The current study sought to determine the significance of the number and frequency of reported compensatory behaviors, as well as the relation between the number of distinct compensatory behaviors endorsed and the severity of eating-related and general psychopathology, in children and adolescents presenting for ED treatment. Results indicate that more than one-third of children and adolescents in our sample reported multiple methods of compensatory behaviors. These youth endorsed higher levels of ED attitudes and cognitions, as well as lower self-esteem and lower overall functioning, and were more likely to present with a comorbid psychiatric diagnosis, relative to youth reporting only a single method of compensatory behaviors. These findings are consistent with the adult literature showing that greater numbers of compensatory methods are related to increased eating-related and general psychopathology.12
By contrast, the reported frequency of compensatory behaviors was associated only with eating-related psychopathology, indicating that the number of compensatory behavior methods may be a better indicator of distress and impairment in children and adolescents with EDs than the frequency of these behaviors.
Older age was associated with the presence of multiple methods of compensatory behaviors as well as the frequency of compensatory behaviors. Previous findings have suggested that late adolescence is a high-risk period for onset of purging behaviors,35
however we cannot claim that the current findings are consistent with this as our data did not include the date of onset of compensatory behaviors. Hispanic youth and youth with higher BMIs showed greater frequency of compensatory behaviors. This is also consistent with past research that has noted the highest levels of disordered eating to occur among Hispanic youth in a general population sample.15
Although the reasons for this are unknown, it is possible that the participants in our sample felt distressed about their appearance and therefore were more inclined to engage in compensatory behaviors. We can also speculate that the positive relationship between BMI and frequency of compensatory behaviors could be related to previous general population findings that compensatory behaviors are more common in overweight youth.36
Gender was not associated with either the number or frequency of compensatory behaviors.
Unlike studies of adults with ED in which self-induced vomiting is the most common method of compensation,37, 38
the most frequently utilized compensatory behavior in this pediatric population was driven exercise. A possible explanation for this difference is that exercise is viewed and experienced as less pathological and more socially acceptable than purging behaviors such as vomiting. Children and adolescents are also under the supervision of parents who might serve as obstacles to engaging in more overt ED behaviors such as self-induced vomiting, whereas exercise is less likely to be viewed as problematic. Additionally, past studies suggest that driven exercise is associated with greater ED and depressive symptomatology 17, 18
and the development and maintenance of EDs.16
Given that driven exercise is the most commonly reported form of compensatory behavior among youth using both single method of compensatory behaviors and multiple methods of compensatory behaviors, this behavior could be serving as a “gateway” behavior that might eventually lead children and adolescents to utilize other, and potentially more harmful, methods as well.
To our knowledge, this is the first study to investigate single versus multiple compensatory methods in children and adolescents. EDs typically onset in this age group and understanding EDs in their early stages of development can result in more effective treatments.39
In addition, a strength of this study is that the sample size was reasonably large and included both males and females. Adolescents included in this sample had diagnoses spanning the ED spectrum (i.e., AN, BN, and ED-NOS), which enhances generalizability. This is particularly important for adolescents, as most youth fall into the EDNOS category22
and diagnostic crossover is often the rule rather than the exception.40
Another strength of this study is the inclusion of a comparison group of youth with ED who do not use compensatory behaviors. This allowed us to make a comparison between youth who engage in multiple or single compensatory behaviors and youth who do not utilize compensatory behaviors. However, with previous adult studies, a non-ED comparison group was used. Our use of an eating disordered comparison group increases the likelihood that it is the specific compensatory behaviors, rather than the presence of an ED, that accounts for the group difference. ED severity was assessed using well-validated measures. Finally, unlike studies of adults, which have only examined purging methods (vomiting, laxative misuse/diuretic misuse),12
this study includes non-purging compensatory behaviors as well.
While this study has multiple strengths it also has several limitations. First, the sample consisted of treatment-seeking children and adolescents, which precludes generalization to non-treatment-seeking samples. For instance, it is possible that a clinical population is typically more distressed by ED symptoms than individuals who are not actively seeking treatment.41
Secondly, our data were limited to the past 3 months, which may only represent a brief glimpse of compensatory behavior patterns as these behaviors may fluctuate significantly over time.40
Finally, due to the cross-sectional nature of this study, it is unclear whether higher numbers and frequency of compensatory behaviors contribute to or result from increased eating-related and/or general psychopathology.
These findings have implications for early identification and treatment. ED assessments with youth should evaluate for the presence of all forms of compensatory behaviors, as well as the frequency of these behaviors. Additionally, assessors should note the distinct number of compensatory behaviors endorsed. Future research should examine whether the number of compensatory behaviors is related to treatment outcome. In addition, research may explore how adolescents with multiple methods of compensatory behaviors could be targeted for more intensive treatment to measure if this reduces the potential for higher ED-specific and general psychopathology. This concept would be in line with the ideal of reducing symptom severity early in treatment.
In conclusion, we found that, irrespective of diagnosis, multiple methods of compensatory behaviors are related to greater ED severity and general psychopathology. This suggests that number of methods may provide a more comprehensive clinical picture than frequency of compensatory behaviors, which was only related to ED severity. Longitudinal studies are needed to determine whether greater general and ED-specific psychopathology leads to the initiation of more forms of compensatory behaviors or whether the behaviors drive the greater levels of psychopathology.