Childhood Maltreatment and Eating Disorders: A Prospective Investigation

Abstract

Objectives:

To determine whether childhood maltreatment is a risk factor for two eating disorders (anorexia nervosa and bulimia nervosa) using objective and subjective case definitions.

Methods:

Using a prospective cohorts design, children with documented cases of physical abuse, sexual abuse, and neglect (ages 0–11) from 1967 to 1971 in a Midwestern metropolitan county area were matched on age, race, sex, and approximate family socioeconomic status with non-maltreated children. Both groups were followed up. Retrospective self-reports about childhood maltreatment were collected at age 29. DSM-IV anorexia nervosa (AN) and bulimia nervosa (BN) disorders were assessed at age 41 (N = 807). Logistic and linear regression results are reported.

Results:

Using documented cases, childhood maltreatment was not a significant risk factor for AN or BN diagnoses or symptoms in adulthood. However, adults who retrospectively reported any maltreatment and physical and sexual abuse reported significantly more symptoms of AN than those who did not.

Conclusions:

The prediction that childhood maltreatment is a risk factor for anorexia nervosa and bulimia nervosa was partially supported in this longitudinal study. While misattribution of cases might have occurred, these results suggest that researchers and clinicians should use caution in drawing inferences about these relationships and designing interventions.

Keywords

eating disorders anorexia nervosa bulimia nervosa child abuse and neglect longitudinal study retrospective self-reports

Introduction

Eating disorders, including anorexia nervosa (AN) and bulimia nervosa (BN), are serious psychiatric conditions associated with numerous negative mental and physical health outcomes, including anemia, endocrine system dysfunction, electrolytes disturbances, and cardiovascular diseases (Rikani et al., 2013), as well as high mortality rates (Birmingham et al., 2005). Eating disorders are not restricted to the developed countries (Patel et al., 2007; Smink et al., 2012). A recent systematic review found that the prevalence of lifetime eating disorders was 8.4% (range 3.3%–18.6%) for women and 2.2% (range 0.8%–6.5%) for men, with highest prevalence in the United States 4.6% (range 2.0%–13.5%), followed by Asia 3.5% (0.6%–7.8%), and then Europe 2.2% (0.2%–13.1%) (Galmiche et al., 2019). Using the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) (American Psychiatric Association, 2013) criteria, the estimate of the lifetime prevalence of any eating disorder was 1.7% (0.8% among men and 2.7% among women). Although females have consistently been reported to be at higher risk for eating disorders than males (Becker & Grilo, 2011; Dunkley et al., 2010; Groleau et al., 2012; Sanci et al., 2008), the associations between eating disorders and other demographic variables such as race, ethnicity, socio-economic status (SES), and educational level have not been as consistent (Kimber et al., 2017; Mitchison & Hay, 2014). However, there is increasing evidence that eating disorders are experienced by males and females (Mond & Hay, 2007; Striegel-Moore et al., 2009) of all ages (Hay et al., 2008), and ethnicities (Cachelin et al., 2000), and who live in both developed and developing countries (Mashhadi & Noordenbos, 2012).

Childhood maltreatment has been increasingly recognized as a risk factor for eating disorders. Previous studies have reported high rates of childhood abuse in the backgrounds of individuals with eating concerns (Guillaume et al., 2016) and eating disorders (Brewerton & Brady, 2014; Carter et al., 2006; Molendijk et al., 2017; Steiger et al., 2011). Eating disorder patients tend to explain their disorders as directly or indirectly related to their childhood traumatic experiences (Rorty & Yager, 1996). In their meta-analysis, Molendjik et al. (2017) found that the prevalence of childhood maltreatment was high for each type of eating disorder, with rates ranging from 21% to 59%, compared to rates of 1%–35% in healthy control groups.

The etiology of eating disorders remains uncertain, although it most likely involves multiple factors (Culbert et al., 2015), including genetic (Bulik et al., 2016; Kaye et al., 2005; Klump et al., 2001; Sachs-Ericsson et al., 2012), psychological, socio-demographic, environmental pressures, and cultural factors that influence attitudes and behavior related to body image and eating (Mitchison & Hay, 2014). Each of these factors provides a potential explanation for the association between child abuse and eating disorders through a mediation model. For example, genetic and non-shared environmental factors have been implicated in the etiology of certain eating disorders, where genetic risk has been expressed as parental psychopathology. From this perspective, on the assumption that parental psychopathology increases the risk for child abuse, this may reflect genetic risk that influences environmental risk (Sachs-Ericsson et al., 2012). Other work has suggested that childhood maltreatment may lead to the development of certain personality traits, including negative emotionality, perfectionism, negative urgency (Culbert et al., 2015), external locus of control and interpersonal sensitivity (Micali et al., 2017), and that these personality characteristics may be risk factors for eating disorders. Researchers have also called attention to the co-morbidity of psychiatric disorders with eating disorders that may explain the relationship between abuse and eating disorders (Molendijk et al., 2017), whereas others have implicated emotional dysregulation and dissociation (Moulton et al., 2015).

However, Jacobi et al. (2004) pointed out that “because for many of these factors (e.g., depression, low self-esteem, and altered serotonin levels), it is unclear whether they precede the onset of the eating disorder, it is impossible to determine whether they are symptoms of the disorder, maintaining factors, or consequences of ‘scars’ of the disorder” (p. 19). In a later review of the literature on the etiology of eating disorders, Rikani et al. (2013) suggested that it is hard to identify risk factors for eating disorders because of the difficulty in differentiating between causes, symptoms, and outcomes. Rikani et al. (2013) called attention to several studies that have noted alterations in serotonin functioning in eating disorder patients (e.g., Kaye et al., 2005), but argued that any alterations of serotonin may be an outcome of aberrant eating behaviors in patients and not necessarily a cause.

Methodological limitations of the existing literature make firm conclusions about the association between childhood maltreatment and eating disorders problematic. First, there is a heavy reliance on retrospective reports of childhood traumatic experiences. Retrospective self-reports are the most common form of ascertainment of childhood traumatic experiences. Recall bias in the report of childhood abuse can artifactually cause an association between self-reported child abuse and neglect and later outcomes. The empirical evidence of the validity of retrospective reports of earlier childhood experiences indicates only weak relationships with childhood events in longitudinal studies of non-maltreated (Henry et al., 1994; Offer et al., 2000; White et al., 2007) and maltreated children (Widom & Morris, 1997; Widom & Shepard, 1996). Retrospective self-reports (versus prospective measures) have tended to demonstrate stronger associations with adult psychopathology (Brown et al., 2005; Everson et al., 2008; Reuben et al., 2016; Tajima et al., 2004; Widom, 1999; Widom & Morris, 1997), even though opposite findings have also been reported (Scott et al., 2012; Shaffer et al., 2008). In a direct comparison of prospective informant-reports and retrospective self-reports, Newbury et al. (2018) found that both types of reports were associated with psychiatric problems in youth at the age of 18; However, the strongest associations were noted when maltreatment was retrospectively reported. In a meta-analysis and systematic review of the extent of agreement between prospective and retrospective measures of childhood maltreatment, Baldwin et al. (2019) found that agreement between retrospective and prospective reports was poor across 16 unique studies with over 25,000 participants. These authors concluded that research based on these two sources of information identify different groups of individuals who may have different life trajectories. Danese and Widom (2020) reported that without the person’s subjective reporting of the experience, the risk of psychopathology in individuals with objectively defined maltreatment (based on court records) was minimal.

Second, there is a heavy reliance on patient or treatment seeking samples. Mitchison and Hay (2014) pointed out that the majority of studies are based on clinical samples and that people with eating disorders who receive treatment are not representative of the wider eating disorder population. Because these eating disorder studies focus primarily on patients who are currently suffering from the disease, they do not take into account individuals with histories of maltreatment who did not go on to have eating disorders, potentially illustrating what has been labeled the “clinician’s illusion” (Cohen & Cohen, 1984).

Third, few studies have examined risk factors for eating disorders using a longitudinal prospective design, with a few exceptions. One prospective study reported a strong association with neglect in childhood (Johnson et al., 2002). A longitudinal study of sexually abused females found a larger number of bulimia nervosa symptoms in adolescents compared to non-abused peers (Li et al., 2019). Li et al. (2019) called for “prospective studies with substantiated CSA (childhood sexual abuse) and subsequent ED [eating disorders]…to clarify these associations and inform clinical decision making regarding which factors to target in interventions” (p. 12).

A fourth limitation is the focus on physical and sexual abuse, not neglect. Neglect cases represent the vast majority of the 3 million cases of childhood maltreatment reported to the child protection system each year (U.S. Department of Health & Human Services, 2019). In a meta-analysis of prevalence rates of child neglect, Stoltenborgh et al. (2013) reported an overall estimated global prevalence of 163/1,000 for physically neglected and 184/100 for emotionally neglected children, although they noted the lack of information about physical neglect in “low resource” countries. Caslini and colleagues (2016) pointed out the emerging literature suggesting that physical neglect and emotional neglect may have relationships to eating disorders different than those of physical abuse. More specifically, they found that while physical abuse was associated with both anorexia nervosa and bulimia nervosa, emotional neglect and abuse was associated only with bulimia nervosa. Given that neglect involves the extreme deprivation of basic necessities for children, including food, clothing, shelter, and medical attention, this deprivation in childhood may lead to binge eating and incessant overeating and higher rates of bulimia nervosa, not anorexia nervosa.

The Present Study

This study sought to overcome a number of problems with prior work by using data from a prospective study in which abused and neglected children and demographically matched controls were followed up and assessed for eating disorders in adulthood. Our goals are (1) to examine the extent to which individuals with documented histories of child abuse and neglect are at higher risk for two eating disorders (anorexia nervosa and bulimia nervosa) and to have a greater number of symptoms of AN and BN in adulthood, compared to individuals without such histories (a prospective analysis based on official cases), and (2) to examine the extent to which adults who retrospectively report having experienced abuse or neglect in childhood are at increased risk for anorexia nervosa and bulimia nervosa disorders and a larger number of symptoms compared to those who do not report these histories. We expect these relationships with eating disorders to be stronger for retrospective self-reports of childhood maltreatment compared to these associations based on documented cases.

Methods

Study Population

The data were collected as part of a large prospective cohort design study in which abused and/or neglected children were matched with non-abused and non-neglected children and followed into adulthood (Widom, 1989a). Because of the matching procedure, the subjects are assumed to differ only in the risk factor; that is, having experienced childhood abuse or neglect. Since it is not possible to assign subjects randomly to groups, the assumption of equivalency for the groups is an approximation.

The original sample of maltreated children (N = 908) was made up of court substantiated cases of childhood physical and sexual abuse and neglect processed from 1967 to 1971 in the county juvenile (family) or adult criminal courts of a Midwestern metropolitan area. The abuse and neglect cases were restricted to those in which children were less than 11 years of age at the time of the abuse or neglect. This element of the design of the original study was implemented to minimize any possible ambiguity in the temporal sequence and to maximize the likelihood that the temporal direction was clear (that is, abuse or neglect preceded the delinquency). It was recognized that the delinquency could precede the abuse or neglect or even that delinquency may provoke the abuse or neglect of the child. Thus, to avoid this ambiguity, the abuse and neglect cases were restricted to this age group.

A control group of children (N = 667) without documented histories of childhood abuse and/or neglect was matched with the abuse/neglect group on age, sex, race/ethnicity, and approximate family social class during the time that the abuse and neglect records were processed. Matching for approximate family social class was important in this study because it is theoretically plausible that any relationship between child abuse and neglect and subsequent outcomes may be confounded with or explained by social class differences. The matching procedure used here is based on a broad definition of social class that includes neighborhoods in which children were reared and schools they attended. Similar procedures, with neighborhood school matches, have been used in studies of individuals with schizophrenia (Watt, 1972) to match approximately for social class. Shadish et al. (2002) recommended using neighborhood and hospital controls to match on variables related to outcomes, when random sampling is not possible.

Children who were under school age at the time of the abuse and/or neglect were matched with children of the same sex, race, date of birth (± 1 week), and hospital of birth through the use of county birth record information. For children of school age, records of more than 100 elementary schools for the same time period were used to find matches with children of the same sex, race, date of birth (± 6 months), and class in elementary school during the years 1967 to 1971 as the abused/neglected child. Overall, matches were found for 74% of the abused and neglected children.

The initial phase of the research compared the abused and/or neglected children to the matched comparison group on juvenile and adult criminal arrest records (Widom, 1989b). Subsequent waves of the study involved interviewing both groups during 1989–1995 (N = 1,196), 2000–2002 (N = 896), and again in 2003–2005 (N = 807). The research presented here uses information from the first interview (1989–1995) and the 2003–2005 interview that included a comprehensive health assessment (Widom et al., 2012).

There was attrition associated with death, refusals, and our inability to locate individuals over the various waves of the study; however, the sample demographic composition has remained roughly the same. There were no differences between the current sample (N = 807) and the first interview sample (N = 1,196) in terms of sex (p = .075), race (p = .341), age at interview 1 (p = .762), and maltreatment status (p = .955). The mean attrition rate (about 25%) did not differ for the maltreatment and control groups. The current sample is 53.2% female, 59.2% White, non-Hispanic, and mean age 41.2 years (SD = 3.54, range 32–49). The sample is heavily skewed toward the lower end of the socioeconomic spectrum: more than half (54.9%) held unskilled or semi-skilled jobs, whereas only 13.7% held semi-professional or professional jobs. There are 458 cases of abuse and/or neglect (78 cases of physical abuse, 61 cases of sexual abuse and 370 cases of neglect) and 349 matched controls. The total number in the abuse/neglect groups is more than 458 because some participants had more than one type of abuse or neglect. Descriptive statistics for the sample are provided in Table 1.

Table 1.

Descriptive Characteristics of the Abused and Neglected and Control Groups.

Variable	Control	Abuse/Neglect	Neglect	Physical Abuse	Sexual Abuse
	N (%)	N (%)	N (%)	N (%)	N (%)
Sex
Males	171 (49)	209 (45.6)	178 (48.1)	40 (51.3)	11 (18)***
Females	178 (51)	249 (54.4)	192 (51.9)	38 (48.7)	50 (82)
Race
White, non-Hispanic	210 (60.2)	268 (58.5)	213 (57.6)	57 (73.1)*	35 (57.4)
Others	139 (39.8)	190 (41.5)	157 (42.4)	21 (26.9)	26 (42.6)
	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)
Age	41.10 (3.6) (3.58)	41.27 (3.51)	41.09 (3.51)	41.33 (3.81)	42.72 (2.65)^***
	N (%)	N (%)	N (%)	N (%)	N (%)
Annual household income >25k	175 (50.1)	148 (32.3)***	115 (31.1)***	33 (42.3)	17 (27.9)*

Note. Asterisks indicate significant differences between the particular type of abuse and the control group on that demographic characteristic.

* p <.05 ^*** p < .001.

Procedures

Participants completed the interview in their homes or, if they preferred, another appropriate place. The interviewers were blind to the purpose of the study and the inclusion of an abused/neglected group. Participants were also blind to the purpose of the study and told that they had been selected to participate as part of a large group of individuals who grew up in the late 1960s and early 1970s. Institutional Review Board approval was obtained for these procedures, and subjects gave written, informed consent.

Measures

Documented childhood maltreatment

Childhood physical abuse, sexual abuse, and neglect were assessed through a review of official records processed during the years 1967 to 1971 when the children were ages 0–11 years old. Physical abuse cases included injuries such as bruises, welts, burns, abrasions, lacerations, wounds, cuts, and bone and skull fractures. Sexual abuse cases included felony sexual assault, fondling or touching, sodomy, incest, and rape. Neglect cases reflected a judgment that the parents’ deficiencies in child-care were beyond those found acceptable by community and professional standards at the time and represented extreme failure to provide adequate food, clothing, shelter, and medical attention to children.

Retrospective self-reports of childhood maltreatment

Retrospective self-report measures, collected during the first interview (1989–1995), were selected to represent a broad set of maltreatment experiences similar to the types included in the documented court cases. Participants were asked to report about experiences that occurred before age 12 to make the retrospective reports as similar to the court cases as possible. In addition, because no single retrospective self-report measure is universally endorsed by researchers, multiple measures of each type of maltreatment were included to be as comprehensive as possible. Four measures were used to assess self-reports of childhood sexual abuse, all of which were adapted from previous work (Finkelhor, 1979, 1986; Russell, 1983). The accuracy of these measures as adult recollections was reported previously in Widom and Morris (1997). Two measures were used to assess retrospective self-reports of childhood physical abuse: the Conflict Tactics Scale (CTS; Straus et al., 1998) and the Self-Report of Childhood Abuse Physical (SRCAP; Widom & Shepard, 1996). Both scales discriminated abused from non-abused individuals (Widom & Shepard, 1996). Retrospective assessments of neglect were more challenging because at the time these were collected, there was no validated neglect instrument. Lacking such an instrument, questions were designed to cover a range of neglect experiences that were similar to the charges in the official neglect case. For neglect, participants were asked three questions: (a) “Were there ever times when you were a young child that a neighbor fed you or cared for you because your parents didn’t get around to shopping for food or cooking, or when neighbors or relatives kept you overnight because no one was taking care of you at home?” (b) “When you were a young child, did anyone ever say that you weren’t being given enough to eat, or kept clean enough, or that you weren’t getting enough medical care when it was needed?” and (c) “When you were a very young child, did your parents ever leave you home alone while they were out shopping or doing something else?” If the participant responded “yes” to any neglect question and the age at which the neglect occurred was reported as prior to 12 years, the participant was coded as having self-reported childhood neglect.

Eating disorders

AN and BN disorders were assessed using the Diagnostic Interview Schedule, Version 4 (Robins et al., 2000), based on DSM-IV (American Psychiatric Association, 1994, 2000), at mean age 41. This is a structured diagnostic instrument administered by trained interviewers, consisting of 23 items measuring AN and BN. For AN, four criteria are required: (1) refusal to maintain body weight at or above the minimally normal weight for age and height; (2) intense fear of gaining weight or becoming fat, even though underweight; (3) disturbance in the way in which one’s body weight or shape is experienced, undue influence of body shape on self-evaluation, or denial of the seriousness of the current low body weight; and (4) in post-menarcheal females, amenorrhea. Reliability and validity of this measure have been reported in several studies (Fichter et al., 1998; Kessler et al., 2004; Kutlesic et al., 1998; Manly et al., 2013; Rogers, 2003). Because only two participants met these four criteria and because DSM-5 (American Psychiatric Association, 2013) omitted the last criterion, a lower threshold for a diagnosis of AN was used and required only that the person meet the first three criteria. A continuous variable was created representing the total number of lifetime symptoms of AN, only for those individuals who reported any symptoms, suggesting sub-threshold AN.

For a lifetime diagnosis of BN, five criteria were required: (1) recurrent episodes of binge eating, characterized by eating in a discrete period of time an amount of food that is larger than most people eat during a similar period of time and under similar characteristics and a sense of lack of control over eating during the episode; (2) recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induce vomiting, misuse of laxatives, fasting, or excessive exercise; (3) binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for 3 months; (4) self-evaluation is unduly influenced by body shape and weight; and (5) the disturbance does not occur exclusively during episodes of AN. A continuous variable representing the number of lifetime symptoms was calculated for only those who reported any symptoms and this variable reflected sub-threshold BN.

Although specific items asked about binge eating, Binge Eating Disorder (BED) could not be assessed. BED as a separate diagnostic category was added after the data was collected for this study and during the transition to DSM-5 (American Psychiatric Association, 2013).

Control variables

Age, sex, and race were included as control variables. Both groups (abuse/neglect and control) were matched on social class in childhood. However, because of concern about an association between eating disorders and SES, current income was also included as a control variable (see Currie & Widom, 2010).

Data Analyses

Logistic regressions were conducted to determine whether child abuse and neglect (and specific types) are risk factors for anorexia nervosa and bulimia nervosa disorder diagnoses separately. Odds ratios (OR) and 95% confidence intervals (CIs), and adjusted odds ratios (AORs) with controls for age, sex, race, and current income are reported. Linear regressions were computed to determine whether childhood maltreatment (and specific types) predicted the number of anorexia nervosa and bulimia nervosa symptoms, among those who reported any symptoms. Because of the skewness of the data on symptoms, the number of anorexia nervosa symptoms was log transformed and the number of bulimia nervosa symptoms was reversed (1/bulimia nervosa symptoms). For both eating disorders, the model fit improved with these transformations, based on the Akaike information criterion (AIC) score. Analyses were conducted first with maltreatment based on official (documented) childhood reports and then repeated with retrospective self-reports. Cohen’s κs for the extent of agreement between the documented cases and retrospective self-reports were only fair (physical abuse = 0.24, sexual abuse = 0.38, neglect = 0.40).

Results

Childhood Maltreatment as a Risk Factor for Anorexia Nervosa: Prospective and Retrospective Reports

Table 2 presents the prevalence of AN diagnoses for the entire sample and the number of AN symptoms among those who reported any symptoms. Although the odds ratios (unadjusted and adjusted) for sexual abuse (OR = 2.53, 95% CI = 0.64–10.05; AOR = 1.63, 95% CI = 0.39–6.73) are substantial, neither was significant. The right-hand side of Table 2 shows that there are also no significant differences between the groups in the number of lifetime AN symptoms reported.

Table 2.

Prevalence of Anorexia Nervosa in Abused and Neglected Children Grown Up and Matched Controls.

	DSM-IV Anorexia NervosaDiagnosis					Number of Anorexia Nervosa Criteria(Among Those With Any Symptoms)
Group	N	n (%)	OR(AOR)	95% CI(95% CI)	N	M	SD	Beta	SE	95% CI	p
Control	349	7 (2.01)			247	2.12	1.14
Abuse/Neglect	458	14 (3.06)	1.54(1.44)	0.62 to 3.86(0.55 to 3.74)	299	2.07	1.19	−0.02	0.05	−0.12 to 0.07	0.61
Neglect	370	9 (2.43)	1.22(1.02)	0.45 to 3.31(0.39 to 2.96)	240	1.97	1.13	−0.06	0.05	−0.16 to 0.03	0.19
Physical abuse	78	2 (2.56)	1.29(1.21)	0.26 to 6.31(0.24 to 6.18)	46	2.46	1.26	0.14	0.09	−0.03 to 0.31	0.11
Sexual abuse	61	3 (4.92)	2.53(1.64)	0.64 to 10.05(0.39 to 6.85)	43	2.28	1.35	−0.01	0.09	–0.19 to 0.17	0.93

Note: Statistical comparisons are between the abuse/neglect group and the matched controls. The number of Anorexia Nervosa symptoms has been log transformed to address skew. OR= odds ratio; AOR= adjusted odds ratio, controlling for age, sex and race and annual household income; CI = confidence intervals; M = mean; SD = standard deviation; SE = standard error.

Table 3 shows the prevalence of AN diagnoses based on retrospective self-reports of childhood maltreatment and the number of AN symptoms among those who reported any symptoms. Rates of AN diagnoses using retrospective self-reports of childhood maltreatment were similar to those based on the court substantiated cases. Again, none of the unadjusted or adjusted odds ratios for AN was significant. In contrast, among those who reported any AN symptoms, Table 3 shows that individuals who retrospectively reported any childhood maltreatment, physical abuse, and sexual abuse all reported significantly more lifetime symptoms of AN compared to those who did not report childhood maltreatment.

Table 3.

Prevalence of Anorexia Nervosa Based on Retrospective Self-Reports of Child Maltreatment.

	DSM-IV Anorexia NervosaDiagnosis					Number of Anorexia Nervosa Criteria(Among Those With Any Symptoms)
Type of maltreatment	N	n (%)	OR(AOR)	95% CI(95% CI)	N	M	SD	Beta	SE	95% CI	p
No self-reported maltreatment	282	8 (2.84)			177	1.86	1.06
Self-reported child maltreatment	514	13 (2.53)	0.89(0.68)	0.36 to 2.17(0.26 to 1.75)	359	2.21	1.21	0.11	0.05	0.01 to 0.20	0.03
Self-reported neglect	270	10 (3.70)	1.32(1.04)	0.51 to 3.39(0.37 to 2.92)	181	2.24	1.26	0.09	0.06	−0.02 to 0.21	0.10
Self-reported physical abuse	418	13 (3.11)	1.10(0.91)	0.45 to 2.69 (0.35 to 2.35)	286	2.23	1.25	0.12	0.05	0.02 to 0.22	0.02
Self-reported sexual abuse	211	9 (4.27)	1.53(0.81)	0.58 to 4.02(0.28 to 2.37)	166	2.40	1.32	0.16	0.06	0.04 to 0.28	0.01

Note: Statistical comparisons are between the abuse/neglect group and the matched controls. The number of Anorexia Nervosa symptoms has been log transformed to address skew. OR= odds ratio; AOR= adjusted odds ratio, controlling for age, sex, race and annual house income; CI = confidence intervals; M = mean; SD = standard deviation; SE = standard error.

Childhood Maltreatment as a Risk Factor for Bulimia Nervosa: Prospective and Retrospective Reports

Table 4 shows that childhood maltreatment (and specific types) were not a significant risk factor for a bulimia nervosa disorder diagnosis. The prevalence rates for BN diagnoses were quite low, and, in contrast to expectations, controls had a slightly higher rate than those with documented histories of maltreatment. There were no significant differences between the maltreated and controls groups in the number of BN symptoms, among those who reported any symptoms.

Table 4.

Prevalence of Bulimia Nervosa in Abused and Neglected Children Grown Up and Matched Controls.

	DSM-IV Bulimia NervosaDiagnosis				Number of Bulimia Nervosa Criteria(Among Those With Any Symptoms)
Group	N	n (%)	OR(AOR)	95% CI(95% CI)	n	M	SD	Beta	SE	95% CI	p
Control	349	5 (1.43)			48	2.38	2.08
Abuse/Neglect	458	3 (0.66)	0.45(0.33)	0.11 to 1.91(0.08 to 1.41)	76	2.07	1.61	0.04	0.06	−0.08 to 0.16	0.52
Neglect	370	3 (0.81)	0.56(0.41)	0.13 to 2.37(0.10 to 1.73)	64	2.03	1.63	0.04	0.06	−0.08 to 0.17	0.48
Physical abuse	78	1 (1.28)	0.89(0.71)	0.10 to 7.76(0.08 to 6.51)	11	1.91	1.76	0.07	0.11	−0.14 to 0.28	0.52
Sexual abuse	61	0	NA	NA(NA)	8	2.62	1.77	0.07	0.13	−0.18 to 0.32	0.59

Note: Statistical comparisons are between the abuse/neglect group and the matched controls. The number of Bulimia Nervosa symptoms has been inverse transformed to address skew and the n represents the number of participants who reported at least one Bulimia Nervosa symptom. OR= odds ratio; AOR = adjusted odds ratio, controlling for age, sex, race and annual household income; CI = confidence intervals; M = mean; SD = standard deviation; SE = standard error.

Table 5 shows the results for bulimia nervosa. As can be seen, the odds ratios for BN disorder diagnoses were higher and the number of lifetime BN symptoms was higher for individuals who retrospectively self-reported childhood maltreatment, particularly those who reported sexual abuse, compared to those who did not report childhood maltreatment. However, neither the odds ratios nor the coefficients reached customary levels of significance.

Table 5.

Prevalence of Bulimia Nervosa Based on Retrospective Self-Reports of Child Maltreatment.

	DSM-IV Bulimia NervosaDiagnosis				Number of Bulimia Nervosa Criteria(Among Those With Any Symptoms)
Self-reports of maltreatment	N	n (%)	OR(AOR)	95% CI(95% CI)	n	M	SD	Beta	SE	95% CI	p
No self-reported maltreatment	282	1 (0.35)			36	1.94	1.62
Self-reported any maltreatment	514	7 (1.36)	3.88(3.08)	0.47 to 31.69(0.36 to 26.33)	85	2.32	1.90	-0.07	0.07	−0.20 to 0.06	0.28
Self-reported neglect	270	2 (0.74)	2.10(2.25)	0.19 to 23.26(0.18 to 26.71)	44	2.39	1.99	−0.08	0.08	−0.23 to 0.08	0.34
Self-reported physical abuse	418	7 (1.67)	4.79(3.75)	0.59 to 39.11(0.44 to 31.92)	72	2.89	2.15	−0.08	0.07	−0.21 to 0.06	0.28
Self-reported sexual abuse	211	5 (2.37)	6.82(6.08)	0.79 to 58.82(0.62 to 59.91)	44	2.34	1.82	−0.15	0.08	−0.31 to 0.01	0.07

Discussion

To our knowledge, this is the first prospective longitudinal study that examined whether abused and neglected children are at increased risk for anorexia nervosa and bulimia nervosa in adulthood. Surprisingly, individuals with documented histories of childhood maltreatment were not at increased risk for these eating disorders compared to children with similar demographic characteristics (a matched control group) when followed up and assessed in adulthood. None of the types of documented maltreatment examined here (physical abuse, sexual abuse, and neglect) was a significant predictor of anorexia nervosa or bulimia nervosa diagnoses or symptoms, although there was a non-significant trend for individuals with histories of sexual abuse to have higher rates of both anorexia nervosa and bulimia nervosa than controls. Interestingly, the rates of eating disorders reported here are quite consistent with rates in national surveys (Afifi et al., 2017). However, the lack of significant differences here may reflect the low prevalence rates and small sample sizes. In addition, the fact that more than a third of this sample is non-White and that non-Whites have been reported to have lower rates of anorexia nervosa and bulimia nervosa than Whites (Bodell et al., 2018; Striegel-Moore et al., 2000; Taylor et al., 2007) may also contribute to the findings. On the other hand, previous research with this sample has found specific increases in risk for psychiatric disorders (Nikulina et al., 2012; Widom, 1999; Widom et al., 2007, 2009, 2018).

When the analyses were repeated using retrospective self-reports as the indicator of childhood maltreatment, the results did not show a significantly increased risk for a diagnosis of anorexia nervosa or bulimia nervosa. However, individuals who retrospectively reported childhood maltreatment reported significantly more lifetime anorexia nervosa symptoms, suggesting sub-threshold anorexia nervosa. A recent paper on eating disorders in adolescents (Li et al., 2019) called attention to the importance of sub-diagnostic threshold eating disorder symptoms, suggesting that eating disorder symptoms may evolve into severe eating disorders over time (Kotler et al., 2001). However, because eating disorders have their onset in the late teens and our participants were assessed in middle adulthood, one would have expected them to have already developed the disorder.

Most of the existing research on anorexia nervosa and bulimia nervosa has been conducted with patients and people suffering from eating disorders. In those cross-sectional studies, childhood maltreatment was typically assessed through retrospective self-reports. Our retrospective self-report findings are consistent with the existing literature, given that the adults in this study who retrospectively reported childhood maltreatment also reported significantly more symptoms of anorexia nervosa. The discrepancy between results with objective (documented) cases and subjective (retrospective) reports is consistent with new research by Danese and Widom (2020) who found that the risk of psychopathology in adulthood was linked to retrospective self-reports of childhood maltreatment and that, without the person’s subjective report of the experience, the risk of psychopathology in individuals with documented court cases was minimal. Our results indicated that neither prospective nor retrospective reports of childhood maltreatment increased risk for a bulimia nervosa diagnosis or symptoms. Although some research has reported relatively high frequencies of abuse and neglect among individuals with bulimia nervosa, these same studies did not find that these rates were significantly higher than in non-maltreated individuals (Miller et al., 1993). The extremely low rates of bulimia nervosa here make it difficult to detect an effect of childhood maltreatment.

Some previous research has suggested that the perception of a traumatic event may be a more important predictor of eating psychopathology than the traumatic experience itself (Kong & Bernstein, 2009). Another possible explanation for the differences in findings between documented cases and retrospectively reported cases is that using court cases to identify maltreatment does not capture aspects of the emotional experiences these children may have had that might be reflected in retrospective self-reports, because many cases of abuse and neglect are often undocumented (Bunting et al., 2010). Nonetheless, the differences between the two sets of results are consistent with the findings of the Baldwin et al. (2019) meta-analysis and systematic review of the extent of agreement between prospective and retrospective measures of childhood maltreatment.

Although our analyses controlled for current socio-economic status, it is possible that the lack of significant differences between the maltreated and control groups in this study may reflect the fact that the groups were originally matched approximately on family social class and that both groups of children were from families predominantly from the lower end of the socio-economic spectrum, i.e. the cases more likely to come to the attention of the courts and the child protection system. Maltreated children who grew up in middle- and upper- class families might manifest different outcomes. Existing eating disorder studies have more often included White, educated and middle socioeconomic status females (Molendijk et al., 2017). A few studies have found that anorexia nervosa is more common among individuals among higher SES (Lindberg & Hjern, 2003; McClelland & Crisp, 2001). However, in an epidemiological study that examined the association between bulimia nervosa and parental education (a proxy for social class) the authors did not find a significant association (Kendler et al., 1991). Similarly, some research that combined anorexia nervosa and bulimia nervosa did not find associations between these eating disorders and social class (e.g., Favaro et al., 2003; Lewinsohn et al., 2000; Moya et al., 2005). In their review, Mitchison and Hay (2014) concluded that there was little evidence of an association between eating disorders and SES.

Another concern regards stigma. Because of the considerable stigma associated with eating disorders, many individuals with eating disorders do not report their problems or seek the attention of health professionals (Kimber et al., 2017; Macmillan et al., 2009; Roehrig & McLean, 2010). However, this would not seem to explain the current results because the prevalence of eating disorders in the control group was high compared to rates reported in epidemiological studies.

Despite the strengths of this study, limitations need to be noted. First, since these cases of abuse and neglect occurred prior to age 12, these results cannot be generalized to cases that could have occurred later. Second, this study represents the experiences of children growing up in the late 1960s and early 1970s in the Midwest part of the United States and may raise concerns about applying these findings to the present society. However, the maltreatment cases studied here are quite similar to current cases being processed by the child protection system and the courts. One difference is that these children were not provided with extensive services or treatment options as are available today and, thus, the results of this study represent the natural history of the development of maltreated children whose cases have come to the attention of the courts. Third, an advantage of this study is its use of documented cases of childhood maltreatment. At the same time, it is unknown how many “true” cases of childhood maltreatment were missed, and it is possible that these missed cases bias the results toward the lack of findings. Danese and Widom (2020) suggested that the difference between subjective and objective reports of childhood maltreatment might reflect misclassification because official court records are highly specific (low false positives) but are not very sensitive (high false negatives). For example, court records have particularly low sensitivity for cases of child sexual abuse (Baldwin et al., 2019; Gilbert et al., 2009). However, we observed a similar pattern of findings across all maltreatment types, despite the known differences in sensitivity, suggesting that this was not an explanation for the null findings. Fourth, this work was based on eating disorders defined by DSM-IV, not DSM-5, meaning that the most recent criteria for eating disorder diagnoses were not used and, unfortunately, binge eating disorder was not assessed. Fifth, a structured diagnostic instrument to assess eating disorders was used rather than a clinical interview, making it difficult to determine subtleties in the appraisal of eating disorders. Finally, emotional abuse or neglect were not included either prospectively or retrospectively, although numerous studies have reported significant associations with bulimia nervosa.

Conclusion

These findings raise questions about the best way to study risk factors for the development of eating disorders. Although these results did not show that individuals with documented histories of childhood maltreatment were at increased risk of anorexia nervosa or bulimia nervosa, we found that subjective perceptions of childhood experiences mattered for anorexia nervosa symptoms. Clinical interventions in the field of eating disorders have emphasized the importance of a person’s previous life experiences (Brewerton, 2007). This work also suggests that etiological studies may need to focus on individuals’ personal accounts of their childhood experiences, not necessarily the objective experiences, and has implications for the design of research to understand mechanisms through which childhood maltreatment leads to eating disorders. At the same time, studies with objectively defined samples of maltreated children should be undertaken to understand why some maltreated children develop eating disorders and others do not. Finally, researchers and clinicians should consider these differences in findings based on objective case histories and retrospective recollections of childhood experiences, particularly when drawing inferences about the nature of these relationships and designing appropriate interventions.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by grants from NIMH (MH49467 and MH58386), NIJ (86-IJ-CX-0033 and 89-IJ-CX-0007), Eunice Kennedy Shriver NICHD (HD40774), NIDA (DA17842 and DA10060), NIAAA (AA09238 and AA11108), NIA (AG058683), and the Doris Duke Charitable Foundation. Points of view are those of the authors and do not necessarily represent the position of the US Department of Justice. Anat Talmon is supported by the Haruv Institute postdoctoral fellowship and by the Israel Science Foundation.

ORCID iDs

Anat Talmon

Cathy Spatz Widom

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