An Investigation of Eating Disorders among Gifted Adolescents

Gifted students may experience greater risk of disordered eating, especially during adolescence, which is already a high-risk time for the development of eating disorders. In particular, the novel Covid-19 global pandemic exacerbates stress that may influence adolescents with disordered eating. This study investigated eating disorders of 33 identified gifted adolescents (77% female) in one Midwest state with an online survey using a well-validated instrument, the Eating Disorder Examination-Questionnaire (EDE-Q), that contains subscales of eating restraint, eating concern, shape concern, and weight concern. Narrative responses were included in the data. Results indicated 20% of the gifted adolescents in this study revealed concerning responses about their weight, shape, and dietary restrictions. Voluntary comments revealed apprehension, concerns, and distress among some respondents. Recommendations are provided for teachers, parents, as well as for students themselves.

U.S. sample of 35,995 participants, snapshot (not lifetime) prevalence of bulimia was 0.24% for heterosexual respondents and more than triple at 1.25% for non-heterosexual respondents (Kamody, Grilo, & Udo, 2019). Help-seeking rates among the 91 out of 36,309 survey respondents who met criteria for bulimia were 62.6%, with men and non-whites seeking help at lower rates than women and whites (Coffino, Udo, & Grilo, 2019). It is noteworthy that the lowest number of survey respondents had bulimic symptoms compared to symptoms of anorexia (275/36,309) and binge eating disorder (256/36,309), yet it had they were the group most likely to seek help.
Binge eating disorder is distinguished by binge eating without compensatory behaviors (purging).
Clinically, a person with binge eating disorder may exhibit emotional eating in addition to the typical bulimia issues of over-evaluation of body shape or weight, body dissatisfaction, weight concerns, and dietary restriction (Culbert, Racine, & Klump, 2015). Lifetime prevalence of binge eating disorder ranges between 2-4% for women depending on the region and population studied and less than 1% to 2% for men (Smink, van Hoeken, & Hoek, 2012). In a U.S. sample of 35,995 participants, snapshot (not lifetime) prevalence of binge eating disorder was 0.81% for heterosexual respondents and more than doubt at 2.17% for non-heterosexual respondents (Kamody, Grilo, & Udo, 2019). Help-seeking rates among the 256 out of 36,309 survey respondents who met criteria for binge eating disorder were 49%, with men and non-whites seeking help at lower rates than women and whites (Coffino, Udo, & Grilo, 2019). In an example of partial-syndrome eating disorders with wide-ranging impact, 154 undergraduate women at Palestine Polytechnic University were assessed and 50% had some level of binge eating symptoms (Badrasawi & Zidan, 2019). Those who struggled with binge eating were more likely to also have higher levels of depression, stress, and anxiety.

Risk Factors for Eating Disorders
Risk factor for eating disorders include those that are sociocultural or socio-environmental, such as social media and living in a culture that idealizes thinness, those that are psychological, such as inborn temperament and the trait of perfectionism, and those that are genetic or biological, such as hormonal changes and disturbances (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015). Reviewing all three of these spheres of influence over 50 research studies, Culbert, Racine and Klump (2015) concluded that all three of the areas interact with each other. For instance, when individuals do not internalize the cultural message of the thin ideal, that is partly due to genetics and partly due to the individual's sociocultural environment. Even with the interactions among them, researchers were able to identify these variables as eating disorder risk factors: "sociocultural influences (media exposure, pressures for thinness, thin-ideal internalization and thinness expectancies) and personality characteristics (negative emotionality/neuroticism, perfectionism, and negative urgency)" (p. 1156).
Biological factors such as serotonin or dopamine disturbances emerged not as risk factors, but rather as correlates of eating disorder development. Similarly, the following sociocultural and psychological risk factors predicted the onset of eating disorders for 1,272 women who were followed from a three-year www.scholink.org/ojs/index.php/ct Children and Teenagers Vol. 4,No.

Biological Risk Factors
Biological risk for eating disorders includes hormonal including hormonal changes associated with puberty as well as genetic risk factors. Although genetic associations have been made with anorexia, bulimia, and binge eating disorder, the manifestation of these disorders is still multifactorial, including input from genetic and environmental factors (Bulik, Blake, & Austin, 2019). The presence of a definite genetic component to eating disorders could reduce the stigma and help individual who are struggling and their families to experience less shame about their condition, but unfortunately, according to one-third of 50 women with a history of eating disorders, blaming genetics could also increase stigma, one half of the interviewees thought that a genetic explanation would lead to less personal agency, and that would be harmful to people with eating disorders (Easter, 2012). Similarly, a study of 216 participants investigating the impact of genetic explanations for eating disorder development, researchers found it less helpful to emphasize the biological nature of eating disorder development because although self-blame was avoided, recovery self-efficacy was decreased (Farrell, Lee, & Deacon, 2015).

Other Familial Factors
Over ten years ago, the Academy for Eating Disorders (AED) released a position paper emphasizing that although families can play a role in the development of their children's eating disorders, it "stands firmly against any etiologic model of eating disorders in which family influences are seen as the primary cause of anorexia nervosa or bulimia nervosa, and condemns generalizing statements that imply families are to blame for their child's illness" ( families can play a role in the development of eating disorders, even if they are not the primary cause. For instance, in a study of 50 families with adolescents receiving treatment for eating disorders, it was found that the adolescents with eating disorders were more likely than the general population to have lower perceived family functioning (Tafà et al., 2017). Additionally, mothers of those with anorexia were more likely to be rigid, mothers of those with bulimia were more likely to be enmeshed, and mothers of those with binge eating disorder were more likely to be chaotic than those in the general population. Similarly, children's attachment relationships with their parents can influence the development of eating disorders.
Cortés-Garcia, Hoffman, Warschburger, and Senra (2019) found that secure attachments between mothers and children were protective against the later development of disordered eating among a general population sample of 904 boys and girls who were followed for six years, starting at age 10. Additionally, secure attachments to fathers were found to play a smaller but significantly positive role, especially for boys. Secure attachments to peers did not have any observable effect on disordered eating.

Adolescents and Eating Disorders
Three major studies have been conducted that follow children over a period of at least five years to When Rohde, Stice, and Marti (2015) followed 496 young women for eight years starting at age 13, they could determine who was at risk by age 14. Over the course of the study, 12% of the participants experienced at least one eating disorder. The sociocultural factors of perceived pressure to be thin, thin-ideal internalization, and body dissatisfaction all had positive linear relationships with increases in eating disorder symptoms, which of course was not positive at all for these young women. All the young women experienced the risk factors at higher rates as they got older, but those who developed eating disorders experienced the risk factors more from the start of data collection.
Onset of puberty is one of the factors that contributes to the development of eating disorders. Davis and Smith (2018) followed 1,906 children from 5 th to 10 th grade (from age 11) and found that when onset of puberty leads to negative urgency ("When I am upset I often act without thinking") and then in turn leads to thinness expectancies ("If I were thin, I would feel more worthwhile") or eating expectancies ("eating helps me forget bad feelings, like being sad, lonely or scared"), binge eating or purging is a significantly significant possible result. It is a developmental sequence that could possibly be interrupted at any point.
Davis and Smith (2018), like Rohde, Stice, and Marti (2015), concluded that risk factors for the later development of eating disorders can be identified in elementary or middle school.
Goldschmidt, Wall, Zhang, Loth, and Neumark-Sztainer (2016) followed 1,902 young people over a 10-year period starting in 7 th grade (age 13). They found that although for over half of participants, overeating and binge eating decreased over time, those with greater psychological challenges (depressive symptoms, body dissatisfaction, and low self-esteem) in late adolescence and early adulthood were more likely to have persistent eating disorder symptoms. Overeating was more likely to resolve itself among participants over time than was binge eating, although some earlier overeaters became later binge eaters.

Eating Disorder Risk for Gifted Students
There is no reason to suspect that gifted students are at lower risk for eating disorders than other students.
Gifted students may experience a greater risk, especially during adolescence, which is already a high-risk time for the development of eating disorders. Fear of fatness and avoidance of fatness through dietary restraint, including dieting and fasting, all put individuals at greater risk for eating disorders. To date, there is very little researcher literature on the experiences of gifted adolescents. In 1991, Garner wrote, "Gifted adolescents may be more vulnerable to the development of both anorexia nervosa and bulimia nervosa because those youngsters possess many of the traits that have been identified as risk factors for these eating disorders" (p. 61), but others have not followed up by investigating gifted adolescents' experiences of their food, eating, body and weight. The current study is a much-overdue response to Garner's suggestion.

Method
This Institutional Review Board (IRB) approved study investigated the question, "What are the experiences of gifted adolescents concerning their eating restraint, shape, and weight concern?" In order to explore this research question, this study was designed to gather data directly from adolescent gifted students with an online survey that included a well-validated instrument, the Eating Disorder Examination-Questionnaire called the EDE-Q containing four subscales of eating restraint, eating concern, shape concern, and weight (Fairburn & Beglin, 1994). The EDE-Q has been widely-used enough that Berg, Peterson, Frazier and Crow (2012) were able to conduct a review of the reliability and validity literature on it based on 10 studies. They concluded that there is a robust test-retest reliability of on the four subscales of the EDE-Q. Additionally, EDE-Q's validity in determining whether a person has an eating disorder was confirmed.

Survey Design
An online survey is an ideal method for allowing secondary gifted students privacy, autonomy, and confidentiality of responses. This online survey of 28 questions (Appendix A) was constructed using Qualtrics© survey software with five sections. First was a sliding scale containing four questions on "How happy are you with your weight, shape, eating, and eating restraint?" The scale represented a happy face J to an unhappy face L and representative faces in between. Next there were 12 questions on feelings pertaining to weight, shape, eating, and eating restraints with a range of seven responses from feeling concerns "every day" to "no days" with responses in between. ranging from "not at all" to "markedly". The last section invited open-ended responses from participants.

Participants
In this Midwest state, the department of education lists 462 teachers or coordinators as "gifted education contacts". An email was sent to all middle school and high school contacts. While the majority of these contacts listed appeared to work in middle school and high school settings, some contacts had changed, some emails were wrong, and some educators were responsible for both elementary and secondary students. Consequently, some emails bounced back as incorrect and others were forwarded to the correct recipient. Eventually, as a result of this outreach email, 462 gifted and talented education contacts were invited to recruit participants in the study by forwarding the survey link to parents of their gifted adolescent students. There were 23 female and 6 male respondents, with one participant defined as "other" for their gender. The participant age range was from 10 years of age to over 18 years, with 22.6% as an average age of 15 years. The 10-year-old was clearly an outlier with respect to the population of respondents, however, her sisters were taking the survey and she chose to respond. All participants were from the same U.S. state and were identified as Talented and Gifted (TAG) according to their school districts. There were an estimated 28,752 identified grade 7-12 (2020) gifted students in this state at the time of this study.

Procedure
An invitation email to TAG educators in each district included four research-based statements highlighting the severity and importance of disordered eating (Arcelus et al., 2011;Mond et al., 2014;Whitaker, 1992). Subsequently, those teachers or coordinators of gifted students in their districts were asked to forward the Qualtrics survey link (Appendix A) to the parents of the middle school and high school gifted students. Parents, then, were asked to share this survey with their gifted child or children.
By this method, researchers were able to gain parental consent, from emails or from U.S. Postal Service as a hard copy to the researchers. Next, the gifted students sent the completed surveys back to the researchers, again via email or postal mail. The time frame of this study was approximately six months from the beginning of the initial communication to district educators until researchers received the completed confidential surveys through Qualtrics. A total of 30 responses were received. Considering the difficulty of getting this survey to the TAG teachers or coordinators, reaching the gifted adolescents, and securing parental consent, we were happy with this response rate. In this study, no direct benefit or compensation was provided.

Results
The EDE-Q (Fairburn & Beglin, 1994) scores were calculated ( My body has changed a lot recently, but I am happy with the way I look". However other comments were concerning such as "I barely tolerate myself". Table 1 represents examples of internal struggles with body image, social isolation, perceived lack of support, focus on controlling food, issues with food, image, eating, weight, and shape. All names represented in Table 1 are pseudonyms.

Concerning Comments of Adolescents from Survey Data
Erin reflects, "I'm not the skinniest girl in the world, nor do I come from a skinny family, so when I was younger I just kinda ate whatever I wanted. Lately I've been losing weight and since coming out as gay I've been trying to lose as much as possible".
Jennifer says, "I'm in recovery from anorexia, but I still struggle to an extreme every day. Whether with wanting to lose weight or feeling like I HAVE to maintain or gain weight to make everyone else happy. There are days I don't eat so the next day I eat till I feel sick because I "have" to make up for it. I "have" to be the poster child in recovery. I have to make everyone happy". Sophie states, "It is really hard to get my mind off of food and the way I look a lot. It is a struggle".
The EDE-Q instrument is divided into four subscales (i.e., Restraint, Eating Concern, Shape Concern, and Weight Concern) and also offers a global score (i.e., a combination) of the four subscales. Gifted adolescent survey participants scored significantly higher in the Eating Concern subscale of the EDE-Q compared to established community norms (Table 2). This indicates greater concern among gifted student participants compared to community norms regarding their eating.  These items are all scored on a 0-6 point scale, with 0=not at all or no days; 2=slightly or 6-12 days; 3-4=moderately or 13-22 days, and 6=markedly or every day. Survey participants are closer to slightly or 6-12 days out of the past 28, whereas community norms are closer to not at all or no days.

Discussion and Implications
The statistically significant difference between study participants and established community norms (Table 2) is consistent with narrative comments of the respondents (Table 1) regarding their distress   around eating where additional comments reflected dissatisfaction with body image, social isolation, perceived lack of support, focus on controlling food, issues with food, image, eating, weight, and shape.
Not all gifted adolescents are overly concerned about food, eating, body image, or weight. However, 20% of the students in this study shared negative attitudes about their body image and eating habits, indicating possible risk factors for mental and physical health challenges. Educators of gifted are well-positioned to help students and their families receive information about disordered eating through knowledge and awareness of the potential that their students may be suffering silently about these issues. Teachers and parents will want to pay special attention to student behaviors and attitudes in order to help them receive early and appropriate interventions.
Multiple risk factors have been identified among the participants in this study. Age alone is a known risk factor for disordered eating, as adolescents are more likely to experience eating disorders. Significantly, while this study was conducted prior to the Covid-19 pandemic, the authors believe that this information is more important than ever, as people with mental health challenges, including eating disorders, are often negatively impacted by unexpected and stressful situations. Students at risk are not likely to cope well with adjustments to teaching and learning environments, virtual communication, and online learning.
Therefore, at the end of the survey, we encouraged students and families to seek resources they may need, such as the in-school counselor or a private counselor. We highly recommended the National Eating Disorders website https://www.nationaleatingdisorders.org/help-support as a resource. They have a screening tool and a helpline number +1 (800)  Please share any insight or thoughts on your feelings around your weight, shape, or feelings around eating. Please answer openly and honestly. Thank you for your reply.