Body Image Disturbance in Children and Adolescents with Eating Disorders
Current Evidence and Future Directions
Abstract
Body image is multifaceted and incorporates perceptual, affective, and cognitive components as well as behavioral features. Only few studies have examined the character of body-image disturbance in children/adolescents with eating disorders. It is unknown whether body-image disturbances in children/adolescent with eating disturbances are comparable to those of adult patients with eating disorders. Body-image disturbance might differ quantitatively and qualitatively according to the cognitive developmental status and the age of the individual. This paper provides an overview of the current evidence for body-image disturbance in children/adolescents with eating disorders, and how they compare with those adults with eating disorders. Current evidence indicates that older adolescent patients show similar deficits as adult patients with eating disorders, in particular for the attitudinal body-image component. However, evidence for a perceptual body-image disturbance in adolescent patients, in particular anorexia nervosa, is not conclusive. Reliable statements for childhood can hardly be made because clinical studies are not available. Investigations of body-image disturbance in children have focused on the predictive value for eating disorders. Limitations of the current evidence are discussed, and future directions for research and therapy are indicated.
Unter Körperbild versteht man ein multimodales Konstrukt mit einer perzeptiven, affektiven, kognitiven und behavioralen Komponente. Nur wenige Studien haben Charakteristika von Körperbildstörungen spezifisch bei Kindern/Jugendlichen mit Essstörungen untersucht. Daher besteht bisher nur wenig Wissen darüber, ob Störungen des Körperbildes bei Kindern/Jugendlichen mit Essstörungen denen erwachsener Patientinnen mit Essstörungen gleichen oder ob sich die Körperbildstörung möglicherweise z. B. aufgrund der unterschiedlichen kognitiven Entwicklungsstadien in Abhängigkeit vom Alter quantitativ und qualitativ unterscheidet. Der vorliegende Artikel zielt zum einen darauf ab, die bisherige Befundlage zur Körperbildstörung bei Kindern/Jugendlichen darzustellen und zum anderen die Ergebnisse bei Kindern/Jugendlichen mit denen erwachsener Populationen zu vergleichen, um Empfehlungen für weitere Forschung und Therapie herauszuarbeiten. Die aktuelle Befundlage weist darauf hin, dass ältere adoleszente Patientinnen vergleichbare Auffälligkeiten wie erwachsene Patientinnen mit Essstörungen zeigen, insbesondere hinsichtlich der affektiv-kognitiven Körperbildkomponente. Hinweise auf eine perzeptive Körperbildstörung bei jugendlichen Patientinnen, vor allem mit einer Anorexia nervosa, sind allerdings nicht einheitlich. Für das Kindesalter lassen sich kaum Aussagen treffen, da hier vor allem körperliche Unzufriedenheit als Prädiktor für die Entwicklung von Essstörungen untersucht wurde und systematische Untersuchungen in klinischen Populationen fehlen. Einschränkungen der bestehenden Studienlage werden diskutiert und Hinweise für mögliche zukünftige Forschungsarbeiten und therapeutische Interventionen gegeben.
Introduction
Extensive research over the last two decades has addressed the question whether body-image disturbance plays a role in the development of mental disorders, particularly as a precursor for eating disorders (e.g., Evans, Tovée, Boothroyd, & Drewett, 2013; Shroff & Thompson, 2006). Body image as the “picture we have in our minds of the size, shape and form of our bodies; and [...] our feelings concerning these characteristics and our constituent body parts” (Slade, 1988) is a multifaceted construct. When referring to body image, most researchers think about body-image evaluation or satisfaction (Thompson, 2004). As a consequence, there is much research on these attitudinal aspects; in particular, most research was conducted regarding the relevance of body-image disturbance for the development of eating disorders. Extending the definition of body image by Slade (1988), body image as we understand it today incorporates perceptual, affective, and cognitive components as well as behavioral features (Thompson, 2004). The perceptual component describes the ability of an individual to accurately perceive his/her body shape and size, either relating to the whole body or specific body parts. The cognitive-affective/attitudinal component relates to the evaluation of one’s own body and to the degree to which this evaluation provokes distress or concern as well as how weight and shape-related thoughts and core beliefs influence self-evaluation (Voßbeck-Elsebusch, Vocks, & Legenbauer, 2013). There are different labels for this aspect of body image, possibly leading to confusion. Some authors use the term “affective-cognitive” component, which is in accordance with the attitudinal body-image component described above and points to body dissatisfaction (e.g., Allen, Byrne, McLean, & Davies, 2008); others describe body-related cognitions separately from affective aspects (Voßbeck-Elsebusch et al., 2013; Vocks, Legenbauer, Rüddel, & Troje, 2007). Some authors further distinguish body-image attitudes into an evaluative-affective and a cognitive-behavioral investment dimension, with the former reflecting attitudes of self-evaluation and the latter motivational aspects (Thompson, 2004). The behavioral component of body image includes body-related checking (e.g., frequently weighing oneself) and avoidance (e.g., wearing too large clothing to hide one’s body shape) behavior that might also be responsible for the maintenance of the disturbed body image, because it prevents positive and corrective body-related experiences (Shafran, Fairburn, Robinson, & Lask, 2004).
Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are among the most common clinical problems encountered by adolescent girls and young women (Thompson & Smolak, 2001) and present with body-image disturbance as key symptoms. Patients with a diagnosis of AN see and feel their own body (in particular thighs, abdomen, and buttocks) as being fatter than they in fact are (e.g., Cash & Deagle, 1997). In addition, they report an intense fear of becoming overweight or “fat.” Both core symptoms are included in the diagnostic criteria of the fifth version of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) as follows: B) “intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significant low weight” and C) “disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight” (American Psychiatric Association, 2013, pp. 338–339). For BN, on the other hand, the criterion D) “Self-evaluation is unduly influenced by body shape and weight” (American Psychiatric Association, 2013, p. 345) refers to body-image disturbance. Thus, in AN both perceptual and affective-cognitive aspects of body-image disturbance are classified, whereas in BN the criteria are related to affective-cognitive aspects only, although previous research also points to the existence of body size misperception in BN (Vocks et al., 2007).
Several studies emphasize the enormous effects of body-image disturbance on childhood development (Westerberg-Jacobson, Edlind, & Ghaderi, 2010; Shroff & Thompson, 2006), maintenance and relapse (Williamson, Stewart, White, & York-Crowe, 2002) of eating disorders. Although over the past decade, research efforts led to strong evidence for the existence of body-image disturbance in adult females with eating disorders (e.g., Shafran et al., 2004; Vocks et al., 2007), only a few studies examined the character of body-image disturbance in children or adolescents with eating disorders. Body image research is of special relevance for this age group for the following reasons:
- 1.The physical appearance is a particularly salient concern among adolescents (Hamel, Zaitshoff, Taylor, Menna, & Le Grange, 2012), possibly because attractiveness is highly important for positive peer regard (Becker & Luthar, 2008).
- 2.There is a stronger association between body-related social comparison processes and eating disorders in adolescents compared to adults (Jackson & Chen, 2006).
- 3.The onset of AN is in early and for BN in late adolescence, and AN represents the highest incidence rate particularly for females aged 15–19 years (Gowers & Bryant-Waugh, 2004).
Based on these considerations, the present paper provides an overview of the current evidence for body-image disturbance in children and adolescents with eating disorders and suggests future directions for research and therapy. We conducted a literature research in Pubmed and PsychLIT with the following keywords: body image, eating disorders, anorexia nervosa, bulimia nervosa, adolescents, children, drive for thinness, and body dissatisfaction. In addition, we reviewed citations from relevant articles to locate any additional studies.
A Theoretical Framework of Body-Image Disturbance in Eating Disorders
Various cognitive-behavioral frameworks on the understanding of the association of body-image disturbance and eating disorders have been developed in recent years. In these models, body-image disturbance is explained by automatic cognitive processes including biased interpretation of food-, weight- and shape-related stimuli, particularly when they are ambiguous or self-relevant (Williamson, Perrin, Blouin, &, Barbin, 2000). The unconsciousness of information processing would also explain the stable negative body image despite the actual low body weight (Stewart, 2004; Williamson, 1996). Several studies support the hypothesis that body-size overestimation is due to attentional, nonsensory factors and represents an information-processing rather than a perceptual deficit (e.g., Williamson, 1996). There is evidence that cognitions related to the dysfunctional body image are negatively associated with worries about physical attractiveness (Davis, Claridge, & Fox, 2000). Research supporting the role of deficits in information processing is evident in recent visual attention studies (Smeets, Jansen, & Roefs, 2011; Jansen, Nederkoorn, & Mulkens, 2005). Jansen and colleagues (2005) provide evidence of a selective attentional bias on negatively evaluated body areas in women with eating disorder symptoms when looking at pictures of their own body, whereas controls attend to more attractively evaluated body parts of their own body. Smeets, Tiggemann et al. (2011) showed that body checking leads to an attentional bias toward body-related cues in a nonclinical sample, which was associated with heightened body awareness. Horndasch and colleagues (2012) found an overall bias for specific body parts in adolescent girls, i.e., abdomen, hips, buttocks, and upper legs when looking at pictures of underweight, normalweight, and overweight women, whereas girls with an AN showed a specific attentional bias toward unclothed body parts, representing the overevaluation of shape and weight.
An extensive body of research provides evidence that the internalization of the thin ideal influences the development of body-image disturbance by enhancing the risk of a cognitive bias (Williamson, White, York-Crowe & Stewart, 2004; Stice & Shaw, 2002). Thin-ideal internalization is defined as “... the extent to which one cognitively ‘buys into’ socially defined ideals of attractiveness and engages in behavior designed to produce an approximation of these ideals” (Thompson & Stice, 2001, p. 55). Children and adolescents are exposed to thin beauty ideals comparable to adults and are aware of the media messages as early as the age of six (Murnen, Smolak, Mills, & Good, 2003). It is well established that high levels of internalization of the thin ideal significantly predict body dissatisfaction and disordered eating attitudes (Evans et al., 2013). Beside the media (Groesz, Levine, & Murnen, 2002), also familial factors contribute to the degree to which the thin beauty ideal is internalized (Kearney-Cooke, 2002). It is assumed that the development of one’s body image is influenced by the attitude toward weight, shape, and eating behavior (e.g., dieting) as directed by family members (e.g., Benninghoven, Tetsch, Kunzendorf, & Jantschek, 2007). The mother’s own body image seems to be of higher importance compared to that presented by the father or siblings, probably because of her function as a female role model (e.g., Taylor et al., 2006). Two possible ways of transmission are proposed (Cooley, Toray, Wang, & Valdez, 2008): The first comprises the indirect pathway and postulates that family members are role models for the adoption of weight-, shape-, and eating-related attitudes, the mother being the most prominent and dominant. The second one includes the direct pathway, and indicates that the daughter’s body image is formed by direct comments by the parents on matters of weight, shape, and eating behavior. It is assumed that both pathways exist, since evidence from self-reports supports both the indirect and direct proposed transmission pathways (e.g., Cooley et al., 2008; van den Berg, Keery, Eisenberg, & Neumark-Sztainer, 2010).
Characteristics of Body-Image Disturbance in Eating Disorders
Perceptual Component
The perceptual component of body-image disturbance is assessed with a variety of methods referring to body parts or the whole body. The assessment procedures range from silhouette or figure drawings over movable calipers and distorting mirrors to video distortion with life-size screens or computer-based image distortion (for an overview, see Skrzypek, Wehmeier, & Remschmidt, 2001).
Recent evidence shows that overestimation of one’s own body size leads to unsafe weight loss behavior (e.g., dieting, skipping meals) in adolescent girls with normal weight (Liechty, 2010). Hence, it can be considered a precipitating factor for eating disorders.
For adolescents with a diagnosed AN, several studies over the last decade showed inconsistent results regarding the perceptual component of body image, with a majority of adolescent AN patients being able to accurately estimate their size. On the other hand, body-size overestimation and underestimation is also reported in adolescents (e.g., Henninghausen, Rischmüller, Heseker, Remschmidt, & Hebebrand, 1999; Skrzypek et al., 2001). For example, Henninghausen and colleagues (1999) investigated 36 inpatients with AN and 18 control patients (age 11–23 years) with a computer-based image-distortion technique that allowed distortion of the whole body as well as of body parts. They found more often overestimation or underestimation in adolescents with AN than in control patients. A more recent study by Schneider, Frieler, Pfeiffer, Lehmkuhl, and Salbach-Andrae (2009) examined a large sample of inpatients and outpatients with both AN (restrictive subtype: 69, mean age 15.4; binge/purge subtype: 26, mean age, 16.2) and BN (34, mean age 17.1) as well as healthy female adolescents (354, mean age 15.2). The authors assessed body-size estimation with the Body Image Distortion in Children and Adolescents test (BID-CA; Schneider, Martus et al., 2009), which provided body distortion indices for the upper arm, waist, and thigh. On the BID-CA, the person is asked to use a string to form the perceived circumference from arm, waist, or thigh. Then, the length of the string is measured and the indices of body-image distortion are calculated by dividing the perceived size through the actual size (length of string when put around the body part) and multiplied with 100. The results show significant differences between adolescent eating disorder patients and controls. While controls were mostly accurate with an overestimation of the body parts between 8% (thigh) and 16% (arm, waist), adolescent eating disorder patients report on average 30% overestimation (ranging from 25% (arm) to 40% (waist)). Thigh and waist indices revealed the best discriminating evidence. There were no differences between AN subtypes and BN. The same body-image distortion assessment technique (BID-CA) was applied by Salbach, Klinkowski, Pfeiffer, Lehmkuhl, and Korte (2007) in 58 adolescent patients with AN (mean age 15.5 years), who were compared to 56 high school girls (mean age 14.9 years). The results were similar to the study of Schneider, Frieler et al. (2009), revealing greater overestimation of body parts, in particular waist and thigh, compared to controls.
Cognitive-Affective/Attitudinal Component
There are different assessment methods to capture disturbance on the cognitive-affective/attitudinal component of body image. Mostly, self-report questionnaires for the assessment of the general degree of body dissatisfaction are used. Several of such instruments that are usually administered within adult samples are available for children and adolescents: The Eating Disorder Inventory (EDI-3, Garner, 2004) is available in an adaptation for children (EDI-C; Thiels, Salbach-Andrae, Bender, & Garner, 2011) as well as the Eating Disorder Examination Questionnaire (Child-Eating Disorder Examination, Ch-EDE), which provides two subscales for weight- and shape-related concerns (Bryant-Waugh, Cooper, Taylor, & Lask, 1996).
There is extensive research in nonclinical samples of children and adolescents assessing body dissatisfaction. The role of body dissatisfaction through a disturbed body image is defined as the negative evaluation of one’s body or body parts (Allen et al., 2008). For instance, this may include discontent with the size of one’s thighs, hips, waist, buttocks, or breasts, and thus introduces strong negative feelings toward own appearance (Tremblay & Limbos, 2009). A wealth of studies show that body dissatisfaction frequently occurs in advance of puberty and can even be observed in preschool children (for a review, see Tremblay & Limbos, 2009). Evans and colleagues (2013) report body dissatisfaction to be present in 40% to 50% of girls between 7 and 11 years, who, for example, wish to have a thinner body than their current perceived shape, a finding supported by several other studies (e.g., Knauss, Paxton, & Alsaker, 2007; Westerberg-Jacobson et al., 2010). The drive for thinness was stronger when parents also reported disturbed eating behavior (Thiels & Schmitz, 2009). In addition, prospective studies show that body dissatisfaction is associated with an elevated risk for disturbed eating behavior such as dieting, irregular meals, or eating alone (Westerberg-Jacobson et al., 2010; Shroff & Thompson, 2008).
Results based on clinical samples are scarce. The study by Schneider, Frieler et al. (2009) described above reports significant differences between all eating disorder patients and controls for both attitudinal measurements as assessed with the EDI-2 (subscales “drive for thinness” and “body dissatisfaction”). They provide evidence that, whereas patients with AN from the binge eating/purging subtype did not differ significantly from patients with BN, the two subtypes of adolescent AN patients significantly differed from each other with patients from the restrictive subtype displaying lower values than those from the binge/purge subtype. These results indicate that binge eating/purging behavior is associated with severe attitudinal body-image impairments – not only compared to controls, but also to the restrictive forms of eating disorders. In line with these results, a Finnish study by Ruuska and colleagues (2005) in 57 adolescent outpatients with BN (age range 14- 21 years) found higher body dissatisfaction (assessed with the EDI-2) than in AN patients (Ruuska et al., 2005).
Behavioral Component
There are not as many studies as for the attitudinal and perceptual body-image components that address body-image avoidance or checking behavior. Avoidance and checking behaviors are assessed mostly via self-report (e.g., Legenbauer, Vocks, & Schütt-Strömel, 2007; Reas, Whisenhunt, Netemeyer, & Williamson, 2002; Rosen, Srebnik, Saltzberg, & Wendt, 1991; Vocks, Mooswald, & Legenbauer, 2008). Descriptive analyses revealed various behavioral features of avoidance behaviors in relation to activities that lead to exposure of one’s own body, e.g., not looking in the mirror, not going in a public swimming pool or sauna (e.g., Rosen, 1998) as well as checking behavior such as touching body parts (e.g., stomach or thighs) or inspecting certain body parts in a mirror. Further body-checking strategies reported are comparison of one’s size of that with other people as well as seeking feedback related to the size and form of one’s own body with those of others (Shafran et al., 2004; Reas et al., 2002). However, no clear differentiation between adolescents and adults were found in these studies. For example Shafran et al. (2004) report results of 64 females fulfilling criteria for an eating disorder with a mean age of 26.7 years (range = 14.9 to 56.1 years), only 16 of whom were younger than 18 years. Similarly, Reas et al. (2002) included women in the age range 15 to 51 years, although the age of the women with eating disorders was not separately reported. To date, to our knowledge no studies on body checking and avoidance behavior have focused exclusively on children and adolescents. Hence, the question remains open whether there are differences in the kind or degree of avoidance and checking behavior between adolescents and adults.
Neuronal Correlates of Body Image Disturbance in Eating Disorders
To date, several studies have been conducted in adolescents as well as in adults to investigate the neuronal correlates of body-image disturbance in eating disorders. The studies focused mainly on the reactivity of emotion-processing brain areas (e.g., amygdala) to the presentation of body-related stimuli (e.g., Seeger, Braus, Ruf, Goldberger, & Schmidt, 2002; Wagner, Ruf, Braus, & Schmidt, 2003). Preliminary evidence shows that female adolescents with AN display a more pronounced activity in the amygdala in response to the presentation of pictures of one’s own body which were individually distorted to the maximum of unacceptability (Seeger et al., 2002). However, in a study with the same paradigm, albeit a larger sample size (Wagner et al., 2003), the finding of the amygdala hyperreactivity was not replicated. Beyond the emotion processing brain regions, the extrastriate body area1 of the visual cortex has been shown to be of relevance in body-image disturbance in adult patients with AN (e.g., Suchan et al., 2012). However, to date, no studies with a focus on the extrastriate body area or its counterpart – the fusiform body area – have been conducted in adolescent and children with an eating disorder.
Limitations of the Current Evidence
In sum, there has been extensive research highlighting the importance of body-image disturbance for the development of eating disorders with a special focus on body dissatisfaction reflecting the attitudinal aspect in children and young adolescents in nonclinical samples. However, only few studies have examined body-image disturbance systematically in children or young adolescents with eating disorders. First evidence points to adolescent patients with eating disorders as holding just as negative attitudes toward their own body as adult patients do. However, only few studies compared body-image disturbance in AN and BN in adolescent patients, despite the evidence from adult research showing a more negative attitude toward their own body in BN patients compared to AN patients (e.g., Mizes, Heffner, Madison, & Varnado-Sullivan, 2004; Cash & Deagle, 1997). Only two studies provide evidence for similar diagnosis-specific discrepancies in adolescent patients with AN and BN (Ruuska et al., 2005; Schneider et al., 2009a). Finally, evidence for perceptual body-image disturbance in adolescent AN patients seems not to be conclusive. There are some limitations of the preliminary findings that need to be discussed.
First, so far, hardly any studies have compared child and adult populations, so it is unknown whether differences in body-image components exist due to different cognitive and emotional developmental states of children/adolescents and adults. In studies with clinical eating disorder samples, it is problematic that adolescents (age range from 13 to 18) and adults often form a single group. For example, in the study of Ruuska and colleagues (2005), the age range was from 14 to 21. As a consequence, differences in body-image characteristics between adolescent and adult samples – if present – cannot be separated. On the other hand, combining both in one group may be appropriate, since the problems associated with adolescence do persist beyond the age of 18 (Gowers & Bryant-Waugh, 2004). However, drawing conclusions from findings generated from adult samples should be considered with care regarding the validity in particular for young adolescents and children with eating disorders.
Another problem that arises is the difficulty in the assessment of psychopathology in children and young adolescents because of the lack of validated measurements for these groups. For example, body-size estimation techniques are described as adjustable for children as young as preschool age (Gardner, Friedman, Stark, & Jackson, 1999). However, cognitive development makes it difficult to determine what these techniques actually assess in preschool children compared to older children and adults (Tremblay & Limbos, 2009). When body-size estimation techniques are applied to children and young adolescents, various difficulties arise: First, most techniques are based on adult body morphology and do not consider variations in size due to growth and sexual maturation (Aleong, Duchesne, & Paus, 2007). Second, they do not provide norms for young age groups (Tremblay & Limbos, 2009). Results regarding the attitudinal component of body image have to be regarded with caution as well, because only few instruments are available that are adapted to the needs of young adolescents or children (e.g., EDI-C, ChEDE-Q) and if so, there still exist psychometric and practical drawbacks (for more details see Gowers & Bryant-Waugh, 2004).
There is initial evidence for specific neurobiological correlates of body-image disturbance in adolescents for emotional processing brain regions (Seeger et al., 2002; Wagner et al., 2003). However, research on adult females with AN and BN did not find the indicated amygdala hyperreactivity to body stimuli (Uher et al., 2005; Vocks et al., 2010). This conflicting preliminary evidence may be due to differences in the stimulus material used, because the presented stimuli in the adolescent sample showed the individual’s distorted body possibly elicited fear (Seeger et al., 2002; Wagner et al., 2003), whereas the adult samples had been confronted with either nondistorted photographs of one’s own body (Vocks et al., 2010) or line drawings of female bodies (Uher et al., 2005). In relation to the specific areas activated when body-related stimuli are processed such as the extrastriate body area, no evidence exists for adolescents or children. Because adults with eating disorders often display a high chronicity, it remains unclear whether the functional and anatomical brain abnormalities already exist in adolescent patients with AN and BN in which the eating disorder is present for a shorter duration.
In sum, the evidence presented is not satisfying, and several questions remain unanswered, especially concerning the time points and mechanisms of the development of body-image disturbance. Future research is urgently needed to enhance our understanding of the qualitative and quantitative specifics of body-image disturbance in children and adolescents with eating disorders. This understanding is an indispensable prerequisite for the adaptation of specific body-image treatment programs which were originally developed and validated for adults to the specific needs of children and adolescents (e.g., Voßbeck-Elsebusch et al., 2013).
Conclusions and Future Directions
Research efforts in adults provide evidence for a cognitive-behavioral framework that has inspired further research and therapy efforts. Many studies showed the predictive value of body-image disturbance for eating disorders. However, little is still known about the underlying complex mechanisms leading to the development of pathological body-image disturbance and eating disorders. Recently, the focus has therefore shifted to the transmission of body-image disturbance from mother to daughter and father to daughter. It is known that critical comments about weight and shape as well as weight teasing are specific risk factors for the development of eating disturbance (e.g., Neumark-Sztainer et al., 2010). Recent results therefore suggest that prevention should target the psychoeducation of parents in relation to role models and transmission of body dissatisfaction and weight related attitudes (Tremblay & Limbos, 2009). Furthermore, it is proposed to change family conversation content from weight/size to healthful eating behaviors, since the latter seems to protect against the development of eating disturbance (Berge et al., 2013). Future research therefore should address the question how and when parental attitudes toward weight and shape influence the child’s body image and contribute to the development of body-image disturbance.
In order to further enhance therapeutic approaches, we need further investigation on the role of dysfunction in information processing. Preliminary evidence about a possible way to enhance unconscious information processing of body-related stimuli and negative attentional bias was reported by Smeets, Jansen and Roefs (2011). The authors trained women in redirecting their attention to more attractive body parts, which in turn led to decreases in body dissatisfaction in women with initial high body dissatisfaction. This shows that the redirection of attentional processes on positive features might help to overcome body-image disturbance. Further research should investigate whether such a technique is transferable to clinical samples and in particular to children and adolescents.
This overview has outlined the lack of research in clinical samples of children and young adolescents with eating disorders as well as methodological limitations. Future studies should therefore consider the methodological and practical issues associated in particular with the assessment of the perceptual body-image component. It may be helpful to administer assessment tools using morphed bodies and modified signal-detection tasks in order to limit the overlap between attitudinal and perceptual body-image components during assessment (Cornelissen, Johns, & Tovée, 2013). In addition, and because body image is such a multifaceted construct (Thompson, 2004), further research needs to take the behavioral component of body image into account. This has been neglected in research of adolescents and children more than other body-image features.
With respect to neurobiological findings, first data indicate the therapeutic convertibility of an abnormal extrastriate body area activity. In a recent randomized-controlled trial with a mixed sample of adult eating-disorder patients applying an exposure-based cognitive-behavioral body-image therapy, the activation of the extrastriate body area during viewing photographs of one’s own body was enhanced after treatment, whereas no such changes were found in the waiting-list control group (Vocks et al., 2011). These results are promising, and future research should further clarify the role of dysfunctions in brain regions in relation to the development of body image and eating disturbances especially in children and adolescents.
Finally, given the fact that most studies were cross-sectional and observational in nature and thus did not address questions regarding the sequence and causality of the development of body-image concerns and eating disturbance, future research needs either a more prospective approach following parents and children over a longer period of time or experimental designs.
Conflicts of interest: None
1This is part of the extrastriate visual cortex that is involved in the visual perception of the human body. It serves as category-selective region for the visual processing of static and moving images. Its ventromedial counterpart is the fusiform body area (e.g., Taylor & Downing, 2011).
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