This study provided the first report of levels of childhood maltreatment among persons with NES and compared these levels to those of persons with BED and non-treatment seeking overweight and obese individuals. Higher rates of neglect and emotional abuse were associated with BED and NES than among overweight and obese participants without disordered eating. Physical and sexual abuse, however, were not more common. Participants with BED showed strikingly higher reports of emotional neglect whereas physical neglect appeared to be more common in NES patients. Of note, all three groups reported very high rates of at least one type of maltreatment, ranging from 71% to 82% across groups, and those with BED met criteria for more different types of maltreatment than the OC group.
Higher levels of depressed mood were significantly correlated with most forms of maltreatment. Additional categorical analyses revealed that moderate to severe levels of depressed mood, which are commonly present among those with BED and NES (Allison, Grilo, Masheb, & Stunkard, 2005
; Gluck et al., 2001
; Napolitano et al., 2001
; Yanovski et al., 1993
), were significantly related to both emotional and physical abuse and neglect. Similarly, childhood maltreatment has been linked to a broad range of psychopathology (Battle et al., 2004
; Fairburn, Doll, Welch, Hay, Davies, & O’Connor, 1998
; Grilo & Masheb, 2002
; Grilo, Sanislow, Fehon, Martino, & McGlashan, 1999
; MacMilliam et al., 2001
; Welch & Fairburn, 1994). These collective findings, together with the emerging literature, support the view that childhood maltreatment may be strongly associated with increased psychosocial problems in general, but not specifically with weight or eating disorder symptomatology (Grilo & Masheb, 2001
In the present study, reported rates of physical and sexual abuse differed little across groups whereas reports of emotional abuse and forms of neglect were higher in the BED and NES groups than in the OC group and were associated with elevated depression levels. One item in the physical neglect scale reads, “I didn’t have enough to eat.” One can speculate that lack of nourishment, along with the lack of attention to other physical needs could contribute to the NES eating pathology or represent the dietary deprivation that may trigger night eating in vulnerable individuals. Likewise, those with BED had a marked elevation in emotional neglect as well as elevated physical neglect scores (when depression score was covaried) relative to the OC group. These findings are broadly consistent with a CBT model that posits a lack of emotional support undermines self-esteem (a general precursor) and when coupled with physical neglect and lack of nourishment this triggers binge eating (Fairburn et al. 1993
; p. 369). We emphasize, however, that the cross-sectional nature of our study precludes any statements regarding causality. These clinical speculations are offered solely to stimulate studies or to receive consideration in prospective longitudinal research which is needed to understand these relationships better.
Clinical lore suggests that childhood maltreatment may negatively influence treatment outcomes for obesity and eating disorders (Felitti & Williams, 1998
) and there are hints of greater attrition and diminished benefits reported in some studies (e.g., Buser et al., 2004; King, Clark, & Pera, 1996
). Critical reviews of the empirical literature conclude that such concerns have yet to be empirically established (Gustafson & Sarwer, 2004
), and recent prospective studies with established assessment methods have reported that high levels of sexual abuse (Grilo, White, Masheb, Rothschild, & Burke-Martindale, 2006
; Larsen & Geenen, 2005
) and other forms of childhood maltreatment (Grilo et al., 2006
) do not appear to represent negative prognostic indicators for bariatric surgery.
Our findings must be considered in the context of the strengths and weaknesses of our methods. As we emphasized above, this study was cross-sectional and no assumptions may be made about causation between these high levels of maltreatment and the manifestation of BED, NES, and obesity without disordered eating. Another limitation is our reliance on retrospective self-report accounts of childhood maltreatment that might be biased or inaccurate. We note, however, that the CTQ has received good psychometric support including strong concurrent validity based on corroboration with independent data (Walker et al., 1999
). Moreover, self-report does potentially remove a barrier to honest self-closure of sensitive material. Importantly, our CTQ findings converge rather closely with other studies of similar eating problems that have assessed sexual abuse rates (Fairburn et al., 1998
; Yanovski et al., 1993
). Regardless of the verifiability of the memories of childhood maltreatment, the reports serve as useful descriptions of the current phenomenological status of the participants. The prognostic significance of childhood maltreatment for treatment outcomes for these problems also remains uncertain and is beyond the scope of our study.
Since our participants with BED were primarily Caucasian, and both the BED and NES groups were primarily female, these findings may not generalize to different groups with other characteristics. Given our recruitment methods, it is also possible that our findings may not generalize to community-based (non-clinical) populations who are uninterested in participating in research or treatment studies. For example, it is possible that persons who respond to such recruitment ads for studies may have experienced more childhood maltreatment or may have more severe forms of disordered eating than others in the community.
A critical avenue for future research concerns the question of factors that represent vulnerabilities or, conversely, serve as protectors against developing negative sequelae of maltreatment. One example of such research that has examined the role of intervening factors is that of Preti and colleagues (2006)
who found that body image mediates sexual abuse experiences and disordered eating. In closing, more definitive prospective research is needed to address these issues both across diverse obese and disordered eating groups and for different treatment methods. Whether the reported abuse actually occurred is unlikely to be determined except by expensive longitudinal studies. One excellent model for these studies is the Dunedin Multidisciplinary Health and Development Study, a 32-year cohort study in New Zealand (e.g. Danese, Pariante, Caspi, Taylor, & Poulton, 2006), and we urge that such studies be undertaken. But whether or not the existing reports describe real events, they are data in their own right and may provide valuable information for prognosis.