Editorial: Adverse Childhood Experiences and Disordered Eating Behaviors: Specific Associations and Individual Implications

Abstract

Potential associations between adverse childhood events and disordered eating have been a topic of research interest for decades, often focused on specific types of child abuse.¹ More recent research has included a wider variety of adverse childhood events, including parental illness or absence.^2,3 The idea that such adversity triggers disordered eating has caught the eye of media and has become socially accepted, with films such as To the Bone focusing on a character’s struggle with an eating disorder in the wake of her parents’ divorce and emotional absenteeism.⁴ Portrayals like this risk oversimplifying complex situations and individual experiences for dramatic purposes and, without additional work to convey risk, lead the public to believe that disordered eating, or eating disorders, are inevitable outcomes of many adverse childhood events. This makes it important for researchers to better understand, and communicate, how individual adverse childhood events relate to specific disordered eating behaviors, as well as what factors may mediate associations between exposures and outcomes.

Potential associations between adverse childhood events and disordered eating have been a topic of research interest for decades, often focused on specific types of child abuse.¹ More recent research has included a wider variety of adverse childhood events, including parental illness or absence.^2,3 The idea that such adversity triggers disordered eating has caught the eye of media and has become socially accepted, with films such as To the Bone focusing on a character’s struggle with an eating disorder in the wake of her parents’ divorce and emotional absenteeism.⁴ Portrayals like this risk oversimplifying complex situations and individual experiences for dramatic purposes and, without additional work to convey risk, lead the public to believe that disordered eating, or eating disorders, are inevitable outcomes of many adverse childhood events. This makes it important for researchers to better understand, and communicate, how individual adverse childhood events relate to specific disordered eating behaviors, as well as what factors may mediate associations between exposures and outcomes.

The article on the PLATE Study by Martin et al.⁵ in this issue of JAACAP Open examines cross-sectional associations between 9 individual adverse childhood events (ACEs) and 5 disordered eating behaviors (DEBs) in a large, nationally representative sample of American youth (N = 47,617). Parent-reported ACEs consist of (1) household mental illness, (2) household violence, (3) household substance use, (4) economic insecurity, (5) parental separation, (6) parental death, (7) parental incarceration, (8) neighborhood violence, and (9) racial discrimination. Included DEBs are (1) picky eating, (2) fasting, (3) binge eating, (4) excessive exercise, and (5) compensatory behaviors (which included vomiting, diet pills, diuretics and laxatives). Results demonstrated strong associations between all DEBs and household mental illness as well as economic insecurity. Weaker associations were found between DEBs and neighborhood violence, household violence, and household substance use that did not all remain significant in analyses adjusted for sex, age, ethnicity, and special health care needs. Additional analyses showed that for youth exposed to household mental illness, both depression and anxiety mediated the relationship between exposure and DEBs. Similar patterns were observed for household substance, parental separation or divorce, and racial discrimination. Moreover, food insecurity accounted for significant portions of the associations between economic insecurity and bingeing, fasting, or picky eating. Furthermore, family resilience (operationalized as greater frequency of family communication, problem solving, and adaptive coping strategies) and frequent family meals were both associated with lower rates of DEBs, although their effects were less prominent in the presence of economic insecurity, household mental illness, or parental separation, respectively.⁵

The authors conclude that their findings extend prior work on psychosocial challenges and youth mental health symptoms by demonstrating associations between specific ACEs and both restrictive and compulsive eating behaviors. They state that the variation in effect sizes among the different adverse events observed highlights the need to assess ACEs individually rather than as a cumulative score, to understand specific vulnerabilities and/or to identify targets for screening, prevention, and early intervention. Specifically, the authors identify internalizing symptoms, food insecurity, and family processes as potentially modifiable risk factors to prevent disordered eating behaviors before also advocating for DEB interventions for vulnerable youth and their families.⁵

Strengths of this study include its large, nationally representative sample of youth as well as its thoughtful statistical analyses including stratifying models by race and ethnicity. Results highlight how prevalent selective or restrictive DEBs are among American youth (19% and 12% respectively) and their associations with specific ACEs. As indicated by the authors, these findings build on prior research that has shown associations between the number of ACEs and disordered eating or between family function and disordered eating, and strengthens calls for preventive care that includes caregivers or addressing basic needs of youth (ie, food security). The primary limitations are its observational design and use of parent-reported ACEs, which may not adequately capture youth experiences either because parents are reticent to report adverse events or may not be aware of all of the adverse events that their children have experienced.

Clinically, results identify family meals, family communication, problem solving, and adaptive coping strategies as modifiable risk factors that can be targeted by health care providers. Other modifiable mediators such as food insecurity or untreated anxiety or depression fall within the scope of public health initiatives. Results also suggest that clinicians who are aware of individual youth’s experiences of ACEs should be alert for the emergence of disordered eating behaviors. Likewise, they reinforce calls for clinicians to screen for traumatic experiences or adverse events in youth with eating disorders and either develop effective trauma-informed interventions for youth or modify existing treatment so as not to perpetuate additional harms.^6,7

The need for trauma-informed care that considers patients as individuals with unique needs is a recurrent theme in lived experience reflection or commentaries on eating disorder treatment.^6,7 Principles of trauma-informed care include the following: (1) awareness and acknowledgement, (2) building safety and trust, (3) choice, control, and collaboration, (4) strengths-based and/or skills-building care, and (5) sensitivity to cultural, historical, and gender issues.⁸ Individuals with lived experience have also challenged oversimplified narratives about eating disorder etiology, noting that not all affected individuals have past experiences of ACEs and that clinicians “digging for trauma” have been harmful to them.⁷ Similarly, they have criticized a perceived “hierarchy of harms” that is able to acknowledge some, but not all, traumatic events, based on clinicians’ perceptions of severity.⁷ These perceptions can negatively affect patient care unless challenged by a focus on individuals’ past experiences and unique care needs. Unlike the protagonist in To the Bone,⁴ not everyone with disordered eating behaviors needs to be bottle-fed by a caregiver to change their disordered behaviors or to recover from an eating disorder.

Practically, the results of Martin et al.’s research challenge us as researchers, clinicians, and policy makers to implement disordered eating prevention and intervention strategies for youth that are informed by what we know about relationships between specific DEBs and ACEs, while also individualizing care. This is a central tension in evidence-based medicine—working to operationalize the best evidence that we have at the group or population level, while acknowledging that statistical significance will not necessarily be personally significant for individuals. Nowhere may this balance be more important than when addressing trauma or adverse events, given the above-mentioned principles of trauma-informed care.

Finally, it is recommended that the design and implementation of individual, caregiver, and societal or public health interventions that target disordered eating behaviors prioritize lived experience engagement to ensure their relevance and effectiveness. The eating disorder field continues to struggle to escape the yoke of dated stereotypes about gender, ethnicity, and body shapes⁹ and cannot afford to create further stereotypes of how adverse events lead to disordered eating or eating disorders. Instead, let us use the results of novel research such as that in this issue to feed the narrative that eating disorders are complex disorders that affect diverse individuals with personalized risk factors and unique care needs. We have an obligation to better understand and to treat without causing further harm.