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A risk model for disordered eating in late elementary school boys

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A risk model for disordered eating in late elementary school boys
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  A Risk Model for Disordered Eating in Late Elementary SchoolBoys Carolyn M. Pearson , Jessica L. Combs , and Gregory T. Smith University of Kentucky Abstract The authors tested the following risk model for disordered eating in late elementary school-ageboys: Pubertal status is associated with increases in negative urgency, i.e., the tendency to actrashly when distressed; high levels of negative urgency then influence binge eating throughpsychosocial learning; and binge eating influences purging. A sample of 908 fifth grade boyscompleted questionnaire measures of puberty, negative urgency, dieting/thinness and eatingexpectancies, and eating pathology. Eating disorder symptoms were present in these young boys:10% reported binge eating and 4.2% reported purging through self-induced vomiting. Eachhypothesis in the risk model was supported. Boys this young do in fact engage in the maladaptivebehaviors of binge eating and purging; it is crucial to develop explanatory risk models for thisgroup. To this end, it appears that characteristics of boys, including their pubertal status,personalities, and psychosocial learning help identify boys at risk. Keywords eating disorders; youth; young boys; risk factors; pubertyResearchers know very little about binge eating and purging in late elementary school-ageboys (Keel, Fulkerson, & Leon, 1997; McCabe & Vincent, 2003). Perhaps because boysengage in disordered eating behaviors at a lower rate than girls (Cotrufo, Cella, Cremato, &Labella, 2007; Leon, Fulkerson, Perry, & Early-Zald, 1995; McCabe & Vincent, 2003),there have been fewer investigations into the process by which boys develop thesebehaviors. This paper introduces a model of risk for binge eating and purging that applies toboys and reports on a cross-sectional test of the model in a sample of 908 5 th  grade boys.The model integrates pubertal onset, personality, and psychosocial learning processes toconcurrently predict binge eater status and purger status in this sample of boys. Following abrief review of the existing literature on eating disordered behaviors in young boys, weintroduce our model, its basis in the literature, and our empirical test of it. Young Boys and Eating Disordered Behavior In order to study boys very early in a possible risk process, we focused on boys in their lastyear of elementary school (5 th  grade). Some of them had experienced the onset of puberty, Correspondence concerning this article can be addressed to Carolyn M. Pearson at the Department of Psychology; University of Kentucky; Lexington, KY; USA; 40506-0044, cpearson824@gmail.com.. Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting,fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version. The AmericanPsychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscriptversion, any version derived from this manuscript by NIH, or other third parties. The published version is available atwww.apa.org/pubs/journals/adb NIH Public Access Author Manuscript Psychol Addict Behav . Author manuscript; available in PMC 2011 December 1. Published in final edited form as: Psychol Addict Behav  . 2010 December ; 24(4): 696704. doi:10.1037/a0020358. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    but none were yet in middle school. The frequencies of binge eating and purging in boysprior to middle school are not known. There is evidence that 25% of 14 year old boys 1  in anAustralian study reported having at least occasionally engaged in one or more extrememethods of weight loss (Maude, Wertheim, Paxton, Gibbons, & Szmukler, 1993), and inother Australian and U.S. samples, approximately 33% of adolescent boys report wanting aleaner body (Drewnowski & Yee, 1987;McCabe & Ricciardelli, 2001). Thus, there is someevidence of eating disordered behaviors and cognitions in adolescent boys. A Risk Model for Binge Eating and Purging in Late Elementary School-Age BoysCommon risk factors for boys and girls?— One important question is whether risk factors identified in girls are also operative in boys. In the few studies that have directlycompared risk factors across gender, findings have suggested they may be. Scores onnumerous measures of risk and symptom expression have proved invariant across gender(Boerner, Spillane, Anderson, & Smith, 2004; Spillane, Boener, Anderson, & Smith, 2004).Importantly, correlations among risk factors, and between risk factors and symptom reports,were also invariant across gender (Boerner et al., 2004; Spillane et al., 2004). Althoughthese studies do not pertain to children as young as those in the current study, the findingsdo suggest the value of investigating similar risk factors for both sexes. Thus, we proposethat a risk model recently developed for girls (Combs & Smith, 2009) and recently validatedon late elementary school-age girls (Combs, Pearson, & Smith, in press-a) applies to youngboys as well. The model includes an integration of puberty, personality and psychosociallearning influences on risk. We next present each component of the model, the integratedmodel, and the hypotheses for the current study. 2 Puberty: Past inconsistent findings and a proposed mechanism of influence— Some studies have failed to find an association between pubertal onset and increased risk foreating disordered behavior in boys (Keel et al., 1997; Leon et al., 1995; McCabe &Ricciardelli, 2003). Some authors, noting that puberty in boys is associated with weight gainand an increase in lean muscle mass, have suggested that pubertal changes tend to bringboys' bodies closer to the socially reinforced ideal (McCabe & Vincent, 2003), with theimplication that puberty may provide a protective function (Cotrufo et al. 2007; Decastro &Goldstein, 1995).However, pubertal development has been found to predict subsequent problem eating inadolescent boys (Leon, Fulkerson, Perry, Keel, & Klump, 1999) and cross-sectional researchhas found that both purging rates and attempts to lose weight were positively associated withpubertal development (Field, Camargo, Taylor, Berkey, Frazier, Gillman, & Colditz, 1999;O'Dea & Abraham, 1999). Thus, puberty may be associated with increased risk in boys.Consistent with this possibility, pubertal onset is associated with increased levels of emotional volatility and negative affect (Allen & Matthews, 1997; Spear, 2000), and alsowith an increase in rash or impulsive action undertaken when emotional (Luna & Sweeney,2004; Steinberg, 2004). This change can be understood to reflect a pubertal-based increasein the personality trait of negative urgency, which is the tendency to act rashly whendistressed (Cyders & Smith, 2008; Whiteside & Lynam, 2001). We believe that this 1Fourteen year old children in the U.S. are most often in middle school; in Australia, they are in secondary school, which goes fromyear 7 through year 12 of education (typically, this spans the period from age 12 through age 18).2The focus of this investigation was on classic symptoms of disordered eating: binge eating and purging. It is certainly possible thatyoung boys are at risk for different forms of eating or body image dysfunction, such as engaging in extreme behaviors to developmore muscular physiques, and this possibility should be investigated empirically. However, such an investigation was beyond thescope of the current study.Pearson et al.Page 2 Psychol Addict Behav . Author manuscript; available in PMC 2011 December 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    developmental increase in negative urgency increases eating disorder risk, through amechanism we will describe below. Personality risk: negative urgency— A recent meta-analysis comparing differentpersonality dispositions to rash action found that negative urgency was related concurrentlyto bulimia nervosa symptoms in women ( r   = .40): all other impulsivity-related traits hadvery minimal relations with symptom levels (Fischer, Smith, & Cyders, 2008), as doesglobal negative affect (Keel, Klump, Leon, & Fulkerson, 1998; Stice, 2002). Change innegative urgency levels is associated with change in bulimia nervosa symptoms (Anestis,Selby, & Joiner, 2007), and negative urgency at the start of college interacted with being avictim of sexual assault to predict subsequent bulimia nervosa symptoms (Fischer, Stojek, &Collins, 2009). In elementary school-age girls, negative urgency concurrently predicts bothbinge eating and purging behavior (Combs et al., in press-a). We thus anticipated thatnegative urgency would also concurrently predict binge eating and purging behavior in 5 th grade boys. Psychosocial learning risk: Expectancies for reinforcement from eating andfrom dieting/thinness— Expectancies are learned anticipations of the likelyconsequences of behavioral choices. They are understood to represent summaries of individuals' learning histories, and are formed based on the multitude of direct and vicariouslearning experiences that individuals undergo. The expectancies one forms then influenceone's future behavioral choices: one tends to choose behaviors from which one expectsrewards and avoid behaviors for which one expects punishment.Individual differences in the expectancy that eating helps one manage negative mood statesand individual differences in the expectancy for overgeneralized life improvement fromdieting and thinness predicted the onset of both binge eating and purging in adolescent girls(Combs, Smith, Flory, Simmons, & Hill, in press-b; Smith, Simmons, Flory, Annus, & Hill,2007). Manipulation of dieting/thinness expectancies reduced eating disorder symptoms incollege women and high school girls (Annus, Smith, & Masters, 2008). It thus appears thatexpectancies may play a causal role in eating disorder symptoms for women. Boerner et al.(2004) found similar associations between expectancies and symptomatology in adolescentboys. Therefore, we anticipated that both types of expectancies would be associated withbinge eating and purging in 5 th  grade boys.Although many past studies have documented linear relations between dieting/thinnessexpectancies and symptom reports (Holhstein, Smith, & Atlas, 1998; Simmons, Smith, &Hill, 2002; Smith et al., 2007; Stice & Whitenton, 2002), Combs et al. (in press-a, in press-b) demonstrated that the relationship between dieting/thinness expectancies and symptomsconsists of a combination of linear and quadratic trends: variation in low and moderatelevels of dieting/thinness expectancy endorsement are unrelated to symptom levels, butvariation within high levels of expectancy endorsement are strongly associated withsymptom reports. It appears that only relatively extreme endorsement of expectancies forlife improvement from dieting/thinness is associated with dysfunction; moderateendorsement of such expectancies may reflect an accurate perception of reality. We believethe same will be true among 5 th  grade boys. Integrating personality and psychosocial learning: the AcquiredPreparedness (AP) model of eating disorder risk extended— In general, APmodels hold that individual differences in personality contribute to individual differences inlearning: specifically, as a function of individual differences in personality, individuals varyin the experiences to which they expose themselves, how they react to those experiences,and what they learn from the experiences (Caspi, 1993; Caspi & Roberts, 2001; Combs et Pearson et al.Page 3 Psychol Addict Behav . Author manuscript; available in PMC 2011 December 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    al., in press-a, in press-b; Cyders & Smith, 2008; Settles, Cyders, & Smith, in press; Smith& Anderson, 2001; Smith, Williams, Cyders, & Kelley, 2006).Applied to eating disorders, the AP model is as follows (Combs & Smith, 2009). Boys highin negative urgency are disposed to act rashly when experiencing distress. Many rashactions, including binge eating, tend to provide relief from distress through both thereinforcement they provide (Agras & Telch, 1998) and through distraction from the srcinaldistress (Heatherton & Baumeister, 1991). In fact, males often report feeling happy after abinge (Leon, Carroll, Chernyk, & Finn, 1985). Thus, the binge eating is reinforced, and,over time, high-urgency boys develop expectancies that binge eating provides the reward of distress relief. This expectancy, in turn, increases the likelihood of future binge eating. Theterm acquired preparedness refers to the concept that, as a function of individual differencesin personality, individuals are differentially prepared to acquire high risk expectancies.The risk model includes two other components in addition to the AP process. First, manyboys do wish for leaner bodies (McCabe & Ricciardelli, 2001). Accordingly, purgingbehavior in 5 th  grade boys should be predictable from binge eating and from expectanciesfor reinforcement from dieting and thinness. Purging behavior is predictable from bingeeating because one is most likely to purge when one has ingested excessive amounts of food,and purging is predictable from dieting/thinness expectancies because purging can be seenas a way to achieve or maintain thinness.Second, we anticipated that pubertal status would increase the likelihood of binge eating andpurging in this population. We propose that pubertal onset is associated with negativeurgency, due to the increased emotionality and emotion-driven rash action characteristic of postpubertal individuals (Luna & Sweeney, 2004; Steinberg, 2004); hence, pubertyindirectly leads to increases in eating expectancies, and thus binge eating and purging.Figure 1 presents a schematic of this risk model.The model describes a temporal sequence of causal processes that increase risk for bingeeating and purging behavior in young boys. The current study is a cross-sectional test of whether the associations specified in the model are present at one point in time: it serves as afirst step toward evaluating the model. If the hypothesized associations are present, thenlongitudinal tests of the model are indicated. If the hypothesized associations are not present,there would be good reason to doubt the validity of the model. Method Participants The participants in this study were 908 fifth grade boys assessed during the spring of theirlast year in elementary school. The mean age of the participants at the initiation of the studywas 10.90 years. Most were Caucasian (62.76%), followed by African American (16.24%);the remainder of the sample identified themselves as Hispanic (7.42%), Asian (2.09%),Arabic (0.72%), or other (10.79%). MeasuresDemographic and Background Questionnaire— This measure provided theassessment of the demographic information reported above. The Pubertal Development Scale (PDS: Petersen et al., 1988)— This scale consistsof five questions for boys and five questions for girls. Sample questions are, for boys, “doyou have facial hair yet?” and, for girls, “have you begun to have your period?” Individualsrespond on a 4 point scale. The scale has acceptable reliability estimates ( α 's ranging from . Pearson et al.Page 4 Psychol Addict Behav . Author manuscript; available in PMC 2011 December 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    67 to .76 for 11 year olds), and scores on it correlate highly with physician ratings and otherforms of self-report ( r   values ranging from .61 to .67: Brooks-Gunn et al., 1987; Coleman &Coleman, 2002). The PDS permits dichotomous classifications as pre- pubertal or pubertal,with mean scores above 2.5 indicative of pubertal onset. As is common (e.g., Culbert, Burt,McGue, Iacono, & Klump, 2009), we used the dichotomous classification in the currentstudy. Eating Expectancy Inventory (EEI; Hohlstein et al., 1998)— This five-factormeasure reflects expectancies for reinforcement from eating. For this study, we used ameasure of the expectancy that eating helps one manage negative mood states. Validityevidence for this scale was presented above: for example, it predicts subsequent onset of binge eating (Smith et al., 2007). In the current sample of boys, as in past samples of girls,the scale was internally consistent ( α  = .93). Thinness and Restricting Expectancy Inventory (TREI; Hohlstein et al., 1998) — This measure reflects overgeneralized expectancies about the life benefits of dieting andthinness. Items include such statements as “I would feel like I could do whatever I wanted toif I were thin.” The scale has been shown to be unidimensional, correlated with eatingdisorder symptoms in adolescent and adult samples, and predictive of eating disordersymptom onset (Hohlstein et al., 1998; MacBrayer, Smith, McCarthy, Demos, & Simmons,2001; Simmons et al., 2002; Smith et al., 2007). As in past samples with girls, the scale wasinternally consistent in this sample of boys ( α  = .91). UPPS-P Negative Urgency Scale (Lynam, Smith, Cyders, Fischer, & Whiteside,2007)— Negative urgency is related to bulimic symptom expression in late adolescents andadults (Fischer et al., 2008), and a child version of the negative urgency scale recentlyproved to be internally consistent ( α  = .87), have good convergent validity across assessmentmethod, good discriminant validity from other impulsivity-related measures, and waspredictive of criteria in theoretically consistent ways (Zapolski, Stairs, Settles, Combs, &Smith, 2010). In the current sample, the internal consistency of the scale was estimated as α = .84. Eating Disorder Examination- Questionnaire (EDE-Q; Fairburn & Beglin, 1994) — The EDE-Q is a self-report version of the Eating Disorders Examination semi-structuredinterview (Cooper & Fairburn, 1993) designed to assess the full range of behavioral andcognitive or attitudinal features of the specific psychopathology of eating disorders duringthe preceding 4 weeks, including patients' extreme concerns about their shape and weight.The EDE-Q has been shown to have good reliability and validity (Cooper & Fairburn, 1993;Luce & Crowther, 1999; Mond, Hay, Rodgers, Owen, & Beumont, 2004). Carter, Stewart,and Fairburn (2001) modified the EDE-Q for use with children ages 12–14, by shorteningthe length of time referred to in the questions to the past two weeks and by using age-appropriate wording. We used their adapted version of the EDE-Q, and, following pilotresearch, we also defined concepts that could possibly be difficult to understand. Examplesof changes from the adult version of the measure include changing the word “restrict” to“cut back on” and the word “influence” to “control,” and defining terms such as “laxatives”,“diuretics”, and “binge eating.” For purposes of comparison, we also used fairly stringentguidelines to define “binge eating” and “purge.” Binge eating was considered present if theparticipants reported having engaged in binge eating in response to two questions, the firstasking for the frequency of loss of control binge eating during the past two weeks, and thesecond asking whether the participant had engaged in binge eating (after defining bingeeating). Purging was considered present if the participants answered yes to the following Pearson et al.Page 5 Psychol Addict Behav . Author manuscript; available in PMC 2011 December 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  
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