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Topic: Bulimia
Researched and written by: Sherry Maisonpierre
                                                I attest that the following report is a product of my own original work.

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The following review is about children in the school systems that are dealing with the ongoing battle of the disorder of bulimia nervosa.  The purpose of this review is to expand the knowledge of bulimia nervosa and by presenting new and useful information to children, parents, and those interested in finding out how bulimia nervosa creates difficulties for students in their daily school setting.  There was much information on the effects that children and adolescents experience while dealing with bulimia.  There was little information discussing the effects of bulimia in the school environment.  Also there was not much to report on how the schools deal with children and adolescents who have eating disorders, such as bulimia.   

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            Many young women have developed abnormal eating-related behavior. The growing preoccupation with thinness has caused girls and young women to feel overweight or fat, even if they are of normal weight. Now thinness, which is seen as synonymous with self-discipline and control, is the desired goal. 

Bulimia Nervosa is characterized by binge eating accompanied by a loss of control over eating and attempts to prevent weight gain by extreme dieting, vomiting, misuse of laxatives and diuretics and excessive exercise (Kaltiala-Henino, Rissanen, Rimpelae, and Rantanen, 2003).  Many times, patients also show an over concern with their body weight and shape.  This disorder is fairly new.  It was first described only twenty years ago and classified in the Diagnostical and Statistical Manual of Mental Disorders III in 1980 (Kaltiala-Henino, et al., 2003).  Bulimia nervosa primarily affects white Western females in late adolescence (Kaltiala-Henino, Rissanen, Rimpelae, and  Rantanen, 2001).  Most of these females are well educated and are at their normal weight for their height (Johnson, 1984).  This disease is rare among males.  Throughout the years, the disorder seems to affect children at a younger age (Kaltiala-Henino, Rissanen, Rimpelae, Rantanen, 2001).  The disease has been seen as a chronic disorder that may last for several years (Singer, Nutter, White, Song, 1993).

Kaltiala-Henino, et al., (2003), examined bulimia and impulsive behavior in middle adolescence.  The researchers studied the associations between bulimic type eating pathology with a number of age specific uncontrolled behaviors such as bullying, truancy, excessive drinking and sexual activity.  The participants were taken from a random sample from the 8th  and 9th grades of all secondary school in Middle Finland.  There were a total of 4,453 girls, and 4,334 boys participating in the study.  The participants were given a self-report questionnaire.  The questions concerning bulimic eating pathology were formulated around the DSM-III-R.  The questionnaire asked questions about frequent drinking by asking, “Did you ever drink so much alcohol that you were really drunk?  How many times?”  Truancy was measured by the absences from school.  Bullying was measured by a few questions concerning the amount of times a person had been bullied.  Sexual activity was addressed by two questions concerning whether or not the participant had ever had sexual intercourse and with how many people.  Results from the study showed that bulimic behavior was associated with bullying, truancy, excessive drinking and sexual activity between both males and females.  Researchers also found that the more uncontrolled behaviors occurring at the same time, the more likely the participant was to show bulimic type eating pathology.        

Johnson (1984) did a study on the incidence and correlation between bulimia and the female high school population.  This study, in particular focused on the estimated incidences of bulimic behavior among female high school students.  The study also investigated the differences between bulimic and non bulimic students regarding demographics, body perceptions, weight concerns, dieting, exercise, menstrual behavior, and frequency of bingeing and purging behavior.  The study took a sample of 1268 adolescent females between the ages of 13 and 19, which represented 98.1% of the total female population.  The girls came from a diverse ethnic and socioeconomic mix.  The participants were split up into two different groups, which consisted of bulimic vs. non-bulimic students.  They were compared over four content areas.  The participants were given a survey during their gym class, all on the same day.  They were told that the survey would be anonymous.  This survey was used to identify the students who met the DSM-III criteria for bulimia nervosa.  After the survey, a presentation was given about dieting behavior, anorexia, and bulimia.  Results showed that 4.9% of the students met the criteria for the diagnosis of bulimia.  Of the 4.9%, 21% of the total sample admitted to weekly or greater episodes of binge eating.  4% of the sample used self-induced vomiting, and 3% used laxatives as a way of evacuation techniques.  When researchers compared the bulimic and the non-bulimic groups, results indicated that the bulimic group had a much poorer body perception, even though they were at normal weight.  They also had a larger desire to be thin.  The bulimic group also started to diet at an earlier age and more frequently and over a longer period of time than the non-bulimic group.

 Kaltiala-Henino, et al., (2001) conducted a study about early puberty and the early sexual experiences that are associated with bulimia in middle adolescence.  The purpose of this study was to explore further the associations between early pubertal timing and early advanced sexual development with bulimic type eating pathology in middle adolescents.  The study took a total of 19,321 males and 19, 196 female students from the ages of 14-16 years old.  The participants were given the School Health Promotion Study.  This was a survey for adolescents about health, health behavior, and school experiences.  The survey was geared toward the DSM-IV criteria for meeting the bulimia nervosa disorder.  The onset of menstruation was simply determined by asking, “How old were you when you had your first menstruation?”  Sexual activity was measured by asking several questions referring to kissing, petting, and intercourse.  Age was measured by calculating the date of birth on the survey.  Researchers found in their results that bulimic type eating pathology in girls were associated with early menstruation, early sexual experiences, and higher in age.  For the male respondents, the onset of ejaculation was at the normative age with little risk of bulimia, but early sexual experiences were associated with bulimic type eating pathology.  Researchers concluded that in order to help prevent the onset of bulimia nervosa, there should be opportunities for early intervention. Special attention should be given to early maturing girls and off time maturing boys.  Attention to early onset of sexual activity should be made.

Many young adolescence find themselves under a severe amount of stress.  Going though puberty can be a very a demanding yet rewarding experience.  For most adolescents, they need a way to release their stress and cope with their problems though the help of social support.  Social support can be found though friends, family, and the school, such as guidance counselors and teachers.                  

Schmidt (1996) conducted a study of adolescent bulimic behavior and its relation to the way adolescents develop, cope, and use social support.  The study examined whether there were any relationships between adolescent bulimia and coping, social support or maturation timing.  The study consisted of 388 adolescent females from the 9th through 12th grades.  These were girls who were attending two different schools but were attending their physical education classes.  Four different self-report measures were taken:

·        The Ways of Coping Checklist,

·         Perceived Social Support From Family,

·        Perceived Social Support from Friends, and

·        The Bulimia Test. 

The surveys also had questions regarding demographics and pubertal timing.  Results showed that female adolescences that reported having stronger symptoms of bulimia were not as likely to use useful forms of coping when dealing with stress.  As well, those girls who had more bulimic symptoms showed lower reports of support from friends and family.  These adolescents also reported that they were going to reach puberty before their peers.  Researchers found an unexpected finding that any of the girls, regardless of whether or not they show signs of bulimia, experienced similar stressful events.  Also, those adolescents who showed more symptoms of bulimia were less likely to find social support when experiencing a stressful event and instead isolated themselves.  Researchers suggest through their findings that early intervention should take place and educational programs should focus on teaching appropriate coping and social skill.

Stein, and Reichert (1990), conducted a study on extreme dieting behaviors experienced in early adolescence.  There were multiple purposes for the study.  One purpose of the study was to find a better understanding of the ages of possible onset of extreme dieting and the patterns in early adolescence.  A second purpose was to obtain a pilot screening procedure that has not been used by other researchers.  Students use these procedures to try to overcome the problems with “false-positive” statements of bingeing.  The participants taken for this study were 235 fourth, fifth, and sixth graders from two elementary schools in North Dakota.  Almost all of the students were Caucasian and the majority of them had at least one parent who had a college degree.  The participants were shown a slide show with audio taped narration of two case stories involving eating disorders.  After they watch the show, they were asked to complete a series of questions about their eating behaviors and to compare their eating habits to that of the case participants.  The case participants were seen to be those of bingers.  Results showed that between 3 and 4% of girls reported that they had either self induced vomiting, or had secretly thrown away food to avoid gaining any weight.  There were 6 students from the fifth and sixth grade that reported that they had skipped more than two meals a day in order to lose weight.  The fifth and sixth grade girls scored much higher than any other group on Food Restriction Dieting.  This study should alert teachers and other professionals to the fact that a lot of fifth and sixth graders are experimenting with extreme dieting behaviors.  Educators should become more familiar with the risk factors and signs and symptoms of eating disorders.  Such risk factors include mood instability, low self-esteem, and sudden weight gain in adolescence, peer modeling influences, and internalization of society’s values of thinness in women. 

In today’s society, women are expected to ideally be thin.  Early on in life females are taught to comply with society’s standards of beauty.  At the age of six, girls have an internalized perception of what is attractive and how is relates to popularity as well as the negative insights of an overweight person.

Girls who are bulimic show signs of body dissatisfaction.  These girls see themselves as being bigger than what they really are and they wish that they were smaller in size (Dacey, Nelson, Clark, and Aikman, 1991).   

Dacey, Nelson, et al., (1991) did a study of how bulimia relates to how adolescents view their body image and how dissatisfied they are with their body’s. The purpose of the study was to examine the body image dissatisfaction in bulimic girls in their adolescent years.  The participants for this study were taken from an all-girl, middle to upper level income, and private Catholic high school in the Midwest.  Fifty-four percent of the students returned their consent forms, which equaled out to be 260 students.  These students were screened for bulimia by using the Bulimia Test and the Eating Disorders Inventory.  After determining whether or not the girls had bulimia, they were interviewed by the Russell’s criteria.  The remaining girls were matched with controls accordingly to their age, height, weight, and year in high school.  The participants next were given the Color-A-Person Test and were asked to indicate their level of body part satisfaction by using five different colors.  Red represented very dissatisfied, yellow for dissatisfied, black for neutral, green for satisfied, and blue for very satisfied.  Results showed that the bulimic participants were more dissatisfied with their hips, buttocks, and thighs compared to the non-bulimic participants.  There was an overall dissatisfaction of all body parts with the bulimic participants.  But, there was no significant difference between either of the groups when it came to the dissatisfaction of side or front view body part discriminations.

Studies have been known to show significant relationship between those people who are bulimic and those who engage in alcohol or drug use.  Research shows that there are three similarities that both the bulimic and binge drinkers in alcohol share.  They characteristics are 1) a loss of control and feelings of compulsion, 2) bingeing to sedation or drinking to intoxication to forget about anxiety and interpersonal problems, and 3) feelings of degradation, powerlessness, anger, self-loathing, and/or depression following the binge eating or drinking behavior (Singer, Nutter, White, and Song, 1993). 

Singer, et al., (1993) examined though a study the problem behaviors, such as substance abuse, and sexual abuse, currently being experienced by hospitalized adolescents who were diagnosed with bulimia nervosa.  There were twenty eight adolescents who were experiencing the bulimic disorder were compared to 201 psychiatrically hospitalized patients who were not suffering from an eating disorder.  Of the 28 eating disorder patients, 29% were identified as substance abusers.  75% of those patients were experiencing depression as well.  Those patients who were not experiencing an eating disorder were found to be more aggressive, delinquent, and undercontrolled than those patients with bulimia are. 

It was also found that sexual abuse was less likely to be prevalent among those adolescents with bulimia nervosa compared to the hospitalized patients.  There were no significant differences in any aspect of alcohol or drug abuse among any of the patients.  As well, there were similar behavioral profiles of substance abuse bulimics and non-eating disordered patients.  Bulimia and substance abuse has been shown to have many similarities that may be related to family functioning. 

After three months, researchers did a follow up on the bulimic patients.  Researchers found that the patients were less depressed, had less somatization, and were less overcontrolled.  On the other hand, they did not show any signs of improvements in their eating attitudes or behaviors or with their drug and/or alcohol use.  Researchers have a few reasons why those patients who showed no improvement: 

·        Both substance abuse and bulimia nervosa are more resistant to change than other behaviors;

·        There is a “lag effect” for improvement in both bulimia nervosa and substance abuse.  Other behavior problems may need to be improved for a period of time before improvement in eating or substance use attitudes/behaviors.

Cultural and sociological factors are of great importance in understanding the development on eating disorders.  Studies show that stress in one’s life leads to a dysregulation of the monoamine, adrenocorrical, and neuropeptide systems which normally relates the feeding behavior.  Patients with eating disorders have reported high

levels of separation and attachment difficulties.  This is related to the importance of separation from primary attachment figures and bulimia nervosa (Horesh, Apter,  Ishai, and Danziger, 1996).

Horesh, et al., (1996) conducted a study on the abnormal psychosocial situations and how they are related to eating disorders in adolescence.  The purpose of this study was to determine the relationship between abnormal psychosocial situations and eating disorders in adolescents.  The study picked twenty girls with eating disorders, which were patients of an eating disorder program, 20 girls with psychiatric conditions, such as mood disorders, and 20 healthy girls.  The participants were given a semistructured interview to complete which was designed by the World Health Organization.  This is used to diagnose the psychosocial situations.  Along with the interview, all the participants were given the Eating Attitudes Test.  According to the results, many life events and psychosocial situations showed significant differences between the patients and the controls.  In particular, inappropriate parental pressure contributed to the participants who had an eating disorder.  Correlations between hostility toward the child, sibling disability, parental overprotection, inappropriate parental pressures, and negative changes in family relationships were significant with the Eating Attitudes Test scores.  Thus, the results support the evidence on the interrelationship between abnormal family relationships and eating disorders.

Even though social pressures for thinness is exposed to adolescence, only about 4-14% of adolescent girls will have bulimia nervosa.  The frequency of boys with bulimia is 0.8-2.1%.  Boys are just as likely as girls to indulge in the binge eating habits, but the full range of bulimic symptoms is more likely to show up in girls (Price, Desmond,  Price and Mossing, 1990). 

Price, et al., (1990) conducted a study of the knowledge that school counselors had about eating disorders.  The researchers wanted to examine the knowledge that school counselor have had of adolescence eating disorders, including bulimia nervosa.  The main questions that were being examined specifically were: How do school counselors discover which students have eating disorders?  What actions do the counselors take?  What do they know about eating disorders?  Does their knowledge vary by age, sex, number of years as a counselor, or level of formal education?  Where have school counselors received most of their information about eating disorders?  The participants for the study were a random sample of 500 participants drawn from the American Association of School Counselors.  They received an anonymous and confidential questionnaire on eating disorders.  There were 16 questions on the signs and symptoms of bulimia and anorexia, along with 16 questions of general knowledge questions on the participant, and one question listing 8 potential sources of information.  Of the 500 counselors asked to fill out the questionnaire, 337 returned it.  There were 220 female and 117 males ranging from the age of 22 to 65 years of age.  On a scale of 0-10 (not competent, extremely competent), respondents were to rate themselves on how competent they believed they were in helping students with eating disorders.  40% of the respondents rated themselves as not very competent, 49% rated themselves that they were moderately competent, and 11% rated themselves as very competent.  75% of the participants did not believe it was their role to treat students with eating disorders, they instead would refer them to eating disorder programs, their parents, or a physician.  The majorities of respondents had encountered bulimic students and were very knowledgeable of signs and symptoms of bulimia.  The two main sources of eating

disorder information used by most counselors were professional journals and workshops and conferences.

            There seems to be a lack of research dedicated to the study of bulimia in a more social and school setting.  Most of the research focuses on the stress, contributing factors, and dieting problems, than how the issue is related to schools and education.  In order to help solve the problem of bulimia, initiative needs to be taken from all points of the spectrum, which includes the help from schools.  Teacher, guidance counselors, and fellow schoolmates need to take a stand and help to further educate students, as well as the staff, on the warning signs and symptoms of bulimia. 

Bulimia nervosa is recognized as being multi-determined with several factors involved in their aetiology.  These are factors in such areas as genetics, biological, familial, psychological and social influences.  Patients who suffer from eating disorders are usually found to be suffering from some sort of psychological problems at the current time.  But studies have found that there are recollections of cognitive social experiences, which include such things as loneliness, shyness and feelings of inferiority in childhood and early adolescence (Troop, and Bifulco, 2002).

Troop, and Bifulco (2002), conducted a study of the childhood social arena and the cognitive sets in eating disorders.  The researchers were interested in finding out whether women with eating disorders who experienced difficulties in the social aspect of life as children involved cognitive factors before the eating disorder developed.  A sample of 43 women with an eating disorder and a sample of 20 women without an eating disorder were interviewed.  Of the 43 women recruited for the study, 16 of them were of the binge/purge subtype and 12 were of normal weight bulimia nervosa.  At the time of the interview, the women were asked about their experiences with such feelings as loneliness, shyness and inferiority in childhood and adolescence.  The period that they were told to recall was up to age 17.  Researchers found that the women who were bulimic experienced a higher level of loneliness, shyness and feelings of inferiority in adolescence than of those women who did not have an eating disorder.  However, when the women were asked about earlier childhood experiences, there was not a significant difference between the two groups. Researchers drew the conclusion that the women, who experienced higher levels of negative cognitive factors in adolescence, may have led to the development of bulimia. 

        In conclusion, for all these reasons, it is becoming more important to educate young adolescents

that dieting is not a gentle process.  Students should know that symptoms such as persistent irritability,

sleep difficulties, poor concentration, menstrual irregularities and impulses to binge eating result from

calorie deprivation and subnormal body weights.  Health educators should be faced with the task of

informing the community that an importance on thinness and weight control for some young

adolescents may result in the development of bulimia or other eating disorders.  School counselors

should become more knowledgeable about eating disorders and school systems should take the time

to prepare them for these situations, as well as the students.  More health promotions should be

available for students who are struggling with their body dissatisfaction and should always have a place

to turn, whether it be family, peers, counselors or teachers, rather than turn away and indulge in more

negative eating habits.  


Dacey, C., Nelson, W., Clark, V., Aikman, K. (1991) . Bulimia and body image

dissatisfaction in adolescence. Child Psychiatry & Human Development, Vol. 21, pages 179-184.

Horesh, N., Apter, A., Ishai, J., Danziger, Y. (1996). Abnormal psychosocial situations

and eating disorders in adolescence. Journal of the American Academy of Child &

Adolescent Psychiatry, Vol. 35, pages 921-927.

 Johnson, C. (1984). Incidence and correlates of bulimic behavior in a female high

            school population. Journal of Youth & Adolescence, Vol. 13, pages 15-26.

 Kaltiala-Henino, R., Rissanen, A., Rimpelae, M., Rantanen, P. (2003). Bulimia and

impulsive behavior in middle adolescence. Psychotherapy & Psychosomatics, Vol. 72, pages


Kaltiala-Henino, R., Rissanen, A., Rimpelae, M., Rantanen, P. (2001). Early puberty

and early sexual activity are associated with bulimic-type eating pathology in middle

adolescence. Journal of Adolescent Health, Vol. 4, pages 346-352.

Price, J., Desmond, S., Price, J., Mossing, A. (1990). School counselors’ knowledge of

            eating disorders. Adolescence, Vol. 25, pages 945-957.

 Schmidt, S. (1996). Adolescent bulimic behavior and its relation to adolescent

development, coping, and social support. Dissertation Abstracts International: The

Sciences & Engineering, Vol. 57, page 4060.

Singer, M., Nutter, L., White, W., Song, L. (1993). Problem behaviors, substance

abuse and sexual abuse in psychiatrically hospitalized adolescents with bulimia nervosa. Child

& Adolescent Social Work Journal, Vol. 10, pages 207-223.

  Stein, D., Reichert, P. (1990). Extreme dieting behaviors in early adolescence. Journal

            of Early Adolescence, Vol. 10, pages 108-121.

Troop, N., Bifulco, A. (2002). Childhood social arena and cognitive sets in eating

disorders. British Journal of Clinical Psychology, Vol. 41, pages 205-212.

This website is a service learning project by the students of "Psychology of the Exceptional Child" at Frostburg State University.  Manager of web page and project: Dr. Megan E. Bradley