The Development of Eating Attitude Test Scores in

Adolescence

Alison Wood Glenn Waller John Miller Peter Slade

(Accepted 1 August 1990)

Age-related norms are presented for adolescent girls completing the Eating Atti- tudes lest (EAT). The relevance of developmental changes (increased Dieting and lower Oral Control) is discussed for clinicians and researchers using the EAT to ‘screen’ for pathological eating patterns.

The Eating Attitudes Test (EAT) was developed by Garner & Garfinkel (1979; Garner, Olmsted, Bohr, & Garfinkel, 1982) as a measure of the pathological at- titudes and behaviors that are associated with anorexia and bulimia nervosa. The questionnaire is not reliable for identifying diagnosable cases in psychiatric practice, due to its rates of false positives and negatives (Williams, Hand, & Tarnopolsky, 1982). However, it is useful in identifying psychopathologies where abnormal eating patterns are an important feature (Button & White- house, 1981; Garner et al., 1982).

A number of clinicians and researchers have used the EAT with adolescent females. Generally, they have used it as a screening device in attempts to iden- tify or predict likely cases of eating disorders (e.g., Johnson-Sabine, Wood, Pat- ton, Mann, & Wakeling, 1988; Whitaker, Davies, Shaffer, Johnson, Adams & Kalikov 1989). Using the EAT with this age group seems to be potentially valu- able, since a large proportion of eating disorders will develop during adoles- cence (Halmi, Casper, Eckert, Goldberg, & Davis, 1979). However, in deciding

Alison Wood, M.Bch.B., M.R.C.Psych., D.R.C.O.G., D.C.H. is a Senior Registrar in Child and Adoles- cent Psychiatry at the Royal Manchester Children’s Hospital. Glenn Waller, B.A., D.Phil., M. Clin Psy- chol., is a Lecturer in Clinical Psychology at the University of Manchester. John Miller, M.Bch.B., M.R.C.C.P., D.R.C.O.C., D.C.H., i s a General Practitioner and School Medical Officer in Manchester. Peter Slade, B.A., M.Phil., Ph.D., i s Professor in Clinical Psychology at the University of Liverpool. Ad- dress correspondence and reprint requests to Dr. Glenn Waller, University of Manchester, Academic Clinical Psychology Unit, Department of Psychiatry, University Hospital of South Manchester, West Didsbury, Manchester M20 8LR, U.K.

International journal of Eating Disorders, Vol. 11, No. 3, 279-282 (1992) 0 1992 by John Wiley & Sons, Inc. CCC 0276-3478/92/030279-04$04.00

2 80 Wood et al.

whether a particular score on such a questionnaire is abnormal, it is important to understand the normal scores for that measure.

Normative EAT data have been reported for adults. It is unwise to depend upon these norms in assessing adolescents, since there is evidence that their attitudes to food, fasting, and dieting vary with age. For example, Whitaker et al. (1989) have reported age-related norms for U.S. female adolescents, show- ing that scores on the EAT increase between 13 and 18 years. The present pa- per presents more extensive norms (including the subscales of the test and scores for younger subjects) for U.K. female adolescents. It is important to have such developmental norms for this population, given the generally less ’pathological’ EAT scores of non-U.S. adolescents (e.g., Williams, 1987). As late adolescence is a high-risk period for developing eating disorders (Halmi et al. , 1979), it is hypothesized that there will be a trend with age towards in- creasingly ’pathological’ eating attitudes during adolescence. More specifically, the EAT scores of older adolescents should be higher, and more of these older girls should score above the cut-off level (20) that Garner et al. (1982) have sug- gested as indicative of possible anorexic or bulimic ’caseness.’

METHODS

Subjects

The entire population of a private girls’ school (502) was asked to participate. The families were generally of a high socioeconomic status. However, Rosen, Silberg, & Gross (1988) concluded that this factor does not affect EAT scores substantially, so that the present results should be widely generalizable. The girls and their parents were informed of the nature of the research, and were given the option of refusing to participate. One girl was withdrawn by her par- ents and 12 were absent on the day of testing. Of the remaining 489 girls, 475 (97%) completed the questionnaire appropriately. For the purpose of establish- ing a developmental picture, the girls were divided into three age groups- 11- 12, 13- 14, and 15- 16 years.

Measures

The EAT consists of a set of statements about eating patterns and attitudes to food and body. Respondents can give one of six answers to each statement, ranging from ’never’ to ’always.’ The girls completed the 26-item version of the questionnaire (Garner et al., 1982). This version includes scales relating to avoidance of fattening foods (Dieting), bulimia and food preoccupation (Bu- limia), and personal and social control of eating behavior (Oral Control).

RESULTS

Table 1 shows the mean scores on the EAT-26 and its three scales for each age group, as well as for the whole sample. The EAT-26 total tended to in- crease with age, as did the scores on the Dieting and Bulimia scales. However, there was a tendency for older girls to score lower on the Oral Control scale.

Development of Eating Attutudes 281

Table 1. Developmental norms for the EAT.

Overall

n Scale

EAT-26 (s.d.)

Dieting (s.d.)

Bulimia (s.d.)

Oral Control (s.d.)

475

6.60 (8.09) 4.67

(6.23) 0.40

(1.37) 1.52

(2.22)

Age (Years)

11-12 13-14 15-16 F p Reliability

137 185 153 - - -

5.73 6.58 7.40 1.51 n.s. 0.87 (7.35) (8.07) (8.69) 3.67 4.75 5.47 3.04 .05 0.88

(5.27) (6.34) (6.79) 0.24 0.42 0.52 1.54 n.s. 0.73

(0.81) (1.46) (1.64) 1.83 1.41 1.37 1.96 n.s. 0.52

(2.52) (2.13) (2.02) ~

n.s. = not significant.

Table 1 also shows that the reliabilities of the scales (using Cronbachs alpha as a measure of internal consistency) were similar to those reported for adults (Garner et al., 1982).

One-way analyses of variance (two-tailed) were used to test the reliability of the differences with age. The only significant difference was in the girls' re- sponses on the Dieting scale [F(2,472) = 3.04; p < .05]. This difference was due to the oldest group having a significantly greater Dieting score than the 11- to 12-year-olds [Tukey's HSD - p < .05].

Discriminant Function Analysis was used to determine whether a combina- tion of the three subscales might be more effective than the single scales in dif- ferentiating the age groups. The analysis showed that a single function, consisting of the Dieting and Oral Control scales, differentiated the groups overall [F = 3.34; p < .02]. While there was no difference between the two older groups [F(2,471) = 0.61; p = .54], the 11- to 12-year-olds were signifi- cantly differentiated from both the 13- to 14-year-olds [F(2,471) = 3.78; p < .025] and the 15- to 16-year-olds [F(2,471) = 6.11; p < .005]. To summarize, there was a developmental pattern in the girls' responses on

the EAT-26. The older girls were differentiated from the youngest group by higher scores on the Dieting scale and lower scores on the Oral Control scale.

These differences were accompanied by a higher proportion of older girls scoring in the 'pathological' range. Overall, 42 (8.8%) of the girls scored above the EAT-26 cut-off point of 20+ (Garner et al., 1982), a similar 'at-risk' rate to that found by Johnson-Sabine et al. (1988) in a U.K. sample, but lower than the rate reports for U.S. adolescents (Whitaker et al., 1989). This proportion in- creased across the three age groups (4.4%, 9.2%, and 12.4%, respectively). The association of age group and 'at-risk' status was significant [Chi-square (two- tailed) = 6.02, df = 2, p < .05].

DISCUSS I ON

Any clinician or researcher who uses the EAT as a screening device for ab- normal eating attitudes in adolescence will need to understand the normal de- velopment of those attitudes. The present research was designed to provide

282 Wood et al.

age-appropriate norms for adolescent girls on the EAT and to demonstrate age- related changes in eating attitudes.

The scores for U.K. girls are markedly lower than those of a similar age group in the U.S., confirming the need for culture-specific norms. The overall score increased with age, as reported by Whitaker et al. (1989). There was also a marked increase with age in the proportion of girls who were in the 'at-risk' range of 20-t. Therefore, our concept of an 'abnormal' EAT-26 score in adoles- cence needs to vary with the age of the child. A score that is in the normal range for a 16-year-old may be signal of pathological attitudes to food in a younger teenager.

The normal change in eating attitudes in adolescence is largely accounted for by an increasing tendency towards restricting intake (Dieting) and a reduced preoccupation with personal and social control of eating (Oral Control). In con- trast, the development of anorexic and bulimic disorders is associated with in- creases on all three scales. This pattern suggests that early screening of adolescent populations should pay particular attention to abnormal increases in the Oral Control and Bulimia scales, since a small rise in the Dieting score alone may be a normal developmental feature.

Our thanks are due to the girls who participated in this study, their families, and the staff of the school for their cooperation.

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Halmi, K. A., Casper, R. G., Eckert, E. D., Goldberg, S. C., & Davis, J. M. (1979). Unique features associated with age of onset of anorexia nervosa. Psychiatry Research, 2 , 209-215.

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