county social workers or law enforcement officials who determined that there was sufficient evidence to suggest that the children had been sexually abused. Given that the children were referred on the basis of a history of alleged sexual abuse, and not on the presence of any form of particular psychopathology, referral bias which could spuriously support the hypotheses of the study should be minimal. Furthermore, therapists who referred the children to the study were not aware of any specific hypotheses regarding eating disorders in the study. They were informed that the study was examining a broad range of behavior in children who had experienced different types of life trauma, thus obscuring the explicit hypotheses in the study. There was no particular recruitment strategy used which would have obviously resulted in a sample that did not represent the general clinic population.
The definition of sexual abuse for inclusion in the study included either intrafamilial sexual activity that was unwanted or that involved a family member 5 or more years older than the subject, or extrafamilial sexual activity that was unwanted or that involved another person 5 or more years older than the subject. At the time of the study, all girls in the sexually abused group were receiving treatment.
The control group (n = 20) was matched to the abused girls on age and parent level of education and recruited through local school newsletters sent to parents. Control subjects were told that the project involved the study of a broad range of behaviors in children who have experienced various life circumstances. They were explicitly told, and this was reviewed with their parents, that they were invited to take part in the study because they had not been victims of childhood sexual, physical, or emotional abuse. If these criteria were met, control subjects were scheduled for assessments.
Each 1-year age interval between 10 and 15 was characterized by equal numbers of control and abused subjects. Racial composition was 92.5% white, 5% African American, and 2.5% Asian. Control subjects had a higher annual household income than abused subjects (Wilcoxon Z = -2.90, p = .004), although the groups did not differ in parental education (Wilcoxon Z = -1.18, p = .240).
Thirty-five percent of the abused girls had been sexually abused on only one occasion, 65% on more than one occasion. Five percent had been sexually abused before they were 6 years of age, 65% between the ages of 6 and 12, and 30% between the ages of 13 and 15. Thirty percent of abuse incidents involved sexual penetration, 85% involved physical sexual contact, and 15% of cases involved some type of force or threat of force. Perpetrators were all male and most commonly a friend/acquaintance (25%), father (20%), stepfather (20%), live-in relative (10%), or other (25%).
Childhood Trauma Questionnaire. The Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 1997) is a 28-item screening instrument that assesses self-reported experiences of abuse and neglect in childhood and adolescence. Respondents rate each item on a 5-point Likert scale with response options ranging from "never true" to "very often true." The CTQ has been validated with both adult and adolescent populations and has demonstrated adequate convergent and discriminant validity (Bernstein et al., 1997; D. Berstein, J.A. Stein, E. Walker et al., unpublished, 1997).
Body Rating Scales for Adolescents. The Body Rating Scales for Adolescents (BRS) (Sherman et. al., 1995) present to subjects a series of figures of various body shapes and sizes; subjects are asked to choose the one that best matches how they think they look and how they would like to look. In addition, subjects are asked to choose the figure that matches how they feel most of the time and the figure that they think "guys" would find most attractive. The BRS have excellent psychometric properties and a high degree of face validity (Sherman et al., 1995).
McKnight Risk Factor Survey. The McKnight Risk Factor Survey (MRFS-III) (Shisslak et. al., 1999) is a 103-item self-report instrument that has been used to identify risk and protective factors for the development of eating disturbances in preadolescent and adolescent girls. The MRFS-III has demonstrated adequate test-retest reliability, internal consistency, and convergent validity (Shisslak et al., 1999). An updated version containing minor changes of this measure, the MRFS-IV, was obtained from the authors and the following scales were included: Body Appearance, Binge, Eat Less When Upset, Eat More When Upset, Media Modeling, Weight/Shape Concern, Risk for Eating Disorder, Perfectionism, and Weight Control.
Kids' Eating Disorders Survey. The Kids' Eating Disorders Survey (KEDS) (Childress et al., 1993a,b) is a 14-item self-report questionnaire that is considered an appropriate screening instrument regarding identification and prevention of eating disorders. The KEDS assesses the presence of eating disorder symptoms on 2 subscales: Weight Dissatisfaction and Purging/Restricting Behavior. It has shown good internal consistency and test-retest reliability (Childress et al., 1993a,b).
Therapists at the childhood abuse treatment center were asked to review their caseloads and provide a written description of the study to children and families who met our inclusion criteria, based solely on the presence of a history of childhood sexual abuse and appropriate gender and age variables. All children who fit these criteria were equally eligible for inclusion in the study, as long as they did not meet our exclusion criteria of active psychosis or inability to read. We had determined before recruitment started that we would attempt to identify 20 child subjects from the clinic, and this took approximately 6 months. One abused child was unable to take part in the study because of current involvement in litigation, and all of the matched control children contacted agreed to be in the study.
At the time of the assessment, the study was explained to each subject and her parent in detail. After consent of both parent and child was obtained, research staff explained to the subject in detail how to complete the child measures. Girls in the control group were given the same instructions. All subjects completed the questionnaires in a room by themselves with research staff made available for questions. Completion of the questionnaires took approximately 1 1/2 hours; subjects were paid $75.00 for their participation.
Demographic characteristics of children and families were compared between abused and control groups using paired t tests for continuous measures, Wilcoxon nonparametric tests for ordinal measures, and [chi]2 tests for categorical measures. Because of significant differences in family income, analysis of covariance controlling for income was used to compare groups on eating disturbance measures, with income dichotomized into 2 categories (<$26,000 versus >=$26,000). Finally, hierarchical multiple regression analysis was used to evaluate whether emotional or physical abuse moderated the relationship between abuse status and eating disturbance. Specifically, using the KEDS Weight Dissatisfaction and Purging/Restricting Behavior scores as the dependent variables, main effects for group and emotional (or physical) abuse (from the CTQ) were entered on the first step. The interaction between group and emotional (or physical) abuse was entered on the second step.
Table 1 presents demographic characteristics by group. Groups were comparable in age, ethnicity, parent education, and parent employment. However, the control group reported a significantly higher family income than the abused group. On this basis, the decision was made to control for income on subsequent analysis of eating disturbance.
Also, the child abuse scores on the CTQ supported the separation of the groups based on abuse histories. The control group scored significantly lower than the sexual abuse group on sexual abuse, physical abuse, and emotional abuse (t values = 2.7-10.24, p values = .02-.0001). Furthermore, review of the control subjects' scores on the CTQ revealed that none of the controls met a clinical cutoff score for history of sexual abuse, 95% failed to meet the cutoff for physical abuse, and 90% failed to meet the cutoff for emotional abuse.
Table 2 presents unadjusted means and standard deviations for groups on measures of eating disturbance. Even with control for differences in family income, abused children reported significantly higher levels of Weight Dissatisfaction (KEDS); reported eating less when bored, upset, or trying to feel better about themselves (MRFS-IV); scored significantly lower on Perfectionism (MRFS-IV); and chose a significantly thinner figure regarding how they would like to look (BRS). Also, there were 3 nearly significant tests which indicated that abused children tend to engage in more purging and restriction of food and attempts to control weight (KEDS) and are at risk of developing eating disorders (MRFS-IV). There were no differences between the groups in height (t = -1.079, df = 19, p = .29), weight (t = 0.489, df = 19, p = .631), or onset of menstruation (Wilcoxon Z = 0.414).
Weight Dissatisfaction. The potential moderating effects of physical abuse on weight dissatisfaction were evaluated using hierarchical multiple regression analysis. Main effects for group and physical abuse were entered on step 1 (R2 = 0.267, F = 6.7, df = 2,37, p = .003). Group status (B = 0.972, t = 2.1, p = .036) but not physical abuse (B = 0.103, t = 1.8, p = .078) contributed significantly to the model. When the physical abuse-by-group interaction was entered on step 2, the term did not contribute significantly to the model (R2change = 0.034, F = 1.8, df = 1,36, p = .192).
Similar analyses were conducted for emotional abuse. As before, the step 1 (main effects) model was a significant (R2 = 0.355, F = 10.2, df = 2,37, p < .001) predictor of weight dissatisfaction. In contrast to the previous analysis, however, emotional abuse (B = 0.127, t = 2.96, p = .005) but not group (B = 0.711, t = 1.65, p = .107) contributed significantly to the model. However, the emotional abuse-by-group interaction did not contribute significantly to the model at step 2 (R2change = 0.003, F = 0.1, df = 1,36, p = .709).
Purging Restriction. Analyses comparable with those described above were performed with the KEDS Purging/Restricting Behavior scale as the dependent variable. Main effects for group and physical abuse were entered on step 1 (R2 = 0.286, F = 7.4, df = 2,37, p = .002). Physical abuse (B = 0.149, t = 2.9, p = .006) but not group (B = 0.423, t = 1.1, p = .294) contributed significantly to the model. When the physical abuse-by-group interaction was entered on step 2, the term did not contribute significantly to the model (R2change = 0.065, F = 3.6, df = 1,36, p = .065).
When emotional abuse was considered as the moderator variable, emotional abuse (B = 0.111, t = 2.7, p = .011) but not group (B = 0.385, t = 0.9, p = .361) contributed significantly to the step 1 model (R2 = 0.261, F = 6.5, df = 2,37, p = .004). The emotional abuse-by-group interaction contributed marginally (R2change = 0.073, F = 3.9, df = 1,36, p = .055) to the model at step 2.
This study revealed that sexually abused children were more likely than controls to express weight dissatisfaction, food restriction when emotionally upset, pursuit of thin body ideals, and heightened purging behavior. Also, the abused children expressed less perfectionism than the control group. These findings are consistent with evidence in studies of adult childhood sexual abuse victims which suggest that childhood sexual abuse is associated with eating disorder behaviors. The reliance on preadolescent and early adolescent subjects in this study reduces the risk of problems associated with studies using retrospective recall of both eating disorder behaviors and sexual abuse histories. In addition, the present findings cannot be easily accounted for by "effort after meaning" criticisms (e.g., Pope and Hudson, 1992) in which spurious abuse-eating disturbance associations are created when individuals with eating disorders search their past lives for some explanation for their disorder, even if the explanation may be implausible.
Causal pathways for the apparent association between childhood sexual abuse and eating disturbances are currently unclear. Sexually abused children may develop broad cognitive patterns of low self-esteem (Briere, 1992) which could include body dissatisfaction (Wonderlich et al., 1996a). It is plausible that sexually abused children may then be more likely to diet in an effort to overcome dissatisfaction with body size, shape, and weight. However, the present finding of lower perfectionism scores in the abused group is not consistent with this idea, although more thorough mediational analyses would be needed to address this issue.
Another less cognitively based conceptualization is that childhood sexual abuse results in pervasive psychobiological dysregulation, which increases the risk of a variety of forms of psychopathology, including eating disorders. The idea that childhood trauma produces marked changes in psychobiological processes (e.g., Field, 1985; Kraemer, 1992; Putnam and Trickett, 1997; vanderKolk, 1987) and neurotransmitter functioning (Charney et al., 1993; Post et al., 1994; Putnam and Trickett, 1997; vanderKolk, 1987), which are associated with eating behavior (Brewerton, 1995), has previously been considered (i.e., Wonderlich et al., 1997). Also, research on nonhuman primates indicates that following early traumatic experiences, rhesus monkeys display dysregulated eating episodes but do not gain commensurate body weight, suggesting both feeding dysregulation and metabolic changes may be associated with trauma (Miller et al., 1971). In human children, more complex causal pathways may be precipitated by trauma, which include a variety of psychopathological states (e.g., affective, dissociative) and serve to mediate the relationship between the traumatic experience and later disturbed eating. The idea that certain eating disorder symptoms may provide relief from intolerable psychological states is well substantiated (e.g., Heatherton and Baumeister, 1991; Meyer et al., 1998) and may help explain the trauma-eating disturbance association.
Although other studies have suggested that multiple forms of child abuse are particularly associated with disturbances in eating (Rorty et al., 1994), our prediction that sexually abused children with high levels of physical or emotional abuse would show the highest levels of eating disturbance was not strongly supported. There was modest support for the idea that the simultaneous presence of high levels of emotional abuse and sexual abuse predicts higher levels of purging and restricting behavior. Our results also suggest, however, that both emotional and physical abuse may be significant predictors of eating disturbance, independent of their relationship to childhood sexual abuse. Future studies with larger sample sizes may clarify the complex relationship between various forms of abuse and subsequent disturbances in eating.
This study is limited by several methodological factors, including the absence of rigorous diagnostic assessments of eating disturbance. However, the self-report measures of eating disturbance which were used have demonstrated adequate psychometric properties in standardization samples and there is no obvious reason to believe that they would prove less adequate among abused children. Another limitation is that all the abused children were currently receiving treatment. Although the assessment of abused children who are not receiving treatment would remove potential effects of clinical intervention, it is both difficult and possibly unethical to recruit untreated child victims for study and not offer treatment. In addition, the sample size is relatively small and generalizability of the findings is thus somewhat limited. Finally, we cannot definitively disentangle the effect of the everyday and ongoing home environment from the effects of the sexual abuse in terms of the impact on eating behavior. This issue has been addressed in the general child trauma literature (Briere and Elliot, 1993), and recent evidence with adolescents suggests that even with control for family functioning variables, childhood sexual abuse displays a significant association to disturbances in eating (Thompson et al., in press).
These findings imply that assessment of childhood traumatic experiences should be included in the comprehensive examination of children with eating disorders. Furthermore, clinicians working with abused children may be able to identify evidence of bulimic behavior, body image disturbance, or severe dieting behavior, which should then be considered as a target for possible intervention. Furthermore, continued study of the association between childhood trauma and eating disturbances may reveal causal mechanisms which increase our understanding of the clinical needs of these children. Possible mediators of this relationship include posttraumatic stress disorder, impulsivity, drug and alcohol use, or significant mood disorders. Studies of adult women with eating disorders suggest that such comorbidity is common, and its early detection in abused children may enhance treatment.
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Key Words: childhood sexual abuse; eating disorders