The present study aimed to examine the prevalence and diagnostic significance of DE in children and adolescents presenting for eating disorders treatment. DE was quite prevalent in our sample, occurring in approximately half of participants regardless of diagnostic group. Consistent with findings in adult populations (Bratland-Sanda et al., 2010
; Penas-Lledo, Vaz Leal, & Waller, 2002
), higher frequencies of compensatory exercise were related to greater eating disorder psychopathology and depressive symptoms. This finding may be related to animal literature that found associations between greater use of exercise and increased vulnerability to stress (Treasure & Owen, 1997
). This connection between exercise and stress may be related to a maladaptive means of managing an emotional state. DE frequency was not related to eating disorder diagnosis, sex, race, BMI, or age.
Participants who reported DE as their sole compensatory behavior were comprised of significantly more males and non-minorities, and were also significantly younger with lower BMIs than the other two groups. These differences are consistent with previous findings from a national survey that reported minority adolescent males are more likely to use self-induced vomiting and laxatives for weight control than their non-minority counterparts (Lowry, Galuska, Fulton, Weschler, & Kann, 2002
). The younger age of the group may support previous studies that suggest that DE has a role in the development and maintenance of eating disorders (Davis et al., 1997
; Davis, Kennedy, Ravelski, & Dionne, 1994
), such that the use of only DE as a compensatory behavior may be a precursor to greater eating disorder severity or increased usage of compensatory behaviors if not treated. It is also plausible that younger children are monitored more frequently by caregivers than their adolescent peers, creating the need for a compensatory behavior that appears more socially acceptable, such as exercise.
The findings also suggest that children and adolescents with eating disorders who engage in both DE and self-induced vomiting are the most severe in terms of eating disorder and depression symptoms, followed by those who report only self-induced vomiting, and those who report only DE as compensatory behaviors. The American Academy of Pediatrics reports on the dangers of self-induced vomiting in children and adolescents, specifically noting concerns over dehydration, orthostatic symptoms, and complications from significant deficits in potassium levels (Rosen, 2010
). Given the concern over the consequences of self-induced vomiting, along with the associations with eating disorder pathology found in this study, the importance of DE is highlighted by the finding that self-induced vomiting combined with DE is associated with a more severe symptom profile than self-induced vomiting alone.
Our findings that DE is associated with higher levels of severity of eating disorder and depression psychopathology, coupled with the medical complications associated with eating disorders and compensatory behaviors in children and adolescents (Katzman, 2005
; Lask, 2000
), speaks to the need for thorough assessment of compensatory behaviors in children and adolescents presenting with eating disorder symptoms. The findings suggest that DE, especially when paired with self-induced vomiting, may be important in determining severity of symptoms in pediatric eating disorder samples. This is especially important for pediatricians who are at the forefront in terms of the initial recognition of eating disorders. As exercise is usually deemed as a healthy behavior, there may be a tendency by pediatricians to not properly assess exercise behaviors, as well as a failure to recognize DE as pathological. This could have significant medical and psychological consequences for youth presenting with DE.
The present study contributes to the literature on the role of DE in eating disorders by investigating the prevalence and correlates of DE in a pediatric sample. There were several strengths to this analysis, specifically a large and diverse sample assessed with well-validated measures. Yet limitations also warrant acknowledgement. Since few participants in our sample endorsed other compensatory behaviors (i.e., laxative or diuretic misuse), we were unable to examine how DE compares to compensatory behaviors outside of self-induced vomiting. Further, these data are cross-sectional, precluding conclusions about causality. Our assessment of psychological correlates of DE was limited to eating-related and depressive symptomatology; future studies should explore the relation between DE and other psychological factors (e.g., anxiety, interpersonal functioning), as well as the role of DE in treatment outcome in children and adolescents. Additionally, it would be beneficial to extend this research to better understand DE’s relation to duration of illness in children and adolescents with eating disorders.
In summary, the findings of the present study suggest that DE is present in approximately half of children and adolescents presenting for eating disorders treatment, and appears to be associated with psychopathology irrespective of diagnostic group. Our findings emphasize the need for rapid identification of youth endorsing such symptoms. As we were only able to compare DE to self-induced vomiting, it is unclear how DE may differ in terms of clinical importance from other compensatory behaviors, such as laxative misuse. Future research should examine the onset of DE relative to other psychological symptoms, and explore the role of DE in treatment outcome among youth.