Treatment-seeking for eating disorders among adolescents: Implications for mental health literacy campaigns

Nora Trompeter
Nora Trompeter, BPsych(Hons), is a PhD candidate within the Centre for Emotional Health, Macquarie University, Sydney, Australia. Nora's research is focused on understanding how eating disorders develop in adolescents. Specifically, she investigates how emotion regulation difficulties contribute to eating disorder development and maintenance among adolescents. Her other research interests include bullying and peer victimisation, social anxiety and body image concerns.

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Abstract

Eating disorders commonly occur during adolescence, however, only a minority (10-25%) of affected adolescents receive appropriate treatment. This is especially concerning given the severity and protracted course of eating disorders, that often continue into adulthood. In the current study we examined if adolescents in treatment for an eating disorder differ from those not receiving treatment in the hope to learn more about potential targets to encourage treatment seeking.

Background

Eating disorders include a range of clinical disorders that encompass disordered eating and weight control behaviours (e.g., dietary restraint, binge eating), and are often accompanied with heightened body dissatisfaction (American Psychiatric Association, 2013). Most eating disorders have an onset during adolescence (Nagl et al., 2016), making this a critical time for intervention. However, treatment-seeking among adolescents for eating disorders is low compared to other mental health problems. For example, research has indicated that among adolescents in the US only 12.8% of adolescents with an eating disorder accessed treatment, as opposed to 37.7% of adolescents who access treatment for a mood disorder (Merikangas et al., 2011). Similar findings have been reported in Australia, where research found that only 10% of adolescents with an eating disorder reported having sought treatment (Fatt et al., 2019).

Factors relating to treatment-seeking

In order to address this gap in treatment-seeking, it is crucial to understand factors relating to treatment-seeking. This information can inform public health campaigns aiding recognition of symptoms. In the context of eating disorders, much of the existing research has focused on demographic factors. For example, research consistently shows that girls are more likely to access treatment compared to boys, and similarly older adolescents are more likely to access treatment compared to younger adolescents (Forrest, Smith, & Swanson, 2017). However, less is known about whether specific eating disorder symptoms are related to seeking help. While there is research indicating that purging behaviours (i.e., self-induced vomiting or misuse of laxatives) are associated with a higher likelihood of treatment-seeking (Forrest et al., 2017), other eating disorder behaviours have not been explored.

The current study

We aimed to examine how adolescents who met criteria for an eating disorder from a community sample and who were not receiving treatment differed from those from a clinical sample who were currently receiving treatment. Specifically, the study examined if differences existed in eating disorder behaviours (fasting, purging, binge eating, and driven exercise), weight/shape concerns, body mass index (BMI), and general psychological distress.

Participants in the community were part of a large longitudinal questionnaire-based study of eating disorders and body image concerns among 5191 Australian high school students (Trompeter et al., 2018). The current study used data from participants aged 13-19 years, whose self-reported data yielded symptoms meeting criteria for an eating disorder, but further indicated having never sought treatment for a body image problem (n = 1011). Participants from the clinical sample were part of the TrEAT study (n = 283), a clinical database of people attending treatment services (private practices, dietician services, private hospitals, etc.) for an eating disorder. Measures in both samples included the weight/shape concerns subscale of the eating disorder examination questionnaire (EDE-Q; Fairburn, Cooper, & O’Connor, 2008), questions regarding frequency of eating disorder behaviours from the EDE-Q, the Kessler Psychological Distress Scale (K10; Kessler et al., 2002), and demographic questions.

Findings

Results showed that adolescents with lower BMI, higher weight/shape concerns, and more frequent purging behaviors were more common in the clinical sample compared to the community sample. By contrast, adolescents who engaged in more frequent driven exercise for weight loss were more common in the community sample compared to the clinical sample. While adolescents in the clinical sample engaged in more frequent binge eating and fasting compared to those in the community sample, these differences were better explained by other factors (i.e., BMI, weight/shape concerns, purging, driven exercise). Once diagnosis was controlled for, BMI was no longer significantly different between the two samples. Importantly, general psychological distress did not differ between the two samples.

Implications

These findings add to the body of research highlighting the role of symptom severity in treatment-seeking. However, the current research also indicates that specific eating disorder behaviours may be more closely related to treatment-seeking. In particular, findings regarding driven exercise may indicate that engaging in driven exercise is not perceived as a ‘red flag’ of eating disorder pathology to the same extent as purging. Public health campaigns might benefit from raising awareness about distinguishing between healthy levels and motivations for exercise versus compulsive exercise behaviour, which may be indicative of underlying psychological problems (e.g., feeling guilty when missing a gym session).

Furthermore, the current study indicated that BMI is associated with treatment-seeking among adolescents due to the high levels of anorexia nervosa (an eating disorder characterised by underweight) in the treatment-seeking sample. Increasing awareness for non-underweight eating disorders among adolescents may be particularly important in increasing early treatment-seeking. Research consistently shows that adults with eating disorders are more likely to receive treatment for weight loss than they are for their eating disorder (Hart, Granillo, Jorm, & Paxton, 2011). However, this focus of treatment may inadvertently exasperate eating disorder pathology by focusing on weight loss, and it is also well documented that non-underweight disorders are equally if not more impairing than underweight eating disorders.

Lastly, the study highlighted the high levels of distress experienced by both adolescents receiving treatment and not receiving treatment, indicating an unmet need for psychological interventions as untreated eating disorders are not benign.

Conclusions

In the current study we found that adolescents with eating disorders experience high levels of psychological distress, regardless of whether they are seeking treatment. However, purging behaviours, high weight/shape concerns and low body weight may be linked to increased treatment-seeking.

Conflicts of interest

The author was the leading author of the study presented in this article.

Differences between Australian adolescents with eating disorder symptoms who are in treatment or not in treatment for an eating disorder https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13027

Other references:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington,DC: Author.

Fairburn, C. G., Cooper, Z., & O’Connor, M. E. (2008). Eating Disorder Examination. In Cognitive behavior therapy and eating disorders (16th ed., pp. 265–308). New York: Guilford Press.

Fatt, S. J., Mond, J., Bussey, K., Griffiths, S., Murray, S. B., Lonergan, A., … Mitchison, D. (2019). Help-seeking for body image problems among adolescents with eating disorders: findings from the EveryBODY study. Eating and Weight Disorders : EWD. https://doi.org/10.1007/s40519-019-00759-9

Forrest, L. N., Smith, A. R., & Swanson, S. A. (2017). Characteristics of seeking treatment among U.S. adolescents with eating disorders. International Journal of Eating Disorders, 50(7), 826–833. https://doi.org/10.1002/eat.22702

Grillot, C. L., & Keel, P. K. (2018). Barriers to seeking treatment for eating disorders: The role of self-recognition in understanding gender disparities in who seeks help. International Journal of Eating Disorders, 51(11), 1285–1289. https://doi.org/10.1002/eat.22965

Hart, L. M., Granillo, M. T., Jorm, A. F., & Paxton, S. J. (2011, July). Unmet need for treatment in the eating disorders: A systematic review of eating disorder specific treatment seeking among community cases. Clinical Psychology Review, Vol. 31, pp. 727–735. https://doi.org/10.1016/j.cpr.2011.03.004

Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L. T., … Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959–976. https://doi.org/10.1017/s0033291702006074

Merikangas, K. R., He, J. P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., … Olfson, M. (2011). Service utilization for lifetime mental disorders in U.S. adolescents: Results of the national comorbidity surveyAdolescent supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 32–45. https://doi.org/10.1016/j.jaac.2010.10.006

Nagl, M., Jacobi, C., Paul, M., Beesdo-Baum, K., Höfler, M., Lieb, R., & Wittchen, H.-U. (2016). Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults [Article]. European Child & Adolescent Psychiatry., 25(8), 903–918. https://doi.org/10.1007/s00787-015-0808-z

Trompeter, N., Bussey, K., Hay, P., Mond, J., Murray, S. B., Lonergan, A., … Mitchison, D. (2018). Fear of Negative Evaluation and Weight/Shape Concerns among Adolescents: The Moderating Effects of Gender and Weight Status. Journal of Youth and Adolescence, 47(7), 1398–1408. https://doi.org/10.1007/s10964-018-0872-z

 

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