JOURNAL (SF ADOLESCENT HEALTH CARE 1990;11:203-209

MARYSE H. RICHARDS, Ph.D., REGINA C. CASPER, M.D., AND

REED I;ARSON, Ph.D.

The emergence of weight and eating concerns in pre- and yoamg adolescents and the relations of these concerns to daily experience and .psychologic adjus~e~t were investi- gated. Four hundced eighty-one children from fifth to ninth grades completed a Weight and Eating Concerns Scale, a depression inventory, self-esteem and body image scales, and reported their daily experiences by the Experience Sam- pling Method. Girls tended to report more weight and eat- ing concerns than boys. This disctepancy increased with age. In older girls (eighth and ninth graders) extreme weight and eating concerns were associated with other signs of emotional maladjustment. Girls who experience emotional distress may try to compensate for the strain by controlling body shape and hi doing soi may place themselves at risk for developing an eating disorder. Boys currently appear to be protected from this difficulty. Our findings suggest that ex- cessive weight and eating concerns in young adolescent girls signal psych~logic maladjustment which may require attention.

REY WORDS:

Eating disorders Anorexia Bulimia

Eating disorders appear to occur as a result of com- plex interactions of sociocultural, psychological, and biologic changes. The youthful age at onset suggests

From the Department of Psychology, Loyoia University of Chicago (M.H.R.); Department of Psychiatry, The Gtiversity of Chicago and Michael Reese Hospital and Medial Center (R.C.C.), and Department of Family and Human Development, University of Illinois (R.L.).

Address reprint requests to: N,nryse H. Richards, Ph.D., Depart- ment of Psychology, Lq& Ukxr:;ity of Chicago, 65.25 North Sheridan Road, Chicago, IL 6&26.

Manuscript accep.2 September 7, 1989.

0 Society for Adolescent Medicine, 1990 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010

that issues related to physical ard emotional ma-

turation may be particularly important, yet few stud-

ies have examined developmental precursors ]l] or gender differences.

There is a general consensus that weight loss is a major symptom of anorexia nervosa ]2] and re- peated dieting appears to contribute to bulimia ner-

vosa [3]. Both of these disorders frequently begin

during adolescence. Thus, conditions associated with weight changes in the young need special at- tention. Although organic illnesses such as diabetes mellit-us [4] occasionally lead to changes in body weight ]5], in contemporary culture, by far the most frequent reason for weight loss among teenagers seems to be deliberate dieting [6,7]. A recent report by Pugliese et al [S] describes growth retardation in prepubertal children who willfully restricted their food intake out of fear of weight gain. This suggests that weight regulation may become a concern in children.

A substantial literature documents distorted body perceptions and extreme weight concerns among many young adolescent girls in the junior high school ages [9,10]. Although we know these concerns become prevalent with puberty, it re-

mains unclear whether they are associated with poorer psychologic adjustment which may tore- shadow the later development of an eating disor-

der. Little is known about whether these concerns precede puberty and whether comparable patterns occur for boys. This work will help in understand- ing the developmental precursors of eating disorders.

Our aim is to study the emergence of weight and eating concerns in a young adolescent population

203 0197-OQ70/90/$3.50

204 RICHARDSETAL JOURNAL OF ADOLESCENT HEALTH CARE Vol. 11, No. 3

and to examine the psychopathology and daily life experiences which may relate to these concerns. We examine weight and eating co.ncems in normal boys and girls from preadolescence through early adoles- cence, in relation to self-perception, body percep- tion, social life, and mood.

Subjects and Method

Sample

The participants were 238 boys and 243 g& from the 5th to 9th grades. These 481 students were ran- domly selected from six schools in a middle class and a working class Chicago suburb using stratifi- cation procedures to obtain equal representation by sex and community. The final sample closely ap proximates a stratified sample design of lOtI students in each grade from the 5th to the 8th grades and 60 students in the 9th grade [ll]. In total 70% of the students invited to take part in the study agreed to do so and completed the research protocol. Previous analysis showed this sample to be comparable to the total school population on several measures of gen- eral well-being [ll].

Method

Participants completed reports on their daily lives, following the procedures of the Experience Sam- pling Method (ESM) [12]. For 1 week they carried electronic pagers and self-report booklets. At ran- dom times within each 2-hour block between 7~30 AM and 930 PM, they were sent a signal which cued them to fill out a report on their situation and sub- jective state at that time. The average student re- sponded to 37.3 (84%) of the signals sent by filling out a self-report, i.e., a total of 17,941 recordings.

Measures

Weight anti Eating Concerns. The Weight and Eat- ing Concerns (WEC) scale was developed to assess children and young adolescents for preoccupation with food in a language they could understand. This six-item scale was designed to assess attitudes to- wards eating and weight maintenance. Items are an- swered with a six-point Likert scale which ranges from “describes me very well” to “does not describe me at all.” The score for the scale is the average of the six items and ranges from a value of 0 to 5 (see Table 2). Adequate psychometric properties were es-

Table 1. Weight and Eating Concerns Scale: Item-Total Correlations

Girls (?I = 243)

Variables t

Terrified of weight gain 0.55 Feel ugly when eat too much 0.61 Wohy about eating when upset 0.49 Think about calories when exercising 0.49 Like empty stomach 0.37 Think about dieting 0.66

BOYS @=23S)

t

035 0.54 0.36 0.45 0.41 0.65

Standardized km alpha for girls is 0.79, for boys is 0.75

tablished by measuring intcritem reliability (Chron- bath Alpha = ble 1).

79 for girls and .75 for boys) (Ta-

Validity was assessed by correlating the WEC score with the students’ average ratings on a seven-point ESM Method item that asked them how thin to fat they felt each time they were sig- naled. The WEC score correlated with thinness only for girls (T = - .31, p < .Ol). In addition, the WEC score correlates with perceptions of weight (Do you see yourself as under-, average, or ave.*- weight?) and personal satisfaction with weight. The correlation coefficients of 44 (p < .001) for girls’ perceptions and .50 (p c .OOl) for boys’ per- ceptions as well as - 23 (p c .05) (girls) and -.26 (p c .iEj (boys) for satisfaction with weight provide additional evidence for scale validity. Young adolescents who reported greater satisfac- tion with weight and saw themselves as under- or average weight reported healthier eating and weight attitudes. As a further validity check, a subsample of adolescents were asked their weight which was correlated with their WEC scores. Ninth graders were not asked their weight.

Depression. Depression was measured using the 27-item Child Depression Inventory (CDI) adopted by Kovacs 1131 from The Beck Depression Inventory [14].

Self-Esteem. Self-esteem was measured by the IO-item self-report questionnaire developed by Ro- senberg [ 151.

Daily Experience. The ESM data provide mea- sures of how participants spend their time and the subjective states they experience during their daily life. Time use is assessed from the students’ re-

hAsty 1990 WEIGHT AND EATING CONCERNS AMONG CHILDREN AND EARLY TEENAGE= 285

sponses to questions asking what they were doing and who they were with using a self-report form. By aggregating across all the self-report forms ob- tained from each person, we were able to estimate how much time the person spends in different ac- tivities (e.g., doing homework, watching TV) and how much time he/she spends with different people (e.g., family members, friends).

Students reported on their subjective states by responding to a set of structured scales. Their affect was assessed by the sum of three seven-point semantic-differential items asking for ratings of whether they felt happy-unhappy, cheerful-irritable and friendly-angry. Their psychologic arousal was assessed by three similar items asking for ratings of strong-weak, excited-bored, and alert-drowsy. At- tention was measured by a single lo-point item ask- ing “How well were you paying attention?” In addition they responded to two seven-point seman- tic differential items, thin-fat and attractive-ugly. Krulings are reported for the aggregate means and standard deviations for each person across all of his/ her self-reports. These measures and procedures are described at length elsewhere [ll].

Age vs. School Grade: All analyses reported were originally carried out using chronologic age as well as school grade to separate younger and older students. Comparisons show that, while the two yield similar results, school grade rather than age provided the strongest findings. The implica- tion is that behavior patterns are more strongly determined by “social age,” i.e., their identifica- tion with a ladder of maturity defined by school. Thus we have included only analyses by school grade. Our interest in developmental differences led us to compare the oldest (eighth and ninth graders) with the youngest (fifth and sixth grad- ers) groups. Seventh graders were omitted from many of the analyses.

Analysis

Analysis of variance was used to determine grade and sex differences as well as compare the groups of older girls with high versus low weight and eating concerns. Pearson-product moment correlai- tions were used to examine the relationship of weight and eating concerns to the measures of psychological adjustment and daily experience. Four multiple regressions, one for each of the groups by gender and grade, were computed to

Table 2. Weight and Eating Concerns by Sex and Grade -_._

Girls (n = 243) Boys (n = 238)

Grade x SD R SD-

5 2.01 1.17 1.79 1.31 6 2.13 1.23 1.65 1.19 7 2.13 1.27 1.85 1.27 8 2.60 1.44 1.56 1.12 9 2.74 1.26 1.48 1.01

F = 3.17 df = 4477 for the interaction of sex by grade, sig- nificant at p < .05.

A high score indicates more concern.

determine the amount of WE variance explained by all of the variables.

ReSUltS

The first question addressed and eating concerns di

was whether weight . oy sex and grade. A

two-way analysis ex by grade) showed a significant main with girls reporting higher levels of wer ting concerns than boys (F= 29.53, p< .OOl). A significant interaction was also found, with older girls reporting .more weight and eating concerns relative to younger girls, and boys not differing by grade (F= 3.17, p< .05). Across all grades few (8%) of the boys reported ex- treme concerns (3.5 and above). In contrast, a clear shift in the rate of extreme concern occurred for girls with substantially more eighth and ninth grade girls reporting extreme concerns compared to fifth and sixth grade girls (Table 2 and Figure 1). About 32% of the oldest girls had scores of above 3.5 compared to about 15% of the younger girls.

For boys and younger girls (fifth and sixth

Figure 1. Frequency of extreme weight and eating concerns (3.5 and abow) by group and sex.

Percent 35

- -I

5th 6th 7th 6th 9th 5th 6th 7th 6th 9th

Qirla Boys

206 RICHARDS ET AL JOURNAL OF ADOLESCENT HEALTH CARE Vol. 11, No. 3

Table 3. Correlates of Weight and Eating Concerns (WEC)

Grades Girls Boys 5-6 B-9 5-6 - 8-9

(n=loo) (n=55) (n=loo) (n=80)

Se&esteem Depression Body image Mean daily rating of:

Affect Activation Attention

Variance in ratings oh Affect Activation Perceived thinness

Percent of time: With family Friends Alone In social activity In sports

Percent variance explainedb

-.lO .2T

-.3Y

-.02 -.09 -.OS

.Ol -.Kl -.06

.08

.03 -.06

.lO

.Ol

.02

- .34** -.ll - .21 .48H* .20 .17

-40”” -.24** -JON

-.25= - .21’ .12 -.22* - .20* .lO - .25+ - .07 -.I2

.13 -04 .19

.a5 .06 .05

.4?‘* .13 .15

-02 .04 -.16 - .29’* -.12 .Ol

.25* 84 - .06 -.26’ .OO .14 - .Ol -.09 - .g6*

35 .Ol .13

‘Using Pearson product-moment correlation coefficients. ‘Adjusted Rz from the regression of these variables on the

wEc score. *p < .05; “‘p < .Ol; l **p < .ool.

grades), weight correlated with weight and eating concerns (younger girls: r= 36, p< .Ol; boys: r=5O, pc .OOl). Weight did not correlate with the WEC score in older gfrls (seventh and eighth grad- ers) (r = .16). Thus an older girl did not necessarily report being overweight when she reported con- cerns about her weight and eating.

How are weight and eating concerns related to other measures of emotional well being? The mea- sures of seksteem and depression related to weight and eating concerns in older adolescent girls and were generally unrelated in younger girls and boys (Table 3). In younger girls depression appeared to be related to eating attitudes even in the fifth and sixth grades. Although the girls’ relations between depression and weight and eating concerns were significant, the correlations in the older girls were stronger than those of the younger girls. General physical self perceptions in the form of body image scores were related to eating and weight attitudes in younger and older boys and girls (Table 3). WEC scores related to several daily psychologic states in older girls, but not in the younger girls or in boys (Table 3). Eighth and ninth grade girls and fifth and sixth grade boys who reported greater weight and eating concerns also reported more dysphoric daily affect and lower daily levels of psychologic arousal

or energy. In addition, older girls with higher WEC scores reported poorer than average attention (Ta- ble 3).

Weight and eating concerns also correlated with how older girls reported spending their time. Older, but not younger, girls with high WEC scores spent more time alone and less time with friends as well as less time in social activities than did their age- mates (Table 3). Family time was unrelated to weight concerns. For boys companionship was not related to weight concerns.

based on previous work done with buknic young adults [16], greater mood variability WJS expected in girls who were most concerned about their weight. This was not found in our sample of children and young adolescents. However, older girls who were more preoccupied with eating also experienced greater swings in their perceptions of thinness, i.e., a girl with many concerns about her weight tended to report feeling fat one moment and thin the next. Those girls with weight concerns tended to report a less stable and consistent body image of thinness than those who were less worried about their weight (see Table 3).

The overall ability of these variables to predict WEC scores varied considerably by sex and grade group. The adjusted R* from four multiple regres- sions showed that these variables predicted 35% of the weight and eating concerns’ variance among the eighth and ninth grade girls only (F = 3.88,. p< .OOl). The variables predicted none of the WEC variance among the younger boys (I: = .94, p = .53) and girls (F = 1.10, p = .38) and only 13% of the WEC variance among the older boys (f= 1.73 p = .07) (Table 3).

To examine the magnitude of the various traits associated with weight concern scores among the older girls, we subdivided them into 27 girls scoring 3.5 and above, i.e., a “high concerns” group and the remaining 58 girls who scored below 3.5, i.e., a “low concerns” group. Relative to their healthier age-mates, the eating and weight preoccupied eighth and ninth grade girls had lower self-esteem, greater depression, and a lower body-image percep- tion. The mean depression score of 15.5 is above the cutoff recommended by Kovacs [13] for identifying depression. They also felt less happy and less aroused on their daily reports. In addition, they spent about seven more hours alone than their peers from the “low concerns” group (Table 4).

To create equivalent sized groups for boys, a dif- ferent cutoff point was used. Twenty-four of the eighth and ninth grade boys were assigned to the more weight and eating preoccupied group using a

May 1990 WEIGHT AND EATING CONCERNS AMONG CHILDREN AND EARLY TEENAGERS 207

Table 4. Psychologic Adjustment and Daily Experience for Eighth and Ninth grade Girls by Weight and Eating Concerns (WEC)

&3l ter XX Lesser WEC (n = 27) (n = 58)

Variables x SD ?i SD

Self-esteem*+ 2.7 0.5 3.0 0.4 Depression*** 15.5 7.0 9.1 6.5 Body image*** 1.4 0.9 4.0 0.8 Mean daily rating ok

Affect* 4.8 0.5 5.2 0.8 Activation* 4.2 0.5 4.5 0.7 Perceived thinnew” 3.8 0.9 4.4 1.0 Perceived time alone* 26.7 13.3 20.0 11.9

Variance in ratings 0S perceived thinness** 1.0 0.5 0.6 0.5

-.

:* p c .05;

p c .Ol; ***p < .OOI.

cutoff score of 2.85, while the rest (n=60) were as- signed to the less preoccupied group. These two groups of boys did not differ on any of the above measures. By early to midadolescence weight and eating concerns alone appear to importantly differ- entiate female, but not male, emotional health from emotional distress.

Thus, among the eighth and ninth graders, the pattern of findings for boys differed consistently from that of girls. One exception to this pattern was an association between weight concerns and the time spent in sports. Older boys who were more active in athletics tended to be less weight and eating preoccupied.

Discussion Our results suggest that weight and eating concerns are infrequent before adolescence and become more frequent for girls as they move into adolescence but remain infrequent for boys. By the eighth grade, or 13 years of age, a substantial proportion of girls en- dorsed items stating they were terrified of gaining weight and worried about eating when they were upset.

These findings raise the question: what is it about this particular age, (12-13 years) that contributes to these concerns? Frisch [17,18] has reported the im- portance of weight gain and an optimal ratio of fat to lean body mass as a prerequisite for menarche. Prior research suggests that this major increase in subcutaneous fat, during puberty, is troubling to young adolescent girls [19] and that this and their

sexual changes may lead to self-consciousness, a dis- torted and more negative body-image, perceptions of being overweight, less satisfaction with weight

[20-221, inaCCUraCy in perceptions of weight [23], and desires to be thinner [24]. One study found that by age 13 years, 80% of girls had already been on a weight-loss diet, compared to 10% of boys 1251.

Our data suggest that preoccupation with food and dieting in girls begins in the fifth and sixth grades and increases in the seventh and eighth grades, a time when most girls are completing pu- berty. Our findings also suggest that, when girls as young as the eighth and ninth grades report rela- tively strong weight and eating concerns, it may signal something more than the commonplace. Per- sistent and negative thoughts about how much is eaten and if she is exercising enough in the young adolescent girl may indicate she is suffering emo- tionally and socially. Indeed, signs of emotional dis- tress in young adolescents are sometimes most apparent in body perception and concerns 1261. This is not surprising considering the importance of the body changes experienced by female adolescents. Hence, the manifestation of strong weight and eat- ing concerns in young adolescents may suggest a need for observation by the physician and some- times a need for clinical assessment for emotional distress. Specifically, eighth or ninth grade girls who report concerns about their weight and eating ex- perience more dyspboric daily moods, and poorer attention span, report more symptoms of depres- sion and lower levels of self-perceptions, and are more socially withdraivn. They also spend more time alone and less ‘with friends and in social activities.

Some of the symptcimatic correlates and experi- ences of our weight- and diet-preoccupied young- sters were remarkably simil,ar to the correlates described in eating disorders. The depressed mood, lowered self-esteem, social withdrawal, and dis- torted body-image displayed by our eighth and ninth grade girls are features believed to contribute to or result from an eating disorder 227-291. Our results suggest that weight preoccupation along with psychological signs of distress may place young adolescent girls at risk for developing an eating dis- order. Our data do not provide information about the sequences of events: i.e., whether emotional dis- tress precedes the eating and weight concerns or the eating and weight concerns precede the emotional distress. Along with the enhanced weight and eating concerns in girls, negative affect tends to increase with age in boys and &IS [30].

208 RICHARDSETAL JOURNAL OF ADOLESCENT HEALTH CARE Vol. 11, No. 3

&vemlcharacteristics of our population are partic- ularly noteworthy. Our eighth and ninth grade girls who worried about th& weight also perceived them- selves to fluctuate from hour to hour in how “fat” to “thin” they were. They seemed to experience height- ened b&y shape awareness and the variability in the hourly reports suggests that the experience of their body boundaries fluctuates. Thus at this age, their symptoms seem to come and go, and may not be read- ily apparent at any point in time. Another important characteristic is the middle to lower middle socioeco- nomic status of most of our population. Weight prob- lems are known to frequent the upper middle class more than the lower classes [24]. The prevalence of

ng concerns may be even greater in an upper middle class young adolescent population than we found in our study groups.

Our yovr;g adolescent girls who reported greater weight concerns were more socially isolated, spend- ing more time alone, less time with friends, and less tin12 in social activity, a pattern of social isolation sim- %rtothatwhichoccursinaneatingdisorder[31]. We wonder if this behavior may deprive them of peer ~;roup feedback which may serve as an important ref- erence source regarding norms of appropriate weight and body size. A constant comparison of one’s body against others may help attenuate extremely unreal- istic attitudes and feelings about the body.

Weight and eating concerns did not differentiate emotional health from emotional distress in our

males. For boys the one correlate of weight and eat- ing concerns was the time spent in athletics. Those boys who report less concerns spent more time in sports. We believe this is not surprising as athletics generally provide opportunities for maintaining a desired body build and weight.

In conclusion, the Weight and Eating Concerns

scale appears to provide a measure of the attitudes of young and preadolescents toward dieting and weight. This valid and reliable scale is short, easily understood, and easy to administer. A high score on this scale for girls, but not for boys, may consti- tute a sign of problems.

we thank Thora DevlescHoward for her generous assistance in the Preparation of the manuscript and Alicia Joebgen for the extensive data analysis. This research was funded by grant 38324 from the National Institute of Mental Health.

References 1. Stmber M. Personality and symptomatoloeical features in

~Y;~;Q&: an&&a n&v&a patie&. J Psychosom : .

2.

3.

4.

5.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

Casper RC, Davis JM. On the course of anorexia nervosa. Am J Psychiatry 1977; 134z974-8.

Crisp AH. Some possible approaches to prevention of eating and body weight/shape disorders with particular reference to anorexia nervosa. Ilrt J Eating Disord 1988;7:1-17.

Powers, PS, Olalone JO, Duncan ]A. Anorexia nervosa and diabetes mellitus. j Clin Psychiatry 1983;44:133-5.

Kirschner BS, Klich JR, Kalmann SS, et al. Reversal of growth retardation in Crohn’s disease with therapy emphasizing oral nutritional restitution. Gastroenterology 1981;80:10-5.

Davis DR, Apley J, Fill G, et al. Diet and retarded growth. Br Med J 1978;1:539-42. Garfinkel PE, Garner DM. Anorexia nervosa: a multidimen- sional perspective. New York: Brumner Mazel, 1982.

Pugliese MT, Lifshitz F, Grad G, et al. Fear of obesity. N Engl J Med 1983; 309~513-8.

Attie I, Brooks-Gunn J. The emergence of eating disorders and eating problems in adolescence: a developmental per- spective. J Child Psycho1 Psychiatry Allied Disclip, in press. Faust J. Correlates of the drive for thinness in young female adolescents. J Clin Child Psycho1 1987; l&313-9.

Larson, R. Beeping children and adolescents: A method for studying time use and daily experience. J Youth Adolesc, in press.

Csikszentmihalyi M, Larson R. Validity and reliability of the experience-sampling method. J Nerv Ment Dis 1987; 175: 526-36. Kovacs M. The children’s depression inventory. Psycho- pharmacol Bull 1985; 21:995-998.

Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-571. Rosenberg M. Society and the adolescent self-image. Prince- ton, N.J.: Princeton University Press, 1965. Johnson CL, Larson R. Bulimia: an analysis of moods and behavior. Psychosom Med 1982;&333-45. Frisch RE. Pubertal adipose tissue: is it necessary for normal sexual maturation? Evidence from the rat and human female. Fed Proc 1980;39:2395-400.

Frisch RE. Body composition and the onset of puberty: effects of undernuhition and physical exercise. In: Venturoli S, Fla- migni C, Givens Jr, eds. Adolescence in females. Chicago: Year Book Medical Publishers, 1984.

Brooks-Gunn J, Warren MP. The effects of delayed menarche in different contexts: dance and nondance students, J Youth Adolesc 1985;14:285-300.

Blyth DA, Sinmone RG, &kin DF. Satisfaction with body image for early adolescent females: the impact of pubertal timing within different school environments. J Youth Adolesc 1985;14:207-26.

Duncan PD, Ritter PL, Dombusch SM, et al. The effects of pubertal liming on body image, school behavior and devi- ance. J Youth Adolesc 1985;14:227-36.

22. Richards MH, Boxer AM, Petersen AC, et al. The relationship of weight to body image in pubertal girls and boys from two different communities, in press.

23. Desmond SM, Price JH, Gray N, et al. The etioloEv of ado- lescents’ perceptions of thhir weight. J Youth Adolesc 1986;15:461-73.

24. Dornbusch, SM, Carlsmith, JM, Duncan PD, et al. Sexual maturation, social class, and the desire to be thin among adolescent females. Dev Behav Pediatr 1984;5:308-14.

25. Hawkins RC, Turrell S, Jackson LJ. Desirable and undesirable masculine and feminine traits in relation to students’ dietary

May 1990 WEIGHT AND EATING CONCERNS AMONG CHILDREN AND EARLY TEENAGERS 209

tendencies and body image satisfaction. Sex Roles 19l?3;9: 705-24.

26. Rierdan J, Koff E, Stubbs ML. Gender, depression, and body image in early adolescents. J Early Adolesc P988;8:109-17.

27. Herzog DB. Are anorexic and bulimic patients depressed? Am J Psychiatry 1964;141:1594-7.

28. johnson C, Maddi KL. The etiology of bulimia: Biopaychu- so&l peqectives. Adolesc Psychiatry, 1986;13:253-74.

29. Striegel-Moore RH, Silberstein LR, Redin J. Toward an un- derstanding of risk factors for bulimia. Am Psycho1 1986; 41:246-263.

30. Larson R, Rattaelli M, Richards MH, et al. The ecology of depression in childhood and early adolescence: a profile of daily psychological states. J Abnorm Psychol, in press.

31. Larson R, Johnson C. Bulimia: disturbed patterns of solitude. Addict Behav 1985;10:281-90.